John M. Lore, Jr., M.D.

Distinguished Member (Clinical Research) Medical Staff, Roswell Park Cancer Institute.
Professor Emeritus, School of Medicine, State University of New York at Buffalo.
Medical Director Emeritus, John M. Lore, Jr., Head and Neck Center, Sisters of Charity Hospital.
Former Head, Department of Otolaryngology-Head and Neck Surgery, Sisters of Charity Hospital.
University Chief, Department of Otolaryngology, Buffalo Children's Hospital and Erie County Medical Center.
Consultant, Veterans Administration Medical Center
Consultant, Roswell Park Cancer Institute
Director of Surgery, Good Samaritan Hospital, Suffern, New York.

Jesus E. Medina, M.D.

Paul and Ruth Jonas Professor and Chair, Department of Otorhinolaryngology,
University of Oklahoma Health Sciences Center College of Medicine, Oklahoma City, Oklahoma.

Illustrated by
Robert Wabnitz
Director Emeritus of Medical Illustration, University of Rochester Medical Center, Rochester, New York.
and

Margaret Pence
M.F.A. in Medical Illustration, Rochester Institute of Technology
Adjunct Professor, School of Fine Art, College of Imaging Arts and Sciences,
Rochester, New York.

ELSEVIER
SAUNDERS
ELSEVIER
SAUNDERS
The Curtis Center
170 S Independence Mall W 300E
Philadelphia, Pennsylvania 19106

AN ATLAS OF HEAD AND NECK SURGERY, FOURTH EDITION ISBN 0·7216-7319-8

Copyright c 2005, Elsevier Inc.
All rights reserved.

No part of this publication may be reproduced or transmitted in any form or by any means,
electronic or mechanical, including photocopying, recording, or any information storage and retrieval
system, without permission in writing from the publisher. Permissions may be sought directly from
Elsevier's Health Sciences Rights Department in Philadelphia, PA, USA: Phone ( + 1)215 238 7869
fax: (+ 1) 215 238 2239 e-mail: healthpermissions@elsevier.com. You may also complete your request
on-line via the Elsevier homepage (http://www.elsevier.com). by selecting 'Customer Support' and
then 'Obtaining Permissions.'

NOTICE

Surgery is an ever-changing field. Standard safety precautions must be followed, but as new
research and clinical experience broaden our knowledge, changes in treatment and drug therapy
may become necessary or appropriate. Readers are advised to check the most current product infor-
mation provided by the manufacturer of each drug to be administered to verify the recommended
dose, the method and duration of administration, and contraindications. It is the responsibility of
the licensed prescriber, relying on experience and knowledge of the patient, to determine dosages
and the best treatment for each individual patient. Neither the publisher nor the author assumes
any liability for any injury and/or damage to persons or property arising from this publication.

Previous editions copyrighted 1988, 1973, 1962

Library of Congress Control Number: 2003114446

International Standard Book Number 0-7216-7319-8

Acquisitions Editor: Rebecca Schmidt Gaertner

Developmental Editor: Arlene Chappelle
Publishins Services Manager: Tina Rebane
Senior Project Manager: Mary Anne Folcher
Cover Designer and In/erior Design Coordinator: Ellen Zanolle

Printed in China

Last digit is the print number: 9 8 7 6 5 4 3 2

 CONTRIBUTORS
AHMED ABDEHALlM, M.D.
Clinical Assistant Professor of Diagnostic Radiology,
State University of New York at Buffalo School
of Medicine and Biomedical Sciences;
Neuroradiologist, Roswell Park Cancer Institute;
Neuroradiologist, Women and Children's Hospital
of Buffalo (Kaleida Health System), Buffalo,
New York
Advanced Techniques for CT in the Head and Neck
(Chapter 1)
RONALD A. ALBERICO, M.D.
Associate Professor of Radiology and Assistant
Clinical Professor of Neurosurgery, State University
of New York at Buffalo School of Medicine and
Biomedical Sciences; Director of Neuroradiology
and Head and Neck Imaging, Roswell Park Cancer
Institute; Director of Pediatric Neuroradiology,
Women and Children's Hospital of Buffalo
(Kaleida Health System), Buffalo, New York
Advanced Techniques for CT in the Head and Neck
(Chapter 1)
JOSEPH M. ANAIN, M.D.
Assistant Clinical Professor, Otolaryngology,
State University of New York at Buffalo School
of Medicine and Biomedical Sciences; Chief,
Division of Vascular Surgery, Sisters of Charity
Hospital, Buffalo, New York
Vascular Procedures (Chapter 22)
SHIRLEY A. ANAIN, M.D.
Assistant Clinical Professor, State University
of New York at Buffalo School of Medicine
and Biomedical Sciences, Buffalo, New York
Facial Paralysis (Chapter 7)
JOHN E. ASIRWATHAM, M.D.
Clinical Associate Professor of Pathology,
State University of New York at Buffalo School
of Medicine and Biomedical Sciences;
Department of Pathology, Sisters of Charity
Hospital, Buffalo, New York
Bone Imaging and Pathology (Chapter 3); Pathology
of the Parathyroid Glands (Chapter 18)
ANGELA BONTEMPO, F.A.C.H.E.
President and CEO, Saint Vincent Health System,
Erie, Pennsylvania
A Comprehensive, Interdisciplinary Head and Neck
Service (Chapter 3)
DANIEL BRODERICK, M.D.
Assistant Professor of Radiology, Mayo Clinic,
Jacksonville, Florida
Bone Imaging and Pathology (Chapter 3)
DANiEl SETTE CAMARA, M.D.
Clinical Associate Professor of Medicine,
State University of New York at Buffalo School
of Medicine and Biomedical Sciences;
Gastroenterology Service, Sisters of Charity Hospital,
Buffalo, New York
Percutaneous Endoscopic Gastrostomy (Chapter 21)
DAVID M. CASEY, D.D.S., M.S.
Clinical Professor, Department of Restorative Dentistry,
State University of New York at Buffalo School
of Dental Medicine; Head, Maxillofacial Prosthetic
Section, John M. Lore, Jr., M.D. Head and Neck
Center, Sisters of Charity Hospital; Maxillofacial
Prosthodontist, Department of Dentistry,
Maxillofacial Prosthetics, Roswell Park Cancer
Institute, Buffalo, New York
Dental and Prosthetic Considerations in Head and
Neck Surgery (Chapter 3); Maxillofacial Prostheses
(Chapter 3)
GREGORY J. CASTIGLIA, M.D.
Neurosurgeon, Buffalo Neurosurgical Group, Amherst,
New York
Supraorbital Approach to the Orbit and Paranasal
Sinuses (Chapter 23)
v
 CONTRIBUTORS
NIEVA B. CASTILLO, M.D.
Assistant Clinical Professor of Pathology,
State University of New York at Buffalo School
of Medicine and Biomedical Sciences; Associate
Chief of Pathology, Department of Pathology,
Sisters of Charity Hospital, Buffalo, New York
Malignant Mixed Tumor (Chapter 17); Endocrine
Surgery (Chapter 18); Vascular Procedures
(Chapter 22)
KANDALA CHARY, M.D.
Medical Oncology, Sisters of Charity Hospital,
Buffalo, New York
Preoperative Chemotherapy, Uncompromised Surgery,
and Selective Radiotherapy in the Management
of Advanced Squamous Cell Carcinoma of the
Head and Neck (Chapter 3)
SCOTT CHOLEWINSKI, M.D.
Director, Department of Magnetic Resonance Imaging,
Sisters of Charity Hospital, Buffalo, New York
CT and MRI (Chapter 1); Bone Imaging and Pathology
(Chapter 3)
KEITH F. CLARK, M.D., Ph.D.
Clinical Professor, Department of Otorhinolaryngology,
University of Oklahoma Health Sciences Center
College of Medicine, Oklahoma City, Oklahoma
Endoscopic Sinus Surgery (Chapter 5)
ERNESTO A. DIAZ-ORDAZ, M.D.
Assistant Professor of Otolaryngology and Assistant
Professor of Communicative and Speech Disorders,
State University of New York at Buffalo School
of Medicine and Biomedical Sciences; Acting Chair,
Department of Otolaryngology, Sisters of Charity
Hospital, Buffalo, New York
Infratemporal Approach to the Skull Base (Chapter 23)
ROBERT W. DOLAN, M.D.
Surgeon, Department of Otolaryngology, Head and Neck
Surgery, Lahey Clinic, Burlington, Massachusetts
Microvascular Surgery (Chapter 24)
MEGAN FARRELL,M.D.
Endocrinologist, John M. Lore, Jr., M.D. Head and
Neck Center, Sisters of Charity Hospital, Buffalo,
New York
Endocrine Surgery (Chapter 18)
DAVID F. HAYES, M.D.
Assistant Clinical Professor of Radiology,
State University of New York at Buffalo School
of Medicine and Biomedical Sciences;
Chair, Department of Diagnostic Imaging,
Sisters of Charity Hospital, Buffalo, New York
CT and MRI (Chapter 1); Ultrasound (Chapter 1)
l. NELSON HOPKINS, M.D.
Chief of Neurosurgery, State University of New York
at Buffalo School of Medicine and Biomedical
Sciences, Buffalo, New York
Vascular Procedures (Chapter 22)
R. LEE JENNINGS, M.D.
Assistant Clinical Professor of Surgery,
University of Colorado Health Sciences Center
School of Medicine; Colorado Surgical Oncology
Associates, Denver, Colorado
Preoperative and Postoperative Care (Chapter 3)
CONSTANTINE P. KARAKOUSIS, M.D., PH.D.
Professor of Surgery, State University of New York
at Buffalo School of Medicine and Biomedical
Sciences; Millard Fillmore Hospital
(Kaleida Health System), Buffalo, New York
Malignant Melanoma (Chapter 3); Soft Tissue
Sarcoma (Chapter 3)
SOL KAUFMAN, Ph.D.
Research Assistant Professor of Otolaryngology,
State University of New York at Buffalo School
of Medicine and Biomedical Sciences; Consultant,
Biostatistics, Buffalo, New York
Preoperative Chemotherapy, Uncompromised Surgery,
and Selective Radiotherapy in the Management
of Advanced Squamous Cell Carcinoma of the
Head and Neck (Chapter 3)
DOUGLAS W. KLOTCH, M.D.
Surgeon in Private Practice, Tampa, Florida
Fractures of Facial Bones (Chapter 13)
ASHOK KOUL, M.D.
Clinical Assistant Professor of Pathology,
State University of New York at Buffalo School
of Medicine and Biomedical Sciences;
Director of Pathology and Laboratory Medicine,
Sisters of Charity Hospital, Buffalo, New York
Commonly Used Terminology for Squamous Epithelium
(Chapter 3)

JOHN LAURIA, M.D.
Professor and Chair Emeritus, Department of
Anesthesiology, State University of New York
at Buffalo School of Medicine and Biomedical
Sciences and Sisters of Charity Hospital, Buffalo,
New York
Venous Air Embolism (Chapter 2); Malignant
Hyperthermia (Chapter 2)
KEUN Y. LEE, M.D.
Assistant Clinical Professor, Department of
Otolaryngology, State University of New York
at Buffalo School of Medicine and Biomedical
Sciences; Attending in Otolaryngology-Head and
Neck Surgery, Sisters of Charity Hospital; Buffalo
Otolaryngology Group, Buffalo, New York
Posterior Neck Dissection (Chapter 16)
JOHN S. LEWIS, M.D.
Associate Clinical Professor Emeritus of Otolaryngology,
Columbia University College of Physicians and
Surgeons, New York, New York
Temporal Bone Resection (Chapter 23)
THOM R. LOREE, M.D.
Chief, Department of Head and Neck Surgery,
Roswell Park Cancer Institute, Buffalo, New York
Management of Salivary Gland Tumors (Chapter 17)
A. CHARLES MASSARO, M.D.
Senior Vice President, Medical Affairs,
Sisters Healthcare System, Buffalo,
New York
A Comprehensive, Interdisciplinary Head and Neck
Service (Chapter 3)
JESUS E. MEDINA, M.D.
Paul and Ruth Jonas Professor and Chair,
Department of Otorhinolaryngology,
University of Oklahoma Health Sciences Center
College of Medicine, Oklahoma City, Oklahoma
The Neck (Chapter 16)
ROBERT S. MILETICH, M.D., Ph.D.
Associate Professor of Clinical Nuclear Medicine,
Department of Nuclear Medicine,
State University of New York at Buffalo School
of Medicine and Biomedical Sciences; Staff Physician,
Veterans Affairs Western New York Healthcare
System, Buffalo, New York; Staff Physician,
Dent Neurologic Institute, Amherst, New York
Positron Emission Tomography (Chapter 1)
CONTRIBUTORS
DOUGLAS B. MORELAND, M.D.
Director, Buffalo Neurosurgery Group;
Chief of Neurosurgery, Sisters of Charity Hospital;
Co-Director, Gamma Knife Center,
Roswell Park Cancer Institute, Buffalo, New York
Endoscopic Endonasal Transsphenoidal Approach to
the Pituitary Gland (Chapter 23)
WILLIAM M. MORRIS, M.D.
Buffalo, New York
Cardiopulmonary Resuscitation (Chapter2)
WILLIAM R. NElSON, M.D.
Clinical Professor Emeritus of Surgery,
University of Colorado Health Sciences Center
School of Medicine, Denver, Colorado
Preoperative and Postoperative Care (Chapter 3)
ROBERT J. PERRY, M.D.
Clinical Associate Professor of Surgery (Plastic),
State University of New York at Buffalo School
of Medicine and Biomedical Sciences;
Chief, Division of Plastic Surgery, Women and
Children's Hospital of Buffalo (Kaleida Health
System), Buffalo, New York
Cleft Lip and Palate (Chapter 10)
JOACHIM PREIN, M.D., D.M.D.
Professor of Maxillofacial Surgery and Chair,
Clinic for Reconstructive Surgery,
Unit for Maxillofacial Surgery, University Clinics
of Basel; Chair, European Maxillofacial Education
Committee, Basel, Switzerland
Compression Plating for Ireatment of Mandibular
Fractures (Chapter 13)
ALLEN M. RICHMOND, PH.D.
Clinical Instructor, Department of Otolaryngology,
State University of New York at Buffalo School
of Medicine and Biomedical Sciences; John M. Lore,
Jr., M.D. Head and Neck Center, Sisters of Charity
Hospital; Staff, Buffalo Hearing and Speech Center,
Inc., Buffalo, New York
Voice, Speech, and Swallowing Rehabilitation of the
Head and Neck Patient (Chapter 3)
ARTHUR J. SCHAEFER, M.D.t
Clinical Professor of Ophthalmology and Clinical
Assistant Professor of Otolaryngology,
State University of New York at Buffalo School
of Medicine and Biomedical Sciences, Buffalo,
New York
Blindness and Ophthalmic Complications of Surgery
of the Head and Neck (Chapter 2)
t Deceased.
 CONTRIBUTORS
DANIEL P. SCHAEFER, M.D.
Director of Oculoplastic, Facial, Orbital,
and Reconstructive Surgery; Clinical Professor
of Ophthalmology; Clinical Assistant Professor
of Otolaryngology, State University of New York
at Buffalo School of Medicine and Biomedical
Sciences, Buffalo, New York
Blindness and Ophthalmic Complications of Surgery
of the Head and Neck (Chapter 2); Thyroid-Related
Orbitopathy (Chapter 3); Supraorbital Approach to
the Orbit and Paranasal Sinuses (Chapter 23)
DHIREN K. SHAH, M.D.
Medical Director, Cancer Treatment Services;
Assistant Clinical Professor, State University
of New York at Buffalo School of Medicine and
Biomedical Sciences, Buffalo, New York
Radiation Therapy for Laryngeal Cancer
(Chapter 20)
DONALD P. SHEDD, M.D.
Professor Emeritus, Department of Head and Neck
Surgery, Roswell Park Cancer Institute, Buffalo,
New York
Common Departures from Sound Management
(Chapter 3)
MONICA B. SPAULDING, M.D.
Associate Professor of Medicine and Otolaryngology,
State University of New York at Buffalo School
of Medicine and Biomedical Sciences; Chief,
Oncology Section, Veterans Affairs Western
New York Healthcare System, Buffalo, New York
The Place for Chemotherapy in Management
of Squamous Cell Carcinoma of the Head and Neck
(Chapter 3)
MAUREEN SULLIVAN, D.D.S.
Chief, Department of Dentistry and Maxillofacial
Prosthetics, Roswell Park Cancer Institute,
Buffalo, New York
Osseointegrated Implants in Head and Neck
Reconstruction (Chapter 3)
NAN SUNDQUIST, R.N.
Formerly Chief Nurse, Department of Otolaryngology,
State University of New YQrk at Buffalo School
of Medicine and Biomedical Sciences, Buffalo,
New York
Preoperative Chemotherapy, Uncompromised Surgery,
and Selective Radiotherapy in the Management
of Advanced Squamous Cell Carcinoma of the
Head and Neck (Chapter 3)
 IN MEMORIAM

Dr. John M. Lore, Jr., passed away on January 12,2004. He continued active medical
practice and cared for his patients until shortly before his death. Dr. Lore was world
renowned as a head and neck surgeon. After receiving his medical degree from New
YorkUniversity, he completed residencies in both otolaryngology and general surgery.
He was the Chairman of the Department of Otolaryngology-Head and Neck Surgery
at the State University of New York at Buffalo School of Medicine, 1966 to 1991. He
later joined the Department of Head and Neck Surgery at Roswell Park Cancer Institute.
Dr Lore was one of the founders of the American Society of Head and Neck Surgery.
He was a past president of that society as well as of the Society of Head and Neck
Surgeons. He contributed to the early efforts to combine the two Head and Neck
Societies. He was also a founding member, and former chairman of the Joint Council
for Advanced Training in Head and Neck Oncologic Surgery, which was instrumental
in establishing the fellowship programs in advanced Head and Neck Surgical Oncology,
accredited by the American Head and Neck Society. During his long and distinguished
career, Dr. Lore received many honors and awards recognizing his many contribu-
tions to the specialty of Head and Neck Oncology. He was passionate and tenacious
in the practice of his profession; he was an early pioneer and champion of the use
of adjuvant chemotherapy in the treatment of head and neck cancer.
Jack was equally passionate and tenacious in his many nonprofessional interests
and pursuits. He was an avid and accomplished skier, sailor, and photographer.
Professionally, his most enduring and cherished attribute was his compassion and
his dedication to his patients. When I first met Dr. Lore, he was one of the leading
members of our specialty. I then became one of his collaborators and colleagues.
Eventually, 1 came to know Jack as my friend. He will be greatly missed. An Atlas
of Head and Neck Surgery, 4th edition, serves as a legacy and tribute to his memory.

Thom R. Loree, M.D.

IX
 Recognition by
The Board of Managers of St. Vincent's Hospital, New York,
New York, at the time of his death.
 To My FATHER

JOHN M. LORE, M.D., F.A.C.S.

1892-1950

whose energy and devotion both in his chosen field in medicine-otolaryngology-

and in his dedicated aim in medical education-a new medical center for his
medical school, New York University-were and still are an inspiration.
His desire for cooperation in and plans for a consolidated surgical training program
in the field of head and neck surgery provided the impetus for this Atlas.

Dr Lore, Sr. was born in Caleane, Sicily, and came to the United States of
America at age 5. He was a naturalized citizen of the United States and served in
World War I as an officer in the United States Navy.

XI
 PREFACE
Over 40 years have passed since the publication of the
first edition of An Atlas of Head and Neck Surgery,
including three English editions and one Spanish
edition. This Fourth Edition has further broadened its
background-an increased scope of each chapter with
an additional number of contributors.
Jesus E. Medina, M.D., is welcomed as an associate
editor to this Fourth Edition. He has been instrumental
in a number of facets, namely in obtaining Robert W.
Dolan, M.D., Department of Otolaryngology, Head and
Neck Surgery, Lahey Clinic, to author the new chapter
on Microvascular Surgery, and Keith F. Clark, M.D.,
Ph.D., for the addition of Endoscopic Sinus Surgery to
Chapter 5. Dr. Medina also has contributed to a number
of other areas.
The additions, it is believed, cover items that hit the
highlights of a number of aspects of head and neck
surgery, which are available to the surgeon as up-to-
the-minute help. It is not a cookbook of surgery, how-
ever. This could be an inherent danger in an atlas. The
surgeon must be experienced with the various proce-
dures and modifications thereof. No dabblers.! The
choice of the surgical procedure must not be based on
the easiest and quickest minimum resection but rather
must be aggressive'> There is a danger of preserving
soft tissue and bone with disease-free minimum margins
and even no margins.
Reference is made to Dr. Murray F. Brennan's presi-
dential address to the Society of Surgical Oncologists
in 1996.3 There should be no such attitude as "leave
disease right up to the line of resection." It appears that
widespread use of radiotherapy as a routine postoper-
ative modality is fraught with the misconception for
the surgeon that if a little tumor is left behind it is
really no worry since routine radiotherapy is the catch-
all. Margins in this methodology mean little since ion-
izing radiation will handle all that the surgeon neglects.
Radiotherapy, as well as chemotherapy, plays an impor-
tant part in the management of head and neck squa-
mous cell carcinoma, Stage III and Stage IV, but is not
meant to give a false sense of security to the surgeon.
Hence, it is believed that radiotherapy should not be
routinely used postoperatively but rather selectively. This
spares the patient of the side effects of radiotherapy, as
well as making radiotherapy available during the entire
follow-up period if indicated. With the use of chemo-
therapy, the surgeon must not compromise the scope of
surgical resection when there is a favorable response to
the chemotherapy. Please confer preoperative chemo-
therapy in Chapter 3.
As more tissue and bone are removed, the reconstruc-
tive measures must be further improved and expanded
from a cosmetic and a functional point. A caveat that
must be emphasized is that wherever possible or prac-
tical the reconstructive measures should not mask early
or late recurrence of disease. At times this is not possible.
As an expansion of the reference to microvascular
surgery in the preface of the Third Edition, a new
Chapter 24 has been added. The indication for micro-
vascular surgery has broadened and has served well in
a number of reconstructive problems, especially free skin
flaps for major skin defects of the cheek, as well as muscle
and bone transfers. This new chapter by Dr. Dolan serves
two purposes: (1) to demonstrate to the head and neck
oncologic surgeon what can be achieved by microvas-
cular surgery and (2) to present the techniques involved.
These techniques are not for the dabblers-only for
experienced microvascular surgeons.
Take time to evaluate and record the extent of disease
utilizing tattoo, when possible, prior to any manage-
ment plan. Do not depend on the site evaluation at the
time of the initial surgical procedure. This admonition
is an absolute with the use of preoperative chemotherapy
or, for that matter, radiotherapy, especially if salvage
surgery becomes necessary following any recurrence
after the radiotherapy.
Regular careful and thorough follow-up of patients
must be carried out to the best possible degree. Follow-
up must be done by the surgeon and by those expert in
the field of head and neck examination and knowledge
of the natural history of the disease. The primary respon-
sibility is the surgeon's and not the primary care physi-
cian's. Keep records, which will be valuable as an eval-
uation of outcome-not only the physical examination,
but also the quality of life. When evaluating the quality
of life, take into account the family support or lack
of support.
It may be worthwhile at different times to have
different physicians in other allied disciplines involved
in the search for early recurrence. For example, the
XIII
 PREFACE
reconstructive surgeon, the prosthodontist, the radia-
tion oncologist and the medical oncologist, and the
specially trained nurse clinicians all should be involved
in evaluation. This approach is time consuming both
for the medical professionals as well as the patient,
and sometimes it's shattering for the HMOs. These
follow-up examinations should be based on a regular
schedule-usually one time per month for the first year
and then every two months for the second year and so
on up to five years. They continue every 5 to 6 months,
as enumerated later. There is some indication or recur-
rence following preoperative chemotherapy. New pri-
maries may appear between the seventh and the tenth
year. Follow-up should not be more than every 5 to
6 months; sooner if there appears to be a predisposing
factor to squamous cell carcinoma.
Follow-up is for life. A patient who continues to smoke
or who has an indication of field carcinogenesis is an
example. Frequencies may be increased or decreased,
depending on the anticipated natural history of the
disease. This is time consuming yet most important.
Review all images-not just reports. CT, MRl, MRA,
angiograms, and PET scans, when appropriate, must
be reviewed by the surgeon. It is not unusual to spend
upwards of one hour in this type of preoperative evalu-
ation. Postoperative examination, especially long-term,
likewise involves considerable time and effort. This is
another problem for those from the HMOs to compre-
hend even though they may be physician consultants.
One HMO recognized this "unique specialty practice"
involving training in both otolaryngology and general
surgery. All this is a significant and tremendous respon-
sibility for the surgeon and all those concerned.
In the Preface of the Third Edition, the concept of
centers of excellence was introduced in the manage-
ment of neoplasms of the head and neck. In 1993, this
concept was initiated at Sisters of Charity Hospital in
Buffalo, NY. The following is a description of such a
center. It has flourished well and its weekly tumor
conferences with surgery, medical oncology, radiation
oncology, and endocrinology, as well as with its special-
ized nurses and support personnel, has attracted local
physicians from other hospitals in the Buffalo area. Since
its inception, it has trained fellows with backgrounds
in otolaryngology, general surgery, and plastic surgery.
The center supports the concept of excellence in patient
care plus the important addition of academia and ecu-
menism. The academia in itself is desirable, and when
joined in a single service including all of the disciplines
involved becomes a sine qua non in the management
of head and neck neoplasms, including thyroid diseases.
A dedicated interest in academia produces interest
in newer concepts-for example, molecular biology
with gene therapy-which may well become the basis
of future treatment of head and neck squamous cell
carcinoma.
Description of Head and Neck Services
at Sisters Hospital4
Over the years, management of neoplastic disease as well
as other diseases has crossed time-honored established
disciplines. In head and neck neoplasia, including thy-
roid malignancy; surgical, medical, and radiation oncol-
ogy; and endocrinology, other supportive disciplines
and services are involved. The input from these disci-
plines is usually achieved by multidisciplinary confer-
ences. To further develop this ecumenical approach, to
avoid "turf battles," and to further enhance cooperative
and close exchange of ideas regarding diagnosis and
management of head and neck neoplasia, a Head and
Neck Oncology Service within the John M. Lore, Jr.,
M.D., Head and Neck Center at Sisters Hospital, Buffalo,
NY, was established 8 years ago. This service encom-
passes the aforementioned disciplines plus all other
germane disciplines and services, including General
Otolaryngology, Reconstructive Surgery, Vascular Sur-
gery, Microvascular Surgery, Neuro-otology, Skull Base
Surgery, Oncologic Ophthalmology, Diagnostic Imag-
ing, Head and Neck Pathology, Nuclear Medicine,
Psychiatry, Maxillofacial Prosthetics, Dental Pathology,
Swallowing and Speech Pathology, Nutrition and
Biostatistics.
The main purpose is to render the best possible
patient care, to attract the best qualified physicians and
other professionals (thus sifting out the dabblers), and
to promote an academic atmosphere. This oncology
service functions as an autonomous service with the
cooperation and support of the Chairman of the Depart-
ment of Surgery and the Chairman of the Department
of Internal Medicine. The Service is responsible for
its own quality review data, which is supplied to the
Quality Review hospital committee. Outpatient; in-
patient; speech and swallowing professionals with labo-
ratory staff, physicians, fellows, and nurse clinicians;
as well as oncologic dentistry, conference rooms, library
and nutritional offices are all contiguous and on the
same floor of the hospital.
On the same floor is the Pathology Department and
up one flight are the OR and ICU. Down one flight is
Diagnostic Imaging and Nuclear Medicine. On another
floor is the Microsurgical Laboratory.
It appears that this approach to head and neck neo-
plasia, including thyroid and parathyroid tumors, truly
improves patient care without the stigma of "treatment
by committee." We may agree or disagree yet each indi-
vidual is free to treat the patient as he or she sees fit.
This type of service avoids the wasted time involved in
turf conflicts. The Head and Neck Oncology Service is
a complete system where the sum of all the components
is much better for patient care than any independent
part. At the very beginning of this project was and still
is Robert E. Rich, the founder of Rich Products, who

gave me the impetus to go ahead with this idea. He
produced the wherewithal to start basically a "one-
step" facility, which minimizes "wasted time" in the
diagnosis and management of head and neck neo-
plastic disease.
There are four team players who helped in the inau-
guration of this multiple discipline service: Kenneth
Eckhert, M.D., Chief of Surgery; Nelson Torre, M.D.,
Chief of Medicine; Sister Angela Bontempo, Adminis-
trator at Sisters of Charity Hospital; and Charles Massaro,
M.D., Vice President of Medical Affairs at Sisters of
Charity Hospital. Without the cooperation of these indi-
viduals this service could never have been developed.
It had previously been proposed when I was Chairman
of the Department of Otolaryngology at the State
University of New York at Buffalo to the dean, and
twice he turned this concept down saying, "We are not
ready for anything like that just yet." Hence, the medical
school was bypassed in this endeavor.
The amalgamation of the Society of Head and Neck
Surgeons, founded by Hayes Martin and Grant Ward
in 1954, and the American Society for Head and Neck
Surgeons, established in 1958 by the hard work of George
Sisson, M.D., along with other dedicated head and neck
surgeons, was a great step forward. Among the other
dedicated surgeons as founders of the American Society
for Head and Neck Surgery was Edwin W Cocke, M.D.,
John S. Lewis, M.D., W. Franklin Keim, M.D., William
M. Trible, M.D., and John M. Lore, Jr., M.D. This amal-
gamation in 1999 united the two societies into one
society, now known as The American Head and Neck
Society. This joined the disciplines of otolaryngology,
general surgery, and plastic surgery into one endeavor.
There are many benefits to this amalgamation, not the
least of which, of course, is improvement of patient
care by the sharing of various ideas among the various
disciplines all present at the same meeting.
The main downside as I see it is the fact that the
larger the society is, the less discussion there is from
the floor and membership. I would strongly suggest
that adequate time be allowed in meetings for this type
of discussion, because this enhances the exchange of
different ideas and different methodologies of treatment.
There is an interesting and laudable result of this
amalgamation in that it should and will eliminate the
striving of one society to have more members than the
other. This inherent danger, which previously existed,
should be eliminated once and for all. This attempt at
getting more members led to the admission of surgeons
regardless of background who were not fully qualified
in the field of head and neck oncology. There is no need
for an unlimited supply of head and neck surgeons
since, to quote from the Third Edition, "There are only
about 50,000 new patients each year with head and neck
cancer, and only approximately 35 to 75 new, well-trained
head and neck oncologic surgeons are necessary each
PREFACE
year to maintain an adequate workforce of some 400
to 1,000 head and neck oncologic surgeons to manage
this number of patients. Thus, we must minimize the
number of 'dabblers.'] There is simply no reason to
accept physicians who are not well-trained in this field.
Quality and not quantity is the objective.
There is no doubt that, except in the rare case, the
residents interested in this field must be dedicated to it
and spend extra time in a fellowship, preferably approved
by the American Head and Neck Society. This would
help them reach near perfection in their chosen field as
best as possible. This concept in medicine has been
useful in the training of hand surgeons, since it involves
the disciplines of general surgery, orthopedic surgery,
and plastic surgery. In hand surgery, this has been recog-
nized by the three boards as an important facet in the
training of a hand surgeon. Unfortunately, in head and
neck surgery, the three boards involved, namely, otolaryn-
gology, general surgery, and plastic surgery, have not
seen fit to endorse this concept. Unless the individual
is a genius, there is simply no way to adequately train a
resident in the various facets of head and neck oncology
and endocrinology in a residency training program,
since the training in that particular specialty involves a
number of other aspects over and above head and neck
oncology. As Harvey Baker, M.A.,s discussed in his
presidential address to the Society of Head and Neck
Surgeons entitled Head and Neck Surgery: The Pursuit
of Excellence in 1971 and pointed out that to be active,
for example in general otolaryngology, simply does
not afford the time and effort needed to become a well-
trained and practicing and active head and neck onco-
logic surgeon.
Logical conclusion to these standards is the active
participation in one of the approved fellowships. Having
been the originator of this additional fellowship train-
ing plus having the position of president of both head
and neck societies, I have had, and I say this with
humility, experience in the endeavor. Changes in the
fellowship curriculum were made from time to time
and rightly so. The latest one of admitting graduates of
well-trained foreign programs is strongly commended.
Remember, American surgeons at the time of the late
1800s and early 1900s were afforded the benefits of
learning from their European counterparts. We have
the same obligation and advantage today to share all
our ideas and techniques with our European colleagues.
We learn from one another.
Some flexibility is worthy of implementation, namely,
possibly one or two types of fellowships. The one-year
fellowship would primarily focus on the clinical aspects
of head and neck oncology but would also include a
reasonable amount of clinical research. The two-year
fellowship would involve basic research along with
clinical exposure in a suitable institution where the
candidate's desires can be realized. Selected arrange-
 PREFACE
ments for rotation of fellows from one parent institu-
tion to one or two other institutions-for one month-
would afford the fellow an excellent exposure to other
methodologies in the overall management of head and
neck neoplasia.
Again, it is my strong admonition that two years
of basic surgical training in an approved general surgi-
cal training program is highly recommended for those
who wish to pursue a head and neck oncologic fellow-
ship. The exposure to basic surgical principles cannot
be achieved, I believe, in a single discipline-oriented
program. I can attest to this again by personal experi-
ence, having completed the approved residency in the
American Board of Otolaryngology and the American
Board of Surgery. I am not inferring that double boards
are necessary. But otolaryngology residents would cer-
tainly benefit from two years of general surgery. The
reverse, namely, dedicated training in otolaryngology,
is also true for the general surgery and plastic surgery
residents. Ideally, another year of plastic surgery would
be fortuitous.
The next step in the joint venture of all three disci-
plines, namely, general surgery, otolaryngology, and
plastic surgery, would be the recognition by the three
boards concerned relative to an approval of this fellow-
ship. To attempt to achieve this objective, plans were
modeled after the three boards of general surgery, plastic
surgery, and orthopedic surgery, agreeing on a post-
residency hand training program. Dr. George Omer,
from Albuquerque, New Mexico, was the driving force
in this venture. It appears that they have succeeded
with the cooperation of the three boards recognizing an
acceptable fellowship in hand surgery.
Following this concept that was developed in hand
surgery, an attempt was made to achieve the same type
of recognition by the three boards involved in training
of head and neck oncologic surgeons. The initial data-
gathering trip was made by Dr. William Nelson and me
going to Albuquerque to review with Dr. George Omer
how he achieved the cooperation of the three boards.
Following his ideas, Dr. Elliott Strong and I developed
a similar concept for the recognition of head and neck
oncologic surgery by the American Boards of Otolaryn-
gology, Surgery, and Plastic Surgery as "added qualifi-
cations." Unfortunately, we failed despite our efforts at
the board level and at the American College of Surgeons
level and it was then that we simply gave up the
endeavor. I decided then to take the next step and that
was to develop a center of excellence in our particular
field and, hence, the development of the Head and Neck
Oncologic Service at Sisters of Charity Hospital.
Another aspect that is most important in the develop-
ment of our field is the realization that we are a profes-
sion and not a business. This is aptly referred to in
Dr. Robert M. Beyers's presidential address to the Society
of Head and Neck Surgeons in 1996 entitled, Barberpoles,
Battlefields,and Wounds that Will Not Heal.6 I quote
him as follows: "If we act like a trade or business rather
than a profession, we shouldn't complain about words
used to describe us such as healthcare providers and
our patients as clients." Dr. Beyers goes on to quote
Simon H. Rifkind, a lawyer, who expressed his views
about how a profession loses its professionalism. It is
recommended that Dr. Beyers's presidential address be
read in its entirety.
And Now a Few Caveats
Insecurity is the main stumbling block for a joint venture.
For management with the best overall survival for
advanced squamous cell carcinoma of the head and
neck, aggressive surgery is the mainstay.2 Radiation
Oncology and Medical Oncology are ancillary and
required fine-tuning. Molecular Biology may alter this
sequence in years ahead.
For organ preservation in advanced squamous cell
carcinoma of the head and neck, chemotherapy and
radiotherapy are the primary modalities with salvage
surgery for failures and backup. Patients must be aware
of the complications and effect on survival and quality
of life, specifically the significant complications of sal-
vage surgery. These complications were experienced
some 40 to 50 years ago when radiation was the first
treatment modality followed by surgery. Because of
these complications, the sequence of treatment was
changed to surgery followed by radiotherapy.
Physicians must be the real leaders in medicine.
Unfortunately, from time to time, physicians have abro-
gated this responsibility and opportunity. Do not admit
physicians into the American Head and Neck Society
who are not adequately and completely trained. Quality
and not quantity is the objective. Our prime objective
is the best of care, the highest quality for patients, regard-
less of the pressures of paperwork and other limitations
by insurance companies and government. Closely related
to the prime objective is evaluation of each and every
service's end results, performance data, and quality of
life- "evaluate your track record." Just because a pro-
cedure can be done, that is not the reason to do it.
Develop the atmosphere of academia, which stimulates
intellectual curiosity and improves quality of patient
care.
Randomization-Is this always necessary? Does it
make any and every presentation valid? Review the pros
and cons of randomized study techniques when you
report your end results.8 (Suggest review of this refer-
ence by Drs. Fung and Lore.)
There are shadows that surround us. Namely, the
insurance companies, the paperwork, and the loss of
valuable time in the encountering and fighting of these
obstacles. In any event, we must not be complacent
and discouraged. We must not lose the main objective

of our calling in life. We must not be dabblers. I We
must assume our responsibilities.? We must return to
the philosophy of the founding fathers of our country
and Constitution when they saw fit to engrave on our
coins In God We Trust.
Recommendations
It is recommended that the head and neck surgeon,
especially the younger ones who are not aware of the
background of this entire field, review a number of
excellent resumes and books. They are as follows:
The Head and Neck Story, by George A. Sisson, M.D.,
1983, published by the American Society for Head
and Neck Surgery, produced by Kascot Media,
Chicago, IL.
The Making of a Specialty, Hayes Martin Lecture, by
Jatin P. Shah, M.D., American Journal of Surgery,
Vol. 176, Nov. 1998, pp 398-403.
History of Head and Neck Surgery,by Jerome C. Goldstein,
M.D., and George A. Sisson, M.D., Otolaryngology
Head and Neck Surgery, Vol. 1, US, #5, 1996.
PREFACE
Donald P. Shedd, Historical Landmarks in Head and
Neck Cancer Surgery, 2000, American Head and
Neck. Society.
REFERENCES
1. Lore, JM, Jr: Dabbling in head and neck oncology (a plea for
added qualifications). Arch Otolaryngology Head Neck Surg 1987;
113:1165-1168
2. Forastiere, A, Koch, W, Trotti, A, Sidransky, D: Head and neck
cancer. N Engl J Med 2001; 345:1890-1900.
3. Brennan. MF: The enigma of local recurrence. Ann Surg Oncol
1997; 4:1-12.
4. Lore, JM, Jr., Massaro, M: Description of Head and Neck Services
at Sisters Hospital Abstract submitted.
5. Baker, HW: Head and neck surgery: The pursuit of excellence. Am
J Surg 1971; 122:433-436.
6. Beyers. RM: Barber poles. battlefields and wounds that will not
heal. Am J Surg 1996; 172:613-617.
7. Lore. JM, Jr: Bill of responsibility. The Hayes Martin Lecture. Am
J Surg 1992; 164:556-562.
8. Fung E, Lore, JM, Jr: Randomized control studies for evaluating
surgical questions. Accepted for publication Arch Otolaryngol In
press.
 ACKNOWLEDGEMENTS
First, I wish to once again thank my wife, Chalis, for all
the ancillary work she did as well as her quiet support
despite the mess of "paper" that I managed to disperse
throughout our home during these more than five years
of work on this Fourth Edition.
Shortly after deciding to go ahead with the Fourth
Edition, Robert Wabnitz, our master illustrator, suffered
a stroke, which to everyone, especially his wife, Sue,
was a terrible shock. He could no longer continue on
with this venture. Fortunately, he had taught medical
illustration at the University of Rochester Medical Center.
Margaret Pence, one of his students, took over for Robert.
She uses the same style that her teacher taught her, and
she has done an excellent and professional job. Not only
for her expertise as an illustrator are we all grateful, but
also her pleasant cooperation in anything and every-
thing we asked of her in her chosen field. She is a
superb Medical Illustrator.
I wish to also thank Jesus E. Medina, our associate
editor, and all of our contributors-in the previous
editions and in this edition-for their time, interest,
and expertise. They are all detailed in the list of contri-
butors. Many, many thanks. The extent of their contribu-
tions is noted in the various chapters. These included
contributions for an entire chapter, for example, Chapter
24, to major portions, inserts, and commentaries.
To a very grateful patient, supporter, and sponsor of
the John M. Lore, Jr., M.D., Head and Neck Center at
Sisters Hospital-Robert E. Rich. He recognized the
importance of an ecumenical approach in the develop-
ment of a medical and surgical service to achieve quality
of patient care. The center is a byproduct of this atlas,
and I am deeply appreciative of Bob's involvement and
support.
The next expression of gratitude goes to the two
transcriptionists: Lauri L. Hess, of Dr. Medina's office,
who, in dedicated fashion, transcribed my illegible
inserts onto the disks, and Leslie Berry, a freelance
transcriber par excellence, who, under considerable
pressure, completed the final draft. Dottie Kane, who
did most of the transcribing for the Third Edition, helped
us with initial note-taking relative to this Edition of An
Atlas of Head and Neck Surgery.
Other acknowledgements go to the staff of our Head
and Neck Service at Sisters of Charity Hospital in Buffalo,
NY: Karen Stawiasz, MS, RN, NP, OCN (Oncology
Certified Nurse), an incredible person who is Jill-of-all-
trades and master of all and, specifically, our Oncology
Clinical Nurse Specialist and Nurse Practitioner. To all
our specially trained head nurses, who tolerated my
idiosyncrasies during this protracted period, to complete
this edition: Joyce Clemons, our patient coordinator,
Jennifer Feltz, Maureen Heatley and Nancy Wojtulski,
Kathleen Killion, RN, OCN, Tracy Trifilo, RN, Jean
Errington, RN, Elizabeth Gryzybowski, RN, and James
Sped ding, a key helper and patient. Thanks to Barbara
Lowe, MS, RD, our nutritionist. Thanks goes to a num-
ber of other transcribers: Becky Lonczak, Sandra Ochs,
and Linda Eick. To the office secretaries and adminis-
trative assistants over the years, I'm indebted to Dottie,
and Linda Runfola. My deepest appreciation goes to
Sharon Eagles who bridged the gap from one Hospital
to another, Sisters of Charity Hospital to Roswell Park
Cancer Institute.
Many thanks to Elsevier Saunders, especially to
Rebecca Schmidt Gaertner, Stephanie Smith-Donley,
Christian Elton, and Arlene Chappelle, who were of
exceptional help in manuscript review, as well as all
the previous medical editors and associates, for with-
out them this publication could not have existed.
Among these are John Dusseau, Robert Rowan, and
Sam Mink.
My condolences to the families of William Bukowski
and Paul Milley-both contributors who have passed
away since the Third Edition. Their contributions were
valued. Bill was my personal primary care physician.
Paul was an excellent head and neck pathologist. (I
remember when he examined 137 sections of a thyroid
gland for the primary tumor in a patient who had an
incidental finding of metastatic papillary carcinoma of
the thyroid in a radical neck dissection, which was
done for squamous cell carcinoma.)
Many thanks to all and to all Ave atque Vale.
JOHN M. LORE,JR.
XIX
 PREFACE
TO THE THIRD EDITION
Twenty-six years have elapsed since the first edition of
this atlas, and 15 years since the second edition. This
third edition has in some respects departed from the
original concept of being simply an atlas. It contains
much more information, with background material in a
number of subjects, such as endocrine surgery of the
head and neck and chemotherapy. This background
material is most important if the surgeon is not to be
relegated to the position of being solely a technician,
which, sad to say, is occurring in a number of surgical
disciplines. This is not to say that diagnosis and manage-
ment of problems such as endocrine diseases involving
the head and neck are to be performed solely and inde-
pendently by the head and neck surgeon. The endocri-
nologist, specialists in nuclear medicine, and imaging
and surgical pathologists are all necessary, integral mem-
bers of the management team. It does mean, however,
that the surgeon operating on, for example, the thyroid
gland and parathyroid glands must have more than just
a superficial knowledge of these endocrine organs.
The third edition has been expanded in a number of
facets. The number of chapters has been increased
from 21 to 23 with the addition and further clarification
of Emergency Procedures (Chapter 2) and Base of the
Skull Surgery (Chapter 23). Although both these new
chapters include some procedures that were covered in
the previous editions, this material has now been signifi-
cantly revised and relegated to these two new chapters.
Virtually every chapter has been enlarged with new
and other time-proven procedures, encompassing addi-
tional text and plates. The reader has simply to refer
to the table of contents to see the increased amount
of material. To emphasize these additions, examples
include the following: expanded listing of complications
following most procedures along with air embolism and
blindness and pitfalls; adjuvant chemotherapy; carbon
dioxide laser surgery; myocutaneous and myomucosal
flaps; updated management of cleft lip and palate;
compression plates in the management of facial frac-
tures; various types of neck dissections and their appli-
cations; expansion of thyroid and parathyroid surgery;
rehabilitation following laryngectomy; expansion of
various reconstructive procedures related to the pharynx
and esophagus; and updated vascular procedures and
tissue expanders that lead to interesting possibilities for
reconstruction. The number of contributors has also
increased.
The anatomic sectional x-ray plates in Chapter 1 have
been related to the newer techniques of imaging. These
reproductions can be of great aid in the correlation
with both CT scans and MRI.
The comments in the preface of the previous editions
are still valid for the most part. Progress has been made
in the training of head and neck oncologic surgeons by
the formation by the American Society for Head and
Neck Surgery and the Society of Head and Neck
Surgeons of a Joint Council for Approval of Advanced
Training in Head and Neck Oncologic Surgery. This was
accomplished during 1976 to 1977 with the result being
the formation of a carefully structured fellowship follow-
ing the completion of a residency in otolaryngology,
general surgery, or plastic surgery. This fellowship is the
only one of its kind in head and neck surgery having a
carefully structured evaluation system, site visits, and
review by the executive councils of both head and neck
surgical societies. A diploma is awarded by these two
societies to those candidates who follow the rigid criteria
and successfully complete the fellowship. The fellow-
ship encompasses three phases: Phase [-basic surgical
training involving 1 or 2 years; Phase II-residency in
one of the aforementioned disciplines; and Phase [[[-
the fellowship portion of 1 or 2 yeats. Details of this
fellowship have been previously reported (Lore, J.M.,
Jr.: Head and neck oncologic training: Where we have
been and where we are going. Am. J. Surg. 142:504-505,
1981). Sixteen programs are now approved for this type
of training-IS in the United States and one in Canada.
The term head and neck oncology might be the better
term applied to this fellowship, since it involves not
only surgical training but also a knowledge of radio-
therapy, chemotherapy, and, where applicable, the future
of immunotherapy. This facet of head and neck oncol-
ogy is only one of five categories involved in head and
neck surgery, with the others being congenitallesions,
cosmetic surgery, and infectious disease. Likewise
involved in head and neck surgery is reconstructive
surgery, which relates to both head and neck oncologic
surgery and cosmetic surgery.
xxi
 PREFACETO THE THIRD EDITION
Head and Neck Oncologic Surgery
The concept of regional surgery appears to be well
established. Stumbling blocks still remain, one of them
being the cliche "fragmentation" of the parent disci-
plines. Interestingly enough, it all depends on one's
biases as to whether the changes of a specific aspect of
a major discipline are termed "fragmentation" or "spe-
cialization." Regardless, it is the marketplace that sets
the pace-specifically, the number of patients available.
To borrow the words of James Humphreys, M.D., "sur-
gery was fragmented when the surgeon left the barber
shop." The bottom line, however, is the search for
excellence in patient care and physician training. These
two aspects must not be compromised.
The thrust of head and neck oncologic surgery is a
cooperative and joint venture encompassing all disci-
plines that can and should contribute to this endeavor.
The initial step has been made with the two head and
neck surgical societies setting up the guidelines, site
evaluations, approval, and awarding of a diploma. The
next step is the formal implementation and recognition
of these postresidency fellowships by the residency review
committees and the specialty boards involved, an exam-
ination, and board recognition. Currently, it appears that
this recognition could be achieved by "added qualifica-
tions" in head and neck oncology by the boards. These
"added qualifications" could then be affixed to the exist-
ing certificate of each board. It is hoped that this would
be accomplished by the three boards jointly agreeing
on the same guidelines and examination. An excellent
example of this type of joint venture is the solution of
education in hand surgery, which has been worked out
by the two hand societies and the three boards of ortho-
pedics, general surgery, and plastic surgery. George
Omer, after many years of dedicated work developing
articles of agreement, is to be congratulated on its fruition.
I hope that a similar modus operandi will be achieved
in head and neck oncology.
To date, this concept of added qualifications has
been stalled by the concern of the three boards and the
three residency review committees as well as a number
of practicing surgeons in the three disciplines. Their
fears surround the worry of fragmentation of their
disciplines as well as the misgivings that such added
qualifications will lead to "a special club" of head and
neck oncologic surgeons and thus restrict their prac-
tice. It must be remembered that there are only about
50,000 new patients each year with head and neck
cancer and that only approximately 35 to 75 new well-
trained head and neck oncologic surgeons are neces-
sary each year to maintain an adequate work force of
some 400 to 1000 head and neck oncologic surgeons to
manage this number of patients. Thus, we must mini-
mize the number of "dabblers." No one who requires
coronary artery bypass surgery would seek treatment
by a surgeon and team who perform only a few such
procedures a year. We as surgeons must seek the solu-
tion, rather than have nonmedical forces outline the
solution for us. Yet with all this protectionism, general
surgery has in fact been fragmented. Otolaryngologists
are going down the same course with the fear of frag-
mentation. Hence, it appears that this concern only
enhances fragmentation rather than alleviating it. The
basic problem is that the profession of medicine and
its physicians and specialty societies react to obvious
changes that are in the making, rather than acting.
Physicians must be the leaders in this change, rather
than the followers. They must shape these changes,
since they are the ones who know the problem and can
best suggest and initiate the changes best suited to
excellency in patient care and physician training.
Unless this is achieved, a number of legitimate con-
cerns that exist will become aggravated. Following is
a list of such concerns (from Lore, J.M., Jr.: Issues in
community hospital or cancer center care of head and
neck cancer patients. In Myers, E. N., Barofsky, I., and
Yates, J. W. [eds.]: Rehabilitation and Treatment of Head
and Neck Cancer. Washington, D.C., U.S. Department
of Health and Human Services, Public Health Service,
National Institutes of Health [NIH Publication No.
86-2762], 1986, pp. 155-165).
1. The occasional patient manager or "dabbler."
2. Loss of expertise and proficiency for even the well-
trained physician.
3. Marginal and then inadequate treatment for head
and neck cancer patients.
4. Loss of concentration of training clinical material.
5. Loss of any significant number of patients for evalu-
ation as to treatment methods, old and new.
6. Increased morbidity, mortality, and cost of medical
care.
To achieve the solution to these problems, it appears
that the three boards and the three residency review
committees should pursue the concept of added qualifi-
cations and recognize the additional training beyond
the residency years so necessary to achieve the desired
excellency. In other words, support the fellowship con-
cept and officially recognize the fellowship concept.
To aid in the solution to these problems in a recog-
nized manner, several additional steps are suggested.
Training
1. The American Board of Surgery should develop recog-
nized training in basic surgery that might encom-
pass 2 years, with examination and certification for
the trainee.
2. The trainee then completes the standard residency
in general surgery, otolaryngology, or plastic surgery.

3. The trainee enrolls in a fellowship approved by the
three boards. An alternate route could be a similarly
approved preceptorship.
Centers of Excellence
Centers of excellence in head and neck oncology can
either be achieved in a university or community hospital
center with adequate patient load, professional person-
nel, and support staff. The interested reader is referred
to the aforementioned NIH publication as well as the
author's Presidential Address at the annual meeting
of the American Society for Head and Neck Surgery
(Dabbling in head and neck oncology-A plea for
added qualifications. Arch. Otolaryngol. 113:1165-1168,
1987).
Controversial Items
There are a number of controversial items quite apart
from the preceding that this author wishes to enumerate.
Correct and Exact Terminology
In the evaluation of statistics relative to survival with
or without disease, a distinction should be made at the
onset of treatment as to whether a patient is "operable"
and whether the lesion is "resectable" for cure or
palliation. Operability refers to whether the patient can
safely undergo a major surgical procedure, whereas
resectability refers to whether a neoplasm can in fact
be totally removed by the surgeon. Nonresectability
distinctly implies advanced disease and actually further
implies a stage beyond stage IV, namely a stage V
disease. This concept has been previously suggested in
a publication entitled Head and Neck Cancer; Proceed-
ings of the First International Conference, The Society
of Head and Neck Surgeons (Chretien et aI., St. Louis,
C.V. Mosby, 1985, p. 434).
Another point of contention are the words partial,
subtotal, near total, and total in regard to the various
surgical procedures, especially thyroidectomy. Granted,
there are fine lines that separate these terms and defy
total exactness, but regardless a more accurate designa-
tion of the surgical procedure is warranted as well as a
close adherence to the exact implication of these terms.
The same goes for the terms referring to the various
types of neck dissections, e.g., radical neck dissection,
classical neck dissection, modified radical neck dissec-
tion, functional neck dissection, and conservation neck
dissection.
Indications for Surgical Procedure
As for indications for surgery, my bone of contention is
a fundamental philosophical and, for that matter,
PREFACETO THE THIRD EDITION
practical problem, which can best be summarized as
follows: Just because a procedure can be technically
performed, that is not the indication to perform the
procedure. Advances in medicine and surgery require
the development and trial elfnew procedures. Neverthe-
less, these trials must be tempered to a certain degree
by past as well as present experience. Again, there
is the "gray zone." Specifically, a number of techniques
and procedures come to mind, for example, microvas-
cular surgery. These procedures have a selected place
in head and neck surgery relative to the following
surgical problems:
1. Augmentation of soft tissue with microvascular anas-
tomosis, e.g., involving massive defects of the top of
the scalp that cannot easily be reached by a myocu-
taneous flap (tissue expanders may have a signifi-
cant application in closing such defects).
2. Certain congenital lesions in which a transposed flap
or myocutaneous flap is not indicated.
On the other hand, microvascular techniques do not
appear routinely warranted in, for example, the
following:
1. Reconstruction of the mandible (associated with
ablative surgery) with an iliac bone graft and over-
lying skin. The added time necessary to accomplish
these procedures must be taken into account when
ablative surgery has already consumed a significant
number of hours of operating time. These microvas-
cular techniques on the other hand are applicable to
massive defects resulting from trauma.
2. Reconstruction of the laryngopharynx with a free
jejunal graft or gastric pull-up. The latter procedure
or colon interposition is definitely indicated when a
total esophagectomy is necessary.
Often, a much simpler reconstructive procedure does
in fact achieve the same end results related to the
reconstructive surgery. For example:
1. Mandibular resection that is reconstructed with the
simple use of a bent Kirschner wire with tie wires.
2. Total laryngectomy with total hypopharyngeal, oro-
pharyngeal, and partial nasopharyngeal resection
reconstructed with a myomucosal tongue flap with
dermal graft or pectoralis major flap with dermal
graft. These simpler forms of reconstructive sur-
gery make total hypopharyngectomy a very feasible
and relatively easy procedure. These techniques are
believed to afford a much better chance of resecting
the entire structure, thus leading to improved survival
rates. Preserving a narrow strip of posterior hypo-
pharyngeal mucosa for reconstruction of the gullet
hardly seems justified.
 PREFACETO THE THIRD EDITION
Other Suggestions
1. TNM classification. It is suggested that in the initial
evaluation of the patient basic information should
be tabulated along with the appropriate drawings,
and, if possible, photographs, which at any time can
then be transferred into virtually any TNM classifi-
cation that may be developed in the future (Kaufman,
S., and Lore, J.M. Jr.: TNM classification and disease
description in head and neck cancer. Am. J. Surg.
136:469-473, 1978).
2. Prevention and treatment of premalignant lesions.
Head and neck oncologic surgeons must face the
fact that to help achieve improved survival rates for
patients with head and neck cancer they should be
actively involved and cognizant of the premalignant
lesion as well as the management of "condemned
mucosa." This concept applies to the high-risk patients
and those with mucosal atypism and dysplasia.
Obviously, the avoidance of tobacco and exposure to
carcinogens is foremost. Next in line is the use of the
retinoic acids-vitamin A-as a dietary supplement,
recognizing, of course, the possible toxic side effects,
particularly of overdosage of vitamin A. This leads
to the establishment of, or at least involvement by,
head and neck surgeons in basic research.
3. Adjuvant chemotherapy. Another consideration is the
admonition that adjuvant chemotherapy be relegated
to organized protocols rather than the haphazard
use of chemotherapeutic agents in the management
of head and neck cancer.
4. Violation of the "Virgin Neck." Many years ago Hayes
Martin emphasized that limited surgical procedures
should be avoided in the unoperated neck, since this
could very well mask future metastatic disease. This
admonition is still true for the most part. For exam-
pIe, I shudder when I see and hear about the use of
the sternocleidomastoid muscle for solely a recon-
structive procedure in a patient with a surgical defect
following ablative surgery for intraoral cancer.
5. Randomized studies evaluating treatment and end
results. Although randomized protocols certainly have
definite advantages, there are a number of draw-
backs. When multiple institutions are included, varia-
tions in technique among the surgeons involved
cause inevitable problems. In addition, these studies
may not be as valid as they are supposed to be if the
number of patients is small or if a study lacks ade-
quate stratification of the various factors involved.
In one recent study (Corey, J.P., et al.: Surgical com-
plications in patients with head and neck cancer
receiving chemotherapy. Arch. Otolaryngol. 112:
437-439, 1986) evaluating surgical complications in
patients receiving chemotherapy, the patients were,
I believe, incorrectly stratified as follows:
Patients Control Chemotherapy
Stage II 5 1
Stage 1Il 8 12
Stage IV 6 10
The control group is overweighted with stage II
disease, and underweighted for stage 1Iland IV disease,
a form of incorrect stratification that places the chemo-
therapy group at a disadvantage.
In short, when a trial is randomized, care should be
taken regarding possible imbalance of results.
In summary, it is hoped that the preceding philo-
sophical comments and suggestions as well as the
expansion of this third edition will be of interest to the
head and neck surgeon.
JOHNM. LORE,JR.
 ACKNOWLEDGEMENTS
IN THE THIRD EDITION
During the years taken to expand this atlas many
friends have contributed-some as formal contributors,
others in ways and at times unknown to them either
in the sharing or exchanging of knowledge, others in
technical help, and still others in the various phases of
patient care, which in effect has had significant bearing
on this revision and expansion.
My wife, Chalis, has tolerated this third episode with
exceptional calm and has also helped in selective typing.
For the third time, Bob Wabnitz has joined me as the
one and only medical artist and illustrator of all the
editions of this atlas, demonstrating his skill par excel-
lence. Working with Bob is actually a pleasure. His skill
in his chosen profession as well as his knowledge of
anatomy and surgical procedures is only surpassed by
his humor and cooperative attitude. I repeat, "without
him, the atlas would not be."
For the bulk of the stenographic labor, I am deeply
indebted to Dottie Kane, who like Bob Wabnitz simply
smiled when I asked that more had to be done, and of
course, done yesterday.
In the patient care arena, which is so important to
a surgeon and the success of patient management, I
extend gratitude in a special way to those primarily
associated with the Sisters of Charity Hospital of Buffalo.
This includes in administration Sister Mary Charles and
Sister Eileen, and more recently, Sister Angela and her
staff; in the operating room, Sister Thomasine, and after
her, Pat Archambault, R.N., and on the special head
and neck nursing unit, the head nurse, Diane Smeeding,
R.N., and her staff of devoted and skilled nurses, prac-
tical nurses, aides and our floor secretary, Beth Powalski.
Along with patient care and many of the facets related
to this endeavor, I am grateful to my office staff, espe-
cially Nan Sundquist, R.N. and Debbie Foschio, and
also to Joan Bilger, R.N., who is our nurse clinician at
the Erie County Medical Center.
I have picked the brains of many physicians, espe-
cially my former associate, Duck Kim, M.D., and my
current associate in practice, Keun Lee, M.D. They
filled in for me while I struggled along with this revi-
sion. Also in this aspect I am grateful to the Pathology
Department of Sisters Hospital. To Paul Milley, M.D., I
am deeply grateful for his contributions both in his
section and in the chapter on endocrine surgery and for
his time, which he afforded me in the numerous prob-
lems associated with surgical pathology. John Sheffer,
M.D., and Ashok Koul, M.D., likewise were helpful in
this phase of surgical pathology, which is reflected in
hidden ways in many of the surgical procedures. These
three surgical pathologists are placed among the best
in the field of head and neck surgical pathology, espe-
cially related to frozen section, cytology, and recuts and
searching through many surgical specimens. This is
specifically applicable not only to carcinoma hidden in
those specimens that had a complete clinical response
to chemotherapy but also in thyroid specimens where
there has been a search for primary tumors as well as
C-cell hyperplasia.
I am indebted to Martha Schmidt, M.D., the expert
in nuclear medicine, especially that related to thyroid
scanning, as well as to Joseph Prezio, M.D., who is
chairman of the Department of Nuclear Medicine at the
School of Medicine, State University of New York at
Buffalo and Kwang Joo, M.D., who covers Sisters
Hospital. Gratitude is also extended to their technicians,
who are most important in this particular phase of
diagnostic imaging.
In a similar vein, Monica Spaulding, M.D., and
Kandala Chary, M.D., our medical oncologists are a
great help in the management of patients with advanced
neoplastic disease.
Included on our team is William Bukowski, M.D.,
our internist, and David Casey, D.D.S., our maxillofacial
prosthodontist, who have contributed significantly to
the team approach in the management of our patients.
Without the expert contribution of the Department
of Diagnostic Radiology and Imaging under the direc-
tion of David Rowland, M.D., and the person who I
pester the most, David Hayes, M.D., many of the surgi-
cal procedures would not have been brought to a suc-
cessful conclusion.
When speaking of "brain picking," the participants
in our endocrine conferences contributed much to my
understanding of thyroid and parathyroid disease. The
"regulars," Robert LaMantia, M.D., Donald Rachow,
M.D., Jack Cukierman, M.D., and James Kanski, M.D.,
are the stalwarts. However, I must say if there are
differences of opinion in the endocrine chapter, these
are my responsibility, not theirs. Contributing in this
xxv
 ACKNOWLEDGEMENTS IN THE THIRD EDITION
same fashion is Richard Blanchard, M.D., who would
come to my office and spend hours reviewing cases of
patients with thyroid and parathyroid disease, thus
affording me a learning experience seldom available to
a surgeon.
I am deeply indebted to Paul J. Davis, M.D., Professor
of Medicine and Chief of Endocrinology at the State
University of New York at Buffalo, for his review, sugges-
tions and additions to the endocrinological aspects of
the chapter on Endocrine Surgery. His help was most
important.
Part of the learning experience is exemplified by
many of my residents and fellows who were involved
in the exchange of knowledge and ideas-so well stated
by John Henry Cardinal Newman in his treatise "The
Idea of a University."
Several general surgeons have been significant contri-
butors to this endeavor in many facets. Frank Marchetta,
M.D., a head and neck surgeon par excellence, is respon-
sible for many original contributions to head and neck
surgery, as is Alfred Luhr, M.D., who operated with me
on some two-team procedures. Joseph Anain, M.D., a
certified general vascular surgeon and co-author of
Chapter 22, was and is a significant collaborator in our
head and neck vascular procedures. He is not only
involved in the operating room but also in the work-up
of patients who are suspected of having vascular prob-
ems associated particularly with neoplasia.
In all of this, a chairman of a department at a medical
school needs the support of his chief, viz. Dean John
Naughton, M.D., who is also Vice President of Clinical
Affairs. This support is afforded in many ways-some
not immediately recognized, but always appreciated.
In the publishing of a medical book with all its
applications, decision making, changes, and additions,
the staff of the W.B. Saunders Company has been
understanding, helpful, and cooperative.
When I try to remember all who have been an inspi-
ration and at the same time contributed much to head
and neck surgery, George Sisson, M.D., Chairman,
Department of Otolaryngology, Northwestern Medical
School, comes often to my mind. Many thanks George.
Although my mother has passed away during the
period between the second and third edition, she was
and still is an inspiration, and once again I dedicated
this atlas to my Dad, who was the inspiration behind
this entire endeavor.
JOHN M. LORE,JR.
 PREFACE
TO THE SECOND EDITION
Eleven years have passed since the publication of the
first edition of this atlas. The convictions expressed
in the preface of the first edition are reiterated here
and, in addition to them, the grave importance of the
cooperation of the various disciplines involved in sur-
gery of the head and neck-both in the management of
patients and in the training of residents-is empha-
sized. The combined efforts, contributions, cooperation
and sharing of patient problems and management must
be part of every aim in medicine and surgery, especially
in head and neck surgery in which there is so much
overlap among the various disciplines.
Fortunately, during the past five years, a definite
cooperative trend among the prime disciplines of general
surgery, otolaryngology, plastic and reconstructive sur-
gery and oral surgery has been developing. A number
of various types of combined head and neck services at
universities known to the author are participants in this
trend-the State University of New York at Buffalo,
Northwestern University, the University of Virginia and
Yale University-and others are surely in existence.
However, even more important than these services is
the emergence of a spirit of cooperation which has been
spread as seeds throughout the surgical community.
Unfortunately, among the fruitful seeds are still the
weeds which attempt to choke out the wheat because
of inherent parochialism, insecurity, jealousy and greed
of power or whatever. Regardless of the type of arrange-
ment of a combined venture, its success or failure depends
not so much on signed documents as on a spirit of equal
cooperation, understanding and trustworthiness. To insist
that a combined head and neck service lies solely within
one discipline or is a subspecialty of general surgery is
to lead the entire endeavor to certain doom.
Flexibility should be tolerated. For example, if need
be, a multidiscipline head and neck service could be
established within one department and thus achieve an
objective similar to that of a head and neck service
which involves more than one department. It is interest-
ing to note that during the past decade otolaryngology
has made significant strides and at present is believed
by many to be the prime discipline in the complete train-
ing of the head and neck surgeon.
The problem does not appear to lie among the various
head and neck surgeons of different backgrounds but
rather with certain autocratic and political forces who
attempt to control a major portion of surgery-the so-
called "umbrella of general surgery," an antiquated and
obsolete concept. However, it is the conviction that
general surgery serves as the foundation and the special-
ties as the superstructure. Therefore it appears that the
concept of regional surgery of the head and neck will
be the end-result.
It was not so long ago that mutual scorn and distrust
between several disciplines were so intense that any
exchange of ideas was tantamount to proclaimed heresy.
Now, it is changing toward a mood of basic ecumeni-
calism. The two head and neck societies, the Society of
Head and Neck Surgeons and the American Society for
Head and Neck Surgery, have had a joint meeting in
1973-an event which might well have been unthink-
able a few years ago. Both societies have opened their
memberships to capable surgeons in the various disci-
plines with similar standards and requirements. It is
believed that this cooperation is leading to a more com-
plete exchange of ideas and that this can be achieved
without the destruction of some of the good points of a
competitive climate.
As we proceed along the common pathway, a num-
ber of questions are encountered. For example:
I. What does the field of head and neck surgery encom-
pass?
2. What is the need in quality and quantity of surgeons
well trained in this field?
3. Should all residents in general surgery, otolaryngology
and plastic and reconstructive surgery be trained as
head and neck surgeons?
4. What should this training entail?
5. Should there be a cooperative effort among the various
disciplines or boards, and if so, how best is this objec-
tive achieved?
6. Should there be a certificate of competency issued
by the various boards involved?
7. Is some type of basic framework for residency training
desirable, or rather, should there be an individual solu-
tion to the training problem at the various large centers?
These queries cannot be answered or solved over-
night, and yet a few responses are possible at present.
xxvii
 PREFACETO THE SECOND EDITION
The field and training in head and neck surgery
should have a broad base and be flexible. Individual
surgeons and groups of surgeons may have their own
specific interests; there is no criticism of this action.
Nevertheless, it is important that the trainee develop
a versatility in the changing world of medicine and
surgery, and hence it is believed that to have a lasting
and firm foundation head and neck surgery should
encompass four categories.
1. Malignant and benign tumors.
2. Reconstructive surgery.
3. Congenital lesions.
4. Infectious surgical diseases.
Thus it is quite obvious that such training crosses
and encompasses a number of specialties as we know
them today. The old boundaries are no longer valid nor
. practical, and the new boundaries are far more flexible.
It must be emphasized that the various surgical spe-
cialties, as well as general surgery, are not in existence
for their own benefit but rather for the promotion of
ultimate excellence in patient care.
Another point appears quite clear. There is not a need
for a large number of head and neck surgeons, but rather
a need for a moderate number (how many??) of well
trained head and neck surgeons. For example, many of
the procedures outlined in this atlas are not intended
for the occasional operator with limited background,
but are intended as a reminder or review for those
well educated in the overall field of head and neck
surgery. For the latter audience, this atlas may be a
source of material in the ever-continuing field of medical
education.
During the past six years as a program director, the
author has realized a number of problems. First of all,
not all residents in either otolaryngology, general sur-
gery or plastic surgery need be, nor should be, trained
as head and neck surgeons per se. Secondly, a solid
block of time in general surgery (two to four years)
followed by a solid block of time in otolaryngology
(three years) has certain drawbacks. There is a psycho-
logical problem of a candidate being a senior resident
in general surgery and then starting at the bottom in
otolaryngology. This is no small matter. Another prob-
lem is that of graded training in both fields. It would
seem much easier to train a resident in physical diag-
nosis in both specialties at an early stage in his career.
The same comparison goes for the senior levels in
which major surgery will be performed. It is at this
stage of one's training that senior responsibility in both
specialties should be achieved, almost side by side, and
certainly not separated by several years, as is the case
in the solid block concepts.
At any rate, it appears worthwhile to outline an inte-
grated step-wise plan for head and neck surgical train-
ing, which recently has been passed by both the
American Board of Otolaryngology and the Conference
Committee on Graduate Education in Surgery, repre-
senting the American Board of Surgery, the American
College of Surgeons and the Council of Medical
Education of the American Medical Association. This
experimental program, applicable to certain selected
candidates with approval on an individual basis, exists
at the State University of New York at Buffalo with
instruction in otolaryngology, general surgery and
plastic surgery.
This concept was originally planned with the coop-
eration of John R. Paine, then Chairman of Department
of Surgery. Glenn Leak played an integral part in the
original outline. With the untimely passing of both of
these friends, G. Worthington Schenk, Jr., now Chairman
of the Department of Surgery, gave his support and
effort to achieve the final approval of this plan. The
program entails a five-year residency which, in step-
wise fashion, integrates in graded responsibility the basic
aspects of otolaryngology and general surgery and the
principles of plastic surgery. The years in training would
alternate between general surgery and otolaryngology,
with plastic surgery training incorporated within general
surgery, and additional reconstructive surgery within
otolaryngology. Senior resident levels in both general
surgery and otolaryngology would be reached in the
final two years. Not all residents in either of these two
fields would be included in the program-only one or
two at the most in anyone year. Nor is this program
intended to be the only avenue of training in head and
neck surgery.
In summary, the second edition of this atlas is
directed to the ecumenical approach in both patient
care and resident training in the field of head and neck
surgery.
REFERENCES
Baker. H. w.: Head and neck surgery: The pursuit of excellence.
Amer. J. Surg., 122:433-436, 1971.
Beahrs, O.H.: The next plateau. Amer. J. Surg. 114:483-485, 1967.
Bordley, J.E.: Problems facing otolaryngology today. Ann. Otol.,
80:783,1971.
Chase, R.A.: I'm against a rigid core curriculum prior to specialty
training in plastic surgery. Plast. Reconslr. Surg., 46:384-388,
1970.
Chase, R.A.: The "core knowledge" principle and erosion of specialty
barriers in surgical training. Ann. Surg., 171:987-990, 1970.
Eckert, C. (panel member): Panel discussion: Head and neck surgical
training. Medical Society of the State of New York Convention,
February 1972.
Fitz-Hugh, G.S. (panel member): Panel discussion: Head and neck
surgical training. Medical Society of the State of New York Con-
vention, February 1972.
James A.G.: Board to Death. Amer. J. Surg., 116:477-481, 1968.
Klopp, C.T.: Presidential address. Tenth annual meeting of Society of
Head and Neck Surgeons. Amer. J. Surg., 108:451-455, 1964.
Lore J.M., Jr.: Editorial. Head and neck surgery. Surg. Gynec. Obstet.
118:117-118, 1964.
 PREFACE TO THE SECOND EDITION

Lore, J.M., Jr.: Future of head and neck surgery. A combined head and Sisson, G.A.: Otolaryngology, maxillofacial surgery embark on chal-
neck service: An ecumenical approach. Arch. Otolaryng. 87:659-664, lenging course. From the Department of Otolaryngology and Maxillo-
1968.
facial Surgery, Northwestern University, Evanstown, Illinois.
Lore, J.M., Jr.: Head and neck surgery: The problem. Arch Otolaryng. Southwick, H.W: Presidential address. Eleventh annual meeting of the
78.842-843, 1963. Society of Head and Neck Surgeons. Amer. J. Surg. 110:499-501,
Lore, J.M., Jr.: Head and neck surgery: Proposed head and neck 1965.
training program. Arch. Otolaryng. 79:112-113, 1964. Wullstein, H.L.: A concept for the future of otorhinolaryngology.
MacComb, WS.: Future of the head and neck cancer surgeon. Amer. Ann. 0101., 77:805-814, 1968.
J. Surg., 118:651-653, 1969.
McCormack, R.M. (panel member): Panel discussion: Head and neck
surgical training. Medical Society of the State of New York Con-
vention, February 1972.
 ACKNOWLEDGEMENTS
IN THE SECOND EDITION
As with the first edition, my prime indebtedness is to
my wife Chalis, who single-handedly transcribed the
changes in the first edition and all the new text for this
expanded second edition. In addition to the manuscript,
she typed the bibliography with some help in classifi-
cation from my daughters Margaret and Joan.
The medical artist and illustrator is the same skilled
and dedicated one-Robert Wabnitz. Without him, this
atlas simply would not be. His persistence in accuracy
and consistent drive for detail is obvious in the artwork.
To him, also, am I deeply indebted.
Again, I am thankful to my mother for her encour-
agement and prayers.
For his revisions and statistics relative to temporal
bone resection, I am thankful to John S. Lewis, M.D.
I wish to thank William R. Nelson, M.D., who has
contributed a new section on pre- and postoperative
care. He has been kind enough to condense a much
larger treatise of this aspect of head and neck surgery,
which he originally produced in booklet form.
Gratitude is extended to James Upson, M.D., for his
review of the section on surgery of degenerative vas-
cular lesions and to John Bozer, M.D., as a consultant
internist.
I also wish to thank a number of photographers at
the various hospitals affiliated with the Medical School
at the State University of New York at Buffalo. They are
Sheldon Dukoff and Charles Jackson, of the Edward J.
Meyer Memorial Hospital; Joseph A. Dommer and
Dough Hanes, of Buffalo General Hospital; and Harold
C. Baitz, Theodore A. Scott and their secretary, Mrs.
Alfred Davis, of the Medical Illustration Service of the
Veterans Administration Hospital, Buffalo, New York.
Although many of their photographs do not appear in
the atlas, they served as a guide for the artwork and the
text.
Thanks also go to Joan R. Bilger, R.N., of the Edward
J. Meyer Memorial Hospital, for help in preparing some
of the photographic arrangements and supplying other
technical data; and to Bette Stinchfield, my secretary at
the Buffalo General Hospital, for aid in obtaining some
of the reference material.
During the time between editions, many new tech-
niques and modifications have reached the surgical
arena, a significant number of changes have occurred
and friends have lent their ideas and methods; how-
ever, one bit of philosophical admonition comes to
mind-primum non nocere-first, do no harm. I know
not the originator of this phrase, but to Julius Pomerantz,
a senior fellow physician from Good Samaritan Hospital,
Suffern, New York, I am indebted. It is to my residents
who have also contributed unwittingly to this endeavor
that I often pass on this thought in management of our
patients.
A great debt of gratitude is due the entire staff of the
W.B. Saunders Company for their unparalleled aid in
publishing this atlas. Their continuing help both as
publisher and personal friends makes an otherwise
burdensome task possible; their skill in the art of
publication makes it all worthwhile.
JOHN M. LORE,JR.
xxxi
 PREFACE
TO THE FIRST EDITION
The purpose and intent of this atlas is to encompass in
one volume related regional procedures of the head
and neck. It is actually a plea for a broader training
program to reunite with basic general surgery the many
surgical specialties and subspecialies concerned in this
area. Surely, there will always be a need for such
specialty groups alone but there is an even greater need
for the amalgamation and dissemination of their skills
in the total treatment of problems of the head and
neck. The foundation upon which this concept is built
is the basic principle that general surgery is the mother
and nurturer of all major surgery. The specialties are
the fruits. Hence, general surgery as well as the special-
ties of otolaryngology, plastic and reconstructive sur-
gery, maxillofacial surgery, neurosurgery, oral surgery
and thoracic surgery are involved. Disease knows not
the man-made barriers that have been set up.
Each field can contribute to the others. One has only
to reflect on the importance of mirror laryngoscopy
before and after thyroid surgery. Adequate examination
of the larynx is felt to be a sine qua non for any sur-
geon who performs a thyroidectomy just as a sigmoi-
doscopy should be performed by the surgeon who
performs the abdominoperineal resection. For anyone
who does major surgery in the neck, extension of
resectability must not be hampered by a lack of famil-
iarity with thoracic surgery when the disease has
extended below the clavicles. This principle holds true
for both malignant disease and trauma. Major surgery
on the larynx sooner or later will involve the cervical
esophagus and basic knowledge of bowel surgery will
enhance the armamentarium of the surgeon and aid
in his decision when selecting the most suitable type
of esophageal reconstruction. Procedures on the nose,
except the very simplest, can be refined and well select-
ed only when the surgeon borrows from the orolaryn-
gologist, the plastic and reconstructive surgeon and the
general tumor surgeon.
The skills and tricks of one field are often applicable
to another field. In the definitive treatment of malignant
tumors the details of an elaborate reconstruction proce-
dure are of little avail unless the primary disease has
been handled correctly with full knowledge of the natural
history of the disease. By the same token, radical surgical
treatment is incomplete if a suitable and adaptable
reconstructive procedure or prosthesis has been omitted
purely through a lack of versatility. Obstructive vascular
disease affecting the intracranial circulation amenable to
surgical correction may have its center of trouble located
either in the chest or neck or in both regions. The selec-
tion of the best-suited vascular procedure is enhanced
by a working knowledge of general vascular surgery.
With anticipation of the criticism that such a con-
cept would lead to a Jack-of-all-trades, master of none,
one need but read the history of surgery. Many of the
great surgeons of yesterday were first primarily general
surgeons; with this basic knowledge they contributed
lasting ideas both in the specialty fields and in general
surgery. Billroth was the master of gastrectomy and at
the same time contributed to cleft palate repair by frac-
turing the hamulus of the pterygoid process, thus releas-
ing the tensor veli palatini muscle. King, a general sur-
geon, made a significant contribution in the treatment
of bilateral abductor cord paralysis of the larynx. Such
examples are not intended to detract from the innu-
merable contributions by the surgical specialists which
in their own fields outnumber these examples. Nor
is the concept that is portrayed in this atlas intended
to lessen or minimize in any way the need for the
specialist. Actually it supports the specialist and re-
emphasizes the natural evolution of surgery.
John Henry Cardinal Newman in his classic The ldea
of a University advocated a liberal education which
would serve as the background for future endeavors.
He pointed out that any student able "to think and to
reason and to compare and to discriminate and to ana-
lyze, who has refined his taste, and formed his judg-
ment will not indeed at once be a lawyer, or a pleader,
or an orator, or a statesman or a physician ... but he
will be placed in that state of intellect in which he can
take up anyone of the sciences or callings ... with an
ease, a grade, a versatility, and a success to which
another is a stranger." So in the art and science of
surgery, a liberal basic foundation is necessary. From
such a foundation and broad outlook, the field of head
and neck surgery seems to have drifted. Reunification
of all groups interested in the field of surgical problems
related to the head and neck is the intention, hope and
aim of this Atlas of surgical techniques.
JOHN M. LORE, JR.
xxxiii
 ACKNOWLEDGEMENTS
IN THE' FIRST EDITION
.-,.-
I am deeply grateful to my wife, Chalis, for her sacrifice,
patience and able skill as an executive secretary. She
has typed and retyped the manuscript under consid-
erable duress.
My children, John III, Peter, Margaret and Joan, have
all felt the pressures and sacrifices resulting from the
loss of many happy hours together which have been
missed because of the time consumed in the prepara-
tion of this work.
I am indebted to my mother for her encouragement
and prayers.
Professionally, my indebtedness extends from books,
journals and other collections of the surgical literature,
through various opinions voiced at surgical meetings
(the authors of which I regret to say have slipped my
memory), to my recent and past teachers and associates.
All education is a compendium, and even more so sur-
gical education. Hence many of the steps in this atlas
are the ideas, thoughts and work of surgeons under
whom I have trained or worked. I owe much to my father
and to John J. Conley who were my early teachers. A
great many of the surgical procedures and techniques
concerned with the treatment of tumors of the head
and neck either originated with or were developed by
Hayes Martin and other surgeons on the Head and Neck
Service of Memorial Hospital. In the basic background
of general surgery which forms an integral part of this
atlas, I owe a debt of great magnitude to John L. Madden,
Director of Surgery at Saint Clare's Hospital.
To make the decision after my father's death to con-
tinue surgical training in general surgery after comple-
tion of the first phase in otolaryngology presented a
crisis. Two men convinced me and gave me advice of
immeasurable value. They are Michael Deddish, M.D.,
and Alexander Conte, M.D. Without them I never would
have completed my surgical training and never would
have come to realize the benefits of a multifaceted
surgical background.
John S. Lewis, M.D., who is mainly responsible for
the present technique of temporal bone resection in
cancer of the middle ear, has kindly contributed to that
section of the atlas.
Edward Scanlon, M.D., has been kind in lending his
original experiences and thoughts in colon transplants
for reconstruction of the esophagus. These ideas have
been of considerable aid and have been a guide to
personal experiences in this problem. Again to Alexander
Conte my thanks for supplying original photographs of
his technique of cervical esophageal reconstruction.
During the two years of pressure to complete this
work, my surgical partner, Louis J. Wagner, M.D., has
unselfishly covered our practice to allow me the neces-
sary undisturbed time. From him, I have also learned a
number of operative steps which have been successful
in the solution of some technical problems.
When this atlas was in its infancy, it was only through
the cooperation of John L. Madden and the administra-
tion of Saint Clare's Hospital, specifically the late Mother
M. Alice, O.S.F, and her successor Sister M. Columcille,
O.S.F., that actual work began. At Saint Clare's Hospital
I met Robert Wabnitz, the sole illustrator of this volume,
who since then has spent many hours in the operating
room making sketches and at the drawing board com-
pleting the art work. Without his skills as an artist and
his knowledge of anatomy, the illustrations would have
been impossible. Both he and I are grateful to the Univer-
sity of Rochester where he now heads the Medical
Illustration Department for allowing him time to com-
plete this work. If it were not for the skill in its repro-
duction, the best of art work would be for naught. The
W.B. Saunders Company has excellently completed this
endeavor. I am deeply indebted to the staff of the
Company for their advice, suggestions and patience. I
am grateful to my colleague William J. McCann, M.D.,
for initiating this most fortunate association with the
Saunders Company.
I wish also to acknowledge the cooperation of the
Administrator and Assistant Administrator of Good
Samaritan Hospital, Sister Miriam Thomas and Sister
Joseph Rita, as well as the Operating Room Supervisor,
Miss Martha Henry, and the entire nursing staff for their
help and vision in the treatment and care of the patients
with many of these operative and postoperative problems.
I would be remiss if I did not add the aid of the admin-
istration and staff of Tuxedo Memorial Hospital.
My thanks to Anthony Paul for drawing many of the
lead lines and some of the labels and to David Hastings
for his care in photographing the x-rays in Chapter I.
JOHNM. LORE,JR.
xxxv
 CONTENTS

1 SECTIONAL RADIOGRAPHIC ANATOMY Contrast Medium-Enhanced High-Resolution CT 40

AND SCANNING 1 CT Angiography of the Neck: Venous Malformation
With Traumatic Arteriovenous Fistula 42
ANATOMIC RADIOGRAPHS .......•..•.......................•......... 1
john M. Lore, Sr., 1938 CT Venography of Facial Venous Malformation 44
Sagittal Section Through the Midportion of the CT Angiogram of ECAjICA Bypass 45
Maxillary Sinus and Orbit 2 Three-Dimensional CT of Vascular Tumor Relationship 46
Sagittal Section Through the Lateral Wall of the Endoluminal and Cut-Away View of the Trachea
Nose, Lateral Border of the Tongue, and Lamina With Medial Deviation of the Carotid Artery ........••.......... 47
of the Thyroid Cartilage Showing Its Superior
and Inferior Cornua .............................................•.............. 4 EXAMPLES OF MRI IN THE SUPERIOR
Sagittal Section Through the Floor of the Nose MEDIASTINUM .•...........•.............•..........•....••......•......... 48
john M. Lore, jr.
and the Body of the Tongue .................................•...•........ 6
Sagittal Section Through the Middle of the Skull 8 OTHER EXAMPLES OF CT AND MRI .............•............•.. 52
Frontal Coronal Section in the Region of the john M. Lore, jr.
Second Molar Teeth 10 Multinodular Goiter in the Mediastinum 52
Frontal Coronal Section Just Beyond the Paraganglioma (Second Primary Thoracic Chain,
Third Molar Teeth 12 T4 by CT Scan) 53
Frontal Coronal Section in the Region of the Metastatic Papillary Carcinoma of the Thyroid
Anterior Faucial Pillar and Tonsil 14 (Usual Type) .....................................................•............... 53

CT AND MRI ....•.............•.............••........•.•.•.......•..•....... 16 Magnetic Resonance Angiography ..........................•.•.••....... 54

David F. Hoyes and Scott Cholewinski
ULTRASOUND ............•..........•......................•............•... 54
Single-Plane CT Scans 16 David F. Hayes
Frontal Coronal Section in the Region of the Example Uses of Ultrasound 54
Second Molar Teeth .......................................•......... 16
Frontal Coronal Section Just Beyond the POSITRON EMISSION TOMOGRAPHy .......•.•..........•.... 56
Third Molar Teeth .............................................•....... 17 Rabert S. Miletich and john M. Lore, jr.

Frontal Coronal Section in the Region of the Role of PETin Oncology 57

Anterior Faucial Pillar and Tonsil 18 Role of FDG-PETin Head and Neck Cancer ......•................... 57
Three-Dimensional Reconstructed CT Scans 18 Conclusion 63
MR Images 26
Imaging in the Diagnosis and Treatment of
Head and Neck Disease 26 2 EMERGENCY PROCEDURES 65
Overview ................................................•..................... 26
Scott Cholewinski VENOUS AIR EMBOLISM ......•...........•.......•.•.....•....•...... 65
john Lauria
ADVANCED TECHNIQUES FOR CT IN THE
HEAD AND NECK ....•.•...........•.........••.•........•.•.........•..... 34 MALIGNANT HYPERTHERMIA ...•.•.......•.•....•.•.•..•......•.•. 65
Ronald A. Alberico and Ahmed Abdehalim john Lauria

The Role of Imaging in the Head and Neck 34 Other Untoward Events Associated With Endotracheal
Anesthesia 66
Detection of Perineural Disease at the Skull Base 35
Oblique Imaging of the Oral Pharynx to Avoid Dental BLINDNESS AND OPHTHALMIC COMPLICATIONS
Artifact 36 OF SURGERY OF THE HEAD AND NECK ....•................. 66
Multiplanar Techniques to Evaluate Tumor Location Daniel P. Schaefer and Arthur f. Schaefer
and Margins 37 Blindness ...............................................•..•.......................... 66
Three-Dimensional CT of the Inner Ear .............•.................. 39

xxxvii
 CONTENTS

CARDIOPU~MONARY RESUSCITATION 70 Common Departures From Sound Management

-"Pitfalls" 123
William M. Marris
Donald P. Shedd
Emergency Cardiac Care ........................................•............. 70
Open Biopsy of a Lump in the Neck
Sequence of BLS .................................................•.•.............. 70 Before Performing a Complete Head and Neck
Closed Cardiac Massage 72 General Examination 124
Open Cardiac Massage Resuscitation ...............•................... 72 Inadequate Incisional Biopsy of an Oral Cavity
Thoracentesis ............................................•.......•.................. 74 Lesion 124
Insertion of Intercostal Catheter 74 Inadequate Excisional Biopsy of a Suspicious Oral
Cavity Lesion 124
Open Thoracotomy for Empyema Drainage 78
Failure to Review Previous Histopathologic Slides 124
Intercostal Catheter Suction Drainage
With Underwater Seals ..........................•.......................... 80 Permitting a Single Histopathologic Benign
Diagnosis to Override a Clinical Diagnosis
Cricothyroidotomy 82 .. 125
of Carcinoma .
Management of Acute Respiratory Emergencies 84
Biopsies of the Laryhx, Hypopharynx,
Emergency Establishment of Airway 84 Nasopharynx, Esophagus, or Trachea
Before Radiologic Studies and Imaging
Techniques 125
3 BASIC CONSIDERATIONS 87 Lack of Multidisciplinary Approach
When Indicated 125
Needle Biopsy Techniques .......................................•........... 87
Tailoring the Scope of Surgical Resection
Ashok Koul to the Ability of the Surgeon Rather Than
Needle Aspiration Biopsy ................................•........ ··· .. 87 to the Objective Requirements Imposed
Core Needle Biopsy ·.········· · 87 by the Lesion 125
Large-Needle Aspiration Biopsy 89 A Compromise of the Ablative Phase of Surgery
to Accommodate Limited Reconstructive Skills 126
Commonly Used Terminology for Squamous
Epithelium 91 Compromise of Surgical Margins Because
Ashok Koul Radiation Therapy or Chemotherapy
Was or Is to Be Given 126
Commonly Used Special Stains for Head and
Neck Lesions 91 Performing the Right Operation on the
Wrong Patient 126
Mucosal Biopsy: Toluidine Blue Staining Technique 91
Assessing the Degree of Successor Failure of
Exfoliative Cytology Biopsy Technique , 91
Radiation Therapy on the Basisof the Response
Z-Plasty 91 of the Lesion During or Immediately
Definition ..................................•..........................••....... 91 on the Completion of Treatment 126
Technique of Basic Z-Plasty .................................•......... 92 Failure to Realize the Implication of the
"Condemned Mucosa" or Multiple Primary
Types and Modifications of Z-Plasty 98
Syndrome 127
Tissue Expansion ...................................................•............ 100
Failure to Perform a Complete General Physical
Effects of Tissue Expansion .......................•.................. 100 Examination as Well as a Complete Head
W-Plasty ..........................................................•.................. 102 and Neck Examination 127
Rhombic Flap .........................•........................••................. 104 Prolonged Watch-and-Wait Attitude in the Face
of an Asymptomatic Mass 127
Excision of Dog-Ears .....................................•.•.................. 106
Bone, Cartilage, and Nerve Grafts 107 Inadequate Search for an "Occult" Primary Tumor 127

Basic Principles Relative to Bone and Cartilage Abandonment of the Patient With Neck Metastasis
Grafts and Implants 107 From an Undetectable Primary Tumor 128

Rib, Iliac, and Costochondral Grafts 107 Enucleation of Tumors of the Major Salivary
Glands and Thyroid Gland 128
Iliac Bone Graft-"Trap Door Type" 110
Treating a Patient With Antibiotics for an
Auricular Cartilage Graft 110 Extended Period of Time Without a Biopsy 128
Sural Nerve Grafts ......................•..................•....•........ 112 The Place for Chemotherapy in Management
Skin Incision ...........................................................•.......... 112 of Squamous Cell Carcinoma of the Head and Neck 128
Nonabsorbable Sutures for Mucosal Repair 112 Monica B. Spaulding

Preoperative and Postoperative Care 114 Recurrent or Metastatic Head and Neck Cancer .. 129
William R. Nelson and R. Lee Jennings Preoperative Chemotherapy, Uncompromised Surgery,
Preoperative Care .....................................•.•............... 114 and Selective Radiotherapy in the Management
of Advanced Squamous Cell Carcinoma of the
Postoperative Care 116
Head and Neck 132
John M. Lore, Jr., Sol Kaufman, Nan Sundquist,
and Kandala Chary
 CONTENTS

A Comprehensive, Interdisciplinary Head and Neck Telescopic Endolaryngeal Surgery 204

Service 141
Nasopharyngoscopy 205
john M. Lore, jr., A. Charles Massaro, and Angela Bontempo
Rigid and Flexible Direct Optical Nasopharyngoscopy,
Bone Imaging and Pathology 142
Laryngoscopy, Cervical Esophagoscopy,
Scott Cholewinski, john Asirwatham, Daniel Broderick,
and Rhinoscopy 210,.
ond john M. Lore, jr.
Rigid Nasopharyngoscopes 210
Methods of Bone Involvement: Mandible 142
Flexible Nasopharyngoscopes 210
VOICE, SPEECH, AND SWALLOWING Rigid and Flexible Direct Optical Rhinoscopy 210
REHABILITATION OF THE HEAD AND NECK
Cervical Esophagoscopy 212
PATIENT ..................................................•..............•.... 143
Allen M. Richmond
Total Laryngectomy 143
5 THE SINUSES AND MAXILLA 214
Conservation Surgery: Cancer of the Larynx 144
Swallowing 144 Intranasal Antrostomy 214
Glossectomy 146 Rhinoscopy ........................................................•........ 214
Palatal Surgery 147 Caldwell-Luc Antrotomy 217
Voice 147 Intranasal Ethmoidal Surgery for Benign Disease 220
Hearing, Cochlear Implants, and Middle Ear Surgery 148 Uncapping of Anterior Ethmoidal Cells 220
Malignant Melanoma 149 Ethmoidectomy 220
Constantine P. Karakousis Endoscopic Diagnosis and Surgery for Sinusitis 222
Soft Tissue Sarcoma 152 External Ethmoidectomy 223
Constantine P. Karokousis
Sphenoidal Sinusotomy 226
Thyroid-Related Orbitopathy 154
Daniel P. Schaefer
Puncture of Anterior Wall of Sphenoidal Sinus 226
Enlargement of Natural Sphenoidal Ostium or
Pathogenesis 154
Anterior Wall Puncture Site 226
Epidemiology 154
Other Approaches to the Sphenoidal Sinus 228
Clinical Course 155
Frontal Sinusotomy (Trephination) 230
Differential Diagnosis 156
External Frontoethmoidectomy 232
Treatment Plan 160
Osteoplastic Approach to the Frontal Sinus 234
Dental and Prosthetic Considerations in Head
Anatomy of Frontonasal Duct 234
and Neck Surgery 161
David M. Casey Partial and Radical Maxillectomy ..............................•......... 236
Maxillofacial Prostheses ......................................•............... 166 Case 1: Esthesioneuroblastoma 237
Dovid M. Cosey Case 2: Esthesioneuroblastoma, Nonresectable,
Osseointegrated Implants in Head and Neck Stage C 238
Reconstruction 171 Case 3: Neuroendocrine Carcinoma,
Maureen Sullivan Nonresectable, Stage C 238
Removal or Saving Remainder of Soft Palate
After Partial Maxillectomy 238
4 DIAGNOSTIC ENDOSCOPy 179 Radical Resection of Maxilla With Orbital and Partial
Ethmoidal Exenteration 239
PERORAL ENDOSCOPY OF THE HEAD AND NECK ..... 179
Resection of Maxilla Including the Floor of the Orbit
Indirect Mirror Laryngoscopy and Nasopharyngoscopy With Preservation of the Globe ...............•....................... 246
and Cervical Esophagoscopy 179
En-Bloc Resection for Chondrosarcoma 246
Direct Optical Laryngoscopy and Nasopharyngoscopy 180
Limited Resection of the Maxilla 248
Cervical Esophagoscopy 181
Cysts of Maxilla ................................................•................ 250
Direct Rigid Laryngoscopy and Nasopharyngoscopy 181
Excision of Nasoalveolar Cyst 252
Direct Rigid Laryngoscopy and Hypopharyngoscopy 182
Excision of Nasopalatine Duct Cyst 254
Rigid Bronchoscopy 188
Closure of Oroantral Fistula 256
Flexible Bronchoscopy 192
Tracheal Lengths 192 ENDOSCOPIC SINUS SURGERy 258
Keith F. Clark
Esophagoscopy 194
Cervical Esophagoscopy After Total Laryngectomy
or Cervical Esophageal Surgery 194
Rigid Esophagoscopy 196 6 THE NOSE AND THE NASOPHARYNX 267
Microscopic Endolaryngoscopy 200 Anatomy of the Lateral Wall of the Right Nasal Cavity 267
 CONTENTS

Uncinate Process 267 Total Resection of Nose for Carcinoma 356

Bulla Ethmoidalis 267 Resection of Nasal Glioma-External Ethmoid Approach 358
Infundibulum Ethmoidalis 267 Excision of Rhinophyma 362
Anatomy of Epistaxis 270
Anterior and Posterior Packing for Epistaxis 272
7 THE FACE 367
Ligation of Ethmoidal Arteries 276
External Ethmoidectomy Approach to Epistaxis 279 Anatomy of Facial and Scalp Muscles 367
Septal Dermoplasty 280 Basic Technique for Facial Excisions 369
Ligation of Internal Maxillary Artery 282 Sebaceous Cysts 369
Removal of Nasal and Nasopharyngeal Polyps 286 Dermabrasion 371
Transpalatine Exposure of the Nasopharynx and the Excision of Tumors of Skin of Forehead 373
Sphenoidal Sinus 288 Excisions for Carcinoma of Skin of Temple 375
Transmaxillary Approach to Nasopharynx and Base Basal Cell Carcinoma 375
of the Skull 294
Squamous Cell Carcinoma 376
Posterior Choana I Atresia 295
Rotation Flaps 377
Newborn and Young Children ........•........................... 295
Temporal Scalp Flap 377
Older Children and Adults 296
Cheek Flap 378
Submucous Resection of Nasal Septum 300
Excision of Tumors of Cheek by Cheek Flap Rotation 379
Septoplasty Type I 304
Facial Paralysis 380
Septoplasty Type II 310 Shirley A. Anain and Jahn M. Lare, Jr.
Rhinoplasty 316 Management Possibilities 381
Alternate Techniques of Rhinoplasty 324 Facial Reanimation 381
Correction of Broad Nasal Tip 325 Cross-Face Nerve Grafts with Microvascular
Augmentation of Dorsum of Nose 326 Muscle Transfer 381
Additional Nasal Tip Procedures 326 Upper Lid Gold Weights 382
Columellar Graft for Collapsed Nasal Tip 328 Hypoglossal-Facial Nerve Anastomosis 384
Type I 328 Masseter Muscle Transposition-Intraoral 386
Type II 328 Fascial Slings for Facial Paralysis 388
Nares and Columella Procedures 330 Treatment of Paralysis of the Depressors of the
Nasofacial and Nasolabial Flaps 332 Lower Lip 390

Septal Flap for External Nasal Defect 334 Trigeminal Neuralgia (Tic Douloureux) 392

Nasolabial Flap 336 Incision and Drainage of Abscesses 394

Excision and Reconstruction of Ala Nasi 336

Excision and Reconstruction of Columella 336
8 GENERAL PURPOSE FLAPS
Resection of Tumor of Tip of Nose 338
Resection and Reconstruction of Tumor of the Introduction: Flap Selection and Design 399
Superior Dorsum of the Nose 340 Classification of Large Transposed Myocutaneous
Full-Thickness Graft to Nose 340 Flaps 400
Composite Graft From Ear to Nose 342 Limitations and Pitfalls with Major Standard
Regional Flaps 401
Type of Flap 342
Limitations and Pitfalls According to Specific Flaps 401
Reconstruction of Nose With Arm Flap 344
Blood Supply to Skin Flaps 402
Nasal Reconstruction With Lateral Forehead Flap 346
Pectoralis Major Myocutaneous Flap 404
Nasal Reconstruction With Combined Scalp
and Forehead Flaps 348 Reconstruction of the Entire Hypopharynx
and Portion of Cervical Esophagus, Oropharynx,
The Sickle Flap 348
and Nasopharynx 412
The "Scalping" Flap 348
Cross Section of Reconstructed Hypopharynx 412
Nasal Turn-in Flaps 350
Applications of the Pectoralis Major Flap 420
Nasal Reconstruction 352
Deltopectoral Flap 425
Transection of Forehead and Scalp Pedicle 352
Reconstruction of Oropharynx, Hypopharynx,
Revision of Nasolabial Fold and Ala Nasi 352 and Portion of Cervical Esophagus 425
Enlargement of Nares With Z-Plasty 352 Applications of Deltopectoral Flap 434
Resection of Nasal Septum for Carcinoma Apron Flap 436
(Lateral Rhinotomy Approach) 354
 CONTENTS

Laterally Based Chest Flap ...........................•...................... 438 Unilateral Cleft Lip Repair 494
Mutter (1842) Nape of Neck Flap 440 Triangular Flap Cleft Lip Repair: Tennison-Randall
Posterior Scapula Flap .........................................•.............. 442 Technique 496
Forehead Flap (Temporal Flap) ..............................•............ 444 Rotation Advancement Cleft Lip Repair 498
Reconstruction of Cheek with Forehead Flap .........•.•......... 446 Bilateral Cleft Lip Repair 500
Midline Forehead Flap ...........................................•.•.•....... 452 Basic Deformities of Cleft Lip (Bilateral Complete) 500
Fat Flip Flap ..............................•...........................•............ 454 Repair of Complete Bilateral Cleft Lip
(Straight-Line Closure) 502
Repair of Incomplete Bilateral Cleft Lip (Rotation-
• THE LIPS 458 Advancement Technique) 504
Cleft Palate ....................................................•................... 506
Lip Excision and Reconstruction 458
Types of Cleft Palate Deformities ...............•................. 506
Planing of Lip .................................•.•.......................... 458
Reconstructive Goals ................................•...•.............. 506
Shield Excision of Lower Lip .............•...•...................... 458
Optimal Age for Operation 506
Cupid's Bow 460
Repair of Complete Cleft of Secondary Palate 506
Elliptical Excision of Benign Lip Lesion 460
Repair of Incomplete Cleft of Secondary Palate 512
Distortion of Mouth Corrected by Z-Plasty 460
Repair of Complete Unilateral Cleft Palate 514
Excision of Large Benign Lesions of Upper Lip
Pharyngeal Flap in Cleft Palate Repair 516
with Nasolabial Flap 460
Pharyngeal Flap for Velopharyngeallnsufficiency 517
Repair of Large Vermilion Defects .............................•........ 462
Abbe-Estlander Lip Operation 464
Correction of Rounded Commissure of Lips 467
11 PERIORBITAL REGION 523
Plication of the Orbicularis Oris Muscle to Repair
Partial Paralysisof the Lower Lip 468 Anatomy 523
Modifications of Abbe-Estlander Lip Operation 469 Repair of Lids and Conjunctiva .........................•................ 523
Reconstruction of Center Lower Lip Defect 469 Wounds of the Conjunctiva ..........................•............. 524
Reconstruction of Upper Lip Defect 470 Repair of Lid Lacerations 524
Correction of Rounded Commissure of Lips 470 Management of Disruption of the Canaliculi 524
Reconstruction of Large Defects of Upper Lip 472 Reconstruction of Lids ................................................•....... 524
Reconstruction of Upper Lip with Cheek Flap 472 Reconstruction of Lower Lid 526
Fan Flap Reconstruction for Large Defects Resection of Large Basal Cell Carcinoma of Lower
of Upper Lip 474 Lid With Reconstruction Using Lateral Cheek
Excision and Repair of Large Lesions of Upper Lip 476 Flap 532

Burow's Technique 476 Reconstruction of Upper Lid 534

Gillies' Technique 476 Bridge Flap Repair of Large Upper Lid Defects,
Cutler-Beard Technique 542
Repair of Large Defects of Upper Lip 478
Resection of Large Basal Cell Carcinoma Involving
Bitemporal ("Visor") Flap for Large Upper Lip
Both Lids and Nose 544
and Cheek Defects 480
Excision of Superficial Basal Carcinoma in Region
Resection of Lower Lip with Bernard Reconstruction 482 of Lateral Canthus of Lower Lid 546
Reconstruction of the Lower Lip 484 Excision of Benign Lesion of Upper Lid 548
Reconstruction of the Lower Lip after the Reconstruction of Superficial Horizontal Defect
Extirpation of a Lip Cancer ..........................•........... 484 of Portion of Lower Lid 548
Reconstruction of the Upper Lip after an Eyelash Reconstruction ...........•.•.................................. 550
Operation of Lip Cancer 485
Eyebrow Reconstruction 550
Reconstruction of the Lower Lip from the Cheeks
after an Operation of a Lip 486 Excision of Lesions at the Medial Canthus 552
Cancer with the Resection of a Part of the Medial Canthoplasty and Repair of Related Injuries 554
Lower Jaw 486 Dacryocystorhinostomy 558
Correction of Scar Contracture of the Lids
and Ectropion 560
10 ClEFT LIP AND PALATE 493 Tarsorrhaphy 562
ROBERTJ. PERRYand JOHN M. LORE,JR. Lateral Permanent Tarsorrhaphy or Canthorrhaphy 562
Cleft Lip .................................................................•........... 493 Temporary Tarsorrhaphy 562
Types of Cleft Lip Deformities 493 Graft for Defect of Infraorbital Rim 564
Normal Anatomy 493 Decompression of the Orbit for Exophthalmos 566
 CONTENTS

Resection of Benign Tumor of Lacrimal Gland 569 Repair of Large Mandibular Defects Utilizing
the DBDB Plate 618
Resection of Adenoid Cystic Carcinoma of the
Lacrimal Gland 570 Open Reduction of Depressed Fracture of Zygomatic
Arch With or Without Fracture of Body of Zygoma
(Gillies' Technique) 620
Open Reduction of Depressed Fracture of Zygoma
12 THE EAR 573 and Portion of Maxilla 622
Otoplasty 573 Early Reduction ........................•.•................................ 622
Cartilage Incision Technique ............................••......... 573 Late Reduction 622
Mattress Suture Technique (Correction of Early Reduction of Depressed Comminuted
Prominent or Deformed Ears) 576 Fracture of Anterior Wall of Maxilla 624
Surgical Treatment of Hematoma of the Auricle: Intraosseous Wiring for Facial Fractures 626
"Cauliflower Ear" 580 "Tent Peg" Method of Reduction and Fixation
Z-Plasty for Stenosis of External Auditory Canal 582 of Facial Bone Fractures 628
Excision of Small Malignant Tumor of Cartilaginous Open Reduction of Complete Fracture of Upper
Portion of External Auditory Canal · 584 Dental Arch of Maxilla (Le Fort I or Guerin) 630
Excision of Malignant Tumors of the Auricle 586 Suspensory Wire Technique 630
Excision of Hemangioma of the Face Involving Lobule Direct Intraosseous Wiring Technique 630
of the Ear 586 Internal Fixation of Fracture Through Middle Third
En Bloc Resection of the External Auditory Bony Canal 588 of Maxilla (Le Fort II or Pyramidal Fracture) 632
Total Resection of the Auricle With a Portion of the Open Reduction of Fractures Through Glabella, Orbit,
External Auditory Canal, Parotidectomy, and Zygomatic Arch (Le Fort III or Craniofacial
and Radical Neck Dissection for Recurrent Dysjunction) 634
Malignant Melanoma 590 Techniques of the Use of Miniplates in Le Fort I, II,
Technique 590 and III Fractures 636
Posterior Approach to the 7th (Facial) Nerve 590 Le Fort I-Basic ..................................................•........ 636
Final Pathology Diagnosis 592 Le Fort I-Complicated ................................•.......•...... 636
Le Fort II ..................................................•.................. 636
Le Fort III 637
13 FRACTURES OF FACIAL BONES 595 Internal Fixation of Fractured Hard Palate 638
JOHN M. LORE,JR.and DOUGLASW. KLaTCH Fractures Involving the Frontal Sinus 638
Basic Principles 595
Fractures of Floor of Orbit 640
Reduction of Fractured Nose 596
External Traction for Depressed Facial Fracture 646
Depression of Right Nasal Bone with Lateral Management of Zygomatic (Malar) Fractures 648
Displacement of Left Nasal Bone 597
Douglas W. Klotch
Depression of Nasal (Frontal) Process of Right Repair of Simple Fractures 649
Maxilla 598
Repair of Complex Fractures 650
Fractures of Mandible-Outline ..............................•.......... 599
Fracture of Condylar Process-Outline ..............•................ 600

FRACTURES OF MANDIBLE 602 14 CYSTS AND TUMORS INVOLVING

Douglas W. Klotch THE MANDIBLE 653
Overview of Fracture Repair 602
Excision of Cysts of the Mandible 653
Open Reduction of Fractures of the Mandible 603
Radicular Cyst ................................•............................ 653
Technical Aspects of Fracture Repair 605
Dentigerous Cyst 656
Compression Plating for Treatment of Mandibular
Marginal Segmental Resection of Mandible 658
Fractures 610
Douglas W. Klotch and Joachim Prein Resection of Large Benign Tumors of Mandible 660
Outline of Procedures for Rigid Internal Fixation 612 Mandibular Reconstruction 664
Fracture in Row of Teeth 614 Reconstruction of Mandible Using Steinmann Pin
and Tie Wires 665
Fracture Posterior to Row of Teeth ..............•............... 614
Mandibular Reconstruction Using Steinmann Pin 666
Fractures at Angle of Mandible 616
Use of Eccentric Dynamic Compression Plate 616 Other Options Relative to Mandibular
Reconstruction 672
Use of Dynamic Mandible Defect-Bridging Plate 616
Results of Reconstruction With Kirschner Wire
Fracture in the Edentulous Mandible 618 and Steinmann Pin 672
Treatment of Oblique Fractures by Utilizing
the Lag Screw Principle 618
 CONTENTS

Reconstruction of the Mandible Using Plates Buccal Wall lesions: Benign, Premalignant,
With or Without Free Autogenous and Malignant Squamous Cell Carcinoma 742
Nonvascularized Bone Grafts 675
Plan for Resection of Premalignant and Malignant
Resection and Second-Stage Reconstruction lesions of the Buccal Wall 744
of Anterior Portion of Mandible Using Iliac
Radical Resection of Buccal Wall With
Bone Graft 678
Mandibulectomy Associated With
Resection and Reconstruction of Major Portion Oropha~ngeal and Retromolar Trigone
of Body of Mandible With Bent Steinmann Pin Invasion: Advanced Squamous Cell Carcinoma 745
and Tie Wires and Forehead Flap 682
Reconstruction of Buccal Wall lesions 746
~=~ ~ Resection of Carcinoma of the Retromolar
Marginal Resection of Mandible, Partial Trigone and the Buccal Wall 747
Glossectomy, and Radical Neck Dissection for
Excisions of lesions of Soft and Hard Palate 752
Carcinoma of the Floor of the Mouth 688
Resection of Extensive Benign Minor Saliva~
Gland Tumors of the Soft Palate 760
Resection of Carcinoma of Soft Palate 764
t5 ORAL CAVITY AND OROPHARYNX 698
Excision of Ranula 766
Excision of Dysplasia (leukoplakia) and/or
Resection of Hemangioma and Neurofibroma
E~throplasia (Erythroplakia) of Tongue and
of Tongue 768
Buccal Mucous Membrane 698
Tonsillectomy and Adenoidectomy 770
Excision of Carcinoma In Situ or Small limited
Carcinoma of Tongue 700 Adenoidectomy 770
Excision of Small Midline Cancer of Anterior Third Salivary Duct Calculi 773
of Tongue 702 Repair of laceration of the Stensen Duct (Parotid) 773
Median labiomandibular Glossotomy (Trotter Reconstruction and Reimplantation of Stensen's Duct
Approach to Base of Tongue, Pha~nx, in the Buccal Wall 774
and Baseof Skull) 704 Pierre Robin Syndrome 774
Resection of Stage T1 Carcinoma of the Midline
of the Floor of the Mouth 708
Inlay Graft to Floor of Mouth for Carcinoma 710 16 THE NECK 780
Resection of Malignant Tumors of the Oral Cavity JESUSE. MEDINA and JOHN M. LORE,JR.
and Oropha~nx With Extension Above Into the Cervical lymph Nodes 780
Nasopha~nx and Below to the Hypopha~nx
With Cervical Metastasis With or Without Spinal Accesso~ Nerve 781
Involvement of the Mandible Including the Cervical lymph Node Metastatic Guide 781
Parapha~ngeal Space 714 Classification 786
Approaches 714 Radical Neck Dissection 788
Bone Involvement: Mandible ...........................•..•....... 716 Evaluation of Cervical lymphadenopathy
Guidelines 716 on Computed Tomography and Magnetic
Resection for Carcinoma of Tonsil, Soft Palate, Resonance Imaging 797
or Baseof Tongue by Mandibulotomy and Modifications of Radical Neck Dissections 797
Reconstruction 720 Parotid Extension of Radical Neck Dissection
Resection of Hemimandible, lateral Oropharyngeal (High Exposure of Internal Jugular Vein
Wall, and Portion of Soft Palate and and Internal Carotid Artery) 798
Hemiglossectomy With Reconstruction Modified Radical Neck Dissection Preserving
Using a Forehead Flap Versus Pectoralis Major Flap 724 the Spinal Accesso~ Nerve (Type I) 802
Combined Radical Neck Dissection, Partial Incision Modifications of Radical Neck Dissection 804
Glossectomy or Hemiglossectomy, and
Modified Radical Neck Dissection Preserving
Hemimandibulectomy Including Retromolar
the Spinal Accesso~ Nerve, the Internal Jugular
Trigone 726
Vein, and the Sternocleidomastoid Muscle
Base of Tongue 732 (Type III) 808
Anatomy of the Tongue 732 Selective Neck Dissections 811
Resection of Baseof Tongue 732 Extended Neck Dissections 814
Approaches to Base of Tongue 733 Resection of lower Margin of Mandible Combined
Resection of Baseof Tongue via Midline with Radical Neck Dissection 814
Mandibulotomy (Mandibular Swing) 734 Posterior Neck Dissection ...........................................•....... 818
Midline Mandibulotomy (Mandibular Swing) 736 Keun Lee

Resection of Baseof Tongue and Total Glossectomy 738 Excision of Thyroglossal Cyst and Sinus 824
Resection of lesions of the Buccal Wall 742 Resection of Submandibular Saliva~ Gland for Benign
Disease 828
 CONTENTS

Phrenic Nerve Crush 832 18 ENDOCRINE SURGERy 892

JOHN M. LORE,JR.,MEGAN FARRELL
Scalene and Infraclavicular Internal Jugular Node
and NIEVAB. CASTILLO
Biopsy 832
Muscle Lengthening for Torticollis .............•....................... 834 THYROID GLAND 892
Branchial Cleft Cysts 836 Diagnostic Evaluation 892
First Branchial Cleft 836 History ...................................•.•.•.•.............................. 892
Second Branchial Cleft (Most Common) 838 Physical Examination 893
Third Branchial Cleft (Rare) 838 Fine-Needle Aspiration of the Thyroid Gland 893
Fourth Branchial Cleft ......................................•..•....... 838 Thyroid Scans ('231 and 99mTc) 895
Resection of Branchial Cleft Cysts ..........................•.•......... 840 Sonography ...................................................•............ 895
Second Branchial Cleft ................................•............... 840 Computed Tomography ..............................•.•............ 896
Excision of Branchial Fistula and Sinus Tract ..........•.•.......... B43 Magnetic Resonance Imaging 896
Excision of Cystic Hygroma (Lymphangioma) 845 Positron Emission Tomography ...........•.•..................... 896
Excision of Benign Lesions of the Submental Space 848 Anatomic Considerations 896
Resection of Ganglioneuroma of the Neck Posterior Suspensory Ligament .........•.•....................... 897
and Superior Mediastinum 850 Recurrent Laryngeal Nerve 897
Excision of Neuroma 852 Inferior Thyroid Artery 898
Incision and Drainage of Abscessesof the Neck 8S4 External Branch of the Superior Laryngeal Nerve 899
Abscess of Tongue and Floor of Mouth Presenting Parathyroid Glands 899
in Submental Space (Ludwig's Angina) 854
Access to the Superior Mediastinum 900
Lateral Cervical Abscess 854
Motor Nerve Supply to the Strap Muscles 901
Penetration Wounds of the Neck ...............................•....... 856
Thyroglossal Duct Tract 901
Diagnosis and Treatment ...................................•........ 856
Normal Ectopic Thyroid 901
Basic Surgical Technique 903

17 THE PAROTID SALIVARY GLAND Definition of Terms ............................................•.•............. 904

AND MANAGEMENT OF MALIGNANT Evaluation of Laryngeal Nerve Function 905
SALIVARY GLAND NEOPLASIA 861 Arytenoid Dislocation 906
Management of Thyroid Cancer 907
General Considerations 861
Total Thyroidectomy Versus Subtotal
Fine-Needle Aspiration Biopsy 861 Thyroidectomy or Lobectomy 907
Total Lateral Lobectomy of the Parotid Salivary Gland 862 Nerve Paralysis 908
Facial Nerve in Infants 866 Hypoparathyroidism 908
Deep Lobectomy of Parotid Salivary Gland 868 Potential Problems in Management 909
Mandibulotomy and Deep Lobe Lobectomy of the Hormonal Replacement 910
Parotid Salivary Gland with Dissection of
Parapharyngeal Space ..........................................•.•....... 872 Additional Evidence Supporting Total
Thyroidectomy 910
Free Facial Nerve Graft .......................................•..••........... 876
Management of Well-Differentiated Thyroid Cancer
Gustatory Sweating (Frey's Syndrome) 876 (Includes Papillary, Follicular, and HOrthle Cell
Excision of the Recurrent Benign Tumor of the Oncocytic Carcinoma) 914
Parotid Gland 878 Pathologic Classification 914
Management of Salivary Gland Tumors 880 Nieva B. Castillo
Thorn R. Loree Danger of Underestimating Malignancy 919
Additional Caveats Relative to Malignant Tumors Treatment 919
of the Parotid Salivary Gland 882
Imaging 922
lohn M. Lore, If.
Adenocarcinoma Not Otherwise Specified (NOS) 883 Medullary Carcinoma of the Thyroid 922

Malignant Mixed Tumor 884 Origin and Characteristics 922

Nievo B. Costilla Types 923
Parotid Extension of Radical Neck Dissection .......•............. 886 Classification of Multiple Endocrine Neoplasia 923
High Exposure of Internal jugular Vein Diagnosis 923
and Internal Carotid Artery .......................•.•............ 886 Familial MCT 924
Parotitis ...........................................................•.•............... 888 Suggested Follow-up Regimen .......................•.•.......... 924
Family Screening .......................................•................. 925
 CONTENTS

Management of Residual or Recurrent MCT 926 Overview of Surgical Principles 985

Scope of the Operation 926 Detailed Review of Surgical Principles ...........•.................... 986
Prognosis .......................................................•............ 927 Excision of Parathyroid Adenomas 990
Hurthle Cell Carcinoma 927 Excision of Mediastinal Parathyroid Adenomas
Papillary Tall Cell Carcinoma 927 and Cystadenoma 996
Undifferentiated or Anaplastic Carcinoma 928 Mediastinoscopy 997
Squamous Cell Carcinoma 928 Anatomy 997
Summary of Management of Thyroid Cancer 929 Discussion 997
Substernal Goiter (Median Sternotomy and Total Excision of Posterior Superior Mediastinal Parathyroid
Thyroidectomy With Superior Mediastinal Node Cystadenoma via Median Sternotomy 999
and Radical Neck Dissection) 929 Postoperative Care 1002
Graves' Disease ........................................•......................... 932 Osteoporosis 1002
Exophthalmic Graves' Disease 934 Hypocalcemia 1002
Toxic Multinodular Goiter 934
Total Thyroid Lobectomy 93S
Subtotal Thyroid Lobectomy 946 1 THE TRACHEA AND MEDIASTINUM 1015
Modified Radical Neck Dissection with Preservation
Tracheoscopy 1015
of the Sternocleidomastoid Muscle and the Spinal
Accessory Nerve 950 Tracheostomy 1015
Total Thyroidectomy Without or With Radical Neck Cervical Mediastinotomy and Tracheomediastinotomy 1024
Dissection 955 Tracheal Resection 1026
Autonomous Thyroid Nodule 960 Closure of Cutaneous Tracheal Fistula 1034
Endemic Goiter Not Due to Iodine Deficiency Closure of Cervical Tracheoesophageal Fistula 1036
(Beierwaltes) 960 Mediastinum Anatomy 1036
Hashimoto's Thyroiditis (1912}-Struma Lymphomatosa 960 Mediastinoscopy .....................•........................................ 1038
Lingual Thyroid 962 Mediastinal Dissection 1040
Complications of Thyroid Surgery 963 Suprasternal Approach via the Superior Thoracic
Suggested Postoperative Orders After Thyroid Surgery 966 Inlet (Limited Dissection) 1040
Resection of the Medial Third of the Clavicle
PARATHYROID GLANDS ...•...............•...............•......... 966 on One Side 1040
Pathology of the Parathyroid Glands 966
Median Sternotomy 1041
john E. Asirwatham
Resection of the Manubrium With or Without
Embryology 966 a Portion of the Sternum and Medial Portion
Anatomy ......................................................•.............. 966 of the Clavicle 1041
Diseasesof Parathyroid 966 Exposure of the Mediastinum by Resection of the
Intraoperative and Frozen Section Examination Medial Third of the Clavicle 1041
of Parathyroid 967 DiseasesAmenable to the Approach With Medial
Hypercellularity 968 Third Clavicle Resection 1041
Surgery of Parathyroid Glands 968 Median Sternotomy, Total Thyroidectomy,
With Superior Mediastinal Node and Radical Neck
Blood Supply of the Parathyroid Glands ...............•...... 968
Dissection 1046
Hyperparathyroidism 972
Mediastinal Dissection for Tracheostoma Recurrence
Hyperparathyroidism Associated With MEN (Sisson Procedure) 1056
Syndromes 975
Transcervical Total Thymectomy 1062
Preoperative and Intraoperative Techniques
for the Surgical Management of Sporadic
Hyperparathyroidism: Adenoma and Hyperplasia 976
john M. Lore, jr. 20 THE LARYNX 1069
Section 1: The Author's (JML) Experience Indirect Mirror Laryngoscopy 1069
and Suggestions Regarding Imaging 976
Anatomy of Superior Laryngeal Nerve 1069
Section 2: Summary Evaluations, Pros and Cons,
for Each Imaging and Nonimaging Modality 980 Punch Biopsy of Lesions of Larynx and Hypopharynx 1073

Section 3: Pearls and Pitfalls Regarding Stripping (De-Epithelialization) of a Vocal Cord 1074
Parathyroid Imaging 982 Endoscopic Removal of Congenital Cyst of Ventricle
Indications for Surgery in Primary in Newborn (Internal Laryngocele) 1076
Hyperparathyroidism 984 CO2 Laser in Laryngeal and Endobronchial Surgery 1077
Chemical Diagnosis of Hyperparathyroidism 984 Microlaryngoscopy Using the CO2 Laser 1077
 CONTENTS

Endoscopic Intracordallnjection of Teflon Paste 1078 Resection of Carcinoma at Posterior Wall

of Hypopharynx and Oropharynx and Radical Neck
Thyroplasty;Vocal Cord Mediallzation 1080
Dissection (Lateral Pharyngotomy Approach) 1181
Laryngofissure (Thyrotomy) 1082
Introduction to Reconstruction of Pharynx
Cordectomy and Arytenoidectomy for Bilateral and Esophagus 1186
Abductor Cord Paralysis 1084
Carcinoma of the Hypopharynx and Cervical
Laterallzation of Arytenoid Cartilage (Arytenoidopexy) Esophagus 1187
for Bilateral Abductor Vocal Cord Paralysis 1086
Myomucosal Tongue Flap and Dermal Graft for
Cancer of the Larynx 1089 Reconstruction of Entire Hypopharynx, Posterior
Treatment 1094 Wall of Oropharynx, and Nasopharynx Associated
With Total Laryngectomy and Total
Radiation Therapy for Laryngeal Cancer
Hypopharyngectomy 1188
Dhiren K. Shah
Cervical Esophagoscopy 1190
Partial Laryngectomy (Outline) 1100
Reconstruction of Hypopharynx and Cervical
Cordectomy for Small Carcinoma of True Vocal Cord 1105
Esophagus Using PMF With Dermal Graft 1190
Vertical or Frontolateral Laryngectomy 1106
Reconstruction After Partial "Cuff" Cervical
Omohyoid Muscle Laryngoplasty 1114 Esophagectomy, Hypopharyngectomy, and Total
Strap Muscle Laryngoplasty 1116 Laryngectomy Above the Thoracic Inlet Using
Horizontal or Supraglottic Laryngectomy 1118 Local Cervical Flaps 1192

Simultaneous Radical Neck Dissection 1120 Free Skin Graft Over Tantalum Gauze 1196

Laryngeal Suspension 1125 Thoracic Skin Flap 1196

Total Laryngectomy 1126 Resection for Cancer of the Cervical Esophagus 1199

Tracheostomal Problems 1134 Gastric Pull-Up 1200

Technique of Construction of Large Tracheal Stoma 1134 Gastric Pull-Up With Extrathoracic Esophagectomy 1200

Correction of Tracheal Stomal Stenosis 1135 Resection of Cancer of Cervical Esophagus

at the Thoracic Inlet 1206
Total Laryngectomy and Radical Neck Dissection 1136
Cervical Esophagocolostomy 1213
Tongue Flap (Myomucosal) for Reconstruction
of Portion of Hypopharynx Associated With Total Reconstruction of Esophagus Using Transverse
and Descending Colon 1216
Laryngectomy 1142
Stamm Gastrostomy ·..· 1222
Voice Prostheses: Post-Total Laryngectomy 1143
Tracheal Esophageal Puncture (TEP) .............•............ 1143 Janeway Gastrostomy · 1224

Singer-Blom Technique (Modified) 1144 Percutaneous Endoscopic Gastrostomy .................•.......... 1227

Daniel Sette Camara
panje Voice Button Prosthesis 1146
Total Laryngectomy and Radical Neck Dissection 1148
Resection of External Laryngocele 1152 22 VASCULAR PROCEDURES 1233
Laryngeal Trauma 1154 JOHN M. LORE,JR.,JOSEPHM. ANAIN,
Correction of Laryngeal Web ......................•.................... 1162 NIEVAB. CASTILLO,and L. NELSONHOPKINS
Technique of McNaught (1950) 1162 Vascular Surgery in Operations of Neck, Extracranial
Portions of Head, Face, and Thoracic Outlet 1233
Technique of Frazer (1968) 1162
Basic Principles 1233
Aspiration ....................................•............................ 1162
Degenerative Vascular Disease 1240
Carbon Dioxide Laser 1164
Extracranial Cerebrovascular Disease 1242
Exposure of Bifurcation of Carotid Arteries and
Endarterectomy 1244
21 THE HYPOPHARYNX AND
Endarterectomy With Patch Graft 1248
THE ESOPHAGUS 1171
Intraluminal Shunts Used in Endarterectomy 1248
Repair of Pharyngoesophageal Diverticulum 1171 Complications of Carotid Artery Surgery 1250
Exposure of the Superior Portion of the Thoracic Controversies of Carotid Artery Surgery 1252
Esophagus 1176
Carotid Artery Stenting: Indications, Technique,
Repair of Iatrogenic Injury to the Esophagus 1176 and Results 1254
Resection of Adenocarcinoma From the Cervical L. Nelson Hopkins
Esophagus 1176 Exposure of Cervical Portion of Subclavian Arteries
Cricopharyngeal Myotomy ............................••............ ·..· 1178 and Proximal Portion of Vertebral Arteries 1256
Transhyoid Pharyngotomy ............................••................. 1180 Vertebral Artery Reconstruction 1258
Anterior Pharyngotomy 1180 Surgical Treatment of Occlusion of Vertebral
Arteries 1258
 CONTENTS

Exposure of Distal Common Carotid Artery Thoracic Outlet Syndrome-Scalenotomy 1340

and Placement of Bypass Graft 1262
Subclavian Steal Syndrome 1262
Surgical Treatment of Occlusion of Common 23 BASE OF THE SKULL SURGERy 1348
Carotid and Subclavian Arteries and Subclavian
Steal 1264 Base of Skull and Parapharyngeal Space 1349
Atherosclerotic Aneurysm 1266 Parapharyngeal Space 1350
Anomalies of the Internal Carotid Artery 1266 Anatomy of the Parapharyngeal Space 1350
Exposure of Innominate Artery and Proximal CT versus MRI 1351
Portion of Right Subclavian and Common Approaches to the Parapharyngeal Space 1352
Carotid Arteries via Sternal-Splitting Incision 1268
Glossopharyngeal Neuralgia 1361
BypassGraft for Obstruction of Innominate Artery 1270
Infratemporal Approach to the Skull Base 1365
Resection of Kinked Obstruction in Internal Ernesto A. Diaz-Ordaz
Carotid Artery 1272
Surgery of the Parapharyngeal Space 1365
Alternate Method to Correct Kinked Internal
Advanced Radical Exposure 1368
Carotid Artery 1274
Mandibular Swing 1374
Fibromuscular Dysplasia 1274
Craniofacial Resection 1377
Vasculitis 1275
Bilateral Total Maxillectomy for Chondrosarcoma 1386
Radiation Arteritis 1275
Supraorbital Approach to the Orbit and Paranasal
Spontaneous Carotid Artery Intimal Dissection 1275
Sinuses 1391
Neoplastic Disease 1276
Cranial Portion 1391
Metastatic Squamous Cell Carcinoma 1276 Gregory /. Castiglia and Daniel P. Schaefer
Resection of Portion of Common and Internal Facial Portion 1394
Carotid Arteries Involved by Cancer 1277 john M. Lore /r. and Daniel P. Schaefer
Results of Resection and Reconstruction of the Reconstruction 1394
Internal Carotid Artery in Metastatic Carcinoma 1283
Transseptal Transsphenoidal Hypophysectomy
Paragangliomas-Head and Neck 1283 -Cryosurgical and Surgical 1395
Resection of Carotid Body Tumor 1294 Cryosurgical Hypophysectomy 1400
Resection of Intravagale Paraganglioma Surgical Ablative Hypophysectomy 1400
With Preservation of Major Vessel Continuity 1300
Endoscopic Endonasal Transsphenoidal Approach
Intravagale Paragangliomas and Bilateral Superior to the Pituitary Gland 1404
Sympathetic Ganglion Paragangliomas and Douglas B. Moreland
Unilateral Carotid Body Tumors 1302
Temporal Bone Resection 1408
Intravascular (Glomus) jugulare Paraganglioma fohn S. Lewis
Tumor 1307
Trauma to Vessels 1310
Vascular Trauma Outline 1310 24 MICROVASCULAR SURGERy 1417
Immediate Sequelae of Vessel Injuries 1310 ROBERTw. DOLAN
Late Sequelae of Vessel Injuries 1313 Microvascular Free Flaps 1417
Resection of Arteriovenous Aneurysm of the Face 1314 Historical Perspective and Introduction 1417
Resection of Aneurysm of Common or Internal Flap Classification 1418
Carotid Artery 1320 Typical Donor Flaps 1418
Transection of Internal Carotid Artery/Internal Recipient Defects and Microvascular Flap Selection 1420
jugular Vein Fistula With Resection of False
Microsurgery 1422
Aneurysm , 1320
Advantages and Disadvantages of Specific Flaps 1428
Lateral Venotomy for Foreign Body 1326
Radial Forearm 1429
Control of Hemorrhage 1328
Fibular Osteocutaneous 1436
Effects of Cancer: Carotid Artery Blowout 1328
Rectus Musculocutaneous 1441
Prevention and Management of Carotid Artery
Blowout 1328 Scapular Osteocutaneous 1448
Protection for Carotid Artery 1331 Latissimus 1456
Protection for Carotid Artery and Sources of Jejunal 1462
Muscle Bulk 1334 Iliac Crest Osteocutaneous 1464
Ligation of More Proximal Vessel 1336 Gracilis 1468
External Carotid Artery Ligation 1336
Harvesting Saphenous Vein for Graft 1338 INDEX 1471
 16 THE NECK
JESUS E. MEDINA
JOHN M. LORE, JR.
Cervical Lymph Nodes
Pharyngeal Nodes
Pharyngeal nodes lining the sides of the entire
pharynx-naso-, oro-, and hypopharynx-and the retro-
pharyngeal nodes behind the entire pharynx are a group
of nodes that are not encompassed in the standard
neck dissection and must be removed in operations
involving any portion of the pharynx. Ballantyne (1964)
has emphasized the importance of removing the retro-
pharyngeal nodes in pharyngeal wall resections but has
also reported that these nodes were involved in some
patients with other primary sites (e.g., pyriform sinus
of the hypopharynx, base of the tongue, tonsil, soft
palate, retromolar trigone, cervical esophagus, gum) and
carcinoma of the thyroid. One author (JML) has had one
patient with thyroid carcinoma and knows of another
similar patient.
Other Cervical Lymph Nodes
Open biopsy of any of these metastatic lymph nodes as
an initial diagnostic step is strongly contraindicated. It
is only performed, and then often as a frozen section,
after a diligent search for the primary lesion has failed.
Needle aspiration is performed before open biopsy (see
p.87).
This diligent search for the primary lesion must include
a complete head and neck examination as well as a
general physical examination. In addition, it must be
emphasized that when a needle aspiration for a lesion
suspected of being malignant is reported as benign with-
out any other specific diagnosis, this so-called negative
needle aspiration cannot be relied on. Either it should
be repeated or, preferably, open biopsy with frozen
section should be performed. Permission for a radical neck
dissection is ideal, depending on the other findings.
The neck dissection can then be performed if there is
an unequivocal diagnosis of differentiated squamous
cell carcinoma or thyroid carcinoma. However, there are
indications to perform node dissection in the absence
of cervical lymphadenopathy (e.g., with a T3 or T4 pri-
mary lesion or with advanced disease on the opposite
780
neck), at times a suprahyoid neck dissection for evalua-
tion of metastatic disease. If the diagnosis is suggestive
of an undifferentiated carcinoma or lymphoma, another
course of action should be taken, which is discussed in
this chapter.
Caution must be taken when performing an open
biopsy of a cervical lymph node regardless of its loca-
tion. First, if feasible, remove the entire node; if this is
not possible, take care not to spread or to implant
malignant cells. In the vicinity of the tail of the parotid
or the submandibular triangle, obvious care must be
taken not to injure the branches of the facial nerve. The
real danger is associated with the nodes in the pos-
terior triangle of the neck because of the very possible
injury to the spinal accessory nerve. These nodes usually
are very close to or actually adherent to the nerve. They
may be anterior or deep to the nerve. The nerve is
relatively superficial along this lower one-half course.
Ideally, general anesthesia would be preferred, because
local anesthesia usually blocks the nerve and makes
identification somewhat difficult. Nevertheless, it seems
excessive at times to use general anesthesia for a "simple"
biopsy. A nerve stimulator can be very helpful, because
this can distinguish between the sensory branches of
the cervical plexus and the spinal accessory nerve. The
sensory branches, like the spinal accessory nerve, should
also be preserved.
When results of the needle aspiration suggest a
lymphoma or undifferentiated carcinoma, open biopsy
is the rule.
1. Before needle aspiration and open biopsy, a careful
complete head and neck examination with
special attention given to the upper aerodigestive
tract and a general physical examination must be
performed.
2. After a needle aspiration and the suggestion of a
lymphoma or undifferentiated carcinoma, the surgeon
and the pathologist should together review the slides
and any other pertinent findings.
3. The biopsy specimen is sent to the pathologist
"fresh"-no fixative-with specific data to the
pathologist regarding the suspicion of a
lymphoma-"stat. "
 THE NECK 781

When biopsy of a tumor results in profuse bleeding, during this procedure is a common reason for malpractice
a very likely diagnosis is metastatic clear cell renal law suits. Hence a complete head and neck preoperative
carcinoma or a paraganglioma (e.g., carotid body tumor). examination with details regarding any neuromuscular
Fine-needle aspiration with a 25-gauge needle is usually dysfunction is a sine qua non before a spinal accessory
quite safe. node biopsy.
When sampling a spinal accessory nerve using local
anesthesia it is recommended not to use electrocautery
Spinal Accessory Nerve except in the immediate subdermal vessels, and then
only after the spinal accessory nerve is identified if
This nerve consists of two parts-cranial and spinal. possible and well away from the cautery. There can be
significant transmission over a short distance, 0.5 to
1. Cranial: The internal branch is the accessory portion 1.0 cm.
that communicates with the jugular ganglion of the Clinical evaluation of nerve involvement is done as
vagus nerve and is adherent to the ganglion nodose, follows:
which in turn supplies the pharyngeal and laryngeal
branches of the vagus nerve. 1. Serratus anterior: arms straight ahead
2. Spinal: The external branch has contributions from 2. Trapezius: arms abducted on the side
the second and third cervical nerves in the posterior 3. Rhomboid: hands together
triangle and then beneath the trapezius it has a
plexus with the third and fourth cervical nerves. It is
this portion of the spinal accessory nerve that is Cervical Lymph Node Metastatic
referred to by surgeons as the spinal accessory nerve Guide (Figs. 16-1 and 16-2)
because of its vulnerability and proximity in a radical
neck dissection. With these possible multiple contri-
butions from the cervical nerves, the spinal accessory The anatomy of the anterior portion of the neck is
nerve could be transected high in the neck and not shown.
have a complete paralysis of the trapezius muscle.
This may explain the various clinical findings following
the removal of the portion of the spinal accessory
nerve, particularly near the jugular foramen, of the
various degrees of muscular weakness of the trapezius.
The rhomboid muscles supplied by the dorsal scapular
nerve from the fifth cervical nerve are the other
shoulder-shrugging muscles.

The relationship of the spinal accessory nerve to the

1
OMOHYOID M.
STERNOHYOID M.
internal jugular vein at the base of the skull is (Tandler- THYROHYOID MEMBRANE
Parsons and Keith): THYROID CARTILAGE
INF. CONSTRICTOR M.

• Nerve is anterior approximately 70%. THYROHYOID M.

• Posteriorly it is less than 27 %. CRICOTHYROID MEMBRANE
CRICOTHYROID M.
• Through the internal jugular vein it is 3 %.
CRICOID CARTILAGE
Injury to the spinal accessory nerve during a node
biopsy of the juxtaposed node can result in a shoulder
droop owing to paralysis of the trapezius muscle. There STERNOTHYROID M.
also may be winging of the scapula. Nevertheless, winging
of the scapula can be a result of the injury to the long
thoracic nerve (C5, C6, C7) that supplies the serratus
anterior as well as injury to the dorsal scapular nerve,
which is motor nerve to the rhomboid muscles. There
is also definite indication that with injury to the spinal
accessory nerve, shrugging of the shoulder may be facili-
tated by the rhomboid muscles, which are also shoulder-
shrugging muscles. Injury to the spinal accessory nerve FIGURE 16-1
 THE NECK

Cervical Lymph Node Metastatic 4. Internal inferior jugular chain

Guide (Continued) (Figs. 16-1 a. Thyroid (pattern of thyroid metastasis is variable
and 16-2) because it is prone to spread to other levels (e.g.,
Nos. 1,2,3,5,6, and 9 as well as paraglandular,
It would be advantageous if a uniform plan of paratracheal, tracheoesophageal, and superior
reporting metastatic cervical lymph node involvement mediastinal nodes).
in squamous cell carcinoma was adopted. Because of b. Larynx
the overlap of disease and the variance of exact inter- c. Cervical esophagus
pretation of the level or location of the disease, such an 5. Posterior cervical triangle (spinal accessory)
ideal is hardly obtainable. Yet it is worthwhile that a a. Nasopharynx
guide or outline be supplied. Depicted in Figure 16-2A b. Thyroid
is one interpretation that has been modified after Martin c. Posterior wall of hypopharynx (occasionally)
and Morfet (1944), as depicted in Figure 16-2B, which 6. Supraclavicular (scalenus anticus lymph nodes
is the standard for staging and literature reporting. deep in this level)
Despite a usual pattern of metastatic disease in relation a. Lung
to the primary lesion, it is emphasized that cancer can b. Breast
spread virtually anywhere. It is also emphasized that c. Virtually any head and neck primary
neoplastic disease below the level of the clavicle can d. Other locations below clavicles (e.g., gastroin-
metastasize to the cervical region, and it becomes neces- testinal tract, genitourinary tract (ovary)
sary for the surgeon to perform a complete physical 7. Submandibular
examination when evaluating the patient. The usual a. Intraoral primary (e.g., floor of mouth, buccal wall)
pattern of metastasis is an aid in locating a primary b. Submandibular salivary gland
lesion that otherwise may go undetected. "Skipped" 8. Submental
metastases must be kept in mind. a.
Lip
b.
Anterior floor of mouth and alveolar ridge
c.
Buccal wall
A Depicted is a guide to usual patterns of early d.
Breast
rnetastases. 9. Cricothyroid (delphian)
Continued a. Larynx
b. Thyroid
10. Preauricular
The primary lesions are listed under each level. a. Parotid salivary gland
b. External auditory canal
1. Internal superior jugular chain. This includes lymph c. Skin of lateral face and temple region and scalp
nodes within the tail of the parotid salivary gland. d. Genitourinary tract
a. Nasopharynx ll. Not depicted: retropharyngeal and parapharyngeal
b. Base of tongue nodes
c. Palatine tonsil 12. Facial lymph nodes:
d. Parotid salivary gland a. Infraorbital (maxillary)
e. Larynx b. Buccinator-on the buccinator muscle opposite
2. Internal middle jugular chain (tonsillar or subdi- the angle of the mandible
gastric lymph nodes) c. Supramandibular-outer surface of the mandible,
a. Palatine tonsil anterior to the masseter muscle-contact with
b. Tongue and other intraoral structures facial artery and vein
c. Larynx 13. Central compartment nodes of thyroid, see p. 926.
d. Oropharynx and hypopharynx
e. Paranasal sinuses Although this next list could be virtually numberless,
f. Thyroid it includes the more common sites of the so-called
3. Internal middle jugular chain unknown primary:
a. Larynx
b. Cervical esophagus 1. Nasopharynx
c. Hypopharynx 2. Base of tongue and walls of vallecula
d. Thyroid 3. Palatine tonsil
e. Tongue 4. Pyriform sinus
 THE NECK

LYMPH NODE LEVELS IN NECK DISSECTION

1. SUPERIOR }
2.& 3. MIDDLE INTERNAL JUGULAR CHAIN

4. INFERIOR

5. POSTERIOR TRIANGLE

6. SUPRACLAVICULAR
7. SUBMANDIBULAR

8. SUBMENTAL

9. CRICOTHYROID

10. PREAURICULAR

A
FIGURE 16-2
 THE NECK

Cervical Lymph Node Metastatic B A simpler version of the cervical lymph node
Guide (Continued) (Figs. 16-1 metastatic guide is presented here. These are the zones
and 16-2) or levels referred to in the literature and staging.
1, Submandibular group; 2, upper internal jugular;
5. Laryngeal surface of epiglottis, especially at base 3, mid-internal jugular; 4, lower internal jugular; 5,
6. Laryngeal ventricle spinal accessory and posterior cervical. The current
7. Thyroid nomenclature for lymph nodes of the neck, and their
8. Hypopharynx anatomic boundaries, is provided in Table 16-1.

Not shown are the paraglandular (thyroid gland), C Depicted is a list, based on frequency, of the rnost
paratracheal, tracheoesophageal, and top superior medi- common types of primary tumors originating below
astinal lymph nodes. These are known as the central the clavicles, with metastasis to the right and left
compartment nodes to which thyroid, larynx, cervical (Virchow's) supraclavicular and mediastinal lymph nodes.
esophageal, and hypopharyngeal primary tumors may These data are from Berge and Toremalm (1969), who
metastasize. reviewed material from 411 3 cases of carcinoma diag-
nosed at necropsy. The total number of cases making
up this analysis is 2366.
 THE NECK 785

1. LUNG 1.LUNG
2. BREAST 2. BREAST
3. STOMACH 3. STOMACH
4. OVARY 4. PROSTATE
5. PROSTATE 5. OVARY
6. COLON + RECTUM 6. COLON + RECTUM
7. PANCREAS 7. BILIARY
8. UTERUS 8. PANCREAS

----
9. LIVER 9. UTERUS
10. KIDNEY 10. LIVER

1.LUNG
c 2. BREAST
3. STOMACH
4. COLON + RECTUM
5. PROSTATE
6. OVARY
7. PANCREAS
8. UTERUS
9. LIVER
10. KIDNEY
FIGURE' 6-2 Continued
 THE NECK
Cervical Lymph Node Metastatic
Guide (Continued) (Figs. 16-1
and 16-2)
Classification
To standardize our understanding of the different types
of neck dissections, we must adopt a common nomen-
clature for the lymph node groups of the neck. The
diagrammatic division of the lymph nodes of the neck,
in groups or levels, is ideal for this purpose; it is simple
and has withstood the test of many years of use (see
Fig. 16-2B).
Taking into account primarily the lymph node groups
of the neck that are removed and secondarily the anatomic
structures that may be preserved, such as the spinal
accessory nerve and the internal jugular vein, the Head
and Neck Surgery and Oncology Committee of the
American Academy of Otolaryngology-Head and Neck
Surgery has recommended classifying neck dissections
into four categories:
1. Radical neck dissection
2. Modified radical neck dissection
3. Selective neck dissection: each variation is depicted
by "SNO" and the use of parentheses to denote the
levels or sublevels removed
4. Extended neck dissection
The selective neck dissections consist of the removal
of only the lymph node groups that are at highest risk
of containing metastases, according to the location of
the primary tumor; the spinal accessory nerve, the inter-
nal jugular vein, and the sternocleidomastoid muscle
are preserved. Four different neck dissections can be
included in this category: the lateral neck dissection,
the supraomohyoid neck dissection, the posterolateral
neck dissection, and the anterior neck dissection.
The term extended neck dissection is used, in addi-
tion to any of the previously mentioned designations,
when a given neck dissection is "extended" to include
either lymph node groups or structures of the neck that
are not routinely removed, such as the retropharyngeal
nodes or the carotid artery.

TABLE 16-1 Lymph Node Groups Found Within the Six Nec:kLevels and the Six Sublevels
Lymph Node Group
Submental (subleveIIA)
Submandibular (sublevel IE)
Upper jugular (includes
sublevels lIA and liB)
Middle jugular (levellII)
Lower jugular (level IV)
Posterior triangle group
(includes sublevels VA
and VB)
Anterior compartment group
(level VI)
THE NECK
Description
Includes lymph nodes within the triangular boundary of the anterior belly of the
digastric muscles and the hyoid bone. These nodes are at greatest risk for harboring
metastases from cancers arising from the floor of the mouth, anterior oral tongue,
anterior mandibular alveolar ridge, and lower lip.
Includes lymph nodes within the boundaries of the anterior belly of the digastric
muscle, the stylohyoid muscle, and the body of the mandible. It includes the
preglandular and postglandular nodes, and the prevascular and postvascular nodes.
The submandibular gland is included in the specimen when the lymph nodes within
this triangle are removed. These nodes are at greatest risk for harboring metastases
from cancers arising from the oral cavity, anterior nasal cavity, and soft tissue
structures of the midface and submandibular gland.
Includes lymph nodes located around the upper third of the internal jugular vein and
adjacent spinal accessory nerve extending from the level of the skull base (above)
to the level of the inferior border of the hyoid bone (below). The anterior (medial)
boundary is the stylohyoid muscle (the radiologic correlate is the vertical plane
. defined by the posterior surface of the submandibular gland), and the posterior
(lateral) boundary is the posterior border of the sternocleidomastoid muscle.
SublevelllA nodes are located anterior (medial) to the vertical plane defined by
the spinal accessory nerve. Sublevel liB nodes are located posterior (lateral) to the
vertical plane defined by the spinal accessory nerve. The upper jugular nodes are
at greatest risk for harboring metastases from cancers arising from the oral cavity,
nasal cavity, nasopharynx, oropharynx, hypopharynx, larynx, and parotid gland.
Includes lymph nodes located around the middle third of the internal jugular vein
extending from the inferior border of the hyoid bone (above) to the inferior border
of the cricoid cartilage (below). The anterior (medial) boundary is the lateral border
of the sternohyoid muscle, and the posterior (lateral) boundary is the posterior
border of the sternocleidomastoid muscle. These nodes are at greatest risk for
harboring metastases from cancers arising from the oral cavity, nasopharynx,
oropharynx, hypopharynx, and larynx.
Includes lymph nodes located around the lower third of the internal jugular vein
extending from the inferior border of the cricoid cartilage (above) to the clavicle
below. The anterior (medial) boundary is the lateral border of the sternohyoid
muscle, and the posterior (lateral) boundary is the posterior border of the
sternocleidomastoid muscle. These nodes are at greatest risk for harboring
metastases from cancers arising from the hypopharynx, thyroid, cervical esophagus,
and larynx.
Includes predominantly the lymph nodes located along the lower half of the spinal
accessory nerve and the transverse cervical artery. The supraclavicular nodes are
also included in the posterior triangle group. The superior boundary is the apex
formed by convergence of the sternocleidomastoid and trapezius muscles, the
inferior boundary is the clavicle, the anterior (medial) boundary is the posterior
border of the sternocleidomastoid muscle, and the posterior (lateral) boundary is the
anterior border of the trapezius muscle. Sublevel VAis separated from sublevel VB
by a horizontal plane marking the inferior border of the anterior cricoid arch Thus,
sublevel VAincludes the spinal accessory nodes whereas sublevel VB includes the
nodes following the transverse cervical vessels, and the supraclavicular nodes (with
the exception of Virchow's node, which is located in level IV). The posterior triangle
nodes are at greatest risk for harboring metastases from cancers arising from the
nasopharynx, oropharynx, and cutaneous structures of the posterior scalp and neck.
Includes the pretracheal and para tracheal nodes, precricoid (delphian) node, and the
peri thyroidal nodes, including the lymph nodes along the recurrent laryngeal nerves.
The superior boundary is the hyoid bone, the inferior boundary is the suprasternal
notch, and the lateral boundaries are the common carotid arteries. These nodes are
at greatest risk for harboring metastases from cancers arising from the thyroid gland,
glottic and subglottic larynx, apex of the piriform sinus, and cervical esophagus.
 THE NECK
Radical Neck Dissection
(Figs. 16-3 to 16-5)
Highpoints
1. Include platysma muscle in skin flaps unless adherent
or invaded by tumor.
2. Use superior belly of omohyoid muscle as medial
guide.
3. Use scalenus muscle fascia as a guide for depth.
4. Critical areas and structures include:
a. Carotid vessels
b. Vagus nerve
c. Internal jugular vein superiorly and inferiorly
d. Subclavian vein
e. Posterior facial vein hidden in tail of parotid gland
f. Superior laryngeal nerve deep to external and
internal carotid arteries
g. Thoracic duct on left side and accessory duct on
the right side
h. Apical pleura
i. Phrenic nerve
j. Sympathetic chain
k. Spinal accessory nerve (in modified neck dissection)
I. Mandibular branch of facial nerve
5. Place incision so that bifurcation does not overlie
the carotid vessels.
6. Methylene blue dye can be used in the oropharynx
and hypopharynx in patients who have had a laryn-
gectomy when a subsequent neck dissection will be
performed. This could be done at the beginning of the
operation and would help detect any small opening
that might occur in the hypopharyngeal closure of
the previous laryngectomy.
The reader is referred to the work of Beahrs and
colleagues (1955). Crile's description (1906) of neck
dissection is one of the classics.
A An H-type incision is made with skin flaps to
include the platysma muscle. The vertical arm of the
incision should be placed so that it will not lie directly
over the carotid vessels. If desired, it may follow a
gentle S-curve that is exaggerated on the plate. Sharp
corners are rounded.
Although the H-type incIsIOn is depicted in these
drawings, other types of incisions are preferred by many
surgeons (see Fig. 16-6). These modifications are based
on the location of the primary tumor as well as on cos-
metic, exposure, and vessel protection aspects. Another
type is with a large superior flap (see Fig. 20-21A to F).
The main drawback of the H-type incision is that it
consists of two trifurcations, which, if slough occurs, may
expose the carotid vessels and be a contributing factor
to carotid artery blowout. In any patient who has had
radiotherapy over the neck, some type of carotid artery
protection is believed always indicated (e.g., levator
scapulae muscle transfer [see Fig. 22-36] or fascial flap).
The dermal graft (see Fig. 22-35) is seldom used, because
there is serious doubt whether this is sterile, and thus
it could contribute to wound infection and carotid artery
exposure and blowout. A pectoralis major myocutaneous
flap can also be used depending on the type and extent
of resection. Because the flap with the best blood supply
is usually the superior flap and because the poorest is
the posterior flap, care during the surgical procedure is
taken to avoid instruments lying over the posterior flap
edge. An area 0.5 to 1.0 cm is excised along the edge of
the posterior flap or any of the other flaps at the close
of the operation.
B Four skin flaps are developed. The platysma muscle
is included in the skin flap. Deep to the platysma
muscle are the mandibular and cervical branches of
the facial nerve. The posterior one is carried to the
edge of the trapezius muscle; the inferior one to the
clavicle; the anterior one to the strap muscles below
and slightly across the midline above; and the superior
one to the inferior edge of the horizontal ramus of the
mandible. In developing this last flap, the ramus
mandibular branch of the facial nerve is preserved only
ifthere is no evidence of gross disease in the submaxillary
space. Otherwise, no attempt is made to separate the
nerve from the lymph nodes about facial vessels. This
nerve lies deep to the platysma muscle. An incision is
then made along the dotted line starting below at the
anterior edge of the sternocleidomastoid muscle, thence
along the anterior edge of the superior belly of the
omohyoid muscle to the hyoid bone. The most viable
flap is usually the superior one, whereas the least viable
is the posterior one. The ramus mandibularis usually is
in close association with the posterior facial vein as the
vein passes deep to the mandible.
C Using a large curved clamp, the space anterior to
the sternocleidomastoid muscle is opened, exposing
the carotid sheath.
D Through an opening at the posterior edge of the
sternocleidomastoid muscle, a large curved clamp is
inserted along the plane deep to the muscle. The sub-
clavian vein, which lies beneath the clavicle and over
the scalenus anticus muscle, must be carefully
avoided. At the posterolateral aspect of the junction of
the internal jugular vein and the subclavian vein, the
thoracic duct on the left side and the accessory duct
on the right side empty into the venous system. It is
important to avoid injury to the thoracic duct, but if it
is transected, the duct should be ligated. The thoracic
 THE NECK

1. Mandibular branch of facial n.

2. External maxillary a.
3. Submaxillary lymph gland
4. Anterior facial v.
5. Tail of parotid gland
6. Posterior facial v.
7. Common facial v.
8. Greater auricular n.
9. External jugular v.
10. Inferior belly omohyoid m.
11. Cervical sensory n.
12. Superior belly omohyoid m.
13. Anterior jugular v.

FIGURE 16-3

duct lies behind the carotid sheath as it leaves the
mediastinum and then curves laterally to reach the
venous junction. Deeper and more inferior beneath
the sternoclavicular junction and deep to the carotid
sheath is the vertebral artery. This must be preserved.
E The muscle is transected using the clamp as a
guide. Few bleeders are encountered in the muscles.
The internal jugular vein, vagus nerve, and common
carotid artery are exposed lying within the carotid
sheath. Branches of the ansa cervicalis are also usually
within the carotid sheath.
Continued
 THE NECK
Radical Neck Dissection (Continued)
(Figs. 16-3 to 16-5)
F The external jugular vein is ligated with a distal
suture ligature and proximal tie and is transected,
again with care taken not to injure the subclavian vein
into which it empties. If the subclavian vein is entered,
immediate occlusion of the opening must be accom-
plished by application of pressure on the opening. This
can be done by pressure on the vein against the
clavicle to prevent air embolism (see p. 65 regarding
air embolism). Using blunt and sharp dissection, the
sternocleidomastoid muscle is reflected upward. The
fascia overlying the scalenus muscles forms the deep
plane of dissection. Deep to this fascia is the phrenic
nerve. Transverse cervical vesselsare removed unless a
trapezius myocutaneous flap is anticipated. The thyroid
gland and ansa hypoglossi are at the medial edge of
the field. The apical pleurae lie deep and inferiorly and
usually are not actually exposed.
G The carotid sheath is opened. The ansa hypoglossi
is transected.
H After the internal jugular vein is separated from
the internal carotid artery and vagus nerve, a 2-0 silk
suture is passed around the vein and tied.
I Using fine silk, a distal suture ligature is placed while
the vein is still intact.
J The same needle is passed eye first around the vein
to complete the suture ligature.
K Two similar ligatures are placed cephalad, and the
vein is then transected. Despite these sutures on the
cephalad venous stump, bleeding can occur; thus, a
Kocher clamp can be used to secure the vessel.
Continued
 THE NECK

1. Anterior jugular v. 6. Vagus n.

2. Superior belly omohyoid m. 7. Common carotid a.
3. Thyroid gland 8. Phrenic n.
4. Ansa of the hypoglossus nerve 9. Scalenus anticus m.
5. Internal jugular v.
FIGURE 16-3 Continued
 THE NECK
Radical Neck Dissection (Continued)
(Figs. 16-3 to 16-5)
L Using a Cushing vein retractor, the common carotid
artery and vagus nerve are retracted medially while the
internal jugular vein and associated nodes are removed.
The sympathetic chain is exposed deep to the carotid
artery and is preserved, if not involved by tumor. The
dissection is carried upward following the plane formed
by the anterior edge of the superior belly of the orno-
hyoid muscle. The inferior belly is transected, and the
dissection posteriorly follows the edge of the trapezius
muscle. In this area, numerous vessels (branches of
transverse scapular and cervical vessels) are encoun-
tered and sacrificed. Bleeding may occur at this site.
M The superior belly of the omohyoid muscle is
detached from the hyoid bone. The brachial plexus
with its overlying fascia is not disturbed whereas the
cervical plexus except for the phrenic nerve is sacri-
ficed. A nerve stimulator may be used to identify the
phrenic nerve. The spinal accessory nerve is transected
and with associated lymph nodes is reflected upward.
In the absenceof metastatic diseasein this chain of lymph
nodes in the region of the tail of the parotid salivary
gland and in the superior level of the internal jugular
chain of lymph nodes, the spinal accessory nerve can
be preserved, or a portion is resected and continuity is
reestablished with a nerve graft (Anderson and Flowers,
1969). Contributions of the spinal accessory nerve from
the cervical plexus, although usually sensory, may be
motor. This can be verified with a nerve stimulator. If
motor and no positive nodes are in the posterior
triangle, the distal portion of the spinal accessory may
be preserved. If clinically positive nodes are suspected
in the superior internal jugular chain of nodes, the
proximal spinal accessory nerve is removed because of
the proximity of the vein to the nerve. The nerve may
actually pass through the vein (3.2%), anterior to the
vein (70%), and posterior to the vein (26.8%) (Parsons
and Keith, from Hollinshead).
N The external maxillary artery and anterior facial
vein are transected at the mandibular edge. The prevas-
cular and retrovascular lymph nodes must be included
in the specimen. The mandibular branch of the facial
nerve is preserved if feasible and only if there is no
gross evidence of disease in this region. Its close rela-
tionship to these nodes precludes its preservation if
there is any doubt regarding disease. Unfortunately,
these nodes are almost always enlarged, thus making
the decision to preserve the mandibular branch of the
facial nerve somewhat difficult. The primary disease
and its potential spread are often the deciding factor.
A nerve stimulator is of help in locating the nerve,
which is usually superficial to the artery and vein and
deep to the platysma muscle. Sacrifice of this nerve
causes paralysis of the inferior depressor of the lower
lip. The other muscle that contributes to the depressor
of the lower lip is the risorius muscle, which is a con-
tinuation of the platysma muscle over the edge of the
body of the mandible. If this deformity is bothersome-
the patient may have slight drooling or may have a
tendency to bite the lower lip when chewing-this
may be corrected (see Fig. 9-6). Some protection of
the ramus mandibularis may occasionally be obtained
by reflecting the superior ligated stumps of the facial
artery and vein superiorly if the nerve is superior to
these ligated stumps. If the ligatures are left long, they
can facilitate the retraction.
o The submental triangle is then dissected crossing
the midline to the opposite anterior belly of the digastric
muscle. The nodes, fat, and fascia are reflected down-
ward over the anterior belly of the digastric muscle.
Posteriorly, the dissection is carried upward along the
trapezius muscle, removing all the contents of the pos-
terior triangle. The spinal accessory nerve is transected
just lateral to the internal jugular vein. The nerve can
be medial to the vein or actually, but rarely, passthrough
the vein. Initially, the nerve may lie between the
internal jugular vein and the internal carotid artery and
then cross the vein to a lateral position. Seethe section
on modified radical neck dissection (see Fig. 16-5) for
a discussion of preservation of this nerve. The bifur-
cation of the carotid artery and the hypoglossal nerve
are exposed as the internal jugular vein is dissected. To
facilitate this, venous tributaries from the thyroid and
larynx are transected as well as the lingual veins, which
are very fragile. The common facial vein is usually
removed with the specimen. Anyone of these veins
may be adherent to the 12th nerve, and extreme care
must be taken not to injure this nerve. If diseaseinvades
the nerve or is hopelessly attached to the nerve, then
the nerve is sacrificed. On exposure of the bifurcation
of the common carotid artery, if bradycardia or hyper-
tension develops or if the patient is taking digitalis,
lidocaine (Xylocaine) without epinephrine is injected
into the carotid sinus, which lies at the inner portion of
the bifurcation. At varying distances above the bifurca-
tion the 12th nerve crosses the internal and external
carotid arteries. The nerve reaches this area by cross-
ing downward along the lateral border of the internal
carotid artery. On its course inferiorly the ansa cervi-
calis joins the 12th nerve and descends inferiorly, send-
ing branches to the strap muscles.
Continued

L 4. Vagus n. over common carotid a.
o
FIGURE 16-3 Continued
A portion of this nerve is often within the carotid
sheath, adherent to the internal jugular vein, and is
removed with the contents of the neck dissection. The
ansa cervi calis has its prime origin from the second
root of the cervical plexus, with possible contributions
from C1. There may also be some contributions from
the 12th nerve, but this is of some doubt. Care must
be taken to avoid injury to the superior laryngeal nerve
as it passes deep to the external carotid artery and as
THE NECK
1. Mandibular branch facial n.
2. Superior belly omohyoid m.
3. Accessory and middle cervical sympathetic
ganglia
5. Phrenic n. over scalenus anticus m.
6. Brachial plexus
7. Anterior edge trapezius m.
8. Stump of inferior belly omohyoid m.
9. Distal cut end spinal accessory n.
10. Superior belly omohyoid m.
11. Cervical plexus
12. Cut end inferior belly omohyoid m.
13. Distal cut end spinal accessory n.
14. Anterior belly digastricus m.
15. Hyoid bone
16a. Internal branch (sensory) of superior laryngeal n.
16b. External branch (motor) of superior laryngeal n.
17. Hypoglossal n.
it lies in a vulnerable area just medial to the vessel.
Here, this nerve divides into an external branch that
supplies motor fibers to the cricothyroid muscle (tensor
of the vocal cord) and the inferior constrictor muscle
of the pharynx and into an internal branch that is the
prime sensory nerve of the larynx. Injury to this nerve
may cause aspiration of food into the trachea,
dysphagia, and hoarseness during the postoperative
period.
 794 THE NECK
Radical Neck Dissection (Continued)
(Figs. 16-3 to 16-5)
P The submandibular space is then dissected (see
Fig. 16-12), preserving the lingual and hypoglossal
nerves. Wharton's duct and tributaries of the lingual
vein are ligated and transected. The excitoglandular
nerve fibers of the chorda tympani to the submandibular
gland are transected. Along with this parasympathetic
nerve is a small blood vessel that is best ligated before
transection of the nerve. Otherwise, the vesselcan retract
and be very bothersome to grasp and then ligate. The
deep plane of dissection is the hyoglossus muscle,
whereas the digastric and stylohyoid muscles form the
inferior plane. In the presence of metastatic disease
high in the neck, the posterior belly of the digastricus
and the stylohyoid muscles are removed with the
contents of the dissection. The occipital and posterior
auricular arteries will be encountered, and they may
be ligated if need be. If a forehead flap is planned, these
vessels should be preserved if their preservation does
not compromise adequate ablative resection. lidocaine
1% is injected into the carotid sinus between the
branches of the carotid artery if there is any drop in
blood pressure or if the patient is on digitalis.
Q The muscle and lymph node mass are reflected
upward to the point at which the internal jugular vein
is no longer mobile. At this point, with extreme care,
a blunt right-angle clamp (Mixter) is placed behind
the vein, and a tie of 2-0 silk is passed about the vessel.
An accessory vein may be located in this area draining
into the internal jugular vein. Care must be taken to
ligate this vessel independently.
R A fine silk suture ligature is then placed distally.
Distal to the suture ligature, a free tie is secured, and
the vessel is cut between the two distal ligatures.
S With the internal jugular vein transected, the neck
mass is further released and dissected upward. The
external maxillary artery is ligated and transected as it
passesdeep to the posterior belly of the digastric and
stylohyoid muscles.
T The tail of the parotid is transected along with the
attachment of the sternocleidomastoid muscle. Deep
in the parotid are numerous vessels that must be
carefully ligated. The largest is the posterior facial vein,
which is doubly ligated with a proximal tie and a distal
suture ligature, because back-pressure may cause
troublesome bleeding. The ramus mandibularis nerve
often is closely related to this posterior facial vein.
U The completed dissection is shown. Before the
closure, the wound is well irrigated with saline. An area
0.5 to 1.0 cm of the vertical border of the posterior
skin flap and any other flap edge that appears dusky
and traumatized is now excised. This serves to remove
any skin that has been injured by pressure from instru-
ments during the procedure. It is particularly useful in
those patients who have had preoperative radiation
treatment, because such a freshened edge to the skin
flap enhances primary healing.
A two-layer closure is employed using continuous
4-0 chromic catgut for the approximation of the
platysma muscle and subcutaneous tissue and
continuous 5-0 nylon for the skin.
V Two Jackson-Pratt drains are used and connected
to wall suction with or without a pressure dressing.
Suction catheters must be secured away from the carotid
artery using gut to prevent carotid artery blowout. Do
not tie the gut tightly around the catheters, otherwise
removal may be impaired. If a significant portion of
the parotid gland is removed, a pressure dressing is
utilized in this area to prevent temporary and possibly
permanent swelling of the parotid salivary gland.
W Skin incision for simultaneous bilateral radical
neck dissection is shown. A tracheostomy is routine.
Bilateral simultaneous radical neck dissection is seldom
performed; and when it is, preservation of one internal
jugular vein is recommended if this is compatible with
adequate ablative surgery.
18. Lingual n.
19. Wharton's duct
20. Stylohyoid m.
21. Lingual a.
22. Internal carotid a.
23. Posterior belly digastricus m.
FIGURE 16-3 Continued
 THE NECK 795

T u

w
1. Anterior belly digastricus m. 13. Internal carotid a.
2. Mylohyoid m. 14. Portion levator scapulae m.
3. Submaxillary salivary gland 15. Portion levator scapulae m.
4. Hyoglossus m. 16. Scalenus posterior m.
5. Posterior facial vein within tail of parotid 17. Scalenus medius m.
6. Mandibular branch of facial n. 18. Brachial plexus
7. Stylohyoid m. 19. Scalenus anticus m.
8. Transected portion of tail of parotid 20. Phrenic n.
9. Posterior belly of digastricus m. 21. Vagus n.
10. Hypoglossal n. 22. Thyroid gland
11. Proximal stump spinal accessory n. 23. Thyrohyoid m.
12. Splenius capitis m. 24. External carotid a.

FIGURE 16-3 Continued

 THE NECK

Radical Neck Dissection (Continued) facial nerve or the platysma muscle via innervation
(Figs. 16-3 to 16-5) from the cervical branch of the facial nerve.
• Edema of face, especially with bilateral neck
Niederdellmann and colleagues (1982) have reported dissection
on the restoration of the internal jugular venous path- • Intracranial complications with bilateral neck
ways with polytetrafluoroethylene (PTFE) grafts after dissection: blindness and cerebral edema
ablative neck surgery in 45 patients. This type of • Myositis ossificans
vascular reconstruction would have application to • Transection of the phrenic nerve in an infant may
bilateral simultaneous neck dissection. well result in scoliosis.

Complications Indications for Postoperative Radiotherapy

During the Operation
• Injury to uninvolved nerves
• Laceration of internal jugular vein near base of skull
or at the thoracic inlet
• Injury to thoracic duct
• Injury to subclavian vein causing air embolism
• Injury to pleura causing pneumothorax
• Danger of ventricular fibrillation with undue pressure
on carotid sinus in patient heavily digitalized
Postoperative
• Hemorrhage, especially from posterior facial vein if
not occluded with a tie and a suture ligature. Despite
these precautions, hemorrhage has occurred from the
stump of the internal jugular vein during struggling
after a severe stormy reaction from anesthesia.
• Skin slough
• Carotid artery blowout
• Wound infection
• Chylous fistula
• Pneumothorax
• Pain referred to shoulder and arm
• Shoulder droop and weakness of arm
• Drainage: suction tube can erode a major vessel or
cause skin necrosis from pressure.
• Deformity (superior tenting) of lower lip. This may be
due to injury to either the mandibular branch of the
(4 to 6 Weeks Post Operation)
• Highest superior and/or lowest inferior neck
dissection nodes positive
• Margins positive
• Tumor extending through the lymph node capsule
(extracapsular spread). (This will subsequently be
referred to as extracapsular spread by Johnson and
coworkers [1981], and Snyderman and associates
[1985].)
• Extension of disease beyond the fascial planes of the
neck
• Invasion of the deep cervical musculatures
• Recurrence within 6 weeks
• Patients who had multiple cervical lymphadenopathy .
(This was later modified according to the extent and
location of the multiple cervical lymphadenopathy,
that is, all patients with multiple nodes did not receive
radiotherapy.)
Table 16-2 presents data discussed previously in
Chapter 3 under Preoperative Chemotherapy, Uncom-
promised Surgery, and Selective Radiotherapy.
It is of interest to note that in an article reporting on
the evaluation of NO necks with positron emission
tomography (PET), of 14 patients with clinically negative
necks, after radical neck dissection 7 patients have posi-
tive histology for metastatic squamous cell carcinoma-
a 50% error in clinical diagnosis. Of the 7 patients, PET
demonstrated 5 patients with positive scans for metastatic

TABLE 16-2 Neck Dissection (Thta. No. of Patients - 82) and Recurrence in Neck (N - 6)

Neck Dissection No. of Patients Positive Nodes Recurrences

Radicalneck dissection' 77 41 6 (7.8%)

Arm A 43 27 6 (13%)
Arm B 34 14 (0%)
Suprahyoid (AllArm A) 2 0 0
No node dissection 3 0 o (Metastases)

*Includes three simultaneous contralateral suprahyoid dissections. No functional neck dissections done.
Arm A-cisplatinjbleomycin; Arm B-cisplatinjS·fluorouracil.
Note: Positive nodes are based on histologic examination of neck dissection specimens after response [Q chemotherapy. Therefore, actual
positive nodes would be high in number, because some nodes will not demonstrate malignant cells after chemotherapy.

carcinoma. Hence, this demonstrates the importance of
radical neck dissection in patients with negative necks
who have stage III or stage IV primary carcinoma in the
head and neck (Myers et aI., 1998).
The recurrence rate amounted to 30% (7 of 23 patients)
in one report when the time lag between the surgery and
the start of radiation therapy exceeded 7 weeks, whereas
it was only 3 % (1 of 33 patients) when the time lag was
shorter. This appears to be statistically significant.
Evaluation of Cervical
Lymphadenopathy on Computed
Tomography and Magnetic
Resonance Imaging
Cervical lymphadenopathy, usually smaller than I cm,
is often considered benign. This may give a false impres-
sion. Other important factors relative to the assertion of
benign or malignant is the location of the node (e.g., in
relation to a draining area from a known carcinoma of
the oral cavity or oropharynx), as well, of course, as
the size of the node and whether there is peripheral
enhancement, meaning that there is a white rim around
the node in a centralized dark area, which may indicate
that the node is suggestive of being malignant. Obviously,
most lymph nodes dissected on the scan, less than 1
cm, are of little concern. Nevertheless, this has to be all
taken into consideration based on clinical examination
and the primary malignant neoplasm.
Modifications of Radical Neck
Dissections (See Figs. 16-4 and 16-5)
The controversy over conservation (functional)
(Ballantyne, 1964; Bocca et aI., 1980; Jesse et aI., 1978)
neck dissection versus radical neck dissection in the
treatment of squamous cell carcinoma continues unabated.
In between these two "camps" is the modified radical
neck dissection in which the sternocleidomastoid muscle,
spinal accessory nerve, and at times the contents of the
submandibular triangle and internal jugular vein are
not resected. From one author's (JML) point of view
this modified radical neck dissection with resection of
the internal jugular vein should be relegated to the treat-
ment of metastatic disease from papillary or follicular
cancer of the thyroid when there is no evidence of
invasion of muscle. The modified radical neck dissection
and the conservation, or functional, neck dissection is
not utilized in metastatic squamous cell carcinoma by
one author (JML). The one exception is the preservation
of the spinal accessory nerve in metastatic squamous
cell carcinoma. Simply put, if there is no clinical or
operative indication of metastasis to the superior internal
jugular lymph nodes or to the lymph nodes in the pos-
terior triangle of the neck, the spinal accessory nerve
may be preserved. Although the posterior triangle is
THE NECK 797
free of disease, the spinal accessory nerve proximally is
intimately related to the superior internal jugular nodes,
and thus its preservation is strongly contraindicated under
such circumstances. At this point the spinal accessory
nerve is not in the posterior triangle but actually in the
superior portion of the anterior triangle of the neck.
There are other factors that must likewise be taken into
account, namely, preservation of the spinal accessory
nerve may not be justified simply to preserve shoulder
function, because occasionally motor contributions from
the upper branches of the cervical plexus may exist.
This can be confirmed at the time of operation with a
nerve stimulator. In addition, the rhomboid muscles
also aid in shrugging the shoulder. Furthermore, the
post-neck dissection shoulder pain may in fact not be
related to the sacrifice of the spinal accessory nerve.
When comparing the long-term results of conservation
neck dissection with those of radical neck dissection,
the available data are rendered confusing by the fact
that some series of conservation neck dissections include
patients with clinically negative necks as well as those
with histologically positive necks who have undergone
postoperative radiotherapy. Obviously, one then is
comparing apples with oranges. That is not to say that
postoperative radiotherapy is not ever indicated-it is
under the following conditions, which were first outlined
in the 1979 National Institutes of Health (NIH) grant
(Lore and Hendrickson; see Chapter 3). There were no
neck recurrences in regimen B (cisplatin and s-f1uo-
rouracil with uncompromised surgery-standard radical
neck dissection). There were 37 patients in the study.
I. The highest and/or lowest nodes are positive.
2. Disease involves the deep muscles of the neck.
3. Disease has broken the capsule of the cervical nodes.
This has subsequently been referred to as extracap-
sular spread (Johnson et aI., 1981; Snyderman et aI.,
1985). This finding indicates a grave prognosis. Post-
operative radiation therapy is usually begun within 4
to 6 weeks.
4. Margins are positive.
5. Multiple positive nodes are present.
6. Disease is left behind, or the surgeon is not satisfied
that the operation has been a "clean dissection."
The functional neck dissection in which the
sternocleidomastoid muscle, internal jugular vein, and
spinal accessory nerve are all preserved in the clinically
negative neck can be considered as an extensive nodal
biopsy. If any node is positive, then postoperative
radiotherapy is utilized CJEM). In this circumstance the
procedure may have a place in the treatment of head
and neck squamous cell cancer. At this point in time
the other author (JML) does not subscribe to this
methodology "across the board" but acknowledges that
it does have a place (e.g., suprahyoid dissection when
there is possibility of undetected metastasis).
 THE NECK
Parotid Extension of Radical Neck
Dissection (High Exposure of Internal
Jugular Vein and Internal Carotid Artery)
(Fig. 16-4)
Indications
Metastatic disease in the high internal jugular nodes, in
the high spinal accessory nodes, and in juxtaposition to
the tail of the parotid salivary gland requires an exten-
sion of the standard radical neck dissection. Although
the standard neck dissection includes the tail of the
parotid, the level of transection of the parotid may be
too low in such metastatic disease because the exact
location of the facial nerve is not known. In addition,
good visualization of the high internal jugular region is
hampered by overlying structures.
This particular exposure, combined with extraoral
transection of the mandible, is also ideal for high anas-
tomoses of the internal carotid artery for replacement
grafts as a result of either local tumor invasion or
obliterative vascular disease.
The operation is well suited to combined neck and
mandible resections when the disease warrants
Exposure of the mandible is enhanced.
Highpoints
1. Expose and preserve the main trunk of the facial
nerve.
2. Electively sacrifice the cervicofacial division of the
facial nerve if necessary.
3. Preserve the zygomaticotemporal division of facial
nerve.
4. Resect the entire lower half of the parotid from the
level of the main trunk of the facial nerve.
5. Resect the posterior belly of the digastric muscle and
the stylohyoid muscle.
A The skin incision of the standard neck dissection is
modified by preauricular and postauricular incisions as
for the exposure in parotid lobectomy. The upper skin
flap is elevated over the lower two thirds of the
parotid.
B The main trunk of the facial nerve is then exposed,
using the technique described in parotid lobectomy
(see Fig. 17-1) except that it is somewhat easier, because
the insertion of the sternocleidomastoid muscle is
shaved off the mastoid process. When this is done, the
posterior belly of the digastricus muscle is clearly seen,
as is the closely related band of fascia running from the
parotid to the tympanomastoid fissure.
C A small Mixter forceps is inserted under
temporoparotid fascial band. The band is cut, and the
facial nerve is exposed.
D The main trunk of the facial nerve is then exposed
to its first major bifurcation into the lower or cervi-
cofacial division and the upper or zygomaticotemporal
division. With a small hemostat underneath it, the
digastric muscle is shown being transected close to its
origin in the mastoid notch of the temporal bone. The
deeper stylohyoid muscle is transected in similar fashion.
Purely of anatomic interest are the first small branches
of the extracranial portion of the facial nerve. These are
three, innervating the posterior auricular muscle, the
posterior belly of the digastricus muscle, and the stylo-
hyoid muscle. These branches have no surgical signifi-
cance, except that in the very rare case when the main
trunk of the facial nerve is obscured the branch to the
posterior belly of the digastricus could conceivably be
traced back to its origin from the main trunk.
E The two main divisions of the facial nerve are then
exposed for a short distance. Whether sacrifice of the
it. entire lower division (cervicofacial) is indicated is decided
now. It usually is sacrificed, because the resulting facial
deformity involves only the ipsilateral lower lip. With
extensive disease in the upper neck, whether or not
this extended operation is performed, preservation of
the mandibular branch of this lower division is not
indicated; hence, there will be weakness of the lip. The
buccinator branch will usually not be affected, because
it has fibers arising from both upper and lower divisions.
F The entire parotid gland from the level of the main
trunk of the facial nerve and the level of the upper
division (zygomaticotemporal) is now transected just
below these nerves, preserving them. The posterior
facial vein is ligated and divided at this same level. If
the remaining portion of the lateral lobe is very thick
and prominent, a portion of this may likewise be
excised purely from the cosmetic viewpoint. This will
avoid a sharp break in the contour of the side of the
face at the level of the major resection. It has been
most helpful in diminishing the usual postoperative
parotid prominence.
The freed lower portion of the parotid is now sepa-
rated from the masseter muscle, while the stylohyoid
and posterior belly of the digastric muscle are turned
downward'. Three arteries are usually encountered: the
occipital, the posterior auricular, and a branch to the
sternocleidomastoid muscle. These are all ligated and
divided. Excellent visualization of the highest reaches
of the internal jugular vein is now gained. lust lateral
to the vein is seen the spinal accessory nerve, which
may be (the relationship of the spinal accessory nerve
this to the internal jugular vein may vary from anterior,
 THE NECK 799

Facial nervei
br. to stylohyoio<..
and post. belly
digastricus

D Zygomatico-
temporal div.
Cervicofacial div.

Post. belly digastricus m.

Post. auricular n.
F

Cervical facial div.

Hypoglossal n.
ost.
auricular a.
Spinal accessory n.
r Occipital a.
.' lnt. jugular v.

FIGURE 16-4

posterior, medial, or lateral or actually passthrough the
vein) preserved or sacrificed at this level, depending
on proximity of the neoplastic disease. Any nodes in
this area can be carefully swept downward, exposing
a sufficient portion of the internal jugular vein for
ligation and division. This is done by very carefully and
slowly passing a small Mixter forceps behind the vein
and pulling through a 2-0 silk tie. A distal suture
ligature of 4-0 silk is used.
Continued
 THE NECK
Parotid Extension of Radical Neck
Dissection (High Exposure of Internal
Jugular Vein and Internal Carotid Artery)
(Continued) (Fig. 16-4)
The reader is referred to page 872 regarding deeper
dissection, which could possibly expose the vertebral
artery, and to page 868 regarding resection of the deeper
lobe of the parotid.
G If preferred, the internal jugular vein may be ligated
and divided by reflecting the neck mass upward, thus
exposing the posterior aspect of the vein from below.
Because the anterior aspect has already been exposed,
the placement of a tie about the vein is not difficult.
H A proximal tie of 2-0 silk is in place around the
internal jugular vein with a distal suture ligature of 4-0
silk being inserted.
I The entire neck specimen is now removed by
transection of the insertions of the posterior belly of
the digastric and the stylohyoid muscles from the hyoid
bone. Lingual veins will require ligation and division at
this site, as will the external maxillary artery as it enters
the digastric triangle laterally. If not involved by the
neoplasm, the hypoglossal nerve is carefully preserved
as it lies over the internal carotid artery and crosses
the external carotid artery and hyoglossus muscle. The
wound is closed in the usual manner for neck
dissection.
This is not cookbook surgery. This is an inherent
danger in an atlas of surgery. There must be experience
with the various procedures and modifications thereof.
The choice must not be based on the easiest, quickest,
minimal deformity, nor influenced by organ preservation.
There is a danger of preserving soft tissue and bone
with minimal margins and even no margins. In other
words, leave disease right up to the line of resection.
The surgeon falls into the trap that if there are a "few
cells left behind" these will respond to the routine post-
operative radiotherapy and this will solve the problem
of this minimal concept of resection of tumor-bearing
tissue-those areas where tumor remains. In the same
breath it must be understood that there is a place for
radiotherapy for the nonresectable disease.
When multiple modalities, for example, surgery,
radiotherapy, chemotherapy, are involved in the man-
agement of carcinoma, compromising-minimizing-
the extent of the resected area must be avoided until
more end-result data become available. In addition,
when various modalities are utilized in the manage-
ment of a neoplasm, additions of a modality or changes
in a modality should be limited to only one of the
modalities at a time.
As more tissue and bone are removed, the recon-
structive measures must be further improved and
expanded from a cosmetic point of view and a func-
tional point of view. A caveat that must be emphasized
is that wherever possible or practical, the reconstructive
measures should not mask early or even late recurrence
of disease. At times this is not possible, so along with
reconstruction regular careful and thorough follow-up
must be carried to the best possible degree. Follow-up
must be done by those expert in the field of head and
neck examination, and it may be best at different times
to have different physicians and other allied disciplines
involved in this search for early recurrence (e.g., the
reconstructive surgeon, the ablative surgeon, the
prosthodontist, the nutritionist, and specially trained
nurse clinicians). This is time consuming both for the
medical profession and for the patient and sometimes
it is shattering for health maintenance organizations.
These follow-up examinations should be scheduled on
a regular basis, usually one time per month for the
first year and then every second month for the second
year. Of course, these frequencies may be increased or
decreased depending on the anticipated natural history
of the disease. Just as it is time consuming and exhaust-
ing to do an adequate initial evaluation of the extent of
the primary tumor and the metastatic disease before the
decision of therapy and the onset of therapy, it is not
unusual to spend upwards of 60 to 90 minutes in this
type of preoperative evaluation.
It is very interesting to note some data that have been
reported comparing mastectomy /lumpectomy followed
with radiotherapy in younger women and older women.
The older women have better results than the younger
women, and it was suggested that the surgeons with
the younger women do a more conservative surgical
procedure because of cosmetics. The lead researcher in
this article, Dr. Frank Vicini of the William Beaumont
Hospital in Royal Oak, Michigan, states: "You have to
do bigger surgeries to make sure you have got all the
cancer cells." Vicini concluded saying that "Post-surgical
radiation cannot compensate for a too small cut."
Recently, Haagensen, who is noted for a very meticu-
lous radical mastectomy for carcinoma of the breast,
reported approximately 900 of his patients with a 50-year
follow-up. The survival figures were 8% better than
compared with the more modern complex treatment of
breast cancer.
Questions have also been raised regarding the reduc-
tion in the lateral extent for surgery for rectal carcinoma.
Although these data are somewhat anecdotal, never-
theless it does seem to indicate that surgery that is
uncompromised, carefully planned, and all encompassing

Mylohyoid m.
Ant. belly digast. m.
Hyoglossus m.
Hyoid bone
Ext. maxillary a.
Occipital artery
FIGURE 16--4 Continued
is still an important modality in the management of not
all, but many, malignant lesions.
The term modified radical neck dissection is used
today to refer to those modifications of the radical neck
dissection that were developed with the intention of
reducing the morbidity of this operation, preserving
one or more of the following structures: the spinal
accessory nerve, the internal jugular vein, or the
sternocleidomastoid muscle. Like the radical neck
dissection, the modified radical neck dissections
remove all five nodal groups in one side of the neck.
THE NECK
The three neck dissections that can be included in this
category differ from each other only in the number of
neural, vascular, and muscular structures that are pre-
served. Therefore, Medina and Byers (1989) suggested
subclassifying these neck dissections into a type !, in
which only "one" structure, the spinal accessory nerve,
is preserved; type II, in which "two" structures, the spinal
accessory nerve and the internal jugular vein, are
preserved; and type III, in which all "three" structures,
the spinal accessory nerve, the internal jugular vein,
and the sternocleidomastoid muscle, are preserved.
 THE NECK
Modified Radical Neck Dissection
Preserving the Spinal Accessory Nerve
(Type I) (Fig. 16-5)*
This operation is defined as the en-bloc removal of the
lymph node-bearing tissues of one side of the neck,
from the inferior border of the mandible to the clavicle
and from the lateral border of the strap muscles to the
anterior border of the trapezius, preserving the spinal
accessory nerve. The internal jugular vein and the
sternocleidomastoid muscle are included in the resect-
ed specimen.
Preservation of the spinal accessory nerve in the
course of a radical neck dissection is advocated on the
basis of the following observations:
1. The morbidity associated with the radical neck dissec-
tion, especially the shoulder disability that results
from resecting the spinal accessory nerve, and, to a
lesser extent, the cosmetic deformity that results
from this operation, particularly when it is done on
both sides of the neck.
2. The realization that, in many instances, the spinal
accessory nerve is not in close proximity to the nodes
grossly involved by tumor and that its preservation
does not compromise the oncologic soundness of
the operation.
Indications
This type of neck dissection is universally accepted as
an adequate operation for the elective treatment of the
neck in patients with squamous cell carcinoma of the
upper aerodigestive tract. Currently, however, the main
role for this type of neck dissection appears to be in the
surgical treatment of the neck in selected patients with
clinically obvious lymph node metastases. An increasing
number of surgeons are advocating preserving the spinal
accessory nerve whenever it is not directly involved by
tumor, regardless of the number, size, and location of
the involved lymph nodes. Obviously then, the deci-
sion to preserve the spinal accessory nerve and, thus,
the indication for this type of neck dissection becomes
a delicate intraoperative judgment call. Much like the
current philosophy about preservation of the facial nerve
during surgery for parotid tumors, the spinal accessory
nerve can be preserved whenever there is a clearly
identifiable, not an artificially created, plane of dissec-
tion between the tumor and the nerve.
Surgical Technique
The incisions used for this type of neck dissection are
the same as those outlined in Figure 16-6A. After the
'Adapted from Medina JE: Modified neck dissection. In Shockley
ww. Pillsbury He III (eds): The Neck: Diagnosis and Surgery. Sl.
Louis, Mosby, 1994, pp 551·572.
skin flaps have been elevated, the operation proceeds
in a manner similar to that described for the radical neck
dissection. The difference, however, is that in this opera-
tion, the spinal accessory nerve is preserved. Therefore,
special attention must be paid in the description of this
technique to the initial exposure and dissection of the
spinal accessory nerve. This can be accomplished in
three ways:
1. After the dissection of the submandibular triangle
is completed and the posterior belly of the digastric
muscle is exposed, the fascia and fibroadipose tissue
immediately below this muscle are elevated in thin,
transparent layers using a hemostat that is opened in
a direction parallel to the muscle. This allows the
surgeon to incise these tissues without injuring the
underlying structures. As this maneuver is repeated
a few times, along the entire inferior border of the
digastric, the fibroadipose tissues of the area are gently
retracted inferiorly, exposing the hypoglossal nerve,
the internal jugular vein, and the upper end of the
spinal accessory nerve. In most instances, the nerve
is found immediately posterior to the jugular vein;
however, it may lie obliquely across the anterolateral
surface of the vein or, less commonly, be completely
posterior to it (see Fig. I6-5A). Exposure and isola-
tion of the nerve then proceeds downward and back-
ward. This requires incising the sternocleidomastoid
muscle, over the course of the spinal accessory nerve,
obliquely across its upper one third.
2. The fascia is incised along the lower one third of the
anterior border of the trapezius muscle. The under-
lying fibroadipose tissue is then incised one layer at
a time until the nerve is visualized (see Fig. 16-5B).
If the electrical cautery is used to incise tissue, it
is best to elevate thin layers of it and incise them
between the jaws of a hemostat opened in a direc-
tion parallel to the trapezius. This minimizes direct
stimulation and/or injury of the nerve.
3. The fascia and underlying tissue are incised imme-
diately behind the posterior border of the trapezius
muscle, in the vicinity of Erb's point (i.e., the point
where the greater auricular nerve curves forward,
around the posterior border of the sternocleido-
mastoid muscle). In doing this, the surgeon should
keep in mind that the relationship of the spinal
accessory nerve to Erb's point is not as consistent as
some anatomy texts proclaim, that in this area the
location of the spinal accessory nerve is the deepest
in its course through the posterior triangle of the
neck, and that the nerve can be easily confused with
the cutaneous branches of the cervical plexus.
Once the nerve has been exposed and isolated through
its entire course in the neck, the upper, posterior, and
inferior dissection of the neck can proceed in the same

manner as in the radical neck dissection. The superior
and posterior portions of the specimen are passed
under the nerve when they are sufficiently freed (see
Fig. 16-5C). The completed dissection is shown in
Figure 16-50.
When performing this operation, the surgeon must
bear in mind that preserving the spinal accessory nerve
does not ensure adequate postoperative function of the
trapezius. Moderate to severe electro myographic abnor-
malities and temporary dysfunction of the trapezius have
been observed in patients who have undergone modi-
fied radical neck dissections (Remmler et aI., 1986;
Sobol et aI., 1985). Consequently, it is critical to handle
the nerve carefully during surgery, avoiding undue
traction and stretching of it.
THE NECK
A The spinal accessory nerve is exposed under the
digastric muscle, and its dissection proceeds down-
ward.
B The spinal accessory nerve is exposed in front of
the trapezius, and its dissection proceeds upward.
C The superior and posterior portions of the speci-
men are passed forward under the nerve, retracted here
by grasping the branch to the sternocleidomastoid.
D Completed modified radical neck dissection with
preserved spinal accessory nerve.
 THENECK
Incision Modifications of Radical Neck
Dissection (Fig. 16-6)
Highpoints
The fact that so many types of neck incisions exist is
strong testimony that there is hardly one incision that
fits all contingencies. Factors that will influence the
surgeon's choice are listed as follows:
1. Exposure
2. Viability of flaps
3. Protection of carotid arteries
4. Previous scars and biopsy sites
5. Location of primary lesion
6. Primary and secondary reconstruction procedures
(e.g., if a deltopectoral flap is a possibility, a low
horizontal incision is a distinct advantage)
7. Preoperative radiation therapy
8. Cosmetic result
9. Cervical flaps based posteriorly have a poorer blood
supply than those based medially and superiorly. A
superior-based flap usually has the best blood supply.
A The H-type incision of Martin affords excellent
exposure and can be combined with the resection of
almost any primary lesion with slight modification. Its
main drawbacks are the sharp triangular trifurcation of
the flaps and poor protection of the carotid artery if
the superior trifurcation breaks down. The free edge of
the posterior flap may have a tendency to become
necrotic because of its poor blood supply plus the fact
that during the neck dissection, hemostats are wont to
lie on the free edge and traumatize the edge. At the
time of closure, it has been found helpful to excise 0.5
to 1,0 cm of this free edge. Cosmetically, this incision
can be objectionable. Occasionally, multiple Z-plasties
are necessary at a later date.
B Schobinger described a neck dissection incision
with a large anterior flap that affords good exposure
and protection for the carotid arteries. The horizontal
or upper incision is about 2 cm behind the angle of the
mandible. It is at this point that the vertical incision
starts at right angles, thus avoiding any acute angles.
Acute angles produce narrow sections of skin, resulting
in a high incidence of necrosis. The vertical limb then
extends to the anterior edge of the trapezius muscle,
curving downward and slightly forward to cross the
middle of the clavicle, extending 2 to 3 cm below the
clavicle. Although it might seem that a neck dissection
on the contralateral side using the same incision may
interfere with the blood supply, such is not the case
when staged with at least a 1-month interval as
described by Yoel and Linares (1964). Nevertheless,
skin slough has been reported with this incision.
C This incision was used by Lahey and associates in
1940 and was later reported by Eckert and Byars (1952)
as well as by Grandon and Brintnall (1960). It affords
good carotid artery protection as well as being cos-
metically acceptable. The main drawback is limited
exposure. It cannot easily be adapted for resection of
primary intraoral cancer; however, it is well suited for
bilateral neck dissection and is useful with thyroidec-
tomy or laryngectomy with neck dissection. If neces-
sary, an inferior posterior extension is made along the
dotted line. The vertical limb of the incision frequently
heals with a very thick scar that is almost keloid in
appearance. However, if placed well posterior, it is not
too conspicuous.
D Latyshevsky and Freund (1960) described a large
superior-based flap that can be modified by shortening
this superior flap. It has a good blood supply and
affords protection for the carotid arteries.
E The two parallel incisions of MacFee (1960)
produce an excellent cosmetic effect, but the exposure
at times can be quite trying. With the upward and
downward retraction of the bipedicle flap, necrosis has
occurred along the upper border of this flap directly
over the carotid artery. Care must be taken to avoid
this complication. Increased mobility of the flaps is
achieved by extending the incision more posteriorly
(Attie).
F Conley (1955) has modified the Schobinger inci-
sion by making the horizontal upper limb continuous
with the vertical lower limb. It slopes inferiorly 3 cm
below the angle of the mandible. The short supero-
posterior extension is at right angles to the main long
portion. The advantages are similar to those of the
Schobinger incision.
Continued
 THE NECK

A B

MARTIN 1951 SCHOBINGER 1957

c D

LAHEY 1940

E F

MACFEE 1960 CONLEY 1966

FIGURE 16-6
 THE NECK
Incision Modifications of Radical Neck
Dissection (Continued) (Fig. 16-6)
G One of the modifications of the H-type Martin
incision is described by Slaughter and Southwick
(1955). Its main advantage over the Martin incision is
the smooth curve of the upper and lower flaps, which
eliminate the sharp trifurcation closure. It affords
excellent exposure. As in the Martin incision, if 0.5 to
1.0 cm of skin is excised along the free edge of the
posterior flap at the time of closure, excellent wound
healing occurs. This is a very versatile and acceptable
incision except for poor protection of the carotid artery
superiorly. Hence, it has its drawbacks in necks that
have been irradiated. The vertical limb is the culprit.
H Depicted is a modification of the Martin and
Slaughter incision by simply making the vertical limb
in "5" fashion. The superior trifurcation is thus brought
away from the carotid artery to some extent with the
vertical limb crossing the carotid artery at a lower level
and at more of a right angle.
I Schweitzer, in 1965, described a visor-type incision
for combined resection of portions of the mandible
with radical neck dissection without splitting the lower
lip. The upper horizontal limb crosses the midline into
the opposite submandibular region. The remainder of
the neck dissection incision can be along the dotted
lines or any of the other modifications depicted. It is
the upper cervical flap that is turned superiorly to form
a visor. To facilitate this mobilization, an incision is
made in the gingivobuccal gutter leaving 1 to 2 cm of
mucous membrane attached to the mandible to facili-
tate easy closure. The cheek flap and entire chin is dis-
sected off the mandible to a point across the midline
corresponding to the area of the canine tooth. Exposure
of the mandible and anterior intraoral contents is good.
This incision also affords exposure for a contralateral
suprahyoid neck dissection when indicated by the
intraoral primary tumor.
J Another neck dissection incision utilizes the concept
of a cervical "turn up and in" or apron flap. This superior-
based flap can be used to close intraoral defects
involving the floor of the mouth and pharynx. The
solid line depicts Edgerton's apron flap, whereas the
dotted line depicts Farr's cervical island flap. If the
defect in the neck is too large for primary closure, the
area can be covered with a pectoralis major myocu-
taneous flap. This is presented in detail in Figures 8-2
and 8-3. A neck dissection is easily performed through
Farr's incision, whereas with Edgerton's incision an
inferior extension is usually necessary. The incision is
then similar to that in D.
K Depicted is a versatile incIsion for virtually any
major head and neck resection with neck dissection. It
affords fairly good carotid artery protection, especially
in those patients with previously irradiated necks (Lon?).
The large superior-based flap usually has a good blood
supply.
SLAUGHTER 1955

SCHWEITZER 1965

EDGERTON 1957
FARR 1969

FIGURE 16-6 Continued

 THE NECK
Modified Radical Neck Dissection
Preserving the Spinal Accessory Nerve,
the Internal Jugular Vein, and the
Sternocleidomastoid Muscle (Type III)
(Fig. 16-7)*
This operation consists of the en bloc removal of the
lymph node-bearing tissues of one side of the neck,
including lymph nodes levels I to V, preserving the
spinal accessory nerve, the internal jugular vein, and
the sternocleidomastoid muscle. The submandibular
gland mayor may not be removed.
The concept of removing lymph node-bearing fibro-
fatly tissue of the neck without removing the sternoclei-
domastoid muscle the submandibular gland, and the
internal jugular vein was introduced by Suarez (1963)
based on his observations in autopsy and surgery speci-
mens of patients with cancer of the larynx and hypo-
pharynx. In 1954, in Poland, Miodonski also reported
his experience with the same concept. It was Bocca,
however, who later popularized this operation, intro-
duced the terms functional, conservative, and conser-
vation neck dissection to designate it, and emphasized
that the muscular and vascular aponeuroses of the neck
define compartments filled with fibroadipose tissue and
that the lymphatic system of the neck contained within
these compartments can be excised in an anatomic block
by stripping the fascia off of muscles and vessels (Bocca
and Pignataro, 1967; Bocca et aJ., 1980).
This operation is advocated by many, particularly in
Europe, as the neck dissection of choice for the treat-
ment of the NO neck in patients with squamous cell
carcinoma of the upper aerodigestive tract, especially
when the primary tumor is located in the larynx and
hypopharynx. In that case, the nodes in the submandibu-
lar triangle are at low risk of containing metastases and
do not need to be removed. Molinari and colleagues
(1980), Lingeman and associates (1977), and Gavilan
and Gavilan (1989) believe that this operation is also
indicated for the treatment of the neck in stage N1,
when the metastatic nodes are mobile and no greater
than 2.5 to 3 em. Bocca and colleagues (1984), on the
other hand, believe that the indications for this type of
modified radical neck dissection are the same as those
of the radical neck dissection and that the only contra-
indication to its use is the presence of node fixation.
This type of neck dissection is the operation of choice
for patients with differentiated carcinoma of the thyroid
gland who have palpable lymph node metastases in the
lateral or posterior compartments of the neck (Block et
aI., 1990).
•Adapted from Medina JE: Modified neck dissection. In Shockley
ww, Pillsbury He III (eds): The Neck: Diagnosis and Surgery. Sl.
Louis, Mosby, 1994, pp 551-572.
Surgical Technique
The position of the patient on the operating table and
the surgical incisions are similar to those recommended
for the radical neck dissection. The elevation of the
cervical flaps and the dissection of the submental and
submandibular triangles are performed in the manner
described for the radical neck dissection.
Once the dissection of the submandibular triangle is
completed (see Radical Neck Dissection), the dissection
is carried out in an inferior direction identifying and
preserving the hypoglossal nerve and the superior thy-
roid vessels. During this portion of the operation, the
upper end of the internal jugular vein and the spinal
accessory nerve can also be identified below the poste-
rior belly of the digastric muscle (see Fig. 16-7A).
The next step consists of dissecting the fascia of the
sternocleidomastoid muscle, beginning at the posterior
border of the muscle and proceeding in an anterior
direction. Although removal of the external jugular vein
and the greater auricular nerve may make the subse-
quent dissection easier and faster, it is often possible to
preserve the greater auricular nerve and, occasionally,
the external jugular vein. The dissection of the fascia
off of the sternocleidomastoid muscle continues around
the anterior border of the muscle and onto its medial
surface. By retracting the muscle laterally, the spinal
accessory nerve is identified as it enters the muscle, at
about the level of the junction of its upper and middle
thirds. The fibrofatly tissue overlying the spinal acces-
sory nerve is carefully divided, exposing the nerve
between its exit at the jugular foramen and its entrance
into the sternocleidomastoid muscle (see Fig. 16-7B).
The dissection proceeds above and behind the spinal
accessory nerve, where the fibrofatly tissue containing
lymph nodes is dissected from the splenius capitis and
the levator scapulae muscles. The dissected tissue from
this area of the neck is then brought forward under the
spinal accessory nerve (see Fig. 16-7C). Below the level
of the nerve the cutaneous branches of the cervical
plexus are divided as they cross the posterior border of
the sternocleidomastoid muscle.
At this point, the dissection of the posterior triangle
begins by identifying the spinal accessory nerve either
at the point where it exits from under the sternocleido-
mastoid muscle or, more easily, as it courses in an
oblique direction through the posterior triangle of the
neck (see Fig. 16-70). Very gentle traction on the nerve
is used to free the spinal accessory nerve from the
surrounding tissues with a scalpel. With the nerve iso-
lated, the fascia and fibroadipose tissues are incised
along the anterior border of the trapezius muscle. This
tissue, which contains lymph nodes, is then dissected
in an anterior direction off of the splenius capitis, the
levator scapulae, and the scalenus medius muscles. The

specimen is then brought forward under the spinal
accessory nerve (see Fig. 16-7E).
The fascia of the sternocleidomastoid muscle is
incised along the posterior border of the muscle, and it
is dissected off of the muscle in a circumferential manner
until the anterior border of the muscle is reached (see
Fig. 16-7F).
The superficial layer of the deep cervical fascia is
then incised along the superior border of the clavicle
between the posterior border of the sternocleidomas-
toid muscle and the anterior border of the trapezius.
The external jugular vein is divided between clamps,
and the omohyoid muscle is transected. The fibrofatty
tissue in this area is then gently pushed in a superior
direction, identifying the proper plane of dissection,
superficial to the fascia of the scalenus medius, the
brachial plexus, the scalenus anticus, and the phrenic
nerve. The contents of the posterior triangle of the
neck, now completely freed, can be brought forward,
under the spinal accessory nerve and then under the
sternocleidomastoid muscle (see Fig. 16-7G). The dis-
section continues in an anterior direction, dividing the
inferior cutaneous branches of the cervical plexus.
Finally, the specimen is dissected sharply from the
FIGURE 16-7
THE NECK
vagus nerve, the carotid artery, and the internal jugular
vein. To avoid injury to the thoracic duct, the dissection
in the anterior inferior area of the neck, lateral to the
internal jugular vein and the common carotid artery, is
carried out carefully, as described in the section on
radical neck dissection. The dissection of the specimen
from the internal jugular vein continues superiorly toward
the upper portion of the neck that was previously dis-
sected, completing the operation (see Fig. 16-7H).
A Anteroinferior extent of the dissection. The hypo-
glossal nerve and superior thyroid vessels are pre-
served.
B Fibrofatty tissue overlying the spinal accessory nerve
is incised over a hemostat.
C Posterosuperior portion of specimen is passed
forward under the spinal accessory nerve.
D Exposure and dissection of the spinal accessory
nerve in the posterior triangle of the neck.
Continued
 THE NECK

Modified Radical Neck Dissection

Preserving the Spinal Accessory Nerve, F Dissection around the sternocleidomastoid muscle.
the Internal Jugular Vein, and the
Sternocleidomastoid Muscle (Type III) G Superior dissection completed. Specimen is brought
(Continued) (Fig. 16-7) forward under the sternocleidomastoid muscle.

H Dissection of the specimen off of the internal

E Posterior dissection and displacement of the speci- jugular vein.
men under the spinal accessory nerve.

FIGURE 16-7 Continued


Selective Neck Dissections (Fig. 16-8)
These dissections consist of the selective en bloc removal
of only the lymph node groups that, depending on the
location of the primary tumor, are most likely to con-
tain metastases.
Anatomic and radiographic studies of the lymphatics
of the head and neck have demonstrated that the
lymphatic drainage of this region follows predictable
pathways (Rouviere, 1938; Fisch and Sigel, 1964).
Although this would suggest only that lymphatic metas-
tases would follow similar patterns, a number of clinical
studies have now demonstrated that the distribution of
cervical lymph node metastases is indeed predictable
in patients with previously untreated squamous cell
carcinoma of the upper aerodigestive tract (Linberg,
1972; Skolnik, 1976; Shah, 1990). Furthermore, en bloc
removal of only the lymph node groups at highest risk
of harboring metastases appears to have the same ther-
apeutic value and provide the surgeon with the same
staging information as the more extensive radical and
modified radical neck dissections (Byers, 1986; Medina
and Johnson, 1991). Such operations also result in less
postoperative morbidity (Remmler et al., 1986; Sobol,
et aI., 1985).
There are four operations in this category of neck
dissections:
1. The lateral neck dissection, which consists of the en
bloc removal of nodal regions II, III, and IV
2. The supraomohyoid neck dissection, which consists
of the en bloc removal of nodal regions I, II, and III
3. The posterolateral neck dissection, which consists
of the removal of the suboccipital and retroauricular
lymph node groups and nodal regions II, III, IV,
and V
4. The central compartment dissection, which consists
of the removal of the pretracheal and paratracheal
lymph nodes
Indications
The lateral neck dissection is indicated in patients with
tumors of the larynx, oropharynx, and hypopharynx
staged T2-T4 NO or NI, or Tl-Nl when the palpable
node is located in levels [ or II. Because the lymphatic
drainage of these regions is such that metastases are
frequently bilateral, the operation is often done on both
sides of the neck.
The supraomohyoid neck dissection is indicated in
the surgical management of patients with squamous
cell carcinoma of the oral cavity staged T2-T4 NO, Tx
Nl when the palpable node was less than 3 em, clearly
mobile, and located in either level I or II. The proce-
THE NECK
dure is performed in both sides of the neck in patients
with cancers of the anterior tongue and floor of the
mouth. This type of dissection is performed when an
elective neck dissection is indicated in the management
of patients who have squamous cell carcinoma of the
lip or skin of the mid portion of the face and when these
lesions are associated with clinically discrete, single
metastases to the submental or submandibular nodes.
A bilateral dissection is performed when the lesion is
located at or near the midline.
The posterolateral neck dissection is indicated in the
treatment of melanomas, squamous cell carcinomas, or
other skin tumors with metastatic potential such as the
Merkel cell carcinomas that originate in the posterior
and posterolateral aspects of the neck and the occipital
scalp. It is rarely indicated in the treatment of squamous
cell carcinoma of the upper aerodigestive tract.
The anterior neck dissection is indicated as part of
the surgical treatment of tumors of the thyroid, sub-
glottic larynx, trachea, and cervical esophagus.
Surgical Technique
A unilateral supraomohyoid neck dissection is usually
performed through an apron-like incision that extends
from the mastoid tip to the mandibular symphysis. The
lowest point of the incision is usually located at the level
of the thyrohyoid membrane. This incision can be ex-
tended into a lip-splitting incision; and if a more exten-
sive dissection of the neck is indicated by the surgical
findings, a descending limb can be easily added for
exposure. Occasionally it is necessary to excise a scar
from a previous lymph node biopsy. In that case, a
modification of the Schobinger incision is used. To per-
form a bilateral dissection, an apron-like incision is made
from mastoid to mastoid overlying the thyrohyoid mem-
brane (Medina and Byers, 1989).
A superior flap is elevated in a subplatysmal plane
up to the inferior border of the mandible. The marginal
mandibular branch of the facial nerve is identified and
preserved, unless it is grossly involved by tumor. The
greater auricular nerve and the external jugular vein
are also preserved during the elevation of the flap. An
inferior flap is elevated usually to about 1 inch above
the clavicles. However, elevation of the flap can be carried
down to the level of the clavicles, if necessary.
The prevascular and retrovascular lymph nodes in
the submandibular region are usually seen through the
fascia that envelops the submandibular gland. They are
carefully displaced inferiorly after the facial vessels are
divided. Removal of these lymph nodes is of utmost
importance when the primary tumor is located in the
lateral floor of the mouth, alveolar ridge, and buccal
mucosa.
 THE NECK
Selective Neck Dissections (Continued)
(Fig. 16-8)
The dissection of the submental and submandibular
triangles is carried out in the same manner described
for the radical neck dissection. Then, the fascia over-
lying the posterior belly of the digastric and the omo-
hyoid is incised, developing an envelope along the
entire length of both muscles. Continuing the dissec-
tion below the digastric and posterior to the omohyoid,
all the fibroadipose tissue in this area is removed,
preserving the hypoglossal nerve and the superior
thyroid vessels. As the dissection is carried inferiorly,
the fascia of the omohyoid muscle is included with the
FIGURE 16-8
specimen, thus outlining the anteroinferior limit of the
dissection (see Fig. 16-8A).
Next, the posterior segment of the dissection is begun
by incising the fascia along the anterior border of the
sternocleidomastoid muscle. With the fascia retracted
anteriorly, the dissection is carried around the muscle
up to the point where the spinal accessory nerve enters
it (see Fig. 16-8B). The spinal accessory nerve is care-
fully dissected free from the surrounding tissues. Above
the level of the nerve, the splenius capitis and the leva-
tor scapulae muscles are dissected clean. The fibroadi-
pose tissue containing lymph nodes from this area is
brought forward underneath the spinal accessory nerve
(see Fig. 16-8C). Below this level, the posterior limit of
 THE NECK

FIGURE 16-8 Continued

the dissection is marked by the cutaneous branches

of the cervical plexus, which are preserved. A block of A Omohyoid outlining anteroinferior limit of the dis-
nodal and adipose tissue is thus formed, and it is reflect- section.
ed anteriorly (see Fig. 16-80). The dissection is then
carried along the vagus nerve, the common and inter- B Dissection of the fascia of the sternocleidomastoid
nal carotid arteries, and the internal jugular vein. The muscle.
inferior limit of the dissection is usually the omohyoid
muscle as it crosses forward, lateral to the internal C Posterosuperior portion of the specimen being
jugular vein (see Fig. 16-8E). However, if a node is passed forward under the spinal accessory nerve.
found in this area that appears to be involved by tumor,
the omohyoid is divided, and the lymph nodes and D Dissection below the spinal accessory nerve. Notice
adipose tissue anterior to the scalene muscles and the the cutaneous branches of the cervical plexus marking
brachial plexus (lymph node group IV) are included in the posterior extent of the dissection.
the specimen.
Finally, the common facial vein is divided and the E Dissection of the specimen from the internal jugu-
surgical specimen removed, or it is reflected toward the lar vein.
midline. beginning the dissection on the opposite site
(see Fig. 16-8F). When the dissection is completed, only F Completed supraomohyoid neck dissection.
a small amount of lymph node-bearing tissue remains
in the posteroinferior aspect of the neck.
 THE NECK
Extended Neck Dissections
Depending on the location of the primary tumor or the
extent of the metastases in the neck, any of the neck
dissections described earlier can be "extended" to include
either lymph node groups that are not routinely removed,
such as the retropharyngeal and para tracheal nodes, or
structures that are not routinely removed, such as the
hypoglossal nerve, the carotid artery, and the levator
scapulae muscle.
Resection of Lower Margin of
Mandible Combined with Radical
Neck Dissection (Fig. 16-9)
Indications
For a bulky metastatic malignant tumor in the sub-
mandibular lymph nodes or submandibular salivary
gland, a somewhat deeper resection may be necessary,
with resection of the lower margin of the horizontal
ramus of the mandible. Resection of the upper margin
of the mandible appears in Figure 14-11.
Highpoints
1. Resect ellipse of lower margin of mandible in conti-
nuity with contents of digastric triangle.
2. It may be possible to preserve the lingual and hypo-
glossal nerves. Sacrifice the nerves if their preser-
vation compromises the ablative surgery.
3. Include the sublingual salivary gland, anterior and
posterior bellies of the digastric muscle, and the
stylohyoid and mylohyoid muscles.
A The standard neck dissection is carried up to the
level of the hyoid bone. The internal jugular vein may
be ligated and transected either from below at this
stage or from above after the tail of the parotid gland
is transected. This may depend on whether a parotid
extension of the neck dissection is to be done (see
Fig. 16-4).
B The tail of the parotid, the external jugular and
posterior facial veins, the mandibular branch of the
facial nerve, the sternocleidomastoid, the posterior belly
of the digastricus, and the stylohyoid muscle all have
to be transected.
C The neck mass is reflected medially, exposing the
internal and external carotid arteries and the hypoglossal
nerve as it overlies the hyoglossus muscle. The index
finger is then inserted under the lower margin of the
mandible, and a tunnel is developed by blunt dissec-
tion deep to the mylohyoid muscle at its origin along
the inner aspect of the mandible.
D A narrow ribbon retractor is inserted through this
tunnel, and, with a Stryker or sagittal plane saw, an
ellipse of the lower margin of the mandible is excised.
The anterior section removed will include the digastric
fossa and the mylohyoid line, whereas posteriorly the
mylohyoid line will be excluded, since it rises much
higher and close to the last molar tooth. The external
maxillary artery is ligated and divided near its origin
from the external carotid artery.
Continued
 THE NECK A1S

FIGURE 16-9
 THE NECK
Resection of Lower Margin of
Mandible Combined with Radical
Neck Dissection (Continued)
(Fig. 16-9)
E With the saw cut completed, the structures deep
to the floor of the mouth are exposed. The origin of the
anterior belly of the digastricus muscle and the origin
of the anterior one half to two thirds of the mylohyoid
muscle are included in the resected section. The poste-
rior fibers of the mylohyoid muscle are cut along with
the mylohyoid nerve. Of anatomic interest, this nerve
supplies motor fibers to the mylohyoid and anterior belly
of the digastric muscle, being a division of the inferior
dental nerve that arises from the trigeminal nerve.
F The median raphe is now cut from chin to hyoid
bone, freeing the insertion of the mylohyoid muscle.
The entire contents of the floor of the mouth and
digastric triangle are easily swept downward. This
includes the sublingual gland. Wharton's duct and the
postganglionic fibers from the submaxillary ganglion
are transected. The lingual and hypoglossal nerves are
depicted, which mayor may not be preserved
depending on the extent of the neoplasm.
G The lingual veins are ligated and divided. The
insertion of the mylohyoid muscle, the intermediate
tendon of the digastric muscle, and the stylohyoid
muscle are now severed from the hyoid bone. The
entire specimen is removed. Closure is as in a standard
neck dissection.
 THE NECK

Sublingual gland

Mylohyoid muscle

Lingual n.

Hypoglossal
n.
Post. facial v.
Int.jug. v.
Parotid gl.
G

Sternocleidomastoid m.

Post. belly digastricus m.

Wab~
Submaxillary salivary gland
FIGURE 16-9 Continued
 THE NECK
Posterior Neck Dissection
(Fig. 16-10)
Keun Y. Lee
Lesions of the posterior scalp such as melanoma or
squamous cell carcinoma may metastasize via lym-
phatic channels and may require regional lymph node
dissection.
The lymphatic channels from the posterior scalp
drain primarily into the occipital lymph nodes, which
consist of one to three nodes located immediately
lateral to the upper border of trapezius muscle and rest
on the upper part of semispinalis capitis muscle (see
Fig. 16-lOB). Efferents from the occipital node drain to
the upper deep cervical nodes as well as to the sub-
occipital nodes located deep to the splenius capitis
muscle and semispinalis capitis muscle in the sub-
occipital triangle.
Postauricular nodes usually consist of one to four
small nodes that rest on the mastoid portion of the
insertion of the sternocleidomastoid muscle. Afferents
to these nodes drain the temporal region of the scalp, the
posterior surface of the auricle, and the external audi-
tory meatus. Efferents drain to the upper deep cervical
nodes and from there down the jugular and spinal
accessory chains.
An additional group of lymph nodes located more
caudal and deep to the trapezius muscle drain the
posterior cervical area. Efferents from these nodes flow
into the lower deep cervical nodes.
A conventional radical neck dissection is indicated
whenever metastases are found in the jugular chain or
posterior cervical triangle.
The spinal accessory nerve is routinely sacrificed
when metastases are identified in the posterior cervical
triangle or in the group of lymph nodes located deep to
the trapezius muscle (see Fig. 16-10C).
Although inferior fibers of the trapezius muscle help
to stabilize the scapula to prevent winged scapula,
preservation of the spinal accessory nerve will not
significantly alter the functional outcome, because the
upper and middle fibers of the trapezius muscle are
removed whereas the serratus anterior muscle (see Fig.
16-100) and its innervation by the long thoracic nerve
are left intact.
Highpoints
1. The spinal accessory nerve is routinely sacrificed
whenever metastases are found in the posterior
triangle or in the group of lymph nodes located deep
to the trapezius muscle.
2. The splenius capitis muscle and semispinalis capitis
muscle are included in the specimen to ensure ade-
quate exposure of the suboccipital triangle and exci-
sion of the suboccipital nodes.
3. Care is taken when dissecting in the suboccipital
triangle not to injure the vertebral artery (see Fig.
16-lOE, point 2).
4. The procedure includes the dissection of the posterior
cervical triangle.
s. The internal jugular vein is preserved.
6. If metastatic nodes are identified in the posterior
triangle, a conventional radical neck dissection is
added to the procedure.
A A horizontal upper incision is made from the post-
auricular area along the nuchal line (1) to the midline.
A lower horizontal incision is made from the spinous
process of (7 to the spine of the scapula (2) and
extended anteriorly along the lateral one third of the
clavicle (dotted line). An oblique incision is then made
from the middle of the upper incision down to the spine
of the scapula. Anterior and posterior flaps are then
elevated. This incision cannot be used for bilateral
posterior neck dissection.
Continued
 THE NECK

1. Superior nuchal line.

2. Spine of scapula.
C2. Spinous process of axis.
C7. Spinous process of the
seventh cervical vertebra.

FIGURE 16-10
 THE NECK
Posterior Neck Dissection
(Continued) (Fig. 16-10)
B The occipital node, postauricular node, posterior
external jugular vein, and lesseroccipital nerve can then
be identified. The spinal accessorynerve (6) is also iden-
tified in the posterior cervical triangle. The trapezius
muscle (7) is then transected along the full length of
the spine of the scapula, extending to the spinous
process of (7. The muscle incision is then extended
superiorly from (7 to the nuchal line. Superiorly, the
trapezius muscle is transected at the occipital region
(dotted line).
C The inferior aspect of the transected trapezius
muscle (2) is reflected superiorly, and the spinal acces-
sory nerve (6, 11), rhomboid muscles (5), levator
scapulae muscle (4), and supraspinatus muscle (12)
are identified. If metastases are found in the lymph
node-bearing fat pad (8), then the spinal accessory
nerve is sacrificed. The suprascapular artery (9) and
transversecervical artery (7) are transected. The trapezius
muscle is further transected along the lateral one third
of its clavicular insertion. The coracoclavicular ligament
(10) is identified and preserved. The lymphatic-bearing
fatty tissue of the posterior triangle is then dissected,
as in conventional neck dissection. The internal jugular
vein is preserved. The spinal accessory nerve and
transverse cervical artery are again identified. If any
metastases are found in the posterior triangle, then a
conventional radical neck dissection is added to the
procedure.
At this point, the specimen is attached to the
semispinalis capitis (1) and splenius capitis muscles (3).
Muscle incisions are made (dotted line) superiorly along
the nuchal line, posteriorly in the midline, inferiorly
along the superior border of the rhomboid muscle,
and laterally along the longissimus (see Fig. 16-100,
point 8) and levator scapulae muscles (4).
Continued
 THE NECK

1. Occipital artery.
2. Occipital node.
3. Postauricular node.
/
4. Sternocleidomastoid muscle.
5. Lesser occipital nerve.
6. Spinal accessory nerve.
7. Trapezius muscle.
8. Posterior external jugular vein.

1. Semispinalis capitis muscle.

2. Trapezius muscle.
3. Splenius capitis muscle.
4. Levator scapulae muscle.
5. Rhomboid muscle.
6. Spinal accessory nerve.
7. Branches of the transverse
cervical artery.
8. Lymph node-bearing fatty
issue.
9. Suprascapular artery.
10. Coracoclavicular ligament.
11. Cut end of spinal accessory
nerve.
c 12. Supraspinatus muscle.

FIGURE 16-10 Continued

 THE NECK
Posterior Neck Dissection
(Continued) (Fig. 16-10)
D The semispinalis capitis (see C, point 1) and splenius
capitis muscles (7) are reflected laterally, exposing the
suboccipital triangle that is bounded by the rectus
capitis posterior major (2), oblique capitis inferior (3),
and oblique capitis superior (see E, point 6) muscles.
The deep cervical artery and vein (6) and the descend-
ing occipital artery are ligated. Suboccipital node-
bearing fatty tissue is reflected while care is taken in
dissection of the suboccipital triangle so as not to injure
the third part of the vertebral artery (see E, point 2).
The splenius capitis muscle (see E, point 8) is then
excised at the posterior aspect of the sternocleidomas-
toid muscle, and the specimen can be removed.
E The completed neck dissection is shown.
 THE NECK 823

1. Rectus capitis posterior minor muscle.

2. Rectus capitis posterior major muscle.
3. Oblique capitis inferior muscle.
4. Semispinalis cervi cis muscle.
5. Rhomboid muscle.
6. Deep cervical artery and vein.
7. Splenius capitis muscle.
8. Longissimus capitis muscle.
9. Levator scapulae muscle.
10. Serratus anterior muscle.
11 . Omohyoid muscle. "
12. Supraspinatus muscle.

1. Rectus capitis posterior minor muscle.

2. Vertebral artery.
3. Rectus capitis posterior major muscle.
4. Brachial plexus.
5. Oblique capitis inferior muscle.
6. Oblique capitis superior muscle.
7. Sternocleidomastoid muscle.
8. Cut end of splenius capitis muscle.
9. Semispinalis cervicis muscle.
10. Longissimus capitis muscle.
11. Levator scapulae muscle.
12. Scalenus posterior muscle.

FIGURE 16-10 Continued

 824 THE NECK
Excision of Thyroglossal Cyst
and Sinus (Fig. 16-11) (After Sistrunk,
1920)
Highpoints
1. Always excise the mid portion of the hyoid bone.
Leaving the midportion of the hyoid is the most
common cause of recurrence.
2. If there is a draining sinus or duct deep to hyoid
bone, or if previous surgery was performed, enter
the vallecula and excise the foramen cecum. A core
of tissue extending to the base of tongue is excised.
3. If previous surgery was performed, postoperative
airway obstruction, although rare, may require
tracheostomy.
4. In all secondary operations or when the cyst is large
and off the midline, care must be taken not to injure
either the internal branch of the superior laryngeal
nerve or hypoglossal nerve.
5. Carefully examine the base of the tongue-inspection
and palpation.
Discussion
Occasionally, what is believed to be a cyst is a thyroid
adenoma and more rarely carcinoma (see Management
of Thyroid Cancer in Chapter 18, page 907). This
author (JML) prefers total thyroidectomy for thyroid
carcinoma regardless of its location. Hence, a frozen
section is required on all solid masses. Another aspect
is the possibility that a solid mass may be normal
thyroid and the only thyroid tissue present. Palpation
for normal thyroid gland is imperative when this is
suspected. Preoperative thyroid scan is recommended
when this situation is suspected preoperatively. Another
possibility is a lingual thyroid (see Fig. 18-13).
A thyroglossal duct cyst may not be in the midline.
One has been seen located laterally to the normal thy-
roid gland. Resection entailed exposure through two hori-
zontal "stepladder-type" cervical incisions. A thyroglossal
duct cyst may be contiguous with a pyramidal lobe.
A A horizontal skin incision is made. When a sinus
tract exists, this is encompassed with an ellipse of skin.
B Diagrammatic representation of a thyroglossal
cyst. The hyoid bone is often traversed by the duct or
is adherent to the duct so that its mid portion must be
routinely excised. At times there is a patent duct
communicating with the lingual wall of the vallecula at
the foramen caecum.
C Upper and lower skin flaps are developed, and an
ellipse of fascia overlying the cyst is outlined.
D This ellipse of fascia serves as a site for traction with
an Allis clamp. Strap muscles are retracted laterally.
E Occasionally, a pyramidal lobe connection inferiorly
is encountered. This is transected between clamps.
F AND G The cyst is now freed from the larynx, thy-
rohyoid membrane, or both and is retracted upward.
H With the duct visualized, an incision is made along
the superior border of the hyoid bone. This incision must
not undercut the hyoid, because the duct running to the
foramen caecum may be transected and its identity lost.
Continued
 THE NECK

Epiglottis
Vallecula
Hyoid bone
Thyroglossal cyst
Thyroid cartilage

E F

Mylohyoid m.
Hyoid bone

Thyrohyoid
membrane
Duct

FIGURE 16-11
 THE NECK
Excision of Thyroglossal Cyst
and Sinus (Continued) (Fig. 16-11)
(After Sistrunk, 1920)
I Using bone-cutting forceps or heavy scissors, the
hyoid bone is sectioned at either side. The thyrohyoid
membrane is transected at its attachment to the
midsection of the hyoid bone along the dotted line. At
this stage, care is taken to identify any duct remnant
running to the base of the tongue.
J The retrohyoid portion of the duct is excised with
an ellipse of tissue at the base of the tongue, including
the foramen caecum. The hypopharynx is entered in
such cases.If a duct is not identified, a core of muscle is
excised to the base of the tongue, and the hypopharynx
mayor may not be entered.
K One or two 3-0 chromic catgut inverting sutures
are placed to close the defect in the hypopharynx.
L Closure consists of approximation of the mylo-
hyoid muscles to the thyrohyoid membrane if tension
is not great. The transected ends of the hyoid bone are
never approximated. The fascia enveloping the strap
muscles is closed in the vertical plane. The platysma
muscles and skin are closed in two separate layers. A
drain at the corner of the wound is used.
Occasionally, a thyroglossal cyst may be located in the
lower third of the neck just off the midline. The sinus
tract will always reach the hyoid bone and requires the
same procedure. The only variation is the use of two
horizontal incisions similar to those used in the exci-
sion of a branchial cleft sinus or fistula (see Fig. 16-17).
Complications
• Recurrence
• Infection
• Airway obstruction associated with secondary
operations
• Injury to internal branch of superior laryngeal nerve
or hypoglossal nerve
 THE NECK 827

K L
FIGURE 16-11 Continued
 THE NECK
Resection of Submandibular
Salivary Gland for Benign Disease
(Fig. 16-12)
With low-grade malignancy on frozen section or even
suspected grossly, a sampling of lymph nodes in the
surgical field is recommended. This same principle of
node sampling applies to the basic lobectomy for similar
lesions of the parotid salivary gland (see Chapter 17).
Highpoints
The most common disease of the submandibular gland
is sialadenitis with calculus formation. The next con-
sideration is neoplasms, both benign and malignant,
which are approximately equal in occurrence. Likewise,
benign and malignant metastatic tumors can involve
the submandibular salivary gland extending from the
parapharyngeal space. Rarely the submandibular gland
can be involved with the sublingual gland to form a
ranula. This is the so-called plunging ranula, which may
not produce the usual sublingual cyst-like mass charac-
teristic of the true ranula. In this latter event, removal
of both the sublingual gland and the submandibular
gland is advised.
1. Make a low skin incision (in a natural skin crease)
to avoid injury to the mandibular branch of the
facial nerve (ramus mandibularis), which is deep to
the platysma muscle; so, too, is the cervical branch
of the facial nerve.
2. Avoid injury to the hypoglossal and lingual nerves.
3. The anterior facial vein is superficial to the gland,
whereas the accompanying artery, the external maxil-
lary (facial artery), usually passes through gland.
4. The anatomic relationships from outside in are as
follows: skin, platysma muscle and thin fascia,
mandibular nerve, vessels, and capsule of gland.
5. Never enucleate neoplasm from the salivary gland.
Total removal with frozen section is the treatment of
choice.
6. Anatomy of submandibular and suprahyoid regions
is shown in Figure 14-4.
A The skin incision is made along a natural skin
crease about 4 em below the lower edge of the hori-
zontal portion of the mandible. This will avoid injury to
the mandibular branch of the facial nerve, which
hangs below the mandible like a hammock. It also
produces an excellent cosmetic result.
B The incision is carried through the platysma
muscle and the superficial layer of the cervical fascia.
These structures constitute the skin flaps. At the pos-
terior or lateral angle of the wound, the anterior border
of the sternocleidomastoid muscle may be exposed.
The common facial vein or its tributaries, the anterior
and posterior facial veins, are identified. Stay sutures
through platysma muscle and fascia are used to avoid
grasping the skin edges with forceps. As the platysma
muscle is transected, small nerve fibers may be encoun-
tered. These fibers are branches of the cervical division
of the facial nerve, which are motor to the platysma
muscle. If possible, preserve these fibers; however, if
they cross the incision at right angles, this will not be
possible. Because the platysma muscle aids in depressing
the lower lip by its insertion with the depressor labii
inferioris and depressor anguli oris (triangularis) there
may be some transient weakness of this function (to
depress the lower lip). Return of this function is almost
complete with careful approximation of the platysma
muscle at the time of wound closure. A more protracted
loss of this function is usually due to interference with
the mandibular branch of the facial nerve, which
perhaps with the lower buccal branches is the motor
supply to the other two depressors of the lower lip.
The platysma muscle joins and is continuous with
the risorius muscle at the angle of the mouth, both
muscles thus retracting the angle of the mouth. A
nerve stimulator is usually helpful in the confirmation
of the motor nerves and if selectively performed will
verify the varied actions of the nerves and muscles. Use
the nerve stimulator at the lowest increment and do
not overstimulate the nerve because the nerves may
become "fatigued."

A
Common facial v.
FIGURE 16-12
An alternative incision is the avoidance of transec-
tion of the platysma muscle by separating the muscle
fibers vertically and retracting them medially and
laterally. With this technique, there will virtually be no
weakness of depression of the lower lip, providing that
the ramus mandibularis and ramus cervicalis nerve are
preserved, both of which are just deep to the platysma
muscle.
C The lower and upper skin flaps are developed, the
lower only to the level of the intermediate tendon of
the digastricus muscle. The upper flap is dissected in
the plane between the superficial cervical fascia and
THE NECK
Ext. maxillary a.
c
the capsule of the submandibular salivary gland. This
plane may be obscure in the presence of recent or old
sialadenitis. In this event, extreme care must be exer-
cised to avoid injury to the mandibular nerve, which
lies in this plane just below the horizontal ramus of the
mandible. The nerve is superficial to the external
maxillary artery and anterior facial vein and deep to
the platysma muscle and superficial cervical fascia.
Therefore, even proper dissection of the skin flap is no
assurance of immunity from injury to the nerve. A
nerve stimulator is helpful in this step.
Continued
 THE NECK
Resection of Submandibular
Salivary Gland for Benign Disease
(Continued) (Fig. 16-12)
Some use the rule of thumb that by transecting the
vessels and reflecting them upward the nerve will not
be injured, because it overlies the vessels (Lampe). The
problem in this rule is that the nerve may be at or
slightly lower than the point at which the vessels are
identifiable. The best rule is to identify the nerve as the
upper skin flap is dissected. Its course in the operative
field is then known exactly and danger of injury either
by the surgeon or by his assistant with a retractor will
be minimal. The nerve may be adherent to the capsule
of the gland or may be within layers of adipose tissue.
It is almost impossible to identify the nerve in this
latter situation. If this were the case, then elevation of
skin, adipose, and platysma is done starting at the
inferior edge of the gland.
It is well to note the close proximity of the sub-
mandibular lymph nodes, which are either anterior,
posterior, or between the artery and vein. These nodes,
lying just under the nerve in some cases, are referred
to as prevascular, retrovascular, and extrasalivary glan-
dular lymph nodes. Lymph nodes are also present within
the capsule of the salivary gland. When the sub-
mandibular salivary gland is resected in conjunction
with juxtaposed carcinoma, preservation of the nerve is
of no concern because these lymph nodes must be
removed with adequate margins of normal tissue.
Complications
• Weakness of depressors of lower lip
• Injury to hypoglossal and lingual nerves
• At times the only visible sign of involvement of the
depressors of the lower lip is when the patient only
slightly opens the lips. The worse scenario can be
drooling and biting of the lower lip to more serious
type involvement of the depressors of the lip. If after
a postoperative period of several months (Le., 9 to
12) there is no improvement, a revision of the lip
can be done. See Figure 9-6.
D The external maxillary artery and anterior facial
vein are clamped and ligated. The artery is medial to
the vein and passes through the capsule and usually
the parenchyma of the gland. The vein is usually super-
ficial to the capsule and does not pass through the
gland. The nerve is kept in full view during this step. If
retraction is necessary, use a Cushing vein retractor.
E The removal of the gland is begun along its inferior
aspect. The plane between the intermediate tendon of
the digastric us and the gland is opened. This may expose
the hypoglossal nerve just opposite the midportion of
the tendon. Somewhat posterior will be the external
maxillary artery as it passes deep to the posterior belly
of the digastricus and stylohyoid muscles and enters
the salivary gland.
F The external maxillary artery is divided between
two proximal clamps and one distal clamp. The vessel
is doubly ligated proximally to minimize the danger of
hemorrhage from a single tie slipping off. Blind clamping
in this area will endanger the hypoglossal nerve. A main
tributary of the lingual vein accompanies the hypoglossal
nerve and passes deep to the digastric muscle. This
also may be a source of bleeding unless care is taken.
Again, blind clamping may injure the hypoglossal
nerve.
G The deep aspect (deep lobe) of the submandibular
salivary gland is exposed by retraction of the mylo-
hyoid muscle anteriorly with a Cushing vein retractor.
The upper edge of the wound is retracted carefully
with a slender finger retractor. With gentle downward
traction on the gland, the lingual nerve is exposed
with the efferent (excitoglandular) fibers of the chorda
tympani to the submandibular gland. Close to these
efferent minor fibers is a small, friable vessel, which
should be carefully ligated, usually with the nerve fibers.
Otherwise, the vessel can retract and be very bother-
some to grasp and then ligate. Be careful not to injure
the lingual nerve. Along these efferent fibers will be
noted the submandibular ganglion. Medial to these
fibers is the submandibular salivary gland duct (Wharton's
duct). Both the lingual nerve and Wharton's duct pass
deep to the mylohyoid muscle.
H Wharton's duct is ligated and divided. The efferent
fibers of the chorda tympani are divided with a clamp
proximal to the site of division. A fine ligature is used
at this point because a small vessel usually accompanies
these efferent nerve fibers. The lingual nerve is preserved.
The hyoglossus muscle, which forms the floor of this
submandibular triangle, is clearly visualized. Anteriorly,
at a slightly deeper plane is the genioglossus muscle.
I The gland is now easily removed with blunt dissec-
tion. The lingual nerve snaps back under the mandible.
Although the lingual vein is exposed, the lingual artery
is hidden, because it lies deep to the hyoglossus
muscle.
J A small drain (preferably a Jackson-Pratt) is inserted
and the wound is closed. The platysma muscle is
carefully approximated as a separate layer using 4-0
chromic gut. The skin is approximated with 5-0 nylon.
 ----------~T:H;:E N:Ec~Kl

Lingual n.

Genioglossus m.

H
Hyoglossus m.

Ant. facial v.
Stylohyoid m.
Post. belly
digastricus m.

Hyoglossus m.
J

FIGURE 16-12 Continued

 THE NECK
Phrenic Nerve Crush (Fig. 16-13)
Although this operation is usually no longer performed,
it is included here for historical and anatomic purposes
relative to the node biopsy (see Fig. 16-13C) purposes.
It also serves as an approach to scalene and infra-
clavicular and internal jugular node biopsy.
Highpoints
1. Always use local anesthesia.
2. Check for accessory phrenic nerves arising from the
fifth cervical nerve.
3. Take care not to injure the subclavian vein.
4. Time for return of function varies from 3 to 18 months.
S. Of interest is the fact that complete section of the
phrenic nerve in children can result in scoliosis. This
has occurred during resection of an extensive lymph
hemangioma of the mediastinum.
A A horizontal skin incision is made about 2 cm
above the clavicle overlying the posterior portion of
the sternocleidomastoid muscle.
A 1 Shown is the site of exposure between the two
heads of the sternocleidomastoid muscle, along the
dotted line.
A2 An alternate exposure is at the posterior border
of the sternocleidomastoid muscle, along the dotted
line.
B The fascia overlying the fat pad, which obscures
the scalenus anticus muscle, is incised.
C With blunt dissection the fat pad is pushed
downward and laterally, exposing the phrenic nerve,
which crosses the scalenus muscle. The phrenic nerve
arises primarily from the fourth cervical nerve with
small branches from the third and fifth cervical nerves.
D The phrenic nerve is crushed with a clamp. If an
accessory nerve is present along the medial border of
the scalenus anticus muscle, it is transected.
Scalene and Infraclavicular
Internal Jugular Node Biopsy
The approach is the same as for a phrenic crush, usually
along the posterior border of the sternocleidomastoid
muscle (see A2). In Figure 16-13C the removal of the
scalene fat pad, which will contain one or more scalene
nodes, is demonstrated.
Discussion
This procedure is primarily limited to patients with
actually palpable scalene nodes. A search for these nodes
otherwise is usually quite fruitless as far as positive
biopsy is concerned. Of much more value is biopsy of
the infraclavicular internal jugular lymph nodes, medi-
astinoscopy, or both (see Fig. 19-8). It is helpful when
palpating for infraclavicular internal jugular lymph
node enlargement to have the patient cough. This tends
to deliver the enlarged nodes above the clavicle.
Complications
• Pneumothorax
• Hemorrhage
 THE NECK

Sternal head

Accessory phrenic n.

FIGURE 16-13
 THE NECK

Muscle Lengthening for Torticollis

(Fig. 16-14) C A horizontal incision then transects the clavicular
portion of the muscle. The deep fascia, which is usually
Highpoints involved in the fibrotic replacement of the muscle, is
also transected along the dotted line. This is most
1. Transect all layers of fascia involved. important.
2. Transect the sternal head cephalad and the clavicu-
lar head caudad. D The shorter cut ends of the two heads of the
3. Overcorrect the deformity. muscle are allowed to retract while the longer ends-
4. Do not use a plaster cast. the caudal sternal end and the cephalad clavicular
5. Simple transection of muscle with reconstruction end-are approximated using through-and-through
does not appear justified. mattress sutures of 3-0 or 2-0 silk.

E After the muscle sutures are tied, the anterior

A The head and neck are positioned with a folded fascia is best left open. The platysma muscle and its
sheet under the shoulder and neck of the affected side. superficial fascia, however, are carefully approximated.
A skin incision follows a natural skin crease about The skin is closed with interrupted 5-0 nylon. No sup-
2.5 cm above the clavicle in a child and about 4.5 cm portive dressing of gauze or plaster is used. Free motion
above the clavicle in an adult. The incision is carried is allowed in the postoperative period.
through the superficial fascia and platysma muscle.
F A schematic drawing depicts the basic principle of
B After inferior and superior flaps are developed, the procedure. The inferior end of the transected
exposing the sternocleidomastoid muscle, an incision sternal head "X" is sutured to the superior end of the
is made along the lower half of the anterior border of transected clavicular head "Y".
that muscle. A curved clamp elevates and exposes the
muscle bundle and its investing fascia, which is then
transected to the mid portion approximating the natural
line of demarcation between the sternal and clavicular
heads. All layers of fascia involved in the fibrotic disease
must be sectioned. The dotted line depicts the down-
ward incision between these two heads. The length of
this vertical incision should be one fourth to one third
of the total length of the sternocleidomastoid muscle.
 THE NECK 835

FIGURE 16-14
 THE NECK
Branchial Cleft Cysts
(See Figs. 16-15 to 16-1 7)
There is considerable variation both in pathologic
anatomy and in interpretation of these anomalies. They
can be a cyst, a fistula, or a sinus tract. They can arise
from the first, second, third, or fourth branchial clefts.
A brief outline for the surgeon follows.
First Branchial Cleft (Modified after Work,
1972)
Work has divided the first cleft anomalies into two
types:
lYpe I: Duplication anomalies of the membranous
external auditory canal (ectoderm)
Type II: Duplication anomalies of both the membranous
and cartilaginous portions of the external auditory
canal, thus arising not only from the first cleft but
also from the first and second branchial arches
(ectoderm and mesoderm)
Neither of these types is believed to be associated
with the pretragal cysts or sinuses that may reach the
periosteum of the temporal bone and are thought to arise
solely from the first and possibly the second branchial
arches. Neither of the two types has any connection
with the tympanic membrane or the middle ear.
The course of these anomalies is either horizontally
for type I or vertically for type II. However, exact dif·
ferentiation into the two types may be difficult. In 11
patients reported by Aronsohn and associates (1976), 2
patients were classified as type I, 5 patients were clas·
sified as type II, and 4 patients could not be separated
into a single type. From the surgeon's point of view, the
important fact is that there is the close relationship to
the facia! nerve and the parotid salivary gland and that
the entire congenital anomaly must be removed. Dupli-
cations can occur and, if present, can split the seventh
nerve or can be deep or superficial to the nerve.
In type I, in general the tract is superior to the main
trunk of the facial nerve and parallel to the external
auditory canal and ends in a cul-de-sac on or near a bony
plate at the level of the mesotympanum (midportion of
the middle ear). In type II, in general the tract involves
the parotid gland more intimately, and lies over the
angle or horizontal ramus of the mandible, lateral or
medial to the facial nerve, or actually but rarely splits
the facial nerve. If a sinus tract or fistula exists in type
II anomalies, it is inferior or posterior to the angle or
horizontal ramus of the mandible or may exit in the
external auditory canal.
Highpoints
1. Avoid definitive operation during period of infection.
2. Use liberal surgical exposure.
3. Partial parotidectomy may be necessary (see Fig. 17-1A
to E).
4. The main trunk of the facial nerve is usually exposed.
Its divisions and branches are likewise exposed and
preserved, depending on the course of the tract and
depending on whether a parotidectomy is necessary.
5. Complete removal of the sinus tract, any branches,
and the cyst is the aim of cure.
A This rare cleft anomaly (solid lines) is associated
with the external auditory canal being located inferior
to the canal (dotted lines) and above the level of the
hyoid bone. When a sinus tract is present, it can drain
in the postauricular or preauricular regions, at the
bony-cartilaginous junction of the external auditory
canal, or near the angle of the mandible just anterior
to the sternocleidomastoid muscle.
Continued
First Branchial Cleft Cyst, Types I and II
Two rare presentations of the first branchial cleft cysts
have been encountered, each with presentation of full-
ness in the lateral oropharyngeal wall, one mimicking
a tonsillar abscess.
First Branchial Cleft Cyst: Type I
One patient, a 24-year-old woman, who had been operated
on twice elsewhere, presented with a relatively large
mass involving the lateral oropharyngeal wall simulating
a tonsillar abscess. The operations had been unsuc-
cessful. A duct-like structure had been identified at one
operation. CT and MRI revealed a horizontal, duct-like
structure extending through the parapharyngeal space
in the region of the oropharyngeal wall toward the
external auditory canal. The patient has refused opera-
tion because of her fear of injury to the seventh cranial
nerve. She has been treated periodically for infections.
First Branchial Cleft Cyst: Type" (See Fig. 23-5)
The second patient, a lS-month-old boy, presented
with an infratemporal mass and a submandibular mass
beneath the body of the mandible at the angle. Surgical
access was via two separate incisions, one above the
hairline in the temporal region extending inferiorly to
the preauricular area and the other oblique upper cer-
vical, 4 em below the body and angle of the mandible.
 THE NECK

TYPE I

FIGURE 16-15
 THE NECK
Branchial Cleft Cysts (Continued)
(See Figs. 16-15 to 16-17)
The first branchial cleft cyst tract extended from the
infratemporal region through the parapharyngeal space
associating with nonencapsulated lipomatous adipose
tissue passing deep to the zygomatic arch. Pterygoid
muscles were exposed along the branch of the
mandibular nerve to the muscles, all preserved. The
temporalis muscle was exposed and revealed a pedicle,
which, when opened, revealed a duct lined with epithe-
lium into which a probe was inserted superiorly to a sac
that was in the infratemporal region. The probe was then
inserted inferiorly into the upper cervical cystic mass.
The cervical cystic portion was anterior to the posterior
digastric and stylohyoid muscles. The midportion of
the tract was attached to the external auditory canal.
The entire cystic mass invading the infratemporal, para-
pharyngeal, and cervical areas was removed completely
intact. The cystic mass was dumbbell-shaped-narrowed
at the zygomatic arch. The temporal branch of the
facial nerve was exposed and preserved. However, the
main trunk of the facial nerve was not exposed because
of the age of the patient. In patients this young the
facia! nerve main trunk is inferior and superficial (see
Fig. 17-11) and very vulnerable. Hence, the main trunk
in this IS-month-old boy was lower than in an adult
and difficult to identify. Extreme care was taken in dis-
secting out the tract and the cyst. There was no post-
operative facial weakness.
Pathologic diagnosis was "Large branchial cleft cyst
with surrounding adipose tissue." Preoperative CT and
MRI accurately located the lesion. The cyst was vertical,
simulating a type II anomaly of the first branchial cleft.
Second Branchial Cleft (Most Common)
(After Simpson, 1969)
B The course and surgical resection of a second
branchial cleft cyst is here. The tract passes between
the external and internal carotid arteries. It passes over
the 12th and 9th nerves and the superior laryngeal
nerve. There may be a fistula above the lower anterior
border of the sternocleidomastoid muscle as well as a
communication in the tonsillar fossa.
Third Branchial Cleft (Rare)
(After Simpson, 1969)
C The cyst is located in the vicinity of the laryngeal
ventricle with a fistula entering the posterior portion of
the thyrohyoid membrane. It may communicate with
the trachea or larynx via the pyriform sinus. The fistula
courses from a site along the anterior border of the
sternocleidomastoid muscle, thence between the
common carotid artery and vagus nerve, being
posterior and inferior to the glossopharyngeal nerve. It
may be confused with a laryngocele.
Fourth Branchial Cleft
Two cases have been reported: one by Tucker and
Skolnick (1973) and another by Shugar and Healy
(1980). Embryologically the duct would be below the
aorta on the left or below the subclavian artery on the
right.
 THE NECK 839

STYLOHYOID L1G.
iL 9th N.

I
j

,...-SUPERIOR LARYNGEAL N.

T. BRANCH SUP. LARYNGEAL N.

EXT. BRANCH SUP. LARYNGEAL N.

STYLOHYOID L1G.

SUPERIOR LARYNGEAL N.

T. BRANCH SUP. LARYNGEAL N.

EXT. BRANCH SUP. LARYNGEAL N.

FIGURE 16-15 Continued

 THE NECK

Resection of Branchial Cleft Cysts

(Fig. 16-16)
Second Branchial Cleft
Highpoints
1. Avoid performing any type of drainage operation if
at all possible.
2. Avoid resection in the presence of active infection.
3. Remove the entire duct or tract if it is patent.
4. Nerves in jeopardy: see under "Complications."
A A horizontal incision following a natural skin crease
5 to 6 em below the horizontal portion of the mandible
is made through the superficial fascia and platysma
muscle.
C Using blunt and sharp dissection, the cyst is care-
fully separated from the anterior and inner aspects of
the sternocleidomastoid muscle. The branch of the
spinal accessory nerve to this muscle may be exposed
during this step and should be preserved. Grasping
the cyst with any type of forceps having teeth is to be
avoided; retraction with moist gauze and gentle pres-
sure is preferred. It is usually easier to remove the cyst
intact and without aspiration.
D Sharp dissection separates the fascial attachments
and adhesions of the cyst medially. The common facial
vein may be preserved or sacrificed as needed. Deep
to the cyst is the carotid sheath with the ansa of the
hypoglossus nerve just anterior to the sheath. These
structures need not be isolated but simply recognized
and preserved.

B Stay sutures are used for traction while superior E The plane between the cyst and the posterior belly
and inferior skin flaps are developed. In the superior of the digastric and stylohyoid muscles is best devel-
skin flap the ramus mandibularis of the facial nerve is oped by blunt dissection.
well protected. An incision is then made along the Continued
anterior border of the sternocleidomastoid muscle
separating the cyst from the fascia that envelops this
muscle. The external and anterior jugular veins may be

transected if necessary as w~1Ias any s~nsory nerves

that cross the line of incision.
 THE NECK

Spinal acessory n.
br. to sternocleidomastoid m.
c

FIGURE 16-16
 THE NECK

Resection of Branchial Cleft Cysts

(Continued) (Fig. 16-16)
F Following the superior extent of the cyst, the
hypoglossal nerve, which is usually crossed by the cyst
or its tract, and lingual vein or veins will be encoun-
tered. The glossopharyngeal nerve is also usually crossed
by the tract. It may be located just below the site at
which the tract reaches the pharynx. Extreme care
must be exercised in this region, because troublesome
bleeding may otherwise ensue and blind clamping
may injure the hypoglossal nerve or even the much
deeper superior laryngeal nerve. This latter nerve, a
branch of the vagus nerve, crosses obliquely downward
and forward behind the external carotid artery.
G The duct of the cyst is followed cephalad as it passes
between the external and internal carotid arteries and
lies deep to the posterior belly of the digastric and
stylohyoid muscles. If the duct is atrophic, it is simply
followed as high as possible deep to the angle of the
mandible, ligated, and then transected. If the duct is
obviously large and patent, it is traced to its pharyn-
geal origin, which is usually the tonsillar fossa, and
then resected as shown in Figure 16-17B to D in the
following procedure. If it is extensive, it passes over the
glossopharyngeal nerve and beneath the styloglossal
muscle and above the stylopharyngeus muscle (see
Fig. 16-15B).
A drain is inserted and the wound is closed with
approximation of the platysma muscle and skin as
separate layers.
Complications
• Recurrence
• Nerve injuries: hypoglossal, greater auricular, supe-
rior laryngeal, vagus, glossopharyngeal, and spinal
accessory. One patient had a lymph node adherent
to the cyst and the spinal accessory nerve. The branch
of the spinal accessory nerve to the sternocleidomastoid
muscle may also be injured.

Post. belly digastricus m.

Duct
Hypoglossus n.
Ext. carotid a.

F G

FIGURE 16-16 Continued

 THE NECK

Excision of Branchial Fistula and

Sinus Tract (Fig. 16-17) A Two separate horizontal skin incisions are made
through the platysma muscle. The lower incision
Highpoints includes the excision of an ellipse of skin around the
fistula. By careful undermining of the skin and platysma
1. Two horizontal incisions are preferred. muscle between the two incisions, adequate exposure
2. Complete dissection to and including the pharyngeal is possible. There is an inestimable cosmetic advantage
communication is done. in two horizontal incisions as compared with a single
3. Meticulous dissection is done to avoid injury to vertical incision along the anterior border of the
hypoglossal nerve, vagus nerve, and superior laryn- sternocleidomastoid muscle.
geal nerve.
B After the skin incision is made, which includes the
Complications fistula opening (1), an incision is made through the
fascia along the anterior border of the sternocleido-
• Recurrence mastoid muscle. The carotid sheath is exposed, and
• Nerve injuries: hypoglossal, glossopharyngeal, supe- the fistulous tract is carefully dissected by retracting
rior laryngeal, vagus, glossopharyngeal, and spinal the upper skin margin superiorly.
accessory and its branch to the sternocleidomastoid Continued
muscle

A
FIGURE 16-17
 THE NECK

Excision of Branchial Fistula and

Sinus Tract (Continued) (Fig. 16-17)
C The upper incision (2) is made, and the fistulous
tract is pulled under the skin flap, separating the two
incisions. The common facial vein is doubly ligated
and divided. Meticulous dissection is necessary at this
location to avoid injury to the carotid arteries, internal
jugular vein, and the hypoglossal and vagus nerves,
because the inflammatory reaction around the fistulous
tract may involve these structures. The tract crosses
the hypoglossal nerve and passesbetween the external
and internal carotid arteries deep to the stylohyoid and
posterior belly of the digastric muscle. The superior
laryngeal nerve is also vulnerable as it lies in the space
between the internal and external carotid arteries
passing deep to these vessels. Occasionally, there may
be accessorytracts that must be removed. Dye injected
into the duct may be of some help.
D The pharyngeal communication is excised and the
defect closed with 4-0 chromic catgut. A small tissue
drain is inserted. The incisions are closed by
approximation of the platysma muscle with 4-0
chromic gut and the skin with 5-0 nylon.

Int. jugular v.
Hypoglossus n.
Sup. laryngeal n.
Common carotid a.

Vagus n.

c D
FIGURE 16-17 Continued
 THE NECK

Excision of Cystic Hygroma A similar but lower incision is used for the hygroma
located in the low cervical region.
(Lymphangioma) (Fig. 16-18)
When the disease extends from the superior to the
inferior cervical levels, two separate horizontal incisions
Highpoints
can be used for exposure (see Fig. 16-17).
1. This disorder may occur anywhere along lymphatic
channels.
2. The only successful treatment is meticulous surgical B After the skin flaps, including the platysma muscle,
dissection and resection of all components. are dissected, an incision is made along the anterior
3. All nerves and major vessels can be vulnerable during border of the sternocleidomastoid muscle opening the
the dissection, which can be exceedingly tedious. plane between the cyst and the anterior and inner
4. Preserve all vital structures. aspects of the muscle. This incision is carried down to
5. It may not be possible to remove all extensions of the lower extent of the cyst, which is usually at or
this disease at one stage, because these extensions below the level where the omohyoid muscle crosses
may defy dissection and may not be apparent at the behind the sternocleidomastoid muscle. Because a
initial operation. cystic hygroma usually arises from the lymph ducts
6. An operation microscope may be of aid in the along the internal jugular vein, it actually lies within a
dissection. portion of the carotid sheath and may distort the
normal relationship between the internal jugular vein,
the vagus nerve, and the carotid arteries as well as the
A The approach to a cystic hygroma located in the sympathetic chain. The ansa of the hypoglossus nerve
upper and middle portion of the neck is through an may be intimately attached to the anterior aspect of
incision made along a natural horizontal or oblique the multicystic tapioca-like mass.
skin crease at the level of the junction of the upper and Continued
middle thirds of the neck.

FIGURE 16-18
 THE NECK
Excision of Cystic Hygroma
(Lymphangioma) (Continued)
(Fig. 16-18)
C With blunt and sharp dissection, the inferior
extension of the cyst is separated from the omohyoid
muscle. Attached lymph nodes are encountered and
removed with the cyst. The internal jugular vein, vagus
nerve, and common carotid artery are identified by
opening the carotid sheath. Care must be taken not to
injure the sympathetic chain deep to the carotid sheath.
The lateral extension often extends to the posterior
edge of the sternocleidomastoid muscle in a multicystic
formation. Every extension when possible should be
excised with the main mass. This is not always feasible,
because not all extensions may be apparent. These
extensions may occur at the periphery of the gross
disease and become apparent days or weeks after the
surgery. Needle aspiration of these persistent cysts is
worthwhile treatment. The spinal accessory nerve is
preserved.
D The cephalad dissection is much the same as for a
branchial cyst except that this superior extension
closely overlies the internal jugular vein. It is closely
related to the hypoglossal nerve, internal and external
carotid arteries, vagus nerve, and ansa of the
hypoglossus. With both blunt and sharp dissection,
these structures are meticulously dissected from the
diseased portion. The dissection is carried upward
along the medial border of the cyst, with care being
taken to identify and to clamp the numerous small
communicating veins draining the lymphangioma.
E Both the anterior and posterior bellies of the digas-
tric muscle and the stylohyoid muscle are retracted to
expose the various ramifications of the hygroma.
There is a plexus of veins at the site of the lingual vein
as it empties into the internal jugular vein, and this
may hide the hypoglossal nerve, which must not be
injured. In the space between the external and internal
carotid arteries lies the superior laryngeal nerve, which
may be obscured by a thin layer of fascia as it passes
behind the external carotid artery. This is a vital sen-
sory nerve to the intrinsic larynx as well as a motor
nerve to the cricothyroid muscle and inferior pharyn-
geal constrictor and possibly the interarytenoideus
muscles.
A lymphangioma may extend to any contiguous
structure, surrounding these nerves as well as the
vagus nerve. If any point of dissection is obscured, the
surgical plane is first developed beyond the hygroma in
an uninvolved area. The nerves and vessels are then
meticulously dissected toward and then through the
hygroma. No important structure is sacrificed, but,
when feasible, no portion of the hygroma is left behind.
All contiguous lymph nodes in the operative field are
likewise removed. Any related nerve may be injured,
especially because nerves may be easily mistaken for
lymphatic ducts.
F The completed dissection in the upper cervical
region is shown. A drain is inserted. The platysma
muscle is approximated with 4-0 chromic catgut, and
the skin is closed with 5-0 nylon.
Discussion
Sacrifice of nerves should be avoided if at all possible.
However, at times these become so involved within the
lesion itself that the dissection simply cannot avoid
injury to certain nerves. Recurrences in cystic hygromas
often occur at the periphery of the surgical dissection,
and it is at these areas specifically that the surgeon
should be extremely careful to delineate the extent of
the disease. At times this becomes totally impossible.
The gross pathology and the histologic pathology may
actually differ; for example, there may be matted lymph
nodes with interposing lymph channels; in others there
are multiple various cystic formations that are confluent
and mayor may not communicate with one another.
When these cysts impede the airway (e.g., in an infant),
decompression with a needle may be lifesaving. The
surgery can then be performed electively at a later time.
Decompression during the surgical procedure may defi-
nitely help in further exposing the extent of the disease.
Cystic hygromas may extend behind the hypopharynx
and extend into the retroesophageal area as well as into
the superior mediastinum and up to the base of the
skull and posteriorly behind the trapezius muscle. In
addition, there may be abnormal courses of the various
nerves, especially the spinal accessory nerve. The thoracic
duct may likewise be involved in a cystic hygroma, and
this may require ligation. Hence, resection of cystic
hygromas can be very complicated, and various forms
of complications may occur. At times, observation is
fortuitous and surgery is deferred; however, if there
is any question of airway compromise or if the mass is
becoming larger, there is no alternative but surgery.
A lymphangioma may be combined with a heman-
gioma and termed a lymph hemangioma. Although these
lesions may be morphologically similar, nevertheless,
the lymph hemangiomas are more likely actually to
"invade" muscle and other structures (e.g., tongue,
mandible, parotid and submandibular salivary glands,
entire oral cavity, oropharynx, and nasopharynx) and to
 THE NECK

In!. jugular v.

Spinal ace. n. '

branch to
sternocleido-
mastoideus

Carotid sheath

Hypoglossal n.

Lingual v.
Com. facial v.
FIGURE 16-18 Continued

be so extensive that they defy complete surgical resec-
tion. Their management can be extremely complicated.
CO2 laser vaporization has been used with mixed results
in an attempt to arrest their spread but with no lasting
or significant results.
The following is an outline of a protracted course in
a white woman who, at birth, had an 11.5 x 12.5-mm
cystic mass involving the left neck and cheek that dis-
placed the left ear superiorly and the trachea laterally.
There was also involvement of the floor of the mouth
and tongue by a cystic mass of purplish coloration, which
displaced the tongue superiorly and posteriorly. The
original diagnosis of the cystic mass in the neck and
cheek was a lymph hemangioma. Subsequent to this
there were a total of 12 surgical procedures. The working
diagnosis up to this point was a lymph hemangioma.
However, on review, our pathologist stated that there
were many vascular spaces and some arteries and some
veins; prominent, smooth muscle walls; and thick-walled
vascular structures. This was consistent with an arterio-
venous malformation and not a true lymph heman-
gioma. Treatment after this diagnosis consisted of emboliza-
tion and administration of interferon. This was deferred,
and selective ligation of the feeding vessels was per-
formed. However, this had little, if any, favorable results.
At 11 years of age a tracheostomy was performed for
supraglottic airway obstruction. At 21 years of age this
amazing young lady is still energetic and hopes to enter
medical or dental school. She is able to speak in a
limited fashion and able to swallow. The small opening
in the hypopharynx and oropharynx measures 5 to 8 mm
in diameter.
An evaluation for the use of OK-432 and/or
thalidomide is in progress.
Complications
• Recurrence
• Multiple nerve injuries
• Vascular injuries
 THE NECK
Excision of Benign lesions of the
Submental Space (Fig. 16-19)
Highpoints
1. Keep the incision well beneath the lower edge of the
mandible.
2. Avoid injury to the mandibular branch of the facial
nerve.
A The incision is curved and placed about 4 cm
beneath the lower edge of the horizontal ramus of the
mandible. As the incision is extended laterally, it is
dropped to follow a natural skin crease. It is at this
point that the mandibular division of the facial nerve,
which hangs like a hammock below the mandible,
may be injured if the incision is too high.
B The incision is carried through the platysma muscles,
and upper and lower skin flaps are developed that
include these muscles. The lesion, which may be a
dermoid cyst, lies below the anterior bellies of the
digastric muscles. The line of cleavage is developed
along the medial edges of these muscles.
C AND D The cyst, usually dermoid, is elevated from
the mylohyoid muscles by sharp dissection. The entire
contents of the submental space are thus excised,
including cyst, lymph nodes, and adipose tissue.
E Simple exploration of the submylohyoid space is
performed by separating the mylohyoid muscles in the
direction of their fibers and exposing the geniohyoid
muscles.
F If more exposure is necessary,the mylohyoid raphe
is incised vertically in the midline. Both mylohyoid
muscles and geniohyoid muscles are then retracted
laterally, exposing the genioglossus muscles.This midline
plane is virtually avascular and may be extended deep
into the body of the musculature of the tongue. Closure
consists in approximation of the mylohyoid raphe and
careful approximation of the platysma muscles as a
separate layer, because these muscles continue up
over the chin and act as depressors of the lower lip.
They connect with the depressor labii inferioris and
depressor anguli oris anteriorly, while their posterior
fibers attach to the skin of the lower part of the face
and to muscles at the commissure and lower lip. A
small tissue drain is inserted deep to the mylohyoid in
the midline. The skin is closed with fine nylon.
 THE NECK 849

Genioglossus m.

FIGURE 16-19
 THE NECK
Resection of Ganglioneuroma of
the Neck and Superior
Mediastinum (Fig. 16-20)
Highpoints
1. Suspect a neurogenic tumor when the common carotid
artery is displaced forward and medially or when
Horner's syndrome is present.
2. Evaluate the chest and abdomen for multicentric
origin.
3. Ganglioneuromas usually are benign; hence, preserve
other important structures (e.g., hypoglossal and
phrenic nerves and vertebral artery).
4. Rule out a malignant lesion involving the cervical
sympathetic chain (rare).
5. Digital subtraction angiography is suggested for all
patients who have any type of neurogenic tumor in
the neck. This is done because of the proximity of
these lesions to the internal carotid artery and possibly
their relationship to the vertebral artery.
6. CT and MRI of neck and mediastinum are advisable.
7. Fine-needle aspiration is of benefit.
8. Evaluate for possible paraganglioma (see Chapter 22).
A Horizontal parallel incisions following natural skin
creases are utilized. One incision is first made for
exploration to ascertain the diagnosis and the extent
of the lesion. This 4-year-old patient had involvement
of all three cervical sympathetic ganglia extending from
the base of the skull to the arch of the aorta. Horner's
syndrome had been present since birth.
B Anterior and posterior as well as smaller upper and
lower skin flaps are developed. The platysma muscle is
included in the flaps. The skin is not mobilized over the
submaxillary triangle.
C The two heads of the sternocleidomastoid muscle
and external jugular vein are transected, exposing the
main tumor mass. The carotid sheath is displaced for-
ward and medially by the ganglioneuroma, which has
the configuration of three confluent masses connected
by neurogenic tissue. The separation between the
upper and middle masses, representing the superior
and middle cervical ganglia, is marked by the 12th
cranial nerve. Adjacent lymph nodes of the spinal
accessory chain (posterior triangle) are adherent to the
sternocleidomastoid muscle; the nodes are removed.
Both the nerve and the muscle are preserved.
D The vagus nerve, internal jugular vein, internal
carotid artery, and hypoglossal nerve are retracted
upward. Fibrous attachments to these structures are
cut by sharp dissection. This exposes the most superior
extension of the disease, which lies just behind the
internal carotid artery and internal jugular vein. The
cervical sympathetic chain is transected at this highest
point and adjacent lymph nodes are reflected down-
ward.
Continued
 THE NECK 851

EXT. JUGULAR V.

INT. JUGULAR V.

FIGURE 16-20
 THE NECK
Resection of Ganglioneuroma of
the Neck and Superior
Mediastinum (Continued) (Fig. 16-20)
E The two upper masses of the ganglioneuroma
have been separated from the lower mass to facilitate
removal of the latter. This lowest mass represents the
stellate ganglion; it rests on the arch of the aorta and
completely encircles the vertebral artery. With blunt
and sharp dissection this tumor is separated from the
carotid sheath medially, the subclavian vein, and a por-
tion of the left innominate vein anteriorly. The thoracic
duct emptying into the junction of the internal jugular
and subclavian veins is identified and preserved.
F The dissection is continued behind the tumor,
exposing the subclavian artery and its branches and
the vertebral and internal mammary arteries. At this
stage the tumor is incised to free the vertebral artery,
which is preserved, because its sacrifice might well
predispose to a basilar artery syndrome. The lowest
extent of the tumor is then carefully freed, exposing
the superior surface of the arch of the aorta. The tumor
is then reflected upward and separated medially from
the scalenus anticus muscle. Extreme care must be
taken to avoid injury to the pleura; if it is injured, closed
underwater drainage is mandatory.
G The exposed anatomy of the superior mediastinum
is shown after removal of the lowest tumor mass. The
position of the vital structures involved is depicted.
Their normal relationship has been distorted by pres-
sure from the tumor. This benign neurogenic tumor
was removed through the supraclavicular approach,
but if safety of exposure warranted it, a sternum-splitting
incision or thoracotomy could be used (see Fig. 19-10).
In an adult, resection of the medial third of the clavicle
(see Fig. 19-9) affords exposure of the mediastinum.
This procedure has not been used in a child.
The sternocleidomastoid muscle is reapproximated
with 3-0 silk.
H The incision is closed with 5-0 nylon, using one
drain in the mediastinum and another drain in the
upper cervical region.
Complications
• Pneumothorax
• Injury to vertebral and subclavian arteries
• Injury to uninvolved nerves
Excision of Neuroma
(See Fig. 16-20H, Inset)
Highpoints
1. Do not resect entire nerve if feasible.
2. Use simple enucleation.
This technique is seldom feasible and is often frus-
trating. It has been utilized for neurofibroma of the vagus
nerve in an attempt to preserve the function of the
recurrent laryngeal nerve. Follow-up is poor. Examination
of frozen sections for possible malignant change is
recommended, with malignant change more likely in
the deeply located lesions.
A A longitudinal incision is made through the nerve
sheath separating the nerve fibers to expose the
neuroma.
B With the uninvolved nerve fibers retracted from
the neuroma, the individual fiber leading to the neu-
roma is sectioned proximally and distally. The neuroma
is then removed by exerting slight pressure from
behind. An operation microscope may be of help.
 THE NECK

PHRENIC N.
BRACHIAL
E PLEXUS

VERTEBRAL A.

THORACIC DUCT

G H

FIGURE 16-20 Continued

 THE NECK
Incision and Drainage of Abscesses
of the Neck (Fig. 16-21)
If the presenting mass is small and superficial, a simple
stab wound suffices. When the mass is large and deep,
a more carefully planned anatomic approach is indi-
cated. A needle and syringe can be of great aid in
localization of a deep abscess. When pus is aspirated,
the needle is left in situ and acts as a guide for the
definitive approach.
Abscess of Tongue and Floor of Mouth
Presenting in Submental Space (Ludwig's
Angina)
A A horizontal incision is made along the inferior
margin of the presenting mass.
B A very limited upper skin flap is developed to
identify the mylohyoid raphe. A vertical incision is made
along the raphe (dotted line).
C The abscess cavity is entered with use of a curved
clamp. The geniohyoid muscles may be identified and
separated.
D A small Penrose drain is inserted. Closure of the
platysma muscle at the ends of the incision is done
and antibiotic therapy is begun.
Lateral Cervical Abscess
E A short horizontal skin incision is made if possible
in a natural skin crease at the most dependent point.
F A very limited upper skin flap is developed to
identify the anterior border of the sternocleidomastoid
muscle. An incision is made along this anterior border.
G A curved clamp is then inserted into the abscess
cavity. This may extend up under the mandible. A false
passage must be avoided.
H A small Penrose drain is inserted. Closure of the
platysma muscle at the ends of the incision is made
with the concomitant use of antibiotics.
Complications
• Airway obstruction, especially with Ludwig's angina;
if in doubt, perform an elective tracheostomy.
• Mistaken diagnosis: arteriosclerotic aneurysm of the
internal carotid artery
• Injury to nerves (7th, 10th, 12th) and major vessels
 THE NECK 855

Mylohyoid m.

Ant. belly rt.

digastricus m.

Geniohyoid m.

Ant. border sternocleidomastoid m.

FIGURE 16-21
 856 THE NECK

Penetration Wounds of the Neck 2. Intracavity: primarily hypopharynx, oral cavity, and
oropharynx
Not all penetration wounds of the neck require explo- 3. Internal, within the soft tissues (e.g., expanding
ration. "Blind" exploration is very difficult and unre- hematoma)
warding. Exploration, therefore, is based on careful a. External swelling
clinical and laboratory evaluation of immediate life- b. Hypopharyngeal, oral cavity, and oropharyngeal
threatening injuries consisting of a compromised airway swelling
and blood loss and an evaluation of associated injuries.
Roon and Christensen (1979) suggest that the neck can Evaluation
be divided into three areas that aid in the diagnosis and
management. 1. Clinical observation
2. Digital subtraction angiography
1. High: above the angle of the mandible. These wounds 3. Peroral endoscopy (see Chapter 4)
are mainly facial and of the oral cavity and
oropharynx and base of skull. Treatment
2. Middle: from the angle of the mandible to the cricoid
cartilage 1. Direct external pressure
3. Low: from the cricoid cartilage to the thoracic inlet 2. Surgical exploration
a. Ligation
Another important point is the fact that multiple-type b. Vascular reconstruction of major vessels. Recon-
injuries can occur (e.g., in transection of the trachea as struction is imperative for common carotid, internal
well as in expanding hematoma of the hypopharynx carotid, and vertebral arteries. Reconstruction should
and laryngeal injury), all of which can cause airway be done if feasible for the subclavian artery, but it
obstruction. A tracheostomy can solve the immediate is not absolutely necessary.
problem, yet the long-term result can be devastating if
the multiple injuries are not recognized and treated as Perforated Viscus
early as possible.
1. Hypopharynx (see Chapter 21)
Diagnosis and Treatment 2. Larynx (see Chapter 20)
3. Trachea (see Chapter 19)
Airway 4. Esophagus (see Chapter 21)

1. Oral cavity and oropharynx (see Chapter 15) Evaluation

2. Hypopharynx (see Chapter 21)
3. Larynx (see Chapters 4 and 20) I. Peroral endoscopy (see Chapter 4)
4. Trachea (see Chapter 19) 2. lmaging techniques: soft tissue radiographs for
emphysema using water-soluble swallow and CT
Evaluation
Treatment
I. Clinical observation
2. Peroral endoscopy (see Chapter 4) I. Surgical exploration
3. Imaging techniques: soft tissue radiographs of the cer- 2. Surgical closure: especially the esophagus
vical area and head, CT and MRI, and chest radiograph 3. Surgical drainage of all closures, especially if closure
is not feasible
Treatment
Neurologic Status
I. Endotracheal intubation (see Chapter 4)
2. Cricothyrotomy (see Chapter 2) Injuries to nerves such as the cranial nerves should be
3. Tracheostomy (see Chapter 19) repaired as indicated.

Blood Loss Basic Supportive Measures

See Chapter 22, especially the section on trauma as 1. Intravenous lines

well as other diagnostic data. 2. Tetanus prophylaxis
3. Antibiotics
1. External 4. Type and cross match

BIBLIOGRAPHY
Agliozzo CM, Reingold 1M: Scalene lymph nodes in necropsies of
malignant tumors. Cancer 20:2148-2153, 1967.
Aimi K, Takino K: Anomaly of the first branchial cleft. Arch Otolaryngol
75:397-400, 1962.
Anain JM, Lore JM Jr: Carotid artery injury. In Current Therapy in
OlOlaryngology-Head and Neck Surgery. Philadelphia, BC
Decker, 1987.
Anderson R, Flowers RS: Free grafts of the spinal accessory nerve
during radical neck dissection. Am J Surg 118:796-799, 1969.
Ariyan S: Functional radical neck dissection. Plast Reconstr Surg
65:768-776, 1980.
Aronsohn RS, Batsakis JG, Rice DH, Work WP: Anomalies of the first
branchial cleft. Arch OtolaryngoI102:737-740, 1976.
Babcock WW Jr, Conley J: Neck incision in block dissection-
experiences with the long anterior cervical flap incision. Arch
Otolaryngol 84:554-S57, 1966.
Bakamjian VY, Marshall 0: Plastic and reconstructive considerations
in selecting incisions used for radical neck dissection. Aust NZ J
Surg 36:184-191,1967.
Baker HW: Surgical analOmy of the neck. Surg Clin North Am
44:I1S1-1160, 1964.
Baker RR, Wood S Jr, Cong PV,et al: Role of the cervical lymph nodes
as a barrier to metastatic tumor. Am J Surg 118:654-659, 1969.
Ballantyne AJ: Significance of retropharyngeal nodes in cancer of the
head and neck. Am J Surg 108:500-504, 1964.
Barlow B, et al: Ten years experience with pediatric gunshot wounds.
J Pediatr Surg 17:927-932, 1982.
Barrie JR, Knapper WH, Strong EW: Cervical nodal metastases of
unknown origin. Am J Surg 120:466-470, 1970.
Bartelink H, Breur K, Hart G, et al: The value of postoperative
radiotherapy as an adjuvant to radical neck dissection. Cancer
52:1008-1013, 1983.
Batsakis JG: The pathology of head and neck tumors: The occult
primary and metastases to the head and neck: X. Head Neck Surg
3:409-423, 1981.
Batsakis JG, Nishiyama RH, Sullinger GO: Synovial sarcomas of the
neck. Arch OlOlaryngol 85:327-331, 1967.
Beahrs OH, Gossel 10, Hollinshead WH: Technic and surgical anatomy
of radical neck dissection. Am J Surg 90:490-516,1955.
Belinke SA, et al: Management of penetrating neck injuries. J lfauma
23:235-237, 1983.
Block BL, Spiegel JC, Chami RG: The treatment of papillary and
follicular carcinoma of the thyroid. Otolaryngol Clin North Am
23:403-411, 1990.
Block MA, Wylie JH, Patton RB, Miller JM: Does benign thyroid tissue
occur in the lateral part of the neck? Am J Surg 112:476-481, 1966.
Bocca E, Pignataro 0: A conservation technique in radical neck
dissection. Ann 0101 76:975, 1967.
Bocca E, Pignataro 0, Oldini C: Functional neck dissection: An evalu-
ation and review of 843 cases. Laryngoscope 94:942-945, 1984.
Bacca E, Pignataro O. Sasaki CT: Functional neck dissection. Arch
OlOlaryngol 106:524-527, 1980.
Brandenburg JH, Lee CYS: The eleventh nerve in radical neck
surgery. Laryngoscope 91:1851-1858, 1981.
Byars LT, Anderson R: Anomalies of the first branchial cleft. Surg
Gynecol Obstet 93:755-758, 19SI.
Byers RM: Modified neck dissection: A study of 967 cases from 1970
to 1980. Am J Surg 150:414-421,1986.
Cabasser HV: Selective surgical management of penetrating neck
trauma: 15 year experience in a community hospital. Am Surg
48:355-358, 1982.
Casson 1R, Blair 0, Gerard G, et al: Eosinophilic granuloma of the
cervical spine in an adult. NY State J Med 81:1102-1104, 1981.
Catlin 0: Surgery for head and neck lymphomas. Surgery 60:
1160-1166, 1966.
THE NECK 857
Catlin 0, Slrong EW: Preoperative irradiation for neck disseclion.
Surg Clin North Am 47:1131-1137, 1967.
Chang JL: Postoperative venous air embolism after removal of neck
drains. Arch OlOlaryngol 107:494-496, 1981.
Cole TB, Fisher SR, Seigler HP: Application of posterior neck dissec-
tion in treating malignant melanoma of the posterior scalp.
Laryngoscope 93:760-765,1983.
Conklin WT, Davis RM, Dabb RW,Reilly CM: Hypothyroidism following
removal of a "thyroglossal duct cyst." Plast Reconstr Surg 68:
930-932, 1981.
Conley JJ: Neurogenous tumors in the neck. Arch OlOlaryngol
61:167-180, 1955.
Conley J, Sachs ME, Romo T, et al: Metastatic basal cell carcinoma
of the head and neck. Otolaryngol Head Neck Surg 93:78-85,
1985.
Crile G: Excision of cancer of the head and neck. JAMA 47: 1780,
1906.
Das Gupta TK, Brasfield RD: Thmors of peripheral nerve origin:
Benign and malignant. Cancer 20:228-233, 1970.
Das Gupta TK, Brasfield RD, Strong EW, Hajdu SI: Benign solitary
schwannomas (neurilemomas). Cancer 24:355-366,1969.
Deanne SA, Telander RL: Surgery for thyroglossal duct and branchial
cleft anomalies. Am J Surg 136:348-353, 1978.
DeCastro CC: The anatomy of the platysma muscle. Plast Reconstr
Surg 66:680-683, 1980.
DeSanto LW, Holt JJ, Beahrs OH, O'Fallon WM: Neck dissection: Is it
worthwhile? Laryngoscope 92:502-509,1982.
Diddle AW: Carcinoma of the cervix uteri with metastases 10 the
neck. Cancer 29:453-455, 1972.
Dykes ER, Anderson R, Hawk WA: Benign Iymphoepithelial cysts
(ectopic salivary gland tissue) in lymph nodes: Report of two
cases. Cleve Clin Q 27:109-113,1960.
Ellenbogen R: Pseudoparalysis of the mandibular branch of the facial
nerve after platysmal face-lift operation. Plast Reconstr Surg
63:364-368, 1979.
Farr HW, Jean-Gilles B, Die A: Cervical island skin flap repair of oral
and pharyngeal defects in the composite operation for cancer. Am
J Surg 118:759-763, 1969.
Fee WE, Wilson GG: lfacheoesophageal space abscess. Laryngoscope
89:1377-1384, 1979.
Feind CR, Cole RM: Contralateral spread of head and neck cancer.
AmJ Surg 11:660-665, 1969.
Fisch UP, Sigel ME: Cervical lymphatic system as visualized by
lymphography. Ann Otol Rhinol Laryngol 73:869-882, 1964.
Fitchett VH, Pomerantz M, Butsch OW, et al: Penetrating wounds of
the neck. A military and civilian experience. Arch Surg 99:307-314,
1969.
Frazell EL, Moore OS: Bilateral radical neck dissection performed in
stages: Experience with 467 patients. Am J Surg 102:809, 1961.
Gavilan C. Gavilan J: Five-year results of functional neck dissection
for cancer of the larynx. Arch Otolaryngol Head Neck Surg 115:
1193-1196, 1989.
Goepfert H, Jesse RH, Ballantyne AJ: Posterolateral neck dissection.
Arch OtolaryngolI06:618-620, 1980.
Goldberg MJ, Belsky MR, Brader 0, Prager RJ: Solitary osteochon-
droma of the cervical spine. Orthopedics 3:759-763, 1980.
Gollin FF, Ansfield FJ, Brandenburg JH, et al: Combined therapy in
advanced head and neck cancer: A randomized study. AJR Am J
Roentgenol 114:83-88, 1972.
Grandon EL, Brintnall ES: A utility neck incision. Arch Otolaryngol
72:743-745, 1960.
Greenway RE, Hurst L, Fenton NA: An unusual first branchial cleft
cyst. J Otolaryngol 10:219-225, 1981.
Haar G, Boulos EJ, Sadeghi MH, Sheffer J: Association of a thyroglossal
duct cyst and a dermoid cyst in the neck. Ann OlOlaryngol 90:
181-182,1981.
 858 THE NECK

Hamlin H, Pecora 0: Subclavicular segmental resection of first rib for Lipshutz H, Stetzer SS: Extended radical neck dissection. Ann Surg
correction of subjacent neurovascular compression. Am J Sueg 168:901-904,1968.
117:754-758,1969. Liston SL: The relationship of the facial nerve and first branchial
Handler SO, Canalis RF, Jenkins HA, Weiss AJ: Management of cleft anomalies-embryologic considerations. Laryngoscope 92:
brachial plexus tumors. Arch OtolaryngoI103:653-657, 1977. 1308-1310, 1982.
Harrison B Jr, Anderson R: Neurilemomas of the lateral region of the Lore JM Jr: Deep infections of the neck: Applied anatomy in deep
neck. Cleve Clin Q 23:274-279, 1956. infections of the neck. Laryngoscope, June 1939.
Harrold CC: The case against unlimited prophylactic neck dissection. Lore JM Jr: Discussion of Dr. John Conley's paper entitled "Radical
In Conley J (ed): Cancer of the Head and Neck. Presented at the Neck Dissection, Cont." Surgery 5(September), 1974.
International Workshop on Cancer of the Head and Neck, New Lore JM Jr: neatment of recurrent tumors of the head and neck.
York, May 1965. Washington, DC, Butterworths, 1967. Laryngoscope 78: 1445-1461, 1968.
Hendrickson M: Carotid sinus reflex during radical neck dissection. MacFee W: Transverse incisions for neck dissections. Ann Surg
South Med J 62:1195-1197, 1969. 151:279-284, 1960.
Henzel JH, Pories WJ, De Weese MS: Etiology of lateral cervical cysts. MacLeod OM, Karandy EJ: Aberrant cervical thymus. Arch
Surg Gynecol Obstet 125:87-94, 1967. Otolaryngol 107: 179-180, 1981.
Hill JH, Olson NR: The surgical anatomy of the spinal accessory Marchetta F, Sako K: Modifed neck dissection for carcinoma of the
nerve and the internal branch of the superior laryngeal nerve. thyroid gland. Surg Gynecol Obstet 119: 1-8, 1964.
Laryngoscope 89:1935-1942,1979. Marchetta F, Sako K, Matsuura H: Modified neck dissection for
Himalstein MR: Correlation of surgical anatomy and embryology in carcinoma of the thyroid gland. Am J Surg 120:4S2-455, 1970.
lateral cervical anomalies. Trans Am Acad Ophthalmol Otolaryngol Martin GL: Long time studies of metastatic cervical lymph nodes
75:974-985, 1971. treated with irradiation. AJR Am J RoentgenoI108:247-256, 1970.
Hiranandani LH, Dishpande CK, Melgiri RD, Deodhar LP: Malignant Martin H: Radical neck dissection. Ciba Clin Symp 13:103-120, 1961.
ganglioneuroma (A report of a case). Indian J Cancer 3:135-139, Martin H, Del Valle B, Ehrlich H, Cahan WG: Neck dissection. Cancer
1966. 4:441-499, 1951.
Hoffer MM, Braun R, Hsu J, et al: Functional recovery and orthopedic Martin H, Morfit HM: Cervical lymph node metastasis as the first
management of brachial plexus palsies. JAMA 246:2467-2470, symptom of cancer. Surg Gynecol Obstet 78:133-159,1944.
1981. Massac E, Siram SM, Leffall LD: Penetrating neck wounds. Am J Surg
Hora JF: Deep neck infections. Arch Otolaryngol 77:129-136, 1963. 145:262-26S, 1983.
Jesse RH, Lindberg RD: Evolution of clinically negative neck: Squamous May M: Neck masses in children: Diagnosis and treatment. Pediatr
cell carcinoma of oral cavity and faucial arch. JAMA 217:453, 1971. Ann S:518-535, 1976.
Jesse RH, Neff LE: Metastatic carcinoma in cervical nodes with an May M, Lee C, Sapote p, et al: Penetrating wounds of the neck:
unknown primary lesion. Am J Surg 112:547-553, 1966. Selective exploration. A study of 100 cases. nans Am Acad
Jesse RH, Ballantyne AJ, Larson 0: Radical or modified neck dissec- Ophthalmol Otolaryngol 85:199-201,1967.
tion: A therapeutic dilemma. Am J Surg 136:516-519, 1978. McCarthy WH, Shaw HM, Milton GW: Efficacy of elective lymph
Johnson Jr, Barnes EL Jr, Myers EN: The exlracapsular spread of node dissection in 2,347 patients with clinical stage I malignant
tumors in cervical node metastases. Arch OtolaryngoI107:725-729, melanoma. Surg Gynecol Obstet 161:575-580, 1985.
1981. McGuirt WF, McCabe BF: Bilateral radical neck dissections. Arch
Johnson Jr, Myers EN, Bedetti CD, et al: Cervical lymph node metas- OtolaryngoI106:427-429, 1980.
tases. Arch Otolaryngollll:S34-537, 1985. McRae RG, Lee KJ, Goertzen E: First branchial cleft anomalies and
Kaplan R, Bratcher GO, Freeman 0, et al: Liposarcoma of the neck: the facial nerve. Otolaryngol Head Neck Surg 91:197-202, 1983.
Report of a case. Laryngoscope 91: 1-4, 1981. Medina JE, Byers RM: Supraomohyoid neck dissection: Rationale,
Karlan MS, Michel SL, Snyder WH Jr: Branchiogenic cysts: Congenital indications and surgical technique. Head Neck 11:111-122, 1989.
or acquired. Am J Surg 110:615-619,1965. Medina JE, Johnson 0: Selective neck dissection. Paper presented at
Karlin RM, et al: Extracranial carotid injury: Current surgical manage- the 33rd Annual Meeting of the American Society for Head and
ment. Am J Surg 146:225-227, 1983. Neck Surgery, Waikoloa, Hawaii, May 7-9, 1991.
Katubig C, Damjanov I: Branchial cleft carcinoma. Arch Otolaryngol Mesara BW, Batsakis JG: Hibernoma of the neck. Arch Otolaryngol
89:92-93, 1969. 85:199-201,1967.
Kirchner JA: Cervical mediastinal emphysema. Arch Otolaryngol Miller 0, Ervin T, Weichselbaum R, Fabian RL: The differential diag-
106:368-375, 1980. nosis of the mass in the neck: A fresh look. Laryngoscope 91:
Lahey FH, Hare HF, Warren S: Carcinoma of the thyroid. Ann Surg 140-145, 1981.
112:977-1005, 1940. Millikan JS, Moore EE, Moore GE: A familial pattern of thyroglossal
Larson DL, Lewis SR, Rapperport AS, et al: Lymphatics of the mouth duct cysts. JAMA 244:1714,1980.
and neck. Am J Surg 110:625-630, 1965. Miodonski J: Treatment of laryngeal cancer. Otolaryngol Pol 8:1, 19S4.
Latyshevsky A, Freund HR: Long upper flap incision for radical neck Molinari R, Chiesa F, Cantu G, et al: Retrospective comparison of
dissection. Surgery 47:206-209, 1960. conservative and radical neck dissection in laryngeal cancer. Ann
Leipzig B, Suen JY, English JL, et al: Functional evaluation of the Otol 89:578-581, 1980.
spinal accessory nerve after neck dissection. Am J Sueg 146: Mulay SG, Hiranandani LH: A clinical study and the surgical manage-
S26-530, 1983. ment of two hundred and fifty cases of tubercular cervical lym-
Linberg R: Distribution of cervical lymph node metastases from squa- phadenitis. J Laryngol.Otol 84:781-794,1970.
mous cell carcinoma of the upper respiratory and digestive tracts. Myers LL, Wax MK, Nabi H, et al: Positron emission tomography in
Cancer 29:1446-1449,1972. evaluation of the NO neck. Laryngoscope 108:232-236, 1998.
Lindberg RD, Barkley HT Jr, Jesse RH, Fletcher GH: Evolution of the Narrod SA, et al: Selective management of penetrating neck injuries:
clinically negative neck in patients with squamous cell carcinoma A prospective study. Arch Surg 119:574-578, 1984.
of the faucial arch. AJR Am J Roentgenol 111:60-6S, 1971. Nichols RT, Greenfield U: Experience with radical neck dissection in
Lingeman RE, Stephens R, Helmus C, et al: Neck dissection: Radical the management of 426 patients with malignant tumors of the
or conservative. Ann Otol 86:737-744, 1977. head and neck. Ann Surg 167:23-34, 1968.

Niederdellmann W, Schilli W, Scholsser V, Jeckel N: 2ur Problematik
des venosen Ruckflusses nach Neck Dissection. Dtsch Z Mund-
Kiefer-Gesichts-Chir 6: 134-136, 1982.
Northrop M, Fletcher GH, Jesse RH, Lindberg RD: Evolution of neck
disease in patients with primary squamous cell carcinoma of the
oral tongue, floor of mouth, and palatine arch, and clinically posi-
tive neck nodes neither fixed nor bilateral. Cancer 29:23-30, 1972.
Noyek AM, et al: The clinical significance of radionuclide bone and
gallium scanning in osteomyelitis of the head and neck. Laryngoscope
94(Suppl 34, pt 2):1-21, 1984.
Ogura JH, Toomey JM, Setzen M, Sobol 5: Malignant fibrous histio-
cytoma of the head and neck. Laryngoscope 90:1-12, 1980.
Olsen JD, Maragos NE, Weiland LH: First branchial cleft anomalies.
Laryngoscope 90:1-14,1980.
Olson NR: Atypical mycobacterial infections of the neck. Laryngoscope
77:1376-1389, 1967.
Park WM, O'Brien W: Computer-assisted analysis of.radiographic neck
lesions in chronic rheumatoid arthritis. Acta Radiol 8:529-534,
1969.
Pico J, Frias Z, Bosch A: Cervical lymph node metastases from carci-
noma of undetermined origin. Am J Roent Radium Ther Nucl Med
61:95-102, 1971.
Princer MH, Plotkin RP, Brownstein HS: Bilateral branchial cartilages.
Laryngoscope 81:423-426, 1971.
Proctor B, Proctor C: Congenital lesions of the head and neck.
Otolaryngol Clin North Am 3:221-248,1970.
Rao DM, et al: Penetrating injuries of the neck: Criteria for explora-
tion. J Trauma 23:47-49, 1983.
Razack MS, Baffi R, Sako K: Bilateral radical neck dissection. Cancer
47:197-199,1981.
Remmler D, Byers RM, Scheetz J, et al: A prospective study of shoulder
disability resulting from radical and modified neck dissections.
Head Neck Surg 8:280-286, 1986.
Richard JM, Garnier HS, Micheau C, Saravane D: Prognostic factors
in upper respiratory and digestive tract carcinomas: Study of 1,713
cases during a 15-year period. Laryngoscope 97:97-101, 1987.
Ripley R, Hollifield J, Nies A: Sustained hypertension after section of
the glossopharyngeal nerve. Am J Med 62:297-302,1977.
Robins RB: Sublingual branchial cleft cyst: A case report. Laryngoscope
79:288-294, 1969.
Rochlin DB: Posterolateral neck dissection for malignant neoplasms.
Surg Gynecol Obstet 115:369-373, 1962.
Roon HJ, Christensen N: Evaluation and treatment of penetrating
cervical injuries. J Trauma 19:391-397, 1979.
Rosenfeld L, Graves H Jr, Lawrence R: Primary neurogenic tumors of
the lateral neck. Ann Surg 167:847-855, 1968.
Roses DF, Snively SL, Phelps RG, et al: Carcinoma of the thyroglossal
duct. Am J Surg 145:265-269, 1983.
Rouviere M: Anatomy of the Human Lymphatic System. Ann Arbor,
MI, Edwards Brothers, 1938.
Roy PH, Beahrs OH: Spinal accessory nerve in radical neck dissec-
tions. Am J Surg t18:800-804, t969.
Sako K, Pradier RN, Marchetta FC, Pickren JW: Fallibility of palpation
in the diagnosis of metastases to celVical nodes. Surg Gynecol Obstet
118:989-990, 1964.
Saletta JD, Falk FA, Freeark RJ: Trauma to the neck region. Surg Clin
North Am 53:73-86, 1973.
Sandeman TF: The radical treatment of enlarged lymph nodes in
malignant melanoma. Am J Roent Radium Ther Nucl Med 97:
967-979, t966.
Sandeman TF: The radical treatment of enlarged lymph nodes in
malignant melanoma. AJR Am J Roentgenol 97:967-979, 1966.
Saunders JR, et al: Liposarcomas of the head and neck: A review of
the literature and addition of four cases. Cancer 43:162-168,1979.
Schobinger R: The use of a long anterior skin flap in radical neck
resections. Ann Surg 146:22t-223, 1957.
THE NECK 859
Schuller DJ::: An assessment of neck node immunoreactivity in head
and neck cancer. Laryngoscope 94(Suppl. 35, pt 2):1-35, 1984.
Schuller DE, McGuirt WF, McCabe BF, Young D: The prognostic
significance of metastatic cervical lymph nodes. Laryngoscope 90:
557-570, 1980.
Schuller DE, Platz CE, Krause CJ: Spinal accessory lymph nodes: A
prospective study of metastatic involvement. Laryngoscope 38:
439-450, 1978.
Schuller DE, Saunders WH, Miglets AW,Kelly DR: Conservative neck
dissection. Arch Otolaryngol 107:642-645, 1981.
Schweitzer RJ: Surgical approach to intraoral neoplasms without
division of lip. Am J Surg 110:656-659, 1965.
Seashore JH, Gardiner W, Ariyan 5: Management of giant cystic
hygromas in infants. Am J Surg 149:459-465, 1985.
Sekula J, Horzela T: Studies on the cervical lymph nodes. Arch
Otolaryngol 94:118-123, 1971.
Shah JP: Patterns of cervical lymph node metastasis from squamous
carcinomas of the upper aerodigestive tract. Am J Surg 160:
405-409, 1990.
Shearin JC, De Franzo AJ: Butterfly correction of webbed-neck defor-
mity in Thrner's syndrome. Plast Reconstr Surg 66:129-133,1980.
Shepard GH, Rosenfeld L: Carcinoma of thyroglossal duct remnants.
Am J Surg 116:125-129, 1968.
Shikhani AH, Shehadi 51: Surgical treatment of giant hemangiomas
of the head and neck. Otolaryngol. Head Neck Surg 94:113-122,
1986.
Shugar MA, Healy GB: The fourth branchial cleft anomaly. Head
Neck Surg 3:72-75, 1980.
Shugar MA, Weber AL, Mulvaney TJ: Myositis ossificans following
radical neck dissection. Ann Otol Rhinol Laryngol 90: 169-171,
1981.
Simpson RA: Lateral cervical cysts and fistulas. Laryngoscope 79:30-
59, 1969.
Sistrunk WE: The surgical treatment of cysts and sinuses of the
thyroglossal tract. Ann Surg 71:121, 1920.
Skolnik EM: The posterior triangle in radical neck surgery. Arch
Otolaryngol 102:1-4, 1976.
Skolnik EM, Loewy A, Ferrer J: Swellings of the neck. Arch Otolaryngol
81:150-152,1965.
Skolnik EM, Tenta LT, Tardy ME Jr, Wineinger M: Elective neck
dissection in head and neck cancer. Arch Otolaryngol 87:471-476,
1968.
Skolnik EM, Katz AH, Becke SP, et al: Evolution of the clinically
negative neck. Ann Otol Rhinol Laryngol 89:551-555, 1980.
Slaughter DP, Southwick HW: Cervical thoracic duct fistulas. Ann
Surg 142:307-310, 1955.
Snyder CC, Webster H deF, Pickens JE, et al: Intraneural neurorrhaphy:
A preliminary clinical and histological evaluation. Ann Surg 167:
691-696, 1968.
Snyderman L, Johnson JT, Schramm VLJr, et al: Extracapsular spread
of carcinoma in cervical lymph nodes. Cancer 56:1597-1599,1985.
Sobol S, Jensen C, Sawyer W II, et al: Objective comparison of physical
dysfunction after neck dissection. Am J Surg 150:503-509, 1985.
Southwick HW: Elective neck dissection for intraoral cancer. lAMA
217:454-455, 1971.
Southwick HW, Slaughter DP, Majarakis JD: Malignant disease of the
head and neck in childhood. Arch Surg 78:678-687, 1959.
Spiro RH, Martin H: Gustatory sweating following parotid surgery
and radical neck dissection. Ann Surg 165:118-127, 1967.
Stell PM, Brown G: Horizontal incisions for radical neck dissections.
Arch Otolaryngol 91:485-487, 1970.
Stella JG, Schweisguth 0, Schlienger M: Neuroblastoma: A study of
144 cases treated in the Institut Gustave-Roussy over a period of 7
years. AJR Am J Roentgenol 108:324-332, 1970.
Suarez 0: EI problema de las metastasis linfaticas y alejadas del cancer
de laringe e hipofaringe. Rev Otorhinolaringol 23:83, 1963.
 a~o THE NECK

Sullivan D, et al: Lymphoscintigraphy in malignant melanoma: TC Widstrom A, Enbom H, Magnusson P: Aspects on the lateral fistulae
antimony sulfur colloid. Am J Radial 137:847-8SI, 1981. and cysts of the neck. J Otolaryngol 9:291-296, 1980.
Swelstad JA, Scanlon EF, Oviedo MA, Hugo NE: Irradiation-induced Widstrom A, Magnusson P, Hallberg 0, et al: Adenocarcinoma origi-
polyglandular neoplasia of the head and neck. Am J Surg 135: nating in the thyroglossal duct. Ann Otol Rhinal Laryngol 85: 1-5,
820-824, 1978. 1976.
Swift TR: Involvement of peripheral nerves in radical neck dissection. Wizenberg MJ, Bloedorn FG, Weiner S, Gracia JR: Radiation therapy
Am J Surg 119:694-698, 1970. in the management of lymph node metastases from head and neck
Torti RA, Ballantyne AJ, Berkeley RG: Sudden blindness after simul- cancers. AJR Am J Roentgenol 114:76-82, 1972.
taneous bilateral radical neck dissection. Arch Surg 88:271-274, Woodring AJ: Cervical cystic hygroma-a review of the literature and
1964. report of an unusual case. Ann OlOlaryngol 77:978-983, 1968.
Travis LW, et al: Cervical approaches to the surgery of cervicothoracic Work WP: Newer concept of first branchial cleft cyst defects.
neoplasia. Laryngoscope 100: 1502-1 S09, 1980. Laryngoscope 83: 1581-1593, 1972.
Thcker HM, Skolnick ML: Fourth branchial cleft (pharyngeal pouch) Yarington CT Jr: Syphilis as a differential diagnosis of neck masses.
remnant. Trans Am Acad Ophthalrnol Otolaryngol 77: ORL 368-371, Arch Otolaryngol 86:219-221, 1967.
1973. Yael J, Linares CA: The Schobinger incision: Its advantages in radical
Wander JV, Chaudhuri P: Dissection of the posterior part of the neck. neck dissections. Am J Surg 108:526-528, 1964.
Surg Gynecol Obstet 143:97-100, 1976.
Weaver AW, Sankaran S, Fromm SH, et al: The management of pene-
trating wounds of the neck. Surg Gynecol Obstet 133:49-52, 1971.
 17 THE PAROTID SALIVARY
GLAND AND
MANAGEMENT OF
MALIGNANT SALIVARY
GLAND NEOPLASIA

For surgery of salivary glands other than the parotid, minor salivary glands. Magnetic resonance imaging
the reader is referred to the following: (MRI) is useful to supplement CT if indicated. One
indication is additional evaluation of deep lobe tumors
• Submandibular-see Figure 16-12 that extend into the parapharyngeal space and/or to
• Sublingual (ranula)-see Figure 15-21 the infratemporal fossa or the base of the skull (see
• Minor salivary-see Chapter 15, pages 760 to 763 Chapter 23).

Fine-Needle Aspiration Biopsy

General Considerations (See also Chapter 3)

There are basically five areas where identification of
the seventh nerve, which is crucial to any type of parotid
surgery, can be made:
1. The main trunk
2. Mandibular branch along the posterior facial vein
3. Within the gland itself
4. At the edge of the gland
5. In the fallopian canal
Actually, the parotid gland is really one lobe with an
accessory lobe along the Stensen duct. The delineation
of two lobes-lateral and deep lobes-based on the
seventh nerve is not so much anatomic but surgical.
The use of the term superficial to refer to the lateral
lobe is a misnomer. This lobe is by no means super-
ficial, which means "near the surface." True, the lobe
is located just beneath the skin but its extent to deeper
planes would indicate to nonmedical personnel that its
removal is a simple operative procedure-an excellent
ploy for health maintenance organizations! Sialography
is of little value in tumor delineation; however, it is of
value in certain patients with sialectasia and suspected
ductal stenosis and radiolucent stones. Computed
tomography (CT) with and without contrast medium
enhancement is a significant aid in delineating the
fibrofatty tissue plane that normally lies between the
medial aspect of the deep lobe of the parotid gland and
the soft tissues of the para pharyngeal space (Som, 1978).
If this fibrofatty tissue plane is absent, a malignant
neoplasm of either the deep lobe or oropharynx may be
present. This plane is also useful in differentiating
whether a tumor in the parapharyngeal space originates
in the deep lobe of the parotid or in parapharyngeal
Fine-needle aspiration (FNA) of a parotid mass is con-
troversial. If the diagnosis is benign, it is by no means
absolute. On the other hand, when a lesion is associated
with physical findings, for example, nerve paralysis
(more often observed in adenoid cystic carcinoma),
very hard consistency, rapid growth, or fixation to the
deep structures, then FNA may be very helpful in plan-
ning treatment. FNA is also useful to avoid surgery in
a debilitated patient with a benign tumor and when a
parotid mass occurs in a patient with a previous history
of cancer (i.e., lung, breast, kidney). With nodal
enlargement, FNA of the suspicious node, if positive
for metastatic disease, yields the diagnosis. Rarely, a
firm, solitary, intraparotid node is a primary squamous
cell carcinoma of the parotid. Although this finding
may be primary in the parotid, more likely it will be
metastatic from the nasopharynx or oropharynx or from
a primary neoplasm of the skin of the face or scalp.
Melanoma can metastasize to preauricular and postau-
ricular and intra parotid areas and to the tail of parotid
lymph nodes (sentinel nodes). A large spongy, nontender
mass may be a lymphoma, and FNA may well lead to
the diagnosis. The same can be said of lymphoep-
ithelial disease of Godwin (very, very rarely malignant
transformation). Kimura's disease (subcutaneous
angioblastic lymphoid hyperplasia with eosinophilia)
may be suggested by FNA but requires histologic
section for a firm diagnosis. The treatment of both
Godwin's disease and Kimura's disease is surgical.
Sentinel node biopsy may be an aid in diagnosis and
management of the melanoma. FNA of a submucosal
oropharyngeal mass may yield a positive diagnosis of a
deep lobe parotid neoplasm. Incidentally, it also may
yield a metastatic node from other head and neck

861
 THE PAROTID SALIVARY GLAND AND MANAGEMENT
sources, even the thyroid gland. When performing phys-
ical examination, palpation and bimanual palpation are
most important in evaluation of any parotid mass.
Evaluation of the lateral wall of the oropharynx is also
important. This may be a tumor of the deep lobe of the
parotid or a primary tumor of the para pharyngeal space.
A mass in the inferior portion of the soft palate could
be an extension from a deep lobe neoplasm but more
likely has its origin from a salivary tumor of a minor
salivary gland. When an FNA yields a diagnosis of
Warthin's tumor and the physical examination reveals
a soft mass, some surgeons may delay resection and
choose to observe. The better course would be to resect
with lobectomy, certainly if there is any concern either
on the part of the patient or the surgeon.
The replacement of 18 G needles by finer needles
(23 or 27 G), the rare complications reported,
and the growing accuracy and simplicity of the
technique have led to a renewed interest in this
technique, as reflected by the large number of
scientific publications (approximately 40) each year.
In our series (1999) it shows 1,253 patients with a
sensitivity of 94%, specificity 97%, and accuracy
95% (Klijanienko and Vielh, 2000).
Total Lateral Lobectomy of the
Parotid Salivary Gland (Fig. 17-1)
The technique depicted in the following illustrations is
based on the identification of the main trunk of the
facial nerve as it leaves the stylomastoid foramen. Two
other techniques to identify the main trunk are (1) by
first identifying the terminal branches and following
them proximally and (2) by using a posterior approach.
Although the author (JML) has very little experience
with the Nerve Integrity Monitor-2 (Xomed), this instru-
ment could be very useful, especially in secondary oper-
ations on the parotid gland for identification of the
seventh nerve.
If the technique of identification is based on locating
the mandibular branch along the posterior facial vein,
it must be noted that this association is proximal rather
than distal, because the mandibular branch goes along
with the posterior facial vein proximally until it then
leaves the vein near the tail of the parotid salivary
gland. It is in this area that this mandibular branch can
be very easily injured, especially if the branch is not
followed from its proximal source to its distal source.
Swinging around the tail of the parotid without following
the nerve, the so-called flanking maneuver, is the most
common source of injury.
In chronic sialoadenitis and lymphoepithelial disease
of Godwin (Sjogren's syndrome and Mikulicz's syn-
OF MALIGNANT SALIVARY GLAND NEOPLASIA
drome) when total parotidectomy is indicated, extreme
caution is necessary to identify and to preserve all the
branches of the facial nerve. The separation of the so-
called lateral lobe from the deep lobe is extremely
difficult because of the fibrosis that may occur, and a
dissection may be aided by using the so-called pinch
scissors technique for dissection (Sachs and Conley,
1981). The use of a fine curved iris scissors is ideal for
this technique. The operation microscope or loupe can
also be of help. Frozen section is freely utilized to aid
the intraoperative diagnosis (Rigual et aI., 1986).
Highpoints
1. Excision of any type of lesion within the parotid
gland requires the approach of a total lobectomy.
2. The first step is to locate the main trunk of the facial
nerve at the site of its emergence through the stylo-
mastoid foramen. If the tumor is extremely large, it
may overlap the main trunk: then it will be necessary
to identify first one or more of the peripheral branches.
3. Dissect the nerve from the proximal to the distal
portion. Do not skip areas; the course of nerve
branches is unpredictable.
4. Never attempt enucleation of any primary parotid
tumor, because this procedure almost guarantees
recurrence. There is evidence that there is an inci-
dence of malignant tumors at the site of previously
benign tumors that were surgically removed inade-
quately. This can be a disaster! In addition, enucle-
ation has been followed by severe fibrosis around
the main trunk and first portion of the two divisions.
In reoperating on such cases it is useful to use the
operating microscope to identify the nerve; if this
fails, then the dissection requires identification and
tracing of the terminal branches of the seventh nerve
proximally.
5. Landmarks of the main trunk of the facial nerve:
a. Mastoid process with insertion of sternocleido-
mastoid muscle
b. Cartilage of external auditory canal. A triangular
extension of the cartilage points downward (Sam,
1978) toward the main trunk of the facial nerve.
c. Temporoparotid fascia, which overlies the main
trunk, extends from the temporal mastoid fissure
to the lateral border of the parotid gland near its
posterior lateral region. This fascia lies over the
main trunk of the seventh nerve. It is deep (see
Fig. 17-6B and C).
d. Posterior belly of digastric muscle
e. Styloid process
f. TYmpanomastoid fissure
6. The main trunk of the facial nerve is more caudad
and superficial in infants and young children (see
Fig. 17-lJ).
 THE PAROTID SALIVARY GLAND AND MANAGEMENT OF MALIGNANT SALIVARY GLAND NEOPLASIA
FIGURE 17-1
With mobilization of a cheek flap, care must be
taken not to injure the nerve supply or the small muscles
of expression. These nerves are via small branches
from the various large branches of the main divisions
of the facial nerve. They arise medially. Nevertheless, it
is important not to elevate a flap so far anteriorly and
medially that these small branches will be transected.
Usually the guideline is 1 to 2 cm from the commissure
of the lips. These small nerves are involved in the
superficial musculoaponeurotic system. In summary,
elevation of the cheek flap is relatively safe in the
parotid area but can become dangerous in the area
anterior to the parotid gland (Mitz, 1976).
A A preauricular incision is made with a curved
cervical extension that follows a natural skin crease
below the angle of the jaw. Other incisions have been
used to avoid the curved cervical incision (e.g., facelift
incision). This is not recommended unless the
diagnosis is unequivocally benign because implan-
tation (e.g., of a highly malignant mucoepidermoid
carcinoma) beyond the ablative surgery can occur.
Care must be taken not to incise any neoplasm
because implantation in any incision can occur. Hence
an open biopsy is contraindicated-perform a lobec-
tomy. This is the same principle for the thyroid nodule.
The one exception to this rule is the obvious non-
resectable fixed mass. When a parotidectomy is com-
bined with resection of the entire auricle of the ear,
approach to the seventh nerve may be better achieved
from posterior to the auricle. Not shown is the place-
ment of %-inch plain strip gauze or a cottonoid sponge
in the external auditory canal to prevent the accumu-
lation of blood in the canal. Blood crusted and dried
can be very annoying to the patient postoperatively.
B Anterior and posterior skin flaps are developed.
The heavy fascia overlying the parotid gland is left
intact. Posteriorly, the mastoid process and the
anterior edge of the sternocleidomastoid muscle are
identified. This muscle serves as an excellent safe initial
structure to identify. With tumors extending poste-
riorly and below the lobule of the ear, this concept is
most important.
Continued
 864 THt PAROTID SALIVARYelAND AND MANACrMrNT m MALICNANT SALIVARY ClAND NWPlASIA
Total Lateral Lobectomy of the
Parotid Salivary Gland (Continued)
C With the use of blunt dissection with a small
curved clamp, the gland is separated from the mastoid
process and the cartilage of the external auditory canal.
Troublesome bleeding usually occurs from branches of
the superficial temporal artery and vein. Occasionally,
sharp dissection is necessary to initiate the plane of
cleavage. No damage can be done if the dissection is
kept along the periosteum of the mastoid process.
Electrocautery is only used for vessels well away from
any possible location of the facial nerve.
D The greater auricular nerve and external jugular
vein are usually transected. The greater auricular nerve
is formed with a loop from the second and third
cervical nerves. It has anterior and posterior branches.
At times the posterior branch, rarely the smaller ante-
rior branch, can be preserved. However, in the experi-
ence of one of the authors (JEM) the anterior branch is
often preserved. Because the anterior branch is closely
adherent or within the parotid tissue, preservation of
the nerve should not be done if the tumor, benign or
malignant, is too close to it. Any lymph node, espe-
cially in the region of the tail of the parotid, is sent for
frozen section. This will aid the surgeon in his or her
decision regarding the extent of the surgery. It must
be remembered that Warthin's tumors can be within
lymph nodes and still be benign. The tail of the gland
is separated from the sternocleidomastoid muscle.
Deep in this plane of cleavage, the posterior belly of
the digastric muscle may be seen.
E Using a very small Mixter-type clamp, the tem-
poroparotid fascia is carefully elevated. This fascia runs
from the tympanomastoid fissure to the gland. It is a
positive landmark for identification of the facial nerve,
because directly beneath this fascia lies the main nerve
trunk. The fascia is transected (see Fig. 17-6B and C).
Palpation is also of help in locating the main trunk of
the nerve. The inferior edge of the cartilage of the
external auditory canal is just superior to this fascial
band and the main trunk of the facial nerve.
F After the main nerve trunk is visualized, the
cervicofacial (lower) and zygomaticotemporal (upper)
divisions (see Figs. 17-4B and 17-6A to F for anatomy)
are exposed. Although not usually identified, there are
three small branches of the main nerve trunk: one
goes to the posterior belly of the digastric, one to the
stylohyoid, and one to the posterior auricular muscles.
A small curved clamp is inserted along the cervicofacial
division, and with sharp dissection the nerve fibers are
followed through the gland. A nerve stimulator may
be used to trace small branches. The nerve stimulator
is helpful in secondary operations and in chronic
sialadenitis and Iymphoepithelial disease. If any diffi-
culty ensues in following the nerve branches, the
operation microscope or loupe is preferred. Paresiscan
occur as a result of using a nerve stimulator. The
posterior auricular artery or a branch may cross the
main trunk of the nerve and may be the source of
significant bleeding (see Fig. 17-2A).
G The mandibular, cervical, and buccinator branches
of the cervicofacial division are now exposed. The freed
portion of the lateral lobe is turned forward using an
Allis clamp while a curved clamp follows the zygo-
maticotemporal division of the nerve. The deep lobe is
now apparent, as it lies deep to the criss-crossing
nerve fibers (pes anserinus).
Continued
 THE PAROTID SALIVARY GLAND AND MANAGEMENT OF MALIGNANT SALIVARY GLAND NEOPLASIA

Sternocleidomastoid m.
Ext. jugular v.

Tympanomastoid fissure

Temporoparotid fascia

Cart. of ext.
auditory canal
Main trunk facial n.

F
Post. belly digastricus m.
Sternocleidomastoid m.
FIGURE 17-1 Continued
 THE PAROTID SAUVARY GLAND AND MANAGEMENT OF MALIGNANT SALIVARYGLAND NEOPLASIA
Total lateral lobectomy of the
Parotid Salivary Gland (Continued)
H The same technique is used to complete the sepa-
ration of lateral and deep lobes. Do not be tempted to
use a flanking maneuver to speed the procedure,
because injury to the terminal nerve branches is very
likely. Always follow each branch in continuity.
Skipping areas of a branch can be disastrous. The
mandibular branch almost always accompanies the
posterior facial vein. Hence, use caution when
clamping this vessel.
When the neoplasm of the parotid salivary gland is
located at the posterior edge of the gland beneath the
lobule of the ear and is sizable, during the approach to
the main trunk of the facial nerve the dissection is
along the anterior edge of the sternocleidomastoid
muscle. During this rather posterior approach this may
lead to a plane of dissection that is posterior to the
posterior belly of the digastric muscle. In this event the
11th cranial nerve may be exposed. The dissection is
then continued along the anterior border of the
posterior belly of the digastric muscle leading to the
main trunk of the facial nerve.
I The Stensen duct (accessory parotid tissue may
accompany the duct) is transected and ligated at the
anterior wound margin. Terminal filaments of the
buccinator branch of the facial nerve may be seen
crossing the duct. The final area to be dissected is the
superior margin, where the zygomatic and temporal
branches are exposed.
The wound is closed with 6-0 nylon sutures, with a
small tissue drain in the lower portion of the wound. A
No. 10 Jackson-Pratt suction drain is preferred. A firm
pressure dressing is used, with care being taken that
the auricle is not folded forward. A small amount of
flattened cottonoid material or gauze is placed behind
the auricle. With the suction drain placed, the pressure
dressing may be eliminated.
Complications
• Nerve injury. At times a temporary paralysis occurs,
possibly owing to traction or edema. The use of cor-
ticosteroids is justified when the surgeon is certain
that the nerve is intact. If a branch or main trunk is
'
sectioned, immediate repair is performed using 8-0
or 10-0 Prolene. Weakness of the lower lip (failure
to depress the lip) is caused by either temporary
impairment of the ramus mandibularis or transection
of the platysma muscle (supplied by the cervical
branch of the seventh nerve), since it, too, is involved
with the depression of the lower lip. Also associated
with depression of the lower lip are the quadratus
labii inferioris and the triangularis muscles, which at
their origin are continuous with the platysma muscle.
All are supplied by the seventh nerve. This weak-
ness of the lower lip is a common observation and
usually will clear in 4 to 6 weeks.
• Recurrence of benign neoplasm. This is usually due
to an inadequate resection failing to perform a
lobectomy.
• Gustatory sweating (Frey's syndrome)
• Postoperative hemorrhage from branches of the super-
ficial temporal artery or vein. This may occur along-
side the main trunk of the facial nerve. Extreme
caution must be exercised in this area.
• Failure to perform a lobectomy. Recurrence may lead
to malignant transformation and severe fibrosis
surrounding the seventh nerve and its divisions.
When there is significant scar tissue in the vicinity
of the main trunk of the facial nerve and particularly
its divisions, they cannot be separated even with the
use of the microscope. The approach would be
through the identification of the various terminal
branches and divisions, following them to the area
of scarring. This problem may arise when someone
performs an enucleation, which is something quite
unheard of in this day and age but it occurs.
Facial Nerve in Infants
J In an infant and young child, the main trunk of the
facial nerve and divisions are more caudad (inferior)
and more superficial than in the adult.
This variation is very important when excising any
lesion in an infant or child that is high in the cervical
region in the vicinity of the angle of the mandible, as
well as when performing a parotidectomy. Transection
of the main trunk of the facial nerve has been reported
in excision of small hemangiomas involving the lower
portion of the parotid salivary gland as well as lesions
in the upper cervical region.
THE PAROTID SALIVARYGLAND AND MANAGEMENT OF MALIGNANT SALIVARYGlAND NEOPlASIA

Zygomatic br.

MAIN TRUNK FACt N.

J (~\

FIGURE 17-1 Continued

 lliE PAROTID SALIVARYGLAND AND MANAGEMENT OF MALIGNANT SALIVARY GLAND NEOPLASIA
Deep Lobectomy of Parotid
Salivary Gland (Fig. 17-2) (See also
Chapter 23)
There are at least two locations or extensions of the
deep lobe of the parotid. One lies deep to the facial
nerve (its divisions and at times its branches) resting
on the masseter muscle and the ascending ramus of the
mandible (see A). The other location is posterior to the
posterior edge of the ascending ramus of the mandible.
This latter location is just inferior to the main trunk of
the facial nerve. The posterior auricular artery (see A)
is vulnerable during its dissection relative to bleeding
as the facial nerve is exposed. As a tumor of the deep
lobe expands, especially in this latter location, it passes
deep to the pterygoid muscles (primarily the internal
pterygoid) and thus can project medially, displacing
the oropharyngeal and at times the nasopharyngeal
wall and the tonsil intraorally as well as the palate.
This deep lobe tumor passes deep to the ascending
ramus of the mandible and then follows the "tunnel"
associated with the stylomandibular ligament. This can
compress the tumor and may account for the dumbbell
configuration of the tumor as it extends into the para-
pharyngeal space. This dumbbell configuration has also
been seen in relation to a branchial cleft cyst, which
may extend into the parapharyngeal space (pharyngo-
maxillary space). This is because the rather thin muscle
medial to the deep lobe tumor as it expands is the
superior pharyngeal constrictor muscle, which joins
the buccinator muscle along the pterygomandibular
raphe. The tumor cannot expand anteriorly because of
the thick pterygoid muscle.
The deep or medial lobe of the parotid can be removed
usually without injury to the facial nerve by first
performing a lateral lobectomy. The anatomy of the
parotid gland is such that once the much larger lateral
lobe has been removed, with transection of the gland's
isthmus and complete identification and preservation
of the facial nerve divisions and major branches, the
deep lobe then can be removed by very gently and
carefully retracting the branches of the nerve using a
small Cushing-type vein retractor. This is performed for
benign tumors only. In high-grade (malignant mixed,
high-grade mucoepidermoid) malignant tumors, a total
parotidectomy, with or without sacrifice of the facial
nerve with or without a radical neck dissection, is the
operation of choice unless there are other mitigating
circumstances. It should be noted, however, that many
surgeons today, including one of the authors (JEM) ,
believe that a total parotidectomy is not mandatory for
every high-grade tumor. Rather, the goal of the opera-
tion is to "adequately" remove the tumor, which for
smaller tumors may require only a lateral lobectomy.
Additionally, there is ample evidence today suggesting
that dissection of the cervical lymphatics is not
necessary in patients with parotid neoplasms, in the
absence of palpable lymph node metastases. Patients
with "high-risk" primary tumors (high-grade tumors,
larger than 4 em, with facial paralysis and extraparotid
extension) benefit from postoperative irradiation. That
being the case, elective radiotherapy is used for the
neck nodes (Medina, 1998; Ferlito et aI., 2002).
The other author (JML) usually does not treat a nega-
tive neck electively with radiation. If the neck is, in
fact, clinically and image-wise negative, then careful
follow-up clinically, along with MRI and CT, is done. If
the neck is positive clinically or on MRI or CT, then a
classic radical neck dissection is performed. On the other
hand, virtually all patients with high-grade tumors of the
deep lobe, as mentioned earlier, are treated with radia-
tion, especially if there is the slightest question regard-
ing the adequacy of resection. The problem is that with
large, high-grade malignant tumors extending to the
edge or beyond the borders of the deep lobe, a com-
plete resection of all contiguous tissue with what is
usually considered adequate margins is virtually impos-
sible, hence the radiotherapy.
If the facial nerve is removed, a primary nerve graft
is performed. Reference should be made to Figure 17-6,
the only modification being a sacrifice of the main
trunk of the facial nerve with the total parotidectomy.
Tumors of the deep lobe may present as a swelling in
the tonsillar area and lateral oropharyngeal wall. This
is because the rather thin muscle medial to the deep
lobe tumor as it expands is the pharyngeal constrictor
(superior), which joins the buccinator muscle along
the pterygomandibular raphe. The deep boundary of
the lateral lobe is the ascending ramus of the mandible
with the masseter muscle. However, depending on the
size of the tumor it may pass deep to the pterygoid
muscles. It is at this region that it projects toward the
lateral oropharyngeal wall. Other neoplasms, neurogenic
tumors (schwannomas, neurofibromas, sarcomas,
 THE PAROTID SALIVARYGlAND AND MANAGEMENT OF MALIGNANT SALIVARYGLAND NEOIWIA
mesenchymal tumors, nonadrenal paragangliomas,
intravagal glomus jugulare tumors and branchial cleft
cyst tumors of the pharyngeal space, and metastatic
squamous cell carcinoma, as well as tortuous or
aneurysmal dilatation of the internal carotid artery,
which may be in the parapharyngeal space) can also
present as a bulge in the lateral oropharyngeal wall
(see Chapter 23).
Never remove or even try to remove a deep lobe tumor
transorally. At times FNA can be done transorally to aid
in the diagnosis. Be sure of the location of the internal
carotid artery. It can be displaced medially or possibly
encased in the tumor.
CT and MRI are a great help in differentiating
tumors of the deep lobe of the parotid versus tumors
arising in the parapharyngeal space lateral to the
oropharyngeal wall. A distinct fibrofatty tissue plane is
the normal boundary between the medial aspect of the
deep lobe and the normal soft tissue of the lateral
oropharyngeal wall. Malignant tumor can obliterate
this fibrofatty tissue plane (Som, 1978). MRI further
delineates the extent of deep lobe tumors and aids in
the differentiation of other tumors of the parapha-
ryngeal space. Deep lobe tumors will usually be in
direct continuity with the remaining portion of the
gland. In highly malignant tumors, which may involve
bone as well as soft tissue, CT affords better evaluation
of bone and MRI is somewhat better in evaluating soft
tissue disease; thus they complement one another. This
is particularly important in tumors that reach the skull
base. See Figure 17-4A and B for the nerve graft tech-
nique. See Figure 17-3 for the technique of additional
exposure in resection of the deep lobe.
In adenoid cystic carcinoma of the parotid, exten-
sion of tumor can occur along the facial nerve within
the temporal bone. A partial temporal bone resection
has been performed using the microscope and a power
drill, following the nerve cranially with serial frozen
sections. The surrounding remaining bone has been
frozen with liquid nitrogen.
661
The extension of a deep lobe parotid tumor can be
divided schematically into three levels (see Chapter
23):
Levell: Extension of the deep lobe tumor follows the
line of least resistance between the ascending ramus
of the mandible and the mastoid process, laterally
and at times inferiorly under the angle of the
mandible. It then may spread medially. If it did pass
medially to the ascending ramus of the mandible and
the masseter muscle, then it would rest on the
venous plexus and the internal maxillary artery as
well as the pterygoid muscles.
Level 2: This extension of deep lobe tumor of the
parotid now is posterior to the pterygoid muscles.
The pterygoid plexus of veins and the internal maxil-
lary artery are anterior to the external pterygoid mus-
cles as well as between the two pterygoid muscles
(see Fig. 5-9L).
Level 3: Further extension of deep lobe tumor medially
may displace the superior pharyngeal constrictor
muscle and the buccinator muscle medially as it enters
the parapharyngeal space. This produces a bulge in
the lateral oropharyngeal wall, tonsil, palate, and
possibly the lower portion of the nasopharynx. Other
neoplasms arising in the parapharyngeal space are,
for example, the neurogenic tumors, paragangliomas,
and those of mesenchymal origin as well as the
unusual branchial cleft remnant, which can cause the
same bulge in the region of the palatine tonsil. If
the internal carotid is displaced and is located over the
bulge, the diagnosis is almost certainly neurogenic
tumor. When the internal carotid artery is displaced
anteriorly and laterally in the neck, the most likely
cause is a neurogenic tumor.
When the internal pterygoid muscle is transected
with mandibulotomy to increase exposure, this may
place the pterygoid plexus of veins in the surgical field
and be the cause of troublesome bleeding.
 THE PAROTID SAUVARY GLAND AND MANAGEMENT OF MALIGNANT SALIVARY GLAND NEOPLASIA
Deep Lobectomy of Parotid
Salivary Gland (Fig. 17-2) (See also
Chapter 23) (Continued)
A By retracting the facial nerve with divisions and
branches upward, the deep lobe of the parotid gland
can be dissected free using blunt dissection for the
most part. At times the cervicofacial division with or
without the buccal branch can be retracted down-
ward. Deep to the deep lobe are the terminal branches
of the external carotid artery and origin of the pos-
terior facial vein. The more comrnonly encountered
branches of the external carotid artery are the internal
maxillary artery, which passes deep to the ascending
ramus of the mandible, and the superficial temporal
artery. This latter vessel with its accompanying vein
is excised. The posterior auricular artery (see also Fig.
23-4A) can be encountered during dissection of the
main trunk of the facial nerve. Bleeding from this vessel
can be substantial, and attempts should be made to
isolate this vessel before any further dissection is done
in this area. This may be encountered in performing
a total parotidectomy but can also be injured in any
exposure of the main trunk of the facial nerve. Obviously,
blind clamping must be done. Cilreful press.ure with a
cottonoid sponge with overlying gauze sponge plus
patience may slow or temporarily stop the bleeding to
facilitate safe clamping. The internal maxillary artery
lies on the external pterygoid muscle. At times it may
pass between the external (lateral) head and the inter-
nal (medial) head. The lingual and inferior alveolar
nerves lie deep to the internal pterygoid muscle and
then pass over the external pterygoid muscle. The
posterior facial vein arises principally from the super-
ficial temporal vein and the pterygoid venous plexus
that accompanies the internal maxillary artery. If the
dissection is extended inferiorly, the occipital and pos-
terior auricular arteries will be encountered. A deeper
dissection medial and below the ascending ramus of
the mandible may expose the internal carotid artery
and internal jugular vein along with the 9th, 10th,
11 th, and 12th cranial nerves. The internal carotid
artery as it goes superiorly passes deep to the posterior
belly of the digastric, stylohyoid, stylopharyngeus, and
styloglossus muscles (see Figs. 23-2 to 23-6).
B The operative field is shown after the deep parotid
lobectomy. Rarely, it may be necessary to identify the
main trunk of the facial nerve by first exposing each
major branch peripherally. Each of those branches is
then traced proximally to the main trunk.
There may be islands of parotid tissue separate from
the main portion of the deep lobe of the parotid lying
free upon the surface of the masseter muscle. This was
seen in one patient in whom a portion of the masseter
muscle was removed after a recurrent mixed tumor
(benign) that had only a thin layer of tissue between
the recurrent tumor and the muscle. This appears to
indicate the importance of removing a layer of the mus-
cle in deep lobe parotid tumors when there is evidence
of recurrence after previous surgery. More extensive to
total resection of the masseter muscle is performed
when the lesion is malignant. Accessory parotid tissue
has been described along the course of Stensen's duct
and specifically in contact with the masseter muscle.
C A schematic of the facial nerve is presented.
 THE PAROTID SALIVARYGLAND AND MANAGEMENT OF MALIGNANT SALIVARYGLAND NEOPlASIA

Mastoid
Process

Post. facial v.

A B

Trunk and Branches of

Facial nerve

FT - Trunk of facial nerve

ZT - Zygomaticotemporal
T -Temporal
Z - Zygomatic
B - Buccal
RM - Ramus mandibularis
CF - Cervical facial
C - Cervical
PD - Posterior digastric
SH - Stylohyoid
PA - Postauricular

FIGURE 17-2
 THE PAROTID SALIVARYGLAND AND MANAGEMENT OF MALIGNANT SALIVARYGLAND NEOPLASIA

Mandibulotomy (See Chapter 15) 3. Mandibulotomy

and Deep Lobe Lobectomy of the a. Transection just proximal to the angle of the
mandible
Parotid Salivary Gland with
i. See Figures 17-3 and 22-33C and D.
Dissection of Parapharyngeal ii. With or without resection of the entire ascend-
Space (Fig. 17-3; See also Figs. 23-2 ing ramus (disarticulation of the temporo-
to 23-6) mandibular joint)
b. Midline mandibulotomy (see Fig. 15-14) when
Highpoints the intraoral lesion extends significantly into the
soft palate and/or extends along the lateral wall
1. Standard preauricular incision for a parotidectomy is of the nasopharynx and to the skull base
done with upper cervical incision extended farther c. Lateral mandibulotomy through the socket of the
medially. premolar tooth
2. If there is evidence that the neoplasm is close to the
internal carotid artery, then expose and control the
great vessels-common carotid, internal and external A Line of transection of the mandible is shown.
carotid arteries, and jugular vein-with vascular
tapes along the upper cervical incision. B For larger tumors of the deep lobe of the parotid,
3. Preservation of the ramus mandibularis of the exposure can be improved by section of the mandible
seventh nerve is feasible. just superior to the angle (see Fig. 22-33A to E). In
4. Transect the stylomandibular and the spheno- addition, section of the stylomandibular ligament is of
mandibular ligaments. some aid. Depicted is a patient with a recurrent
5. Perform a mandibulotomy, either lateral or at or malignant mixed tumor of the deep lobe in whom a
above the angle of the mandible. radical neck dissection had already been performed at
6. Transect the internal pterygoid muscle to further a previous operation. The main trunk of the facial
mobilize the mandible. nerve with its two divisions, the zygomatic temporal
7. Disarticulation (forward) of the temporomandibular and cervicofacial, is exposed. Because a lateral lobec-
joint is done, if necessary, for further exposure. tomy had not been performed elsewhere, this resection
8. Remove the proximal ascending ramus of the is being done along with a resection of the recurrent
mandible, either for adequate ablative surgery or tumor of the deep lobe. The cervicofacial division is
additional exposure. sacrificed while the zygomatic temporal division is pre-
9. If the facial nerve is paralyzed secondary to the served. Preservation of this latter division is important
neoplasm, transect the nerve and reflect the entire if compatible with the ablative surgery, because the
soft tissue mass superiorly. function of orbicularis oculi muscle will be preserved.
A juxtaposed portion of the masseter muscle is
There are several approaches to resection of the included in the resection. This exposes the angle of the
deep lobe of the parotid tumor when the tumor is large mandible, under which is carefully inserted a curved
and infiltrating: clamp. This clamp passes just superior to the angle
and reaches the inner border of the ascending ramus
1. The usual approach to the lateral lobectomy (see of the mandible several centimeters behind the third
Fig. 17-2). molar region. If care is used, the mucous membrane is
2. Mobilization of the mandible, upward and medial, not punctured. By retraction of the remainder of the
by transection of the stylomandibular ligament (see masseter muscle, the tip of the clamp is identified, and
Figs. 17-3, and 22-33A to E). a Gigli saw is drawn around the mandible.
 THE PAROTID SALIVARY GLAND AND MANAGEMENT
FIGURE 17-3
C The mandible is transected, and the ends are
retracted. The stylomandibular ligament is transected.
It attaches to the inside of the mandible just above the
angle. The resected specimen includes the total parotid,
portion of the masseter muscle, hypoglossal and glos-
sopharyngeal nerves,cervicofacialdivision of facial nerve,
posterior belly of the digastric muscle, stylohyoid
muscle, and deep muscles forming the inside wall of
the area (i.e., pterygoid, styloglossus, and stylopha-
ryngeus). The lesion was carefully dissected from the
internal carotid artery, the vagus nerve, and the stump
of the previously ligated internal jugular vein. All of
these structures along with the 12th and 9th nerves
are deep to the pterygoid muscles and ascending
ramus of the mandible.
Resection of the lateral wall of the pharynx should
be performed if it is imbedded with tumor. This may
occur if a previous biopsy approach is made through
the tonsillar area, a procedure that should be avoided.
Because resections of this type are more palliative than
OF MALIGNANT SALIVARY GLAND NEOPlASIA
curative, postoperative irradiation is recommended
(see Fig. 3-8). Nerve graft using the sural nerve or ansa
hypoglossus is performed with the aid of the operation
microscope or magnifying loupe. The cut ends of the
mandible are approximated using a Kirschner wire or
Steinmann pin in the medullary portion of the bone
plus two wires passed through drill holes (see
Fig. 14-11 N). It is most important that the Kirschner
wire or Steinmann pin be bent to conform to the angle
of the mandible. This is done to prevent migration of
the Kirschner wire or Steinmann pin superiorly toward
the base of the skull. Postoperative radiographs are
obtained to verify the position of the Kirschner wire or
Steinmann pin. If there is not sufficient bend in the K
wire, it is removed and a small plate is used. Radio-
graphs at appropriate times are obtained to verify its
position. If there is evidence of significant migration or
of puncture through the cortex, the Kirschner wire is
removed.
Continued
 THE PAROTID SALIVARYGLAND AND MANAGEMENT OF MALIGNANT SALIVARY GLAND NEOPLASIA
Mandibulotomy (See Chapter 15)
and Deep Lobe Lobectomy of the
Parotid Salivary Gland with
Dissection of Para pharyngeal
Space (Continued) (Fig. 17-3; See also
Figs. 23-2 to 23-6)
Deeper resections in this area may require resection
of the pterygoid muscles (see Fig. S-9K and L) and
possibly a portion of the longus capitis muscle. The
internal carotid artery lies on the longus capitis muscle.
Although the authors have not encountered the verte-
bral artery at this site it is quite conceivable that injury
to this vessel could occur as it courses between the
foramina of the transverse processes. The reader is
referred to Surgical Anatomy by Anson and McVay
(1971, p. 282) for a detailed description of the course
of the vertebral artery.
D Inner aspect of left hemimandible depicts the
relationship of the deep lobe of parotid to the
stylomandibular and sphenomandibular ligament and
styloid process. The stylomandibular ligament may not
be well defined and usually is simply a thickening of
the deep cervical fascia associated with the parotid
gland (Hollinshead, 1968). Transection of this ligament
may facilitate exposure and may obviate the necessity
of transection of the mandible. But if the mandible
requires resection, stabilization and reconstruction are
performed following the technique in Figures 14-5,
14-6, and 14-8.
When a deep lobe malignant parotid tumor extends
into the parapharyngeal space (see Figs. 23-2 to 23-6),
resting on or invading the pterygoid muscle, the sur-
geon must be prepared for additional exposure by
performing a mandibulotomy. If there is evidence of
the tumor adherent to the ascending ramus of the
mandible, this portion is resected. This maneuver
greatly enhances exposure, particularly of the external
and internal carotid artery (see Fig. 23-4FI). The neo-
plasm may be adherent to the external auditory canal
and reach the base of the skull. The tumor may be seen
to enter the foramen spinosum through which the
middle meningeal artery passes to enter the middle
cranial fossa. It may be better to leave a small portion
of tumor at the base of the skull and follow with
postoperative gamma knife treatment or radiotherapy
to the entire surgical field. However, in some instances
a transtemporal or infratemporal approach can be used
to resect this area. With this spread of disease, pallia-
tion may be the main object, particularly in view of the
severe pain that can be associated with this extensive
tumor.
THE PAROTID SALIVARYGLAND AND MANAGEMENT OF MALIGNANT SALIVARYGLAND NEOPlASIA

STYLOID PROCE.-
STYLOGLOSSUS M.
STYLOPHARYNGEUS M.
D STYLOHYOID L1G.
STYLOMANDIBULAR L1G.

INT. PTERYGOID M.

FIGURE 17-3 Continued

 THE PAROTID SALIVARYGLAND AND MANAGEMENT OF MALIGNANT
Free Facial Nerve Graft (Fig. 17-4)
When a total parotidectomy has been performed for a
malignant tumor, an attempt can be made to use free
nerve grafts to reestablish continuity of the facial nerve.
Martin and Helsper (1960), however, have presented
some evidence that function may return without grafts,
suggesting motor innervation via the trigeminal nerve.
When the facial nerve has been interrupted far
within the temporal bone, crossed anastomoses can be
tried using the proximal end of the hypoglossal nerve.
Fascial strips can be used with or without transplanta-
tion of muscle slips (temporal, masseter, and ster-
nocleidomastoid). The result is usually an expression-
less side of the face. If practical, by using the operation
microscope and power drill, a decompression and expo-
sure of the infratemporal portion of the nerve can be
attempted so that sufficient proximal stump of the nerve
is made available for a nerve graft (see Fig. 7-12 for
fascial slings).
Refer to Chapter 7 for a discussion of facial nerve
paralysis and treatment and technique for neurorrhaphy.
Highpoints
1. Meticulous suturing technique with 8-0 to 10-0 Prolene
is used. A microscope or loupe is recommended.
2. Divisions of the proximal nerve trunk are realigned
with distal divisions or branches.
3. Grafting is done at time of definitive surgery.
4. Multiple single nerve grafts or a divided nerve graft
is used. The greater auricular nerve graft (or other
cervical sensory branches from the contralateral neck)
has been described by Beahrs and colleagues (1961)
as ideal. The ansa hypoglossi as a free graft has been
used from the ipsilateral side when a concomitant
radical neck dissection is performed. A sural nerve
graft has been described (see Fig. 3-8).
5. Fenestrated plastic tube around the graft and
anastomoses is optional and not believed necessary.
Alignment of the fascicles is controversial. A portion
of a vein as a sleeve may prevent invasion of fibrous
tissue.
A Cervical nerve grafts in place measure up to 6 em.
The upper graft is to the zygomaticotemporal division,
the middle graft to the buccinator branch, and the
lower graft to the mandibular branch.
SALIVARY GLAND NEOPLASIA
The anastomoses are performed. The sutures are
carefully placed through the nerve sheaths. An optical
loupe or operating microscope is ideal for this step.
One to four sutures are used for each anastomosis
depending on the size of the nerves sutured.
Al Alignment and suturing are shown.
Gustatory Sweating (Frey's
Syndrome) (See Fig. 17-4B)
After operations on the parotid gland, 5% to 90% of
patients will experience the unpleasant phenomenon of
almost painful sweating while eating; this occurs over
the skin of the side of the face that has been operated
on. This is believed to be caused by the regrowth of
fibers from the auriculotemporal nerve-parasympathetic
motor fibers to the parotid gland-into the cutaneous
sympathetic pseudo motor nerve fibers at the site of
operation. Hence, there is crossed innervation of the
sweat glands of the face-the parasympathetic to the
sympathetic.
It is suggested that whenever possible, during any
type of parotid surgery, the auriculotemporal nerve
should be identified and as long a section of the nerve
as possible should be resected. Another suggestion is
that the skin flaps should be made as thick as possible
without violating the anterior parotid fascia.
Additional data relative to Frey's syndrome have
been developed by Gordon and Fiddian (1976) in which
they point out that not only the auricular temporal
nerve may be involved in this syndrome but also the
greater auricular nerve. In considerable detail they
outline the distribution of the greater auricular and the
auricular temporal nerves. Utilizing Minor's starch test
they demonstrate that the gustatory sweating may be
in the distribution of either or both of these nerves.
Minor's test is performed by painting the skin of the
neck and face of the affected side with a solution of
3 g of iodine, 20 g of castor oil, and up to 200 mL of
absolute alcohol. After this solution dries, the area is
then lightly dusted with starch powder. The patient is
then asked to suck on a lemon for 2 minutes, which
induces the salivary response. Shortly thereafter the
area involved with the Frey syndrome is revealed by
the occurrence of dark blue spots. The iodine can be
removed by a 5% solution of sodium thiosulfate.
Hence, it would seem that possible blocking not only of
 THE PAROTID SALIVARY GLAND AND MANAGEMENT OF MALIGNANT SALIVARY GlAND NEOPlASIA

Fascicles

Sural nerve
A

Superf. temp. v.

Superf. temp. a.

Auriculotemporal
nerve excised

Cervical facial div.

FIGURE 17--4

the auricular temporal nerve but also of the greater A cream-based preparation consisting of atropine
auricular nerve may be an advantage in the manage- sulfate 0.25% in Eucerin cream (40 mg/16 g; apply
ment of this distressing sequela of parotid surgery. sparingly 15 minutes before meals) has shown
Tympanic neurectomy has likewise been described parasympatholytic activity for at least 6 hours
as a method to treat gustatory sweating; however, the (Rademaker, RPh).
results, both short and long term, have left much to be
desired.
Scopolamine cream 3 % may also be used, but this B A section of the auriculotemporal nerve is excised.
can result in blurred vision and possible urinary reten- The nerve is closely related to the superficial temporal
tion, depending on the absorption of the scopolamine. artery and vein. This phenomenon has been described
Likewise, excision of the skin involved, if it is small, for the upper cervical region as well (Spiro and Martin,
has also been suggested. 1967).
 THE PAROTID SALIVARY GLAND AND MANAGEMENT OF MALIGNANT SALIVARY GLAND NEOPLASIA

Excision of the Recurrent Benign

Tumor of the Parotid Gland C The main trunk of the facial nerve is identified,
(Fig. 17-5) using much the same technique as in a primary lateral
lobectomy (see Fig. 17-1). It may be no more difficult,
Highpoints because the first operation on this mixed tumor of the
parotid that has recurred was probably an enucleation
1. The facial nerve is preserved. Procedure is reserved or limited procedure. A portion of the sternocleido-
for benign recurrence only. mastoid muscle is removed in continuity with the
2. If recurrence is malignant. the facial nerve will recurrent tumor. Branches of the spinal accessory
probably have to be sacrificed and a total parotidec- nerve may be seen traversing the muscle.
tomy performed.
3. The operation microscope is ideal to follow the D As the nerve is dissected, it is apparent that the
nerve through scar tissue. cervicofacial division was previously injured. The
4. Carefully review original histopathology regarding operation microscope is of tremendous aid in
any possible change of diagnosis from benign to following, dissecting, and preserving the branches of
malignant. the facial nerve. This is used in preference to a nerve
stimulator. The deep lobe and the posterior belly of
the digastricus are resected easily. The entire lateral
A A wide area of overlying skin is included with the lobe is included in the specimen, using the technique
previous scar. for primary total lobectomy.

B Anterior and posterior skin flaps are developed

with further extension of the posterior flap, because
the recurrence is near the tail of the parotid.
 THE PAROTID SALIVARY GLAND AND MANAGEMENT OF MALIGNANT SALIVARY GLAND NEOPLASIA

A B

Mastoid tip

Recurrent mixed tumor

Ext. jugular v.

Post. belly
digastricus m.

Masseter m.
Resected
sternomastoid m.
Post. belly
digastricus m.

In!. jugular v.

c D

FIGURE 17-5
 THE PAROTID SALIVARYGLAND AND MANAGEMENT OF MALIGNANT SALIVARY GLAND NEOPLASIA
Management of Salivary Gland
Tumors
Thom R. Loree
Tumors of salivary gland ongm can present in the
paired major salivary glands, in the parotid and sub-
mandibular glands, or in minor salivary gland tissue.
Minor salivary gland tissue is present in the oral cavity,
oral pharynx, paranasal sinuses, and nasal cavity and
larynx. The most common presentation of a tumor of
the major salivary glands is an asymptomatic mass.
The differential diagnosis of a major salivary gland
mass includes a primary neoplasm, sialoadenitis, and
peri glandular or intraglandular lymphadenopathy. For
tumors of the salivary glands the incidence of malig-
nancy is dependent on the site. For the parotid gland,
80% of tumors are benign and 20% are malignant. For
the submandibular glands, approximately 50% of the
tumors are malignant. For the minor salivary glands,
approximately 80% are malignant.
There are 14 types of benign salivary gland tumors
according to the World Health Organization classifi-
cation. The most common benign tumor of the salivary
glands is a benign mixed tumor, which is also called a
pleomorphic adenoma. This tumor represents approxi-
mately 75% of benign salivary gland tumors. The second
most common benign tumor of the salivary glands is a
Warthin tumor. This tumor has a significantly increased
incidence in those patients who are heavy cigarette
smokers. The remaining benign tumors of the salivary
glands are more uncommon. The benign lymphoep-
ithelial lesion is an entity of increasing frequency.
Traditionally, this tumor was seen primarily in the
submandibular glands associated with Sjogren's syn-
drome. However, it has also been associated with
human immunodeficiency virus infection and in this
setting often presents in the parotid glands. The diag-
nosis can often be obtained by FNA. Other tumors
infrequently encountered include a variety of monomor-
phic adenomas and benign oncocytomas. In general,
these tumors have presentation and behavior similar to
pleomorphic adenomas and in most cases should be
treated in a similar fashion. Usually the work-up of a
major salivary gland tumor is straightforward. A his-
tory and physical examination are usually sufficient.
FNA can sometimes be informative but is often mis-
leading. For cases in which lymphadenopathy or a
Iymphoepitheliallesion is strongly suspected, FNA may
be helpful. However, given the variety of benign and
malignant salivary gland tumors, FNA often cannot
discriminate between malignant and benign tumors. In
addition, because the most common benign tumor is a
pleomorphic adenoma and the recommended treat-
ment for this is surgical excision, FNA in this setting is
of little value. Imaging studies are useful and should be
performed in patients who have unusual presenta-
tions. This includes presentation with facial nerve
deficit, trismus, or large tumors. Presentation with a
facial nerve deficit almost always suggests a malignant
process.
The treatment of a benign tumor of the major
salivary glands is surgery. For the submandibular gland
this usually is a complete excision of the involved
gland (see Fig. 16-12). For the parotid gland, the sur-
gical procedure most frequently appropriate is a lateral
lobectomy with identification, dissection, and preser-
vation of the facial nerve. Because the majority of
benign tumors present in the lateral lobe this procedure
is usually sufficient to entirely remove the tumor. In
cases in which the tumor extends to or arises from the
deep lobe, then a Iotal parotidectomy with facial nerve
preservation should be performed. Enucleation is not
recommended. This procedure places the facial nerve
at greater risk for injury. Also, enucleation of a benign
mixed tumor has an unacceptably high risk of local
recurrence. Despite its benign nature, a pleomorphic
adenoma does have a high propensity for local recur-
rence if it is not removed completely. A local recurrence
of a benign mixed tumor can often be very difficult to
treat. The recurrence often presents as multiple small
nodules within the entire previously operated field.
Further surgery carries an increased risk of facial nerve
injury.
As with benign tumors of the salivary glands, there
are a variety of malignant salivary gland-origin tumors.
Treatment of salivary gland cancer depends on the
specific histologic type, stage, and site of involvement.
Mucoepidermoid carcinoma is the most frequent malig-
nancy of the parotid gland. Adenoid cystic carcinoma is
the second most common salivary gland cancer and is
the most common malignancy involving the sub·
mandibular gland. Other malignancies of the salivary
glands include malignant mixed tumors, acinic cell car-
cinoma, adenocarcinomas, and, rarely, squamous cell
carcinoma. Each of these tumors has unique features
and characteristics.
Histologically, mucoepidermoid carcinoma is a
mixture of epidermoid features and glandular features.
This tumor is graded by the pathologist and catego-
rized as low, intermediate, or high grade. This grading
system depends on the relative degree of epidermoid
and glandular features. The more epidermoid features
predominate, the higher the grade. Clinically, high-grade
mucoepidermoid carcinomas behave like squamous
cell carcinomas. They can be locally aggressive and metas-
tasize to regional lymph nodes and, less frequently,
metastasize distantly.
In contrast, glandular features are predominant in
low-grade mucoepidermoid carcinoma. These tumors
tend to be more indolent and rarely metastasize.
 THE PAROTID SALIVARY GLAND AND MANAGEMENT
Adenoid cystic carcinoma is a cancer with some
unusual characteristics. This tumor tends to be slow
growing and often indolent but is extremely insidious.
Nerve invasion and spread is a common feature. Micro-
scopically, the tumor can often be quite infiltrative,
with microscopic disease being present far beyond the
gross extent of the disease. A tendency for lung metas-
tasis has also been associated with adenoid cystic carci-
noma. Interestingly, these metastases are often asymp-
tomatic and can be present for many years with minimal
deleterious effects. From a statistical point of view, it is
difficult to cure an adenoid cystic carcinoma. Recurrences
can occur decades after treatment and following very
long disease-free intervals.
There are two categories of malignant mixed tumors
of the salivary glands. The first category is quite rare
and is sometimes referred to as a carcinosarcoma. This
tumor is thought to occur de novo from salivary gland
tissue. More commonly, malignant mixed tumors of the
salivary gland arise from preexisting benign mixed
tumors. These tumors are also called carcinoma ex
pleomorphic adenoma. Histologically, the diagnosis
requires an identifiable component of benign mixed
tumor. The malignant transformation rate of a benign
mixed tumor is quite low. However, the phenomenon does
occur occasionally, probably in less than 2 % of cases.
Typically, the patient with this problem presents with a
long-standing history of a salivary gland mass that
recently has changed in size and character.
Adenocarcinomas of the salivary glands often
present challenging diagnostic and treatment decisions.
When this diagnosis is encountered, the first priority is
to determine whether the cancer is primary to the sali-
vary gland or whether it represents a metastasis from a
distant organ site. The next consideration with this
diagnosis is the pathologic grade of the tumor. Most of
the time, primary adenocarcinoma of the salivary gland
is considered a high-grade aggressive tumor. However,
occasionally, a low-grade adenocarcinoma is encoun-
tered. For the usual high-grade adenocarcinomas of the
salivary glands, aggressive behavior is manifest. These
tumors will frequently have multiple lymph node
metastases on pathologic examination in patients who
were clinically NO. In addition, the incidence of distant
metastases is also high. Adjuvant chemotherapy should
be considered in patients with a diagnosis of adeno-
carcinoma of the salivary glands.
Squamous cell carcinoma of the salivary glands is
exceedingly rare. Its reported incidence is 1% to 2% of
salivary gland cancers. The incidence of squamous cell
carcinoma of the major salivary glands is so low that a
possible error in diagnosis should be considered when
this entity is encountered. The lesion may represent a
very high-grade mucoepidermoid carcinoma or pos-
sibly an intraparotid lymph node metastasis from a
OF MALIGNANT SALIVARY GlAND NEOPlASIA
squamous cell carcinoma of the skin or other head and
neck site.
For treatment decisions, salivary gland cancer is
categorized into low-grade tumors with a low propen-
sity for metastasis versus the more high-grade and
aggressive tumors. For the low-grade tumors such as
acinic cell carcinoma, low-grade mucoepidermoid car-
cinoma, and some low-grade adenocarcinomas, com-
plete surgical excision will suffice. The high-grade
tumors are intermediate- and high-grade mucoepider-
moid carcinoma, adenoid cystic carcinoma, malignant
mixed tumors, most adenocarcinomas, and squamous
cell carcinomas. For these tumors, with the exception
of very early stage lesions, complete surgical excision
should be supplemented by postoperative adjuvant
radiotherapy (Spiro, 1973). For high-grade adenocar-
cinomas, adjunctive chemotherapy may be of benefit
as well.
The surgical treatment of salivary gland cancer is
dependent on the site. Complete surgical excision of all
gross and microscopic disease is desirable. For cancers
arising from minor salivary glands and involving the
mucosa of the head and neck region or paranasal
sinuses, the surgical approach is dictated by the
location of these tumors. The minimal procedure for
submandibular gland tumors is complete excision of
the submandibular gland. For low-stage and low-grade
histologies, this procedure is usually sufficient. For
tumors of high grade and/or high stage, resection of
the submandibular gland and neck dissection is
required.
For tumors of the parotid gland, the minimal proce-
dure is a lateral lobe parotidectomy, which involves
identification and preservation of the facial nerve and
resection of the lateral lobe of the parotid gland. As
with the submandibular gland, this procedure is usually
sufficient as treatment for benign parotid gland tumors
or malignancies of low grade and stage. The deep lobe
of the parotid gland should be resected regardless of
tumor histology and stage if it is involved with tumor.
During parotidectomy, every effort should be made to
preserve the facial nerve and its branches if the nerve
is functional. Facial nerve invasion is associated with a
poor prognosis. If the facial nerve is involved with
tumor, then its resection is indicated. In this situation,
facial nerve reconstruction should be considered. For
patients presenting with clinically involved lymph nodes,
neck dissection should be added to parotidectomy. For
patients presenting with clinically uninvolved lymph
nodes, the need for neck dissection should be indi-
vidualized. Interoperative frozen section is usually per-
formed after parotidectomy of the tumor. If the diag-
nosis proves to be one of the high-grade malignancies,
then neck dissection should be considered, particularly
if the tumor is of high stage.
 THE PAROTID SALIVARYGLAND AND MANAGEMENT OF MALIGNANT SALIVARYGLAND NEOPLASIA
Additional Caveats Relative to
Malignant Tumors of the Parotid
Salivary Gland*
John M. Lore, Jr.
Although there is a divergence of opinion regarding
initial imaging-CT and MRI-for evaluation of parotid
salivary gland disease-for that matter also sub-
mandibular and always sublingual disease-the author
(JML) and others (Kim et at., 1998) recommend these
imaging modalities. The added cost is justifiable because
it will aid in the preoperative and intraoperative deci-
sions regarding the extent of a surgical procedure. The
aggressiveness of the first operation is most important.
MRI and/or CT and positron emission tomography
(PET) all may be of help in determining whether there
are suspicious lymph nodes that are not detected
clinically, as well as juxtaposed soft tissue invasion
beyond the capsule of the gland. With sublingual gland
disease this imaging is most important. Obliteration of
the fibrofatty tissue plane is also of significance in
carcinoma involving the deep lobe of the parotid gland.
This tissue plane is in the parapharyngeal space. This
is due to the sublingual gland's location and its
extremely high propensity for malignant disease.
Frozen sections are obtained on all tumors of the
parotid. If the diagnosis is unequivocally high-grade
malignant, definitive additional surgery is performed
immediately, as indicated by the surgical findings. The
surgical procedures would include the basic lateral
parotid lobectomy; total parotidectomy, with or with-
out sacrifice of the main trunk or branches of the facial
nerve; radical parotidectomy with sacrifice of the main
trunk of the facial nerve with or without nerve grafting;
and extended parotidectomy to include dissection of
the parapharyngeal space and other adjacent structures
superiorly to the base of the skull with flap reconstruc-
tion. Histologically positive lymph nodes usually warrant
a radical neck dissection because positive cervical
lymphadenopathy is a poor prognostic finding. Elective
neck dissection (Korkmaz et a!., 2002) is a moot ques-
tion and usually not performed. Postoperative radio-
therapy is utilized in selective situations, for example,
when margins are questionable or show malignant cells
on histologic examination, or when there is the slightest
doubt regarding the adequacy of surgical resection.
Elective radiotherapy (Spiro, 1986) to the neck is not
usually recommended and never used to selectively
treat, for example, the suprahyoid area alone.
Sacrifice of the facial nerve is dictated by the his-
tology of the tumor (importance of frozen section) and
the location and size of the malignant tumor. Low-
'These caveats are taken in part from Staggers-Deberney and Lore
(1999). with permission from the publisher.
grade (predominance of cystic mucous features)
mucoepidermoid tumors (Guzzo et a!., 2002) do not
merit sacrifice of the nerve unless the nerve is directly
invaded, which is unusual. High-grade (predominance
of poorly differentiated epidermoid features) mucoepi-
dermoid carcinoma, malignant mixed tumor, adenoid
cystic carcinoma, and usually the adenocarcinomas not
otherwise classified (NOS) are indications for sacrifice
of the nerve and/or its branches when preservation
would compromise the definitive surgical resection.
This decision is at times difficult and depends not only
on the expertise and judgment of the surgeon but also
on the expertise of the pathologist who has had expe-
rience with salivary gland tumors. A head and neck
surgeon must have the services of an expert pathologist
to help in this decision (JML). The accuracy of expert
pathologists' diagnoses based on frozen sections has
been well documented (Rigual et a!., 1986). This results
in the importance of the surgery being performed ina
hospital setting, which includes such a qualified
pathologist and surgeon qualified in head and neck
oncology. The initial operiltion is thus paramount. Yet
even with the best surgeon and pathologist, problems
can arise, for example, because of a sampling error at
the time of frozen section by the surgeon (see earlier
section on FNA).
The tumor histologic grade and stage are important
prognostic factors. For intermediate and high-grade
mucoepidermoid carcinoma, the 5-year absolute cure
rate for stage I is 100%; stage II, 65%; and stage III,
10% (Spiro, 1986, 1995; Spiro et a!., 1973, 1975, 1976,
1991). Cervical node metastases are a poor prognostic
factor and are associated with a high local regional
recurrence and possibly distant metastasis. There are
two exceptions to the relationship of histologic grade
and prognosis, although a difference of opinion exists:
one is adenoid cystic carcinoma and the other is acinic
cell carcinoma. In the adenoid cystic carcinoma there is
little to no correlation found between increase in grade
and aggressive behavior of the tumor. Initially, the
survival curves are better than other carcinomas, but at
10 years no difference is seen. There also can exist
pulmonary metastasis, with which the patient may sur-
vive for many, many years. The acinic cell carcinoma
can be an extremely difficult neoplasm for the patholo-
gist to grade: low or high grade. The reader is referred
to this subject in Thmors of the Head and Neck, second
edition, by John G. Batsakis, pp. 39 to 44, in which the
rather interesting and somewhat startling history of the
evaluation of this neoplasm is reviewed. At one time
this tumor was almost always considered rather
benign, but time has shown that there is a serious high-
grade type. The author has encountered a patient who
had a lateral parotid lobectomy performed for what
appeared to be a benign pleomorphic adenoma. No
frozen section was obtained by the surgeon. Permanent
 THE PAROTID SALIVARY GLAND AND MANAGEMENT
sections revealed an acinic cell carcinoma. The patient
was then re-examined and a 1.2-cm cervical lymph
node was revealed beneath the angle of the mandible,
which proved to be metastatic disease. A total parotidec-
tomy and radical neck dissection was then performed.
Batsakis goes on to state "it is generally considered that
there is not a good correlation between histologic appear-
ance of the acinous cell carcinoma (acinic cell) and its
biological course in the host." He rates these high and
low grade. The bottom line is a total parotidectomy
regardless. Preservation and/or reconstruction of the
seventh nerve is dictated by the surgical findings.
Acinic cell carcinoma, even though it is considered a
carcinoma of low grade, nevertheless has a risk of local
recurrence of 20% after surgery, as well as neck metas-
tasis, 10%, and distant metastasis, 6 %. It accounts for
2 % to 7% of the malignant tumors of all salivary
glands, and it has been reported that there are few
instances of bilaterality in the parotid salivary gland.
The sublingual salivary glands are the smallest of the
major salivary glands, and their neoplastic processes
are almost all malignant. Poor prognosis results from
inadequate surgery, unless a wide surgical resection is
performed. Preoperative imaging is most important, as
it is for any mass, solid or cystic, located under the
tongue. This is a distinct aid to the extent of the surgical
resection. Preoperative FNAs may be of considerable
help in establishing a diagnosis, or at least a suspicion
thereof. Many of the solid masses in the anatomic
location of the sublingual salivary glands should not be
sampled and not partially removed. The minimum
operation is a total removal and frozen section. These
glands are closely related to the submandibular gland
and obviously the tongue, as well as to the lingual
artery and both the lingual and hypoglossal nerves (see
Figs. 15-90 and E and 15-21), with the latter being some-
what inferior. Although the gland can be technically
resected transorally, nevertheless if there is any ques-
tion regarding the adequacy of exposure, the approach
is via a midline mandibulotomy. In any event, the best
approach is that a mandibulotomy be performed if there
is any question of a neoplasm of the sublingual gland.
The only other cause of a mass involving the sub-
lingual gland is a ranula, which, of course, is a benign
cyst (see p. 766).
Basically the type of resection would follow the same
principles regarding the two nerves, as is performed
with parotid surgery for a malignant lesion relative to
the seventh cranial nerve. Metastasis is reported in
levels II and III (suspect level !, as well). In the event
of metastatic disease a radical neck dissection is recom-
mended. If the malignant tumor has extended to involve
the mandible, a segmental resection of the mandible
would be performed (see Fig. 14-4E), or possibly a
marginal resection of the mandible, as depicted in
Figure 14-11H. Reconstruction would be done with a
OF MALIGNANT SALIVARY GLAND NEOPLASIA
bent Steinmann pin, as described in Figure 14-5A, or
with an appropriate free flap. This illustration, of course,
represents a virtually much larger area that would have
to be resected. A much smaller segment of the mandible
should be adequate. Resection of the mandible, although
not very commonly indicated with carcinoma of the
submandibular gland, is certainly the procedure if the
disease involves the mandible.
Adenocarcinoma Not Otherwise
Specified (NOS)
The following is a quote directly from the monograph
by Klijanienko and Vielh (2000):
Not othelWise specified literally means that the
histopathologist cannot classify a tumour into one of
the specific types listed in the World Health
Organization (WHO) classification (Seifert, 1991).
A general description is as follows: this is a
diminishing group of salivary gland malignancies
(Batsakis et al., 1992). The various carcinomas not
othelWise specified represent approximately 4-9% of
all salivary gland tumours (Ellis et al., 1991;
Spiro et aI., 1982). Adenocarcinomas NOS mainly
arise in the minor salivary glands, followed by the
nasal sinuses and larynx. Major glands are involved
in 32% to 60% of cases (Ellis et aI., 1991).
Clinically, tumours present features of low- or high-
grade malignancy, with a potential for local
recurrence and lymph node and distant metastases
(lung, bone, skin).
The author (JML) has seen this type of tumor respon-
sible for severe local recurrence involving cutaneous
spreading characteristics, which can be devastating.
Hence, the initial aggressive surgery plus radiotherapy,
as indicated, is most important.
Histologically, positive lymph nodes warrant a radical
neck dissection, as discussed earlier. There is no place
for any modified or functional neck dissection, as per
author (JML). Some surgeons perform a suprahyoid
neck dissection based on the absence of nodes below the
level of the hyoid bone (palpable or on image analysis).
The author (JML) usually performs a complete radical
neck dissection when there are positive nodes in the
suprahyoid region. To rely on postoperative radiation to
sterilize the entire neck under these circumstances may
be a mistake.
Chemotherapy usually has little to offer in the
management of the malignant salivary gland neoplasia.
Nevertheless, there are two patients with major sali-
vary gland involvement known to the author (JML)
who have had significant remission: one patient with a
recurrent pleomorphic adenoma and another with a
 THE PAROTID SALIVARY GLAND AND MANAGEMENT OF MALIGNANT SALIVARY GLAND NEOPLASIA

high-grade "anaplastic carcinoma" (undifferentiated). Carcinoma ex pleomorphic adenoma is a carcinoma

The chemotherapeutic agent utilized was carboplatin
with paclitaxel (Taxo!).
A retrospective review was conducted of 100 patients
with major or minor salivary gland neoplasms to ascer-
tain the accuracy and effect of frozen section diagnosis
on therapy. Of these neoplasms, 23 % were malignant
and 77% were benign. Threlve patients benefited by
further surgery during the initial operation, and no
treatment delay occurred as a result of frozen section
diagnosis. There were four incorrect diagnoses of clinical
significance: two false positives (benign tumor called
malignant on frozen section) and two false negatives
(malignant tumor called benign on frozen section). The
frozen section accuracy for specific pathologic diagnosis
was 92%. No unnecessary radical surgery was performed.
Frozen section diagnosis of salivary gland neoplasms,
in our institution, was found to be reasonably accurate
and useful. Table 17-1 presents the prognostic grades of
various malignancies.
Malignant Mixed Tumor
Nieva B. Castillo
Under the umbrella of malignant mixed tumor are three
clinical and pathologic entities: carcinoma ex pleomor-
phic adenoma, true malignant mixed tumor (carci-
nosarcoma), and metastasizing mixed tumor. The last
two are extremely uncommon.
arising from the epithelial component of the mixed
tumor. The carcinoma is frequently adenocarcinoma,
squamous cell carcinoma, or undifferentiated carcinoma,
although uncommonly it could be adenocystic carcinoma,
papillary carcinoma, or even polymorphous low-grade
adenocarcinoma. Destructive infiltrative growth is the
most reliable criterion for the diagnosis. The carcinoma
can arise in the primary tumor or in the recurrence.
When it metastasizes, only the malignant epithelial
element does so.
Carcinosarcoma or true malignant mixed tumor is
a tumor in which both the epithelial and the stromal
elements are malignant. When it metastasizes, both the
epithelial and sarcomatous elements are malignant.
This tumor is very rare. The sarcomatous component
can be chondrosarcoma, osteosarcoma, fibrosarcoma,
or malignant fibrous histiocytoma. The epithelial element
is frequently ductal or squamous cell carcinoma. Lung
is the most frequent site of metastasis, followed by
lymph nodes.
Metastasizing mixed tumor is histologically iden-
tical to benign mixed tumor, yet for some unknown
reason it metastasizes to distant sites, particularly to
bone and lungs. Most of the reported cases had a his-
tory of one or more excisions for benign mixed tumor.
It is postulated that repeated surgical manipulations
had allowed access of the tumor cells to vascular
spaces. Table 17-2 provides staging criteria for salivary
gland neoplasms.

TABLE 17-1 Histologic Classification of Salivary Gland Malignancies According to Prognostic Grade'

High and Intermediate Grade Low Grade

Adenoid cystic carcinoma Polymorphous low-grade adenocarcinoma

Carcinosarcoma Metastasizing pleomorphic adenoma
Squamous cell carcinoma Basal cell adenocarcinoma
Undifferentiated carcinoma
Salivary duct carcinoma
Myoepithelial carcinoma
Epithelial-myoepithelial carcinoma
(Papillary) cystadenocarcinoma
Sebaceous carcinoma
Mucinous carcinoma
Oncocytic carcinoma
Secondary tumors
Mucoepidermoid carcinoma
Adenocarcinoma not otherwise specified
Carcinoma ex pleomorphic adenoma
Lymphoma

'Based on the WHO classification (Seifert, 1991) with modifications by the U.s. Armed Forces tnstitute of Pathology.
From Klijanienko J, Vielh P: Salivary Gland Thmours. Volume 15 of the Monographs in Clinical Cytology Series. Basel, Switzerland, Karger,
2000.
 THE PAROTID SALIVARY GLAND AND MANAGEMENT OF MALIGNANT SALIVARY GLAND NEOPLASIA

TABLE17-2 Staging Criteria for NeoplaslDll of the Major Salivary Glands

Primary Thmor (T)

TX Primary tumor cannot be assessed
TO No evidence of primary tumor
Tl Thmor 2 em or less in greatest dimension without extra parenchymal extension"
T2 Thmor more than 2 em but not more than 4 em in greatest dimension without extraparenchymal extension"
T3 Tumor more than 4 em and/or tumor having extra parenchymal extension"
T4a Tumor invades skin, mandible, ear canal, and/or facial nerve
T4b Thmor invades skull base and/or pterygoid plates and/or encases carotid artery
Regional Lymph Nodes (N)
NX Regional lymph nodes cannot be assessed
NO No regional lymph node metastasis
Nl Metastasis in a single ipsilateral lymph node, 3 em or less in greatest dimension
N2 Metastasis in a single ipsilateral lymph node, more than 3 em but not more than 6 em in greatest dimension, or
in multiple ipsilateral lymph nodes, none more than 6 em in greatest dimension, or in bilateral or contralateral
lymph nodes, none more than 6 em in greatest dimension
N2a Metastasis in a single ipsilateral lymph node, more than 3 em but not more than 6 em in greatest dimension
N2b Metastasis in multiple ipsilateral lymph nodes, none more than 6 em in greatest dimension
N2c Metastasis in bilateral or contralateral lymph nodes, none more than 6 em in greatest dimension
N3 Metastasis in a lymph node, more than 6 em in greatest dimension
Distant Metastasis (M)
MX Distant metastasis cannot be assessed
MO No distant metastasis
Ml Distant metastasis
Stage Grouping
I Tl NO MO
II T2 NO MO
III T3 NO MO
Tl Nl MO
T2 Nl MO
T3 Nl MO
IVA T4a NO MO
T4a Nl MO
Tl N2 MO
T2 N2 MO
T3 N2 MO
T4a N2 MO
IVB T4b Any N MO
Any T N3 MO
lve Any T Any N Ml

*Note: Extraparenchymal extension is clinical or macroscopic evidence of invasion of soft tissues. Microscopic evidence alone does not
constitute extra parenchymal extension for classification purposes.
Reproduced from the American Joint Committee on Cancer Staging, January 2003.
 THE PAROTID SALIVARY GLAND AND MANAGEMENT
Parotid Extension of Radical Neck
Dissection (Fig. 17-6)
High Exposure of Internal Jugular Vein
and Internal Carotid Artery
Indications
Metastatic disease in the high internal jugular nodes, in
the high spinal accessory nodes, and in juxtaposition to
the tail of the parotid salivary gland requires an exten-
sion of the standard radical neck dissection. Although
the standard neck dissection includes the tail of the
parotid, the level of transection of the parotid may be
too low in such metastatic disease because the exact
location of the facial nerve is not known. In addition,
good visualization of the high internal jugular region is
hampered by overlying structures.
This particular exposure, combined with extraoral
transection of the mandible, is also ideal for high anas-
tomoses of the internal carotid artery for replacement
grafts as a result of either local tumor invasion or
obliterative vascular disease.
The operation is well suited to combined neck and
mandible resections when the disease warrants it.
Exposure of the mandible is enhanced.
Highpoints
1. Expose and preserve the main trunk of the facial
nerve.
2. Electively sacrifice the cervicofacial division of the
facial nerve if necessary.
3. Preserve the zygomaticotemporal division of the
facial nerve.
4. Resect the entire lower half of the parotid from the
level of the main trunk of the facial nerve.
5. Resect the posterior belly of the digastric muscle and
stylohyoid muscle.
A The skin incision of the standard neck dissection is
modified by preauricular and postauricular incisions as
for the exposure in parotid lobectomy. The upper skin
flap is elevated over the lower two thirds of the
parotid.
B The main trunk of the facial nerve is then exposed,
using the technique described in parotid lobectomy
(see Fig. 17-1) except that it is somewhat easier, because
the insertion of the sternocleidomastoid muscle is
shaved off the mastoid process. When this is done, the
posterior belly of the digastricus muscle is clearly seen,
as is the closely related band of fascia running from the
parotid to the tympanomastoid fissure.
OF MALIGNANT SALIVARY GLAND NEOPLASIA
C A small Mixter forceps is inserted under this
temporoparotid fascial band. The band is cut, and the
facial nerve is exposed.
D The main trunk of the facial nerve is then exposed
to its first major bifurcation into the lower or cervi-
cofacial division and the upper or zygomaticotemporal
division. With a small hemostat underneath it, the
digastricus is shown being transected close to its origin
in the mastoid notch of the temporal bone. The
deeper stylohyoid muscle is transected in similar
fashion. Purely of anatomic interest are the first small
branches of the extracranial portion of the facial nerve.
There are three innervating the posterior auricular
muscle, the posterior belly of the digastricus muscle,
and the stylohyoid muscle. These branches have no
surgical significance, except that in the very rare case
when the main trunk of the facial nerve is obscured,
the branch to the posterior belly of the digastricus
could conceivably be traced back to its origin from the
main trunk.
E The two main divisions of the facial nerve are then
exposed for a short distance. Whether sacrifice of the
entire lower division (cervicofacial) is indicated is
decided now. It usually is sacrificed, because the
resulting facial deformity involves only the ipsilateral
lower lip. With extensive disease in the upper neck,
whether or not this extended operation is performed,
preservation of the mandibular branch of this lower
division is not indicated; hence, there will be weakness
of the lip. The buccinator branch will usually not be
affected, because it has fibers arising from both upper
and lower divisions.
F The entire parotid gland from the level of the main
trunk of the facial nerve and the level of the upper
division (zygomaticotemporal) is now transected just
below these nerves, preserving them. The posterior
facial vein is ligated and divided at this same level. If
the remaining portion of the lateral lobe is very thick
and prominent, a portion of this may likewise be
excised purely from the cosmetic viewpoint. This will
avoid a sharp break in the contour of the side of the
face at the level of the major resection. It has been
most helpful in diminishing the usual postoperative
parotid prominence.
Continued
 THE PAROTID SALIVARY GLAND AND MANAGEMENT OF MALIGNANT SALIVARY GLAND NEOPlASIA

~ " ,'7-
~
D Zygomatico-
temporal div.
Cervicofacial div.

Post. auricular n.
F

Cervical facial div.

Hypoglossal n.

Sternocleidomastoid m.
Spinal accessory n.
Occipital a.
In!. jugular v.

FIGURE 17-6
 THE PAROTID SALIVARYGLAND AND MANAGEMENT OF MALIGNANT SALIVARYGLAND NEOPLASIA
Parotid Extension of Radical Neck
Dissection (Continued) (Fig. 17-6)
The freed lower portion of the parotid is now sepa-
rated from the masseter muscle, while the stylohyoid
and posterior belly of the digastric muscle are turned
downward. Three arteries are usually encountered: the
occipital, the posterior auricular, and a branch to the
sternocleidomastoid muscle. These are all ligated and
divided. Excellent visualization of the highest reaches
of the internal jugular vein is now gained. Just lateral
to the vein is seen the spinal accessory nerve, which
may be (the relationship of the spinal accessory nerve
to the internal jugular vein may vary from anterior,
posterior, medial, or lateral or actually pass through the
vein) preserved or sacrificed at this level, depending on
proximity of the neoplastic disease. Any nodes in this
area can be carefully swept downward, exposing a suf·
ficient portion of the internal jugular vein for ligation
and division. This is done by very carefully and slowly
passing a small Mixter forceps behind the vein and
pulling through a 2-0 silk tie. A distal suture ligature of
4-0 silk is used. The reader is referred to page 872
regarding deeper dissection, which could possibly expose
the vertebral artery, and to page 868 regarding resec·
tion of the deeper lobe of the parotid.
G If preferred, the internal jugular vein may be
ligated and divided by reflecting the neck mass
upward, thus exposing the posterior aspect of the vein
from below. Because the anterior aspect has already
been exposed, the placement of a tie about the vein is
not difficult.
H A proximal tie of 2-0 silk is in place around the
internal jugular vein with a distal suture ligature of 4-0
silk being inserted.
I The entire neck specimen is now removed by
transection of the insertions of the posterior belly of
the digastric and stylohyoid muscles from the hyoid
bone. Lingual veins will require ligation and division at
this site, as will the external maxillary artery as it enters
the digastric triangle laterally. If not involved by the
neoplasm, the hypoglossal nerve is carefully preserved
as it lies over the internal carotid artery and crosses the
external carotid artery and hyoglossus muscle. The
wound is closed in the usual manner for neck dissection.
Parotitis
Etiology
Acute parotitis may be secondary to one or more calculi
in Stensen's duct or to a diffuse inflammatory disease
usually seen in debilitated patients. Another rather rare
cause is external auditory canal otitis that extends to the
parotid salivary gland via a patent fissure of Santorini.
Treatment
1. Antibiotics are used in virtually all patients with
parotitis.
2. Calculi are removed by dilatation or incision of the
orifice of Stensen's duct. If the calculi recur several
times and/or they are diffuse and multiple within
the salivary gland, consideration is given to
parotidectomy.
3. This is a diffuse disease in the elderly. If there is no
response to the just-listed methods, incise the thick
superficial fascia to relieve tension and pain.
4. Treat external otitis with careful cleansing and the use
of alcohol and boric acid ear drops or local antibiotics,
plus systemic antibiotics. If a fungus infection is asso-
ciated with the external otitis, appropriate fungicidal
agents are utilized. Some antibiotics may aggravate
the fungus infection.
 THE PAROTID SALIVARY GLAND AND MANAGEMENT OF MALIGNANT SALIVARY GLAND NEOPlASIA 889

Mylohyoid m.

Ant. belly digast m.

Hyoglossus m.

Hyoid bone
Ext. maxillary a.

Occipital artery

Lingual artery

Super!.
temporal artery
and vein

\V~
FIGURE 17-6 Continued
 THE PAROTID SALIVARYGLAND AND MANAGEMENT OF MALIGNANT SALIVARYGLAND NEOPLASIA
BIBLIOGRAPHY
Abrams AM, Cornyn J, Scofield HH, Hansen LS: Acinic cell adeno-
carcinoma of the major salivary glands: A clinicopathologic study
of 77 cases. Cancer 18:1145-1162,1965.
Adie R: Gustatory sweating. Aust NZ J Surg 38:98-103,1968.
Anderson R: Surgery of the Parotid Gland. St. Louis, CV Mosby, 1965.
Anson BJ, McVay CB: Surgical Anatomy, Sth ed. Philadelphia, WB
Saunders, 1971.
Baker DC, Conley J: Surgical approach to retromandibular parotid
tumors. Ann Plast Surg 3:304-314, 1979.
Baker HW: The salivary glands. In Walters W (ed): Lewis-Walters
Practice of Surgery. Vol. IV. Hagerstown, MD, WF Prior, 1967.
Bardwill JM: Tumors of the parotid gland. Am J Surg 114:498, 1967.
Barton J, Slevin NJ, Gleave EN: Radiotherapy for pleomorphic
adenoma of the parotid gland. Int J Radiat Oncol Bioi Phys 22:
925-928, 1992.
Batsakis JG: Tumors of the Head and Neck. Baltimore, Williams &
Wilkins, 1974.
Batsakis JG: Tumors of the Head and Neck: Clinical and Pathological
Considerations, 2nd ed. Baltimore, Williams & Wilkins, 1979.
Batsakis JG, EI-Naggar AK, Luna MA: Adenocarcinoma not otherwise
specified and diminishing group of salivary carcinomas. Ann Otol
Rhinol LaryngoII01:102-104, 1992.
Beahrs OH, Judd ES, Wodington JF: The use of nerve grafts for repair
of defects in the facial nerve. Ann Surg 153:433-440, 1961.
Beahrs OH, Woolner LB, Carbeth SW, Devine KD: Surgical manage-
ment of parotid lesions: A review of 760 cases. Arch Surg 80:890,
1960.
Beahrs OH, Woolner LB, Kirklin JW, Devine KD: Carcinomatous
transformation of mixed tumors of the parotid gland. Arch Surg
75:605, 1967.
Berg JW, Hutter RVP, Foote FW Jr: The unique association between
salivary gland cancer and breast cancer. JAMA 204:771-774,1968.
Bernier JL, Bhaskar SN: Lymphoepitheliallesions of salivary glands:
Histogenesis and classification based on 186 cases. Cancer
11:1156-1179, 1958.
Bissett RJ, Fitzpatrick PJ: Malignant submandibular gland tumors.
Am J Clin Oncolll:46-51, 1988.
Blatt 1M:The parotid-masseter hypertrophy-traumatic occlusion syn-
drome. Presented at the Meeting of the So. Section of the American
Laryngological, Rhinological and Otological Society, Inc., January
1969.
Blatt 1M: On sialectasis and benign Iymphosialadenopathy (the pyo-
genic parotitis, Gougerot-Sjogren's syndrome, Mikulicz's disease
complex). Laryngoscope 74:1684-1746, 1964.
Brown JB, Fryer MP, Zografakis G: The treatment of primary malignant
tumors of the parotid gland. Surg Gynecol ObstetI29:40-44, 1969.
Chaudhry AP, Gorlin RJ: Papillary cystadenoma Iymphomatosum
(adenolymphoma). Am J Surg 95:923-931, 1958.
Cocke EW: Preservation of the facial nerve in a recurrent mixed
tumor of the parotid gland. Laryngoscope 88:2032-2034, 1978.
Cohen IK, Holmes EC, Edgerton MT: Parotid duct transplantation for
correction of drooling in patients with cancer of the head and neck.
Surg Gynecol Obstet 133:664-665,1971.
Conley JJ: Facial nerve grafting and treatment of parotid gland tumors.
Arch Surg 70:359-366, 1955.
Conley JJ, Dingman DL: Adenoid cystic carcinoma in the head and
neck. Arch Otolaryngol 100:81-90, 1974.
Cramer SF, Gnepp DR, Kiehn CL, Levitan J: Sebaceous differentiation
in adenoid cystic carcinoma of the parotid gland. Cancer 46:
1405-1409,1980.
Dedrick CG: The solitary pulmonary nodule and staging of lung
cancer. C1in Chest Med 5:345-363, 1984.
Oishell WO: Tympanic neurectomy in chronic parotitis. Arch
Otolaryngol 94:471-473, 1971.
Dodd GO, Jing BS: Radiographic findings in adenoid cystic carcinoma
of the head and neck. Ann Otol 81:591, 1972.
Doyle PJ: Surgery for tumors of the deep lobe of the parotid gland.
J Otolaryngoll1:155-160, 1982.
Ellis GL, Auclair PL, Gnepp DR: Surgical Pathology of the Salivary
Glands. Philadelphia, WB Saunders, 1991.
Eneroth CM: Salivary gland tumors in the parotid gland, submandibular
gland, and palate region. Cancer 27:1415-1418, 1971.
Ferlito A, Pellitteri PK, Robbins KT, et al: Management of the neck in
cancer of the major salivary glands, thyroid and parathyroid
glands. Acta Otolaryngol 122:673-678, 2002.
Franklin OJ, Smith J, Person RJ, Pflugfelder SC: Sjogren's syndrome
in children. Otolaryngol Head Neck Surg 94:230-235, 1986.
Frazell EL: Clinical aspects of tumors of the major salivary glands.
Cancer 7:637, 19S4.
Freeman FJ, Beahrs OH, Woolner LB: Surgical treatment of malignant
tumors of the parotid gland. Am J Surg 110:S27-533, 1965.
Frey L: Le syndrome du nerf auriculotemporal. Rev NeuroI2:97-104,
1923.
Fu Y-S,Wenig BM, Abemayor E, Wenig BL: Head and Neck Pathology.
London, Churchill Livingstone, 2001.
Gaisford JC, Hanna DC: Salivary gland tumors and miscellaneous
associated problems: Diagnosis, pathology and treatment. Plast
Reconstr Surg 19:458-477, 1957.
Gates GA: Current status of radiosialography in tumor diagnosis.
'lrans Am Acad Ophthalmol Otolaryngol 74:1183-1195, 1970.
Gates GA: Diseases of the salivary glands. In Bluestone CD, Stool SE
(eds): Pediatric Otolaryngology. Philadelphia, WB Saunders, 1983,
pp 1023-1037.
Gibson WS Jr, Hora JF: Intraparotid facial neurilemmoma. Ann Otol
79:412, 1970.
Gordon AB, Fiddian RV:Frey's syndrome after parotid surgery. Am J
Surg 132:54-58, 1976.
Greene GW, Bernier JL: Primary malignant melanomas of the parotid
gland. Oral Surg 14:108-116, 1961.
Grove AS Jr, Di Chiro G: Salivary gland scanning with technetium
99M pertechnetate. AJR Am J Roentgenol 102:109-116, 1968.
Guzzo M, Andreola S, Sirizzotti G, et al: Mucoepidermoid carcinoma
of the salivary glands: Clinicopathologic review of 108 patients
treated at the National Cancer Institute of Milan. Ann Surg Oncol
9:688-695, 2002.
Hanna DC, Gaisford JC, Richardson GS, Bindra RN: Tumors of the
deep lobe of the parotid gland. Am J Surg 116:524-527, 1968.
Harkin JC, Skinner MS: Experimental and electron microscopic studies
of nerve regeneration. Ann Otol 79:218, 1970.
Healey WV, Perzin KH, Smith L: Mucoepidermoid carcinoma of
salivary gland origin. Cancer 26:368-388, 1970.
Heeneman H: Identification of the facial nerve in parotid surgery.
Can J OtolaryngoI4:14S-1S1, 1975.
Hemenway WG: Chronic punctate parotitis. Laryngoscope 81:485-509,
1971.
Hollinshead WH: Anatomy for Surgeons: Head and Neck, 2nd ed, vol
1. New York, Hoeber-Harper, 1968, pp 350-363.
Jack GA: Irradiation of metastatic carcinoma of the parotid. Cancer
48: 1557-1562, 1981.
Jones JK, Baker HW: Liposarcoma of the parotid gland. Arch
Otolaryngol 106:497-499, 1980.
Kaltreider HB, Talal N: Bilateral parotid gland enlargement and
hyperlipoproteinemia. JAMA 210:2067-2070, 1969.
Kim KH, Sung MW, Yun JB, et a1: The significance of CT scan or MRI
in the evaluation of salivary gland tumors. Auris Nasus Larynx
25:297-402, 1998.
Klijanienko J, Vielh P: Salivary Gland Tumours. Volume 15 of the
Monographs in Clinical Cytology Series. Basel, Switzerland, Karger,
2000.
Kolson H, Aslam P: Accuracy and value of needle biopsy of the
parotid gland. Arch Otolaryngol 87:75-79, 1968.
Korkmaz H, Yoo GH, Du W, et al: Predictors of nodal metastasis in
salivary gland cancer. J Surg Oncol 80:186-189, 2002.
 THE PAROTID SALIVARY GLAND AND MANAGEMENT
Kott ET, Goepert H, Ayala AG, Ordonez NG: Lymphoepithelial carci-
noma (malignant Iymphoepithelial lesion) of the salivary glands.
Arch OtolaryngolllO:50-53, 1984.
Leafstedt 5W, Gaeta JF, Sako K, et al: Adenoid cystic carcinoma of
major and minor salivary glands. Am J Surg 122:756-762, 1971.
Lee K, McKean ME, McGregor IA: Metastatic patterns of squamous
carcinoma in the parotid lymph nodes. Br J Plast Surg 38:6-10, 1985.
Levitt SH, McHigh RB, Gomez-Marin 0, Hyams VJ, et al: Clinical
staging system for cancer of the salivary gland. Cancer 47:
2712-2724, 1981.
Little JW, Rickles NH: Malignant papillary cystadenoma Iym-
phomatosum. Cancer 1:851-856, 1965.
Love JT Jr, Marchbanks JR: Injury to the facial nerve associated with
the use of a disposable nerve stimulator. Otolaryngology 86:61-64,
1978.
Martin H: Surgical removal of parotid tumors. Ciba Clin Symp 13:
121-131, 1961.
Martin H, Helsper JT: Spontaneous return of function following
surgical section or excision of the seventh cranial nerve in the
surgery of parotid tumors. Ann Surg 151:538, 1960.
Medina JE: Neck dissection in the treatment of cancer of major
salivary glands: Management of the neck in head and neck cancer:
II. Otolaryngol Clin North Am 31:815-822, 1998.
Mitz V: The superficial musculo-aponeurotic system (SMAS) in the
parotid and cheek area. Plast Reconstr Surg 58:80-88, 1976.
Moberger JG, Eneroth CoM: Malignant mixed tumors of the major
salivary glands. Special reference to the histologic structure in
metastases. Cancer 21:1198-1211, 1968.
Moertel CG, Elveback LR: The association between salivary gland
cancer and breast cancer. JAMA 210:306-308, 1969.
Nicolai JPA: An early account of gustatory sweating (Frey's syndrome):
A chance observation 250 years ago. Br J Plast Surg 38:122-123,
1985.
Patey DH, Thackray AC: The pathological anatomy and treatment
of parotid tumour with retropharyngeal extension (dumb-bell
tumours). Br J Surg 44:352-358, 1957.
Perzik SL, Fisher B: The place of neck dissection in the management
of parotid tumors. Am J Surg 120:355-358, 1970.
Poulsen P, Jorgensen K, Grontved A: Benign and malignant neo-
plasms of the parotid gland: Incidence and histology in the Danish
county of Funen. Laryngoscope 97:104-109,1987.
Povah WB, Beecroft W, Hodson I, Yazdi H: Malignant Iymphoepithelial
lesion-the Manitoba experience. J OtolaryngoI13:153-159, 1984.
Pulec JL: Facial nerve grafting. Laryngoscope 79: I562-1583, 1969.
Rice DH, Mancuso AA, Hanafee WN: Computerized tomography
with simultaneous sialography in evaluating parotid tumors. Arch
Otolaryngol 106:472-473, 1980.
Richardson GS, Dickason WI, Gaisford JC, Hanna DC: Thmors of
salivary glands. Plast Reconstr Surg 55:131-138, 1975.
Rigual NR, Milley P, Lore JM Jr, Kaufman 5: Accuracy of frozen
section diagnosis in salivary gland neoplasms. Head Neck Surg
8:442-446, 1986.•
Ross JAT: The function of the tympanic plexus as related to Frey's
syndrome. Laryngoscope 80:1816-1833, 1970.
Sachs ME, Conley J: The Pinch scissors technique for motor nerve
dissection. Laryngoscope 91:822-825, 1981.
Scarcella JV, Dykes ER, Anderson R: Hemangiomas of the parotid
gland. Plast Reconstr Surg 36:38-47, 1965.
Seifert, G: Histological typing of salivary gland tumours. In World
Health Organization International Histological Classification
Thmours. Geneva, Springer, 1991.
Siegelman 55, et al: CT of the solitary pulmonary nodule. AJR Am J
Roentgenol 135:1-13, 1980.
Skibba JL, Hurley JD, Ravelo HV: Complete response of a metastatic
adenoid cystic carcinoma of the parotid gland to chemotherapy.
Cancer 47:155-163,1981.
OF MALIGNANT SALIVARYGLAND NEOPlASIA
Smith LC, Lane N, Rankow RM: Cylindroma (adenoid cystic carci-
noma): A report of fifty-eight cases. Am J Surg 110:519-526, 1965.
Smith RO Jr, Hemenway WG, Stevens KM, Ratzer ER: Jacobson's
neurectomy for Frey's syndrome. Am J Surg 120:478-481, 1970.
Som ML: Isolation of the facial nerve in parotid surgery.
Laryngoscope 87:355-356, 1978.
Spiro RH: Salivary neoplasms: Overview of a 35-year experience with
2,807 patients. Head Neck Surg 8:177-184,1986.
Spiro RH: Treating tumors of the sublingual glands, including a use-
ful technique for repair of the 1100rof the mouth after resection.
Am J Surg 170:457-460, 1995.
Spiro RH, Hajdu 51, Strong EW: Thmors of the submaxillary gland.
Am J Surg 132:463-468, 1976.
Spiro RH, Huvos AG, Strong EW: Cancer of the parotid gland: A
clinicopathologic study of 288 primary cases. Am J Surg 130:
452-459,1975.
Spiro RH, Koss LG, Hajdu 51, Strong EW: Tumors of minor salivary
origin: A clinicopathologic study of 492 cases. Cancer 31:117-129,
1973.
Spiro RH, Martin H: Gustatory sweating following parotid surgery
and radical neck dissection. Ann Surg 165:118-127, 1967.
Spiro RH, Strong EW, Huvos AG: Adenocarcinoma of salivary origin:
Clinical pathologic study of 204 patients. Am J Surg 144:423-431.
1982.
Spiro RH, Thaler HT, Hicks WF, et al: The importance of clinical
staging of minor salivary gland carcinoma. Am J Surg 162:330-336,
1991.
Staggers-Deberney J, Lore JM Jr: Salivary gland tumors. In McKellar
DP, Reiling RB, Eiseman B: Prognosis and Outcomes in Surgical
Diseases. 51. Louis, Quality Medical Publishing, 1999.
Stoop DR: The solitary pulmonary nodule. Prim Care 5:373-384,
1978.
Tabb HG, Scaleo AN, Fraser SF: Exposure of the facial nerve in
parotid surgery. (Use of the tympanomastoid fissure as a guide.)
Laryngoscope 80:559-567, 1970.
Touloukian RJ: Salivary gland diseases in infancy and childhood. In
Rankow RM, Polayes 1M (eds): Diseases of the Salivary Glands.
Philadelphia, WB Saunders, 1976.
Turnbull AD, Frazell EL: Multiple tumors of the major salivary glands.
Am J Surg 118:787-789, 1969.
Wallenborn WMcK: Parotid gland atrophy produced by transtympanic
destruction of tympanic plexus. Laryngoscope 78:132-144, 1968.
Wallen born WMcK, Hsu YT, Olinger BR: The experimental produc-
tion of parotid gland atrophy. Laryngoscope 78:1314-1328, 1968.
Weitzner 5: Plexiform neurofibroma of major salivary glands in
children. Oral Surg 50:53-57, 1980.
Wilkie TF: The problem of drooling in cerebral palsy: A surgical
approach. Can J Surg 10:60-67, 1967.
Wise RA, Baker HW: Tumors of the deep lobe of the parotid gland.
Am J Surg 100:323, 1960.
Work WP: Basic concepts in surgery of the parotid glands.
J Otolaryngol 9:303-308, 1980.
Work WP, Gates GA: Thmors of the parotid gland and para pharyngeal
space. Otolaryngol Clin North Am, October, 1969.
Work WP, Habel DW: Mixed tumors of the parotid gland with
extension to the lateral pharyngeal space. Ann Otolaryngol Rhinol
Laryngol 72:843-860, 1963.
Work WP, Hecht DW: Epithelial cell malignancies of the parotid
gland. Laryngoscope 78: 1295-1302, 1968.
of Work WP, Johns ME: Symposium on salivary gland diseases.
Otolaryngol Clin North Am 10:2, 1977.
Wright GL, Smith R, Katz CD, Atkins JH: Benign parotid diseases of
childhood. Laryngoscope 95:915-920, 1985.
 18 ENDOCRINE SURGERY
JOHN M. LORE, JR.
MEGAN FARRELL
NIEVA B. CASTILLO
THYROID GLAND
Before any operation on the thyroid gland, the surgeon
must not only be an expert in surgical technique but
also have an understanding of diagnostic evaluation,
including competency in laryngoscopy, basic endocrinology,
anatomy, embryology, surgical pathology, preoperative
and postoperative management, nuclear scanning tech-
niques, radioiodine treatment of thyroid cancer, and
the careful follow-up systems involving patients with
thyroid cancer and hyperthyroidism. The surgeon must
also have a working knowledge of the indications for
surgery, the pros illld cons of fine-needle aspiration
(FNA), and the intricacies of hyperthyroidism. Ability
to recognize pheochromocytomas coexisting with the
multiple endocrine neoplasia (MEN) II syndrome is
most important.
To cover all of these areas in detail would involve a
volume of data far beyond the scope of this atlas. Never-
theless, a review of some of these data in outline fashion
is mandatory, otherwise the surgeon will simply be
relegated to the position of a technician. This does not
mean to imply that the surgeon "knows all." Expert
anesthesia is a sine qua non in endocrine surgery, as is
teamwork entailing the various disciplines involved,
with the extent of teamwork depending on the type of
thyroid disease encountered.
Cooperation and teamwork related to endocrine sur-
gery are as follows:
1. Thyroid carcinoma: the surgeon, nuclear medicine
specialist, pathologist, endocrinologist, and, in some
cases, the geneticist. Specifically, in medullary carci-
noma, close cooperation with the endocrinologist is
most important in relation to careful examination
and follow-up of patients in a family with familial
medullary carcinoma of the thyroid (MCT). Previously,
the use of pentagastrin stimulation testing was essen-
tial in the evaluation and follow-up of families at
risk. This type of dynamic testing still has a role but
with the advances in genetic testing such as the
detection of the RET proto-oncogene, many family
members can now have their risk for MCT assessed
much more simply.
2. Graves' disease: the surgeon, endocrinologist, and
anesthesiologist
892
3. Hyperparathyroidism: the surgeon, endocrinologist,
clinical laboratory staff, and diagnostic radiologist
Indications for thyroid surgery include the following:
• Probable or known thyroid carcinoma
• Hyperthyroidism when nonsurgical methods fail, are
contraindicated, or are not acceptable to the patient
• Symptoms of pressure on the trachea and/or
esophagus
• A substernal thyroid
• For cosmesis, such as the large bulky goiter refractory
to medical management or the prominent multinodu-
lar colloid goiter, stage 5, of Beierwaltes (see p. 960)
• Endemic goiter not related to iodine deficiency
Total thyroid lobectomy and isthmusectomy is the
basic minimal operation and is recommended for uni-
lateral nodules or an autonomous nodule (see Fig. 18-9).
Total thyroidectomy with sampling of the central nodes is
chosen for bilateral multinodular goiter (see Fig. 18-12A
to H), Graves' disease (pp. 932 to 934), and bilateral
Hashimoto's thyroiditis (p. 960). The exception may be
bilateral Hashimoto's thyroiditis when after one lobec-
tomy the viability of the recurrent laryngeal nerve is in
question. The patient can then be awakened and an
optical laryngoscopy performed. If the vocal cord is
immobile-even though estimated to be temporary-it
is better to terminate the surgery and stage the opera-
tion. Total thyroidectomy and central neck dissection is
the procedure for any type of carcinoma (Chonkich et
aI., 1987).
Diagnostic Evaluation
History
The surgeon must be aware of events such as exposure
to radioactive material, especially in childhood, and
familial disease, especially in relation to medullary carci-
noma and hypertension (e.g., in Sipple's syndrome) as
well as signs and symptoms, which can have a variety
of presentations: none, pressure, pain (thyroiditis), dys-
phagia, dyspnea, voice change, and growth characteristic
changes.

Physical Examination
1. Size, shape, consistency, and tenderness of the thyroid
gland
2. Presence or absence of cervical lymphadenopathy
3. Laryngoscopy. Absence of hoarseness is not verifi-
cation of normally functioning vocal cords. Sluggish-
ness or an immobile vocal cord indicates possible
recurrent nerve involvement. A bowed vocal cord
that is slightly inferior to the level of the opposite
normal vocal cord indicates possible involvement of
the external branch of the superior laryngeal nerve.
4. Tracheal deviation
5. Tumor fixation
6. Skin fixation
7. Normal thyroid
Fine-Needle Aspiration of the Thyroid
Gland
FNA of thyroid masses that may be difficult to palpate
but appear on a scan or sonogram can be performed by
using high-resolution lO-MHz ultrasound. The technique
is performed with a small transducer placed laterally to
the thyroid and directed medially. This is a great help
not only in locating the mass but also in directing the
needle. The needle itself may not be visible on the
screen, but its deflection of the anterior and posterior
wall of a cyst, for example, is clear. Hence, the author
(JML) has revised his impression regarding ultrasound
and thyroid imaging. It is very useful not only in facili-
tating difficult FNA but also in charting the size of the
thyroid mass when the patient is on thyroid hormone
suppression therapy.
When FNA of the thyroid reveals fluid (e.g., xan-
thochromic or black), this usually is associated with a
benign lesion. Aspiration of blood-tinged fluid should
be carefully evaluated for the possibility of thyroid car-
cinoma. Aspiration of a lateral neck mass, if it is pink
stained, is very, very suggestive of metastatic thyroid
carcinoma. If the aspirate is black or xanthochromic,
there is the possibility of thyroid carcinoma, and this
should be further evaluated by repeat careful physical
examination of the thyroid and with a thyroid sono-
gram. If this fails, then computed tomography (CT)
and/or magnetic resonance imaging (MRI) is indicated.
Cytologic Aspects
-------------- Nieva B. Castillo
It is estimated that 4% to 10% of the population in the
United States have clinically evident thyroid nodules.
Over 90% of the nodules are non-neoplastic and can be
treated or followed medically. The main goal of FNA is
to distinguish nodules that require surgery from those
that do not. The principal indication is a solitary nodule.
ENDOCRINE SURGERY
The presence or growth of a nodule during suppressive
therapy also warrants FNA. FNA is also indicated in
thyromegaly when there is question regarding diagnosis.
It is estimated that under experienced hands, FNA has
decreased the number of cases that need exploratory
surgery by 50% and has doubled the number of cancers
in the surgical specimens removed (Aggarwal et aI., 1989;
Altavilla et aI., 1990; Caraway et aI, 1993; Hall et al,
1989; Hamburger et aI., 1982; Kini, 1996; Nathan et aI.,
1988; Suen and Quenville, 1983).
FNA cytology is a safe, almost painless, cost -effective,
and highly reliable diagnostic procedure. It should be
used as the initial screening test for patients with thyroid
nodules. FNA of the thyroid gland has a specificity of
70% to 91 % and a sensitivity of 66% to 93% (Aggarwal
et aI., 1989; Altavilla et aI., 1990). The diagnostic accu-
racy of FNA is excellent for papillary carcinoma and
less so for medullary carcinoma. It will not distinguish
benign from malignant follicular neoplasms and Hiirthle
cell neoplasm because capsular and vascular invasion
cannot be assessed. The value of FNA, however, is
limited by its inability to distinguish a follicular lesion
reliably in view of overlapping cytologic criteria among
cellular nodules in nodular goiter, Hiirthle cell nodules
in Hashimoto's thyroiditis, follicular adenoma, well-
differentiated follicular carcinoma, and follicular variant
of papillary carcinoma (Caraway et aI., 1993; Hall et aI.,
1989; Hamburger et a!., 1982; Kini, 1996; Nathan et a!.,
1988; Suen and Quenville, 1983). Fortunately, specific
cytologic diagnoses in the just-described situations are
not critical from the standpoint of management because
surgery would be the accepted standard of treatment.
When following a patient on thyroid hormone suppres-
sion therapy with periodic sonograms, even though
there is no indication of increase in size, a repeat FNA
is usually indicated at least every 12 to 18 months.
Technique
The patient is placed in the supine position with a pillow
under the shoulder to hyperextend the neck and instruct-
ed not to move or swallow. The nodule is fixed by
immobilizing it with two fingers. The skin is cleansed
with alcohol. Local anesthesia mayor may not be used.
Nodules at the suprasternal area are difficult to eval-
uate with FNA because of the risk of trauma to the great
vessels of the superior mediastinum. FNA is performed
using a 23- to 2S-gauge needle attached to a 3- to S-mL
disposable syringe. Applying 2 to 5 mL of suction or no
suction is recommended. The needle is moved rapidly
to and fro for several millimeters in the same needle
track. The procedure is stopped as soon as the sample
begins to fill the clear hub of the needle. When a cyst
is encountered, it is drained and the remaining solid
area should be re-aspirated. The specimen is expressed
onto slides. Six slides may suffice. The specimen may
 ENDOCRINE SURGERY
be smeared with the edge of another slide as in prepar-
ing blood smears, or it may be compressed between
two slides and pulled. The smears are immediately
spray-fixed or wet-fixed in alcohol. In most laboratories
Papanicolaou staining technique is used, but at Sisters
of Charity Hospital hematoxylin and eosin stain is
used. To remove any residual aspirant in the hub of the
needle use a small intradental brush and smear on a
slide (Lon».
Question of Adequacy
Criteria for specimen adequacy vary from institution to
institution. One team of investigators requires five to six
groups of well-preserved, well-visualized follicular cells
with each group containing 10 or more cells (Goellner
et al., 1987). Another group requires 8 to 10 tissue frag-
ments of well-preserved follicular epithelium on each
of two slides (Hamburger et aI., 1982; Kini, 1996).
The first step is a low-power (x4) assessment of cellu-
larity. We require 6 to 10 groups of well-preserved
follicular cells in at least two slides. The background is
examined for presence or absence of colloid, inflam-
matory cells, calcific debris, and tumor diathesis. The
next step (xlO) is assessment of architecture or manner
of grouping of the follicular cells, whether they are in
mono layers, syncytial arrangements, or follicle forma-
tion. The final setup is high-power (x40) assessment of
nuclear size and nuclear features. Red blood cell or
lymphocyte size is used for comparison.
Diagnostic Groups
1. Unsatisfactory. Smears are acellular; specimen is
inadequate, too thick, or too bloody, obscuring cells,
or cellularity may be adequate but there is poor
cellular preservation.
2. Benign or negative for cancer cell. This category
includes adenomatous nodule (nodular goiter) and
thyroiditides.
3. Abnormal or suspicious. This category includes fol-
licular and Hiirthle cell neoplasms.
4. Positive for cancer cells. This category includes papil-
lary, anaplastic, medullary, and insular carcinomas,
malignant lymphoma, and metastatic carcinomas.
Cytology of Adenomatous Nodule
(Nodular Goiter)
The background shows abundant colloid with scattered
macrophages, occasional multinucleated giant cells,
stromal cells, and calcific debris. Smear may be hyper-
cellular or hypocellular with follicular cells arranged in
monolayers with honeycomb pattern or in follicles. Cells
are cuboidal and may show Hiirthle cell metaplasia.
Nuclei are approximately the same size as a lymphocyte
or red blood cell and are round with fine chromatin
usually without visible nucleoli (Kini, 1996; Kline, 1988).
Cytology of Thyroiditides
FNA of suppurative and granulomatous thyroiditides is
not routinely done. The presence of giant cells on FNA
is highly suggestive of subacute thyroiditis. The aspirate
of Hashimoto's thyroiditis shows a mixture of epithelial
and inflammatory cells. The epithelial cell component
consists of follicular cells and Hiirthle cells and may
show considerable nuclear atypia. The Hiirthle cells may
be seen in sheets. The inflammatory component consists
of lymphocytes, plasma cells, and stimulated lympho-
cytes. Colloid is scanty or absent. The prominent Hiirthle
cell in Hashimoto's thyroiditis may be mistaken for
Hiirthle cell neoplasm. The nuclear pleomorphism of
follicular cell may be mistaken for follicular neoplasm,
and a dense aggregate of lymphoid cells may be mistaken
for malignant lymphoma.
Cytology of Follicular Neoplasm
Smears are cellular with scanty or absent background
colloid. The follicular cells are in a syncytial aggregate
with or without follicle formation. The nuclei are over-
lapping, enlarged, and round to oval, and the chromatin
is coarsely or finely granular. Nucleoli are frequently
present (Atkinson et aI., 1986; Kini, 1996; Kini et aI.,
1985; Kline, 1988).
Cytology of Hiirthle Cell Neoplasm
Hiirthle cells are altered follicular cells that are large
and polygonal with abundant granular cytoplasm. They
may be seen in adenomatous nodules, Hashimoto's
thyroiditis, Graves' disease, and after irradiation and
partial thyroidectomy.
Hiirthle cell tumors are neoplastic tumors composed
almost exclusively of Hiirthle cells. Smears are very
cellular with a monomorphic population with absent or
scanty colloid. The cells are loosely cohesive, in sheets
or follicles. They are large, oval to polygonal, and vari-
ably sized. The nuclei are frequently eccentrically locat-
ed; chromatin is finely granular and there is a single
prominent, cherry-red macro nucleolus (Gonzalez et aI.,
1993; Kini, 1996; Kline, 1988).
Cytology of Papillary Carcinoma
Smears are cellular with background sticky colloid in
which are scattered histiocytes and multinucleated
giant cells. Psammoma bodies may be seen. The cells
are in a papillary arrangement, in monolayers, or a syn-
cytial aggregate with or without follicle formation. They
are cuboidal, columnar, oval, polygonal, hiirthloid, or

squamoid. The nuclei are enlarged, overlapping, and
round to oval with finely granular, powdery, or dusty
chromatin with nuclear grooves, intranuclear inclusions,
and multiple micro nucleoli or macronucleoli (Kini,
1996; Kini et ai, 1980; Kline, 1988; Naib, 1996).
Cytology of Anaplastic Carcinoma
Smears are frequently cellular except for the spindle
cell type, which may be hypocellular. The cells are
isolated or in tissue fragments with a tumor diathesis
background and are extremely pleomorphic. The nuclei
are large and bizarre, with clumped chromatin with
parachromatin clearing. Mitotic figures are seen (Brooke
et aI., 1994; Kini, 1996; Kline, 1988; Naib, 1996).
Cytology of Insular Carcinoma
Smears are very cellular with clean or necrotic back-
ground. They are isolated or in loosely cohesive aggre-
gates or syncytia with or without microfollicle forma-
tion. The cells are small with round nuclei and granular
chromatin and parachromatin and single or multiple
micronucleoli (Kini, 1996; Pietyibiasi et aI., 1990).
Cytology of Medullary Carcinoma
Smears are cellular with background or eosinophilic
material (amyloid). Cells are in loosely cohesive aggre-
gates or syncytia. They are small, round, cuboidal, oval,
plasmacytoid, polygonal, or spindled. The nuclei are
eccentric, chromatin is coarsely granular, and nucleoli
are inconsistent. There may be intranuclear inclusions
similar to those in papillary carcinoma (Geddie et aI.,
1984; Kini, 1996; Kline, 1988; Naib, 1996).
Thyroid Scans (1231 and 99mTc)
The preoperative scan utilizes 1231and occasionally 99mTc.
A diagnostic scan is by itself not a certain and absolute
diagnostic tool. Its outcome must be correlated with
clinical findings just as must the results of FNA. Data
in the literature vary from institution to institution
regarding the incidence of carcinoma in a cold nodule,
with anywhere from 8% to 20% being malignant. A
pinhole collimator of high resolution is utilized for this
diagnostic scanning.
Although most hot nodules are benign, malignant
hot nodules do exist or can coexist with a cold nodule.
This association may occur at a later date after a hot
nodule is first detected. Linear areas of decreased uptake
that are associated with linear firm areas on physical
examination that appear to be benign, in fact, may be
malignant. The decision as to whether to operate may
be difficult. When there is doubt, total lobectomy is the
choice. The cold area on the scan may not correlate
ENDOCRINE SURGERY
with the findings in the surgical specimen. It is recom-
mended that a marker be placed on the patient's neck
alongside the nodule to attempt to correlate the phys-
ical examination with the scan. Thyroid scans and any
tests using radionuclides must not be used in a preg-
nant or lactating woman.
It is very dangerous to adopt the attitude that well-
differentiated thyroid cancer is a relatively benign dis-
ease, because this disease can be rapidly fulminating
or life threatening many years later. An evaluation of
Seer's case-fatality rates indicates that these rates for
well-differentiated carcinoma of the thyroid are very low
for up to 20 to 25 years after the diagnosis and treat-
ment. After this period of time, the fatality rates then
suddenly rise, approximating those related to squamous
cell carcinoma. These data are likewise supported by a
recent Canadian review of 2214 patients (Simpson and
McKinney, 1985).
Sonography
The sonogram is utilized more frequently than the radio-
iodine scan in the management of thyroid nodules. The
sonogram yields a reasonably accurate measurement of
size as well as whether the nodule is solid or cystic in
character, whereas a scan using 1231will tell whether the
nodule is hot or cold. Neither will yield a firm diagnosis
of the lesion as benign or malignant. On the other hand,
FNA, when cytologically positive for carcinoma, is very
reliable, depending on the expertise of the pathologist.
Cystic Lesions on Sonography (Fig. 18-1)
1. A thyroid cyst may have a solid component. This can
be suggestive of a neoplasm (e.g., papillary carci-
noma); perform total thyroid lobectomy.
2. If re-aspiration is necessary and the total number of
aspirations is more than two or three, perform a total
lobectomy.
3. If the cyst is very large (e.g., >3 em), it probably is
a parathyroid cyst, if the aspirated fluid is clear to
light yellow. The fluid can be analyzed for parathy-
roid hormone (PTH) (mid molecule) if it is imme-
diately frozen in dry ice.
The problem with sonography is the high incidence
of small lesions « 1 em). The reasonable method of
handling these lesions is either suppression of thyroid-
stimulating hormone (TSH) to a low-normal level and
following the patient with repeat sonography or follow-
up alone. If the TSH value is close to low normal, then
schedule an initial follow-up sonogram in 3 to 6 months.
If the lesion is smaller or there is no increase is size,
then repeat sonography two to three times per year.
Sonography is usually not reliable for evaluation of
location and size of substernal lesions.
 ENDOCRINE SURGERY
FIGURE 18-1 Sonogram of thyroid cyst with solid
component.
When comparing thyroid sonograms several features
are extremely important:
1. The possibility that equipment varies from facility to
facility.
2. Even in the same facility, equipment may become
improved and comparison is difficult or unreliable
or questionable.
3. It is important to ascertain whether the physician is
present during the actual sonogram. It appears that
physicians simply interpret sonograms without being
present or actually doing the sonogram, and these
results are not as reliable as when the physician is
actually doing the procedure.
In one case the patient did show a very large (3 cm)
cyst on sonography. FNA revealed 22 mL of clear watery
fluid. This type of aspirate is typical of a pure parathyroid
cyst. The fluid was sent for PTH levels, which were sig-
nificantly high, confirming the diagnosis of a parathyroid
cyst, despite normal serum PTH levels and normal serum
calcium levels. Actually, the sonogram was not neces-
sary, because the needle aspiration made the diagnosis.
Computed Tomography
CT may be of considerable aid in evaluating massively
large goiters (either benign or malignant) to ascertain
the extent of disease. This type of imaging is very
helpful in assessing the relationship of a diseased gland
to other vital structures of the head and neck, particu-
larly the airway. It can also be used to detect subclinical
lymphadenopathy of the neck and mediastinum, espe-
cially in obese patients and those with short bull neck.
CT can be used to follow-up tall cell papillary and
Hiirthle cell carcinoma in patients with advanced papil-
lary carcinoma both in the neck and mediastinum. It is
of aid in evaluation for pulmonary metastasis (MRI is
not as good because of patient motion), and it can be
of value in follow-up relative to the size of cervical
lymphadenopathy (sonography also may be of aid).
Magnetic Resonance Imaging
MRI is especially valuable in evaluation of the medi-
astinum for extent of lymphadenopathy. It can show
the relation of substernal goiter and any lymphade-
nopathy to the great vessels. Axial, sagittal, and coronal
views are essential.
Positron Emission Tomography
The role of positron emission tomography (PET) (see
also the discussion in Chapter 1) in evaluation of thyroid
disease is expanding at this time. It can reveal residual
thyroid tissue after "total" thyroidectomy. It also can
differentiate normal thyroid tissue from malignant
tissue. PET also may be a help in localizing metastatic
thyroid carcinoma of the lung and neck and has been
shown to be of aid in the detection of parathyroid
adenomas, for example, in the mediastinum (see later
section on parathyroids). PET also may be used in
locating ectopic thyroid tissue. PET has been reported
to be useful in the follow-up of thyroid cancer patients
in whom the quantitative thyroglobulin level is elevated
but the J31[ imaging is negative.
Anatomic Considerations (Taken in
Part From Lore, 1983a)
The following discussion includes practical anatomic
considerations relative to thyroidectomy. Of these, the
relationship of the recurrent laryngeal nerve to the
posterior suspensory ligament of the thyroid rather
than the nerve's relationship to the inferior thyroid
artery is believed to be the most important to avoid
injury to the nerve. Thus, the surgeon is admonished
first to locate the nerve at or just above the superior
thoracic outlet or at the inferior pole of thyroid as one
of the initial steps in thyroidectomy. If this approach
fails, a search is done along the lateral side of the
trachea from below upward or from the lateral to the
inferior thyroid pole areas. The other more important

considerations are the surgical anatomy of the external
branch of the superior laryngeal nerve and the fact that
often the parathyroid glands can be retrieved from the
surgical specimen while still in the sterile surgical field
and then can be reimplanted.
Posterior Suspensory Ligament
(See Figs. 18-2 and 18-9)
This ligament, located on either side of the trachea,
extends from the cricoid cartilage and the first, and at
times the second, tracheal ring to the posteromedial
aspect of each thyroid lobe. It is distinct from the
anterior suspensory ligament that extends from the
superior-anterior medial aspect of each thyroid lobe to
the cricoid and thyroid cartilages. This anterior suspen-
sory ligament is actually a thickened portion of the
pretracheal fascia. Superiorly, this fascia covers the
cricothyroid muscle and in its medial portion envelops
moderate-sized vessels. The posterior suspensory liga-
ment was described by Gruber; it was later described
by Henle in 1880, by Berry in 1888, and by Piersol in
1930 (see Piersol [1930, p. 1791]). Although Berlin
(1935) did not describe it as a ligament, he detailed this
structure as an adherent zone with four different types.
This ligament is extremely important in total thyroid
lobectomy, which is the basic minimal operation for a
lesion in the thyroid lobe that is suspected to be
carcinoma or for any other lesion of the thyroid. There
is virtually no indication for subtotal thyroidectomy or
for open biopsy unless the lesion is nonresectable for
the following reasons:
1. The recurrent laryngeal nerve passes deep to the
ligament or between the main ligament and the
lateral leaf of the ligament on its course to the
larynx; rarely (1 of 934 nerves) the nerve passes
over the ligament.
2. Deep to the ligament is a posteromedial portion of
the thyroid lobe that otherwise might be overlooked.
This portion varies in size from less than I em up to
or greater than 4 em. Carcinoma has been located in
this portion.
3. Deep to the ligament or along its inferior edge crosses
a branch of the inferior thyroid artery, a vessel of
importance only if its bleeding tempts the surgeon
to clamp it indiscriminately, because injury to the
recurrent laryngeal nerve may occur. In addition,
there may well be a plexus of veins and arteries
either superior or inferior to the major portion of
this ligament.
4. The recurrent laryngeal nerve, when it does branch
extralaryngeally, often branches proximal to the
ligament.
5. Parathyroid adenomas or hyperplasia (superior para-
thyroid) may be deep to this ligament.
ENDOCRINE SURGERY
Sometimes there may be a lateral leaf to the ligament
that extends more laterally than the main portion of the
ligament. If this variant exists, the recurrent laryngeal
nerve actually lies between the main portion of the liga-
ment and this lateral leaf. Occasionally, the recurrent
laryngeal nerve may almost appear to be within a
portion of the ligament; however, this is more apparent
than real. In addition, within the ligament itself may be
extension of thyroid tissue to the attachment of the
ligament to the trachea. This may explain the uptake of
131] in the thyroid bed so often seen in postoperative
scans after total thyroidectomy.
Recurrent Laryngeal Nerve
The right recurrent laryngeal nerve arises from the vagus
at the base of the neck and swings around the sub-
clavian artery, passing inferior and behind the artery
(see Fig. 19-90 and E), whereas the left recurrent laryn-
geal nerve leaves the vagus nerve at the arch of the
aorta, passing inferior and behind the arch lateral to
the obliterated ductus arteriosus. Both nerves pass pos-
terior to the carotid sheath as they proceed superiorly.
As the main trunk of this nerve emerges from the
superior thoracic outlet, it lies in a triangle bounded
laterally by the common carotid artery and internal
jugular vein and vagus nerve and medially by the trachea
and esophagus (Fig. 18-2). The distance from the trachea
and esophagus varies from side to side and patient to
patient. The esophagus lies somewhat to the left of the
midline; thus, the position of the recurrent laryngeal
nerve varies. The right nerve may enter the triangle
laterally as it passes deep to the carotid artery. The left
nerve may be several centimeters lateral to the tracheo-
esophageal sulcus. The left nerve is more likely to be
entrapped by the thyroid capsule; this may occur on the
right side as well, depending on the pathologic process.
It has been observed for years that the recurrent
laryngeal nerve branches before its entrance into the
larynx. Nemiroff and Katz (1982), in a study of 153
recurrent laryngeal nerves, found that 39 % bifurcated
into extralaryngeal branches. Most of these nerves were
found to branch within 0.6 to 3.5 em from the cricoid
cartilage, and anterior and posterior branches were
described. However, it has been our observation that
these appear to be medial and lateral branches. Never-
theless, this lateral branch corresponds to their poste-
rior branch and this medial branch corresponds to their
anterior branch. It appears that the lateral or posterior
branch is probably the abductor branch, whereas the
medial or anterior branch is the adductor branch. This
extra laryngeal branching of the recurrent laryngeal nerve,
although known for years, is extremely important from
the surgical point of view in that if this branching is not
recognized, two or three branches may easily be injured,
hence the importance of identification of the main
 ENDOCRINE SURGERY

POSTERIOR
SUSPENSORY
RECURRENT (BERRY)
LARYNGEAL LIGAMENT
NERVE RECURRENT
TRIANGLE LARYNGEAL
COMMON NERVE
CAROTID B
A ARTERY

FIGURE 18-2 A, Anatomy of the thyroid region. B, Photograph of fresh cadaver dissection of the right lobe of the
thyroid: 1, Right lobe mobilized; 2, Posterior suspensory ligament; 3, Trachea; 4, Recurrent laryngeal nerve (never pass
the stay suture around the nerve during surgery); 5, Probe under posterior suspensory ligament; 6, Common carotid
artery.

trunk of the recurrent laryngeal nerve before its point cate with the external branch of the superior laryngeal
of possible division. The identification of this main nerve. The number of branches of the recurrent laryn-
trunk just above the superior thoracic inlet appears to geal nerve can be anywhere from two to as many as
be the best guarantee for avoiding injury to the nerve four to six. Most of these smaller branches appear to
and its branches. innervate the cervical esophagus and the inferior
The same admonition applies to the nonrecurrent pharyngeal constrictor muscle. No nerve should be
laryngeal nerve. This nerve does not pass around the sacrificed in the surgical field unless a malignant tumor
subclavian artery on the right but is a direct medial extends into the nerve.
branch of the vagus nerve. Its course is directly from Another consideration is dislocation of an arytenoid
the carotid sheath and has not been observed to cross cartilage secondary to intubation, which can cause an
behind the carotid artery. Hence, an approach to the immobile vocal cord. With immediate postoperative
recurrent laryngeal nerve from the lateral aspect of the flexible optical laryngoscopy, this rare complication
thyroid lobe may well injure this nonrecurrent laryn- can be identified and treated as soon as possible within
geal nerve. This anomaly of a nonrecurrent laryngeal 24 to 48 hours or immediately after operation. The
nerve is more common on the right side and is usually sooner the treatment, the better the outcome (see
associated with an anomalous (retroesophageal) right Arytenoid Dislocation, p. 906).
subclavian artery. It can occur on the left side if there
is a transposition of the great vessels. Inferior Thyroid Artery
In addition to this anomalous nonrecurrent laryngeal
nerve, other anomalous branches of the nerve have been The inferior thyroid artery arises as a branch of the
observed, one passing over a portion of the inferior thyrocervical trunk and, along with the superior thyroid
pole of the thyroid lobe while another passes over the artery (a branch of the external carotid artery), is the
posterior suspensory ligament. At times the nerve may main blood supply to the thyroid gland. The inferior
be only 0.5 cm deep to the most superficial inferior thyroid artery passes deep to the carotid sheath. In
thyroid veins. Branches of the recurrent laryngeal nerve addition, it supplies both parathyroid glands; however,
also have been seen to pass laterally and superiorly and, the superior parathyroid gland may likewise have a
although not followed to their termination, appeared to blood supply either independently or conjointly with
be directed superiorly. These branches may communi- the superior thyroid artery (see Fig. 18- 14). The inferior

thyroid artery may also send muscular branches to the
scalenus anticus and the inferior constrictor muscles of
the pharynx. The branch that travels on the inferior
edge of the posterior suspensory ligament is usually
not mentioned in anatomic texts and is probably the
most important one as far as operations on the thyroid
gland are concerned. There may be additional branches
of the inferior thyroid artery that pass either just supe-
rior or just inferior to the ligament, and often there is
an actual network of arteries and veins in the region of
the ligament that can cause considerable annoyance
during total thyroid lobectomy. The relationships of the
inferior thyroid artery and its branches to the recurrent
laryngeal nerve, its main trunk, and its branches are so
varied that it is useless to attempt to describe them.
Because of this variation and also because of the blood
supply to the parathyroid glands, the main trunk of the
inferior thyroid artery is usually not ligated laterally
unless control of bleeding is necessary. Rather, the
smaller branches are ligated close to their entrance into
the thyroid lobe, thus, it is hoped, preserving the blood
supply to the parathyroid glands (see Fig. 18-14).
External Branch of the Superior
Laryngeal Nerve (See Fig. 18-9L and M)
This nerve supplies the cricothyroid muscle (two por-
tions: anterior or vertical and posterior or oblique), one
of the primary tensors of the vocal cord. Injury to this
nerve will cause bowing and some inferior displace-
ment of the vocal cord. The anatomic consideration of
this nerve in relation to thyroid lobectomy is its close
relationship to the superior thyroid artery and veins.
Actually, this small nerve may, in fact, intertwine
between these vessels or be adherent to them. Hence,
it is most important to dissect and to visualize the
vessels before their ligation during thyroid lobectomy.
The author (JML) prefers that this portion of the opera-
tion be performed as the final step of the surgery, at
which time gentle traction downward can be applied to
the superior pole. The vessels can then be exposed and
the nerve carefully displaced superiorly. However, the
nerve is not routinely exposed. It has been identified
approximately 10% of the time. The superior pole vessels
enter the thyroid capsule inferior to the most superior
portion of the superior pole of the thyroid. That is, they
are not located at the top of the superior pole. This is
important in the protection of the nerve.
The high points of the surgical technique relative to
the external branch of the superior laryngeal nerve are
as follows:
1. Superior pole exposure is the last step in thyroidectomy.
2. The artery and veins are exposed 1.5 to 2.0 em
proximal to their penetration of the capsule. This
could be referred to as the critical area.
ENDOCRINE SURGERY
3. Vessels are ligated and divided as close to the thyroid
capsule as possible without a clamp on the proximal
stump.
4. Ideally, the artery and veins are separately dissected
and ligated. The artery and veins are ligated together
when small veins are adherent to the artery or its
branches after careful evaluation ensures that the
nerve is not entrapped. To attempt to dissect these
vessels may result in bleeding, which then can make
the dissection extremely difficult and puts the nerve
at even greater risk.
Approximately 10% of the time this nerve can be
identified. However, its identification is not believed
necessary to preserve it. If at all possible, the artery and
veins can be separately ligated (Thompson and Harness,
1970). This aids in avoiding injury to this nerve and
also prevents the possibility of an arteriovenous fistula
(never encountered by the author [JML] but reported).
No clamps are used during the ligation and suture liga-
tion of these vessels. If the artery cannot be easily dis-
sected from the accompanying veins, then a 2-0 silk
ligature and a 3-0 silk suture ligature are utilized to
occlude these vessels en masse. In any event, bleeding
is to be avoided in the attempt to separate the artery
from the veins. Liberal exposure is necessary, elevating
the upper skin flap almost to the thyroid cartilage notch.
Paralysis of this nerve always causes hoarseness.
The conclusion of the study of all 934 external
branches of the superior laryngeal nerves is as follows
(Lore et aI., 1998): "although the function of the external
branch of the superior laryngeal nerve appears to be
normal on mirror or optical laryngoscopy, there are
other factors involved in the fine tuning of this nerve
which cannot be seen on laryngoscopy. When bowing
was evaluated by laryngoscopy in all 934 nerves (in
675 patients), there is only one patient with limited
follow-up whose bowing was minimal but permanent
(0.1 %). Of the 66 patients evaluated by our retro-
spective patient voice questionnaire, 9 had temporary
changes and 5 had permanent changes. Of these 14
patients, 13 found no effect on lifestyle and in one the
effects were indeterminate (unavailable for follow-up).
The estimated deleterious effect of voice changes on
lifestyle is no greater than 1.5% based on 66 patient
responses. "
Parathyroid Glands (See Figs. 18-14 to
18- 19)
The parathyroid glands, although usually four in num-
ber, can range anywhere from two to nine. They can be
located anywhere from the level of the hyoid bone to
down into the mediastinum. If located in the medi-
astinum, the inferior parathyroid glands may be located
in the anterior mediastinum, thymus, or within the thy-
 ENDOCRINE SURGERY
roid gland, whereas the superior glands may be located
in the posterior mediastinum or within the thyroid gland.
The blood supply to the parathyroid glands is usually
from the inferior thyroid artery; however, the superior
thyroid artery may supply the superior parathyroid
glands (see Fig. 18-14). Along with the various ectopic
locations, of particular concern during thyroid lobec-
tomy is location of the parathyroid glands on the ante-
rior aspect of the thyroid lobe itself and juxtaposition
to the strap muscles. Their color typically is caramel
and their shape oblong, and thus in situ they can usu-
ally be distinguished from adipose tissue, which is more
yellow, and from lymph nodes, which are slightly grayish.
The lymph nodes are seldom oblong. In addition, the
parathyroid glands can be located beneath the capsule
of the thyroid and at times within the folds of thyroid
tissue or actually within the thyroid gland itself. The
superior parathyroid glands rather than the inferior
parathyroid glands are more likely to be located within
the thyroid gland and the inferior parathyroid glands
within the thymus gland. When located in their normal
position, the inferior glands are usually somewhat more
anteriorly located than the recurrent laryngeal nerve.
The superior glands may be posterior to the nerve
and thus posterior to the posterior suspensory ligament
(Gruber, Henle, Berry ligament) and possibly deep to
and behind the esophagus. The nerve is almost always
medial to the parathyroid glands. As was mentioned
under the description of the inferior thyroid artery, the
terminal branches of the inferior thyroid artery to the
parathyroid glands are preserved whenever possible.
However, if the vessel is impossible to preserve, it is
best that devascularized parathyroid glands be sectioned
in the smallest portions possible and be reimplanted in
the base of the sternocleidomastoid muscle or the mus-
cles of the forearm or in any other muscle outside of
any other area that may be resected at any future time.
Parathyroid glands, when deprived of their blood supply,
may turn jet black. After the thyroid lobe is removed, it
is most important to scrutinize the surgical specimen
carefully for subcapsular parathyroid glands or glands
within folds of the thyroid lobe if the usual two para-
thyroid glands are not definitely identified on the side
of the lobectomy. Confirmation, when in doubt, is
obtained by sending a very small portion for frozen
section and by placing the remaining parathyroid glands
in normal saline for implantation on confirmation. Care
must be taken not to reimplant carcinoma. Parathyroid
glands sink in normal saline, whereas adipose tissue
floats. However, thyroid tissue as well as lymph nodes
also sink in normal saline.
Access to the Superior Mediastinum
The practical anatomic consideration in reference to
the removal of either a substernal thyroid or a superior
mediastinal lymph node is the fact that usually both
of these procedures can be accomplished through the
suprasternal approach. As far as the lobectomy is con-
cerned, often transection of the thyroid isthmus will
facilitate mobilization of the substernal thyroid lobe as
well as aid in the identification of the recurrent laryn-
geal nerve. It should be emphasized again that the right
recurrent laryngeal nerve on two occasions has been
seen to cross the anterior aspect of the inferior lobe of
the thyroid gland: once with a substernal lobe and the
other with a normal cervical lobe in which the nerve
was anterior to the posterior suspensory ligament. If,
however, adequate mobilization and exposure is not
feasible, and there is concern regarding mediastinal
hemorrhage, the superior mediastinum on one side can
be easily exposed by resection of the medial third of the
ipsilateral clavicle (see Fig. 19-9). When the medial third
of the right clavicle is removed, the innominate artery
and its branches into the subclavian and common carotid
arteries as well as the trachea are well exposed. Expo-
sure of the contralateral side is somewhat limited. With
resection of the medial third of the left clavicle, the
proximal portion of the left common carotid artery is
well visualized and at times so is the proximal portion
of the subclavian artery as well as the trachea. A mid-
line sternotomy is reserved for those patients in whom
there is extensive disease and exposure is necessary
down to and beyond the arch of the aorta. This is not
often necessary in thyroid surgery. Approaches to the
superior mediastinum are detailed (see Chapter 19).
Additional access can be achieved by transection of the
interclavicular ligament along with the fascial bands
just superior and attached to the manubrium. Incisions
in this area must be performed with extreme care,
because the innominate artery and/or the right com-
mon carotid artery may lie superior to the manubrium
above the thoracic inlet.
At times there may be a substernal thyroid com-
pletely independent of the normally located cervical
thyroid gland. Removal may be difficult and fraught
with possible hemorrhage, because the blood supply
may be substernal. An incomplete median sternotomy
not only aids in additional exposure by transecting
the skin and underlying fascia vertically but also facil-
itates a rapid completion of the sternotomy if hemor-
rhage occurs during the suprasternal dissection. This
partial sternotomy is performed via this vertical skin
incision, which transects the cervical fascia down to
the manubrium and transects the outer cortex of the
sternum, leaving the inner cortex intact, using a
sagittal plane saw. The sternotomy can be completed
rapidly if necessary by using a Lebsche knife. Another
approach to the uppermost portion of the superior
mediastinum is attained by removing a portion of the
manubrium. The latter approach is not used by this
author.

In summary, the median sternotomy is useful mainly
for dissection of the anterior mediastinum whereas the
resection of the clavicle is for the posterior mediastinum.
Both of these approaches can be combined in the single
operation if necessary and can likewise be applied to
remove mediastinal parathyroid adenoma, which can be
in the anterior mediastinum or posterior mediastinum
or also just deep to the sternoclavicular junction.
Motor Nerve Supply to the Strap Muscles
Although transection of strap muscles is seldom per-
formed in thyroid surgery, occasionally this does afford
additional exposure, especially in the extremely large
and relatively fixed thyroid lobe. One should not hesi-
tate to transect the strap muscles if necessary. Strap
muscles should be transected high in the neck, because
the motor nerve supply from the ansa hypoglossi enters
these strap muscles inferiorly. If there is evidence that
the thyroid neoplasm has invaded the strap muscles,
these muscles are removed in continuity with the thyroid
gland and, if indicated, neck dissection is performed in
thyroid carcinoma with cervical metastasis.
Thyroglossal Duct Tract
The practical anatomic point of the thyroglossal duct
tract is the location of the pyramidal lobe, which can be
either on the right or the left side of the midline and
extends up as far as the hyoid bone and at times to the
foramen caecum. Ordinarily, in thyroid lobectomy before
the confirmation of thyroid cancer, the pyramidal lobe
mayor may not be removed immediately with the lobe.
If, however, the frozen section discloses carcinoma or
if there is any suspicion of it, then the pyramidal lobe
should be removed. In operations on patients with
Graves' disease the pyramidal lobe is removed. The
pyramidal lobe may be the primary site of carcinoma
and adenoma; carcinoma may likewise arise in a remnant
of the thyroglossal duct tract. A total thyroidectomy
with central node dissection is the choice of this author
(see Fig. 16-11).
Normal Ectopic Thyroid
Normal thyroid tissue has been described, although
rarely within cervical lymph nodes, by Nicastri and
colleagues (1965). These inclusions (disputed by some
pathologists) within the capsule of the lymph node are
interpreted as being histologically benign thyroid tissue
when the follicular cells are normal and limited to the
periphery of the lymph node in a circular or a wedge-
shaped pattern. This occurrence is not to be confused
with the abominable term "lateral aberrant thyroid,"
which is in fact metastatic well-differentiated carcinoma
ENDOCRINE SURGERY
of the thyroid. The term "lateral aberrant thyroid" must
be put to rest permanently.
Normal ectopic thyroid tissue can be the origin of
primary carcinoma of the thyroid. The most common
location for normal ectopic thyroid tissue is at the base
of the tongue; however, it may be located anywhere
along the thyroglossal duct tract extending from the
foramen caecum at the base of the tongue down to the
normal location of the thyroid gland as well as into the
superior mediastinum and the posterior mediastinum
(Myers and Bhatti, 1970). These areas are depicted in
Figure 18-3 as the "solid" indicated areas. Normal thyroid
tissue can likewise be located alongside and completely
detached from either lobe of the thyroid, in the lateral,
superior, or inferior position as well as within the walls
of the trachea and/or esophagus. Other areas have been
described (see Fig. 18-3) (Paloyan and Lawrence, 1981;
Schmidt et aI., 1980) located between the trachea and
the esophagus, behind the esophagus, behind the hypo-
pharynx, and in the mediastinum.
Other areas that are questionable as to whether they
are normal ectopic thyroid or metastatic disease include
positions alongside the thyroid cartilage and hypophar-
ynx and cervical esophagus as well as posterior to the
esophagus and likewise between the esophagus and
the trachea. These areas are depicted by the "stippled"
areas in Figure 18-3. All of these areas are well demon-
strated by post-total thyroidectomy scans using the tech-
nique of Schmidt, utilizing ]31j scan and 99111Tc swallow.
Figure 18-3 has been developed based on our own expe-
rience using Schmidt's technique plus material pub-
lished by Paloyan and Lawrence (1981) and by White
(1974). Paloyan and Lawrence report the very rare
occurrence of thyroid tissue in an ovarian teratoma
(struma ovarii) and, more rarely, associated with thyro-
toxicosis and malignancy with peritoneal metastases.
Adenomas, well-differentiated thyroid cancer, and ana-
plastic carcinoma have all been encountered in rem-
nants of the thyroglossal duct tract.
The technique of Schmidt aids in the decision to insti-
tute post-total thyroidectomy treatment with ]3]1 when
determining whether relatively midline (central cervical
area) functioning thyroid tissue is normal ectopic thyroid
or possibly metastatic or residual thyroid carcinoma.
For example, the base of the tongue and the hypopharynx
are clearly delineated with the 99111Tc swallow combined
with the ]3]1 scan. If the uptake of 13]1 is at the base of
the tongue, it is most likely normal ectopic thyroid, as
shown in the postoperative scans in Figure 18-4.
This is visualized and confirmed in the anterior,
anteroposterior, and lateral positions. Uptake in the
region of the thyroglossal tract is relatively easily ascer-
tained, and this uptake is usually normal ectopic thyroid
tissue. These areas are evaluated approximately 9 months
after the initial examination. If the areas enlarge or the
 ENDOCRINE SURGERY

FIGURE 18-3 Normal ectopic thyroid tissue (solid areas).

'.

Base of
'f';;''''':' tongue
Uptake
:~.,:
':~.t ...
,'.

A
• B c .'
1311
FIGURE 18-4 Postoperative scan after thyroidectomy. Pinhole images with 5 mCi and 21 mCi 99mTc swallow
(technique of Schmidt). A, An anterior pinhole image using only 5 mCi of 1311 after total thyroidectomy for well-
differentiated thyroid carcinoma. The significant uptake is located in the midline well above the sternal notch (SN). It
is not possible to ascertain the uptake in relation to the anterior-posterior dimensions. B, An anterior technetium
swallow using 21 mCi 99mTc with the 5 mCi of 1311 confirming the relationship of the uptake to the hypopharynx.
C, The lateral view with both 1311 and technetium swallow now localizes the uptake area in the thyroglossal duct tract
close to the base of the tongue, indicating that this uptake is probably at or near the base of the tongue and is most
likely normal ectopic thyroid tissue. Any of these areas can be sites of de novo carcinoma or of micrometastases.
(Courtesy of Dr. Kwan Joo, Nuclear Medicine, Sisters of Charity Hospital, Buffalo, New York.)

number increases, then the patient is treated with 1311.
At times these areas disappear, ostensibly owing to
suppression with thyroid hormone. In addition, there
may be isolated portions of thyroid tissue completely
unconnected with either lobe of the thyroid within the
immediate surgical field of the thyroid lobectomy. If
this tissue is encountered, it should be removed at the
initial surgical procedure. The surgeon, however, is
warned that reoperation to remove any of this thyroid
tissue as previously outlined becomes very hazardous
and difficult. Such tissue is best left in situ if in fact a
total thyroidectomy has been performed. This tissue
can be well demonstrated on post-total thyroidectomy
scans using 5 mCi of 131], but it is virtually impossible
to locate these small areas, and reoperation poses immi-
nent danger of injury to the recurrent laryngeal nerve
as well as the parathyroid glands. If need be, these
areas of uptake can be treated with 1311 in doses of 100
to 150 mCi. On the other hand, if total lobectomy has
not been performed then the surgeon may choose to
reoperate, depending on the amount of residual tissue.
One of the unsolved problems with this so-called
normal ectopic thyroid tissue detected in the central
portion of the neck on postoperative scans utilizing
5 mCi of 1311is whether these areas of uptake are in fact
normal thyroid tissue or metastatic thyroid carcinoma.
The corollary problem is whether all such patients
should be treated with radioiodine. Our rule of thumb
is that if the uptake is definitely along the embryologic
course of the development of the thyroid gland (e.g.,
base of the tongue and thyroglossal duct tract), if there
was no metastatic disease in any of the removed nodes
during total thyroidectomy, and if there was no capsular
invasion, bloodstream invasion, or satellite tumor areas
outside the capsule, then we usually do not utilize
radioiodine postoperatively. If these other conditions
are present, we do in fact use postoperative radioiodine
(131 J). If the uptake is in the lateral neck, modified neck
dissection is performed (see Fig. 18-11).
If the uptake is in the mediastinum, then radioiodine
is utilized, depending on the degree of uptake and
whether a superior mediastinal dissection has been per-
formed. If there is significant uptake and a mediastinal
dissection has not been performed, then it is advised to
perform a mediastinal dissection via a median ster-
notomy. If uptake is in the thyroid bed, and the nodes
were positive, or if there is capsular invasion or blood-
stream invasion, or if the uptake exceeds 0.5% to 1.0%,
radioiodine is utilized. The dosages follow the regimen
of Beierwaltes:
1. 150 mCi for significant residual uptake in the thyroid
bed
2. 175 mCi for uptake in cervical nodes (we would first
opt for a modified neck dissection for uptake in the
lateral cervical nodes)
ENDOCRINE SURGERY 903
3. 150 to 200 mCi for distant metastasis
Basic Surgical Technique
(See Fig. 18-9)
The basic surgical procedure of total thyroid lobectomy
begins between the superior thoracic inlet and the infe-
rior thyroid pole for the following reasons:
1. The recurrent laryngeal nerve is located before its
entrance into the surgical field. This identifies the
nerve when it is a single trunk and thus facilitates
identification and preservation of all its branches.
This approach is a great aid in the event that a
nonrecurrent nerve exists.
2. Early evaluation of the blood supply to the parathy-
roid glands can thus be allowed.
3. The external branch of the superior laryngeal nerve
is protected, because the upper pole is removed as
the last step in the lobectomy.
During the initial step in total thyroid lobectomy the
recurrent laryngeal nerve is identified above the supe-
rior thoracic inlet just inferior to the inferior thyroid
pole (see Fig. 18-9G). The inferior pole of the thyroid
gland is then mobilized and rotated upward as the
nerve is followed superiorly. The inferior parathyroid
gland is usually on a plane somewhat more anterior
than the nerve. The thyroid isthmus is then transected
and the relationship of the nerve and/or its branches to
the posterior suspensory ligament is then visualized.
The nerve passes deep to this ligament on its course
into the larynx. In the author's (JML) evaluation of over
934 nerves exposed during thyroidectomy, there have
been two instances in which the recurrent laryngeal
nerve is seen to cross anterior to the inferior pole of the
thyroid lobe and on one occasion was seen to pass
anterior to this ligament. The posterior suspensory liga-
. ment extends from the first and second tracheal rings
and the cricoid cartilage to the posteromedial aspect
of the thyroid lobe. More anteriorly and superiorly is
located the anterior suspensory ligament (thickening of
the pretracheal fascia), which is transected along the
dotted line (see Fig. 18-9G). The relationships of the
inferior thyroid artery and its branches to the recurrent
laryngeal nerve and its branches are so varied that the
artery cannot be used as a reliable surgical landmark.
The posterior suspensory ligament fixes the thyroid
lobe to the first and second rings of the trachea and the
cricoid cartilage. Deep to the ligament is seen the recur-
rent laryngeal nerve and two branches (see Fig. 18-9KI).
Along the inferior edge of the ligament is a small branch
of inferior thyroid artery, probably the inferior laryn-
geal artery. This vessel may be either lateral or medial
to the nerve. It is at this site where numerous veins
 ENDOCRINE SURGERY
may also be located. This is one of the most critical
areas in total thyroid lobectomy. If bleeding occurs, it
is best controlled by gentle pressure with a cottonoid
sponge. After the bleeding is adequately controlled, the
vessel may then be clamped, with the recurrent laryn-
geal nerve and/or its branches in full view. Blind clamp-
ing must be avoided, because injury to the recurrent
nerve may ensue.
Another approach to this critical area is lateral (see
Fig. 18-12E). This recurrent laryngeal nerve has first been
identified inferiorly and traced superiorly. The superior
thyroid vessels have been ligated, and the thyroid lobe
has been reflected medially. This exposes the lateral
portion or leaf of the posterior suspensory ligament,
which mayor may not be present. With a small Mixter
clamp stretching the ligament, this portion of it is tran-
sected along the dotted line. This approach is specifi-
cally used in total thyroidectomy when the isthmus is
not transected as in known or highly suspicious carci-
noma. It may also be preferred in total lobectomy when
the previously described medial approach affords limited
exposure to the vessels associated with the ligament.
The main portion of the posterior suspensory liga-
ment along with the recurrent nerve and its branches
are in full view (see Fig. 18-12F). Any vessels asso-
ciated with the ligament are ligated, and the ligament
is transected, freeing the thyroid lobe from the trachea
and cricoid cartilage.
If the recurrent laryngeal nerve cannot be identified
inferior to the inferior pole of the thyroid near the
tracheoesophageal sulcus, several other approaches can
be utilized, all from a combined inferior approach.
I. Careful separation of the gland from the trachea from
below upward. Blunt dissection is preferable; how-
ever, occasionally sharp dissection is necessary. This
is done very meticulously. The depth of this dissec-
tion must be limited to a maximum of 1.2 to 1.5 cm,
with less distance as the dissection proceeds supe-
riorly. The nerve may be entrapped in fascia and
desmoplastic reaction between the gland, its true
capsule, and the trachea. If this does not facilitate
exposure, then:
2. With the inferior pole carefully mobilized for 1 or 2 cm
superiorly and retracted superiorly and medially, the
deep aspect of the gland is exposed and the nerve is
sought. The nerve may be located somewhat medial
to the tracheoesophageal sulcus to 1 to 1.5 cm. The
area may be enveloped by fibrous tissue, adhesions,
and lymph nodes. This dissection can be extended
superiorly to a level of posterior suspensory ligament
if necessary. Under no circumstances is any struc-
ture crossing in a vertical plane sacrificed. Especially
in Hashimoto's thyroiditis, desmoplastic tissue can
encompass the nerve. At times the nerve can be
identified inferiorly and pass through this fibrous
tissue and be exposed more superiorly. Do not try
to skeletonize the nerve. Use slow and meticulous
dissection. The inferior parathyroid gland is usually
anterior to the level of the recurrent laryngeal nerve,
whereas the superior parathyroid gland is usually
posterior to the nerve but can be medial or lateral.
In summary, of these practical anatomic considera-
tions, one of the most important is the relationship of
the posterior suspensory ligament of the thyroid to the
recurrent laryngeal nerve and the vessels associated
with this ligament. It is important for the surgeon to
recognize this anatomic relationship, which is little dis-
cussed in current anatomic and operative texts. These
important relationships are depicted in Figures 18-2A,
18-91 to 0, and 18-12E to H.
Definition of Terms
Total thyroidectomy-the entire gland and the pyramidal
lobe are resected, with removal of all thyroid tissue
deep and posterior to the posterior suspensory liga-
ment of the thyroid and any grossly identifiable thyroid
tissue that is extracapsular. Preservation of the exter-
nal branch of the superior laryngeal nerve, the recur-
rent laryngeal nerve when not directly involved, and
the parathyroid glands as well as the thymus gland is
undertaken, because parathyroid tissue may be embed-
ded in the thymus. The surgical specimen is carefully
searched for any parathyroid glands not identified in
the surgical field.
Modified radical neck dissection (see pp. 950 to 954)-
this allows for preservation of the sternocleidomastoid
muscle and the spinal accessory nerve, with removal
of the ipsilateral internal jugular vein, and usually
preservation of the internal jugular vein on the con-
tralateral side when contralateral neck dissection is
indicated. Other modifications may involve preserva-
tion of the contents of the submandibular triangle-
one report indicates 3 % incidence of metastasis in
this area-and variations relative to the internal jugu-
lar veins (see 18-11A to Al).
Classic radical neck dissection-this procedure includes
resection of the sternocleidomastoid muscle with the
internal jugular vein, associated lymph nodes, sub-
mandibular triangle, tail of the parotid gland, spinal
accessory nerve, and associated lymph nodes. Never-
theless, the spinal accessory nerve may be preserved.
Superior mediastinal node dissection-this involves
removal of the nodes inferiorly until the lowest node
is negative and/or to the level of the arch of the
aorta. The approach is as follows:
1. Suprasternal approach with or without transection
of the interclavicular ligament and fascia

2. Resection of the medial third of the clavicle on the
ipsilateral side
3. Median sternotomy
4. Resection of portion of the manubrium
Central neck dissection-this term has been used in
relation to total thyroidectomy for MCT as the basic
minimal operation for this type of carcinoma. Actually,
it includes pretracheal and paratracheallymph nodes,
tracheoesophageal nodes, cricothyroid node (delphian),
top superior mediastinal nodes to the innominate
vessels, and possibly the submental nodes but at least
to the level of the hyoid bone. In other words, it
includes all the nodal-bearing tissue between both
carotid sheaths that we actually remove in the mini-
mal operation of total thyroidectomy in patients with
any type of thyroid carcinoma. The submental nodes
in this latter situation are not removed. If positive
nodes are encountered in the jugular chain, then a
radical neck dissection is performed-classic in
medullary, anaplastic, and squamous cell carcinoma
and modified in well-differentiated carcinoma-unless
there is muscle invasion or previous violation of the
neck, mitigating a modified neck dissection.
Capsule of the thyroid gland-there is virtually always
an obvious true capsule of the gland, which is closely
contiguous with the parenchyma of the gland. How-
ever, fascia and "capsules" have been described that
mayor may not envelop the gland and its true cap-
sule. The anatomic description in various texts and
articles and this author's (JML) experience lead to
the conclusion that this secondary thyroid capsule
and fascia varies in thickness, location, and, worse,
its relationship to the recurrent laryngeal nerve. There
is no agreement-it obviously varies, sometimes seen
and sometimes not readily seen. It is no firm surgical
landmark except in the rare situation.
Evaluation of Laryngeal Nerve
Function
Preoperative laryngoscopy is a sine qua non for thyroid
surgery as well as the complete head and neck exam-
ination. After thyroidectomy, when the patient is fully
reactive, the vocal cords are examined using a flexible
optical nasolaryngoscope passed through a nostril
sprayed with topical 4% lidocaine (Xylocaine) or tetra-
caine (Pontocaine) (see Chapter 4). In this way, an
accurate evaluation of vocal cord function is obtained,
noting whether the vocal cord is fully mobile (recurrent
nerve) and straight (external branch superior nerve).
Direct laryngoscopy while the patient is still under
anesthesia is not recommended or believed to be valid
for evaluation of vocal cord function. If the vocal cord
ENDOCRINE SURGERY
is immobile, the recurrent laryngeal nerve is paralyzed.
The paralysis is temporary if the surgeon is certain that
the nerve has been identified and preserved. On the
other hand, if he or she has reason to believe that the
nerve has been damaged, or has not been identified,
then re-exploration is justified and believed indicated,
especially in the latter circumstance. Both recurrent
laryngeal nerves have been seen caught in ligatures
when another surgeon ligated the inferior thyroid arter-
ies. The ligatures were freed immediately and even-
tually there was return of function of both vocal cords.
Because there was bilateral abductor vocal cord paral-
ysis, a tracheostomy was performed. If the nerve has
been transect ed, there is difference of opinion regard-
ing reanastomosis and whether it is worthwhile. At
this time, reanastomosis is advised despite the fact that
this repair has not been successful in most surgeons'
hands, although some have reported return of function
(Gordon and McCabe, 1968). Sutures of 8-0 or 10-0
nylon are utilized with the aid of the microscope for
reanastomosis.
There have been three recurrent nerves reanasto-
mosed in our series in the past 25 years, two at the time
of the thyroidectomy and one after emergency tra-
cheostomy performed by another surgeon under dire
circumstances. There has been no return of function in
any of these four patients. The three patients who had
thyroid surgery had no hoarseness whatsoever. This
emphasizes the importance of postoperative as well as
preoperative laryngoscopy to evaluate the presence or
absence of vocal cord dysfunction. The overall perma-
nent paralysis of the preoperative normally functioning
recurrent laryngeal nerve in the author's consecutive
series of 934 nerves placed in jeopardy is 0.6%. Tempo-
rary paralysis using a corticosteroid regimen is 3 %.
Before using the corticosteroid regimen, the temporary
vocal cord paralysis was 9% (P < .008). This steroid
regimen, which is used in all patients undergoing thy-
roidectomy, consists of methylprednisolone preopera-
tively and at times repeated during the surgery if excess
edema, fibrosis, or difficult exposure of the recurrent
nerve is encountered. A Medrol Dosepak is continued
during the postoperative period.
If a patient exhibits signs of severe hypoparathy-
roidism in the immediate postoperative period, a deci-
sion should be made regarding the continued use of
corticosteroids, because steroids are known antago-
nists to PTH. There were two patients with temporary
paralysis of the external branch of the superior laryn-
geal nerve; however, neither of these was permanent.
There were no complications related to the use of
corticosteroids, except for the possible temporary effect
on parathyroid function. The magnesium level, which
if low can depress calcium level, should also be
checked.
 ENDOCRINE SURGERY
Of the three patients with permanent paralysis of
the recurrent laryngeal nerve after thyroidectomy (one
total thyroidectomy; one total thyroid lobectomy), one
patient's recurrent laryngeal nerve, although identified,
was very small and crossed anterior to the inferior pole
of the gland. Because a larger nerve posterior to the
inferior pole was believed to be the recurrent laryngeal
nerve, the smaller nerve was sacrificed, because it
complicated the dissection and ligation of branches of
the inferior thyroid artery. In the other patient, the
recurrent laryngeal nerve was accidentally transected
during total thyroidectomy for Graves' disease. The third
patient underwent a total thyroidectomy for Hashimoto's
disease. The nerve was identified inferiorly and supe-
riorly. The midportion was entrapped in desmoplastic
tissue and transected at this site. The nerve was re-
anastomosed. There was no nerve function; however,
the vocal cord was straight and firm. The patient had
an excellent voice, the only problem being that later
with excessive talking it became weak. There appears
to be some evidence that immediate anastomosis of
the recurrent laryngeal nerve may aid in an improved
glottic approximation and firmness of the vocal cord,
which in turn aids in good speech without hoarseness.
The nerve was in an abnormal position, crossing anterior
to the posterior suspensory ligament (Gruber, Henle,
Berry). There was limited exposure and considerable
edema associated with Graves' disease. There appears
to be some evidence that immediate anastomosis of the
recurrent laryngeal nerve may aid in an improved
glottic approximation and firmness of the vocal cord,
which in turn aids in good speech without hoarseness.
Hence, the surgeon must take time for adequate expo-
sure and, again, must not sacrifice any nerve in the sur-
gical field regardless of its position. The cord paralysis
in these patients was asymptomatic and was only veri-
fied by laryngoscopy. In both patients immediate neuror-
rhaphy was performed, without success.
If a vocal cord is bowed and at times in a slightly
lower plane than the normal vocal cord, the external
branch of the superior laryngeal nerve is paralyzed.
Unlike paralysis of the recurrent laryngeal nerve, in
which there mayor may not be hoarseness, depending
on the compensatory action of the normal vocal cord,
paralysis of this external branch is almost always asso-
ciated with hoarseness, because no compensation by
the normal vocal cord is possible. We have had no
patients with total permanent paralysis of the external
branch of the superior laryngeal nerve. Only two
patients have had temporary paralysis, and these had it
before the use of a corticosteroid regimen, and there
was no type of paralysis after the use of a steroid
regimen. Teflon injection (see Fig. 20-7) into the bowed
vocal cord will usually correct this complication if it is
permanent.
There is little doubt that operations on patients with
Graves' disease and Hashimoto's thyroiditis place the
laryngeal nerve in greater jeopardy when edema and/
or fibrosis is present. Nevertheless, in the analysis of
our data, there does not appear to be a significant
statistical increase of paralysis in these diseases. This
may be due to the extra care taken by the surgeon when
edema and/or fibrosis is present.
With patients in whom a total thyroidectomy is
planned, if exposure of the recurrent laryngeal nerve is
extremely difficult and there is question as to its func-
tion, the patient can be awakened before the other
thyroid lobe is resected. After the patient is awakened,
with the endotracheal removed and able to phonate,
optical flexible laryngoscopy is performed. If the vocal
cord is immobile, it is better to stage the completion of
the total thyroidectomy. For information about treatment
of the parathyroid glands, see the section on blood
supply and location of ectopic parathyroid glands (see
Fig. 18-14A to D). Also see the discussion relative to
hypoparathyroidism after total thyroidectomy (p. 908).
Arytenoid Dislocation
Sataloff (1997) provided the following information:
Arytenoid dislocation is characterized by impaired
mobility of the vocal cord. This must be differentiated
from vocal cord paralysis, which obviously could be
related to the thyroid surgery, and also from arytenoid
fixation, which might occur in severe rheumatoid arthri-
tis. This latter problem would be seen on preoperative
laryngoscopy. Stroboscopy or recorded optical laryn-
goscopy on video formalized the diagnoses. The two
types of arytenoid dislocation include:
1. Posterior dislocation-the vocal process of the ary-
tenoid along and the vocal cord are higher on the
dislocated side.
2. Anterior dislocation-the vocal process of the ary-
tenoid and the vocal cord are lower on the dislo-
cated side.
In either type, the affected vocal cord may have slug-
gish motion or be entirely immobile, causing initially
significant hoarseness.
Reduction is ideally performed as soon as practical
after the dislocation. In posterior dislocation a Miller-3
laryngoscope blade is placed in the pyriform sinus with
its rolled tip in the dislocated joint. Then anteromedial
lifting motion is applied. Considerable force may be
necessary to reduce the dislocation. In anterior disloca-
tion reduction is done with the tip of a Hollinger laryn-
goscope. We have encountered arytenoid dislocation in
one patient.

Management of Thyroid Cancer
Total Thyroidectomy Versus Subtotal
Thyroidectomy or Lobectomy
The basic principle in the management of well-differen-
tiated thyroid cancer, as practiced by this author (JML) ,
is surgical resection of all neoplastic disease as well as
normal thyroid tissue commensurate with reasonable
ablative surgery, low morbidity, and virtually zero mor-
tality. This principle applies to papillary, follicular, and
medullary carcinoma as well as Hiirthle cell carcinoma
of the thyroid and, when resectable, anaplastic and
squamous cell carcinoma of the thyroid. This minimizes
the competition of surgically resectable normal thyroid
tissue in well-differentiated thyroid cancer from the
future uptake of radioiodine by nonresectable disease
(e.g., metastasis to bone or lungs) or other distant
metastases as well as local invasion of the trachea and/
or the larynx. Laryngectomy, partial or total, is only indi-
cated when treatment with 1311 has failed. The nonre-
sectable disease is managed by the use of 131I, external
radiation when there is no significant uptake of the 1311,
and postoperative chemotherapy when surgery and radi-
ation therapy have failed. Chemotherapy with doxoru-
bicin has been encouraging in one patient with invasion
into the right atrium. All patients are given thyroid
hormone at doses that achieve adequate suppression of
their TSH levels. The question of what degree of TSH
suppression is optional for the long-term management
of thyroid cancer remains unanswered. It is fairly well
recognized that oversuppression with excess exognosis
thyroid hormone increases the risk of osteoporosis and
cardiac complications.
The author prefers total thyroidectomy to totallobec-
tomy for any patient exposed to radiotherapy who has
a thyroid abnormality that histologically proves to be
benign. Total thyroidectomy obviates possible future
reoperation. Nonpalpable disease, which may be or
may become carcinoma, can be present in the opposite
lobe.
The objectives of total thyroidectomy are:
1. To remove intraglandular metastases and/or multi-
centric disease when these are present but may be
clinically undetectable
2. To aid in evaluation of nonpalpable and/or clinically
undetectable extraglandular metastatic disease with
postoperative scanning using 3 to 5 mCi of 131] (e.g.,
detection of early pulmonary metastases when chest
radiograph is normal)
3. To direct the therapeutic dose of 1311 to the metastatic
nonresectable disease or to structures that might be
spared (e.g., invasion of the larynx and/or significant
invasion of the trachea). If these lesions do not respond
to the 131] treatment, extended surgery is then possible.
ENDOCRINE SURGERY
4. To avoid possible 131[ treatment in patients who have
had only a lobectomy
5. To remove the focus of anaplastic carcinoma, if pres-
ent, or the possibility of residual well-differentiated
carcinoma that may convert to anaplastic carci-
noma
6. To aid in the prevention of recurrence
Nevertheless, many surgeons and endocrinologists
do not subscribe to total thyroidectomy in the treat-
ment of primarily papillary as well as follicular thyroid
carcinoma. They also do not believe that postoperative
scans and treatment with 131] are indicated. This is
based primarily on the high complication rate of total
thyroidectomy by some surgeons and the doubts regard-
ing the efficacy of 1311 in the treatment of this disease,
which is believed by some not to be very lethal. Baker
and Hyland (1985) and others have reported a lower
incidence of recurrent laryngeal paralysis in patients
having had total thyroidectomies as compared with a
lesser procedure. They ascribe this to the skill of the
surgeon. Fortunately, the incidence of thyroid cancer is
relatively low: 2 to 3.8 cases/lOO,OOO in women and 1.2
to 2.6 cases/lOO,OOO in men (Nagataki and Nystrom,
2002). Because the current forms of therapy are so
successful, with as much as a 90 % success rate, there
are significant survival rates over several decades. Thus,
there is a substantial magnitude of the prevalence of
the disease in the population because of this phenome-
non. Although statistically the rate of treatment failure
is not high, clinical cure and long-term survival should
be the objective whenever possible. It appears from the
current evidence that the management of this disease
as described forthwith will reduce the case-fatality rate.
One difficulty in the evaluation of results is the lack of
randomized studies but more so is the long natural
history of the disease. The surgeon and endocrinologist
who perform the operation are more likely to die before
the young 20-year-old patient whose recurrence may
not appear until some 25 years later. This is not to
imply that the young patient is guaranteed 25 years of
life free of disease; death can also occur in the young
adult within 2 to 3 years of the initial diagnosis.
The problems related to anything less than total
thyroidectomy revolve around the fact that with a
significant portion of thyroid tissue remaining the
ablation of the remaining normal thyroid tissue with
131] may in fact take months, and its ablation may not
be achieved at all. This situation then reduces the
uptake of 131I in the areas of metastatic disease that are
nonresectable. Anaplastic, squamous cell, and medullary
carcinoma and pure papillary tall cell carcinoma typi-
cally do not take up 1311. Hiirthle cell carcinoma may
or may not take up 1311. Some Hiirthle cell carcinomas
take up 1311 quite well, but most do so poorly (w. H.
Beierwaltes, personal communication). Another prob-
 ENDOCRINE SURGERY
lem is that even though the primary tumor may con-
centrate radioactive iodine, the metastatic lesion may
not and vice versa.
Unfortunately, in well-differentiated tumors with a
minimal amount of follicles there may be no uptake
of 131 I, such as in pure papillary carcinoma. In addition,
if there has been metaplasia to anaplastic carcinoma.
the tumor either at the primary site or at the metastatic
lesion will not take up 1311. External radiation may inter-
fere with 1311 uptake depending on the dose of external
radiation.
Another problem related to less than total thyroidec-
tomy is that larger doses of 131] will be necessary over
longer periods of time, and, finally, the surgeon may be
faced with the problem of a secondary operation. This
is extremely difficult and hazardous to both the external
branch of the superior laryngeal nerve and the recur-
rent laryngeal nerve as well as to preservation of the
parathyroid glands.
Objections to total thyroidectomy are based on three
considerations: nerve paralysis, hypoparathyroidism. and
hormonal replacement. Hormonal replacement will be
necessary regardless of whether a total thyroidectomy
is performed or something less than total thyroidectomy.
External beam radiotherapy is used when the other
methods of management have failed or as adjunctive
treatment. At times, significant favorable responses
have occurred. Wilford and associates (1991) noted
that it is very important to design the ports to include
surrounding areas beyond the obvious disease. There
are other articles in the literature that support their
concept, and we have experienced similar very favor-
able results.
Nerve Paralysis
The incidence of permanent nerve paralysis, whether it
is the external branch of the superior laryngeal nerve or
the recurrent laryngeal nerve, should range from 0.5%
to 2 %. To minimize the injury to the external branch of
the superior laryngeal nerve. it is recommended that
this portion of the dissection be performed near the
termination of the surgical procedure in which the
superior pole vessels are carefully skeletonized and that
a no clamp technique be utilized. To minimize injury to
the recurrent laryngeal nerve, this nerve is identified at
the onset of the operation near the superior thoracic
inlet and is followed superiorly, with identification of
various branches in the process of the dissection, and
with the realization of the importance of the posterior
suspensory ligament of the thyroid, behind which the
recurrent nerve passes. Because of the possibility of a
nonrecurrent nerve or the possibility of other anasto-
motic branches of the recurrent nerve, all nerve struc-
tures in the bed of the thyroid must be preserved (Lore
et aI., 1977).
Hypoparathyroidism
The incidence of permanent, severe hypoparathyroidism
should be no more than 3 %. Minor aberrations are
usually easily managed by the ingestion of 2 to 12 g of
calcium carbonate or 1 to 3 tablespoons of calcium
glubionate three times a day. Calcium carbonate is not
suitable in patients with hypochlorhydria or achlorhy-
dria. The addition of 50,000 to 150,000 units of vitamin
O2 or 03 may be required. If symptoms are more pro-
nounced, faster-acting 1,25-dihydroxycholecalciferol
(Rocaltrol, 0.25 fig) can be used.
During the surgical procedure, the identification of
the parathyroid glands (the inferior glands are usually
on a slightly more anterior level than the recurrent
laryngeal nerve, whereas the superior glands are more
likely to be posterior) is an essential part of total thy-
roidectomy. If at all possible, the blood supply to the
parathyroid glands is preserved. If the glands are not all
identified in the surgical bed. then the surgical speci-
men is very carefully scrutinized and examined in the
surgical field and a search made for any adjacent or
subcapsular parathyroid glands. Fissures in the thyroid
gland are scrutinized. The glands may be black or normal
caramel color and are usually oblong or flattened if
subcapsular. Bowen (personal communication) washes
the thyroid specimen in saline and searches for parathy-
roid tissue with the microscope. The saline wash empha-
sizes the typical parathyroid color.
These glands, when recovered, are embedded in the
base of the sternocleidomastoid muscle in the smallest
possible sections (about 1 mm). Their location is marked
with a titanium clip or a black silk tie, and an appro-
priate designation is placed on the patient's chart, with
a copy also given to the patient. If it is necessary to
confirm histologically that the tissue is, in fact, para-
thyroid gland that can be left in situ, then a small sliver
is removed for microscopic examination. This sliver is
removed in such a fashion that the blood supply to the
tissue in question is not interrupted, if in fact it is
normal parathyroid gland. A metal clip may be used to
obtain this small sliver and also serves as a marker
(Clark, 1985).
Of 66 consecutive patients evaluated having total
thyroidectomy, 28 patients (42%) had significant signs
and/or symptoms of hypocalcemia during the imme-
diate postoperative period. Their chief complaints were
tingling of the fingertips or circumoral area and leg
cramps. One patient had nausea and vomiting for 2 days.
No frank tetany was experienced. The remaining 38
patients (58%) were asymptomatic. Of the 28 patients
(42%) with postoperative hypocalcemia, 26 patients
(39%) proved to have only temporary hypocalcemia.
The remaining two patients (3 %) have had varying
forms of signs and symptoms of hypocalcemia or hypo-
parathyroidism. One had mild intermittent symptoms,

and one patient had moderate symptoms and more or
less continuous symptoms. No patient has had severe
permanent symptoms if taking adequate supplements
of calcium and vitamin D.
This series of patients included those in whom refined
technical skills were developed. The techniques included
the following:
• Extra care in the identification of the parathyroids
• Preservation of blood supply to the parathyroids
• Search for parathyroids in the surgical specimen
• Extra care in the autotransplantation of parathyroids
that require reimplantation
In a small number of patients who require total thy-
roidectomy and unilateral neck dissection with massive
disease, large doses of calcium and vitamin ° may be
necessary to maintain a normal serum calcium concen-
tration. The routine use of corticosteroids to reduce the
incidence of temporary vocal cord paralysis predis-
poses to temporary hypocalcemia and also can aggra-
vate hyperglycemia. Magnesium deficiency can also
predispose to hypocalcemia.
Potential Problems in Management
• Overtreatment with calcium and vitamin O2
• Poor patient compliance
The evaluation of these statistics is somewhat diffi-
cult, because the signs and symptoms of hypocalcemia
were transient in two of the patients. Thus, it appears
that the incidence of permanent continuous hypopara-
thyroidism is 1 in 66 patients, or 1.5 %. On the other
hand, if these two patients are considered to have perma-
nent hypoparathyroidism, the incidence would be 3%.
It should be noted that both of these patients are female.
Of the total 66 patients, no patient has had hypocal-
cemia associated with persistent severe symptoms. The
therapy for this condition is reasonably simple. Thus,
it is our opinion that permanent hypoparathyroidism
requiring treatment after total thyroidectomy has a low
and acceptable incidence, is relatively easily managed,
and is not a significant deterrent to total thyroidectomy.
In addition to thyroid surgery, other procedures in
the head and neck can result in hypoparathyroidism
(e.g., parathyroid surgery alone or thyroidectomy com-
bined with total laryngectomy). Symptoms of hypocal-
cemia or ones simulating hypocalcemia can also occur
after surgery not related to the head and neck, such as
cholecystectomy. Differentiation from symptoms of low
magnesium levels is relevant, because symptoms of
hypomagnesemia can simulate those of hypocalcemia.
The clinical findings of muscular aches, paresthesias,
and carpopedal spasm (Trousseau's sign), facial irri-
tability elicited by a slight tap over the main trunk of
ENDOCRINE SURGERY
the seventh cranial nerve (Chvostek's sign), and increased
neuromuscular excitability to galvanic and frequently
faradic current (Erb's sign) usually occur within the first
postoperative week in the hypoparathyroid patient.
Severe symptoms of acute psychosis and respiratory
complaints may be early or late. The late sequelae are
cataracts, convulsive seizures, and mental deteriora-
tion. None of these symptoms has occurred in these 66
patients in our review.
The signs and/or symptoms do not always correlate
with the laboratory test results; for example, patients can
have a serum calcium concentration of 6 to 7 mg;ctL
and yet be asymptomatic, whereas those with normal
calcium levels can show either mild symptoms and/or
signs. Ionized calcium levels are more accurate than
the total serum calcium levels. Hence, protein levels are
considered by some clinicians as an important corol-
lary to total serum calcium level determinations. At the
present time, our inclination is to treat patients with
mild or even moderate signs and/or symptoms very
conservatively, usually with only oral calcium (calcium
carbonate, one to two 0.5-g tablets three times a day or
calcium glubionate [Neo-Calglucon] 1 to 3 tablespoons
three times a day).' If the signs and/or symptoms are
severe, then 10 mL of 10% calcium gluconate is admin-
istered intravenously slowly as a bolus, and additional
calcium gluconate is placed in an intravenous line if
necessary. Calcium given intravenously must be given
with extreme caution in patients on digitalis.
Electrocardiographic (ECG) monitoring may be indi-
cated, because arrhythmias may occur. If severe signs
and/or symptoms appear to persist, dihydrotachysterol
is administered orally in doses ranging from 0.125 to
0.4 mg twice daily (maximal dose: 1.5 mg), whereas
vitamin O2 is begun at 50,000 units twice daily plus up
to 1.5 to 2 g of elemental calcium per day. The dihydro-
tachysterol is discontinued gradually over 1 to 4 days or
as long as 10 days, whereas the vitamin O2 is continued.
First the vitamin D2 and then the calcium supplement
is gradually decreased, depending on the signs and/or
symptoms and the serum calcium levels. Rocaltrol, or
1,25-dihydroxyvitamin 0, may be preferable to the
dihydrotachysterol in the acute postoperative phase in
which patients are symptomatic because it is the active
metabolite of vitamin D, thus having a fast onset of
action. The alternative, longer-acting vitamin D prepa-
rations should be considered for chronic treatment of
persistent hypoparathyroidism in terms of cost effec-
tiveness. Overtreatment is to be avoided as well as
indiscriminate continuation of treatment, because it is
believed that this will suppress PTH production, ass um-
'One gram of elemental calcium is contained in II g of calcium
gluconate. Regular TUMS (calcium carbonate, 0.5-g tablets) contain
0.2 g of elemental calcium per tablet, and 5 mL of Neo·Calglucon
contains 115 mg of elemental calcium.
 ENDOCRINE SURGERY
ing that some parathyroid tissue remains. In any event,
surveillance is necessary based on both the clinical
situation and the laboratory test results.
Serum calcium levels should be obtained daily in the
immediate postoperative period or in the event of
development of symptoms of hypocalcemia. If the
patient requires treatment, weekly, bimonthly, or monthly
levels of serum calcium are obtained while the patient
is gradually weaned off supplements.
It is important that an accurate assessment of signs
and/or symptoms be made, especially in relation to the
preoperative status of the patient as well as other
concomitant disease, such as Paget's disease. Often,
adult females will have had signs and/or symptoms for
some years before surgery and will have been taking
supplemental calcium.
Measurement of intact PTH levels is reserved for
those patients who have had persistent signs and/or
symptoms beyond several months. These levels must
be correlated with current medication, and it is best to
discontinue medication before obtaining PTH levels up
until the signs and/or symptoms return. At times the
relationship of signs and/or symptoms to calcium and
PTH levels seemingly defies explanation. Although the
literature has many references to the difficulty of
managing hypoparathyroidism, this has not been our
experience.
Paloyan and Lawrence state: "It should be pointed
out that following thyroidectomy for Graves' disease,
that hypocalcemia may occur regardless as to whether
or not the parathyroid glands have been preserved.
This is a result of rapid accretion of calcium back into
bone-the hungry bone syndrome-because many
patients with Graves' disease are osteoporotic. Their
serum phosphorus level is usually normal or low, and
the parathyroid function is normal."
The author (JML) has treated a teenager with Graves'
disease by performing a total thyroidectomy with preser-
vation of the parathyroid glands in whom moderate
to severe early signs of hypocalcemia occurred. This
patient, treated vigorously with supplemental calcium
of up to 15 g a day, suddenly developed nausea and
vomiting with a serum calcium level of 15 mg/dL.
Treatment consisted of discontinuation of all calcium
and all forms of vitamin 02 and intravenous fluids. Such
resulting hypercalcemia may shorten the QT interval on
the ECG and may well be associated with myocardial
irritability and digitalis sensitivity. Rocaltrol (calcitriol;
1,25-dihydroxycholecalciferol) has a short half-life,
reducing the risk of hypercalcemia if it does occur. This
patient responded to intravenous fluids, and the symp-
toms and hypercalcemia disappeared within 2 to 3 days.
In such patients, there may be hypophosphatemia and
hyperphosphaturia. This complication of hypercalcemia
has never been noted in patients who have had Iotal
thyroidectomy for thyroid carcinoma.
Thus, hypercalcemia can be a significant complica-
tion of overdose of calcium and is thus characterized
by nausea, vomiting, anorexia, polyuria, polydipsia, and
possibly cardiac arrhythmias and, questionably, renal
calculi. Hypertension with a very confused state and
symptoms simulating meningeal irritation has been
observed in one patient. Cataracts are late sequelae of
hypocalcemia.
Hormonal Replacement
All patients with well-differentiated thyroid cancer,
regardless of the type of surgery performed, are main-
tained on a dosage of thyroid hormone that achieves
and maintains adequate suppression of TSH. The specific
type of hormonal replacement and dose in which it is
administered depends on a number of factors, not the
least of which is patient tolerance. Table 18-1 presents
information on desiccated thyroid, levothyroxine
(Synthroid), and liothyronine (Cytomel, synthetic
triiodothyronine [T3]) for total thyroidectomy patients.
Comorbidities, such as underlying cardiac disease, are
also important considerations. Synthetic levothyroxine
is usually the preferred pharmaceutical. Liothyronine is
usually reserved for use during the period before and/
or after the performance of 131 I surveillance scans. The
short half-life of liothyronine provides the advantage
when following patients to continue some form of thy-
roid hormone replacement until shortly before the scan,
thereby reducing the time that patients are symptomatic
from low thyroid hormone levels. Liothyronine needs
to be prescribed with caution and should usually be
avoided in patients who are elderly or have underlying
cardiac disease. Because liothyronine is T3' it is asso-
ciated with very low serum thyroxine (T4) levels in a
euthyroid patient, a picture that is sometimes confusing.
Extended periods of 4 to 6 months without thyroid
hormone are to be avoided, because cardiomyopathy
can occur. If the period is extended, this can be life
threatening. Therefore, the patient is warned about not
discontinuing thyroid hormone replacement except when
postoperative 131I scans are indicated, and then discon-
tinuance is only done under the care of a physician.
Additional Evidence Supporting Total
Thyroidectomy
To further support the concept of total thyroidectomy
and the management of thyroid carcinoma, Beierwaltes
(1983) is quoted from his discussion of total thyroidec-
tomy versus subtotal thyroidectomy:
There is general agreement that the risks of total
versus subtotal thyroidectomy are dependent upon
the skill and experience of the surgeon. We agree
that the risks of a true total thyroidectomy for
 ENDOCRINE SURGERY

TABLE 18-1 Thyroid Replacement (Comparable Dose Resume)

Thyroid, U.S.P. Synthroid (L-Thyroxine, T4) Cytomel (1fiiodothyronine, T,)

Potency 1/1000 as potent as T. 1 Five times as potent as T.

Equivalent dosages 1 grain (65 mg) 6511g 13 lIg
2 grains (130 mg) 130llg 2611g
3 grains (l95 mg) 19511g 3911g
Onset of action 1 day Begins in several days Several hours
Maximal effect 10 to 14 days 10 days 3 to 4 days
Duration 3 to 4 weeks 3 to 4 weeks 10 days

1. Desiccated thyroid. U.S.P., is powdered, dried thyroid gland obtained from cattle or pigs. It is a crude extract-not synthesized-and
therefore, it is not exactly standardized like a synthetic chemical compound (e.g., Synthroid or Cytomel). Because of its variable biologic
activity, authorities question its use. Goodman and Gilman state, however, that "the potency is sufficiently standard that variation cannot
be detected clinically if the official preparation is prescribed." The author prefers the Armour brand.
2.Synthroid [levothyroxine, T.) is better absorbed than racemic thyroxine and may be given PO, IV, or 1M. Intravenous "works" within 24
hours; PO takes days to weeks. The proportion of a single oral dose absorbed may vary from 42% to 74%. The rest is excreted. Daily
maintenance is 2.2 ).lg/kg.
3. Cytomel (T,) is available in 5- and 25-).lgtablets. It is effective within days; hence caution should be exercised.
In the treatment of myxedema, T, may be given in an initial dose of 5 ).lg.Care should be taken with this medication in the presence of
cardiac disease and it is best avoided, especially in older patients.

proven thyroid cancer by an inexperienced surgeon
are unnecessary. We also believe that the risks are
unnecessary for a total thyroidectomy in a child for
the treatment of Graves' disease by an inexperienced
surgeon. However, we also believe the solution to the
problem is not inadequate surgery followed by 1311
ablation of uptake in the remnant for several
reasons:
1. Adequate surgery is more effective than 131[ in
removing the primary cancer. The most common
cause of death from thyroid carcinoma is
invasion of the structures of the superior thoracic
inlet. We have reviewed the literature showing
that the death rates are lower after adequate
surgery at the primary operation.
2. Total surgical thyroidectomy may remove thyroid
cancer that does not concentrate 1311. Leeper has
reported an alarming death rate from anaplastic
transformation of well-differentiated thyroid
cancer in patients not having a total surgical
thyroidectomy.
3. There is a lower recurrence rate after total
surgical thyroidectomy than after subtotal
thyroidectomy. Recurrence of well-differentiated
thyroid cancer after subtotal thyroidectomy has
been found to be twice as common as after
bilateral total thyroidectomy.
4. Recurrences after inadequate surgery result in a
higher surgical morbidity from further surgeries
and a 19% to 25% incidence of metastases that
do not concentrate 131[ therapeutically.
Mazzaferri and Young reported that in 576 patients
during a lO-year follow-up there were 84 recurrences.
All six deaths from carcinoma occurred in this group.
Nineteen percent of the patients with recurrences could
not have their disease eradicated by any technique.
Deaths in these patients occurred after they reached
30 years of age. Cervical lymph node metastases were
associated with an increased recurrence rate.
In a study of 352 patients, the M.D. Anderson group
found 97 patients with recurrent disease. One fourth of
these patients failed to concentrate radioiodine. Forty-
four patients died of progressive thyroid carcinoma.
Their deaths began after age 40 years. It also should be
remembered that recurrences that occurred because
the surgeon initially wished to be "conservative" led to
a logarithmically increasing incidence of surgical mor-
bidity for each repeated surgery because of distorted
anatomy.
In a group of patients with papillary thyroid carci-
noma, recurrences occurred in eight of nine patients
(89%) after nodulectomy and/or subtotal thyroidec-
tomy. Furthermore, five patients (56%) in this group
died from the disease. In the group of ten patients with
follicular carcinoma who were similarly treated, four
(40%) developed recurrences, and one patient died
from the cancer.
It is not possible to predict which lesions will respond
to limited surgery. The malignancy has already spread
 ENDOCRINE SURGERY

to involve regional cervical nodes in approximately 50%
of patients with papillary adenocarcinoma even though
metastases are not clinically evident. Summarizing their
experience, Sawyer and associates have indicated that
a significant number of patients with papillary and fol-
licular adenocarcinoma of the thyroid will die of their
disease. Most of the patients with these types of thyroid
malignancies are young and have a long life expectancy.
Thus, some radical surgery appears reasonable and jus-
tified. The more radical surgery for this disease need not
be more mutilating than repeated, limited procedures.
Another point is made that just because a surgical
procedure is "smaller" does not necessarily mean the
complications are fewer. For example, recurrent laryn-
geal nerve permanent paralysis may in fact go unde-
tected unless postoperative laryngoscopy is performed
on several occasions. It is granted, however, that in
total thyroid lobectomy and isthmectomy hypoparathy-
roidism is virtually unknown.
In our experience, when anything less than total
thyroidectomy, central neck dissection, and adequate
1311 monitoring and treatment is performed, disastrous
results have been observed. Some examples are shown
in Table 18-2. Indications for types of lateral neck
dissection and other extensions of surgery are given
under Treatment (see p. 919).
To give an example of the potential lethal effect of
Hiirthle cell follicular carcinoma of the thyroid, although
anecdotal, Figures 18-5 to 18-8 depict this carcinoma.
The patient was treated by total thyroidectomy, central
node dissection, and bilateral radical neck dissection.
There was no time to wait the usual 6 postoperative
weeks for elevation of TSH because of the cardiovas-
cular involvement, so the patient was given 500 units
of thyrotropin-releasing hormone (TRH) and then imme-
diately treated with 1311. This was followed with courses
of doxorubicin and repeated doses of 1311. The residual
tumor responded remarkably well, and the patient was
alive and well 20 months later. Although not officially
approved for treatment purposes yet, recombinant TSH
(Thyrogen) (see p. 921) may be suitable for extreme
cases. We have utilized this regimen, suggesting it to

TABLE 18-2 Results of Inadequate 1teatment

Procedure and Diagnosis Disaster Result

Subtotal thyroid lobectomy
(follicular carcinoma)
"Node picking" (papillary
carcinoma)
Lobectomy (papillary, follicular,
and mixed carcinoma)
Subtotal lobectomy and external
radiation (papillary carcinoma)
Subtotal thyroidectomy (mixed
carcinoma)
Subtotal thyroidectomy (papillary,
mixed carcinoma)
Staged total thyroidectomy without
adequate 131J monitoring and
treatment (Htirthle cell
carcinoma)
Subtotal thyroidectomy listed
incorrectly as a total
thyroidectomy (Htirthle cell
carcinoma)
Extension of residual disease into trachea
and mediastinum causing airway
obstruction.
Significant recurrence of cervical lymph
node disease.
Metastases to C7 and T1 vertebrae,
pulmonary metastasis.
Attachment and displacement of the
common carotid artery, tracheal and
esophageal compression, dysphagia,
airway compression, and vocal cord
paralysis.
Circumferential involvement of the
common carotid artery bifurcation.
Direct invasion of larynx with failure of
late 1311 treatment.
Bone metastasis.
Extension into trachea and adherence to
the esophagus; hemoptysis.
Death with airway obstruction.
Alive after radical neck dissection.
Death with paraplegia and
respiratory paralysis.
Alive with total thyroidectomy,
radical neck dissection, resection
of residual disease and overlying
skin, reconstruction using
pectoralis major myocutaneous
flap.
Alive with carotid resection with
vascular reconstruction using an
autogenous vein graft.
Alive with total laryngectomy.
Death refractory to radiation and
chemotherapy.
Alive after external radiation: total
thyroidectomy, resection of
trachea and portion of cricoid
cartilage, laryngeal release, and 1311
treatment.
 ENDOCRINE SURGERY

FIGURE 18-5 CT demonstrates the tumor completely

encircling the trachea. (Courtesy of Dr. David Hayes,
Diagnostic Imaging, Sisters of Charity Hospital, Buffalo,
New York.)
FIGURE 18-6 Venogram demonstrates extension of
tumor to the great veins of the neck, both
brachiocephalic veins, and the superior vena cava.
(Courtesy of Dr. David Rowland, Diagnostic Imaging,
Sisters of Charity Hospital, Buffalo, New York.)

",

FIGURE 18-8 131j scan delineates the uptake of

radioactive nucleotide after removal of resectable disease
and treatment dose of 379 mCi of 1311. Anterior views.
/' (Courtesy of Dr. Kwan )00, Nuclear Medicine, Sisters of
Charity Hospital, Buffalo, New York.)
FIGURE 18-7 A retrograde venogram demonstrates
tumor in the right atrium. (Courtesy of Dr. David
Rowland, Diagnostic Imaging, Sisters of Charity Hospital,
Buffalo, New York.)
 ENDOCRINE SURGERY
many of our patients on thyroid hormone who require
an 131( scan. It is costly, but the benefits far outweigh
the cost. Not all health maintenance organizations agree
with this concept, unfortunately.
Management of Well-Differentiated
Thyroid Cancer (Includes Papillary,
Follicular, and Hiirthle Cell
Oncocytic Carcinoma)
The basic principle of management is the surgical removal
of all normal thyroid tissue as well as metastatic dis-
ease in the cervical area and superior mediastinum
commensurate with reasonable ablative surgery, with-
out mutilation.
The disease is especially virulent in the following
groups:
• In males older than age 40 years, with large primary
tumors (4 to 5 cm in diameter) (Frazell, 1970)
• In young patients with metastatic disease
• In the presence of bone metastasis
Pathologic Classification
Nieva B. Castillo
To fully understand the management of thyroid cancer
a detailed review of the current classification of malig-
nant epithelial tumors of the thyroid gland follows.
The thyroid gland is a unique organ in that it is the
origin of papillary carcinoma, an innocuous tumor
whose prognosis is measured in decades, and also the
origin of an anaplastic (undifferentiated) carcinoma,
one of the most lethal malignancies known to man
whose prognosis is measured only in months. The
incidence of thyroid carcinoma is low: it is diagnosed
in only 37 to 40 per million of population in the United
States, constituting only 1.3% of all malignancies and
accounting for 0.4% of cancer deaths. Despite this low
incidence, thyroid cancer elicits great interest among
different medical specialties, from primary physicians
to surgeons, endocrinologists, radiation therapists, onco-
logists, radiologists, and pathologists, because it is
included in the differential diagnosis of thyroid nodules
in general and in the United States it is estimated that
7% of the population will have a clinically evident
thyroid nodule.
There are two types of epithelial cells in the thyroid
from which primary carcinoma can arise: (I) the follic-
ular cell derived from the foregut endoderm from which
papillary, follicular, and anaplastic carcinoma arise and
(2) the parafollicular or C cell derived from the ultimo-
branchial body from which medullary carcinoma arises.
Traditionally, carcinomas of follicular cell origin are
classified into two types: well-differentiated carcinoma,
including papillary, follicular, and Hiirthle cell carci-
noma, and undifferentiated carcinoma. The most recent
classification has expanded the morphologic spectrum,
and several rare types and subtypes have been described
and characterized. A category of "poorly differentiated"
carcinoma was added, the prototype of which is the insu-
lar carcinoma whose behavior is intermediate between
well-differentiated and undifferentiated carcinoma.
Papillary Carcinoma
Papillary carcinoma is the most common thyroid carci-
noma of follicular cell origin and accounts for 65 % to
80 % of all thyroid cancers. With more recent classifica-
tion, the incidence is probably close to 80 %. It is more
common in women with a ratio of 2:1 to 3:1 and occur-
ring mostly in the third to fifth decades, although it can
occur at any age, even in utero. Studies indicate that
individuals older than 45 to 50, especially men, fare
less well overall.
Exposure to radiation increases the risk for the
development of papillary carcinoma. In most cases,
radiation was given in childhood with a latency period
of 20 years. The increasing incidence of papillary carci-
noma after radiation therapy to the neck for malignant
disease and the recent epidemic of pediatric thyroid
carcinoma after the Chernobyl nuclear disaster further
support this association.
There may be an association of radiation-induced
carcinoma of thyroid with parathyroid adenoma. Clini-
cally, papillary thyroid carcinoma can present as a thyroid
mass, a thyroid mass plus neck mass, or as a neck mass
alone. Grossly, the appearance of papillary carcinoma
is quite variable, ranging from minute subcapsular white
scars to a large solid, firm mass to diffusely infiltrative
tumor involving the entire lobe or both lobes without
forming nodules.
It was the practice in the past to classify thyroid car-
cinoma according to the predominant growth pattern.
If the tumor was predominantly papillary, it was called
papillary carcinoma. When it was predominantly follicle
forming, it was considered follicular carcinoma, and
when follicular and papillary structures were approxi-
mately equal, it was termed mixed papillary-follicular
carcinoma. Over the years, architectural pattern has taken
a back seat, with nuclear features acquiring a more
significant role in the diagnosis of papillary carcinoma.
The World Health Organization has defined papillary
carcinoma as a malignant epithelial tumor of follicular
cell differentiation characterized by the formation of
papillae and/or a set of distinctive nuclear features. The
papillae consist of connective tissue core with blood
vessels surrounded by epithelial cells. The nuclei have
a distinctive appearance: they are enlarged, overlapping,
and round to oval, with a nuclear membrane that shows
irregularities or indentations. These nuclear irregular-

ities may manifest in the form of nuclear grooves and
pseudoinclusions.
The nuclei appear pale or ground glass or "empty,"
resembling the eye of the cartoon character Little
Orphan Annie, hence the term "Orphan Annie nuclei."
The nuclei also contain prominent nucleoli, which are
often pushed toward the nuclear membrane. Mitotic
figures are usually absent. The cytoplasm of papillary
carcinoma cells is usually cuboidal, eosinophilic, or
amphophilic and may look squamoid. Additional fea-
tures found in papillary carcinoma include the pres-
ence of psammoma bodies, desmoplasia, squamous
metaplasia, and lymphocytic infiltrates. Psammoma
bodies are round calcified structures with concentric
laminations. Although present in only 45% to 50% of
papillary carcinomas, their presence is practically pathog-
nomonic. They are considered to represent the "tomb-
stone" of dead papillae. Fibrosis or desmoplasia is par-
ticularly present at the advancing edges of the tumor.
The desmoplasia could acquire a nodular fasciitis-like
picture. Lymphocytic infiltrates can be seen along the
tumor periphery or within the fibrovascular core of
the papillae. Squamous metaplasia is most common
in the tumor foci surrounded by fibrous stroma.
Biologically, as a group, papillary carcinomas are
indolent growths that avidly invade lymphatics, lead-
ing to multifocal lesions and to regional lymph node
metastasis. In contrast to other body sites, lymph node
metastasis does not appear to adversely affect long-
term prognosis. Vascular invasion is unusual (4% to
7% of cases). 1\venty-year survival is over 90%.
Papillary Carcinoma Variants
Over the years, the morphologic spectrum of papillary
carcinoma has expanded considerably, with some
variants considered as favorable ("good") and others as
unfavorable ("bad").
Favorable Variants
Papillary microcarcinoma is defined as papillary carci-
noma measuring less than 1 em. lt roughly corresponds
to what was previously called occult sclerosing carci-
noma. The reported incidence in autopsy material has
ranged from 4% (United States) to 35.6% (Finland).
Harach and colleagues (1985) suggested that tumors
measuring less than 5 mm be considered "normal" and
be left untreated. There are, however, documented cases
of distant metastasis as well as deaths from such
microcarcinomas.
Encapsulated papillary carcinoma is a type that is
totally surrounded by fibrous capsule grossly simulating
an adenoma. In the past this was called papillary ade-
noma. The tumor shows the characteristic nuclei fea-
tures and may show exclusive papillary or follicular
ENDOCRINE SURGERY
formation or both. This subgroup has an even lower
incidence of lymph node metastasis (25 %), and no
death has been reported. This subgroup is associated
with even better prognosis than papillary carcinoma in
general.
The follicular variant shows almost exclusive (> 75 %)
follicular patterns, but the nuclei have the characteristic
features of papillary carcinoma. There may be scattered
psammoma bodies, desmoplastic reaction, and lympho-
cytic infiltrates.
The macrofollicular variant consists of macrofol-
licles (> 50%) simulating a nodular goiter, but the
nuclei of these cells are those of conventional papillary
carcinoma. This type has a low incidence of lymph
node metastasis. Although entirely nonpapillary in the
thyroid, the lymph node metastasis may contain papillae.
The follicular and especially the macro follicular variant
are difficult to recognize on frozen section. The macro-
follicular variant is indolent and has a low metastatic
rate.
Unfavorable Variants
The tall cell variant originally described by Hawk and
Hazard (1976) is a papillary carcinoma in which at
least 30% of the tumor is composed of columnar cells
that are twice as tall as they are wide with basally
oriented nuclei and abundant eosinophilic (pink) cyto-
plasm. Mitotic figures can be seen easily, unlike the
conventional papillary carcinoma. In their study, this
variant constituted 9 % to 10 % of papillary thyroid
carcinomas, occurring in older patients (> 57 years)
with a female-to-male ratio of 5:1. The lesions were
often more than 6 em, spreading extrathyroidally in
42 %. There was lymph node metastasis in 75 % and
distant metastasis in 17%, and death resulted in 25%.
Johnson and colleagues (1988), at the University of
Michigan, compared 12 patients with the tall cell variant
with 12 control patients with the usual type of papillary
carcinoma matched for age, sex, tumor size, and date
of diagnosis. The result of this study was that tall cell
variant is indeed a more aggressive lesion with a worse
prognosis than the usual papillary carcinoma.
The columnar cell variant is a tumor composed of
tall columnar cells with nuclear stratification or
columnar cells with subnuclear vacuoles resembling
early secretory endometrium. The first few reported
cases, all in males, had an aggressive clinical course
with extrathyroidal extension, lymph node and distant
metastases to lungs and bone, and death in less than
4 years. Wenig and associates (1998) reported the most
cases of columnar cell variant. Only two patients had
aggressive biologic course, both showing extra thyroidal
invasion; and one died of metastatic disease to the
lungs 3 years after diagnosis. Thirteen cases were
encapsulated and confined to the thyroid. One patient
 ENDOCRINE SURGERY
died of sepsis. Wenig and associates concluded that
thyroid papillary carcinoma of the columnar cell type
is a distinct clinical type and the biologic behavior
depends on clinical stage and presence or absence of
extrathyroidal invasion, which appears as the single
most important parameter.
The diffuse sclerosing variant reported by Vickery
and co-workers (l985), which often affects children,
is characterized by the presence of numerous tumors
with papillae and/or squamous morules within cleft-
like spaces (lymphatic vessels) throughout a thyroid
lobe or both lobes with abundant psammoma bodies,
marked lymphocytic infiltration, and prominent fibrosis.
This tumor has a greater incidence of lymph node me-
tastasis (lOO%) and lung metastasis (37%). Patients
presented with bilateral painful thyroid enlargement,
leading to a clinical diagnosis of thyroiditis.
Diffuse follicular and macro follicular variants diffusely
involve the thyroid without forming nodules, mimick-
ing diffuse goiter. These variants show a high frequency
of lymph node and distant metastasis but respond well
to radioactive iodine. Other variants include solid, clear
cell, and oxyphilic (Hiirthle cell). The few reported cases
have conflicting biologic behavior.
Follicular Carcinoma
Follicular carcinoma is defined as malignant epithelial
tumor showing evidence of follicular cell differentia-
tion and not belonging to any of the other distinctive
types of thyroid malignancy. The incidence has ranged
from 5% to 15%. The higher incidence is due to inclu-
sion of the follicular variant of papillary carcinoma. The
relative incidence of follicular carcinoma is increased in
iodine-deficient areas, reaching up to 30% to 40% of all
thyroid cancers. lt is more prevalent in women at middle
age and rare in children. lt typically presents as a soli-
tary thyroid mass. Occasionally, distant metastasis (e.g.,
pathologic fracture) may be the first manifestation of
the disease. Follicular carcinoma disseminates hematoge-
nously and usually metastasizes to the bones, lung,
brain, and liver. Lymph node metas-tases are rare.
Follicular carcinoma is composed of follicular cells
arranged in follicles, cords, trabeculae, and solid sheets
not associated with fibrosis unlike that of papillary carci-
noma. The nuclei are normochromatic or hyperchro-
matic, unlike the ground glass, watery, or empty-looking
nuclei of papillary carcinoma. There are two subtypes
of follicular carcinoma: the encapsulated minimally
invasive type and the widely invasive type.
The minimally invasive follicular carcinoma is usually
a solitary mass that is encapsulated, is light tan to brown,
and has a bulging cut surface not different from that of
an adenoma, although the capsule is usually thicker.
Microscopically, the tumor again resembles the benign
follicular adenomas, although it is more likely to show
microfollicular, trabecular, and solid patterns. Mitotic
activity is often seen. The diagnosis of malignancy
depends primarily on the demonstration of unequivocal
capsular invasion and/or vascular invasion. The diag-
nosis is rarely made on frozen section. In one study, 3
of 39 (8 %) masses were correctly diagnosed on frozen
section. The tumor must penetrate the entire thickness
of the capsule to be regarded as unequivocal capsular
invasion. The vessel should be located within the cap-
sule or outside the capsule, and it should be vein rather
than capillary with endothelial lining and identifiable
wall. The tumor embolus should be covered by endothe-
liallayer, should project into vessel lumen, and should
be attached to vessel wall. The widely invasive follic-
ular carcinoma shows extensive areas of infiltration
grossly and microscopically and lacks encapsulation.
This can usually be diagnosed on frozen section. Lang
and co-workers (l986) have suggested including in this
category encapsulated follicular carcinoma, in which
more than four blood vessels are involved. In their
series, 80% of the patients with widely invasive cancers
developed metastasis and 20% died of tumor. Woolner
(l97l) found a 50% mortality for widely invasive type
compared with only 3% for the minimally invasive type.
The prognosis of encapsulated follicular carcinoma
is excellent, as good as the favorable variant of papillary
carcinoma, with a 95% lO-year survival. The prognosis
for the widely invasive subtype is guarded with a
lO-year survival reportedly 38% to 50%.
Oncocytic Carcinoma (Hiirthle Cell)
Oncocytic (HiirthIe cell) carcinoma is a malignant thyroid
neoplasm composed exclusively or predominantly
( > 70 %) of oncocytes. The name Hiinhle cell as used is
a misnomer. The cell described by Hiirthle is now
believed to be the parafollicular cell, whereas the cell
that now bears the name Hiinhle cell was first described
by Askanazy.
Hiirthle cell carcinoma constitutes 2 % to 3 % of all
thyroid cancers. The clinical presentation does not differ
from that of other malignant follicular tumors. The gross
and microscopic appearances do not differ from their
benign counterparts (Hiirthle cell adenomas), although
the carcinomas have more solid or trabecular patterns.
In the past, all Hiirthle cell neoplasms were considered
malignant or potentially malignant. Hiirthle cell tumors
are diagnosed the same as are non-HiirthIe cell follicular
tumors, that is, by capsular penetration and vascular
invasion. The pathologic criteria for malignancy are met
more frequently by Hiirthle cell neoplasms as compared
with non-Hiirthle cell neoplasms (30% to 35% vs. 2%
to 3%). In contrast to follicular carcinoma, which rarely
metastasizes to lymph nodes, Hiirthle celI carcinoma
metastasizes both to lymph nodes and hematogenously.
The overall 5-year survival is 50% to 60%.

Undifferentiated or Anaplastic Carcinoma
Undifferentiated carcinoma of the thyroid, comprising
10% to 15% of all thyroid malignancy, is probably one
of the most lethal carcinomas in the human body, with
most cases fatal within 6 to 12 months of diagnosis. It
is usually a tumor of elderly individuals and is more
common in women. The classic presentation is that of
a rapidly enlarging thyroid mass or a recent, sudden
enlargement superimposed on a preexisting goiter asso-
ciated with dyspnea, hoarseness, dysphagia, cough, and
neck pain.
Grossly, undifferentiated carcinoma is usually large
and widely invasive with extrathyroid extension and has
a variegated grayish-white hemorrhagic to necrotic cut
surface. Remnants of capsule may be seen, providing
evidence of a preexisting differentiated carcinoma.
Morphologically, there are three subtypes or patterns,
designated as spindle, giant cell, and squamoid. At one
time, small cell type was included in this category.
However, electron microscopy and immunohistochem-
ical studies have shown that many of the tumors that
would have been classified as small cell carcinoma
represent either small cell variant of medullary carci-
noma, malignant lymphoma, or insular carcinoma. In
general, the three major growth patterns occur in
various combinations, with spindle and giant cell usually
predominating. High mitotic rate, cellular pleomorphism,
necrosis, and marked tissue invasiveness, including
high propensity to invade and replace blood vessel wall
(angiotropism), are common to all subtypes. The spindle
cell pattern can mimic any of the soft tissue sarcomas,
especially malignant fibrohistiocytoma, malignant
hemangiopericytoma, and fibrosarcoma. The squamoid
pattern resembles nonkeratinizing squamous cell carci-
noma, and the large giant-cell pattern can resemble
undifferentiated carcinoma of the lung.
Anaplastic carcinoma is generally regarded as the
result of dedifferentiation of a preexisting well-
differentiated tumor, which can be papillary, follicular,
Hurthle cell, insular, and even medullary carcinoma.
The author has seen a case of tall cell papillary carci-
noma that dedifferentiated into spindle cell type of
undifferentiated carcinoma in a lymph node metastasis
that was unrecognized in the initial surgery. The tumor
recurred in the neck 2 years later as undifferentiated
carcinoma massively invading the larynx and trachea.
The author has seen a case of follicular carcinoma
dedifferentiating into squamous cell carcinoma.
The reported coexistence of differentiated and undif-
ferentiated carcinoma varies from 8% to 80% in the
literature. Fortunately, the probability of a differentiated
carcinoma transforming into anaplastic carcinoma is
low, probably no higher than I % to 2 %. It has been
suggested that the administration of radioactive iodine
or external radiation therapy induces this transformation.
ENDOCRINE SURGERY
Most cases of undifferentiated carcinoma are fatal
within 6 months of diagnosis. The cause of death is
usually extensive invasion of vital regional structures.
Metastasis to lymph nodes and blood-borne distant
metastasis are also frequent but are overshadowed by
the massiveness of the primary growth. There is no
effective treatment for undifferentiated carcinoma.
Poorly Differentiated Carcinoma
The traditional classification scheme had divided thyroid
carcinoma of follicular cell origin into the indolent,
often curable, well-differentiated category on one pole
and the highly aggressive, often fatal, undifferentiated
carcinoma on the opposite pole. Some carcinomas,
however, do not easily fit into either group based on
morphologic as well as biologic behavior. The proto-
type of this group, which is now called "poorly differen-
tiated thyroid carcinoma," is insular carcinoma.
Carcangiu and co-workers (1984) described this tumor,
which they believe to be analogous to the tumor des-
cribed by Langhan in 1907 as "Wuchernde Struma."
The tumor is characterized by the formation of a large
well-defined nest of monotonous small cells with round
nuclei and scanty cytoplasm with scattered mitotic
figures. They noted that this type is rare in the United
States but fairly common in central Italy and Paraguay.
Grossly, insular carcinomas are large, solid, and
grayish white with foci of necrosis. They are widely
invasive, often with extrathyroid extension. They are
aggressive, often fatal tumors. Metastases are common
both to lymph node and to distant sites, especially bone
and lung. In the series of Carcangiu and colleagues
(1984), 14 of 25 patients died of the tumor and 7 were
alive with persistent and recurrent disease. Insular
carcinoma may be seen focally in both papillary as well
as follicular carcinomas.
Papotti and co-workers (1993) also reported poorly
differentiated thyroid carcinoma with a "primordial cell
component" based on cytologic and immunohisto-
chemical features of the tumor cells resembling fetal
thyroid in the prefollicular stage. They had collected 63
cases, which they had divided into two groups. Group
A (31 tumors) corresponded to insular carcinoma, and
group B (32 tumors) had a more heterogeneous cell
population, forming trabeculae and a solid or focally
follicular pattern. None of the tumors proved fatal within
6 months. The tumors showed angioinvasion as well as
regional and distant metastasis. The tumors are aggres-
sive but generally show a slow course and good response
to radioiodine therapy.
It is now increasingly recognized that not all papil-
lary carcinomas are innocuous and there are "good"
types and "bad" types. The acknowledged unfavorable
or "bad" types are tall cell, diffuse sclerosing, colum-
nar, diffuse follicular, and macrofollicular variants. The
 ENDOCRINE SURGERY

widely invasive follicular and Hiirthle cell carcinomas
also behave badly. Perhaps the unfavorable papillary
variant and the widely invasive follicular and Hiirthle
cell carcinomas should also be included under the
umbrella of "poorly differentiated thyroid carcinomas."
We at Sisters Hospital have devised a classification
scheme based on morphology and biologic behavior to
serve as a guideline for our surgeons, which is sum-
marized in Table 18-3.
Medullary Carcinoma
Medullary carcinoma, a malignant tumor of parafollic-
ular or C-cell origin and usually containing calcitonin,
accounts for up to 10% of all thyroid malignancies.
This tumor can arise sporadically (70%) or in a familial
form (30%). The familial type may occur in association
with adrenal pheochromocytoma and hyperparathy-
roidism (MEN IIA) or with pheochromocytoma, neuro-
gangliomatosis, mucosal neuromas, marfanoid habitus,
and skeletal abnormalities (MEN lIB). The sporadic type
occurs in one lobe, whereas the familial type is usually
bilateral and multicentric, accompanied by C-cell hyper-
plasia. It is important to recognize familial disease so
that proper screening can be initiated in relatives. The
TABLE 18-3 Sisters Hospital Classification
Scheme for Carcinoma
Well-Differentiated Carcinoma-"The Good"
Papillary carcinoma
Usual
Microcarcinoma
Follicular
Macrofollicular
Encapsulated
Clear cell
Follicular carcinoma, minimally invasive
Hiirthle cell carcinoma, minimally invasive
Poorly Differentiated Carcinoma- "The Bad"
Papillary carcinoma
Tall cell
Columnar
Diffuse sclerosing
Diffuse follicular
Diffuse macrofollicular
? Oncocytic
Follicular carcinoma, widely invasive
Hiirthle cell carcinoma, widely invasive
Insular
Primordial
Undifferentiated Carcinoma-"The Ugly (Deadly)"
Squamoid
Spindle
Giant
laboratory diagnosis of both sporadic familial types
depends on the demonstration of increased levels of
calcitonin in the serum. Levels of carcinoembryonic
antigen (CEA) and histaminase are also elevated in
most patients.
The sporadic form of medullary carcinoma is pri-
marily a tumor of middle age with mean age of 51.
Generally, patients present with unilateral involvement
of the gland with or without associated cervical nodal
metastasis. Distant metastasis, particularly to lung or
bone, may be noted initially in 15% to 25% of the
cases. In patients with MCT associated with MEN IIA
the mean age at diagnosis is 20 years. Prognosis is
similar to the sporadic type. Medullary carcinoma asso-
ciated with the type lIB syndrome occurs at a mean age
of 15 years. The carcinoma in this syndrome is aggres-
sive and tends to metastasize early.
Medullary carcinoma is usually located in the area
of the highest C-cell concentration in the lateral upper
two thirds of the gland. The tumors range in size from
barely visible to several centimeters. They can be circum-
scribed but not encapsulated or infiltrative, with gray-
white, yellow, or tan cut surface. The histologic appear-
ance is quite variable and may mimic other types of
primary thyroid malignancies, including follicular, papil-
lary, and undifferentiated carcinomas. The classic histo-
logic pattern or prototype consists of nests and sheets
of uniform spindled to round cells separated by fibro-
vascular stroma with amyloid. Mitosis and necrosis are
uncommon. Like papillary carcinoma, medullary carci-
noma may show many histologic variants including
tubular (follicular) variant, pseudopapillary and true
papillary, small cell variant, giant cell, clear cell, onco-
cytic, melanotic pigmented variants, mucin-producing
paraganglion-like, and encapsulated. The extreme vari-
ability in pattern accentuates the need for appropriate
immunostaining for both thyroglobulin and calcitonin.
Medullary carcinoma not only shows pattern variation
but also product variation, including amyloid, mucin, and
many polypeptides such as calcitonin, CEA, adrenocor-
ticotropic hormone (ACTH), prostaglandin, bradykinin,
synaptophysin, chromogranins, bombesin, somato-
statin, vasoactive intestinal peptides, human chorionic
gonadotropin, serotonin, histaminase, and so on. Patients
with medullary carcinoma show considerable variation
in overall survival. Ten-year survival rates have ranged
from 60% to 63 %, and 20-year survival rates are from
44% to 53%.
Mixed Medullary-Follicular and Mixed
Medullary-Papillary Carcinoma
These are malignant tumors composed of a mixture of
C-cell and follicular cell differentiation, thus some tumor
cells immunostain with calcitonin or other peptides
and other tumor cells stain with thyroglobulin. The cel-

lular origin is unknown, but it has been suggested that
such mixed tumors could arise from uncommitted stem
cells of the ultimobranchial body that would have the
potential to differentiate into either C cells or follicular
cells.
Other Malignant Tumors
Other malignant tumors of the thyroid include primary
squamous cell carcinoma, mucoepidermoid carci-
noma, malignant lymphoma, sarcomas, and metastatic
carcinoma.
Danger of Underestimating Malignancy
One of the unfortunate concepts prevalent in the litera-
ture on well-differentiated thyroid carcinoma is the
misconception that these tumors are all innocuous and
"benign." In addition to many of the papers on the
subject representing inadequately long clinical follow-
up periods, another problem with reports in the litera-
ture is that significant morbidity in patients not ulti-
mately dying of their disease has been ignored. In centers
with a large referral service, it is not uncommon to find
patients with significant morbidity, including patients
with recurrent cervical lymph node disease with involve-
ment of major vessels and those with clinically signif-
icant metastatic bone disease. The tragic finding of
advanced disease is frequently associated with a clinical
history of inadequate surgical management at the time
of discovery of the tumor. Unfortunately, this inade-
quacy of initial management commonly results from
the misconception that all well-differentiated thyroid
carcinomas are low-grade malignancies.
Treatment
Surgery
Total Thyroidectomy with Pyramidal Lobe and
Central Neck Dissection (See Fig. 18-9)
Regardless of the size of the primary tumor (we have
seen one patient with extensive neck metastasis from
papillary follicular carcinoma with a very small primary
tumor that was only detected after reviewing over 150
microscopic sections), frozen section is important in
making this decision if thyroid cancer was not proved
preoperatively. If the diagnosis is made based on the
permanent sections, then the completion of the total
thyroidectomy is performed 4 to 8 weeks later.
Neck Dissection (Usually Modified)
This is performed under the following conditions:
ENDOCRINE SURGERV
1. When there is evidence of lateral cervical node metas-
tasis: clinical and/or on imaging: CT or MRI-confirm
with FNA if possible. When aspirate of lateral node is
serosanguineous there is a 90% to 99% certainty of
metastasis when yellowish (xanthic)-be suspicious.
2. When there are "significant" positive nodes in the
central neck dissection and there is other evidence
of significant disease (e.g., positive nodes in the
juxtaposed internal jugular chain of lymph nodes).
Classic radical neck dissection is done if the neck has
been previously violated and/or significant extra lymph
node capsular invasion into muscle has occurred.
Resection of Strap Muscles When Invaded by Tumor
The sternothyroid muscle, however, is frequently tran-
sected at its superior insertion to facilitate exposure of
the upper pole of the thyroid lobe.
Resection of Trachea (See p. 1026), Larynx,
Esophagus, and Hypopharynx
This is very seldom performed initially. Rather it is used
as a postoperative ablative treatment when 1311therapy
has failed (a possible exception would be a large inva-
sive Hiirthle cell carcinoma; some Hiirthle cell carcino-
mas will take up 1311,and some will respond in limited
fashion to external radiation).
Radioactive Iodine Treatment
The patient should be off all thyroid hormone therapy
until the TSH level rises to at least 35 J.!U/mL. This is
often achieved by 3 to 4 weeks after surgery. The patient
should be placed on a low iodine diet during this period.
Among the well-differentiated cancers, there may be
limited to no uptake of radioactive iodine in papillary
(usual), tall cell papillary, and Hiirthle cell cancers.
1311
Postoperative Scan Using 2 to 5 mC; of
The hypothyroid state is the important point. It is report-
ed that occasionally patients who are hypothyroid will
develop temporary hypocalcemia. At the time of the
postoperative scan and at subsequent 131[scans with
technetium swallows, in addition to TSH determination
a chest radiograph is performed and thyroglobulin levels
are determined. It is emphasized that pulmonary metas-
tasis-if the metastasis picks up 1311-may be demon-
strated while at the same time the chest radiograph is
normal. The chest radiograph on the other hand may
detect pulmonary metastasis when the lesion does not
concentrate 1311.Although in the authors' practice we
continue to evaluate the thyroglobulin level, there are
reports in the literature that thyroglobulin levels will rise
 ENDOCRINE SURGERY
with recurrent or metastatic disease and thus obviate
the routine use of 131]scans. Both pieces of clinical data
complement one another. There is general agreement at
this time that elevation of quantitative thyroglobulin
levels will take place with recurrent or metastatic
disease. Some authors have indicated that this may
obviate the routine use of 131[scans. By and large,
quantitative thyroglobulin should not replace the 131[
scan but can be used at intervals between the scans as
well as at the time of the scans and complement one
another. Hence, we follow the regimen of Beierwaltes
using 131[scans as follows:
1. If uptake of 131 [ occurs in lateral cervical nodes, then
a modified neck dissection should be done.
2. Treatment with 131] is done under the following
conditions:
a. If there is uptake of 131[ in nonresectable metastatic
disease (e.g., lung, bone, other soft tissue)
b. If there is significant uptake of 1311in the central
neck area, including the thyroid bed and/or lateral
neck and/or mediastinum when these areas have
had surgical node resection with confirmed histo-
logic evidence of metastatic disease. (Beierwaltes
states that significant uptake is considered when
there is greater than a 0.5% 1311dose at 24 hours.)
A number of centers are moving to the use of
dosimetry to more accurately calculate appro-
priate 131]dosages in treatment.
c. If there is histologic evidence of vascular invasion
d. If there is invasion of the trachea and/or larynx
and/or hypopharynx with uptake of 131[
Treatment With 131/
If treatment is indicated and has been performed, a
follow-up total body scan and a thyroid scan are per-
formed on day 6 to 7 after the treatment dose of 1311.
The development of DNA technology and the poly-
merase chain reaction technique may afford us even
more effective monitoring tools in the future for thyroid
cancer. Dr. Michael Levine of Johns Hopkins University
School of Medicine has reported a study using this
technology to detect the presence of thyroid cells con-
taining the gene for thyroglobulin at the lowest of levels
in circulation. If any thyroid cells are present, their
genetic component for this protein can be amplified.
This may obviate the need for routinely scheduled
surveillance scans in the future, thus eliminating the
morbidity associated with the hypothyroidism accom-
panying thyroid hormone withdrawal.
Hormonal Therapy
This consists of the use of T4 (sodium leva thyroxine
[Synthroid]). The necessary dose of levothyroxine is
quite varied and depends on patient tolerance as well
as the TSH level. One should aim to keep the TSH
adequately suppressed but not overly suppressed. Now
that supersensitive TSH assays are commonly used in
most commercial labs one is able to tolerate the dose
of thyroid hormone with much more precision. T3
(Cytomel) is at times used in preference to T4 when a
short-acting thyroid replacement is indicated, such as if
there is an anticipated re-treatment with 131[,which may
be necessary in a short period of time. T3 is approxi-
mately five times as potent as levothyroxine and must
be used with care in the elderly patient and avoided in
patients with heart disease.
Beierwaltes' management of well-differentiated
carcinoma of the thyroid is essentially the same as
ours, and we basically follow his guidelines. He points
out (Beierwaltes et aI., 1983, 1984) that "radioiodine is
never given for ablation of remnants in the thyroidal
bed unless significant uptake of 131[(generally greater
than 0.5 % of the dose at 24 hours) is demonstrated by
the scintiscan." All possible thyroid tissue, normal or
neoplastic, is excised from the neck without mutilation
before treatment with 1311.It is frequently impossible to
determine whether a patient has distant metastases
before the removal of all normal thyroid tissue, which
effectively competes with the metastases for uptake of
1311.Beierwaltes' treatment of well-differentiated thyroid
carcinoma has been divided into 10 procedures, which
are summarized as follows:
1. Perform thyroidectomy without reasonable delay.
2. Perform lobectomy and isthmectomy with a frozen
section and, if carcinoma is found, a lobectomy on
the other side immediately.
3. Keep patient off T4 and T3 from the time of surgery
until the TSH level rises above 35 IlU/mL. The time
necessary to achieve this degree of hypothyroidism
varies from patient to patient.
4. Do 131 [ scan 6 weeks after surgery.
5. If there is significant residual uptake in the thyroidal
bed, treat with 150 mCi of radioactive iodine to
ablate the uptake in this "remnant."
a. Treat with 175 mCi of radioactive iodine if there
is uptake in cervical node metastases.
b. Treat with 200 mCi of radioactive iodine if there
are metastases outside the neck.
6. Place patient on T4 therapy between check-ups.
7. Re-check at 1 year after radioiodine treatment with
the patient off all thyroid hormone for 6 weeks.
8. If the I-year scan after treatment is negative, re-
check 2 years later.
9. If this 3-year scan is negative, re-check every 5 years
with the patient off all thyroid hormone for 6 weeks
before the scan.
10. [f there is recurrence of uptake, we usually treat
with 200 mC!.

Steps 7 to 10 vary depending on the extent of disease
and histology.
External Beam Radiotherapy
External beam radiotherapy is not used in place of 131[
when the lesion is able to take up 1311.It is usually used
when surgery as well as 131[treatment has failed and
when the disease is localized to an area amenable to
external radiotherapy. It has been used regardless of
the histologic type of the neoplasm both at the primary
site and at the metastatic disease. External radiation does
not have any effect on subsequent use of 131i1f there are
cells that could have uptake of 1311.
1. Total thyroidectomy as the initial operation is impor-
tant if the frozen section is positive. This depends on
an excellent pathologist. In addition, we perform a
central neck dissection at the time of the total
thyroidectomy.
2. A postoperative scan with 5 mCi of 1311at times is
combined with technetium swallow after the total
thyroidectomy (thyroid hormone withheld from the
time of surgery). This is done when the patient's
TSH level is over 35 ~U/mL.
3. The dose of 1311is based on the degree of uptake,
extent of disease at the time of surgery, and aggres-
siveness of tumor (i.e., histologic findings of tumor
type and degree of invasiveness).
4. Dosimetry is done in some centers to more precisely
calculate the maximal safe dosage of 131t1hat can be
used in a given patient.
Recently (2001), it has been suggested that the initial
postoperative scan has been eliminated and the patient
is treated with radioactive iodine (l00 mCi) when the
quantitative thyroglobulin value is elevated (usually
6 weeks after the surgery).
Postoperative Hormonal Therapy
The dosage of T4' T3' or desiccated thyroid (Armour)
should be the maximum tolerated by the patient. At
times, the "normal ectopic thyroid tissue" seen on post-
operative scans becomes suppressed and/or disappears
TABLE 18-4 Recommended Protocol for the Recombinant TSH (Thyrogen) Scan"ing Proc:ecIureUsing a 1\vo-
Dose Regimen
Monday Tuesday Wednesday
Day 1 Day 2 Day 3
Thyrogen (0.9 mg 1M) Thyrogen (0.9 mg 1M) 1311 (4mCi)
ENDOCRINE SURGERY 921
as verified on future scans. It must be emphasized that
at times metastatic cancer can be suppressed. Hence,
continued monitoring of the patient is necessary.
Beierwaltes indicates that "there is no question that
we should ablate normal thyroid tissue as a part of the
treatment of well-differentiated thyroid cancer." He goes
on to state that when he used higher doses of 1311in a
group of 103 patients with distant metastasis with a
follow-up of up to 35 years, none has died of leukemia
nor has there been increased incidence of second cancers.
He also found no decrease in fertility or abnormal birth
histories in 43 children treated with a mean dose of
196 mCi with a total dose of 691 mCi followed for a
mean period of 18.7 years (Sarkar et aI., 1976). There
are other reports that leukemia, although problematic,
may occur. The incidence of lymphoma may be slightly
higher than that of leukemia.
Thyrogen (Recombinant TSH)
With the advent of commercially available recombinant
TSH (Thyrogen) or thyrotropin alfa, there will be signif-
icant changes from the past practices of thyroid cancer
surveillance. Currently, the pharmaceutical is being
marketed for imaging purposes only and not treatment.
Therefore one should not use recombinant TSH for
scanning purposes if the patient is high risk and treat-
ment with 131i1s anticipated because withdrawal will be
necessary anyway before proceeding with a treatment
dose of 1311.It is recommended that 131s1canning, using
recombinant thyrotropin alfa (TSH) to prepare the
patient be done in conjunction with quantitative serum
thyroglobulin testing. Obviously the benefit of using
this scanning modality is that it eliminates the need to
withdraw thyroid hormone from patients before scan-
ning, thereby avoiding those debilitating symptoms
commonly experienced. There are currently ongoing
studies evaluating the efficacy of recombinant TSH for
treatment purposes.
Table 18-4 shows the protocol recommended for the
recombinant TSH scanning procedure using a two-dose
regimen. After the sample is drawn and quantitative
thyroglobulin is assayed, an assay also must be done of
the thyroid antibodies, because if these are elevated,
then the quantitative thyroglobulin report may be high
Thursday Friday
Day 4 Day 5
Whole body scan
QTg (quantitative thyroglobulin)
 ENDOCRINE SURGERY
or low. Ideally, the quantitative thyroglobulin test should
be done when the patient is off replacement thyroid
hormone or immediately after recombinant TSH. It is
at this time when the quantitative thyroglobulin level
is most sensitive. If it is elevated while the patient is
on thyroid hormone, then there may be some serious
problems. It will go higher under the above circum-
stances.
When a patient is on recombinant TSH, the quanti-
tative thyroglobulin level will rise significantly (if, in
fact, there is metastatic disease). When the patient is
on levothyroxine, that elevated quantitative thyroglobulin
value can return to normal. This may be another use of
recombinant TSH in evaluating a patient in whom
metastatic disease is suggested. This is a very impor-
tant point. If the quantitative thyroglobulin value is
elevated when the patient is on levothyroxine, then if
either levothyroxine is stopped or recombinant TSH is
begun, the number may be even higher.
Precautions and Observations Regarding the Use
of Scans of 1311 With Pinhole Collimator and 1311
Treatment for Thyroid Carcinoma
1. Pregnancy tests are recommended III patients of
child-bearing age.
2. Limit the 1311 treatment to the first 2 weeks of the
menstrual cycle.
3. The pinhole collimator represents the actual size of
the uptake on a postoperative scan. The size of the
image on the scan depends on a number of factors,
one of which is the calibration of the equipment
(Johnson, personal communication) and another is
the relationship of the distance of the pinhole colli-
mator to the neck. This distance can change not
only the "size" of the lesion but also its relative
distance from the sternal notch to the base of the
tongue. This distance is better determined on the
whole body scan, which outlines the head and neck
as well as the suprasternal notch area.
4. The calculation of percentage uptake after 131[ scans
may not be entirely accurate.
5. The hypothyroid state that develops after the discon-
tinuation of T4 and before the scan and treatment
may result in fatigue, headache, myxedema, and
hypocalcemia with mild symptoms. Cardiomyopathy
may develop if the hypothyroid state is allowed to
persist beyond 8 weeks. The hypothyroid state may
thus be confused with the hypoparathyroid state
and may actually be common to both. By the same
token, a hyperthyroid state can be at times confused
with a hyperparathyroid state. Under such circum-
stances, serum calcium, serum phosphorus, and thy-
roid function tests may be helpful in the differential
diagnosis.
6. Problems with radioactive iodine treatment may
occur; there may be no or very little uptake of radio-
active material in the following:
a. Tall cell papillary
b. Hiirthle cell
c. Predominantly papillary
d. No uptake in undifferentiated or anaplastic
Imaging
1. CT and MRI. In the management of the "bad" and
"ugly" carcinomas of the thyroid, imaging with CT
and MRI is indicated to evaluate the extent of the
primary lesion as well as lateral neck and mediastinal
metastasis. CT of the chest is preferred even when
standard chest radiographs are normal (MRI is usu-
ally not used to evaluate lungs because of patient
motion). MRI (see Chapter 1) is excellent for anatomy
of vessels and mediastinal masses and lymph nodes.
These images are used initially and in follow-up and
become very important in this group of thyroid cancers.
2. PET. This modality is used to identify metastases or
recurrent disease in those tissue types that fail to
have uptake of 1311.
Medullary Carcinoma of the
Thyroid
Origin and Characteristics
1. Parafollicular or thyroid calcitonin C cells form from
neural crest (ectoderm). C cells are located primarily
in the upper and middle portions of the thyroid lobe.
2. Ultimobranchial bodies migrate to the lateral aspect
of the thyroid gland.
3. A precursor of MCT is C-cell hyperplasia, which is
considered precancerous. C-cell hyperplasia is prob-
ably related only to familial MCT.
4. Amyloid deposits (Woolner et aI., 1961) are present
in the stroma of virtually all MCT.
5. The tumor secretes an excess of calcitonin (a hypocal-
cemic factor) that, when elevated, is a marker for
MCT and C-cell hyperplasia.
6. CEA has been shown to be a possible marker in
MCT using immunohistochemical techniques.
7. MCT accounts for 5% to 10% of all thyroid carci-
nomas and may occur either sporadically or as an
inherited trait that is autosomal dominant.
8. MCT can be a very deadly disease and resistant to
treatment after it has metastasized.
9. Regional lymph node metastases have been report-
ed in 50 % of patients.
10. MCT patients may have Cushing's syndrome, caused
by ectopic production of ACTH.

11. MeT is more malignant than well-differentiated
thyroid carcinomas.
For pathologic details, see page 924.
Types
1. Sporadic (80% to 90%): usually only detected by a
thyroid mass. An FNA may be of help in the diag-
nosis. The firm diagnosis, however, is made on histo-
logic examination of the surgical specimen. lt usu-
ally occurs in a somewhat older age group than the
familial type and is always unilateral.
2. Familial (10% to 20%)
a. With MEN llA
b. With MEN lIB
c. Without evidence of MEN
d. With family history of MCT and with C-cell hyper-
plasia but without evidence of MEN and without
histologic diagnosis of MCT
e. Carriers of the familial trait can now be detected
quite reliably utilizing genetic screening techniques.
There are a number of laboratories that can screen
for the presence of the culprit RET proto-oncogene
in family members considered at risk.
Familial MCT is a disease usually related to MEN ll,
but it may exist independently. In at least 90% of cases
the disease is bilateral or multi focal in the thyroid gland.
lt is an autosomal dominant disease present in approx-
imately half of the siblings and half of the children of
individuals with this familial trait.
Another variant of MCT that is suggested as a pos-
sible separate classification includes a family history of
MCT but no definite evidence of MCT on total thyroidec-
tomy; however, it does demonstrate C-cell hyperplasia,
which can be considered as precancerous MCT. Patients
with such disease have been encountered with no other
associated endocrine neoplasia. This author (JML) uses
the abbreviation F-N-MEA-CCHfor this group.
If there are bilateral thyroid masses or associated
C-cell hyperplasia, or both, the patient should be con-
sidered to have the familial type of MCT and the family
should be screened for MEN II. Early detection of RET
proto-oncogene mutations is essential because it allows
"preventive" thyroidectomy in affected individuals
(Vieira et aI., 2002; Sanso et a!., 2002).
Classification of Multiple Endocrine
Neoplasia
MEN [ (not related to MCT, Werner's syndrome) is a
pluriglandular syndrome involving more than one but
almost never all of the following glands: pituitary, para-
thyroids (90% of patients have hyperparathyroidism),
thyroid, pancreatic islets, and adrenals (rarely cutaneous
ENDOCRINE SURGERY
lipomas, bronchial adenomas, intestinal carcinoids, and
gastric polyps). Hyperparathyroidism is the most com-
mon component. Bleeding from a peptic ulcer can be
significant. (Zollinger-Ellison syndrome consists of
non-beta cell lesions of pancreatic islets, aggressive
peptic ulcer, and massive gastric hypersecretion.) Hyper-
parathyroidism is usually the result of hyperplasia of
several parathyroid glands rather than a single ade-
noma (Greene et a!., 1983).
MEN II (related to MCT) is divided into two types in
which familial MCT is a primary constituent. (However,
familial MCT can also occur in the absence of MEN.)
1. MEN IIA
a. MCT
b. Pheochromocytoma
c. Hyperparathyroidism (adenoma-may be multi-
ple-or hyperplasia)
2. MEN liB
a. MCT
b. Pheochromocytoma
c. Multiple mucosal neuromas (tongue and/or lips)
d. Marfanoid characteristics
e. Parathyroids usually normal « 4% abnormal)
The most virulent types of MCT are those associated
with MEN liB and the sporadic variety.
Diagnosis
The diagnosis of MCT should be suspected when a
patient presents with a thyroid nodule and a history of
hypertension, headaches, sweating, palpitations, and
diarrhea and has a family history of death due to thy-
roid neoplasm or "throat" cancer associated with hyper-
tension. When thyroid carcinoma is present or suspect-
ed, signs and symptoms of hypercalcemia can be caused
not only by medullary carcinoma but also by radiation-
induced well-differentiated carcinoma with parathyroid
adenoma.
Hence, all these patients should be strongly suspect-
ed of having a pheochromocytoma and must be evalu-
ated for pheochromocytoma in either the adrenal or
extra-adrenal glands. This is most important, because
hypertensive crisis and death have been reported during
the induction of anesthesia in patients with pheochro-
mocytoma who have not been adequately prepared for
surgery. Pheochromocytoma, which may be bilateral, is
resected before the operation on the thyroid gland. If,
in fact, a hypertensive crisis does occur during anesthe-
sia induction in a patient with an unsuspected pheochro-
mocytoma, the patient is treated with nitroprusside.
Another possible complication (rare) related to anesthe-
sia is malignant hyperthermia, and this can be treated
with dantrolene.
 ENDOCRINE SURGERY

Tests for pheochromocytoma include the following: gland (the location of the greatest concentration of
C cells). Also, calcium may be detected in cervical
I. A 24-hour urine collection for total metanephrines lymph nodes as well as in the liver.
(metanephrine plus normetanephrine) is the most 5. Thyroid scan and ultrasound (optional)
reliable screening test.
2. Urinary free catecholamines (norepinephrine, epi- Laboratory tests for hypercalcemia are described on
nephrine, and dopamine) are measured to confirm page 975.
the diagnosis of pheochromocytoma in patients with
elevated levels of metanephrines. If only epinephrine Familial MeT
or dopamine is being secreted, measurement of frac-
tionated catecholamines can be useful. 1. A hereditary history of thyroid carcinoma, hyperten-
3. Testing for urinary vanillylmandelic acid (VMA) is sion, and/or hyperparathyroidism is extremely critical
available but less reliable because of a high incidence in the diagnosis.
of false-negative and false-positive results. 2. The patient mayor may not have palpable thyroid
4. Plasma catecholamines collected before and imme- mass with or without cervical lymphadenopathy or
diately after an attack (spontaneous or provoked) with or without vocal cord paralysis.
can be measured, but many conditions can elevate 3. Multicentric and/or bilateral masses occur in 90% to
catecholamine levels in the absence of a pheochro- 100 % of cases.
mocytoma. 4. Elevated calcitonin levels occur either as a base
5. If screening laboratory tests are inconclusive, pro- measurement or after provocative stimulation. Penta-
vocative and suppression tests can be performed, gastrin, followed by calcium gluconate, is reported
such as: to stimulate higher levels of plasma thyrocalcitonin
a. Clonidine suppression test in patients with MCT than does either agent alone
b. Pentolinium suppression test (Wells et aI., 1978). Occasionally, this is combined
c. Glucagon and histamine provocative tests-not with selective venous catheterization of an inferior
commonly done (associated with pressor crisis). thyroid or peripheral vein. This may be necessary to
Only when the existence of a pheochromocytoma localize the source of the calcitonin and thus aid in
has been documented should localization of the the diagnosis as well as in the localization of the neo-
tumor be pursued. Localization techniques include: plasm. A pentagastrin provocative test with calcium
1) CT of the abdomen with attention to the can be associated with significant side effects (e.g.,
adrenal glands cardiac arrhythmias, chest discomfort, and even pos-
2) Metaiodine-131 benzyl guanidine nuclear scan- sible syncope). Reported calcitonin levels may vary
ning (131] MIBG) (especially for extra-adrenal from laboratory to laboratory.
pheochromocytomas) 5. An abdominal mass may be present that might indi-
3) MRI cate hepatic metastasis.
4) Central venous blood sampling of catecholamines
Calcitonin is a polypeptide biologic marker, and besides
Extra-adrenal pheochromocytoma may be found at its level being elevated in MCT it may also be elevated in
the initial work-up for MCT or may not occur until other malignant diseases, such as metastatic breast carci-
years after the MCT has been treated. Persistent or noma, small cell carcinoma of the lung, and carcinoid.
recurrent hypertension could be related to renal artery One point of contention is whether the calcitonin
disease. Pheochromocytoma has been reported to occur level, either above the baseline measurement or after
with renal artery disease, although rarely, and we have provocative testing, is significant. Deciding this is diffi-
seen a patient with MCT, pheochromocytoma, and renal cult and depends on a number of factors, not the least
artery fibromuscular hyperplasia. Patients with sporadic of which is the so-called baseline of the laboratory
pheochromocytoma should be screened for MCT. performing the radioimmunoassay. A small percentage
Tests for MCT include the following: of normal patients have a substance in their plasma
that appears to react in the calcitonin radioimmuno-
1. Calcitonin: base levels and, as indicated, provocative assay, yielding high false-positive levels. After the pro-
tests vocative testing, there is no increase in the plasma
2. Chest radiograph calcitonin levels in these patients.
3. FNA of thyroid mass
4. Cervical radiograph for calcium deposits. Approxi- Suggested Follow-up Regimen
mately 40% of patients with medullary carcinoma
have calcification in the thyroid gland, usually at the After total thyroidectomy and central node dissection
junction of the upper and middle portions of the for MCT and C-cell hyperplasia one should:

1. Perform careful physical examination of the neck and
larynx as well as imaging as indicated by elevated
calcitonin.
2. Obtain baseline calcitonin determinations at 1 and
3 months. However, there are reports that calcitonin
levels may remain elevated for several months whether
disease is present or absent.
3. Determine levels of VMA, metanephrines, cate-
cholamines, calcium, and, if elevated, PTH every
2 years or annually.
4. If laboratory data suggest recurrence, perform CT of
the neck and superior mediastinum, obtain a chest
radiograph, and order thallium-20l scintigraphy
(Arnstein et aI., 1986).
S. If hypertension recurs or persists, perform CT of the
entire abdomen for extra-adrenal pheochromocytoma.
Consider evaluation for renal artery disease to explain
persistent hypertension.
6. The advent of genetic technology may make these
cumbersome provocative tests less vital in the detec-
tion of family members at risk. Genetic screening
tests for the RET proto-oncogene mutations are now
available and make it possible to identify patients at
risk who are carriers with a high degree of certainty.
In greater than 90% of individuals with the RET
proto-oncogene mutation, MCT will develop, most
within the first 2 decades of life. This technology may
eliminate the need for stimulation testing in screen-
ing kindreds. It remains useful in the long-term
surveillance of patients for recurrence, however.
7. Other tumor markers, including CEA, have been
reported to be useful in follow-up of MCT. Other tumor
markers relative to MCT are pro-opiomelanocortin,
TRH, gastrin-releasing peptide, vasoactive intestinal
peptide, neurotensin, substance P, and histaminase
(Gagel, 1982).
Kindred patients with MEN IIA are treated with total
thyroidectomy and central node dissection based on
minimally elevated plasma calcitonin levels after pen-
tagastrin stimulation. These patients did not have MCT
but had C-cell hyperplasia without nodal disease (pre-
malignant). Their calcitonin values were slightly double
the normal after the provocative testing. It would appear
that less than significant elevation of calcitonin pro-
vocative testing was in fact a worthwhile indication to
perform total thyroidectomy, because C-cell hyper-
plasia is the precursor of MCT. This appears to be the
ideal time to operate, because metastatic disease can be
associated with a grave prognosis. Much also has to be
said regarding the persistence of the pathologist in
reviewing the histopathologic slides and in the number
of slides made from the surgical specimen. As this
persistence increases, so too will the incidence of C-cell
hyperplasia.
ENDOCRINE SURGERY
Nodal metastases are reported to be absent in C-cell
hyperplasia with the absence of MCT. Nevertheless, it
appears that a central node dissection is warranted.
However, an elective lateral neck dissection does not
appear indicated with C-cell hyperplasia alone. The
problem, of course, arises that at the time of thyroidec-
tomy a careful examination of the specimen may not in
fact show microscopic medullary carcinoma. It would
appear then that the decision to do the lateral neck
dissection depends on whether any of the central nodes
are positive for metastatic disease. If they are positive,
indicating microscopic MCT, then a lateral neck dissec-
tion is indicated. The dissection could be a modified
type (see pp. 904 and 90S) in the absence of clinically
positive lateral nodes.
After surgery for MCT it may take months for the
calcitonin levels to normalize. Normal levels of calci-
tonin (basal) are the best indicator of the efficacy of sur-
gery. Investigations for metastatic MCT are numerous,
but their true utility requires further study. Some scan-
ning techniques that have been tried include 1311MIBG
scanning as well as somatostatin receptor imaging
(Octreoscan). The sensitivity of the latter seems to be
less for MCT than for other neuroendocrine tumors
because of variability of the somatostatin receptor
expression on the tumor.
Family Screening
In 1993, two independent investigative groups identi-
fied the RET proto-oncogene as the gene responsible
for the development of MEN II (Donis-Keller et aI.,
1993; Mulligan et aI., 1993). The gene encodes a tyro-
sine kinase receptor.
The use of genetic screening in MCT has reduced
but not necessarily eliminated the pentagastrin stimu-
lation test, which historically had been the gold stan-
dard. If an index patient with MCT tests negative for a
mutation in the RET proto-oncogene, most believe
family screening is not necessary. Some advocate repeat
analysis in a separate laboratory on a separate sample
because the impact of incorrect risk assessment is
tremendous. If the index patient does demonstrate a
mutation with REI; then all first-degree relatives should
be screened. Total thyroidectomy should be completed
in all those family members who test positive. The
surgery should be done by an experienced head and
neck surgeon in all affected members, even children.
Controversy over the limits of age at which to perform
the surgery remain, but C-cell hyperplasia has been
reported in a child as young as 2 years old. The con-
cern over false-positive or false-negative results in genetic
screening tests due to sampling error for example has
led some clinicians to use the pentagastrin stimulation
test for confirmation.
 ENDOCRINE SURGERY
Management of Residual or Recurrent
MeT
This aspect of the management of MCT can be perplex-
ing and varies from aggressive, meticulous surgical pro-
cedures to a more conservative approach. This author
prefers the former course of action. If the disease is
clinically evident and resectable, then surgery is the
course to follow; otherwise radiotherapy, as later dis-
cussed, should be done. Chemotherapy reports are
sparse and not favorable. The problem is the patient
with consistently elevated calcitonin without any clinical
evidence of disease. (There are reports of postoperative
elevated calcitonin in patients who do not have MCT;
see Becker et a!., 1982.) A possible aid in localizing the
side of the disease is selective venous sampling of
calcitonin. It appears that at this time the more aggres-
sive surgical approach should be offered to the patient
as an option. After total thyroidectomy and central
node dissection, this would entail modified lateral neck
dissection on the side with the more prominent disease
in the thyroid lobe. If this procedure fails to lower the
calcitonin level, then a contralateral modified neck dis-
section should be considered. If this is performed and
fails, then complete the superior mediastinal dissection.
In any event, if total thyroidectomy and central node
dissection was not initially performed, then this opera-
tive procedure should first be done. There is some
evidence that thallium-201 SCintigraphy may be useful
in the preoperative localization of recurrent MCT
(Arnstein et a!., 1986). There are a number of reports
in the literature of patients in the older age group who
evidently have had MCT over a long period of time and
show no evidence of metastatic disease.
Scope of the Operation
Total thyroidectomy, resection of the pyramidal lobe,
and central node dissection (see Fig. 18-9) are a must
for both sporadic and familial forms of MCT. There is
no justification for leaving a small strip of thyroid tissue
posteriorly allegedly to protect the recurrent laryngeal
nerve and parathyroid glands. We have seen one patient
(operated on elsewhere) who had a serious recurrence
in this posterior thyroid remnant. The recurrent disease
distorted the esophagus, causing dysphagia as well as
recurrent laryngeal nerve paralysis. The tumor was
impinging on the esophageal musculature and had
invaded the recurrent laryngeal nerve.
Along with a total thyroidectomy, a central lymph
node dissection is performed. This dissection consists
of the removal of all lymph nodes extending from the
level of the hyoid bone to the superior thoracic inlet
into the superior mediastinum down to the innominate
vessels, including the thymus, and laterally between both
carotid sheaths. This lymph node dissection includes
cricothyroid, para tracheal, tracheoesophageal, top supe-
rior mediastinal, and juxtaposed paraglandular thyroid
gland lymph nodes as well as the pyramidal lobe and
any remnant of the thyroglossal duct tract. If top medi-
astinal nodes are positive on frozen section, then com-
plete superior mediastinal node dissection is done, which
requires median sternotomy (see pp. 1041 to 1061). If
there are clinically enlarged lateral cervical lymph nodes
either along the internal jugular chain or in the poste-
ior triangle, a classic radical neck dissection (not modi-
fied) is performed. The problem arises when there are
no clinically palpable lateral cervical lymph nodes. In
this case the least that should be performed is a biopsy
of any internal jugular nodes that are juxtaposed to the
thyroid gland. If the biopsy is positive, a radical neck
dissection should then be performed. Otherwise, a modi-
fied neck dissection is recommended with clinically
negative lateral nodes. If central nodes are positive,
then modified or radical neck dissection is strongly
advocated. Bilateral radical neck dissection can be
staged with possible preservation of one internal jugular
vein depending on the findings at the time of surgery
(see Fig. 18-12; see also Fig. 16-3W).
A serious error can be made in the palpation of
cervical lymph nodes, because a significant number of
histologically positive nodes are all too often missed
clinically. Hence, if there is significant nodal disease in
the central nodal group, it is more prudent to perform
elective modified neck dissection. If the lateral neck
dissection has been deferred and when post-
thyroidectomy provocative testing is done and con-
tinues to reveal significantly elevated calcitonin levels,
a radical neck dissection (possibly modified) and more
extensive mediastinal node dissection appear indicat-
ed. In addition, a contralateral neck dissection is indi-
cated-modified if there is no invasion. Clark (1985)
suggests consideration of simultaneous sampling of the
cervical and hepatic veins for calcitonin, followed by
neck exploration and modified neck dissection if the
calcitonin level is elevated.
Care should be taken to identify all four parathyroid
glands and to remove any parathyroid adenoma or
hyperplastic glands. If the parathyroid glands appear
normal, a small sliver is taken for frozen section and
any remaining parathyroid glands are tagged with silk
with long loose ends and metal clips so that they may
be re-identified if hyperparathyroidism occurs later on.
Basically, the parathyroid glands are treated as in hyper-
parathyroidism, with the reimplantation of any normal
parathyroid tissue that has impaired blood supply in
the forearm. Some recommend total parathyroidectomy
with parathyroid autotransplantation only in MEN IIA
patients who have hypercalcemia and enlargement of
all four parathyroid glands.
Unless there is preoperative recurrent laryngeal nerve
paralysis, the recurrent laryngeal nerves are identified

and preserved if they are not grossly encircled by tumor.
The importance of the posterior suspensory ligament
cannot be overemphasized, not only to protect the
recurrent laryngeal nerve but also to perform a bona
fide total thyroidectomy. Similar care is taken regarding
preservation of the external branch of the superior
laryngeal nerve. Before any thyroid surgery when an
MEN syndrome is suspected, full evaluation for a
possible pheochromocytoma is warranted. One should
proceed with the work-up as outlined earlier. The
pheochromocytoma (unilateral or bilateral) is removed
before any thyroid surgery.
It is generally agreed that MCT does not concentrate
or have uptake of 131 I. However, there still seems to be
some anecdotal evidence that concentration of 1311 may
occur (more likely in residual normal thyroid tissue);
therefore, in persistent and nonresectable disease, treat-
ment with radioactive iodine appears indicated. External
beam radiotherapy may be helpful in the treatment of
nonresectable MCT.
A review of 45 patients with MCT noted that 80%
had lymph node metastasis and that about 20% had
bilateral metastatic cervical lymph nodes despite the
fact that in some patients there was no evidence of any
clinical metastasis. It was pointed out that the role of
radiotherapy in this disease seems to be significant,
and when given as an adjuvant postoperative course, it
reduced the local recurrence from 50% to about 7%.
The 5-year survival rate for this group was 57%, with
almost a similar lO-year survival figure of 50%. Patients
continued to die of disease after rather long periods of
follow-up, indicating the necessity for a careful contin-
ued follow-up policy. It also appears to be indicated that
radiotherapy is worthwhile in the treatment of that
portion of MCT that is nonresectable. Thyroid suppres-
sion, although endocrinologically it does not seem to
be indicated, is likewise used in all patients with total
thyroidectomy, and this may, in fact, suppress MCT, as
reported in a few anecdotal case reports. MCT, how-
ever, is generally not believed to have any relation to
TSH stimulation. The reader is referred to Clark (l985)
pages 91 to 103, and to the April 1987 issue of the
Surgical Clinics of North America.
Prognosis
I. Prognosis is good to excellent if calcitonin levels are
low or normal.
2. If calcitonin levels are high, there is probably residual
or metastatic disease, but not necessarily so.
3. "DNA measurements in medullary thyroid carcinoma
contribute valuable prognostic information that adds
to standard clinical and morphological parameters"
(Backdahl et aI., 1985).
ENDOCRINE SURGERY
4. Serial measurement of CEA levels should be done
(Mendelsohn et aI., I984).
Hiirthle Cell Carcinoma
This histologic type, when widely invasive, is a very
serious type of thyroid carcinoma. It deserves maximum
surgical management with superior mediastinal node
dissection when superior mediastinal nodes test posi-
tive on frozen section. Unfortunately, it may not have
uptake of 131 I. Therefore, scanning for metastatic disease
as well as treatment of local, nonresectable disease
with 1311 may be useless. Free use of CT is of no help.
External beam radiotherapy is advised. Free use of CT
and MRI for cervical and mediastinal lymphadenopathy
is recommended. Hiirthle cell carcinoma spreads both
by lymphatics and through the bloodstream. PET may
be of aid in the detection of persistent or metastatic
disease.
Papillary Tall Cell Carcinoma
When the percentage of tall cells is at least 30%, this
histologic type can be extremely serious. In a review from
1999 to 2000 of 26 patients with tall cells (from Sister's
Hospital, Buffalo, New York, and Roswell Park, Buffalo,
New York) (Lore et aI., 2000), 30% or more had aver-
age tumor size of 3.8 em and 62% had extrathyroidal
extension. Eight patients died of disease and 2 were alive
with disease. Ten patients had local/regional recurrence.
Distant metastasis developed in 6 of the 26 patients.
This cell type must be recognized at the initial oper-
ation and deserves maximum surgical management. A
total thyroidectomy is done with central node dissec-
tion and complete superior mediastinal node dissection
when the top superior mediastinal nodes are positive
on frozen section. Lateral cervical node dissection is
usually modified unless there is evidence of fixation
and/or extension of disease into the strap muscles or
breakthrough of the capsule of a lymph node (extra-
capsular spread). This deserves radical neck dissection.
Where there are positive central nodes, a lateral modi-
fied cervical node dissection is suggested and strongly
advocated when the primary tumor is 3.8 to 4 em or
larger (see pp. 950 to 954).
This is done because of the difficulty in detection of
very early metastatic disease. Very close follow-up with
free use of CT of the neck and mediastinum is recom-
mended. MRI when indicated can be used to evaluate
mediastinal disease (see Chapter I). External beam
radiotherapy is done for recurrent or residual disease
that is not accessible surgically.
 ENDOCRINE SURGERY
Undifferentiated or Anaplastic
Carcinoma
Undifferentiated carcinoma of the thyroid, constituting
10% t015% of all thyroid malignancy is probably one
of the most lethal carcinomas in the human body, with
most cases fatal within 6 to 12 months of diagnosis. It
is usually a tumor of elderly individuals, again more
common in women. The classic presentation is that of
a rapidly enlarging thyroid mass or a recent sudden
enlargement superimposed on a preexisting goiter asso-
ciated with dyspnea, hoarseness, dysphagia, cough, and
neck pain.
Grossly, undifferentiated carcinoma is usually large
and widely invasive with extrathyroid extension; it has
a variegated grayish white hemorrhagic to necrotic cut
surface. Remnants of capsule may be seen providing
evidence for a preexisting differentiated carcinoma.
Morphologically there are three subtypes or patterns
designated as spindle, giant cell, and squamoid. At one
time small cell type was included in this category.
However, electron microscopy and immunohistochem-
ical studies have shown that many of the tumors that
would have been classified as small cell carcinoma
represent either small cell variant of medullary carci-
noma, malignant lymphoma, or insular carcinoma.
Generally, the three major growth patterns occur in
various combinations, with spindle and giant cell usu-
ally predominating. High mitotic rate, cellular pleomor-
phism, necrosis, and marked tissue invasiveness
including high propensity to invade and replace blood
vessel wall (angiotropism] are common to all subtypes.
The spindle cell pattern can mimic any of the soft
tissue sarcomas, especially malignant fibrohistiocytoma,
malignant hemangiopericytoma, and fibrosarcoma. The
squamoid pattern resembles nonkeratinizing squamous
cell carcinoma, and the large cell/giant cell pattern can
resemble undifferentiated carcinoma of the lung.
Anaplastic carcinoma is generally regarded as the result
of de-differentiation of a preexisting well-differentiated
carcinoma that can be papillary, follicular, Hurthle cell,
insular, and even medullary carcinoma. We had a case
of tall cell papillary carcinoma that de-differentiated into
spindle cell type of undifferentiated carcinoma, not within
the thyroid but in a lymph node metastasis that was
unrecognized in the initial surgery. The tumor recurred
in the neck 2 years later as undifferentiated carcinoma
massively invading the larynx and trachea. We also saw
a case of follicular carcinoma de-differentiating into
squamous cell carcinoma.
The reported coexistence of differentiated and undif-
ferentiated carcinoma varies from 8% to 80% in the
literature. Fortunately, the probability of a differentiated
carcinoma transforming into anaplastic carcinoma is
low, probably not higher than 1% to 2 %. It has been
suggested that administration of radioactive iodine or
external beam radiotherapy induces this transformation.
Most cases of undifferentiated carcinomas are fatal
within 6 months of diagnosis. The cause of death is
usually extensive invasion of vital regional structures.
Metastasis to lymph nodes and blood-borne distant
metastasis are also frequent but are overshadowed by
the massiveness of the primary growth. There is no
effective treatment for undifferentiated carcinoma.
Anaplastic carcinoma of the thyroid for some years
had been divided histologically into large cell types and
small cell types. The existence of anaplastic small cell
carcinoma had been challenged, because there was a
question of whether it was, in fact, a lymphoma of the
thyroid gland. When this is in question, a determina-
tion of B- and T-cell markers on a fresh specimen and
electron microscopy may be helpful in distinguishing
between a lymphoma and a true small cell tumor of the
thyroid. If the lesion proves to be a lymphoma, it should
be carefully staged and treated appropriately. There have
been some studies (small number of patients) suggest-
ing that the small cell carcinoma of the thyroid does
respond to a combination of chemotherapy and local
radiotherapy. This response may be an indication that
the disease is, in fact, lymphoma.
Patients with anaplastic carcinomas of the thyroid
have an extremely grave prognosis, because this variety
is the worst of any thyroid carcinoma. Although all forms
of treatment are of little avail, if the lesion is resectable,
as is infrequently the case, then surgery may be attempt-
ed. Chemotherapeutic studies have been limited, but
the drug doxorubicin appears to have the best response
rate in this tumor. These responses, however, have been
limited and generally brief. The survival is usually meas-
ured in months. The classic clinical picture is one of a
rapidly enlarging mass in the lower cervical region that
appears to infiltrate the entire lower and midcervical
areas and then the mediastinum. It is often shaped like
a pedestal. A large-bore aspiration or FNA often facili-
tates or leads to the diagnosis and is often better than
open biopsy. It is indicated by a number of authors
(Baker, 1969; Harada et ai., 1977), and we also have
found that preexisting well-differentiated carcinoma of
the thyroid may transform into anaplastic carcinoma,
which is another reason to treat well-differentiated
carcinoma of the thyroid by total thyroidectomy.
Squamous Cell Carcinoma
Primary squamous cell carcinoma of the thyroid gland
is an extremely rare neoplasm. Shimaoka and Tsukada
(1980) have reported six patients with this cancer, and
we have had experience with one patient who was
initially operated on elsewhere. The lesion must not be
mistaken for squamous cell metastasis from a primary
tumor in other tissue (e.g., larynx or hypopharynx or

cervical esophagus). Although the survival rate of the
few patients reported is extremely poor, we believe that
very radical ablative surgery possibly combined with
adjuvant preoperative chemotherapy and/or postopera-
tive chemotherapy and radiotherapy may offer some
hope. Total thyroidectomy with central neck dissection
is without a doubt the basic operation; this is combined
with classic radical neck dissection and resection of strap
muscles as indicated by gross and histologic evidence
of spread of disease. We would not hesitate to extend
the operation to laryngectomy as well as resection of
cervical trachea, esophagus, and hypopharynx as indi-
cated by the spread of the disease.
Summary of Management of
Thyroid Cancer (Table 18-5)
1. Small areas of trachea when involved may be surgi-
cally removed or treated with 1311 depending on the
histology of the tumor.
2. Strap muscles are always removed when invaded
or adherent to neoplasm.
3. Laryngectomy is performed when postoperative
radiotherapy fails (1311 and/or external beam radio-
therapy). This is rarely necessary in well-differentiated
tumor. When cartilage is involved, partiallaryngec-
tomy may be feasible; otherwise, total laryngectomy
is advised. Frontolateral laryngectomy was per-
formed in a patient with metastatic disease to a
vocal cord from papillary (usual) carcinoma of the
thyroid. Subsequently, there were scattered laryngeal
mucosal metastases. These were removed locally.
It is difficult to explain the methodology of spread.
There was no other distant metastasis. The patient
is now living with a recently detected positive node
in the contralateral neck. This is 11 years after treat-
ment with total thyroidectomy and a mediastinal
node dissection and central node dissection and a
right modified radical neck dissection.
4. The entire gland is submitted for gross evaluation
and frozen section of suspicious areas.
5. Frozen section of lymph nodes is obtained.
6. Tall cell papillary carcinoma and those cancers with
minimal to no follicles very rarely take up 1311.
7. Hiirthle cell carcinoma mayor may not take up 131J.
8. Bone metastasis usually indicates poor prognosis
and vascular spread-follicular cancer.
9. Well-differentiated carcinoma may transform into
anaplastic carcinoma, which has an extremely poor
prognosis.
10. The basic minimal operation for diagnostic purposes
is a total thyroid lobectomy and isthmectomy.
11. The basic operation for thyroid carcinoma is total
thyroidectomy with central node dissection and
removal of the pyramidal lobe.
ENDOCRINE SURGERY
Substernal Goiter (Median
Sternotomy and Total
Thyroidectomy With Superior
Mediastinal Node and Radical Neck
Dissection) (See Fig. 19-10)
Highpoints
1. Existence with or without symptoms is reason for
removal. Sequelae may result in airway compression,
especially in later life. Scans utilizing 1311 rather than
123[ to differentiate a thyroid mass from a nonthyroid
mass are seldom necessary. Thyroid sonography is
usually not effective because of the sternum. CT and
MRI, especially sagittal views, are important to visu-
alize the relation of the great vessels and the goiter.
2. Usually the isthmus is transected to deliver the infe-
rior pole and then the recurrent laryngeal nerve is
identified.
3. Delivery of the substernal portion is done using any
or a combination of the following:
a. Via the suprasternal cervical route, transect the
interclavicular ligament for improved exposure
along with hyperextension-be careful that head
is not floating.
b. Resect the medial third of the clavicle (see Fig.
19-9A to E). Better for posterior superior media-
stinum (see Fig. 19-7).
c. Median sternotomy (see Fig. 19-10) is better for
exposure of the anterior superior mediastinum
(see Fig. 19-7).
d. Resect the manubrium sterni if necessary.
There are basically three types of substernal
thyroid:
I) Substernal extension of a cervical thyroid gland
2) Completely located substernal thyroid with-
out any thyroid tissue in the neck
3) Completely located substernal thyroid tissue
associated with a separate and unconnected
cervical thyroid
The substernal extension (type I) of a cervical thyroid
is by far the more common and can almost always be
removed via the cervical approach by delivering the
gland superiorly through the suprasternal notch. The
technique is the same as that in a total thyroid lobec-
tomy (see Fig. 18-9) and in total thyroidectomy (see
Fig. 18-12E to H) except that the isthmus is usually
transected before identification of the recurrent laryn-
geal nerve. This is done to facilitate the delivery of the
inferior pole of the thyroid out of the mediastinum and
thus expose and preserve the nerve. Occasionally, this
maneuver fails, the inferior pole being adherent infe-
riorly in the vicinity of the arch of the aorta. Either one
 ENDOCRINE SURGERY
or both recurrent laryngeal nerves may be stretched as
a loop inferiorly around the thyroid gland. The left and/
or right nerve may be located very anteriorly, crossing
over the inferior portion of the thyroid. Danger to the
nerve is ever present, as well as danger of avulsion of
the lowest thyroid vessels and/or inferior thyroid veins.
It then becomes advisable to improve the exposure.
Resection of the medial third of the clavicle (see Fig.
19-9) usually affords excellent exposure on the homo-
lateral side and limited exposure on the contralateral
side. The alternative is a median sternotomy (see Fig.
19-1OAto L). However, this very seldom becomes neces-
sary with this type of substernal extension of a cervical
thyroid gland.
The true substernal thyroid, either type II or type III,
can be a more formidable problem. Nevertheless,
delivery of one inferior pole and then the other via the
suprasternal notch at times can be achieved by tran-
secting the isthmus if, in fact, one can visualize the
isthmus. A high-lying innominate artery that may arise
slightly to the left of the midline and the possibility of
the right common carotid artery crossing the trachea
must be kept in mind. Palpation for this vessel is of
paramount importance. If there is any question regard-
ing the safety of the suprasternal route, then the addi-
tional precautions and exposures described previously
under type [ substernal thyroid are followed. If the sub-
sternal thyroid is strongly suspected of being malignant
or is confirmed as malignant by, for example, frozen
section of the lymph node, then median sternotomy is
preferred. The technique follows the mediastinal node
dissection depicted in Figure 19-1OAto L. Rarely is a
thoracotomy necessary (see Fig. 21-12A to P).
The mere presence of a substernal thyroid even
without symptoms of tracheal compression, especially
types II and III, is believed to be an indication for
elective removal. Symptoms may not develop until
after 60 years of age and at times become so severe that
emergency relief for tracheal compression becomes
necessary. The author (JML) advocates emergency thy-
roidectomy rather than only a tracheostomy, especially
because the obstruction is usually below the site of the
tracheostomy. After the emergency thyroidectomy, the
tracheostomy is usually not necessary and is to be
avoided if at all possible.
Complications
Injury to recurrent laryngeal nerves is foremost. How-
ever, with proper exposure and following the just-
described technique the author has had only one
instance of temporary vocal cord paralysis and none
that were permanent. Refer to Complications of Thyroid
Surgery, page 963.
Anaplastic Substernal Carcinoma (See p. 928)
This extremely malignant tumor may extend subster-
nally and cause tracheal compression. Such an extent
of this disease does not warrant mediastinal dissection.
Emergency care of this catastrophe, which may result
in a tortuously distorted trachea, can be handled by a
tracheostomy. No standard type tracheostomy tube will
solve the problem. Occasionally a "cane" type" will
suffice. This type tube is not readily available and still
may not be able to negotiate a double bend in the
trachea. Some years ago, the author (JML) utilized two
endotracheal tubes, one tube inside the other, for a tra-
cheostomy tube. The inner tube can be removed for
cleaning purposes. A word of caution: the differentia-
tion of small cell anaplastic carcinoma from lymphoma
must be kept in mind. Cell markers should be obtained
on the specimen.
There now appears to be little doubt that well-
differentiated thyroid cancer (e.g., tall cell papillary) can
in fact result in transformation to an anaplastic carci-
noma, hence the argument for aggressive treatment of
the well-differentiated carcinoma.
Squamous Cell Carcinoma of the Thyroid
(Substernal)
Primary squamous cell carcinoma of the thyroid is
fortunately very rare. When this is verified on frozen
section at the time of the initial surgery, the most radi-
cal operation is believed justified. This would encom-
pass not only the mediastinal dissection but also resec-
tion of the esophagus, trachea, larynx, and hypopharynx,
with classic radical neck dissection, depending on the
extent of the disease and its resectability. The first
operation is the most important step. Thus, ideally no
surgeon should perform any type of thyroid surgery
unless he or she is skilled in previously described
extension of the initial operation or has back-up assis-
tance. Secondary procedures may be difficult. On the
other hand, second-stage operations may well be indi-
cated, depending on many circumstances.
Squamous cell carcinoma can coexist with well-
differentiated carcinoma of the thyroid. The histopatho-
logic diagnosis must be carefully evaluated by the patho-
logist, because cellular morphology in well-differentiated
carcinoma, especially papillary, may have cells that
suggest squamous metaplasia but not in fact be squa-
mous cell carcinoma.
Closure
Before closure, the wound is filled with saline and
observed for any bleeding (especially venous). The
 ENDOCRINE SURGERY

TABLE 18-5 Summary Outline of Management of Thyroid Cancer

Complete Superior
Mediastinal
Histologic Type Thyroid Gland Lateral Neck Dissection Dissection Radiation Therapy

Well-differentiated Total with central Modified radical if When highest superior 131{for metastatic
papillary, neck dissection clinically positive or mediastinal nodes disease other than
follicular with uptake of 131{ in are positive on in lateral neck or
lateral compartment frozen section uptake on
nodes postoperative scan
>0.5%
Hlirthle cell Total with central Modified or radical for When highest superior But may not have
(widely neck dissection clinically positive mediastinal nodes uptake of 1311 and
invasive) lateral nodes are positive external radiation
for residual disease
Papillary tall cell Total with central Modified or radical: When highest Usually no uptake of
30% or more node dissection clinically positive mediastinal nodes 1311. If uptake,

tall cells when primary tumor are positive treated with 1311.
is 3.8 to 4 cm or If no uptake, use
larger and accom- external radiation
panied by positive for residual or
central nodes recurrent disease
MCT, "C" cell Total with central Radical with positive When highest superior External radiation for
hyperplasia neck dissection lateral nodes; mediastinal nodes nonresectable
modified with are positive residual disease;
negative lateral nodes treatment with 131{
or delayed modified if there is uptake
if calcitonin level is by contiguous
elevated; modified thyroid tissue
with positive central
neck dissection
Anaplastic Total with central Bilateral radical Total superior 1311 if there is uptake;
(if resectable) neck dissection mediastinal external radiation
and contiguous dissection and chemotherapy
strap muscles
and involved
contiguous
structures
Primary squamous Total with central Unilateral or bilateral Total superior Combined external
cell neck dissection radical mediastinal radiation and
and contiguous dissection chemotherapy
strap muscles
and involved
contiguous
structures

Valsalva maneuver is helpful and is achieved by asking the vocal cords are examined for mobility and bowing
the anesthesiologist to inflate the lungs and to close the using an optical laryngoscope via the vocal cavity.
exhaust valve on the anesthesia equipment. Pressure
on the chest will then increase the venous pressure, Complications
which will allow detection of any vein that may be
open. Lightening the anesthesia to induce "bucking" • Pneumothorax
may also serve the same purpose. After the patient has • Hemorrhage
recovered from the anesthesia. the endo-tracheal tube • Recurrent laryngeal nerve Injury (possibly external
has been removed, and the patient is able to phonate, branch of superior laryngeal nerve)
 ENDOCRINE SURGERY

• Airway obstruction • Airway compromise

• Hypoparathyroidism
• Hypothyroidism Evaluation
• Anesthesia problems, especially intubation
A complete history and physical examination includes
the following: pulse; blood pressure; examination of
Graves' Disease the thyroid regarding size, consistency, and presence or
absence of substernal extension; tracheal deviation;
Although the details of the total management of Graves' presence or absence of any cervical lymph nodes;
disease is beyond the scope of this atlas, a resume laryngoscopy, with either mirror or optical type laryn-
for the surgeon is presented. Graves' disease (Basedow goscopes, specifically evaluating mobility and any bow-
disease) is a multisystem disease whose principal mani- ing of the vocal cords; measurement of proptosis with
festations are thyrotoxicosis, diffuse goiter, ophthalmopa- a Hertel exophthalmometer; and evaluation of any lid
thy, and, occasionally, dermopathy. It is autoimmune in or eye signs. Tests in addition to Sequential Multiple
nature. One can think of autoimmune thyroid disease as Analyzer (SMA) -18 (for hypercalcemia) should include
a spectrum with Graves' disease at one end and Hashimoto's a chest radiograph, ECG, total T4' T3RU (or T3 uptake),
thyroiditis at the opposite end (see p. 960). TSH, and thyroid 1231scan. Occasionally the diseased
Graves' disease is caused by the aberrant production gland will preferentially make T3' Measurements of this
of the antibody known as thyroid-stimulating immuno- hormone may be helpful especially if the measurement
globulin (TSlg), which triggers the state of hyperthy- of T4 is normal or nearly normal in the presence of sup-
roidism. In Hashimoto's thyroiditis, on the other hand, pressed TSH measurement. Optional tests are sonograms
one commonly finds elevation of antithyroid antibodies (rarely) and FNA. In addition, a sensitive, specific, and
(specifically antithyroid peroxidase antibody). This practical bioassay for TSlg is available for clinical use
autoimmune process often leads to diffuse goiter and (Rapoport et a!., 1984).
thyroid failure. To measure the degree of exophthalmos accurately,
Falling between these two conditions in the spec- a Hertel exophthalmometer is utilized. The first step is
trum of autoimmune thyroid disease is a condition to test the patient in the same position (sitting position
known as hashitoxicosis. In this disease, patients often is ideal) and to keep an accurate record of the setting
present with hyperthyroidism but do exhibit some of between the two lateral orbital rims so that the follow-
the features of Hashimoto's thyroiditis as well as ele- up examination is performed at the same setting. The
vated antithyroid antibodies and somewhat inhomo- reference measurement is made from the lateral orbital
geneous uptake of iodine isotopes on imaging. All rim to the corneal apex, using the exophthalmometer.
patients with autoimmune thyroid disease are at risk The average normal distance in the adult is 16 mm,
for the development of ophthalmopathy. The highest with distances up to 21 mm beyond the orbital rim. If
incidence of ophthalmopathy is seen in patients with a distance of more than 21 mm is recorded or a differ-
Graves' disease. ence between the two globes of more than 2 mm is
found, then exophthalmos is indicated.
Indications for Thyroidectomy
Options in Management
• Young patients not adequately managed with med-
ical treatment or failure of medical treatment Discuss the options in management of Graves' disease
• Pregnant or lactating women not responding to med- with the patient. The patient should be made aware of
ical treatment, in whom 131[is contraindicated the possible side effects of medical management, which
• Large and/or multinodular goiters, especially those include allergic dermatitis, hepatic dysfunction, and,
with poor uptake of 1311 very rarely, agranulocytosis with either propylthiouracil
• Women who desire to become pregnant within 1 year or methimazole. Blocking the thyroid with use of thion-
after 131[treatment amides, leading to hypothyroidism, is also a concern;
• Patients who fear exposure to radiation therefore, measurements of the thyroid hormone levels
• Pain and dysphagia associated with a toxic goiter- need to be monitored fairly frequently.
these symptoms may not respond to 1311. The risk of thyroid storm exists with both forms of
• Cold nodules-incidence of carcinoma is the same definitive treatment, namely, ablation with 1311or sur-
in toxic goiter as in those that are not toxic. Cold gery. This risk can be minimized by adequate medical
nodules in themselves are usually not an indication treatment before proceeding with either modality.
for surgical intervention. FNA of the nodules should Explain the surgery to the patient, whether it be total
be performed regardless of the underlying diagnosis or subtotal thyroidectomy. The author's (JML) prefer-
of Graves' disease. ence is total thyroidectomy (Razack et aI., 1997). If

surgery is chosen as the option, discuss the following
with the patient:
1. Eye signs and symptoms may remain the same, may
become worse, or may improve. With total thyroidec-
tomy the eye signs either remain the same or improve.
In the author's (JML) experience with subtotal thy-
roidectomy, aggravation of eye signs may occur but
this is very rare with total thyroidectomy.
2. Hyperthyroidism has not recurred, except in one
patient, after total thyroidectomy. After subtotal thy-
roidectomy, recurrence ranges from 2.4% to 6.7%.
3. Thyroid hormone treatment is necessary indefinitely,
especially after total thyroidectomy. Hypothyroidism
is much easier to treat than recurrent hyperthyroidism.
4. Examination of frozen sections may disclose a malig-
nant lesion, so that permission is needed to do addi-
tional surgery as deemed necessary by the surgeon.
5. Specific complications are nerve paralysis, hypopara-
thyroidism, hemorrhage, airway problems, and thyroid
storm (extremely rare).
6. Total thyroidectomy will usually eliminate any residual
thyroid tissue that could become malignant.
7. Suggested informed consent for all thyroid surgery
follows; this is a checklist of topics covered by physi-
cians in discussion with the patient:
a. Anterior neck suture line
1) Fine line
2) Thickened scar
3) Keloid
4) Movement of scar when swallowing
b. Reaction to anesthesia
c. Reaction to drugs
d. Infection
e. Use of blood-seldom necessary
1) Red Cross screened
2) Self donation
f. Nerves to larynx
1) Two superior-control pitch
2) TWo inferior-control volume, hoarseness if
unilaterally injured; possible tracheostomy if
bilateral injury
g. Is patient singer or public speaker? Warning.
h. Parathyroid glands
1) Four glands (two to nine) for regulation of
calcium in blood
2) Possibility of low calcium level after surgery
3) After lobectomy the chance of permanent low
calcium level is virtually nonexistent.
4) With total thyroidectomy, a 3% to 3.5% chance
of permanent low calcium concentration is
treated with calcium and vitamin D.
i. Pathology: frozen section
1) One lobe benign-surgery completed
2) One lobe malignant-total thyroidectomy and
ENDOCRINE SURGERY
adjacent lymph nodes (lymph nodes: central
area, neck, mediastinum)
j. Pathology: final section
1) Sometimes malignancies are picked up on final
section and require additional surgery.
k. Postoperative care (if malignant)
1) To be off thyroid hormone 4 to 6 weeks
2) Postoperative thyroid 1311 scan
3) Possible treatment with radioactive iodine
4) Additional follow-up scans for lifetime
I. Thyroid hormone replacements
1) Blood work determination
2) Lobectomy versus total thyroidectomy
m. Evaluate quantitative thyroglobulin periodically
and during entire life span-an important cell
marker (depends on histology of malignant lesion,
for example, papillary variance and follicular)-
more sensitive when patient is off thyroid hormone
replacement and TSH level is elevated
Preoperative Management
The patient must be euthyroid. Take the following steps:
1. Continue on medical management, which may include
propylthiouracil (PTU), methimazole (Tapazole),
and/or propranolol (daily dose range: 40 to 650 mg
to establish the euthyroid state). Propranolol alone
is not recommended. It should be used in combina-
tion with PTU and Lugol solution. The final dose of
propranolol is given orally with a few sips of water
just before the surgery or at least 1 to 2 hours before
the surgery.
2. Lugol solution, 10 drops every day preoperatively for
10 days (note iodine may precipitate toxicity in a
euthyroid multinodular goiter)
3. Methylprednisolone (Solu-Medrol), 40 mg preopera-
tively. Repeat during operation if excess edema and/
or increased jeopardy to recurrent laryngeal nerve
exists. This reduces the incidence of temporary nerve
paralysis.
Type of Surgery
Total thyroidectomy with pyramidal lobe resection is
preferred over subtotal thyroidectomy (see Fig. 18-12E
to H).
1. Eye signs remain same or improved (Perzik, 1963;
White, 1974).
2. Complete and permanent control of hyperthyroidism
is more certain with total thyroidectomy than with
subtotal thyroidectomy. The results of 12 different
surgeons performing subtotal thyroidectomy indicated
a prevalence of recurrent hyperthyroidism ranging
from 2.4% to 27.9%. Of these, six surgeons reported
 ENDOCRINE SURGERY
ranges of 11% to 27.9%; the other six reported ranges
of 2.4% to 6.7% (Hedley et aI., 1971). It is the author's
(JML) belief that the varying incidence of recurrent
toxicity with subtotal thyroidectomy is due to the
difficulty in evaluation of the amount of thyroid tissue
remaining deep to and behind the posterior suspen-
sory ligament (Berry), as well as extending behind
the trachea and/or the esophagus (see Fig. 18-90).
Another problem with subtotal thyroidectomy is the
possibility of leaving behind a pyramidal lobe. The
remaining pyramidal lobe may approach the size of
a normal thyroid lobe.
3. The hypothyroid state is easier to manage than
recurrent hyperthyroidism.
4. The complication is acceptably low: nerve paralysis
and hypoparathyroidism may occur (see pp. 908 to
909).
5. The reported incidence of carcinoma is as high as
3.5%.
6. Hungry bone syndrome may be noted postopera-
tively-some patients with Graves' disease are osteo-
porotic (see p. 910).
Postoperative Medication
1. Methylprednisolone (Medrol Dosepak) reduces the
incidence of temporary vocal cord paralysis.
2. Propranolol is continued with doses gradually reduced
for at least 3 days and up to 7 days. This is done
because the half-life of levothyroxine is about 1 week,
whereas the half-life of propranolol is only 2 to
4 hours. Hence, there is the potential of a thyroid crisis
postoperatively if propranolol is not continued during
this period. Propranolol may have been used for other
reasons before the surgery; under those conditions it
would obviously be continued indefinitely.
a-Adrenergic blocking agents should not be com-
bined with ~ blockers (propranolol), otherwise if
hypotension develops during the surgery, the patient
may not respond to medication to raise the blood
pressure.
3. Levothyroxine is usually used routinely postopera-
tively with a dose that leads to normalization of the
TSH level (usually between 75 and 150 f.!g depend-
ing on the age and size of the patient). It may take
several weeks to observe normalization of the TSH
from its previously suppressed state. If any normal
ectopic thyroid remains, levothyroxine may suppress
it and thereby prevent the remaining thyroid from
functioning. This may prevent repeat toxicity.
Treatment of Thyroid Storm
This is an extremely rare condition and must be differen-
tiated from malignant hyperthermia, which is also rare
(see p. 65).
1. Stop manipulation of thyroid gland; stop surgery.
2. Administer sodium or potassium iodide, 1 to 2.5 g,
intravenously every 8 hours.
3. Start hydrocortisone, 100 mg stat, then 300 mg/day
minimal dose.
4. Administer oxygen.
5. Give glucose intravenously in large doses.
6. Avoid hypothermia.
7. Provide fluid and basic electrolyte therapy.
8. Administer a ~ blocker (propranolol), a synthetic~-
adrenergic receptor blocking agent, 4 to 10 mg/kg,
intravenously, not to exceed 1 mg/min with ECG
monitoring (see drug information data).
9. Other adrenergic blocking agents may include:
a. Reserpine, up to 2.5 mg intramuscularly, four to
six times daily
b. Guanethidine, 50 to 150 mg/day orally
10. Propylthiouracil, 600 mg, is given stat and as 200 mg
every 6 hours (some physicians advocate the use of
propylthiouracil before the use of iodides to prevent
the incorporation of iodides into more hormone).
See Complications of Thyroid Surgery, page 963.
Exophthalmic Graves' Disease (See Also
Thyroid-Related Orbitopathy in Chapter 3)
Exophthalmic Graves' disease can occur (although
seldom) in patients in whom the usual clinical signs
and symptoms of toxic goiter are absent except for the
exophthalmos. If T3 and T. levels are normal, then
obtain a TRH level and/or a T3 suppression test
(Werner). These tests may be abnormal and will aid in
the diagnosis. Measurement of serologic markers of
underlying autoimmune thyroid disease (antithyroid
antibodies and TSlg) may be helpful in confirming the
diagnosis. CT as well as coronal scans (CCT) of the
orbits can be helpful in visualizing abnormalities of the
extraocular muscles and optic nerve. We have seen one
such patient who falls into this clinical category with
positive CT scans depicting edema of the inferior rectus
muscle. Attempts by endocrinologists to halt and to
reduce the ophthalmologic signs of exophthalmos,
diplopia, and periorbital edema by thyroid suppression
have for the most part failed. Because we have had
very encouraging results with true total thyroidectomy
in the management of classic Graves' disease, we specu-
late whether this operation may be of some help to
alleviate the ophthalmopathy. Obviously, the patient
must be evaluated for other causes of proptosis, such
as neoplasm.
Toxic Multinodular Goiter
Toxic multinodular goiter is a form of hyperthyroidism
that occurs in an older patient with a long history of
nontoxic multinodular goiter (Plummer, 1913). The

toxicity is usually less severe than in typical Graves'
disease, but there can be significant cardiovascular symp-
toms without eye signs. Multinodular goiter becomes
toxic in less than 10% of cases. The change is probably
on the basis of functional autonomy.
Total Thyroid Lobectomy
(Fig. 18-9)
Indications
This operation is the basis of all procedures of the thyroid
gland, with the possible exception of an isthmectomy
for a nodule directly in the middle of the isthmus. The
principle of total thyroid lobectomy in which the recur-
rent laryngeal nerve is exposed in its entire cervical
course is applicable to most lesions of the single thy-
roid lobe. When bilateral benign disease exists (e.g.,
multinodular nontoxic colloid goiter), a total thyroidec-
tomy is preferred by the author (JML) if only because
recurrences have been seen on the side of a subtotal
lobectomy and reoperation is usually more difficult and
prone to complications involving the laryngeal nerves
and parathyroid glands. Total thyroid lobectomy and
isthmectomy with all juxtaposed lymph nodes are
excellent basic surgical procedures in the initial diag-
nosis and treatment of thyroid cancer. The operation is
then expanded to total thyroidectomy with central node
dissection and removal of the pyramidal lobe (see Fig.
IB-12A to H) with or without neck dissection, either
modified (see Fig. 18-11), as with well-differentiated
carcinoma, or classic (with preservation or sacrifice of
eleventh nerve), as with medullary or anaplastic carci-
noma or squamous cell carcinoma or as in a violated
neck with muscle invasion.
All thyroid lobes thus removed are examined by
frozen section. Juxtaposed lymph nodes are also exam-
ined in a similar manner. Usually, thyroid tissue in lymph
nodes indicates metastatic thyroid cancer. However, it
must be kept in mind that normal thyroid tissue has
been demonstrated in lymph nodes, thus not repre-
senting metastatic thyroid cancer. This situation is
extremely rare (Klopp and Kirson, 1966; Nicastri et aI.,
1965) and is disputed by our pathologist.
All thyroid lobes thus removed are sent to the
pathologist for frozen section. Also included are any
paraglandular, tracheoesophageal, pretracheal, and top
superior mediastinal lymph nodes. If the top superior
mediastinal node or nodes are positive on frozen sec-
tion, then a complete superior mediastinal dissection is
performed. If lateral cervical nodes are clinically posi-
tive or if frozen section on an internal jugular node
juxtaposed to the thyroid bed is positive, then a modi-
fied cervical neck dissection is performed. These criteria
apply to well-differentiated carcinoma, whereas if the
ENDOCRINE SURGERY
frozen section is medullary carcinoma, a more aggres-
sive approach is recommended. In any event, this deci-
sion is difficult at times and depends on other factors
such as local invasion, suspected lateral nodes, size of
the primary tumor, age, and sex, as well as histologic
features. On the other hand, if preoperative CT of the
neck and mediastinum was performed because of a
positive FNA of the main thyroid nodule, then the
decision is much easier.
Another argument for total thyroid lobectomy is that
if unsuspected malignancy is diagnosed from the per-
manent sections and a subtotal lobectomy has been
performed, a secondary operation to remove the vari-
ously sized remaining wedge of thyroid tissue is most
difficult and frustrating. In addition, there is extreme
danger of injury to the recurrent laryngeal nerve, the
external branch of the superior laryngeal nerve, and
parathyroid glands.
Preservation of the parathyroid glands, with the
recurrent laryngeal nerve and the external branch of
the superior laryngeal nerve, is a sine qua non. The
inferior parathyroid gland is usually on a more anterior
plane than the recurrent laryngeal nerve, whereas the
superior gland may be on a more posterior plane unless
it is attached to the thyroid capsule near the superior
pole of the gland. On several occasions, they have been
located anterior to the strap muscles being identified
after the initial skin flaps have been elevated. The
superior parathyroid glands are more often located just
posterior to the superior pole of the thyroid gland. They
may be within the thyroid gland or in the posterior
superior mediastinum. The location of the inferior
parathyroid glands is more variable, being lateral, ante-
rior, or posterior to the inferior portion of the thyroid
gland or somewhat more lateral near the inferior
thyroid artery (Attie et aI., 1971). They also may be
close to or within the thymus or anterior superior
mediastinum. Other varied locations range from the
angle of the mandible down into the superior medi-
astinum. When in the superior mediastinum, the supe-
rior parathyroids are in the posterior mediastinum and
the inferior parathyroids are in the anterior mediastinum.
They can also be hidden in the thyroid lobe. Attie and
colleagues (1971) and others state that, when this occurs,
they are located within folds of the thyroid gland and
can be fetched out of these folds. We have found intra-
thyroid parathyroid glands completely surrounded by
thyroid tissue. They can also be within the carotid
sheath and just beneath the thyroid capsule.
The parathyroids are usually caramel colored or tan,
are 6 to 8 mL in size, and are often ovoid and rather
flat. Adipose tissue is more yellow and lobulated, and
lymph nodes are grayish white and round. Parathyroid
tissue along with lymph nodes and thyroid tissue sink
in normal saline whereas fat floats. When the blood
supply has been interrupted, the parathyroids often
 ENDOCRINE SURGERY
Total Thyroid Lobectomy
(Continued) (Fig. 18-9)
turn black. Their blood supply is from branches of the
inferior thyroid artery, while occasionally the superior
parathyroid gland is supplied by a branch from the
superior thyroid artery or from an anastomotic loop
between the superior and inferior thyroid arteries
(Curtis, 1930) (see Fig. 18-14).
Lore and Pruet (1983) have described a technique
for retrieving parathyroids beneath the thyroid capsule.
If the parathyroids have not been located in their usual
position, the thyroid lobe or entire gland, if a total
thyroidectomy has been performed, is carefully scruti-
nized while still in the surgical field. At times, sub-
thyroid capsular parathyroid glands may appear as small
black lobules. The thyroid capsule is carefully incised,
and the suspected parathyroid tissue is dissected free.
The suspected parathyroid gland is then placed in
normal saline and will sink. Remember that lymph
nodes and thyroid tissue also sinks; and if there is any
question, a small portion is sent for frozen section. Any
free parathyroid is then sectioned into as small pieces
as possible and reimplanted in an incision in a muscu-
lar bed, usually at the base of the sternocleidomastoid
muscle. The site is marked with a metallic clip and black
silk tie. Other optional muscle beds are the trapezius
muscle, if a neck dissection is performed, the pectoralis
major muscle, or the antecubital region. The important
points are the following:
1. Do not reimplant parathyroids in a muscle that may
be removed at a future operation.
2. Do not reimplant carcinoma.
3. Provide explicit documentation in the operative report
showing where the parathyroid gland has been reim-
planted; a copy of this documentation on an appro-
priate anatomic stamp is recorded in the chart as well
as given to the patient for his or her medical file.
4. If a parathyroid is reimplanted in the antecubital
region, one must keep that location in mind if draw-
ing blood to measure PTH for any reason in the
future. If the sample is drawn from a vessel near the
implant the PTH levels will be quite elevated because
the hormone has not been circulated systemically in
the bloodstream.
In Hashimoto's thyroiditis and Graves' disease (both
diseases probably related to an autoimmune reaction)
there is often considerable edema, which makes iden-
tification of the recurrent laryngeal nerve and parathy-
roids more difficult. More care must be taken. When a
total thyroidectomy is planned (e.g., in Graves' disease,
where there is significant concern about the physio-
logic function of the nerve after one lobectomy), to
proceed with a total thyroidectomy without evaluating
the function of the nerve might result in a temporary
bilateral vocal cord paralysis. To obviate this problem,
the patient can be awakened after the initial lobe is
removed and then while awake and with the endotra-
cheal tube having been removed and the patient able to
phonate, a flexible laryngoscopy can be performed. If
the vocal cord is functioning well, proceed with the
total thyroidectomy; if not, then stage the operation.
There appears to be a higher incidence of malfunction
of both nerve and parathyroid glands in these patients.
If there is any question regarding the blood supply to
the parathyroids, especially if they turn black, reimplan-
tation appears to be the best procedure.
It is now our routine to administer 40 mg of methyl-
prednisolone (Solu-Medrol) either immediately preoper-
atively or intraoperatively (total dose up to 120 mg) to
all patients undergoing thyroidectomy based on the
theory that temporary vocal cord paralysis is due to
edema and/or stretching of the recurrent laryngeal
nerves. A Medrol Dosepak is then administered orally
during the postoperative period. This has reduced our
incidence of temporary nerve paralysis significantly (P
< .002). Basically this procedure is similar in principle
to a total lateral lobectomy of the parotid salivary gland
in which in each case the respective vital nerve is
exposed near its origin in the surgical field and then
followed and carefully preserved.
Central Node Dissection
1. Cricothyroid
2. Paratracheal
3. Tracheoesophageal
4. Top superior mediastinal
5. Juxtaposed (paraglandular) thyroid gland
Highpoints
1. Expose and identify recurrent laryngeal nerve at
the superior thoracic inlet just inferior to the infe-
rior thyroid pole before any major vessels are
ligated. This may require transection of the
isthmus with substernal extension. Remember that
this nerve may not be "recurrent" and reach the
larynx via a direct horizontal route from the vagus
nerve. This is more common in the right side. This
can occur on the left side with transposition of the
great vessels.
2. Proceed with retrograde dissection from below
upward, keeping nerve in constant vision. The
nerve may divide into two or more branches before
entering the larynx (in 39% of cases according to
Nemiroff and Katz). The nerve passes deep to the
posterior suspensory ligament (Berlin, Gruber,

Henle, Berry) either as a main trunk or its branches.
Very, very rarely will a small branch cross anterior
to the main portion of the posterior suspensory
ligament. The recurrent laryngeal nerve must be
traced in its entire course until it enters the larynx.
Smaller branches may enter the esophagus and/or
pass superiorly to communicate with the superior
laryngeal nerve (nerve of Galen).
3. If bleeding occurs from small inferior thyroid vessels,
pressure will usually suffice to control it until they
can be ligated. The main trunk of the inferior thyroid
artery is usually not ligated laterally. It is preferred
that its smaller branches to the thyroid gland be
ligated as they enter the thyroid gland, at the same
time identifying the branches supplying the parathy-
roid glands. Identification of these vessels may be
of aid in the identification of the parathyroid glands.
In this way the blood supply to the parathyroid
glands is preserved (see Fig. 18-14). If oozing con-
tinues, especially from the origin of the posterior
suspensory ligament, a small piece of surgical-type
absorbable gauze is applied. Surgicel is routinely
placed in the surgical bed.
4. Meticulously expose the posterior suspensory liga-
ment and transect this ligament with branches of
recurrent nerve in full view and preserve all branches.
5. Recognize the proximity of the external branch of
the superior laryngeal nerve (motor of cricothyroid
muscle. tensor of the vocal cord) to the superior
pole vessels.
a. Superior pole exposure is usually the last step in
thyroidectomy.
b. The artery and veins are exposed 1.5 to 2.0 cm
proximal to the penetration of the thyroid
capsule-CRITICAL AREA; exposure is achieved
by gently cleaning these vessels from below
upward, displacing any portion of this nerve
that may be close to the site of ligation.
c. Vessels are ligated and divided as close to the
thyroid capsule as feasible without a clamp on
the proximal stump.
Specific identification of the nerve is not neces-
sary; only about 10% are identified. In any event,
the nerve should not be injured, especially in singers.
ENDOCRINE SURGERY
This nerve is the tensor of the vocal cord. Injury
results in a bowed vocal cord. The vocal cord may
also be lowered.
6. Ligate and suture-ligate the superior pole vessels
before section of these vessels; in other words, do
not use a clamp at the proximal end of the vessels
to avoid injury to the nerve. The vessels do not
enter the gland at the top of the superior pole but
1 to 1.5 cm inferior to it. Ideally the artery and
veins are ligated separately. This aids in prevention
of injury to the external branch of the superior
laryngeal nerve (Thompson and Harness, 1970).
7. Identify and preserve parathyroid glands (see Figs.
18-19 and 18-20). If the glands are removed. reim-
plant them in an appropriate muscle (e.g., base of
sternocleidomastoid muscle) (see Fig. 19-1OKand
L). In malignant disease do not jeopardize an ade-
quate resection to preserve them in situ. Rather,
remove them and reimplant them. Frozen section
may be necessary to verify them. Do not reimplant
a lymph node with metastatic cancer.
8. Mirror or optical laryngoscopy is performed to
evaluate that the function of vocal cords must be
routine before and after any thyroid surgery; pre-
operative paralysis or paresis may indicate a malig-
nant tumor (see Fig. 20-2). In addition, preopera-
tive weakness or paralysis must be ascertained and
documented to protect the surgeon from litigation.
Postoperative immobility can be permanent, tem-
porary, or extremely rare, such as from a dislocated
arytenoid secondary to anesthesia (Sataloff, 1997)
(see p. 906).
9. Remove the entire isthmus in all total lobectomies.
10. Preserve blood supply to parathyroids if feasible; if
this is not possible, reimplant them.
11. Freely use frozen section of lobe and lymph
nodes.
12. Refer to Anatomic Considerations on p. 896.
13. Do not skeletonize the recurrent nerve. Do not
stretch the recurrent nerve or apply any pressure to
it with instruments. Do not grasp the recurrent
nerve with any instrument.
14. Administer preoperatively methylprednisolone,
40 mg (see p. 936).
 ENDOCRINE SURGERY
Total Thyroid Lobectomy
(Continued) (Fig. 18-9)
A A horizontal incision is made about two finger-
breadths above the clavicles, preferably in a natural
skin crease. A piece of silk may be pressed against the
skin to facilitate a graceful curve. One or more very
superficial cross notches are made in three equidistant
locations along the incision to facilitate proper realign-
ment of the skin edges at the time of closure. A single
cross notch usually suffices.
B The incision is carried through the first layer
(superficial) of cervical fascia and the platysma
muscles.
C Four stay sutures or very fine retractors are
. inserted through the fascia and platysma muscles to
avoid grasping the skin edges with forceps. Using
sharp or blunt dissection, skin flaps are developed
upward almost to the notch of the thyroid cartilage
and downward to the supraclavicular region.
D A midline vertical incision is made through the
second layer (deep) of cervical fascia that surrounds
the strap muscles (dotted line in C). The right and left
sternohyoid muscles are thus separat~d, exposing the
thyroid isthmus. Close observation for parathyroid
glands is begun at this stage of the operation.
E Using blunt dissection, the right and left groups of
strap muscles are separated from the underlying
thyroid gland. At this point, both lobes and isthmus
are gently and carefully felt with the examining finger
for any nodules. Avoid separating the strap muscle on
the contralateral side because this may cause fibrosis
and interfere with a subsequent lobectomy. Usually, it
is not necessary to transect the strap muscles, because
they are readily retractable, but if exposure is not ade-
quate, they should be sectioned high in the neck,
above or at the level of the cricoid cartilage (see Fig.
18-10B and C). The nerve supply from the ansa
hypoglossi enters the strap muscles low in the neck.
When only a minimal additional exposure is necessary
a short horizontal incision (about 1 cm) is made on the
medial border of the sternothyroid muscle close to its
attachment to the thyroid cartilage. This will aid in
exposure of the superior pole vessels and external
branch of the superior laryngeal nerve.
Continued
Before proceeding further, careful palpation for
enlarged lymph nodes is first performed. They may be
located in the region of the cricothyroid ligament, in
the paraglandular and tracheoesophageal regions, and
along the internal jugular vein as well as the superior
mediastinum. If exposure for complete evaluation is
not satisfactory at this moment, the evaluation is
repeated at a later time during the surgical procedure.
Frozen section is done immediately.
 ENDOCRINE SURGERY

Anterior Jugular V.
B c

Inferior
Thyroid
Vein

E
FIGURE 18-9
 ENDOCRINE SURGERY
Total Thyroid Lobectomy
(Continued) (Fig. 18-9)
The inferior thyroid veins are usually in two trunks,
the right passing anterior to the innominate artery to
empty into the right brachiocephalic vein, or anterior
to the trachea to empty into the left brachia cephalic
vein, and the left inferior thyroid vein to empty into
the left brachiocephalic vein. Occasionally, when both
inferior thyroid veins form a common trunk, this trunk
is then referred to as the thyroid ima vein, which
empties into the left brachiocephalic vein. A plexus
between both inferior thyroid veins may exist called
the plexus thyroideus impar, which may be a source
of bleeding in thyroid surgery and for that matter in
tracheostomy and in other operations in the supra-
sternal region.
A high-lying innominate artery or right common
carotid artery may cross the trachea above the sternal
notch. It is vulnerable.
F With a slender finger-type retractor (Langen beck)
in the inferior lateral portion of the wound, the inferior
pole of the thyroid gland is mobilized gently by blunt
dissection and retracted upward with moist gauze
between the operator's fingers and the gland.
Grasping instruments such as a Lahey clamp, which
might puncture or tear the gland or tumor, are not
used. Avoidance of this clamp is especially important
in thyroid cancer. The inferior thyroid vein is thus
exposed as well as the recurrent nerve triangle, bound-
ed laterally by the common carotid artery, medially by
the trachea, and superiorly by the thyroid lobe. The
apex of the triangle is pointed downward to the thoracic
inlet, the site of entrance of the main trunk of the
recurrent laryngeal nerve. Be cognizant of the fact that
this nerve may arise from the vagus nerve in the neck
and thus reach the larynx directly, passing deep to the
lateral border of the thyroid lobe. Thus when the nerve
is not readily located in this triangle, carefully search
for it at a higher level-a non-recurrent nerve arising
directly from the vagus nerve.
G The inferior thyroid vein or veins are doubly ligated.
The inferior pole is further retracted upward, com-
pletely exposing the recurrent nerve triangle. The infe-
rior parathyroid gland is identified as a tan (caramel),
usually oval mass of round or flat tissue lying in some
adipose material (see Fig. 18-190). Usually it is on a
plane anterior to the recurrent laryngeal nerve, often
attached to the inferior pole of the thyroid. It can lie
subcapsular or within folds of the thyroid. Its blood
supply should be preserved. Thus, do not ligate the
main trunk of the inferior thyroid artery. If the gland is
removed, reimplant it as thin slices (0.3 mm or less)
into the base of sternocleidomastoid muscle (see Fig.
19-10K and L) (Matsuura et aI., 1969). Feind (1971)
implants four thin slices (1 mm). Here, the main trunk
of the recurrent nerve is found by blunt dissection,
lying between the common carotid artery and the
trachea, at a depth equivalent to or slightly more
superficial than the tracheoesophageal sulcus as it
passes from front to back around the subclavian artery
and thus behind the common carotid artery-this on
the right side. It is neither necessary nor advisable to
section any structure other than the superficial inferior
thyroid vein before visualization of the nerve. Dissec-
tion is then carried upward to the level of the inferior
thyroid artery. The middle or median thyroid veins are
also exposed. The use of suction as well as complete
mobilization of the nerve is to be avoided. Cottonoid
strip sponges are used rather than gauze over or near
the nerve.
H The thyroid isthmus is clamped and transected at
its attachment to the opposite lobe. Thus, the entire
isthmus is removed. The incision is extended along the
dotted line cutting the anterior suspensory ligament
from the cricoid cartilage. The anterior suspensory liga-
ments are extensions of the pretracheal fascia that run
from the upper and inner aspects of the gland to the
cricoid cartilage and trachea.
I The lobe is separated from the trachea and the
branches of the inferior thyroid artery are doubly
ligated. The trachea is gently retracted with a curved
retractor. Care must be taken not to allow the retractor
to slip inward. It might hit the recurrent laryngeal
nerve. Whenever any retractor slips out of the wound
the surgeon must replace it, otherwise an assistant
may engage the nerve and stretch it. Avoid ligation of
the main trunk of the inferior thyroid artery to preserve
the blood supply to the parathyroids (see Fig. 18-14).
Here, the various relationships of artery to nerve are
 ENDOCRINE SURGERY

Inf.Thyroid A., ,
Trachea Parathyroid
\
Recurrent Laryngeal N..

Anterior
Suspensory Lig.

Posterior
Suspensory Lig.

FIGURE 18-9 Continued

easily seen under direct vision. Either structure may
cross the other or either or both structures may be
single or multiple and intertwined. The division of the
nerve into abductor and adductor (this designation is
controversial) branches is usually apparent at this
point. Small nerve fibers to the cervical esophagus and
inferior constrictor muscle of the pharynx may also be
seen. Do not sacrifice any nerve structure regardless of
its position. In two patients the recurrent laryngeal
nerve was the smallest nerve seen. It crossed anterior
to the inferior portion of the thyroid lobe in one patient;
in the other, it crossed anterior to the posterior suspen-
sory ligament. A communication between the recur-
rent nerve and the superior laryngeal nerve may pos-
sibly exist (nerve of Galen). It, too, is not sacrificed.
Continued
The recurrent laryngeal nerve or its branches are
seen to pass deep to the posterior suspensory liga-
ment. This ligament may have a thin lateral leaf (see
Fig. 18-12£) that is deep or lateral to the recurrent
laryngeal nerve. It is this ligament that is so important
in the performance of a total thyroid lobectomy and
in the preservation of the recurrent laryngeal nerve
and its branches. A more detailed discussion of this
ligament is found in the introduction to this chapter
(see p. 896). The inferior parathyroid gland is usually
at a plane somewhat anterior to the recurrent laryngeal
nerve. The various locations of the inferior parathyroid
gland have been discussed previously. A detailed list of
these locations is provided in the parathyroid section
(see p. 968).
 ENDOCRINE SURGERY
Total Thyroid Lobectomy
(Continued) (Fig. 18-9)
J The middle thyroid vein or veins are doubly ligated
and divided, and the gland is further mobilized.
K, Kl The lobe is now attached only by its superior
vessels and the posterior suspensory ligament running
from the inner or medial aspect of the gland to the
trachea and cricoid cartilage. This portion of the sus-
pensory ligament is thick and dense and is referred to
as the pedicle or adherent zone (Berlin) of the thyroid
gland; it affixes the gland to the trachea. The branches
of the recurrent nerve pass under this ligament or
pedicle (K'). Deep and posterolateral to these recur-
rent nerve fibers is usually a projection of the gland
that is associated with the esophagus. This projection
can be up to 4.0 cm or even larger. It is removed in
continuity with the main portion of the gland. Along
the lower margin of this pedicle is a small artery, a
branch of the inferior thyroid artery, along with at times
a complicated plexus of veins and arteries. This region
is a critical site, and extreme care must be taken to
avoid injury to the nerve fibers while at the same time
performing a total lobectomy. Despite this fact, the
area is usually easily (there may be fibrous adhesions
with Hashimoto's thyroiditis) visualized, and by gently
passing a small Mixter clamp under this pedicle and
artery (which is ligated) the pedicle is carefully tran-
sected. This frees the gland dramatically and the remain-
ing thin lateral ligament (see Fig. 18-12E) (may be
imperceptible) and fascia extending to the esophagus
and cricopharyngeus muscle is easily separated by
sharp and blunt dissection. The abductor (lateral or
posterior) and adductor (medial or anterior) branches
of the nerve are seen passing behind the inferior edge
of the cricopharyngeus muscle and thyroid cartilage.
The nerve leaves the surgical field at this point (see
Fig. 21-3A). If bleeding occurs from the artery or
plexus of vessels along the posterior ligament, it may
be too risky to clamp the vessels because of their close
association with the nerve fibers. Gentle pressure usu-
ally controls the hemorrhage, and then the vessel or
vessels can be ligated in a dry field. More often than
not there are a number of vessels associated with the
posterior suspensory ligament, and extreme care must
be taken to avoid injury to the nerve. Cauterization of
these vessels is avoided so as not to injure the nerve or
its branches.
The superior parathyroid gland is located usually
deep or lateral or medial to the recurrent laryngeal
nerve. The gland can also be adherent to the posterior
aspect of the lower portion of the superior pole of the
thyroid gland and can be located as the thyroid gland
is reflected superiorly.
L The superior pole vessels are then exposed. The
small external branch of the superior laryngeal nerve,
the motor supply to the cricothyroid muscle, is closely
related to the vessels. This muscle is the tensor of the
vocal cord, and injury to its nerve supply will cause
bowing and inferior displacement of the vocal cord
and voice changes (see p. 899).
Continued
 ENDOCRINE SURGERY

Superior pole

Cricothyroid m.

FIGURE 18-9 Continued

 ENDOCRINE SURGERY
Total Thyroid Lobectomy
(Continued) (Fig. 18-9)
M, Ml The lobe is pulled downward, further
exposing the superior pole vessels. The external branch
of the superior laryngeal nerve may be intertwined
with or adherent to these vessels, and extreme care
must be used, especially when the lesion encroaches
on the superior pole. A plane of blunt dissection is
carefully followed superiorly along the presenting por-
tion of the cricothyroid muscle. A careful exposure of
these vessels is started at the area where the vessels
perforate the thyroid capsule (1 to 1.5 cm inferior to
the superior tip of the superior pole) and proceed
superiorly for 1.5 to 2.0 cm along the vessels (critical
area) (step Ml). This nerve will be protected. The nerve
is seldom identified (approximately 10%), yet this
technique will minimize injury to the nerve.
In a 38-year study of 934 nerves placed in jeopardy,
there was temporary bowing in four patients and per-
manent in one patient (limited follow-up). In post-
operative voice evaluations, the effect of voice changes
on lifestyle is a very important factor (the estimated
deleterious effect of voice changes on lifestyle is no
greater than 1.5% in a group of patients during the last
2 years of the study [Lore et al., 1998]).
In the same group of 934 nerves there were 6 (0.63 %)
with permanent paralysis of the recurrent laryngeal
nerve and 53 (5.67%) with temporary paralysis. There
was zero incidence of bilateral permanent or temporary
paralysis. Corticosteroids (preoperative and intraopera-
tive methylprednisolone; postoperative Dosepak) signif-
icantly reduced the incidence of temporary bowing as
well as temporary paralysis of the recurrent laryngeal
nerve.
The superior pole vessels are occluded by using a
proximal tie and a distal suture ligature. No clamp is
placed on the proximal stump of the vessels. This mini-
mizes the possibility of injury to the nerve and avoids
the catastrophe of a clamp slipping off the stump prior
to ligature. The vessels are transected along the dotted
line. If feasible, the artery and vein are ligated sepa-
rately to prevent the formation of an arteriovenous
fistula. This also aids in the prevention of injury to the
extemal branch of the superior laryngealnerve (Thompson
and Harness, 1970). Ifthe parathyroid glands were not
identified, the thyroid lobe is carefully scrutinized for
subcapsular parathyroids, as previously discussed.
N The wound is then irrigated with normal saline
and examined for bleeding sites. Cottonoid strips are
utilized for sponging over the nerve. Hemostasis must
be complete. Care is taken not to dislodge parathyroid
glands nor allow them to become adherent to gauze.
A Jackson-Pratt suction drain is brought out through a
small opening lateral to the strap muscles and through
the lateral end of the skin incision. The second (strap
muscles) and first layers of cervical fascia are approxi-
mated with interrupted absorbable sutures, and the
skin is closed in two layers with fine absorbable sutures
and 5-0 or 6-0 nylon.
Before closure, the wound is filled with saline and
observed for any bleeding (especially venous). The
Valsalva maneuver is helpful: ask the anesthesiologist
to inflate the lungs and to close the exhaust valve.
Pressure on the chest then will increase the venous
pressure to detect any vein that may be open. lighten-
ing the anesthesia to induce "bucking" may serve the
same purpose.
Recently there has been a trend not to drain thy-
roidectomy wounds. It is true that Penrose drains are
minimally helpful for drainage purposes. The main
issue is postoperative bleeding, which can cause airway
obstruction and death. (Two such sequelae have been
noted by other excellent thyroid surgeons.) Hence, the
Jackson-Pratt drains with suction are necessary. The

one drawback is puckering of the skin edges at the
drain site: careful approximation after the drain is
removed is necessary.
o Cross section depicts the relationship of the thick
posterolateral suspensory ligament with the recurrent
laryngeal nerve branches just posterior to the liga-
ment. Anterior and/or posterior to the ligament are
vessels that must be meticulously ligated, avoiding
injury to the recurrent laryngeal nerve. The dotted
lines indicate the inconstant lateral leaf of the liga-
ment. The branches of the nerve may thus be encased
to a greater or lesser extent within the ligament, if, in
fact, there is a lateral leaf. Deep to the ligament and
the nerve is a portion of the thyroid gland that can
extend behind the esophagus or encroach on the
tracheoesophageal sulcus. Thyroid tissue may be
enmeshed within the ligament and attached to the
trachea, where it defies removal because of the prox-
imity of the recurrent laryngeal nerve.
ENDOCRINE SURGERY
Vessels
In extensive fibrosing Hashimoto's disease, it has
been necessary in one patient to use the operation
microscope to dissect and free the recurrent laryngeal
nerve from the extremely fibrotic reaction surrounding
the posterolateral suspensory ligament. The ideal instru-
ments for this dissection are fine scissors and micro-
surgical instruments or a very firm dissection clamp.
After the patient has recovered from the anesthesia,
the endotracheal tube has been removed, and the patient
is able to phonate, the vocal cords are examined with a
fiberoptic laryngoscope for mobility and bowing of the
vocal cords. This will detect any impairment of vo'cal
cord mobility as well as the very, very rare arytenoid
dislocation (secondary to anesthesia), which can cause
vocal cord dysfunction and mimic paresis or paralysis
(see p. 906).
Complications
• Refer to Complications of Thyroid Surgery, page 963.
 ENDOCRINE SURGERY
Subtotal Thyroid Lobectomy
(Fig. 18-10)
There is virtually no reason for this procedure except
in a very, very rare instance. For example, to leave a
portion of the thyroid lobe is not acceptable in sus-
pected or outright cases of thyroid carcinoma nor in a
case of multinodular goiter, because in both instances
secondary operations are difficult, thus placing the
recurrent laryngeal nerve and the parathyroids in
jeopardy. There are a number of articles pointing out
that injury to these two structures are more common in
subtotal thyroidectomy than in total thyroidectomy,
depending on the expertise of the surgeon. Neverthe-
less, one can almost never say never. Hence, the proce-
dure is described.
Highpoints (See pp. 936 and 937)
1. Avoid deep clamping and deep sutures in the remain-
ing wedge of thyroid gland that overlies the recur-
rent laryngeal nerve.
2. Isolation of the recurrent nerve only at the level of
the inferior thyroid artery does not ensure that the
nerve cannot be injured. At this level the nerve may
already have branched into abductor and adductor
fibers (this designation is controversial), and the nerve
identified may be only one branch.
3. Under no circumstances should blind clamping be
done to prevent hemorrhage. Direct pressure with
proximal dissection of the vessel must be done in a
dry field.
Subtotal lobectomy is not indicated when only one
lobectomy is to be performed, regardless of the pa-
thology. According to some authors it is indicated for
benign disease, such as bilateral multinodular nontoxic
colloid goiter, when the other lobe is being totally
removed. This author (JML) does not agree. Secondary
operations to remove a remaining posterior wedge of
thyroid tissue are extremely difficult because of possible
injury to the recurrent laryngeal nerve and the parathy-
roid glands. Moreover, more and more patients are seen
with recurrent disease after subtotal thyroidectomy.
Proposed reasons for leaving a posterior wedge of
thyroid tissue are the following:
• To avoid injuring the recurrent laryngeal nerve as it
passes beneath the posterior suspensory ligament
• To preserve viability of the parathyroid gland
• To retain thyroid function
None of these objectives, and especially not the first
and last, is always achieved. In addition, patients with
multinodular nontoxic goiter are given thyroid hormone
replacement. The author (JML) does not use subtotal
lobectomy in bilateral disease; total thyroidectomy is
preferred. There is recent evidence that subtotal thy-
roidectomy may be prone to more complications than
total thyroidectomy (Baker and Hyland, 1985; Chonkich
et aI., 1987). When one lobe is removed, hypoparathy-
roidism is not the issue.
A An incision is made about two fingerbreadths
above the clavicles, preferably in a natural skin crease.
A piece of silk may be pressed against the skin to
outline a graceful curve. A cross hatch is gently marked
in the midline. As in Figure 18-9B to D, the thyroid
incision is extended and strap muscles are separated in
the midline.
B If necessary, the strap muscles are transected at
their superior level to avoid injury to the ansa
hypoglossi. The lateral border of the strap muscles is
thus separated from the anterior border of the ster-
nocleidomastoid muscle at the upper third of the
wound. This incision is not carried to the lower por-
tion, because unnecessary sacrifice of the ansa hypoglossi
and accompanying vessels would occur. Angulated
thyroid muscle clamps are then placed across the
upper third of the strap muscles. These muscles are
transected along the dotted line, or they are retracted
without transection. The latter usually is sufficient for
adequate exposure.
C With careful blunt dissection, the recurrent nerve
is identified in the lower portion of the wound. The
inferior thyroid vein or veins are ligated. The middle
thyroid vein is seen emptying into the internal jugular
vein. This vessel may be ligated and divided at this
stage or later. The dissection continues as depicted in
Figure 18-9F to j, or the dissection can proceed as
follows in D and E.
D With a slender finger retractor and using blunt
dissection, the superior pole vessels are skeletonized.
Extreme care is taken, because small vessels in this area
may be avulsed. Blind clamping may injure the
external branch of the superior laryngeal nerve (see
Fig. 18-9K to M). A small Mixter clamp is inserted
beneath the vessels. If possible, the artery and veins
are ligated separately, each with two ligatures, the distal
one preferably suture ligature. This, combined with
gentle downward traction (see Fig. 18-9L and M)
avoids injury to the external branch of the superior
laryngeal nerve. A clamp is used on the stump of the
vessels remaining on the gland. During this entire
maneuver, traction is placed on the gland using gauze
without insertion of any type of instrument in the
gland itself. The vessels are then transected distal to
the suture ligature.

Strap muscles
Sternothyroid m.
Sup. thyroid a. and v.
FIGURE 18-10
E The middle thyroid vein has been ligated with a
proximal tie and distal suture ligature and has been
divided. With the entire recurrent nerve under vision,
the inferior thyroid artery is skeletonized using a small
Mixter clamp. The relationship of this artery to the recur-
rent nerve is so varied that the only dictum to follow is
complete visualization, remembering that both artery
and nerve may be branched and intertwined. The nerve
may reach the vicinity of the thyroid gland directly on
ENDOCRINE SURGERY
Cricothyroid muscle and
ext. branch sup. laryngeal n.
a lateral horizontal plane from the vagus nerve without
being recurrent. Hence, extreme care is needed. The
artery or its branches are then ligated and divided. The
parathyroid gland or glands may be seen as tan or
caramel-colored, ovoid, flattened structures: 3 to 6 mm
in length, 2 to 4 mm in width, and 0.5 to 2 mm in thick-
ness. More often than not they will be hidden behind
the remaining posterior portion of the thyroid lobe.
Continued
 ENDOCRINE SURGERY
Subtotal Thyroid Lobectomy
(Continued) (Fig. 18-10)
F The lobe is reflected medially, and an incision is
made across the thyroid to the trachea after fine clamps
have been placed at vessel sites. The exposed recur-
rent nerve is kept in view during this step. The clamps
on the remaining posterior wedge of thyroid must not
penetrate deeply lest injury to the nerve occurs. By the
same token, any suture ligatures placed in this wedge
of remaining thyroid must not be deep. It is difficult to
state exactly how much thyroid tissue should remain;
roughly, a piece about 2 to 3 cm in length and about
1.5 cm wide is left. The depth extension is impossible
to judge. Thyroid tissue could extend behind the trachea
or the esophagus or both, hence the high recurrence
of hyperthyroidism in Graves' disease with subtotal
thyroidectomy plus the high incidence of recurrent or
persistent carcinoma of the thyroid. This also hampers
the effect of a radioactive iodine treatment in the
follow-up treatment of thyroid carcinoma.
G The thyroid lobe is now reflected laterally, and the
isthmus is transected close to the opposite lobe, thus
removing the entire isthmus between a series of fine
clamps. The incision is carried upward and laterally
to transect the anterior suspensory ligament (see Fig.
18-9H and I). The remaining attachments to the trachea
are separated by sharp dissection.
H An alternate method to transect the isthmus is
depicted. Here, the lobe is first separated from the
trachea, and then the isthmus is cut from the opposite
lobe between fine clamps. This technique is used in a
bilateral subtotal thyroid lobectomy, a procedure not
performed by the author. The opposite lobe is dissect-
ed in similar fashion. Another alternate method is to
transect the thyroid isthmus as the initial step in the
mobilization of the thyroid lobe before identification
of the recurrent laryngeal nerve. Actually, this may be
necessary when a very large bulky gland, especially
with substernal extension, prevents the delivery of the
inferior pole of the thyroid. In these circumstances,
the recurrent laryngeal nerve cannot be identified at
the superior thoracic inlet until this transection of the
isthmus is performed, and the inferior pole is then
delivered superiorly.
Fine suture ligatures are used for hemostasis.
J The transected strap muscles are approximated
with two mattress sutures of 3-0 silk. The fascia that
envelops the strap muscles is approximated in the
midline. A small rubber tissue drain is brought out
between the strap muscles and the sternocleidomas-
toid muscle and through the lateral aspect of the skin
incision. The platysma muscles are closed as a separate
layer with 4-0 chromic gut. The skin is approximated
with 6-0 nylon.
Before closure, the wound is filled with saline and
observed for any bleeding (especially venous). The
Valsalva maneuver is helpful in this and can be done
by asking the anesthesiologist to inflate the lungs and
close the exhaust valve on the anesthesia equipment.
Pressure on the chest then will increase the venous
pressure, which allows detection of any vein that may
be open. Lightening the anesthesia to induce "buck-
ing" may also serve the same purpose. After the patient
has recovered from anesthesia with endotracheal tube
removed and is able to phonate, the vocal cords are
examined for mobility and bowing with a fiberoptic
laryngoscope.
Complications
• Refer to Complications of Thyroid Surgery. page 963.
 ENDOCRINE SURGERY

Cricothyroid muscle with

ext. br. sup. laryngeal n.

Int. jugular v.

Stump infothyroid artery Recurrent laryngeal n. Common carotid a.

PARATHYROID GL.
FIGURE 18-10
 ENDOCRINE SURGERY
Modified Radical Neck Dissection
with Preservation of the
Sternocleidomastoid Muscle
and the Spinal Accessory Nerve
(After Marchetta et aI., 1970)
(Fig. 18-11)
Indications
This operation is usually preferred for metastatic disease
related to well-differentiated papillary and follicular
carcinoma of the thyroid, and for MCT in the absence
of significant and invasive metastatic cervical lymph
node disease. A classic radical neck dissection is per-
formed when the neck has been significantly violated
and is considered for invasive metastatic MCT, invasive
tall cell papillary and widely invasive Hiirthle cell car-
cinoma of the thyroid, primary squamous cell carcinoma
of the thyroid, and anaplastic carcinoma. Modified
radical neck dissection for the control of metastatic
squamous cell carcinoma is not endorsed by this author
(JML) , nor is the so-called functional neck dissection.
Classic radical neck dissection is rarely performed for
cervical metastasis in papillary carcinoma. However, if
there is invasion of the sternocleidomastoid muscle
and/or breakthrough of the deep cervical fascia, this
operation is warranted. This is particularly also appli-
cable to the well-differentiated carcinomas that are con-
sidered "bad" or "ugly." If there is significant superior
mediastinal adenopathy that extends beyond the reach
of the suprasternal approach, a complete anterior supe-
rior mediastinal node dissection is also warranted. The
basic problem in the evaluation of statistics that com-
pare the standard radical neck dissection with the
modified neck dissection is that in most reports the
latter procedure is combined with radiotherapy whether
or not nodes are positive clinically or histologically
whereas the former procedure is done without radio-
therapy. This confuses the issue. In many patients, the
modified neck dissection combined with radiotherapy
is performed for both clinically and histologically nega-
tive necks. When radiotherapy is utilized, the surgeon
must be certain that the technique of radiotherapy is of
the highest caliber. Danger lurks with less than optimal
radiotherapy. Unfortunately, the issue is not resolved,
because control of cervical metastasis is still a formi-
dable problem, even when radical neck dissection is
combined with radiotherapy and chemotherapy specif-
ically in squamous cell carcinoma. (See the discussion
of modified radical neck dissection, pp. 802 and 803.)
Highpoints
I. The factors are the same as with standard radical
neck dissection.
2. Identify the spinal accessory nerve in the inferior
portion of the posterior triangle just before it enters
the trapezius muscle.
3. Transect the sternocleidomastoid muscle caudad to
offer an improved visualization of the deep struc-
tures. Other modifications of this operation do not
transect the muscle. Rather, the muscle is retracted.
The author does not perform this latter type.
4. Preserve the cervical nerve contribution from as high
as the third cervical to the first thoracic (Piersol,
1930) to the spinal accessory nerve if motor function
is verified.
5. Remember there are numerous deviations from the
so-called normal anatomy in regard to the spinal
accessory nerve and its relationship to the internal
jugular vein and its motor branch to the sternoclei-
domastoid muscle and the trapezius muscle (Piersol,
1930).
A This modified radical neck dissection is modeled
after that described by Marchetta and colleagues
(1970). The skin flaps containing the platysma muscle
are elevated; the incision (AI) is usually the Lahey type.
This form of modified neck dissection is utilized with
metastatic well-differentiated carcinoma of the thyroid.
Depicted is the exposed anatomy. The dotted line
indicates the incision through the anterior sheath of
the sternocleidomastoid muscle. Thus, the muscle is
elevated out of its entire sheath. The sheath is removed
with the contents of the neck dissection. Stay sutures
are in the reflected edges of the sheath. N depicts the
author's modification of the skin elevation in that the
skin is left attached to the sternocleidomastoid muscle,
forming a myocutaneous flap and both are then reflect-
ed superiorly. There could be a theoretical objection to
this technique in that nodes between the platysma
muscle and the anterior sheath of the sternocleidomas-
toid muscle are not removed. The author has not detect-
ed any such nodes in metastatic well-differentiated
carcinoma of the thyroid. The posterior portion of the
muscle sheath is removed with the neck contents.
Continued
 ENDOCRINE SURGERY

MANDIBULAR BRANCH FACIAL N ..

.Cr ~I
/
/

A2
FIGURE 18-11
 ENDOCRINE SURGERY
Modified Radical Neck Dissection
with Preservation of the
Sternocleidomastoid Muscle
and the Spinal Accessory Nerve
(After Marchetta et al., 1970)
(Continued) (Fig. 18-11)
B The sternocleidomastoid muscle is transected
inferiorly leaving a 1.5- to 2-cm portion attached to
the sternum and the clavicle to facilitate reapproxi-
mation at the end of the dissection. As the muscle is
elevated, the fascia that forms the anterior and pos-
terior sheath envelope of the muscle is left in place
along with the fascia covering the anterior and pos-
terior triangles of the neck. Before the muscle is dis-
sected superiorly, the spinal accessory nerve is iden-
tified in the inferior portion of the posterior triangle.
Several sensory branches of the cervical plexus are in
close proximity to the spinal accessory nerve. Verifi-
cation of the spinal accessory nerve is checked if neces-
sary with a nerve stimulator. The elevation and dis-
section of the sternocleidomastoid muscle is now
completed superiorly to its attachment to the mastoid
process. There may be a motor contribution from C2,
C3, and C4 (possibly as low as T1) to the spinal
accessory nerve. This can be verified with a nerve
stimulator, and, if in fact it is a motor contribution, it
is best that this contribution is left intact. During this
dissection, the external jugular vein is transected,
because the vein is usually external to the muscle. Care
is taken to preserve the spinal accessory nerve, espe-
cially the point at which it passes through the ster-
nocleidomastoid muscle superiorly. The course of the
nerve through the muscle is variable. Superiorly, mus-
cular branches of the occipital artery to the sternoclei-
domastoid muscle are preserved if feasible. This vessel
lies deep to the splenius capitis muscle, being a branch
of the external carotid artery.
C The dissection of the neck contents commences
inferiorly with double ligation (suture ligation and tie)
of the internal jugular vein as is done in a classic radical
neck dissection. This vein with lymph nodes and fascia
and omohyoid muscle is dissected superiorly exactly as
is done in a classic radical neck dissection (Marchetta
and colleagues [1970] usually preserve the internal
jugular vein). As the spinal accessory nerve is dissected,
any nodes along this nerve are sent for frozen section.
If they are positive for metastatic carcinoma, a decision
is then made regarding sacrifice of the spinal accessory
nerve. If the nodes can be adequately removed from
the spinal accessory nerve, then the nerve is preserved.
Again, it must be noted that there may be consider-
able variations relative to the anatomy of the spinal
accessory nerve. This nerve may in fact not pass
through the sternocleidomastoid muscle; in one
patient the nerve terminated in the sternocleidomas-
toid muscle, the trapezius muscle being supplied by
the third and fourth cervical branches as verified by
Piersol (1930). If the nerve is transected, neurorrhaphy
is suggested, if feasible. This procedure is worthwhile,
because return of function has been observed.
Continued
 ENDOCRINE SURGERY

POSTERIOR FASCIA OF
TERNOCLEIDOMASTOID M.
; TRAPEZIUS M.

SCALENUS MEDIUS M.
INT. SCALENUS
JUGULARV. POSTERIOR M.
11th NERVE
SCALENUS
TICUSM.
LE :TOR
~
SCA VLAE M.

PHRENIC N.

SUBCLAVIAN V.
C
FIGURE 18-11 Continued
 ENDOCRINE SURGERY

Modified Radical Neck Dissection

not to cross the carotid artery. Depicted is the very
with Preservation of the
variable motor contribution to the spinal accessory
Sternocleidomastoid Muscle nerve from C2.
and the Spinal Accessory Nerve
(After Marchetta et al., 1970) Ideally, this modified neck dissection is combined
(Continued) (Fig. 18-11) with total thyroidectomy for well-differentiated thyroid
cancer. The strap muscles mayor may not be resected
depending on the local extent of disease. If the tumor
D This shows the complete neck dissection including has broken through the thyroid capsule, or if there is
the contents of the submandibular triangle. To include any question regarding strap muscle invasion, these
the contents of this triangle may be difficult when the muscles are removed concomitantly during the thy-
myocutaneous flap is used. This latter portion of the roidectomy and neck dissection. This technique is des-
dissection is optional, depending on the findings at cribed in Figure 18-12C to I.
the time of surgery. Nevertheless, metastasis to the Mediastinal dissection may likewise be combined
submandibular salivary gland has occurred in Hurthle with either of these neck dissections when there is evi-
cell carcinoma. Closure consists of reapproximation of dence of metastatic disease in the anterior-superior
the sternocleidomastoid muscle with mattress sutures mediastinum beyond a suprasternal approach. This
of 3-0 silk. Suction catheters are utilized, with care taken requires a median sternotomy or resection of the medial
third of the clavicle or a combination of both.

SPLENIUS CAPITIS M.
12th NERVE
LONGUS CAPITIS M.
11th NERVE
TRAPEZIUS M.
LEVATOR SCAPULAE M.
SCALENUS
STERIOR M.

o
FIGURE 18-11 Continued

Total Thyroidectomy Without
or With Radical Neck Dissection
(Fig. 18-12)
Figure 18-12A to H describes total thyroidectomy. This
is usually combined with a modified neck dissection
(see Fig. 18-11) for lateral cervical metastasis. The strap
muscles on the ipsilateral side are included, depending
on histology and invasion (Fig. 18-9 depicts the basic
total thyroid lobectomy). Figure 18-121 and J describes
a classic radical neck dissection including resection of
the ipsilateral strap muscles. Other details relative to
radical neck dissection are in Figure 16-3. This proce-
dure is relegated to highly malignant thyroid carcino-
mas, for example, medullary carcinoma with evidence
of invasive metastatic disease, squamous cell carcinoma
of the thyroid, and, if resectable, anaplastic carcinoma
of the thyroid. It may also be utilized in papillary car-
cinoma in which there has been invasion of the ster-
nocleidomastoid muscle and/or the fascial planes of
the neck as well as tall cell papillary and Hiirthle cell
carcinomas in advanced stages. For additional details,
see Figure 18-9, which describes total lobectomy and
shows steps that are easily adaptable to total thyroidec-
tomy and are actually the same as for total thyroidectomy,
because both lobes are removed in the same fashion.
The only difference is that ideally with carcinoma, the
isthmus is not transected. Obviously, preservation of the
continuity of the entire gland is only feasible if the
diagnosis of carcinoma is verified beforehand or intra-
operatively. When total thyroidectomy is performed for
Graves' disease (which is the author's preference) or
any other benign disease such as bilateral multinodular
goiter (also the author's preference), transection of the
Hyoid bone
FIGURE 18-12
ENDOCRINE SURGERY
isthmus is the surgeon's choice and depends primarily
on mobility and exposure.
The depicted total thyroidectomy and classic radical
neck dissection is relegated to those patients with
medullary carcinoma with positive nodes, to those with
anaplastic carcinoma who are deemed to have resectable
disease, to those with squamous cell carcinoma of the
thyroid, and to those with well-differentiated carcinoma
who have evidence of invasion of the sternocleidomastoid
muscle, either by the natural spread of the disease or
as a result of violation of the neck by a previous surgi-
cal procedure.
A modified radical neck dissection that preserves the
sternocleidomastoid muscle and the eleventh cranial
nerve (see Fig. 18-11) is the operation of choice for
well-differentiated thyroid carcinoma with clinical and/
or histologic evidence of nodal metastasis. Node picking
is condemned. Elective neck dissection is not performed.
A Several incisions are adaptable (see Fig. 16-6A to
K), specifically the Lahey (C), MacFee (E), Slaughter
(G), and S-curved vertical limb (H). Depicted is the
Lahey incision. The dotted line is optional, depending
on exposure. The incision is excellent; the only draw-
back is the keloid type scar of the vertical posterior
limb, which occurs about 50% of the time. Place this
limb as far posterior as possible.
B Skinflaps are dissected with the exposure as depict-
ed. The platysma muscle is preserved in the skin flaps.
The strap muscles are separated by sharp dissection in
the midline along the dotted line.
Continued
 ENDOCRINE SURGERY
Total Thyroidectomy Without
or With Radical Neck Dissection
(Continued) (Fig. 18-12)
Highpoints
1. Refer to pages 936 and 937 and to Anatomic Con-
siderations, page 896.
2. With carcinoma, remove all pretracheal, paratracheal,
tracheoesophageal, cricothyroid, paraglandular, and top
superior mediastinal nodes-central neck dissection.
3. Order frozen section of any nodes that might indi-
cate further extent of the surgical resection (e.g., the
top superior mediastinal nodes).
4. In carcinoma of the thyroid be sure the pyramidal
lobe and thyroglossal duct tract if present is removed;
otherwise, residual normal tissue may enlarge and
be the cause of abnormal uptake.
C With the left radical neck dissection, the right lobe
of the thyroid is dissected first. As in a total thyroid
lobectomy, the recurrent laryngeal nerve is identified
first in the lower portion of the wound between the
inferior pole of the thyroid and the superior thoracic
inlet. The inferior thyroid vein or veins have been ligated
and divided. The relationship of the inferior thyroid artery
to the recurrent nerve is so varied that careful iden-
tification of both structures is the only key to safe dis-
Middle thyroid v.
Inferior
parathyroid gl.
Inf. thyroid a.
Stump middle
thyroid vein
Inferior
parathyroid gl.
Recurrent laryngeal n.
FIGURE 18-12 Continued
section. The parathyroid glands are identified and pre-
served or reimplanted. The inferior parathyroid gland
is usually on a plane anterior to the recurrent laryngeal
nerve. It is often located near the inferior pole of the
thyroid embedded in adipose tissue with its vascular
supply from the inferior thyroid artery. For further
details applicable to total lobectomy, see Figure 18-9.
D The middle thyroid vein has been ligated and divided.
Here the technique differs from the total thyroid lobec-
tomy in that the lobe is mobilized laterally rather than
medially. The isthmus is not transected. This presupposes
a preoperative or intraoperative diagnosis of cancer.
Using a small Mixter clamp, the superior pole vessels
are skeletonized. The external branch of the superior
laryngeal nerve to the cricothyroid muscle is preserved
following the technique described in Figure 18-9L and
M. The thin areolar tissue deep and lateral to the supe-
rior lobe is separated by blunt dissection. The division
of the recurrent laryngeal nerve into abductor and
adductor fibers (this designation of the branches is
controversial) usually is now apparent. The strap mus-
cles on the right side-contralateral to the neck dissec-
tion-may be preserved if there is no evidence of inva-
sion of the tumor and they are not adherent to the cap-
sule. Otherwise, they are removed, as are the strap muscles
on the left side-homolateral to the neck dissection.
Continued
Sup. thyroid a. and V.
D
Stump Inf.thyroid a.

Total Thyroidectomy Without
or With Radical Neck Dissection
(Continued) (Fig. 18-12)
E As the lobe is dissected, it is retracted medially by
blunt pressure with a finger. Under no circumstances
is any type of clamp used that would perforate the
capsule of the gland. The thin inconstant lateral
portion of the posterior suspensory ligament (Berlin,
Gruber, Henle, and Berry) is carefully elevated with a
small Mixter clamp, avoiding injury to the two or more
branches of the recurrent nerve that lie deep to the
ligament. The ligament is then transected with the
nerve in full view.
F The thick (pedicle of the thyroid gland) posterior
suspensory ligament is transected. Some nuisance
bleeding may occur from branches of the inferior
thyroid artery and other vessels that are in very close
proximity to the branches of the recurrent laryngeal
nerve. Very selective clamping is possible, after pres-
sure, which will usually control the bleeding. The infe-
rior laryngeal artery arises from the inferior thyroid
artery. The anterior suspensory ligament has been
detached (see Fig. 18-91). The terminal branches of the
inferior thyroid artery as they enter the thyroid gland
are ligated, thus preserving the main trunk of the
artery and the artery to the inferior and possibly the
superior parathyroid glands. See the discussion of the
parathyroids in Figure 18-14.
Continued
Inf.laryngeall
FIGURE 18-12
ENDOCRINE SURGERY
It is at this point of the surgery that certain modifi-
cations are performed, depending on the histology of
the tumor. If the tumor is follicular, or for that matter
papillary, limited invasion of the trachea, esophagus,
and/or the larynx can be locally removed without
radical resection. If the unilateral recurrent laryngeal
nerve is totally encased in tumor and the vocal cord is
immobile as determined preoperatively, then resect the
nerve. If the nerve can be dissected from the tumor and
there is some mobility of the vocal cord, then preserve
the nerve. The operation may require the use of an
operating microscope for the resection. This type of
surgery is mainly for the low-grade "good" types of
histologic carcinomas (see p. 918). Surgery is extended
and radical if the histologic diagnosis falls into the
"bad" or "ugly" histologic types (e.g., tall cell papillary,
widely invasive Hiirthle cell, and widely invasive follic-
ular and insular carcinomas, as well as the medullary,
squamous cell, and anaplastic [if resectable] carcinomas).
In these histologic types of carcinomas unilateral sacri-
fice of the recurrent laryngeal nerve is performed when
there is vocal cord immobility. No attempt is made to
preserve the nerve. Any residual tumor is later treated
with 1311 with initial doses of 125 to 150 mCi, depending
on uptake and location of the uptake after a scan of 3
to 5 mCi of 131) administered 5 to 6 weeks postoperatively
with an elevated TSH level of at least 35 to 40 IlU/mL.
Papillary carcinoma without obvious follicles can have
adequate radioiodine uptake (Beierwaltes, 1978).
The tall cell papillary carcinoma that is a rare form
of papillary carcinoma does not usually take up radio-
iodine (Beierwaltes, 1978), and the judgment of the
Branches of
recurrent
laryngeal n.
Post. Suspensory Iig.thyroid gl.
(BERRY)
Continued
 ENDOCRINE SURGERY
Total Thyroidectomy Without
or With Radical Neck Dissection
(Continued) (Fig. 18-12)
G As the isthmus is separated from the trachea, the
left sternohyoid, sternothyroid, and sternocleidomastoid
muscles are transected at their origins. The thyroid ima
and inferior thyroid veins are ligated and divided. With
the thyroid gland retracted upward, the left recurrent
laryngeal nerve and the carotid sheath, with the inter-
nal jugular vein, common carotid artery, and vagus
nerve, are exposed.
H If there has been no gross evidence of disease
outside the deep aspect of the thyroid capsule, the left
lobe is dissected free of the trachea, recurrent nerve,
and esophagus by ligating and transecting the branches
of the inferior thyroid artery and by cutting the poste-
rior suspensory ligament, as is done in a total thyroid
lobectomy (see Fig. 18-9K). On the other hand, the
disease may have extended to the recurrent nerve and
become affixed to the esophagus, trachea, or both.
Continued
Ree. laryngeal n.
FIGURE 18-12 Continued
surgeon is the determining factor as to how extensive
the resection should be. If the tumor is medullary, ana-
plastic, or squamous cell carcinoma, a more aggressive
resection of these involved structures is performed,
because none of these usually will take up radioiodine.
Beierwaltes (personal communication) has noted variants
of medullary carcinoma that have areas of papillary
and follicular carcinoma and, thus, may concentrate
radioiodine. It is a moot question as to how extensive
the resection should be in the case of anaplastic carci-
noma, because the outlook in this disease is very grim.
On the other hand, all reasonably resected disease
should be removed along with a total thyroidectomy if
surgically feasible. Squamous cell carcinoma demands
a very formidable resection, because it, too, has a very
poor out-look. Involvement of the trachea, larynx, and
esophagus might well require resection. Some forms
of Hiirthle cell carcinoma (a variant of follicular carci-
noma) concentrate radioiodine well, but most concen-
trate it very poorly. Some do not concentrate it at all.
Therefore, more extensive resection and/or external
radiation is the method of therapy. Hiirthle cell carci-
noma has a poorer prognosis than follicular carcinoma.
In any event, a total thyroidectomy with central node
Int. jug. vein

Total Thyroidectomy Without
or With Radical Neck Dissection
(Continued) (Fig. 18-12)
dissection as the minimal basic surgical procedure should
be performed in all types of thyroid cancer. Postoper-
atively, the patient should be kept off thyroid hormones
for 6 weeks to allow for elevation of serum TSH levels.
Radioiodine uptake is then utilized.
The nerve, if directly invaded and associated with
paralysis of the vocal cords, with an ellipse of trachea
or esophagus, is resected as necessary. The defect in the
trachea may serve for a tracheostomy site (if at all indi-
cated), whereas the esophagus is closed with interrupt-
ed or continuous Connell-type sutures of 4-0 chromic
gut. The internal jugular vein is doubly ligated above
and below the site of transection as is done in the
standard neck dissection (see Fig. 16-3). It is important
to remove all lymph nodes in the paraglandular, para-
tracheal, tracheoesophageal, and top superior mediasti-
nal areas, because these may be the prime area of
metastasis. If these nodes are grossly suspicious, frozen
section is performed and further evaluation of superior
mediastinal nodes is done. Mediastinoscopy may be of
value (see Fig. 19-8). If disease extends into the medi-
astinum, see Figure 19-10.If the larynx and the hypophar-
ynx are directly involved, partial laryngectomy (see
Fig. 20-11), total laryngectomy (see Fig. 20-18), or partial
pharyngectomy may become necessary in squamous
cell carcinoma and possibly but very rarely medullary
carcinoma and Htirthle cell carcinoma but certainly not
in those tumors that take up 1311. Invasion of tall cell
papillary carcinoma would best be treated by preserv-
ing the larynx and using a trial of 131[ or external radia-
tion, even though the tall cell variety does not usually
pick up 1311, because there may be follicles in the por-
ENDOCRINE SURGERY
tion invading the larynx. The author (JML) has p~rform-
ed only one total laryngectomy in well-differentiated
carcinoma of the thyroid and then only when 1311 treat-
ment failed.
A NO.6 tracheostomy tube is inserted (if indicated),
and catheters for suction are then placed in the wound.
The edges are approximated with continuous 3-0 gut
for the platysma muscle and continuous 5-0 or 6-0
nylon for the skin. More often than not, depending on
the extent of resection, tracheostomy is not necessary
if both recurrent laryngeal nerves are preserved and
there was no paralysis preoperatively.
The thyroid gland is carefully scrutinized for sub-
capsular parathyroid glands and if any are found, they
are reimplanted in the anterior edge of the trapezius
muscle and marked with a metal clip and black silk
suture. When it is suspected that all parathyroid tissue
has been removed, hypoparathyroidism must be antici-
pated in the immediate postoperative period.
Before closure, the wound is filled with saline and
observed for any bleeding (especially venous). The
Valsalva maneuver is helpful in this and can be per-
formed by asking the anesthesiologist to inflate the
lungs and close the exhaust valve on the anesthesia
equipment. Pressure on the chest will then increase
the venous pressure to allow for detection of any vein
that may be open. Lightening the anesthesia to induce
"bucking" may also serve the same purpose. After the
patient has recovered from anesthesia, the endotra-
cheal tube has been removed, and the patient is able to
phonate, the vocal cords are examined with a fiberoptic
laryngoscope for mobility and bowing.
Complications
• See Complications of Thyroid Surgery, page 963.
 ENDOCRINE SURGERY
Total Thyroidectomy Without
or With Radical Neck Dissection
(Continued) (Fig. 18-12)
I, J The technique of the standard neck dissection
(see Fig. 16-3) is then followed except that usually the
11th nerve can be preserved (see discussion of modi-
fied neck dissection and Fig. 18-11). The sternothyroid
and sternohyoid muscles along with the omohyoid
muscle are transected at their insertions and removed
in continuity with the thyroid gland and contents of
the neck dissection. The thyrohyoid muscle is left intact,
as are the internal branch (sensory to the larynx) and
external branch (motor to the inferior pharyngeal con-
strictor and cricothyroid muscles) of the superior laryn-
geal nerve (see Fig. 20-16K to M) which passes deep
to the external carotid artery and close to the superior
thyroid artery and vein. The superior thyroid artery
is ligated and transected close to its origin from the
external carotid artery. The accompanying vein may
be resected in continuity with the internal jugular vein
after superior tributaries are divided.
Autonomous Thyroid Nodule
An autonomous thyroid nodule is a single mass in the
thyroid gland that functions independently of ISH
stimulation. It usually appears "hot" on the thyroid 1231
scan, with the remainder of the gland showing a very
low uptake. The incidence of malignancy is low but
possible in any hot nodule, as it is in toxic goiter. The
previously recommended suppression of the nodule with
exogenous thyroid hormone is not necessary because
the diagnosis is usually straightforward with the presence
of a hot nodule and suppression of TSH on laboratory
testing. The suppression test would be contraindicated
if hyperthyroxinemia and clinical toxicity were present.
Ablation is indicated when the nodule becomes
larger, reaching 3 em or more, and/or the patient is toxic.
Ablation can be achieved with radioactive iodine or
total thyroid lobectomy and isthmectomy. The latter is
preferred by this author if for no other reason than that
incidence of malignancy, although low, nevertheless
can exist. In addition, a histologic diagnosis can be
obtained. Another indication for treatment is long-term
persistence of disease, leading to irreversible atrophy of
normal thyroid parenchyma.
Functional autonomy may occur in toxic multi-
nodular goiter (Plummer's disease, p. 934) and merits
thyroidectomy.
Endemic Goiter Not Due to Iodine
Deficiency (Beierwaltes)
Beierwaltes (l987a, 1987b) describes this entity as "the
most common thyroid disease in the United States ...due
to environmental goitrogens both naturally occurring
and man-made, rather than to iodine deficiency." An
example of such a goitrogen is toxic waste. Early thy-
roidectomy is indicated to avert symptoms of airway
compression as well as to prevent death from thyrotoxi-
cosis and thyroid cancer in older patients. The presence
of substernal goiter alone is a sufficient indication for
operation. A sudden increase in size causing an emer-
gency airway problem is an indication for emergency
thyroidectomy, an outcome that can be avoided by
early management.
Hashimoto's Thyroiditis (1912)-
Struma Lymphomatosa
Highlights
1. This is an autoimmune thyroiditis; the incidence is
higher in females.
2. Antithyroid antibodies are elevated. Many other
diseases also have these same elevations. The anti-
bodies usually measured are antithyroid peroxidase
(formerly antimicrosomal) and antithyroglobulin.
The antithyroid peroxidase antibodies are more
specific to underlying Hashimoto's thyroiditis.
3. Problems in diagnosis:
a. Elevated antibodies not exclusive to Hashimoto's
disease
b. Can coexist with carcinoma and toxicosis
(hashitoxicosis)
c. Usually but not always hypothyroid; may be
normothyroid or toxic (hashitoxicosis)
d. Gland is granular and may be small or enlarged
(not exclusive to Hashimoto's disease).
e. Multiple very firm nodules; carcinoma can be the
same.
t. Usually varied areas of diminished uptake on
scan; multinodular goiter can appear the same.
4. Evaluation is the same as virtually any abnormality
of the thyroid:
a. Complete head and neck examination concen-
trating on laryngoscopy and careful evaluation of
the thyroid gland and the cervical lymph nodes
b. FNA: lymphocytes and Hiirthle cells, possibly
c. Scan: solitary or multiple areas of decreased
uptake
 ENDOCRINE SURGERY

Ant. belly digastricus m.

Hyoid bone

Stemohyoid m.

Omohyoid m.

Sternothyroid m.

Trapezius m.

Stump of
infothyroid a.

Int. br. sup. laryngeal n.

Thyrohyoid m. /'

Ext. br. sup. laryngeal n. I

Cricothyroid m.
J

Esophagus

Com. carotid a.
Vagus n.
Recurrent laryngeal n.

Stump intojug. v.
FIGURE 18-12 Continued
 ENDOCRINE SURGERY
5. Decision to operate may be difficult if the diagnosis
of Hashimoto's disease is highly suspected, because
surgery by and large is not usually indicated in this
disease. Nevertheless, the reasons to operate on these
patients are the same as in any other patient with
similar findings:
a. Carcinoma suspected for any reason
b. Signs and symptoms of compression of vital struc-
tures of the neck
c. Cervical lymphadenopathy
d. Vocal cord paralysis
e. Enlarging mass
f. Previous exposure to radiation, especially
childhood
g. Suspicious FNA
h. Cosmetic reasons
6. Coexistence of Hashimoto's thyroiditis and carcinoma.
There does not appear to be a c'ausal relationship. At
times well-differentiated carcinoma has a surrounding
area of lymphocytes that may simulate Hashimoto's
disease but in fact is a reaction to the carcinoma and
not to primary Hashimoto's disease.
7. Surgery
a. Total lobectomy, if disease is limited to one lobe
(rare)
b. Total thyroidectomy, if disease is bilateral.
Surgery can be staged (e.g., when function of one
vocal cord is impaired as noted by preoperative
laryngoscopy) .
c. Sampling of central nodes for the possibility of
any metastatic carcinoma
d. Extreme caution must be exercised because of
edema and fibrosis, with special attention
laryngeal nerves (recurrent and external branch
of the superior laryngeal nerve) and parathyroid
glands; there is an increased risk of paresis and
paralysis associated with thyroidectomy.
8. In his original description Hashimoto reported
hoarseness or at least voice changes. Unfortunately,
laryngoscopy was not reported.
9. There can be increased uptake on a 1231 scan because
of lack of organification of iodine. This is not a sign
of toxicity.
Lingual Thyroid (Fig. 18-13)
Incidence
This disease has a range from 1:3000 to 1:4000 patients
with thyroid disease.
Discussion
Embryologically, lingual thyroid is located at or near
the foramen cecum at the base of the tongue. It may be
ectopic thyroid tissue in addition to the normal thyroid
gland or other ectopic thyroid tissue along the course
of the thyroglossal duct tract, or it may be the only
thyroid tissue in the patient. Hypothyroidism has been
reported to occur in 14.5% to 33% of patients with
lingual thyroid, whereas hyperthyroidism is rare. The
main problem with lingual thyroid is its potential size,
which, if large, can cause symptoms associated with
III both airway obstruction and dysphagia. Visualization
may be relatively easy, with simple examination of the
oral cavity or with a mirror that reveals a somewhat
lobulated mass, which is reddish or blue at the base of
the tongue. If the patient is symptomatic, surgical extir-
pation appears to be the treatment of choice. The patient
is then informed that thyroid hormone replacement is
usually necessary for life. Reimplantation or partial resec-
tion does not appear warranted. A mass at the base of
the tongue must be differentiated from a tumor arising
in a minor salivary gland, squamous cell carcinoma,
lymphoma, or other neoplasm.
A The base of the tongue is viewed via a suprahyoid
transpharyngeal approach. The surgical approach is
depicted via a suprahyoid incision with exposure of
the entire mass (see Fig. 21-4). A horizontal skin
incision is made in a natural skin crease in the vicinity
of the hyoid bone. Skin flaps containing the platysma
to muscle are developed only superior to the hyoid bone.
The hyoid bone need not be resected unless the thyroid
is massive and the additional exposure is necessary.
The suprahyoid muscles are transected approximately
1 em above their attachment to the hyoid bone. This
facilitates the ease of approximation of the muscles at
the time of closure. The horizontal lateral extension is
about 3 em, thus avoiding the 12th nerve and the
lingual arteries. The pharyngeal mucosa forming the
lingual wall of the vallecula is exposed.
B Through this mucosa the epiglottis and endotracheal
tube are visualized. The mucosa is incised. Bimanual
examination delineates the extent and exact position
of the lingual thyroid, which may, in fact, be off center.
A T-type incision or a horizontal incision is made
through the mucosa overlying the lingual thyroid. The
gland is dissected from the mucosa and the underlying
tongue musculature using Metzenbaum scissors.
Numerous vessels require careful ligation and/or elec-
trocoagulation. A Lahey thyroid clamp is ideal for grasping
the gland during the dissection. A clear view of the

FIGURE 18-13
demarcation between the thyroid gland and the
tongue musculature may not exist. After the gland is
removed, it is submitted for frozen section.
The mucosa is reapproximated wherever possible
over the tongue musculature. The pharyngeal mucosa
is closed with a Connell-type absorbable suture (3-0).
The suprahyoid muscles are reapproximated. The super-
ficial portion of the wound is drained with two V4-inch
Penrose drains. An elective tracheostomy is recommend-
ed, because postoperative edema and/or bleeding is
possible.
Complications of Thyroid Surgery
1. Nerve injury (Table 18-6)
a. Recurrent: may be abductor or adductor but
more often is abductor; can be temporary or
permanent.
b. External branch of the superior laryngeal nerve:
bowed vocal cord, which may be on a lower
plane than the normal vocal cord.
2. Hemorrhage: this may be prevented by increasing
the intrathoracic pressure before the wound is
closed to help identify any vein that may be open.
ENDOCRINE SURGERY
A light dressing should be applied to alert the
surgeon or nurse to any bulge or swelling, which
would indicate postoperative hemorrhage. Pressure
dressing is to be avoided.
3. Airway obstruction may occur either from the
bilateral abductor vocal cord paralysis or hemor-
rhage with tracheal compression. Flexible optical
scope examination after anesthesia should be per-
formed to evaluate whether vocal cords are mobile
and straight. This is performed immediately or
within 30 minutes after the surgery.
a. Expose the wound immediately. If swelling exists,
open the wound to evacuate the hematoma.
b. Perform mirror or optical flexible laryngoscopy.
If compromised glottic chink (from whatever cause)
is found, re-intubate or perform tracheostomy. If
it is certain that' the recurrent laryngeal nerves
were identified and preserved, re-intubation plus
corticosteroids could be used for several days. If
the integrity of the recurrent laryngeal nerves is
not certain, then immediate exploration of the
wound is recommended. This has proved suc-
cessful when both nerves were caught in the ties
around the inferior thyroid arteries by another
surgeon. The ties were relocated and nerve
function returned within 9 months.
4. Pneumothorax
 ENDOCRINE SURGERY

TABLE 18-6 Results of Surgery: Nerve Injury (N - 934 Nerves Placed in Jeopardy)

Recurrent Laryngeal Nerve Paralysis (Immobile Vocal Cord)

Permanent: 6/934 ~ 0.63%
Temporary:53/934 ~ 5.67%
External Branch Superior Laryngeal Nerve (Bowed Vocal Cord)
Permanent: 1/934 ~ 0.19%
Temporary:4/934 = 0.4%

The surgical technique described (see Fig. 18-9) affords reasonable protection of the external branch of the superior laryngeal nerve (EBSLN)
during thyroideclOmy. Routine exposure of the nerve does not appear 10 be necessary. Individual ligation of vessels is recommended
unless there are adhesions of the small vessels to the artery. Ligation of the vessels is performed in an area 1.5 x 2.0 cm immediately
proximal 10 the thyroid capsule area, which is cleared of soft tissue to protect the EBSLN. Although the function of the EBSLN appears to
be normal on mirror or optic laryngoscopy, there are other faclOrs involved in the fine-tuning of this nerve that cannot be seen on
laryngoscopy.
Data from Lore JM Jr, Kokocharov SI, Kaufman S, et al: Thirty-eight-year evaluation of a surgical technique 10 protect the external branch of
the superior laryngeal nerve during thyroidectomy. Ann 0101 Rhinol Laryngol 107: 1015-1022, 1998.

5. Hypoparathyroidism with hypocalcemia should be
treated conservatively unless symptoms are severe,
and then intravenous calcium gluconate can be used.
Otherwise several grams of calcium carbonate each
day will suffice. If calcium supplements fail to correct
the problem, calcitriol (Rocaltrol), 0.25 mg, once or
twice a day is necessary. For long-term hypocal-
cemia, vitamin B2 (50,000 units daily in two or three
doses per day) can be used. In any event, weaning
from medication should begin within several weeks,
and over a course of several weeks calcium can
suppress the PTH (see pp. 910 and 1002).
6. Hypothyroidism
7. Thyroid storm in Graves' disease (extremely rare;
must be differentiated from malignant hyperthermia,
which is also rare; see p. 65).
a. Stop manipulation of thyroid gland; stop surgery.
b. Sodium or potassium iodide, 1 to 2.5 g intra-
venously every 8 hours
c. Hydrocortisone, 100 mg stat, followed by 300
mg/day minimal dose
d. Oxygen
e. Intravenous glucose in large doses
f. Avoid hypothermia.
g. Provide fluid and basic electrolyte therapy.
h. ~ Blocker: propranolol hydrochloride: a synthetic
~-adrenergic receptor blocking agent (4 to
10 mg/kg) intravenously, not to exceed 1 mg/min,
with ECG monitoring (see drug information data
supplied with drug).
i. Other adrenergic blocking agents:
1) Reserpine: up to 2.5 mg intramuscularly, four
to six times daily
2) Guanethidine: 50 to 150 mg orally daily
J. Propylthiouracil: 600 mg stat and 200 mg every
6 hours thereafter
8. Arteriovenous fistula may occur at superior pole
vessels (reported, but no personal experience).
This complication can be prevented by ligating the
superior pole vessels at the end of the surgery and
by isolating arteries and veins and ligating them
independently. This maneuver also helps in the
prevention of injury to the external branch of the
superior laryngeal nerve (Thompson and Harness,
1970).
9. Nerve paralysis and hypoparathyroidism (based on
author's experience with these complications):
a. Laryngeal nerve paralysis after thyroidectomy. A
consecutive series in which recurrent laryngeal
nerve and external branch of the superior laryn-
geal nerve at risk (N ~ 934) has been analyzed.
All of these operations were primary procedures
in which these nerves were normal on mirror or
optical laryngoscopy before surgery. In this series
there were six patients (0.6%) with permanent
unilateral recurrent laryngeal nerve paralysis.
No patients had either temporary or permanent
bilateral recurrent nerve paralysis among the
267 patients (534 nerves) who had total
thyroidectomies.
Temporary recurrent laryngeal nerve paralysis
(none bilateral) is 9% without the use of corti-
costeroids. With the use of methylprednisolone,
40 mg, preoperatively and/or intraoperatively (up
to a total of 80 mg) and with Medrol Dosepak
postoperatively, temporary paralysis was reduced
to 3% (P < .008). The use of corticosteroids
also reduced the longest duration of the tempo-
rary vocal cord paralysis from 9 to 2 months.
Before the use of corticosteroids there were two
patients with temporary paralysis of the external
branch of the superior laryngeal nerve. One of

these patients had complete return of function;
the other had definite progressive recovery when
she died unexpectedly of a myocardial infarct.
Hence, it is considered that there is no perma-
nent paralysis of this nerve. No patient in the
group receiving corticosteroids had either perma-
nent or temporary paralysis of the external branch
of the superior laryngeal nerve.
No complications occurred as a result of the
use of corticosteroids except that these possibly
contribute to the temporary hypocalcemia. It is
granted that unilateral temporary recurrent laryn-
geal nerve paralysis has no grave consequences.
However, the bilateral temporary recurrent laryn-
geal nerve paralysis associated with total thy-
roidectomy could well have grave consequences
if the vocal cords were paralyzed in the adduct-
ed position (Le., abductor paralysis), thereby
causing compromise of the airway. A temporary
tracheostomy would very well be necessary but
should be avoided if at all possible. Hence,
corticosteroids do have a legitimate place in total
thyroidectomy. No tracheostomy was indicated
or necessary in this series. Corticosteroids can
also exacerbate diabetes (this complication did
not occur in this series) and contribute to
hypocalcemia.
b. Hypoparathyroidism after total thyroidectomy.
In this consecutive series all four parathyroids
were placed at risk during total thyroidectomy
(N ~ 66). This series of patients comprised
those in whom refined technical skills were
developed, including:
1) Extra care in the identification of the
parathyroids
2) Preservation of blood supply to the parathyroids
3) Search for parathyroids in the surgical specimen
4) Extra care in the autotransplantation of
parathyroids that require reimplantation
Of these 66 patients, 38 (58%) had normal
calcium levels postoperatively. The remaining
28 (42 %) had postoperative hypocalcemia. Of
these patients having postoperative hypocalcemia,
26 patients (39%) had temporary hypocalcemia
and 2 patients (3%) had permanent hypocal-
cemia. Of the 2 patients who had permanent
hypocalcemia, one patient (1.5%) had intermit-
tent hypocalcemia with normal PTH levels con-
sisting of mild signs and symptoms. and one
patient (1.5 %) had continuous hypocalcemia
consisting of moderate symptoms. Potential prob-
lems in management consist of (1) over-treat-
ment with calcium and vitamin 0 (Rocaltrol)
and (2) poor patient compliance.
10. Anesthesia complications: arytenoid dislocation
(see p. 906)
ENDOCRINE SURGERY
It is the opinion of the authors that total thy-
roidectomy had a lower complication rate relative
to nerve paralysis and hypoparathyroidism than
subtotal thyroidectomy. This is supported by other
reports. The argument that the operation should be
limited (especially in carcinoma) due to the higher
incidence of these complications does not appear
justified. The solution to this problem is improved
surgical training and skill of the surgeon perform-
ing thyroid surgery. This is the ultimate goal.
The reader is referred to the publications of Perzik,
White, Baker, Wells, Clark, Lennquist, Thompson,
and Beierwaltes (see Bibliography).
This is not to imply that all of these authors
agree with the author (JML) on all of the indica-
tions for total thyroidectomy, although some do.
Nevertheless, they do support the concept of the
feasibility of total thyroidectomy with an accept-
able complication rate.
11. Voice changes (Table 18-7)
12. Lifestyle changes (Table 18-8)
TABLE 18-7 Besults on Voice CIaaJaga-
QuestionDaJre In 66 Patientll (96 Nerves)
(Evaluation of Follow-Up of F1mcIion of
ExtemaI Braucl1 Superior LaryqeaI Nerve)
Voice Changes Temporary Permanent
High pitch 3 3
Hoarseness 3 1
Fatigability 3 1
14 patients (24 nerves: 9 (13.6%) 5 (7.6%)
21%)
Data from Lore JM Jr, Kokocharov Sl, Kaufman 5, et al: Thirty-
eight-year evaluation of a surgical technique to protect the
external branch of the superior laryngeal nerve during
thyroidectomy. Ann 0101 Rhinal LaryngoI107:1015-1022, 1998.
TABLE 1•...• BesultlI on LifeItyIe-
QuesdoDDalre In 66 PatieDtlI (96 Nerves)
No effect on lifestyle in 65 patients
Other patient not available for follow-up
Estimated deleterious effect of voice changes on lifestyle
is no greater than 1.5 %
Data from Lore JM Jr, Kokocharov 51, Kaufman 5, et al: Thirty-
eight-year evaluation of a surgical technique 10 protect the
external branch of the superior laryngeal nerve during
thyroidectomy. Ann Otol Rhinal Laryngol 107:1015-1022, 1998.
 ENDOCRINE SURGERY
Suggested Postoperative Orders
After Thyroid Surgery
1. Connect drain to wall suction in recovery room
then on floor to bulb suction when drainage is less
than 10 mL.
2. Water is given orally when patient is fully
responsive, then a progressive diet as tolerated.
3. A Medrol Dosepak is begun as soon as patient is
able to swallow tablets.
4. Patient is allowed out of bed when able; head may
be elevated.
5. Pain medication: as necessary.
6. If there are any symptoms of hypocalcemia (tin-
gling and/or numbness in lips or fingers or cramps
in legs), give 10 mL 10% calcium gluconate intra-
venously as a bolus over 10 minutes. Repeat 1 to
2 hours if symptoms persist. If symptoms continue,
notify physician.
7. Give 5 % glucose in Ringer's solution, 80 mL/hr.
8. Check serum calcium concentration in morning.
9. If there is bleeding or swelling in the region of the
wound, remove surgical dressing and notify
physician stat! If there is airway problem and
wound is swollen, remove sutures stat! And notify
physician; do not use a pressure dressing!
10. 1\vo small, straight clamps should be available to
clamp bleeding vessels.
11. Tracheostomy set is available at bedside.
PARATHYROID GLANDS
Pathology of the Parathyroid
Glands
John E. Asin.vatham
Embryology
The parathyroid glands are derived from the third and
fourth branchial pouches. From the third branchial
pouch the inferior parathyroids and thymus are derived.
These tissues migrate downward, and parathyroid glands
separate from thymus and remain at the lower poles
of thyroid. Failure of the parathyroids to separate from
thymus results in their location in the lower neck and
anterior mediastinum (Gilmour, 1937). The fourth
branchial pouch gives rise to the superior parathyroids
together with the ultimobranchial body, and the para-
thyroids separate from the ultimo branchial body and
remain in the upper poles of thyroid (and may descend
into posterior mediastinum).
Anatomy
The parathyroid glands are flattened, bean shaped, and
measure 4 to 6 mm in length, 2 to 4 mm in width, and
1 to 2 mm in thickness. The combined average weight
of parathyroid glands in males is around 120 mg and in
females it is around 145 mg (Grimelius et aI., 1981).
The color of the parathyroid gland is red-brown to
yellow-brown, depending on the ratio of parenchymal
cell to stromal fat. Eighty-four percent of normal adults
have four parathyroid glands; about 13 % of adults
have more than four glands; and about 3% have three
glands (Ackerstrom et aI., 1984).
Each gland is surrounded by a thin fibrous capsule
that extends into the gland as fibrous septa dividing the
gland into lobules. The normal gland is composed of
chief cell, clear cell, and oxyphil cells and stromal fat;
there is a parenchymal cell-to-fat ratio of 50:50 in the
normal adult gland. The cells are arranged in cords and
nests around delicate capillaries. The chief cell is poly-
hedral and 6 to 8 mm in diameter, with centrally placed
round nucleus and amphophilic to eosinophilic cyto-
plasm. The clear cells represent chief cells with exces-
sive glycogen in the cytoplasm. The oxyphils are larger
-10 to 12 mm in diameter-and contain granular
eosinophilic cytoplasm and pyknotic nucleus. They
appear at puberty and increase with age. They are
usually arranged in small nodules (Castleman and
Roth, 1978).
Diseases of Parathyroid
Abnormalities of parathyroid glands are always associated
with hyperparathyroidism. In primary hyperparathy-
roidism in the absence of known stimulus, one or more
parathyroid glands secrete excess PTH and produce
hypercalcemia. Secondary hyperparathyroidism refers
to increase of PTH induced by hypocalcemia and hyper-
phosphatemia associated with renal failure. Tertiary
hyperparathyroidism refers to development of autonomous
parathyroid hyperfunction in individuals with secondary
hyperparathyroidism. The most common abnormalities
of parathyroid gland associated with hypercalcemia
include adenomas, hyperplasias, and carcinomas
(Ackerstrom et aI., 1986).
Parathyroid Adenoma
Parathyroid adenoma with enlargement of a single
gland is the most common lesion. In fact, 75% to 80%
of primary hyperparathyroidism is caused by a solitary
adenoma. Adenomas develop in all four glands with
equal frequency. They weigh from 100 mg to several

grams. The size ranges irom 1 to over 3 em. The nodule
is red-brown, smooth, and circumscribed. Occasionally
in adenomas a grossly visible rim of normal yellow-
brown parathyroid tissue may be seen.
Microscopically, adenomas are encapsulated nodules
composed of chief cells arranged with a delicate capillary
network. Unless very large, about 50% of adenomas
will have a normal or atrophic rim of parathyroid tissue
outside the capsule of the adenoma. However, absence
of a rim does not preclude the diagnosis of adenoma.
The stromal fat is usually absent. The cells are uniform
with dark nuclei and contain minimal to no intracyto-
plasmic fat or lipid content. Chief cell adenomas are
the most common, but oxyphilic and clear cells may be
encountered. Oxyphilic cell adenomas are also func-
tiona] and should be diagnosed when 90% or more of
the glands are composed of oxyphilic cells (Wolpert et
a!., 1989).
Primary Parathyroid Hyperplasia
Parathyroid hyperplasia can occur sporadically or as a
familial lesion. Chief cell hyperplasia is the most common
type. Clear cell hyperplasia is rare. Familial hyper-
parathyroidism may be a component of MEN] or ]1.
Grossly, all four glands are enlarged equally or
unequally. If unequal in size, the lower glands are
usually larger. The weight of all four glands ranges
from 150 mg to over 20 g.
Microscopically there is diffuse chief cell hyperplasia
with minimal or no stromal fat. Asymmetrica] glandular
enlargement with predominantly chief cell hyperplasia
is common. Nodular hyperplasia and oxyphilic nodules
as well as chief cell nodules may be present. Usually in
hyperplasia, there is no rim of normal parathyroid
tissue. Intracellular fat or lipid content is decreased
(Castleman et aI., 1976).
Parathyroid Carcinoma
Parathyroid carcinoma is a rare neoplasm accounting
for 0.5 % to 2 % of primary hyperparathyroidism. Grossly,
parathyroid carcinoma presents as an ill-defined mass
densely adherent to the surrounding soft tissues and
thyroid. The tumors are gray-tan, firm, and ill defined.
Microscopically, they show a trabecular arrangement of
tumor cells divided by thick fibrous bands, mitotic
activity, capsular invasion, and vascular invasion. The
bands are composed of relatively acellular collagenous
tissue, dividing the neoplasm into irregularly shaped
compartments. An important clue to diagnosis of malig-
nancy is the finding of adherence or invasion into local
structures. There may be local invasion into nerves and
soft tissues. The tumor cells are larger than norma] chief
cells, and their nuclei are round to oval. Occasional
ENDOCRINE SURGERY
cases show marked nuclear pleomorph;sm wllh coarse
chromatin and prominent nuclei. Most parathyroid
carcinomas are slow growing with indolent behavior.
Metastases may occur in up to one third of cases. The
common metastatic sites include regional cervical lymph
nodes, lung, liver, and bone (Schantz and Castleman,
1973).
Secondary Hyperparathyroidism
This is usually due to renal disease. All four glands are
enlarged and vary in size. Histology is similar to that of
primary parathyroid hyperplasia.
Miscellaneous Lesions
Parathyroid Cyst
Parathyroid cysts are rare and are located in the neck or
occasionally in the mediastinum. Mediastina] parathy-
roid cysts may also contain fragments of thymus
(Ca]andra et a!., 1983). Many believe that the parathy-
roid cyst may represent a degenerated parathyroid
adenoma. However, a few may arise from embryologic
remnants of pharyngeal pouches.
Grossly, they are large (1 to 6 em) and contain clear
fluid with high PTH content. The cyst wall is made up
of fibrous connective tissue with entrapped parathyroid
tissue. Occasionally they are lined by a layer of chief
cells.
Lipoadenoma
These are benign tumors composed of parathyroid cells
with normal histologic arrangement and mixed with
abundant adipose tissue. They are well circumscribed
and encapsulated (Weiland et a!., 1978). They are
usually associated with hyperparathyroidism.
Parathyromatosis
Parathyromatosis is a rare condition in which patients
with primary hyperparathyroidism may show multiple
small nests of hyperplastic chief cells scattered through-
out the soft tissues of the neck and mediastinum. This
is probably as a result of stimulation of embryonic
nests of parathyroid cells in patients with primary
hyperparathyroidism.
Intraoperative and Frozen Section
Examination of Parathyroid
A close working relationship between the pathologist
and surgeon is a must. The role of pathologist is to
determine the nature of the underlying process, hyper-
plasia versus adenoma. The pathologist should know
whether the biopsy is from a normal-sized gland or an
enlarged gland. The diagnosis of hyperplasia and ade-
noma depends on the number of enlarged parathyroid
glands. In a patient with adenoma there will be enlarge-
ment of one gland and the remaining will be of normal
size. Usually the largest parathyroid gland is resected
first. The pathologist should weigh it and measure it,
and a representative section including the capsule should
be taken for frozen section and examined. If the gland
shows diffuse growth of chief cells, decreased stroma
fat, and a rim of normal parathyroid, a diagnosis of ade-
noma can be rendered. Because a rim of parathyroid is
seen only in 50% of cases, a pathologist cannot rely on
this alone.
Hypercellularity
If the histology is that of hypercellularity, biopsy of
another gland is needed. If this gland is of normal size
and cellularity, the diagnosis is most likely adenoma.
The diagnosis of hyperplasia is likely when more than
one gland is enlarged. If the second gland is enlarged,
it is most likely hyperplasia. Fat stains are helpful in
making the diagnosis.
The use of fat stains is based on the fact that in
normal parathyroid glands 80% of chief cells contain
intracytoplasmic fat or lipid, which is markedly decreased
or absent in hyperfunctioning chief cells (Bondeson et
a!., 1985a). Fat stains (oil red a or Sudan IV) are help-
ful in about 80% of the cases and should be used as an
adjunctive test but cannot be relied on by themselves.
Surgery of Parathyroid Glands
(Fig. 18-14)
Blood Supply of the Parathyroid Glands
(After Attie and Khafif, 1975)
Knowledge of the anatomy of the normally located
parathyroid gland's blood supply is most important,
both during thyroidectomy and parathyroidectomy, in
an attempt to preserve this blood supply when it is
consistent with the objectives of the surgery. If these
vessels cannot be preserved, the parathyroid glands are
then thinly sliced and reimplanted in a muscle: cervi-
cal, anterior chest wall, or forearm. It has long been
realized that lateral ligation of the inferior thyroid
artery is to be avoided to preserve the major blood
supply of the parathyroid gland. However, more under-
standing of the detailed anatomy of this blood supply
is necessary. This blood supply can be represented as
follows:
1. Inferior parathyroids: the inferior thyroid artery or
the inferior and superior thyroid arteries
2. Superior parathyroids: the inferior thyroid artery or
the superior thyroid artery or the inferior and superior
thyroid arteries
Although Attie and Khafif (1975) state that these
vessels can be preserved in most instances during total
thyroid lobectomy and total thyroidectomy using an
optical loop or microsurgical techniques, this author at
times runs into difficulty in the gross dissection of the
terminal vessels from the thyroid capsule when the
parathyroids are actually covered by the thyroid capsule.
Although Attie and Khafif describe the identification of
these vessels and their preservation with the use of
microsurgical technique, this author has not used this
magnification technique. The other problem is the
venous drainage of the parathyroid glands. In short, an
attempt is made to preserve the vascular supply. If there
is the slightest question as to the integrity of these
vessels or if the parathyroids turn dark to jet black, the
parathyroids are then reimplanted. Care must be taken
so that when a parathyroid and its blood supply are
preserved, sponging and irrigation of the wound do not
destroy the vessels or actually remove the parathyroid
glands, which may become adherent to the surgical
sponge. Strip cotto no ids are used to protect these struc-
tures and are used for gentle sponging. Bare unpro-
tected suction is never used. These precautions are also
utilized to protect the laryngeal nerves.
In general, the inferior parathyroid glands are on a
slightly more anterior plane than the recurrent laryn-
geal nerve. They may be located anywhere from the
inferior pole of the thyroid, which can be surrounded
by adipose tissue, fixed to the capsule of the thyroid, or
be subcapsular. They may be located anywhere in the
anterior mediastinum, again, hidden in adipose tissue
or within the thymus. The superior glands may be on a
plane deeper than the recurrent laryngeal nerve or attached
to the deep surface of the superior pole on a plane ante-
rior to the recurrent laryngeal nerve. The cricoid cartilage
is usually a good landmark for the immediate region
where the recurrent laryngeal nerve passes deep to the
cricopharyngeus muscle. It is at this point that the
superior parathyroid may be deep to the recurrent laryn-
geal nerve. It may be hidden in some adipose tissue.
Depicted in Figure 18-14A to C are the more common
anatomic vascular networks encountered in thyroidec-
tomy and parathyroidectomy. In these steps, as well as
in Figure 18-140, the left thyroid lobe has been reflected
medially, exposing the recurrent laryngeal nerve.
Hence, the superior parathyroid gland, if attached to
the thyroid capsule as shown diagrammatically, has
been displaced from its more usual position, which is
 ENDOCRINE SURGERY

Surgery of Parathyroid Glands

(Continued) (Fig. 18-14)
posterior to the plane of the recurrent laryngeal nerve,
to an anterior position. During thyroidectomy the recurrent
laryngeal nerve must be exposed and thus preserved to
achieve total thyroid lobectomy or total thyroidectomy.
In parathyroid surgery, exposure of the recurrent laryn-
geal nerve is not routine but depends on the area of
exploration. During thyroidectomy every attempt is made
to preserve the parathyroid blood supply. During parathy-
roid surgery the blood supply aids in the location of the
parathyroids and is preserved to any parathyroid that is
A Both the inferior and superior parathyroid glands
are supplied by branches of the inferior thyroid artery.
The vascular ligatures are placed to preserve this
vascular supply during total thyroid lobectomy.
B Both parathyroid glands are supplied by both
inferior and superior thyroid arteries, which form a
vascular loop. Nevertheless, the inferior parathyroid
gland is primarily supplied by the inferior thyroid
artery and the superior parathyroid gland is supplied
by the superior thyroid artery.
Continued

INF.
PARATHYROID GL.
REC.
LARYNGEAL N.
'""

INFE~~l SUPERIOR
EXT. SR.
SUP. LARYNGEAL N.
A
ESOPHAGUS
LEFT SIDE
" SUP. THYROID A.

INFERIOR
+--
I SUPERIOR

SUP.
THYROID A.
B
REC. LARYNGEAL N.
LEFT SIDE
FIGURE 18-14
 ENDOCRINE SURGERY
Surgery of Parathyroid Glands
(Continued) (Fig. 18-14)
left in situ. The relationship of the recurrent laryngeal
nerve branches to the inferior thyroid artery is so varied
that the various possibilities cannot be represented in
detail. It is sufficient to say that the recurrent laryngeal
nerve may be in a single extralaryngeal trunk or may
have two major extralaryngeal branches, several smaller
branches to the esophagus, and other branches (e.g., a
nerve [Galen] that possibly communicates with the
superior laryngeal nerve). Still other terminal branches
have been encountered. All of these branches and the
main trunk likewise have varied relationships to the
inferior thyroid artery and its branches. The technique
of thyroid lobectomy that commences inferiorly, as
shown in Figure 18-9, is used to identify the recurrent
laryngeal nerve if it is not readily exposed with medial
reflection of the thyroid lobe or if there is associated
thyroid disease. The relationship of the superior thyroid
vessels to the external branch of the superior laryngeal
nerve is described in detail in Figure 18-9L and M.
The parathyroid glands at times may be entirely
within the thyroid gland (rarely) or beneath the thyroid
capsule or within the thymus. In the former, identifica-
tion of the blood supply is virtually impossible. In the
latter the blood supply is probably from a branch of the
C The inferior parathyroid gland is supplied solely
from the inferior thyroid artery, and the superior
parathyroid gland is supplied from the superior thyroid
artery. It is obvious that ligation of the entire superior
thyroid artery would interrupt the blood supply to the
superior parathyroid gland. It is also obvious that if this
step were taken at the initial stage of thyroid lobec-
tomy, the surgeon would not be cognizant of this type
of anatomic vascular supply until after the fact, hence
another reason for commencing thyroid lobectomy
inferiorly at the superior thoracic inlet.
D This rather typical large inferior parathyroid
adenoma is supplied by a branch of the inferior thyroid
artery. It has been relatively easy to expose by gentle
reflection of the thyroid lobe medially after ligation
and transection of the middle thyroid vein. The ade-
noma is on a more anterior plane than the recurrent
laryngeal nerve, which is seen deep to the adenoma.
The blood supply of the superior parathyroid gland is
from the superior thyroid artery and a loop from the
inferior thyroid artery. With the use of a titanium clip
(optional) a small slice of the superior parathyroid gland
is taken along the edge opposite to the vessel for
frozen section to ascertain whether it is hyperplastic,
normal, or hypoplastic.
 ENDOCRINE SURGERY

Inferior
Parathyroid gl.
Recurrent Laryngeal N.

SUPERIOR

Superior Thyroid A.

! I
\- I
It ~

Superior
D Thyroid A.

Inferior Thyroid A.
LEFT SIDE
FIGURE18-14 Continued
 ENDOCRINE SURGERY
internal mammary artery (internal thoracic artery). If
this does occur, it is usually the superior parathyroid
gland that is within the thyroid parenchyma and the
inferior parathyroid gland that is within the thymus.
The blood supply of mediastinal parathyroid glands is
still another problem. The superior parathyroid glands
are usually then located in the posterior mediastinum,
and the inferior parathyroid glands are in the anterior
mediastinum. Additional discussion on identification of
abnormally located parathyroid glands is on page 899.
Another problem relative to the blood supply of the
parathyroids is that the branches of the superior and/or
inferior thyroid arteries may be deep to the capsule of
the thyroid. Hence, the dissection and the preservation
of these vessels are very difficult, if not impossible,
when this situation occurs.
Hyperparathyroidism
Diseases of the parathyroid glands include the
following:
1. Adenomas (single or multiple: 80% to 90% of cases
of primary hyperparathyroidism).
2. Hyperplasia (chief or clear cell: 10% to 20% of cases
of hyperparathyroidism). This is suspected when there
are few or no fat cells or there is hypercellularity.
3. Cysts (true and cystadenomas). True cysts are cysts
of the parathyroid glands that mayor may not be
associated with the symptoms of hyperparathyroidism
and at times are palpable as a mass in the cervical
region. If the mass is palpable, FNA may reveal up
to 22 mL of clear fluid that has the appearance of
water and on assay may reveal the presence of PTH.
The fluid can be measured for PTH by a mid-molecular
assay. These cysts may also contain amber and/or a
serosanguineous fluid or a combination of all three
characteristics. In the author's experience, the level
of PTH is highest with the clear fluid (e.g., up to
235,871 pg/mL PTH, with serum levels of 333 pg/mL),
less with the amber, and still less with the serosan-
guineous fluid (e.g., 412 pg/mL PTH with serum
levels of 93 pg/mL) (normal range < 50 to 340 pg/mL).
These findings have also been reported by Pacini and
colleagues (1985). To further evaluate amber-colored
fluid of any significant amount, thyroglobulin levels
may be obtained to aid in the differentiation of a
colloid cyst from a parathyroid cyst.
Rosenberg and associates (1982) reported 8 patients
with parathyroid cysts associated with hypercalcemia
out of a total of 14 patients with parathyroid cysts.
They indicated that the fluid aspirate is clear and
stressed the importance of assaying PTH in the fluid,
which may be elevated. Four of the cysts were found
in the superior position, three in the inferior position,
and one in the mediastinum. Five of the patients
manifested symptoms and signs of hyperparathy-
roidism, mainly hypercalcinosis, weakness, confusion,
nausea, dysphagia, and constipation. One patient had
a neck mass. The calcium levels ranged from 2.59 to
3.5 mmol/L (mean 2.96). The remaining patients had
nonfunctioning cysts.
A cystadenoma (see Fig. 18-20) is an adenoma with
cystic hemorrhagic degeneration and dark brown
fluid. The one in the mediastinum was asymptomatic
at the time of excision; however, radiographs revealed
calcific deposits within muscle. The cyst wall was
thick and not thin, as in the true cyst. Years earlier
the patient had had some of the classic symptoms of
hyperparathyroidism that spontaneously disappeared,
evidently owing to hemorrhage in the adenoma and
then cystic degeneration of the tumor. This adenoma
(7 x 5 em) was reported as histologically benign. A
similar cystadenoma, 5.5 x 3.7 x 2.5 em and with a
very thick wall, was found in another patient and
was in fact a carcinoma as determined by vascular
and lymphatic invasion and paralysis of the recur-
rent laryngeal nerve. In addition, there were mitoses,
hemosiderin, and fibrosis, as described by Castleman
and Roth (1978).
4. Carcinoma (rare: < 1 % of cases). These tumors can
be the size of the more common adenomas or can be
massive, measuring up to 5 x 6 em in diameter, thus
simulating a thyroid neoplasm or goiter. The author
(JML) has had personal experience with three patients
with parathyroid carcinomas. One had no symptoms,
the hypercalcemia being detected by routine labora-
tory tests. At the time of surgery an examination of
the ipsilateral thyroid lobe which contained the
recurrent laryngeal nerve revealed that the carcinoma
of the parathyroid eventually invaded the nerve;
however, the filaments of the nerve were intact. The
other two patients had minimal (headache and hoarse-
ness) to severe symptoms, the latter in the terminal
phase of the disease. The histologic diagnosis can be
difficult to make, hence the clinical picture and opera-
tive findings are important in verifying the diagnosis.

When the parathyroid adenoma is significantly
enlarged and surrounded by adhesions, the surgeon
must be very suspicious of parathyroid carcinoma.
The definitive surgical procedure should be done at
that time, namely, a total ipsilateral thyroid lobec-
tomy and extensive resection of all lymph nodes, at
least inferiorly to the superior thoracic inlet. This
initial surgical procedure is most important in con-
trolling the disease (see p. 989 for additional discus-
sion of carcinoma of the parathyroid gland). Metastasis
to regional lymph nodes and local invasion into the
larynx, trachea, thyroid, and recurrent laryngeal nerve
have been observed by this author, as has distant
metastasis (e.g., to the lung). Others have seen metas-
tasis to liver, bone, kidneys, and pancreas (Holmes
et aI., 1969; Shane and Belezikian, 1982).
Grossly, diagnosis of parathyroid carcinoma can
be highly suspected by local invasion and by a thick
capsule with fibrous reaction. It may be very adherent
to surrounding structures (i.e., thyroid, deep cervical
fascia, esophagus, trachea, larynx, and recurrent laryn-
geal nerve). Lymph nodes may reveal metastatic
carcinoma on frozen section. Parathyroid cells may
be seen in small vessels and lymphatics that are
associated with or outside the capsule, and these
have been detected histologically in that portion of
the capsule adherent to the thyroid, hence the impor-
tance of multiple frozen sections, especially in the
adherent areas. If local invasion is not present at the
time of operation, diagnosis of carcinoma may be
made by histopathologic examination (which can be
difficult). These tumors, as reported by Fujimoto
and Obara (1987), "are usually less aggressive and a
simple tumor resection may be curative." Histologic
diagnosis of carcinoma of the parathyroid is difficult
and depends on:
a. Invasion of vessel wall
b. Invasion of the recurrent laryngeal nerve
c. Intravascular and intralymphatic parathyroid cells
in a configuration that exactly matches the out-
side wall of the vessel or lymphatic. This aids in
differentiating parathyroid cells that may be mis-
placed within the vessel lumen by microtome
sectioning of the specimen.
d. Capsular invasion. This is a moot point because
it may not be possible to differentiate invasion of
the capsule or whether there has been fibrous
tissue simply surrounding the parathyroid cells.
ENDOCRINE SURGERY
Follow-up of patients with parathyroid cancer
must be careful and continuous. In addition to phys-
ical examination for a local mass, lymphadenopa-
thy, and vocal cord paralysis, it is recommended
that routine chest radiographs, CT of the chest
and neck with contrast ultrasonography, thallium
technetium subtraction, barium swallow, and pos-
sibly MRI as well as digital subtraction angiography
be obtained postoperatively as a baseline and be
repeated as indicated. The serum calcium concen-
tration is the "most reliable indicator of tumor
recurrence" and is performed "every three months"
(Fujimoto and Obara, 1987).
5. Rarer lesions:
a. Parathyroid hamartomas
b. Adenolipomas
Multiglandular disease, at one time thought to
be a rarity, is not reported more frequently. This
includes multiple adenomas as well as hypertrophy
of two or more parathyroid glands. Paloyan and
Lawrence (1981) indicate that surgeons may well
expect to find a 20% to 30% incidence of multi-
glandular disease. The incidence of multiple
adenomas is reported to be 1 % to 3 %.
Hyperparathyroidism may be any of the following
(other classifications exist):
1. Primary. Excessive production of PTH may be due to
intrinsic disease of the parathyroids (e.g., when the
normal feedback control by serum calcium is leading
to autonomous production of PTH). It may also be
related to MEN I and IlA and occasionally IlB as well
as familial hyperparathyroidism.
Most often in primary hyperparathyroidism one
observes hypercalcemia in the presence of frankly
elevated levels of intact PTH. It is not uncommon
though to find hypercalcemia in the presence of a
normal or high normal intact PTH. This would also
indicate primary hyperparathyroidism because the
PTH production is occurring in an inappropriate
fashion or without the normal feedback control
mechanisms.
2. Secondary. This form results from any disease that
produces hypercalcemia. It stimulates increased pro-
duction of PTH and is most commonly associated
with chronic renal failure as well as being secondary
to radiotherapy in head and neck cancer.
 ENDOCRINE SURGERY
3. Tertiary. Autonomous function of the parathyroid
gland results from the prolonged compensatory sti-
mulation. This, for example, is associated with long-
standing chronic renal failure in which the hyper-
parathyroidism persists or becomes more severe
even after renal transplantation. Another group that
might be considered tertiary is the nonparathyroid
tumors that produce a PTH-like substance.
Other causes of hypercalcemia are benign familial
hypocalciuric hypercalcemia (FHH), vitamin D intoxi-
cation, milk-alkali syndrome, thiazide diuretics, exces-
sive calcium intake, lithium intoxication, hyperthyroidism
and hypothyroidism, and sarcoidosis. Neoplastic lesions
that may well be associated with hypercalcemia are
many. The more common include metastatic carcinoma
of the breast, pulmonary and renal cell carcinoma, as
well as certain carcinomas of the head and neck.
Humoral hypercalcemia of malignancy is caused by
the secretion of parathyroid hormone-related protein
(PTHrP). It resembles PTH at the amino terminus of
the polypeptide chain. The two related proteins are
distinguishable by radioimmunoassay. If a patient with
a known malignancy develops hypercalcemia, he or she
should have an intact PTH measurement to rule out
primary hyperparathyroidism as a possible intercurrent
illness.
Hypercalcemia may be associated with elevated crea-
tinine, elevated blood urea nitrogen, and also shorten-
ing of the QT segment of the ECG. If there is significant
shortening of the QT segment, the patient may not be
able to handle rapidly the "flushing out" with intra-
venous fluids and furosemide; hence, the patient may
have to be monitored during this period of rehydration.
Patients may also demonstrate psychic disturbances as
well as abdominal pain and weakness of the legs.
Management of hypercalcemia and hyperparathy-
roidism requires a team approach by an endocrinolo-
gist, radiologist, surgeon, and pathologist. During the
operative procedure, patience and expertness are vital.
Embryology and Anatomy
1. About 80 % of people have four parathyroid glands,
15% have more than four to as many as nine, and
5% have fewer than four (Ackerstrom et aI., 1984).
2. Superior parathyroids arise from the fourth
branchial pouch. Inferior parathyroids arise from
the third branchial pouch.
3. Inferior parathyroids are more likely to be ectopic
in the thymus. Both lobes of the thymus should be
searched. The thymus should be removed if search-
ing for an adenoma when the inferior glands are
not located in the neck.
4. Superior parathyroids are more likely to be ectopic
in the thyroid lobe.
5. Inferior parathyroids are more likely to be ectopic
in the anterior superior mediastinum.
6. Superior parathyroids are more likely to be ectopic
in the posterior superior mediastinum.
7. Superior parathyroids are usually located close to
or posterior to the level of the recurrent laryngeal
nerve at its entrance into the larynx, cricopharyn-
geal muscle, behind the superior thyroid pole, or in
a retroesophageal position.
8. Inferior parathyroids usually are located close to the
inferior thyroid pole, alongside or behind, and usu-
ally on a plane anterior to the recurrent laryngeal
nerve as well as associated with adipose tissue.
9. Blood supply (see Fig. 18-14): the inferior parathy-
roid gland is supplied by the inferior thyroid artery
and at times by the superior thyroid artery or both.
The superior parathyroid gland is supplied by the
inferior thyroid artery, the superior thyroid artery,
or both.
10. Weight: total (all glands) is 120 to 160 mg. One gland
weighs 30 to 40 mg (if over 60 mg it is probably an
adenoma). Size ranges from 3 to 6 mm in length, 2
to 4 mm in width, and 0.5 to 2 mm in thickness.
11. Color: The gland is tan or caramel in the natural
state and dark brown to black when manipulated
or its blood supply is compromised.
12. Shape: ovoid or bean shaped (83%), elongated
(11%), bilobed (5%), multilobed (1%), rarely flat
(Ackerstrom et aI., 1984).
13. Parathyroids can be superior at the level of the
mandible and within the carotid sheath and extend
inferiorly as far as the pericardium.
a. Parathyroid tissue sinks in normal saline; thy-
roid tissue and lymph nodes also sink whereas
fat floats.
b. Rarely, parathyroid glands may be associated
with the strap muscles, close to the midline,
during an initial thyroidectomy incision.
c. Parathyromatosis: this is a rare finding (one
patient) of 1- to 2-mm innumerable portions of
parathyroid tissue scattered throughout adipose
tissue between the suprasternal notch and the
inferior pole of the parathyroid.
d. Mediastinal location
1) Anterior in the midline or lateral in the adipose
tissue
2) Posterior closely related to the esophagus
3) Under the sternoclavicular joint

Signs and Symptoms
• Fatigue
• Headache
• Mental aberrations (psychosis and memory loss)
• Pain of bones and bone lesions called osteitis fibrosis
cystica; pain in joints and muscles
• Weakness and lack of energy
• Polyuria, polydipsia
• Gastrointestinal symptoms: ulcer, cholelithiasis,
pancreatitis, and diarrhea
• Renal calculi
• Hypertension
• Renal failure
• Demineralization of bones
• Calcific deposit in muscles
• Coma: acute hyperparathyroid crisis
• No signs or symptoms
Although there has been a valid difference of opinion
regarding whether the asymptomatic patient with pri-
mary hyperparathyroidism should be operated on, the
evidence at this point in time supports operation not only
for the symptomatic patient but also for the asympto-
matic patient (Sivula and Ronni-Sivula, 1987). This
author supports this course of action as the ideal time
to operate to avoid the possible sequela of hyperparathy-
roidism and to treat an unsuspected parathyroid carci-
noma in the early stage of disease.
Certainly asymptomatic patients require thorough
evaluation before deciding not to operate. This evalua-
tion should include an assessment of bone density,
such as a DEXA bone densitometry study, and urinary
calcium excretion with a 24-hour urine collection. If
the bone density is compromised or the renal excretion
of calcium is significantly elevated, one should
consider surgical intervention even if the patient is
asymptomatic.
History
1. Inquire about radiotherapy to the head and neck.
2. Ask about familial hypertension: possible associa-
tion with MEN I and IIA and rarely lIB. In addition
we have treated one patient with MEN II or with
pheochromocytoma and renal artery hyperplasia.
3. Review other causes of hypercalcemia.
Laboratory Tests for the Evaluation of
Hypercalcemia and Hyperparathyroidism
The following tests measure elevations of various blood
serum variables critical to diagnosing hypercalcemia
ENDOCRINE SURGERY
and hyperparathyroidism. They should be repeated several
times as indicated.
1. Intact nitrogen-terminal PTH determination (the
validity of this test depends on the manner in which
the blood sample is drawn and preserved as well as
the laboratory techniques, which vary from laboratory
to laboratory)
2. Serum ionized calcium
3. Total serum calcium concentration with serum
protein
The serum phosphorus level is low in hyperparathy-
roidism, except there may be a retention of phosphorus
in renal insufficiency. Blood urea nitrogen and creatinine
levels should then be measured. Alkaline phosphatase
is elevated with associated bone disease. Additional tests
for a complete evaluation of hypercalcemia include the
following:
1. Uric acid
2. Urinary protein electrophoresis or immunoelec-
trophoresis
3. Chest radiograph, urinalysis
4. Intravenous pyelogram, soft tissue radiograph of the
abdomen
5. 24-hour urinary calcium collection
6. Cyclic adenosine monophosphate: an indicator of
postoperative parathyroid function (Spiegel et aI.,
1981)
7. Calcitonin (provocative testing when indicated)
when MEN II is suspected
Hyperparathyroidism Associated With
MEN Syndromes
In MEN I, hyperparathyroidism is usually caused by
hyperplasia of several or all of the glands, rather than
a single adenoma. In MEN lIA, hyperparathyroidism is
usually caused by adenoma (single or multiple) or
hyperplasia. In MEN lIB, the parathyroids are usually
normal (less than 4% are abnormal).
A graph plotting the calcium and PTH in various
categories (done according to the technique of Arnaud)
with the patient's findings indicated is of great visual
aid in the evaluation of these laboratory data. The classic
laboratory picture of primary hyperparathyroidism is
repeated elevations of serum calcium level and PTH
level. There are reports that the PTH value can be
normal, evidently suppressed by the hypercalcemia.
This finding of suppression of the PTH level is likely to
indicate a nonparathyroid disease. Therefore, a very careful
and complete evaluation is necessary. Hypercalcemia
 ENDOCRINE SURGERY
can result in a shortened QT interval on the ECG
associated with myocardial irritability and digitalis
sensitivity.
Preoperative and Intraoperative
Techniques for the Surgical
Management of Sporadic
Hyperparathyroidism: Adenoma
and Hyperplasia
John M. Lore, Jr.
Imaging for the detection of parathyroid adenoma and
hyperplasia of the parathyroid glands is subject to so
many different modalities and opinions that the author
(JML) not only will delineate his own preferences
relative to imaging in section 1 but also will attempt to
give an overview of this controversial subject in the
review of data from a publication entitled Endocrinology,
abstracted in section 2. As a further aid, a review of
articles on this subject, both in 2001 and 2002, as
abstracted by Ovid-Medline, is presented in section 3,
with some additional comments from JML.
Section 1: The Author's OMl) Experience
and Suggestions Regarding Imaging
Imaging is always utilized with attempted bilateral
exploration for four or more glands in most patients. A
unilateral or very limited so-called focus surgical tech-
nique approach is used under selected circumstances,
for example, to shorten time in surgery for medical or
surgical reasons as one would encounter in some geriatric
patients or findings at the time of surgery indicating
difficulty in exposure or unsuspected bleeding tendency
during the surgery.
Parathyroid imaging and nonimaging has evolved
over the years in a number of modalities as listed earlier
under the outline. In addition, other modifications of
some of these modalities exist, for example, time and
type of injection of the PTH assay, as well as combination
of 1231 and sestamibi scan as described by Neumann
and co-workers (1997). CT and MRI are helpful for deter-
mining ectopic parathyroid adenomas in the lateral
neck and mediastinum. MRI can identify a lesion in the
mediastinum relative to whether it is anterior or posterior.
The same is accomplished by single-photon emission
CT; for example, transverse SPECTscan can demonstrate
a parathyroid adenoma that is deep to the sternum
located in the superior posterior mediastinum. Sagittal
SPECT can also identify the adenoma in the superior
posterior mediastinum. These two tests corroborate
one another (Fig. 18-15). The gamma probe is used
intraoperatively by surgeons who prefer a small skin inci-
sion (2.5 cm). This so-called focused surgical approach
is used for cosmetic reasons, allegedly shorter operating
time, and the ability to discharge the patient on the
same day as surgery. However, there can be a significant
risk of a recurrent laryngeal nerve injury with this
limited exposure, as well as missing multiple parathy-
roid glandular disease, with the use of the gamma
probe. The gamma probe has been used by this author
for intra thyroidal and aberrant parathyroid adenomas.
The fundamental "modality" for the best imaging is
the experience of the surgeon who operates without
any imaging. Nevertheless, there will be some failures
at the first operation, even by these experts. The number
of failures in the group that could be avoided by
selective imaging are, for example, locations in the
mediastinum or lateral cervical, retroesophageal, or
diaphragmatic areas. Adenomas here as well as in the
lateral neck can often be detected with a sestamibi SPECT
scan. Cost containment often fits into the equation as
to whether imaging should be done and which imaging
should be done based solely on cost. Nevertheless, re-
operation is costly and can be very trying for the patient.
Cost may be difficult to evaluate and calculate under
these circumstances. Once again the expertise of the
surgeon may be the deciding factor, as aptly stated by
Doppman and colleagues (1975). Image localization is
overshadowed by "localization" of this type by a sur-
geon. At this time, initial imaging with a combination
of ultrasound and sestamibi SPECT scans is the choice
of this author and also appears to be the choice of a sig-
nificant number of other surgeons. Ultrasound depends
to a great extent on the expertise of the radiologist
working with an expert technician. The author recalls
an exhibit at the American College of Surgeons a
number of years ago when the exhibitor of parathyroid
imaging challenged passerby physicians to allow him
to demonstrate normal parathyroids in the passerby
physician! Another real expert. His success rate was
impressive, but not 100%.
It is the conviction of this surgeon that combined
sestamibi SPECT and ultrasound is always indicated,
the latter, if for no other reason, to evaluate clinically
evident or suspected thyroid pathology. This gives the
surgeon an opportunity to discuss with the patient pre-
operatively the possibility of thyroid surgery during the
treatment for hyperparathyroidism. Ultrasound com-
bined with sestamibi SPECT is the imaging of choice
with the other modalities as backup, especially CT and
MRI. In a review of the author's experience, the results
of this study of 79 of 83 patients indicated that ultra-
sound localizes the parathyroid adenoma in 43 % of the
 ENDOCRINE SURGERY

Ant
Pt

FIGURE 18-15 Sestamibi SPECT scans from two patients. In the transverse view (A) (from patient 2 under "Patient
Examples"), the adenoma is deep to the sternum, in the superior posterior mediastinum. Ant, anterior; Pt, parathyroid
adenoma. In the sagittal view (B) (from patient 1 under "Patient Examples"), the adenoma is in the superior posterior
mediastinum. Pt, adenoma; Th, right thyroid lobe. (From Lore JM Jr, Staggers-Deberney J, Farrell M, et al: Approach to
superior mediastinal parathyroid adenomata via resection of the medial third of the clavicle: Operative techniques.
Otolaryngol Head Neck Surg 11 :21 6-220, 2000.)

patients, with localization by MRI in 57%; CT, 39%;
TIS, 61 %; 99mTc-sestamibi (planar), 75%; and sestamibi
SPECT, 93 %. Of the original 83 patients reported, four
tumors were located in the mediastinum and excluded
because the study was focused on the parathyroid
adenomas relative to the thyroid gland. Hence, the
resulting percentages are based on 79 of the 83 patients.
It is important to note that of the parathyroid adenomas
in the cervical area, three patients had multiglandular
disease. Ultrasound, MRI, TTS, and CT revealed no
significant difference in localizing parathyroid adenomas
with or without thyroid pathology. The sestamibi SPECT
and planar scans showed a decrease in localization of
the tumor if it was associated with thyroid pathology.
This discrepancy noted in these earlier years was due
to timing and interpretation because both thyroid and
parathyroid tissue take up sestamibi. The uptake in the
parathyroid, however, is stronger and lasts longer than
in thyroid tissue.
It is noteworthy to compare these data with a much
larger series reported by Arici and associates (2001),
who report that "sestamibi scans were most inaccurate
in patients with multiple abnormal parathyroid glands."
The same observation is reported by Thompson and
colleagues (1994). Further comment was that sestamibi
scan accuracy is also lower in patients with small
 ENDOCRINE SURGERY

parathyroid adenomas. Nevertheless, it must be empha-

sized that sestamibi (SPECT) is very helpful when the
parathyroid adenoma is in the lateral cervical or medi-
astinal regions (see Fig. 18-15). The surgical cure in the
total number (83) of patients in this 1996 study based
on the multifaceted imaging was 98.7% (82/83).

PET

There are few reports on the use of PET with 1Bfluo-

rodeoxyglucose (FOG) for preoperative parathyroid
localization. Neumann and co-workers (1995) reported
on their experience with this technique in patients with
recurrent postoperative hyperparathyroidism. In their
series of 20 patients, PET with FOG correctly localized
79% (11/14) of adenomas, 29% (2/7) of the hyperplastic
parathyroid glands, and a parathyroid carcinoma
(Fig. 18-16). (See also the section on PET in Chapter I;
note: Figure 18-16 is not related to either of the patients
described in the following examples but describes the
use of PET to confirm the findings of the sestamibi
planar scan.)
Patient Examples
Patient 1
This patient demonstrates the pearls and pitfalls of
various types of imaging, which are sometimes necessary
to perform to finally remove the parathyroid adenoma.
A 78-year-old woman with extensive osteoporosis and
dementia was found to have a calcium concentration of
11.8 mg/dL and an intact PTH of 106. Preoperative
localization included an ultrasound and 99mTc-sestamibi
planar images. The ultrasound revealed a thyroid cyst,
and the 99mTc-sestamibi planar images revealed a
parathyroid adenoma in the right inferior position. On
surgical exploration of the neck and anterior superior
mediastinum, through a cervical incision, no adenoma
was found. Postoperatively, a 99mTc-sestamibi SPECT
(see Fig. 18-158) localized the adenoma in the right
superior posterior mediastinum. CT and MRI were falsely
negative. Surgical exploration with the aid of resection
of the medial third of the right clavicle revealed the
parathyroid adenoma in the right superior posterior
mediastinum adherent to the thoracic esophagus and
thoracic vertebra, approximately 7 cm below the supra-
sternal notch. The patient developed a temporary right
vocal cord paralysis and is normocalcemic.
In the evaluation of mediastinal parathyroid adenoma
the ultrasound evaluation is useless because the sternum
interferes with the signal. Hence the selection of imag-
ing for mediastinal parathyroid adenoma is CT, MRI,
and sestamibi (SPECT). Adenomas in the mediastinum
can be located anterior, posterior, in the pericardium,
pericardial, and in the dome of the diaphragm; sagittal
FIGURE 18-16 Transverse PET image shows a rounded
focus of FOG accumulation within the neck (arrow) asso-
ciated with the parathyroid lesion. (From Lore JM Jr,
Staggers-Oeberney J, Farrell M, et al: Approach to
superior mediastinal parathyroid adenomata via resection
of the medial third of the clavicle: Operative techniques.
Otolaryngol Head Neck Surg 11 :216-220, 2000.)
MRI is particularly helpful in locating a lesion on the
aortic arch and specifically in the lateral mediastinal
adipose tissue. Sestamibi SPECT is also a helpful imag-
ing technique for these locations. Other cervical ectopic
locations of parathyroid adenomas found by Joseph
and co-workers (1982) are listed later (Table 18-9).
Patient 2
In another example of pearls and pitfalls, a 29-year-old
woman presented with bone pain and fatigue in 1991
to another institution and was diagnosed with symp-
tomatic primary hyperparathyroidism with a calcium
concentration of 11.0 mg/dL and a mid-C PTH value
greater than 600. She underwent preoperative scanning,
namely, thallium 201 (201Th)/99mTc subtraction scintig-
raphy and CT, which failed to localize the parathyroid
adenoma. Subsequently, an exploration was performed
with excision of a right inferior hypercellular parathyroid
gland and half of a normal left superior parathyroid
gland. No adenoma was found with a thymic/superior
mediastinal exploration. Persistent hypercalcemia led
to a Il3ljlOlTh SPECT. This was read as a right superior
parathyroid adenoma. A second surgical exploration
failed to reveal the adenoma; a right subcapsular thyroid
lobectomy was performed. Thereafter, a 99mTc-sestamibi
 ENDOCRINE SURGERY

TABLE 18-9 Reports of Cervical EctopIc: Parathyroid Tissue

In phrenic nerve (Askanazy, 1911)

One in carotid sheath and two behind esophagus or pharynx (Gilmour, 1938)
Cystic thymus and parathyroid at carotid bifurcation (Gilmour, 1939)
In the vagus nerve and another in the submucosa of the pharynx at the level of the cricoid (Gilmour, 1941)
In the left tonsil with thyroid and thymus in a patient with a brachial cleft and other anomalies (Robinson, 1959)
In posterior pharyngeal wall at the level of the cricoid (Herrold, 1961)
In retropharyngeal and retroesophageal position (Abul-Haj, 1962)
In the epignathus attached to the lateral wall of the nasopharynx (Willis, 1962)
In the left cricopharyngeal area indenting left pyriform sinus (Scatliff, 1963)
One on the lateral wall of esophagus, one behind the esophagus, and one on the carotid (Vail, 1966)
In the vagus (Reiling, 1972)
Behind the pharynx (Hines, 1973)
Behind cervical esophagus (Monchik, 1975)
Three at carotid bifurcation with thymic remnant; 1 % in series retropharyngeal or retroesophageal (Wang, 1975)
In posterolateral aspect of hypopharynx (Deeb, 1976)
In right posterior pharyngeal submucosa (Trippe, 1976)
One near hyoid, one near thyroid cartilage, one near carotid bulb, and one behind the esophagus (Beahrs, 1977)
Behind cervical esophagus (Wang, 1977)
Two retropharyngeal and seven high in neck almost to the angle of the jaw (Edis, 1978)
Three in carotid sheath (Van Vroonhoven, 1978)
Seven high in neck, either retropharyngeal or parapharyngeal or along larynx or at carotid bifurcation (Edis, 1979)
Two on pedicle from posterior pharyngeal wall with thymus remnant (Wang, 1979)
One in carotid sheath and one retroesophageal (Scott, 1981)

Data from Joseph MP, Nadol JB, Pilch BZ, Goodman ML: Ectopic parathyroid tissue in the hypopharyngeal mucosa (pyriform sinus).
Head Neck Surg 5:70-74, t982.

SPECT scan (Fig. 18-17) revealed the adenoma in the
superior mediastinum anterior to the spine and extending
to the left. PET confirmed this. A third surgery, includ-
ing a left subcapsular thyroid lobectomy, failed to reveal
the adenoma. The patient developed a permanent left
vocal cord paralysis. A fourth surgery, performed at our
institution, with the aid of resection of the medial third
of the clavicle, isolated a parathyroid adenoma in the
left superior anterior mediastinum deep to the left
sternoclavicular joint. Postoperatively, the patient is
normocalcemic.
An angiogram (Fig. 18-18) demonstrates recurrent
parathyroid carcinoma in a patient operated on three
times elsewhere. At the time of surgery there was evi-
dence of invasion of the thyroid/cricoid/trachea carti-
lage. At the time of the subsequent surgery performed
on our service there was evidence of invasion of the
thyroid/cricoid/trachea cartilages. The patient refused
ablative surgery, which would involve, at the minimum,
a laryngectomy and the removal of the major portion of
the cervical trachea. She died of pulmonary metastasis.
Diagnostic Adjuncts to Preoperative Imaging
As an adjunct to preoperative imaging, FNA is per-
formed when a distinct mass is palpable in evaluation
of primary hyperparathyroidism. Clear fluid is virtually
diagnostic of a parathyroid cyst. At times a very faint
xanthochromic fluid is suggestive, which of course
could be either thyroid or parathyroid. Two milliliters
of the aspirate, the total of which may amount to over
20 mL, is sent refrigerated, preferably packed in dry
ice, to the laboratory for PTH levels. Another adjunct
to imaging for the normal parathyroid gland in the
mediastinum is mediastinoscopy without the aid of any
imaging or localization procedure.
Summary of Imaging and Nonimaging for
Localization of Abnormal Parathyroid Glands by
the Author (JML)
1. Routine sonogram and sestamibi SPECT scan
a. If either one positive ~ surgery
b. If both tests negative ~ CT and/or MRI
c. If either one positive ~ surgery
d. If all above tests are negative then consider intra-
operative methods (e.g., selective angiography,
venous sampling, and quick intraoperative PTH).
2. If during surgery diseased parathyroids cannot be
located:
a. Try hand-held gamma probe.
b. Try quick intraoperative PTH.
 ENDOCRINE SURGERY

SAG11if=t.. 47
S

FIGURE 18-18 Angiogram demonstrating recurrent

FIGURE 18-17 Sestamibi SPECT scan (from patient 2
under "Patient Examples"). Transverse image with
sagittal cut location. The straight arrow indicates the
parathyroid adenoma, whereas the curved arrow
indicates the right sternoclavicular joint. The adenoma
lies beneath the left sternoclavicular joint. This places the
adenoma in the left superior anterior mediastinum. (From
Lore JM Jr, Staggers-Deberney j, Farrell M, et al: Approach
to superior mediastinal parathyroid adenomata via resec-
tion of the medial third of the clavicle: Operative tech-
niques. Otolaryngol Head Neck Surg 11:216-220, 2000.)
Section 2: Summary Evaluations,
Pros and Cons, for Each Imaging and
Nonimaging Modality
This section is abstracted from the article by Le and
Norton (2001) (see Bibliography). The author (JML)
has his comments in parentheses.
Procedures for Preoperative and Intraoperative
Localization of Adenoma of Parathyroid Glands
Preoperative Imaging with Localization Techniques
I. Ultrasound (US)
Pros:
• Least expensive, least invasive
• Localizes enlarged parathyroid glands
• Thirty to 60% localized even in re-operations, very
good for juxta thyroid and intrathyroid parathyroid
adenomas (and status of thyroid)
parathyroid carcinoma that invaded thyroid, cricoid, and
tracheal cartilages.
Cons:
• Poor with ectopic parathyroid adenomas especially
in the superior glands, which may be within the
tracheoesophageal groove
• Worthless in mediastinum, both anterior and pos-
terior, because the sternum blocks the sound waves
• Is not reliable in multiple glandular hyperplasia
• Requires expert radiologist and technician (as
explained in David F. Hayes's comments on ultra-
sound in Chapter 1)
2. Sestamibi scintigraphy (MIBI)
Pros:
• Excellent for solitary parathyroid adenoma, 70%
to 90% sensitive
• Both thyroid and parathyroid uptake with sestamibi,
but stronger and persistent longer in adenomas
and hyperplasia of parathyroids
Cons:
• Sestamibi may be deficient with multiglandular
disease and small parathyroid adenomas.
• (May have problem with concomitant thyroid
disease)
3. SPECT with sestamibi
Pros:
• Improved sensitivity, about 85 %, especially in
deep cervical and mediastinum
• When combined with gamma probe intraopera-
tively for some surgeons has facilitated more
limited surgical technique at the first operation.

Cons:
• With limited surgical exploration based on
sestamibi may not localize multiglandular disease
or hyperplasia.
4. CT
Pros:
• Very effective for localized ectopic parathyroid
adenomas (e.g., neck, carotid bifurcation, medi-
astinum, tracheoesophageal groove), especially
for parathyroid adenomas attached to the esophagus
and in the fat-replaced thymus and even small
adenomas
Cons:
• Not as effective to localize intrathyroid or jux-
tathyroid parathyroid adenomas
• Danger to patient with the contrast material and
radiation
5. MRI
Pros:
• Ectopic parathyroid adenomas can be located
very well.
• T2-weighted image or stir-pulse sequences yield a
bright signal.
• In the mediastinum a Tl-weighted image is usually
necessary.
• Higher sensitivity than CT with gadolinium-
enhanced and Tl- and T2-weighted images (sagittal
MRI excellent relative to anterior and posterior
mediastinal localization)
Cons:
• T2-weighted images in the mediastinum may
confuse parathyroid adenoma with adipose tissue
• More expensive than CT
6. Angiography: digital subtraction technique (see
Fig. 18-18)
Pros:
• Indicated when most other imaging modalities
fail
• Localizes parathyroid adenomas in exact position
Cons:
• Invasive
Intraoperative Nonimaging Techniques
1. Intraoperative gamma probe (hand-held) (Norman
and Denham, 1998)
Pros:
• Small incision
• Shorter operating room time
• Discharged the same day
• Frozen section not necessary
• May be worthwhile when all else fails during
surgery (see Section 3 for more updated data)
Cons:
• Missed multiple glandular disease
ENDOCRINE SURGERY
• If thyroid lobectomy is necessary, incision will be
longer (remember, an incision heals from side to
side, not from end to end [JML]).
• Early reports focused on first operation when the
usual technique nearly always was efficacious.
• Recurrent laryngeal nerve injury could be more
with less exposure or some claim less with less
exposure. In any event, it requires more data on
these aspects.
• Thyroid lobectomy requires additional exposure.
(italian literature describes a video-assisted
thyroidectomy via a limited incision.)
• May miss multiglandular disease and hyperplasia.
• If thyroid lobectomy is indicated, incision will be
longer.
2. Selective venous sampling
Pros:
• When all else fails
Cons:
• Does not specifically localize the parathyroid ade-
noma, only a general region, for example, whether
it be in the neck or mediastinum, right or left,
superior or inferior
• Radiation exposure
• High cost
3. OPTH-intraoperative evaluation of PTH
Pros:
• Rapid monitoring of parathyroid status during
surgery
• Use only as an adjunct to the basic standard
management-complements surgical skill and
histopathologic information
• With removal of parathyroid adenoma, elevated
PTH levels decline rapidly (15 minutes); may help
intraoperative diagnosis of hyperplasia because
the rate of decline would be less.
Cons:
• False-negative results
• Needs more experienced data
• Limited at this time (see Section 3 for more
updated data on this technique)
• (Cost factor)
Summary of Radiographic Localizations and
Surgery (Le and Norton, 2001)
1. First operation:
a. No imaging because it is expensive with no
improvement of outcome
2. Re-operation:
a. Liberal use of each: ultrasound, CT, sestamibi,
and MRI
b. If two studies locate adenoma in same location ~
surgery.
 ENDOCRINE SURGERY
c. If above are equivocal, then do angiography and
if positive --7 surgery.
d. If above imaging is negative, do venous sampling
for PTH.
Section 3: Pearls and Pitfalls Regarding
Parathyroid Imaging*
The following is a review of 22 abstracts in the current
literature regarding parathyroid imaging:
1. Zettinig G, et al: Suppressed double adenoma-a
rare pitfall in minimally invasive parathyroidectomy.
Horm Res 57:57-60, 2002, University of Vienna,
Austria.
Quick intraoperative parathyroid hormone (QPTH)
has its false reports. After removal of large para-
thyroid adenomas by minimally invasive parathy-
roidectomy utilizing QPTH some 9 months later a
repeat sestamibi scan revealed a contralateral small
adenoma. This report points out the uncertainty of
QPTH in a patient with two adenomas. The larger
adenoma evidently suppressed the smaller one. This
supports the search for all four parathyroid tech-
niques at the initial surgical procedure and ques-
tions the validity of QPTH, at least in the presence
of multiple parathyroid adenomas.
2. Saaristo RA, et al: Intraoperative localization of
parathyroid glands with gamma counter probe in
primary hyperparathyroidism: A prospective study.
J Am Coil Surg 195:19-22, 2002, University Hospital
of Tampere, Finland.
To evaluate the efficiency of intraoperative gamma
probe, a study was done comparing the surgery uti-
lizing sestamibi imaging with the intraoperative
gamma probe. The sensitivity with sestamibi imag-
ing was 81 % for parathyroid adenoma and 100%
for hyperplasia, whereas the gamma probe for para-
thyroid adenoma was 50% and 0% for hyperplasia.
This indicates that sestamibi scan was more accu-
rate than intraoperative gamma probe in localizing
parathyroid adenoma.
3. Jaskowiak NT, et al: Pitfalls of intraoperative quick
parathyroid hormone monitoring and gamma probe
localization in surgery for primary hyperparathy-
roidism. Arch Surg 137:659-668; discussion 668-
669, 2002, University of Chicago, Illinois, USA.
The question of pitfalls of QPTH monitoring and
gamma probe localization revealed that the gamma
probe was less useful but nevertheless crucial in two
operations but not specific for parathyroid tissue.
"The intraoperative QPTH monitoring confirmed
cure in most cases." For single adenomas use of the
• Abstracted from Ovid, in MEDLlNE, selected articles on imaging,
2001 and 2002.
Nichols criteria for QPTH assessment allowed more
accurate and faster confirmation than the normal-
limit criteria. Both techniques have potential pitfalls
that can result in surgical failure.
4. Zettinig G, et al: Value of a structured report for the
interpretation of parathyroid scintigraphy in primary
essential hyperthyroidism. Acta Med Aust 29:68-71,
2002, Germany.
In single-gland disease sestamibi scintigraphy is
recommended in primary localization for minimally
invasive parathyroidectomy operation.
5. Casara 0, et al: An ectopic mediastinal parathyroid
adenoma accurately located by a single-day imag-
ing protocol of Tc-99m pertechnetate-MIBI subtrac-
tion scintigraphy and MIBI-SPECT-computed
tomographic image fusion. Clin Nucl Med 27:186-
190, 2002, General Hospital of Padova, Italy.
Multimodality imaging procedures for accurate
preoperative localization of parathyroid adenomas
are recommended, especially when they are in ectopic
mediastinal locations, specifically sestamibi SPECT
imaging.
6. Berczi C, et al: Technetium-99m-sestamibijpertech-
netate subtraction scintigraphy vs. ultrasonography
for preoperative localization in primary hyperparathy-
roidism. Eur RadioI12:605-609, 2002, University of
Oebrecen, Hungary.
Evaluation of the sensitivity of technetium-99m
sestamibi and technetium-99m pertechnetate sub-
traction scintigraphy, which were higher when com-
pared to ultrasound. "The sensitive method could
help surgeons in performing a rapid and direct
parathyroidectomy." Bilateral neck exploration was
performed on all patients.
7. Civelek AC, et al: Prospective evaluation of delayed
technetium-99m sestamibi SPECT scintigraphy for
preoperative localization of primary hyperparathy-
roidism. Surgery 131: 149-157, 2002, Johns Hopkins
Medical Institutions, Baltimore, Maryland, USA.
The report of sestamibi SPECT is highly accurate
for the localization of parathyroid adenomas and
re-explored casesin which it is often the only imaging
required. Its sensitivity is limited in multiglandular
disease.
8. Casara 0, et al: Clinical role of 99mTc04/MIBI scan,
ultrasound and intraoperative gamma probe in the
performance of unilateral and minimally invasive
surgery in primary hyperparathyroidism. Eur J Nucl
Med 28:1351-1359, 2001, Regional Hospital of
Padova, Italy.
Conclusions included that sestamibi and ultra-
sound imaging are accurate in selecting patients for
unilateral neck exploration. An indication for bilateral
neck exploration is the coexistence of nodular goiter.
Dual-tracer scintigraphy and ultrasound imaging
are strongly recommended in all patients with pri-

mary hyperparathyroidism. SPET (SPEeT) is recom-
mended for an enlarged parathyroid gland located
deep in neck or mediastinum. Intraoperative gamma
probe appears useful with solitary parathyroid ade-
noma with a normal thyroid gland, permitting
minimally invasive surgery.
9. Scheiner JD, et al: Preoperative localization of
parathyroid adenomas: A comparison of power and
color Doppler ultrasonography with nuclear medi-
cine scintigraphy. Clin Radiol 56:984-988, 2001,
Brown University School of Medicine, Providence,
Rhode Island, USA.
Ultrasound and nuclear medicine are comple-
mentary for localization of parathyroid adenomas.
10. Ott MC, et al: Intraoperative radio-guided thoraco-
scopic removal of ectopic parathyroid adenoma.
Ann Thorac Surg 72: 1758-1760, 2001, New London
Health Science Center, University of Western Ontario,
Canada.
A case is reported of an occult ectopic parathy-
roid adenoma removed thoracoscopically using an
intraoperative hand-held gamma probe.
11. Geissler B, et al: Radio-guided parathyroidectomy:
Successful intraoperative parathyroid localization
diagnosis with 99mTc-sestamibi in primary and recur-
rent hyperparathyroidism. Chirurg 72: 1179-1185,
2001, Klinikum Augsburg, Germany.
This article supports the use of the gamma probe
in primary and recurrent hyperparathyroidism and
thus promotes minimally invasive techniques.
12. Krausz Y, et al: Diagnostic dilemmas in parathyroid
scintigraphy. Clin Nucl Med 26:997-1001, 2001,
Hadassah University Hospital, Jerusalem, Israel.
Diagnostic dilemmas in parathyroid scintigraphy
are discussed. "Differential washout of MISI from
thyroid and parathyroid tissue is not universal.
When MISI is washed out rapidly from parathyroid
adenomas, subtraction of thyroid image should be
performed and differences in contour delineated to
localize the adenoma accurately. Some, but not all,
thyroid lesions account for the false positive find-
ings." (Author's [lML] comment: these conclusions
are similar to author's finding in relation to thyroid
lesions with parathyroid adenoma.)
13. Sprouse LR II, et al: Minimally invasive parathy-
roidectomy without intraoperative localization. Am
Surg 67:1022-1029, 2001, University of Tennessee
College of Medicine, Chattanooga, Tennessee, USA.
"We conclude that minimally invasive parathy-
roidectomy (MIP) can be successfully performed on
the basis of a positive MISI scan. The present study
highlighting many of the advantages of MIP
questions the necessity of additional adjuncts such
as intraoperative PTH measurement and gamma
probe. In two patients, however, bilateral exploration
was necessary. Three patients required subsequent
ENDOCRINE SURGERY
successful bilateral exploration." Thus there was a
total of five bilateral explorations out of a total of so
patients.
14. Rubello D, et a1: Ectopic parathyroid adenomas located
at the carotid bifurcation: The role of preoperative
Tc-99m MIBI scintigraphy and the intraoperative
gamma probe procedure in surgical treatment plan-
ning. Clin Nucl Med 26:774-776, 2001, Regional
Hospital and University of Padova, Italy.
In ectopic parathyroid adenoma not only should
sestamibi scans be done preoperatively, but also
there seems to be a place for intraoperative gamma
probe for ectopic parathyroid adenoma located at
the carotid bifurcation. In another patient with
multinodular goiter, but no enlarged parathyroid
gland a parathyroid adenoma was located with a
gamma probe.
15. Kebebew E, et al: Localization and reoperation
results for persistent and recurrent parathyroid
carcinoma. Arch Surg 136:878-885, 2001, University
of California, San Francisco, California, USA.
Eighteen patients were treated for parathyroid
carcinoma from 1966- I 999. "Recurrence is common
in patients with parathyroid carcinoma. Patients with
this disease should have frequent lifelong follow-up
to ensure early detection of recurrence. Although re-
operation for persistent or recurrent parathyroid
carcinoma provides significant symptomatic relief
and normalizes serum calcium and PTH levels in
most patients it is associated with some morbidity.
Localizing studies of parathyroid carcinoma are
helpful but do not detect all tumor foci. " (The author
[lML] has utilized angiography to detect recurrent
parathyroid carcinoma. This is very helpful in a
scarred neck when palpation can be confusing in
the presence of recurrent tumor and scar tissue [see
Fig. 18- I 8}.)
16. Saky MT, et a1: Ectopic primary hyperparathyroidism.
Endocr Pract 7:272-274, 2001, MCP Hahnemann
University Hospital, Philadelphia, Pennsylvania,
USA.
The use of extended-field 99mTcsestamibi scan
was recommended for ectopic parathyroid adenoma
in the right dome of the diaphragm, which was
confirmed by selective venous sampling and
angiography.
17. Jones JM, et al: Preoperative sestamibi-technetium
subtraction scintigraphy in primary hyperparathy-
roidism: Experience with 156 consecutive patients.
Clin Radiol 56:556-559, 2001, Royal Victoria
Hospital, Belfast, Ireland.
Sestamibi technetium subtraction scintigraphy
accurately localizes a high proportion of solitary
parathyroid adenomas but is not dependable
because it may be unable to consistently identify
smaller tumors.
 ENDOCRINE SURGERY
18. Arici C, et al: Can localization studies be used to
direct focused parathyroid operations? Surgery
129:720-729, 2001, University of California, San
Francisco, California, USA.
Authors question direct focused parathyroid opera-
tions: "There is considerable controversy today (June
2001) concerning the most appropriate surgical
approach for patients with primary hyperparathy-
roidism. The conventional surgical operation involves
bilateral neck exploration through a collar incision
with identification of all parathyroid tissue and
removal of abnormal parathyroid tissue while the
patient is under general anesthesia. The success
rate of this operation is about 95% or greater in the
hands of an experienced endocrine surgeon. Pre-
operative localization techniques are generally con-
sidered to be unnecessary before initial parathyroid
operations. The purpose of this investigation was
(1) to evaluate the individual and combined accu-
racies of ultrasound and technetium-99m sestamibi
scans in localizing abnormal thyroid glands, and
(2) determine whether such scans can be used to
direct a focused operation.
"When both ultrasonography and sestamibi scans
identify the same solitary parathyroid tumor in
patients with sporadic primary hyperparathyroidism,
this was the only abnormal gland in 96% of the
patients. A focused parathyroidectomy could there-
fore be performed in such patients with an accept-
able ( 95%) success rate."
N surgical intervention for primary hyperparathyroidism:
19. Sullivan DP, et al: Intraoperative gamma probe local-
ization of parathyroid adenomas. Laryngoscope Ill:
912-917,2001, Lenox Hill Hospital, New York University
School of Medicine, New York, New York, USA.
"The gamma probe is a useful tool that comple-
ments a well-performed localization study. It is most
useful in patients who have multiple or ectopic adeno-
mas or who have had prior parathyroid surgery."
20. Irvin GL III, Carneiro OM: "Limited" parathyroidec-
tomy in geriatric patients. Ann Surg 233:612-616,
2001, University of Miami School of Medicine,
Miami, Florida, USA.
Article describes limited parathyroidectomy in
geriatric patients utilizing parathyroid adenoma
excision guided by intraoperative PTH assay.
21. Rubello 0, et al: The role of scintigraphy with dual
tracer and potassium perchlorate (99mTc04 and
KCl04/MIBI) in primary hyperparathyroidism. Min
Endocrinol 26:13-21, 2001, Azienda Ospedaliera,
Padua, Italy.
The addition of potassium perchlorate (KC10,,)to
sestamibi scintigraphy accomplished a rapid wash-
out of the MIBI from the thyroid and thus a good
quality of the sestamibi images for the parathyroid
adenoma. This also contributes to diagnosis of
possible thyroid disease, being thus very useful in
geographic areas with populations with high thyroid
pathology.
22. Nordin AJ, et al: Dual phase 99m-technetium ses-
tamibi imaging with single photon emission
computed tomography in primary hyperparathy-
roidism: Influence on surgery. Australas Radiol
45:31-34, 2001, University of Sydney, Westmead
Hospital, Westmead, New South Wales, Australia.
SPECT imaging is excellent for parathyroid ade-
nomas or hyperplasia, but it does not reduce the
duration of the surgical procedure in primary opera-
tions. However, a negative SPECT scan does not
exclude an adenoma or hyperplasia.
The author (JML) questions the localized limited
incision to be used universally under the circumstances
described in a number of these articles. The problem
comes up since multiple glandular disease is not detect-
ed usually with a sestamibi SPECT scan. Then the
bilateral exploration indication comes into play. Credit
for the use of sestamibi in parathyroid evaluation goes
to Coakley and colleagues (1989).
Indications for Surgery in Primary
Hyperparathyroidism
The following recommendations were outlined by the
National Institutes of Health in 1990 as indications for
1. Significant elevation of serum calcium concentration
(over 11.4 to 12 mg/dL)
2. Previous episode(s) of life-threatening hypercalcemia
3. Reduction of creatinine clearance to less than 70%
of normal
4. History or presence of nephrolithiasis
5. Marked elevation of urinary calcium excretion
(> 400 mg/24 hr)
6. Reduction of bone density that is more than 25 SO
below that of a matched cohort
7. Young age « 50 years of age and/or premenopausal)
Chemical Diagnosis of Hyperparathyroidism
(Davis and Davis, 1985)
Among the diagnostic considerations of hypercalcemia,
other than hyperparathyroid hypercalcemia, are the
following:
1. Thmoral hypercalcemia, in which the neoplasms
secrete a PTH-like substance, osteoclast-activating
factor, or prostaglandins
2. Familial hypocalciuric hypercalcemia (5 % of
patients with suspected hyperparathyroidism)

A careful evaluation of the history will aid in the
differentiation of additional clinical states associated
with hypercalcemia:
1. The MEN syndromes (types I, IIA, and lIB) are
linked with hyperparathyroidism.
2. Patients with thiazide-related hypercalcemia may
in fact have latent hyperparathyroidism that is
"unmasked" by thiazide intake.
3. Propranolol administration can mask primary
hyperparathyroidism by lowering PTH and calcium
levels.
4. Lithium administration can cause increased PTH
secretion.
Overview of Surgical Principles
As of this date (2003) considerable controversy has
developed starting some years ago relative to the varied
options regarding the indications for the evaluation of
disease of the parathyroid gland and the surgical treat-
ment, particularly techniques. The various aspects of
preoperative imaging with localization techniques, as
well as the intraoperative nonimaging techniques, were
discussed in the preceding pages.
The common denominator is the expertise of the
surgeon. Some do not use any preoperative tests under
certain conditions, reserving these tests for the more
difficult problems, whereas others use various tests
preoperatively and intraoperatively. In addition to the
expertise of the surgeon, the expertise of the radiologist
and the technician, especially in sonography as well as
sestamibi scanning, is most important.
The author (JML) routinely uses preoperative testing
and believes that the following detailed description of
surgical anatomy and the surgical technique is most
important, regardless of the various surgical options
available. If a surgeon is leaning toward focus surgery,
that is, a small incision (cosmetic: 2.5 em) and limited
exposure, either combined or not combined with intra-
operative localization and monitoring, for example,
with the hand-held gamma probe or intraoperative
PTH (QPTH), the surgeon must know what to do if
bilateral exposure is indicated. The author has utilized
modified limited surgery under certain conditions, for
example, in a geriatric patient in whom the operation
time should be shortened because of medical reasons.
However, just to accomplish removal of a parathyroid
adenoma through a small cosmetic incision and then
discharge the patient the same day is a decision subject
to significant evaluation. On the other hand, a very
reasonable consideration is that reported by Arici and
colleagues (2001), who suggested that when both ultra-
ENDOCRINE SURGERY
sonography and sestamibi scans identify a single ade-
noma at a single location, focus surgery is worth con-
sideration. Again, the surgeon must have the experience
and skill to expand the dissection as deemed necessary.
Time and experience will no doubt clarify this option.
This author's preference relative to preoperative
localization is:
1. Preoperative localization
a. The routine preoperative use of sonography and
sestamibi scanning
b. If one or both of these tests are positive ~ surgery
c. If both of these are negative, then CT and MRI
d. If one of these or both are positive ~ surgery
e. If negative, consider angiography.
f. If this is positive ~ surgery.
g. If this is negative, then consider intraoperative
nonimaging techniques, namely, gamma probe,
venous sampling, and intraoperative evaluation
(PTH). This last test may well be used earlier in
this sequence, as indicated.
2. Basic operation:
a. Attempt to identify all four parathyroids.
b. Freely use frozen section, if for no other reason
than to have a working understanding with the
pathologist and his or her skill relative to frozen
section in evaluating parathyroid disease, for exam-
ple, hyperplasia and hypercellularity. Do not delay
this joint experience to the time of an isolated
frozen section, which may be very important.
Other considerations in the preoperative imaging
and the surgery include the fact that small and multiple
parathyroid adenomas may not be detected on sestamibi
scanning. These and other situations, such as ectopic
adenomas in the mediastinum, intrathyroidal parathy-
roid adenomas, and the coexistence of parathyroid and
thyroid disease, including hyperplastic glands, may require
not only additional localization studies but also an expe-
rienced surgeon. Such a trained surgeon is preferred in
the overall management of diseases of the parathyroid
glands. Such a surgeon must know:
1. When he or she could consider a focus operation
2. When and how to perform a bilateral cervical explo-
ration, as well as explore the mediastinum. In other
words, dabblers beware.
Other admonitions are:
1. Be sure to monitor the patient, as well as the current
literature.
2. An expert endocrinologist can be a significant help.
3. Primum non nocere (first, do no harm).
 ENDOCRINE SURGERY
Detailed Review of Surgical
Principles
1. Standard thyroidectomy incision and approach (see
Fig. 18-9A to 1). Corticosteroids (Medrol Dosepak)
preoperatively, intraoperatively, and postoperatively
reduce the incidence of temporary recurrent laryn-
geal nerve paralysis as well as temporary bowing
of a vocal cord.
2. Begin the search for the glands as soon as the skin
flaps are elevated and retracted and the strap mus-
cles are separated in the midline. Rarely, parathy-
roid glands have been located just beneath the
strap muscles anterior to the thyroid capsules as
well as anterior to the strap muscles.
3. Strap muscles are then retracted. Division of the strap
muscles is usually not necessary unless carcinoma
is suspected. Palpate the thyroid gland and juxta-
posed thyroid tissue, especially posterolateral to
the thyroid gland.
4. Search for the inferior parathyroid glands (these
glands are usually at a more anterior level than the
recurrent laryngeal nerve). Expose and gently
mobilize the inferior pole of the thyroid gland. The
inferior thyroid veins may require ligation and
division. Often an adenoma can be visualized by
reflecting the thyroid lobe medially as the initial
step in the search (see Fig. 18-19C and D).
5. Expose the recurrent laryngeal nerve inferiorly as
in a thyroid lobectomy if the parathyroid disease is
not readily exposed on medial and superior reflec-
tion of the thyroid lobe, or if there is associated
thyroid disease. Follow the nerve superiorly as it
passes deep to the posterior inferior ligament of the
thyroid. Routine exposure of the recurrent laryngeal
nerve is not necessary.
6. Search for the superior gland and conduct an addi-
tional search for the inferior glands by mobilizing
the lateral portion of the thyroid gland by ligation
and division of the lateral thyroid veins. Reflect the
thyroid gland medially and inspect and palpate the
posterior aspect of the thyroid gland and the poste-
rior aspect of the superior thyroid pole, taking care
not to injure the recurrent laryngeal nerve or the
external branch of the superior laryngeal nerve. A
search is likewise made posterior to the recurrent
laryngeal nerve as it enters the larynx beneath the
cricopharyngeus muscle (lower fibers of the inferior
pharyngeal constrictor muscle), posterior to the
trachea and posterior to the esophagus, and in the
area between the superior pole of the thyroid gland
and the larynx, taking care not to injure the external
branch of the superior laryngeal nerve. Palpation of
the cricoid cartilages provides a good landmark,
the inferior edge of which marks the site where the
recurrent laryngeal nerve leaves the surgical field.
This landmark also is the usual location-within
0.5 to 1.0 em of the superior parathyroid gland (see
Fig. 18-19E). Extreme care is taken when the imag-
ing technique pictures an adenoma in relation to
the inferior pole of the thyroid. Such an adenoma
may arise from the inferior parathyroid, but it also
may arise from the superior parathyroid. In the latter
event, the recurrent laryngeal nerve will be ante-
rior to the adenoma and may be fixed to the anterior
portion of the capsule of the adenoma, a very vul-
nerable position for injury to the nerve. This ade-
noma may then extend into the posterior portion of
the superior mediastinum.
7. Inspect and palpate the superior portion of the
superior mediastinum and the thymus (especially
evaluate the adipose tissue in the vicinity of the
great vessels, namely, the brachiocephalic veins
and the innominate artery) as well as posterior to
the trachea and the tracheoesophageal sulcus and
esophagus. Parathyroid adenomas have been
located anterior to the pericardium between the
aorta and the pulmonary artery as well as posterior
to the pericardium near the mainstem bronchus.
More than one adenoma can be located in the medi-
astinum as elsewhere. Nathaniels and colleagues
(1970) have described 20 mediastinal parathyroid
tumors, a number of these being in relation to the
aorta and the pericardium. This is an indication for
a complete median sternotomy for adequate explo-
ration of the mediastinum. On the other hand, if the
adenoma is in the posterior superior mediastinum,
the median sternotomy may not be necessary. The
author resected a deeply located cystadenoma (7 to
8 em) in the posterior mediastinum adherent to the
esophagus via the suprasternal approach. If addi-
tional exposure is required, resection of the medial
third of the ipsilateral clavicle may be necessary
(see Fig. 19-9). In general, a median sternotomy is
used to explore the anterior mediastinum, whereas
a resection of the medial third of the ipsilateral
clavicle is used for the posterior mediastinum.
8. Evaluate the thymus for entrapped inferior parathy-
roid glands. Thymectomy may be necessary and
appears indicated with hyperplasia, because a fifth
parathyroid gland may be within the thymus.
Mediastinal adenoma at the level of the second
interspace can be located in a more inferior portion
of the thymus.
9. Evaluate accessible areas that are known to harbor
ectopic parathyroid (e.g., within the carotid sheath
at least up to the bifurcation of the common carotid
artery, the central area between both carotid arteries
at the level of exposure, the thyroid cartilage lamina,
and the vicinity of the hyoid bone).
10. Thyroid lobectomy. It has been reported that the
superior glands are more likely to be in the thyroid

(Milley). Consider a thyroid lobectomy when the
usual and complete search for the superior parathy-
roids has failed. However, an adenoma located deep
to the sternoclavicular joint (located by imaging
including PET), although in the anterior superior
mediastinum, was exposed and removed by resection
of the medial third of the clavicle. Three previous
explorations at other institutions failed to locate this
adenoma. On the other hand, an adenoma located
in the posterior superior mediastinum can be
reached with median sternotomy (see Fig. 18-20)
although it is usually easier with resection of the
medial third of the clavicle. If one approach fails or
affords only limited access, the other approach can
be used at the same time-a combined approach.
11. Thorough cervical exploration: the complexity of
this type of exploration is emphasized by a listing
of the cervical ectopic parathyroids, as reviewed by
Joseph and associates (1982) (see Table 18-9). To
this list of cervical ectopic parathyroid glands these
researchers added one patient in whom the glands
were located in the mucosa of the pyriform sinus;
they recommend indirect and direct endoscopy as
well as pharyngoesophagography.
To facilitate thorough cervical exploration, two
surgical techniques are suggested. One is to extend
the initial horizontal cervical incision laterally so
as to be able to mobilize the superior skin flap up
to the level of the hyoid bone and the bifurcation
of the common carotid artery. The other approach
would be a second horizontal incision at the level
of the thyrohyoid membrane, taking care not to
injure the internal and external branches of the
superior laryngeal nerves.
Intraoperative PTH levels are of help both in
indicating the side of adenoma and whether an
additional adenoma is present.
If, after a thorough cervical exploration, the
diseased parathyroid gland is not located, then the
following procedures may be considered. When a
sestamibi test is done before exploration, and thor-
ough exploration is negative, we have found the
use of a gamma counter probe useful for intrathy-
roidal, or aberrant, adenomas which may pick up
the sestamibi, as described by Dr. John Van Heerden
of the Mayo Clinic.
To rule out a second adenoma, or removal of
the wrong gland, Irvin and co-workers (1991) have
described a rapid intraoperative PTH level kit. If a
50% or more reduction of PTH level occurs after
removal and confirmation of an adenoma, this affords
added assurance of no further residual hyper-
functioning glands. If no hyperfunctioning glands
are found, then, using this rapid PTH kit, samples
of blood drawn from bilateral internal jugular veins
ENDOCRINE SURGERY
can be taken at three levels to determine possible
locations in the neck of an aberrant adenoma.
Finally, if all else fails, and two normal glands
are found on one side, and only one or none on the
other side, Dembrow has performed thyroid lobec-
tomy, or ligation of the superior and inferior thyroid
pedicles on the side lacking a gland, and has pro-
duced long-lasting normocalcemia. This should be
done, however, only after exhausting all other diag-
nostic measures (Irvin et aI., 1991). (See Imaging
and Nonimaging Parathyroid Adenomas and Hyper-
plasia, p. 979.)
12. Ideally all four parathyroid glands are identified and
a small biopsy of each gland is examined by frozen
section before the resection of any gland. The small
biopsy should not interrupt the blood supply of the
gland. Regardless, postoperative hypocalcemia can
be significant. A titanium clip can be placed on the
free edge of a small portion of the gland (Clark, 1985).
The clip will serve to achieve hemostasis and at the
same time is left in situ to allow for identification
of the gland if necessary at a secondary procedure.
An intraoperative decision is based not only on the
frozen section but also on the gross findings.
Hypercellularity on frozen section with all grossly
enlarged glands are indications that at least a three
and three-quarter parathyroidectomy should be per-
formed. Hypercellularity alone is not an indication
to remove a gland. The remaining parathyroid
tissue must have its blood supply intact; otherwise,
autotransplantation of the remaining parathyroid
tissue should be performed. The transplantation is
done ideally in a muscle of the forearm for future
monitoring and possible removal. A problem may
be encountered with the metal clip in that at times
the metal clip can become dislodged, and hence a
black silk suture is also used to identify the remain-
ing parathyroid gland.
13. Although rare (this author has operated on three
such patients), a suspected adenoma can be malig-
nant; hence do not rupture the capsule of any
adenoma (rupture of capsule of adenoma may lead
to seeding). Malignancy may not be detected by
histologic examination. Gross findings of invasion
and vocal cord paralysis may give the clue.
In one patient, a massive parathyroid carcinoma
resembled a large goiter and was virtually insepa-
rable from the thyroid lobe. A total thyroidectomy
and central node dissection was performed. This
neoplasm invaded the recurrent laryngeal nerve,
separating this nerve into its various nerve bundles.
The nerve was paralyzed. In one of the other patients
the carcinoma of the parathyroid with a very thick
capsule was likewise contiguous with the thyroid
lobe and adherent to the deep cervical fascia and
 ENDOCRINE SURGERY
cervical esophagus, extending down to the posterior
portion of the thoracic inlet. The recurrent laryngeal
nerve was anterior to the neoplasm and although
adherent to the capsule was not invaded and able
to be preserved. Because of these relationships, the
neoplasm most likely arose from the superior parathy-
roid gland, hence the need for great care in identifi-
cation of the recurrent laryngeal nerve under these
circumstances.
This relationship of the nerve to the capsule has
also been observed in benign adenoma. The basic
cervical exploration should include, in addition to
the usual locations of the four parathyroids, the
following:
a. Retropharyngoesophageal area
b. Tracheoesophageal area
c. Thyroid cartilage areas including the superior
cornu
d. Carotid sheath
e. Hyoid bone area
f. Top superior mediastinum region, both anterior
and posterior, and tracing the various branches
of the inferior thyroid artery, thyrocervical trunk,
and the superior thyroid arteries that supply the
parathyroid glands
14. Thorough mediastinal evaluation. This may be par-
tially performed as a limited median sternotomy
down to the second or third intercostal space (see
Fig. 19-10). If this exposure is unsatisfactory and
no adenoma is found, then a complete median ster-
notomy to the xiphoid is recommended. If sestamibi
planar and SPECT, CT, MRI, or digital subtraction
angiography indicates an adenoma at the level of
the pericardium, a complete median sternotomy is
performed as the initial procedure. It may even be
simpler and more straightforward to perform the
complete sternotomy at the onset. The areas to expose
and to search are from the suprasternal notch above
to the lower edge of the pericardium below and
laterally to the pleura. The thymus gland, which is
removed, may be adherent to the aorta and pul-
monary artery. The problems associated with thorough
mediastinal search immediately after a thorough
cervical search are the factors of time already spent
during the surgical procedure and the exhaustion
of the surgeon. Nevertheless, before any parathyroid
surgery, it is believed to be important to obtain the
permission from the patient for a mediastinal explo-
ration. The advantage of an immediate mediastinal
exploration is the presence of a fresh, clean, surgical
wound rather than the scar tissue that may occur
at a second stage. On the other hand, staged explo-
ration may be the better choice. This will allow
time for additional imaging if not already done.
Intraoperative PTH evaluation kits could then be
obtained if not already available. The final decision
rests with the surgeon and should be based on the
findings at the first surgical procedure. For example,
if four normal parathyroid glands are identified and
a thorough cervical and top superior mediastinal
exploration has been performed to no avail, an exten-
sive mediastinal exploration may best be delayed
to a second stage, because occasionally interruption
of the blood supply may in fact relieve the hyper-
parathyroidism, or there may have been a mistaken
diagnosis. Clark (1985) indicates that a thorough
mediastinal exploration is indicated at the first opera-
tion "only if the serum calcium level is I3 mg/dL
or greater."
Once mediastinal exploration is decided on, it
should be recognized that usually the inferior parathy-
roid glands are more likely to be in the anterior supe-
rior mediastinum, whereas the superior parathy-
roids are more likely to be in the posterior superior
mediastinum. Hence, the surgeon may be directed
to the anterior or posterior area depending on
which parathyroid cannot be located in the cervical
exploration (e.g., if the right inferior parathyroid is
not identified in the cervical region, the mediastinal
area on which to concentrate would be the right
anterior mediastinum). Anterior superior mediastinal
exploration must include a careful, time-consuming
search and examination of all adipose tissue under
the sternum and sternoclavicular joints. This involves
teasing out all the adipose tissue, with examination
of the lobules of the adipose tissue as well as the
tissue between the lobules of the adipose tissue.
This examination should extend laterally well beyond
the midline, including all the tissue surrounding
the great vessels anterior to the pericardium between
the aorta and the pulmonary artery. The posterior
mediastinal exploration is initially concentrated on
the paratracheal and paraesophageal areas through
the intact suprasternal approach. One such parathy-
roid cystadenoma was found deep in the posterior
superior mediastinum adherent to the thoracic
esophagus and the left recurrent laryngeal nerve.
Others report glands associated with the left main-
stem bronchus and in the posterior superior
mediastinum. In this location there is the problem
of exposure as well as bleeding from small arteries
arising from the aorta. For additional and adequate
exposure of the posterior mediastinum as well as
inferior to the sternoclavicular junction, resection
of the medial third of the clavicle affords excellent
exposure (pp. 1041 to 1045). Care is taken not to
injure the left recurrent laryngeal nerve as it swings
around the aortic arch anterior to posterior as well
as the right recurrent laryngeal nerve around the
subclavian artery from anterior to posterior. The

left recurrent laryngeal nerve also passes anterior
to posterior around the aortic arch (see Fig. 18-19C)
and then between the trachea and the left common
carotid artery. The right recurrent laryngeal nerve
passes deep to the right subclavian artery and deep
to the common carotid artery and then lies between
the trachea and the right common carotid artery.
More than one adenoma can be located in the
mediastinum, although rarely, so that regardless of
the success of locating one adenoma, the search is
continued for additional adenomas for a reasonable
period of time. Ideally, intraoperative intact PTH
levels will solve the problem almost immediately. It
may even be worthwhile for two surgical teams to
search the mediastinum independently. This affords
the initial surgeon time to relax. The key words are
patience and extra time.
15. When an adenoma is located, it must be empha-
sized that before its removal every effort should be
made to identify the remaining three glands or at
least to make free use of frozen section. The ade-
noma is then removed along with a small sliver
biopsy (away from the hilum, which is the site of
vascular supply of the gland) of all three glands or
at least one other parathyroid gland to confirm that
it is normal or hypoplastic. The typical adenoma
on frozen section usually has a rim of normal
parathyroid tissue, whereas the "normal"-appearing
glands reveal suppressed or normal parathyroid
tissue on frozen section. However, a rim of normal
parathyroid tissue surrounding a hyperplastic gland
may be misleading. If only the adenoma is located,
then a portion of the adenoma may be preserved
by cryopreservation for reimplantation for the pos-
sible use of treating any postoperative hypopara-
thyroidism. It has been reported that these frozen
parathyroids may be viable for up to 18 months
(Brennan et aI., 1979). If the cryopreservation
technique is not available and there is reasonable
question of postoperative hypoparathyroidism, a
small portion of the adenoma can be implanted in
the forearm.
In the evaluation of circulating intact PTH
postoperatively, when a portion of parathyroid
gland has been implanted in the forearm, a blood
sample is taken from the contralateral forearm.
An adenoma may have a stalk that grossly appears
normal. It is important to remove the entire stalk.
16. In hyperplasia without adenoma, the basic technique
at this point is a three and one-half to three and
three-quarter gland removal. Retained parathyroid
tissue must have an adequate blood supply, or it is
cut in I-mm sections and reimplanted in the
forearm or other area that can be easily located and
marked with a titanium clip or black silk suture.
ENDOCRINE SURGERY
The failure rate for reimplanted parathyroid tissue
is reported to be 5% for early failure and 5% for
late failure. If there is recurrent hyperparathyroidism,
resection of a portion of this reimplanted gland can
be done. Cryopreservation is utilized when there is
questionable viability of reimplanted parathyroid
tissue, especially when the hyperparathyroidism is
secondary to renal insufficiency. Cryopreservation
requires costly special techniques and equipment
and may not be available.
17. Young (personal communication) cited one problem
related to reimplantation of a parathyroid gland that
on frozen section was indicated to be an adenoma.
The portion of the gland that was reimplanted in
the forearm increased in size, and this proved to be
a carcinoma. Often, it may be very difficult for the
pathologist to diagnose carcinoma on frozen sec-
tion. In one of our patients, the original histologic
diagnosis was a benign adenoma. However, this
patient had preoperative vocal cord paralysis, and
at the time of surgery there was gross involvement
of the recurrent laryngeal nerve with vocal cord
paralysis as well as involvement of the thyroid gland.
Total thyroidectomy and central node dissection
was performed. This also demonstrated the impor-
tance of examination of the larynx preoperatively.
On further review of the slides, carcinoma, which
was suspected by the surgeon, was confirmed.
Hence, the clinical picture and the gross surgical
findings are important in the diagnosis of carcinoma.
We have encountered pulmonary metastasis in one
patient. The author has had one patient, who was
exposed to radiation in childhood, with thyroid car-
cinoma and a parathyroid adenoma. This combi-
nation is known to occur as well as each entity
separately as a result of radiation exposure. Total
thyroid lobectomy should be performed with any
associated thyroid nodule. If thyroid carcinoma is
found on frozen section, the procedure of choice is
total thyroidectomy and central node dissection.
18. Carcinoma of parathyroid gland. If carcinoma of
the parathyroid is suspected (see p. 972), it must
be kept in mind that the initial surgical procedure
is most important, because re-operation for parathy-
roid carcinoma may be extremely difficult and the
outcome may be poor. Nevertheless, this initial
diagnosis may be difficult and not obvious, if not
impossible.
However, if there is local invasion and/or fibrous
adhesions with a thick fibrous capsule, then "en
bloc" or at least wide resection is suggested, includ-
ing the thyroid lobe and isthmus, ipsilateral central
nodes, and paratracheal and paraesophageal tissue
dissection and the ipsilateral thymus with associated
adipose tissue. Wide exposure is recommended
 ENDOCRINE SURGERY
with extension of the initial skin incision and section
of the strap muscles, or their removal if adherent to
the neoplasm. Every effort must be made to avoid
rupture of the neoplasm. Neck dissection is then
advised when there is evidence of nodal metas-
tasis. The dissection should be extended to the supe-
rior thoracic inlet and further into mediastinum,
depending on the operative and histologic findings.
Identify at least one normal parathyroid, and the
suggestion is then to explore the contralateral side
of the neck and identify and mark the parathyroids.
This is important, because postoperative hyper-
calcemia in a patient with parathyroid carcinoma
could conceivably be due to hyperplasia or an
adenoma in a gland on the contralateral side. The
other gland on the ipsilateral side definitely should
be identified.
More often than not, this intraoperative diagnosis
rests with the surgeon when the findings suggest
carcinoma rather than on frozen section or even
final paraffin sections.
The surgical management of recurrent or per-
sistent disease must be very aggressive except for
those patients with rapidly progressive multiple
hematogenous metastasis. Fujimoto and co-workers
(I986) reported the resection of multiple bilateral
pulmonary metastasis with relief of hypercalcemia
in a young girl without any other evidence of
metastatic disease. This author (JML) has seen
recurrent disease invading the trachea, cricoid
cartilage, and previous skin incisions and others
report seeing it located between the trachea and
spine, between the trachea and esophagus, and
behind the carotid sheath.
If such aggressive surgical management fails,
then the options include chemotherapy with mul-
tiple drugs, as well as symptomatic medical treat-
ment of the hypercalcemia with mithramycin (may
have severe side effects), calcitonin, diphosphonate,
hydration, furosemide, dacarbazine, and disodium
clodronate. Because the efficacy of these drug regi-
mens are problematic a medical oncologist consul-
tation to ascertain the best chemotherapeutic agents
is recommended.
A significant problem in the treatment of patients
with severe hypercalcemia is a psychosis that may
induce the patient to give up all hope and refuse
treatment. This problem has been seen by this author
not only in carcinoma but also in what appeared
clinically to be nonmalignant primary hyperparathy-
roidism. Acute psychosis can also occur in post-
operative severe hypocalcemia.
Shane and Belezikian (I982) in a review of 62
patients with parathyroid carcinoma report an
average 5-year survival rate of approximately 50 %,
yet some patients survive for many years with
known metastasis.
19. Hyperparathyroid crisis (acute hyperparathyroidism)
refractory to medical management may require
emergency surgery. Wang (1979) reports elevated
levels of blood urea nitrogen in 50% as well as a
rise of creatinine levels in 80% of these patients.
The usual symptoms of hyperparathyroidism are
progressive, with mental derangement and severe
gastrointestinal symptoms. Coma can then lead to
death. Wang states that "prompt surgical inter-
vention is the ideal treatment for hyperparathyroid
crisis, preferably within 72 hours of the acute onset
of symptoms."
The immediate medical management of hyper-
calcemia is the following:
a. Vital signs are monitored carefully.
b. Diuretics should be initiated only after the patient
has undergone volume replacement or the inherent
state of hypovolemia will be worsened.
c. Intravenous plicamycin (formerly mithramycin)
is a cytotoxic antibiotic that is a potent inhibitor of
bone resorption. It is given in a dose of 25 mg/kg
with a reduction of serum calcium acutely within
24 hours. It reaches a nadir in 2 to 3 days. Its use
is limited by its renal, hepatic, and bone marrow
toxicity; therefore it is usually reserved for acute
control of severe hypercalcemia.
d. Pamidronate disodium is a bisphosphonate that
inhibits osteoclastic bone resorption. The initial
dose is 60 to 90 mg by intravenous infusion over
4 hours. The full effect on serum calcium levels
is not demonstrated for 4 to 5 days, but its effect
can last as long as 6 weeks. This agent would
obviously be more helpful in managing hyper-
calcemia chronically if surgical intervention was
not an option.
e. Hemodialysis may be necessary.
In emergency parathyroidectomy, the patient requires
little, if any, anesthesia.
Excision of Parathyroid Adenomas
(Fig. 18-19)
The search for the cervical parathyroid is based on the
entire thyroid and parathyroid area from the superior
thoracic inlet and then superiorly to the submandibular
area and laterally to include the carotid sheath (see
Fig. 18-19C). Removal of an adenoma posterior to the
thyroid lobe requires reflection of the thyroid lobe
medially with transection of the middle thyroid veins.
This is usually the first step in parathyroid exploration
unless the imaging indicates otherwise.

For a detailed discussion of imaging, please see
page 979. The author (JML) always obtains the thyroid
sonogram, not only relative to the possible identifi-
cation of a parathyroid adenoma but also for evaluation
of the thyroid gland. If a thyroid lesion is demonstrated
on sonography, the surgeon must discuss with the
patient the possibilities of additional concomitant
thyroid surgery.
Although injury to the recurrent laryngeal nerves is
uncommon in parathyroid surgery as compared with
thyroid surgery, laryngoscopy is a sine qua non. Paralysis
of the recurrent laryngeal nerves is one of the presenting
symptoms of a patient with carcinoma of the parathyroids.
Preoperative and postoperative laryngoscopy establishes
the function of the recurrent laryngeal nerves. A
preoperative weakness or paralysis of a vocal cord will
save the surgeon much grief if it is verified before he or
she enters the operating room.
Guidelines for Cervical Parathyroids: Search and
Excision
(See also p. 979 regarding intraoperative identification and
localization of parathyroid adenoma and hyperplasia.)
1. Search for the inferior parathyroids.
a. Search adipose tissue and vascular network at
the inferior pole of the thyroid gland and then
inferiorly toward the superior thoracic inlet (see
Fig. 18-190).
b. Deep to the inferior pole-if this becomes
extensive, be careful of the recurrent laryngeal
nerve. The inferior parathyroid is usually on a
more anterior plane than the recurrent laryngeal
nerve. However, the reverse may occur. The infe-
rior thyroid veins will require transection (see
Fig. 18-190).
c. Another technique in searching for parathyroids
is tracing the inferior thyroid artery, because not
only the inferior parathyroids are supplied with
this vessel but also the superior thyroid may be
supplied by this vessel. Superior parathyroids
may as well be supplied by a branch of the supe-
rior thyroid artery (see Fig. 18-14). With magni-
fication it may be a help in tracing these small
vascular branches to the parathyroids.
2. Search superior parathyroid gland.
a. Expose area within 1 to 1.5 em of site where the
recurrent laryngeal nerve leaves the thyroid
bed-this is usually at the inferior edge of the
cricopharyngeus muscle along the fibers of the
inferior pharyngeal constrictor muscle. The infe-
rior edge of the cricoid cartilage is a good land-
mark (see Fig. 18-19E). Tracing branches of the
superior and inferior thyroid arteries and their
ENDOCRINE SURGERY
branches may lead to the superior parathyroid
gland. The inferior thyroid artery may supply both
the inferior and superior parathyroid glands.
b. To adequately expose this area, the lateral leaf of
the posterior suspensory ligament of the thyroid,
if present, may require transection (see Fig. 18-12E).
c. In this area, be careful of the recurrent laryngeal
nerve. The superior parathyroids are usually
nestled in adipose tissue just deep to the nerve,
deep to the thyroid, and slightly medial. Parathy-
roid gland may be in the tracheoesophageal
sulcus or behind the esophagus. The nerve may
have to be exposed to prevent injury. At times
the superior parathyroid may be adherent to the
inferior deep aspect of the thyroid. At other times
the adenoma may be actually adherent to the
recurrent laryngeal nerve itself.
d. If the parathyroid glands cannot be located with
this type of search, then expose the thymus in
the top portion of the superior anterior medi-
astinum, if the parathyroids are missing. If the
superior parathyroid glands are missing, then
consider a thyroid lobectomy if all of the other
areas are searched. Whether to delay thyroid
lobectomy before a mediastinal evaluation and
exploration is a preference decision. Careful
review of all images that may have been done is
necessary. The top anterior superior mediastinum
can be more adequately searched by transecting
the intra clavicular ligament.
3. Exposure of the recurrent laryngeal nerve:
a. Only selectively indicated in parathyroid surgery
b. Always necessary in thyroid surgery
4. Identify and examine and label (with black silk,
close to but not interfering with blood supply of the
parathyroid) and, if necessary, biopsy (small sliver)
at least one other parathyroid, preferably three.
These other glands may well indicate hyperplasia.
Treatment after sampling all parathyroids is per-
formance of three and three-quarters removal with
one fourth implanted in the forearm. Diagnosis of
hypercellularity is very difficult and impossible
to differentiate from hyperplasia. "About 85% of
patients with primary hyperparathyroidism have
solitary, benign parathyroid adenomas, about 12 %
have hyperplastic parathyroid glands, and the
remaining 3 % have multiple parathyroid adeno-
mas. Some of the latter patients may actually have
primary parathyroid hyperplasia with a marked
variation in the size of the parathyroid glands"
(Clark, 1985). Add I % or less for parathyroid
carcinoma.
5. Intraoperative PTH, if available, can aid in the deci-
sion regarding the search for another parathyroid
adenoma.
 ENDOCRINE SURGERY
6. When ligating the stalk of an adenoma, be sure the
site of ligation is well away from the adenoma. If
there is any question, do a frozen section on the
stalk to be sure.
7. Take care not to break the capsule of the adenoma,
because this may well cause reimplantation and
hyperfunctioning.
8. Excision of a parathyroid adenoma can be a very
simple and swift operation. On the other hand, it can
be a very exhausting, tedious, and time-consuming
procedure. Patience and diligence is necessary. It is
not the procedure for a neophyte operating without
proper skilled guidance and training.
9. The author (JML) selectively utilizes methylpred-
nisolone (Solu-Medrol) preoperatively and post-
operatively (Medrol Dosepak). The purpose of this
is to minimize the occurrence of temporary vocal
cord paralysis due to edema or retraction of the
recurrent laryngeal nerve. It is used when there has
been significant dissection at the nerve site.
10. Frozen section is utilized when there is any doubt
regarding the pathology.
Exposure of the superior mediastinum is deemed
necessary; then this may be best left to a second-stage
operation after additional imaging is performed, for
example, CT and MRI (see Fig. 18-20).
Highpoints
1. Perform thyroidectomy incision.
2. Search for parathyroid glands at level of the strap
muscles.
3. Explore operative site either by resecting or tran-
secting strap muscles superiorly.
4. Palpate for parathyroid adenoma.
5. Palpate for thyroid nodules-possibly perform FNA.
6. If parathyroid adenoma is identified or suspected:
a. Attempt to locate blood supply. This may lead to
the parathyroid adenoma and thus confirm the
diagnosis.
b. Careful dissection will depend on the exact loca-
tion of the adenoma, for example, subcapsular
(of the thyroid), within adipose tissue, or rela-
tively free.
7. Do not break capsule of the adenoma, because this
could cause reimplantation. When ligating the stalk
of an adenoma, be sure the site of ligation is well
away from the adenoma. If this is in question, do a
frozen section on the stalk to be sure no adenoma
tissue is left.
8. Frozen section: This is controversial. However, this
author (JML) usually uses frozen section.
9. Recommend identification of all parathyroids, at
least one on ipsilateral side.
10. If no adenoma is found, hyperplasia is more likely.
All four glands must be exposed and it is best to
perform a biopsy. If the tissue is confirmed to be
hyperplastic or hypercellular, perform a three and
three-quarters resection with reimplantation of one
fourth into the brachial area of the forearm.
11. Label all remaining parathyroid tissue. Avoid plac-
ing sutures within the gland-avoid injuring blood
vessels. Labeling is done with black silk suture.
12. If parathyroids are extremely small, it is best not to
perform a biopsy unless otherwise indicated; most
likely the tissue is hypoplastic or normal.
13. If there is local invasion of contiguous structures
(cervical fascia, esophagus, trachea, larynx, or recur-
rent laryngeal nerve or very thick capsule), suspect
carcinoma of parathyroid. Frozen section inter-
pretation is difficult, except if a node is involved by
parathyroid-like tissue. Diagnosis is usually made
initially on the operative findings.
14. Do not remove normal gland without biopsy.
IS. Treatment of carcinoma of parathyroid: remove at
least contiguous thyroid lobe, all contiguous lymph
nodes, any muscles that may be involved, or any
suspicious nodes or disease in the superior medi-
astinum. The first operation is the best opportunity
to control disease.
A1 Usual location of the parathyroid glands as viewed
from behind (after Hollinshead, 1985); however, their
location is so varied that this representation may be
deceptive to the surgeon, realizing that they may be at
as high a level as the bifurcation of the carotids and
submandibular area and at as Iowa level as the inferior
edge of the pericardium, in the anterior or posterior
portions of the superior mediastinum, or "hide" deep
to the sternoclavicular joint. They are, nevertheless,
confined for the most part to the central compartment
of the neck. The parathyroids may be outside or inside
the capsule of the thyroid, within the capsule of the
thymus gland, and actually embedded within thyroid
tissue. Normal parathyroid gland is yellow-tan, where-
as the adenoma is usually red-brown to yellow-tan.
A The usual thyroidectomy incision is made approxi-
mately two fingerbreadths above the sternoclavicular
junction, following, if possible, a natural skin crease.
B The cervical fascia enveloping the strap rnuscles is
incised in the midline. Search for parathyroid glands is
begun as soon as the strap muscles are exposed.
Parathyroid glands have been located at this level. It
usually is not necessary to transect the strap muscles,
although some surgeons prefer to cut the muscles for
improved exposure (Esselstyn, 1971).
 ENDOCRINE SURGERY

Thyrocervical trunk
ParathyroidGis.

Arch Aorta

Inf. parathyroid
adenoma 1 Adipose
tissue
c Branch of
inf. thyroid a.
Parathyroid
Parathyroid adenoma2
Adenoma
Inf. parathyroid
adenoma 3

Recurrent laryngeal n. Int. jugular. V.

FIGURE 18-19

C Excision of inferior parathyroid adenoma is shown.
An initial reflection of the thyroid lobe medially will
often expose an adenoma involving an inferior or
superior parathyroid gland, lying deep to the thyroid
lobe in the area of the tracheoesophageal sulcus. Be
wary of the recurrent laryngeal nerve. An adenoma
can be adherent to the nerve. The inferior parathyroid
gland is usually anterior to the recurrent laryngeal
nerve, whereas the superior parathyroid gland may be
posterior to the recurrent laryngeal nerve.
D Excision of inferior parathyroid adenoma shows
three locations of inferior parathyroid adenomas in
relation to the inferior pole of the thyroid gland.
Expose the nerve inferiorly and follow it superiorly.
Location 1: This is an area where there may be
several small vessels intermingled with adipose tissue.
This area is explored very carefully.
Location 2: If the first approach fails, the inferior
thyroid vein or veins are ligated and transected and
the thyroid lobe is reflected superiorly. Identification of
the recurrent laryngeal nerve is not absolutely neces-
sary; however, its proximity to the adenoma must be
realized and care taken not to injure the nerve. If there
is any question, the recurrent laryngeal nerve is iden-
tified before the dissection of the adenoma.
Location 3: If the first and second approaches fail,
then a deeper, more inferior approach toward the
thoracic inlet is used. Identification of the recurrent
laryngeal nerve is advised, because the dissection is
inferior, realizing even though the location of the
inferior parathyroid gland is anterior to the nerve it
may be posterior to the nerve in this area.
Continued
 ENDOCRINE SURGERY
Excision of Parathyroid Adenomas
(Continued) (Fig. 18-19)
16. Simplistic caveat as follows:
a. Explore all four glands (may vary from two to
nine).
b. If one gland is enlarged, biopsy at least one
other to be sure that tissue is normal.
c. If another gland is hypercellular or hyperplastic,
then biopsy all remaining glands.
d. If suggestive of hyperplasia, perform three and
three-quarters resection with reimplantation of
one fourth in the forearm.
17. Excision of parathyroid adenoma can be very simple
and a swift operation. On the other hand, it can be
a very exhausting, tedious, and time-consuming
procedure. Patience and diligence are necessary. It
is not the procedure for a neophyte operating without
proper skilled guidance and training.
lB. The author (JML) selectively utilizes 40 mg of Solu-
Medrol preoperatively and uses Medrol Dosepak
postoperatively. The purpose of this is to minimize
the incidence of temporary vocal cord paralysis due
to edema or retraction of the recurrent laryngeal
nerve.
Do not rely on color entirely for this distinction
between normal and abnormal parathyroids. Size is
usually more important. The parathyroids must be dif-
ferentiated from adipose tissue and lymph nodes, as
well as ectopic thyroid tissue close to the thyroid gland.
As age increases or as parathyroids may be suppressed,
the usual color approaches that of adipose tissue. Size
and shape aid in the differentiation. In general, parathy-
roids sink and adipose tissue floats in normal saline.
However, lymph nodes and thyroid tissue also sink in
saline. Small biopsies away from vascular pedicle with
frozen sections may be necessary. One must keep in
mind the possibility of carcinoma of the thyroid (when
secondary to exposure of ionizing radiation) existing
with a parathyroid adenoma. Hence, a lymph node must
be distinguished from a parathyroid gland in that the
node may have metastatic carcinoma. A metastatic lymph
node obviously must not be implanted.
E Excision of superior parathyroid adenoma (orien-
tation anatomy) is diagrammed. Cricoid cartilage can
be a guide to the initial search for a superior parathy-
roid adenoma. This is in the region just below the infe-
rior edge of the cricoid cartilage. The superior parathy-
roid gland is usually on a deeper plane than the recurrent
laryngeal nerve, located medially and deep to the site
where the nerve passes out of the surgical field just
inferior to the cricopharyngeus muscle (the lower edge
of the inferior pharyngeal constrictor muscle). The
parathyroid adenoma is usually near the cricopharyn-
geus muscle but may migrate inferiorly and stay poste-
rior or even anterior to the nerve. It may be adherent
to the nerve. Hence, the importance of identification
of the nerve when pursuing a search in this area unless
the adenoma is readily apparent.
F1 Another location of a superior parathyroid adenoma
is adherent to the undersurface of the thyroid gland. It
may likewise be adherent to the capsule of a portion of
the thyroid lobe that is deep to the recurrent laryngeal
nerve and may extend behind the esophagus.
F Orientation anatomy at the superior pole of the
thyroid shows the superior parathyroid adenoma, which
has migrated inferiorly. The anatomy is shown in more
detail than would usually be seen at the time of
surgery. This is done for orientation purposes. The
lateral leaf of the posterior suspensory ligament (see
Fig. IB-12E) has been transected to facilitate medial
reflection of the thyroid gland. The superior thyroid
vessels as well as the external branch of the superior
laryngeal nerve are not usually exposed as depicted in
the illustration. Thus, occasionally, a superior parathy-
roid adenoma may migrate inferiorly and be located
posterior to the mid portion of the thyroid lobe; if it is
in this location it could be identified by the technique
described in C.
G If the dissection rarely approaches a portion of the
superior thyroid lobe, care must be taken not to injure
the external branches of the superior laryngeal nerve.
 ENDOCRINE SURGERY

___ Sup. laryngeal n. Sup. belly omohyoid m.

F
Superior thyroid a.
E ~"
Ext. br. sup. laryngeal n.
Inf. pharyngeal
Sup. thyroid a. and v.
constrictor m.
Thyroid
cartilage Ext. branch Sup. parathyroid
sup. laryngeal n. adenoma
Cricothyroid m.
Sup. parathyroid
Cricoid Inf. thyroid a.
adenoma
cartilage Rec. laryngeal n
Recurrent
Inferior laryngeal a. laryngeal n.
Vagus n.

Int. branch of
sup. laryngeal n.
Superior thyroid a.

Ext. branch
superior laryngeal n.

Sup. parathyroid
adenoma
Inferior
laryngeal a. Recurrent
Inf. thyroid a. laryngeal n.

Sup. thyroid v. & al- - - - - -

Ext. branch
,"p"'" I.~"g''''"./
Site where vessels enter gland ~ - - - -
)"".,.re.
1.5-2 cm

G I Thyroid gl. ' ,

FIGURE 18-19 Continued

 ENDOCRINE SURGERY
Excision of Parathyroid Adenomas
(Continued) (Fig. 18-19)
The blood supply to a parathyroid adenoma may be
from the superior thyroid artery, the inferior thyroid
artery, or a branch from the anastomosis of both infe-
rior and superior parathyroid arteries (see Fig. 18-14).
The adenoma may likewise be tucked under the lateral
border of the trachea embedded in adipose tissue.
Proximity of the recurrent laryngeal nerve is depicted.
In this situation it is best to expose the nerve. For
further detailed anatomy in the region of the cricoid
cartilage, see Figure 21-3.
Esselstyn (1971) has demonstrated a number of
observations relative to the surgery of the parathyroid
glands:
• Gentle backward pressure (toward the trachea) on
the thyroid lobe with the retrothyroid space in view
may have a tendency to displace a parathyroid ade-
noma laterally and thus the adenoma will be quite
visible.
• To differentiate grossly adipose tissue from the parathy-
roid gland, a small portion of the tissue in question
is sectioned (opposite end of vascular pedicle) with
an iris scissors. If it is fat, there is no bleeding; if it
is the parathyroid gland, there is a rapid bloody blush.
• If the search for a parathyroid gland fails, and if
careful examination of the thymus does not reveal
parathyroid tissue, the ipsilateral thyroid lobe is then
removed. It is important, however, that before these
two glands are removed some parathyroid tissue is
identified that will be left undisturbed or be
reimplanted.
The thymic lobe is removed through the thyroid inci-
sion utilizing fine strands and small veins extending
from the inferior pole of the thyroid gland to the thymus
as a means of identification. Careful blunt dissection
with the strap muscles retracted or, if necessary, tran-
section is performed. When painstaking exploration of
the central cervical area, from the top portion of the
superior mediastinum to and above the level of the
hyoid bone, including thyroid lobectomy and removal
of the thymus, reveals no evidence of parathyroid ade-
noma or hyperplasia, a median sternotomy is performed
(see Fig. 19-10).
Excision of Mediastinal Parathyroid
Adenomas and Cystadenoma
An outline of the approaches to the mediastinum is as
follows:
1. Top anterior superior mediastinum
a. Substernal: transection of the intraclavicular liga-
ment; at times vertical skin incision over the manu-
brium sterni may aid in additional visualization.
2. Anterior superior mediastinum
a. Median sternotomy: partial or complete (see
Fig. 19-1OAto L)
b. Resection of medial third of the clavicle: exposure
beneath the sternoclavicular joint area (see
Fig. 19-9)
3. Posterior superior mediastinum
a. Resection of medial third of the clavicle (see
Fig. 19-9)
b. Medial sternotomy (see Fig. 18-20)
4. Resection of the manubrium sterni (see Fig. 19-11B
to 0)
S. Or a combination of any of the above
If there is an option between the resection of the
medial third of the clavicle and a median sternotomy,
it might be well to realize that there can be a median
sternotomy dehiscence with demineralization associated
with long-standing hyperparathyroidism. Table 18-10
gives advantages and disadvantages for each approach.
Removal of mediastinal parathyroid adenomas at times
can be relatively "straightforward, easy" or very difficult.
The first scenario is the patient who is referred after a
negative cervical sonogram but with a suggestion of a
small mass at the arch of the aorta as depicted on CT
and MRI (before the advent of 99mTc-sestamibiscanning).
A cervical exploration was first performed. The right supe-
rior and inferior and left superior parathyroid glands
were identified and confirmed to be small and slightly
hypoplastic on sliver biopsy. It was then reasoned that
the "absent" parathyroid gland was the left inferior and
it would be located in the anterior superior mediastinum.
This tied in with the imaging. A median sternotomy was
then performed at the same operation, and the ade-
noma was removed from its location at the aortic arch.
Other scenarios are not so straightforward inasmuch
as a long cervical search has led to only one conclu-

sion, and that is that the adenoma (one or two) may be
in the mediastinum. Thus, it is best to terminate the
procedure after possibly sampling the right and left
internal jugular veins for intact PTH levels and perform
the mediastinal search as a second-stage operation. It is
a good idea to discuss this staging with the waiting
family. Imaging would include (if not already per-
formed): 99ffiTc-sestamibiplanar and SPECT (see Figs.
18-15 and 18-17), CT or MRI (see Figs. 1-56 and 1-57),
and PET (see Fig. 18-16) in staged fashion as indicated.
Approaches to the superior mediastinum are based
on the anatomy (see Fig. 19-7) and the location of the
pathology (whether anterior or posterior superior
mediastinum) as well as the build or topography of the
patient. In other words, what works for one patient
may not work for another. Hence, at times more than
one approach to the specific area in the mediastinum
may be necessary; for example, median sternotomy can
be combined with resection of the medial third of the
clavicle for additional exposure. With parathyroid
adenoma, usually the inferior parathyroids are located
in the anterior mediastinum (e.g., the thymus), whereas
the superior parathyroids are usually located in the pos-
terior mediastinum or within the ipsilateral thyroid lobe.
Inferior parathyroids are usually located in the anterior
superior mediastinum, whereas the superior para thy-
1'ABLE 18-10 Compari8oD of Rnn:doa of Medial Third of the CIavide VerIu MecUm Sternotomy
Approach Advantages
Resection medial Easier approach to both anterior and posterior
third of mediastinum
clavicle Good exposure in obese patients, particularly
laterally in the anterior mediastinum
Median Usuallya good exposure to the entire anterior
sternotomy mediastinum bilaterally except in the very
obese patient
If need be:
The median sternotomy can be combined with the resection of the medial third of the clavicle.
Bilateral resection of the clavicles is possible and has been utilized with minimal morbidity.
Details of median sternotomy for resection of large parathyroid cyst adenoma of the posterior mediastinum are depicted in Figure 18-20.
ENDOCRINE SURGERY
roids are usually located in the posterior mediastinum.
The location of the adenomas suggests the surgical
approach. For example, an adenoma in the superior
anterior mediastinum, close to the pericardium or farther
inferior, requires a complete median sternotomy. An
adenoma in the posterior mediastinum, if not accessible
via the suprasternal approach, can be reached via resec-
tion of the medial third of the clavicle along with tran-
section of the intraclavicular ligament or via median
sternotomy. It is important to know the exact location
of the adenoma, whether it is anterior or posterior in
the superior mediastinum or on the right or left side or
in the midline. Sestamibi SPECT is a diagnostic imaging
technique helpful in localizing mediastinal adenoma
because it may locate the depth of the adenoma and
whether it is anterior or posterior.
Mediastinoscopy (See Fig. 19-8)
If a parathyroid gland or an adenoma is suspected to be
in the anterior mediastinum, search with the medi-
astinoscope may be rewarding. The author has located
one normal parathyroid gland in a patient with car-
cinoma of the thyroid with hypercalcemia secondary to
a cervical parathyroid adenoma (no preoperative parathy-
roid imaging or intraoperative localization studies were
Disadvantages
Contralateral side has limited exposure
Limited exposure of the more inferior anterior
mediastinum
Exposure deep to substernoclavicularjoint may be
limited
Limited but can be used for the posterior
mediastinum (see Fig. 18-20)
Possible dehiscence of sternal repair in patients
with demineralization secondary to prolonged
hyperparathyroidism
 ENDOCRINE SURGERY
used) (data presented before the Eastern Great Lakes
Head and Neck Society, 1991).
Anatomy (See Fig. 19-7)
The following quotes are from Lore and colleagues
(2000):
"To further categorize the location of the mediastinal
adenomata, with their anatomic relationships within
the superior mediastinum, the superior mediastinum is
divided into anterior and posterior areas as depicted in
Figure 19-7. The arbitrary line between the anterior
and posterior mediastinum is between the trachea and
the great vessels anteriorly and the trachea and esopha-
gus posteriorly. The division between superior and
inferior portions of the mediastinum is an imaginary
horizontal line at or slightly below the sternal angle
(Louis). This imaginary line extends posteriorly and
approximates the fifth thoracic vertebra. In most text-
books on anatomy, the superior mediastinum is not
divided into anterior, posterior portions. This type of
division is believed helpful to the surgeon, specifically,
relative to the search for mediastinal parathyroid ade-
nomata. The anterior portion of the superior medi-
astinum would be concentrated upon when the inferior
parathyroid gland is suspected to be the missing gland
and the posterior mediastinum when the suspected
missing gland is the superior parathyroid gland.
"The superior anterior mediastinum contains the
great vessels: arch of the aorta, innominate artery, left
and right common carotid arteries and left and right
subclavian arteries, right and left brachiocephalic veins
and superior yen a cava, thymus, adipose tissue, and
lymph nodes, while the superior posterior mediastinum
contains the trachea, esophagus, thoracic duct, azygos
vein, lymph nodes and portions of the roots of the lungs.
The vagus and phrenic nerves traverse from anterior to
posterior. The left recurrent laryngeal nerve swings
around the arch of the aorta from anterior to posterior
while the right recurrent nerve passes from anterior
then below and behind the right subclavian artery and
the right common carotid artery as it leaves the vagus
nerve. The origin of the right common carotid artery and
the innominate artery can reach as high as, or even above,
the suprasternal notch and may cross the trachea in the
lower cervical area."
Discussion
Although many mediastinal parathyroid adenomas may
be removed using the suprasternal approach, additional
exposure may be necessary for other adenomas. The
initial step is transection of the intraclavicular ligament.
Median sternotomy, usually ideal for superior anterior
adenomas, is rather difficult to afford adequate expo-
sure of the superior posterior mediastinal adenoma
because of the great vessels and at times the area deep
to the sternoclavicular joints. As far as the superior
posterior mediastinum is concerned if the adenomas
are within several centimeters of the suprasternal notch
they can be removed via the suprasternal approach.
However, exposure is limited and if the adenomas are
located beyond several centimeters inferior to the
suprasternal notch additional exposure may be neces-
sary to avoid injury to contiguous structures (e.g., the
great vessels, the esophagus-mediastinal pleura and more
inferiorly the azygos vein). For example, in a lean, thin,
and tall individual the relationships are much different
than in a short, stocky, obese patient. Hence, the method
of approach not only varies relative to the location of
the adenoma, whether it is anterior, posterior, right,
left, or median, but also to the "build" of the patient.
Resection of the medial third of the clavicle has been
described for access to the mediastinum for excision of
a substernal goiter. It has a low morbidity. The author
(JML) has noted no postoperative infections, only mild
pain and limitation of range of motion of the arm on
the operative side. This limitation is only temporary.
The only long-term effect with this technique may be a
slight decrease in the height of the fingers in some
patients on the operative side when both arms are
raised together with hands and fingers extended.
Preoperative parathyroid imaging is controversial for
initial exploration. It is used by the author (JML). Most
surgeons agree with its use prior to a second surgical pro-
cedure. The accuracy of the tests available varies (see
p. 979). In two patients as examples 99mTc-sestamibi
planar SPECT revealed the location of the parathyroid
adenomas. This localizing technique utilized three-
dimensional images and allowed for the identification
of the adenoma in either the anterior or posterior medi-
astinum. This is a most important aspect. Neumann
and associates utilized 99mTc-sestamibi SPECT in the

localization of the parathyroid adenomas to the medi-
astinum after failed cervical exploration. This report
utilized median sternotomy as the access technique.
Neumann and associates (1997) have reported on their
experience with PET technique in patients with recur-
rent postoperative hyperparathyroidism. In their series
of 20 patients, PET with FOG correctly localized 79 %
(11/14) of the parathyroid adenomas, 29% (2/7) of the
hyperplastic parathyroid glands, and a parathyroid
carcinoma.
Excision of Posterior Superior
Mediastinal Parathyroid Cyst
Adenoma via Median Sternotomy
(Fig. 18-20; See also Fig. 19-10)
This is a description utilizing a median sternotomy for
the removal of a posterior superior mediastinal adenoma.
Posterior superior mediastinal pathology is usually
approached via resection of the medial third of the
clavicle. The median sternotomy may be more complex,
consume more time especially in closure, and be more
painful in the postoperative period. Nevertheless, this
approach may be necessary.
The sternotomy is closed with stainless steel or
malleable silver wire. A drain is brought out from the
mediastinum through the thyroidectomy incision (see
Fig. 19-100 to Q).
Before closure, the wound is filled with saline and
observed for any bleeding (especially venous). The
Valsalva maneuver is helpful in this and can be accom-
plished by asking the anesthesiologist to inflate the
lungs and to close the exhaust valve on the anesthesia
equipment. This will increase the venous pressure
(40 mm Hg) to detect any vein that may be open.
Lightening the anesthesia to induce "bucking" may also
serve the same purpose or suction patient at the same
time. We have seen one patient in whom the Valsalva
did not induce bleeding while suctioning with light
anesthesia did!
For closure details, see Figure 19-100 to Q and
page 1054.
ENDOCRINE SURGERY
Surgical Technique
An example is presented of application of resection of
the medial third of the clavicle in two patients in whom
initial cervical exploration failed. Subsequent localiza-
tion was performed with sestamibi planar SPECT and
PET. The approaches to the left superior anterior medi-
astinum and to the right superior posterior mediastinum
relative to two patients are outlined. The initial surgical
approach is the same for either the right or the left side.
For complete details of resection of the medial third of
the clavicle, see Figure 19-9.
Highpoints (See also Fig. 19-90)
1. Skin incision: the thyroidectomy incision is slightly
longer, usually with a median inferior extension
over the sternum to the angle of Louis.
2. Dissection of the medial third of the clavicle is in a
plane exactly on the cortex. This is subperiosteal
and includes transection of muscles attached to the
cortex. An Alexander periosteal elevator and Doyen
separator are utilized.
3. Muscles are separated from the attachment to the
clavicle: clavicular head of the sternocleidomastoid
muscle, pectoralis major muscle, and the subclavius
muscle (see Fig. 19-9A).
4. Muscles are transected from attachment to the ster-
num: sternal head of the sternocleidomastoid muscle
and strap muscles. The sternal head of the ster-
nocleidomastoid muscle may be transected 2 to 3 cm
proximal to its attachments to the sternum if it is
reasonably certain that resection of a portion of the
sternum is unnecessary for adequate exposure.
Leaving this stump of the sternocleidomastoid muscle
facilitates and somewhat improves closure. 1fthe strap
muscles previously are transected superiorly, for exam-
ple in a thyroidectomy, they may be left attached to
the sternum and then reflected into the mediastinum
at the closure of the operation. This facilitates partial
obliteration of the substernal dead space.
5. Protect the internal jugular and subclavian vein.
6. Transect the clavicle with a Gigli saw or preferably
with a rib cutter if feasible (see Fig. 19-9B).
 ENDOCRINE SURGERY
Excision of Posterior Superior
Mediastinal Parathyroid Cyst
Adenoma via Median Sternotomy
(Continued) (Fig. 18-20; See also
Fig. 19-10)
A The sternum is split with an extension into the
second or third interspace. Care should be taken not
to injure the pleura or the internal mammary vessels.
Even more important is recognizing such injury and
treating the resulting pneumothorax with underwater
drainage (see Figs. 2-3G to 2-6D), if necessary. Often,
the pleura can be closed with the lung fully expanded
with underwater drainage. Postoperative chest
radiography is mandatory.
B A sternal retractor is inserted, and the contents of
the anterior superior mediastinum, especiallythe thymus
gland, are examined for parathyroid adenoma. This
may necessitate removal of the entire thymus gland
and associated adipose tissue. See Figure 19-12 for
transcervical removal of thymus. With the left innomi-
nate vein gently retracted downward, the posterior
compartment of the superior mediastinum is explored.
Heredeep in the tracheoesophageal sulcus liesa 7 x 5-cm
parathyroid cystadenoma. Because it is in the posterior
mediastinum, it most likely arose from the superior
parathyroid gland. The left recurrent laryngeal nerve is
intimately associated with the cyst wall. The nerve is
freed carefully by sharp dissection; and, if necessary,
the cyst contents may be aspirated to permit better
visualization of the surrounding structures: laterally the
left common carotid artery, medially the trachea and
esophagus, and inferiorly and anteriorly the arch of the
aorta.
C With the recurrent laryngeal nerve in view and
carefully retracted with a small vein retractor, the cys-
tadenoma is dissected from the esophagus to which it
is intimately adherent. Retraction of the recurrent laryn-
geal nerve must be done with extreme care: stretching
the nerve can easilycause temporary vocal cord paralysis.
A search is made for the remaining parathyroi,d glands
in the cervicaland mediastinal regions. Multiple parathy-
roid adenomas have been reported in the mediastinal
region. At least one remaining gland is identified,
preferably three, and sampled. Identification of addi-
tional parathyroids is done before sending the entire
surgical specimen to the pathologist. Ifno other parathy-
roids are located, consideration is given to reimplant-
ing a portion of the adenoma in the antebrachial area.
7. Sternoclavicular joint capsule and the interclavicular
ligament are transected by sharp dissection and
electrocautery, with extreme care taken to not injure
any vessels deep to the plane of dissection.
8. Grasp the transected clavicle with bone forceps for
rotation to visualize the posterior capsule of the
joint and transect the capsule. Remove and discard
this portion of the clavicle.
9. From this point on it depends on whether the ade-
noma is in the anterior or posterior mediastinum.
10. Location of adenoma:
(Patient 1: Adenoma in superior anterior left side
mediastinum deep to the sternoclavicular joint)
a. Dissection is in a plane just anterior to the external
jugular vein and the subclavian vein, where they
join to form the left brachiocephalic vein.
b. Adenoma is located in massive adipose tissue deep
to the sternoclavicular joint and the sternothyroid
muscle. Use careful blunt dissection so as not to
break the capsule and then ligate the feedingvessels.
c. Insert a Jackson-Pratt drain in the bed of the left
clavicle and bring it out through the thyroidectomy
incision. Take care to avoid pressure on vessels.
Surgicel is used for protection and possible
decrease in serous collection.
(Patient 2: Adenoma is in superior posterior right
mediastinum attached to the esophagus and thoracic
vertebrae [see Fig. 19-9EJ)
a. Vessels, all or some of which may be exposed,
are from superior to inferior: right internal jugular
vein and right subclavian vein forming the right
brachiocephalic vein, right common carotid artery,
and right subclavian artery, both arising from
the innominate artery. The right recurrent laryn-
geal nerve leaves the vagus nerve and passes
anterior then below and behind the subclavian
artery and the common carotid artery. This nerve
is exposed and protected during the dissection.
If there is difficulty in its identification, the vagus
nerve is identified and followed to the recurrent
laryngeal nerve. Care is taken not to injure the
vagus nerve or sympathetic chain.
b. Retract trachea to the left (medially).
c. The innominate, right common carotid, and sub·
clavian arteries are retracted to the right (laterally).
Vascular tape is placed around any vessel for
retraction. Care is taken not to injure recurrent
laryngeal nerve. This area forms the "approach"
to the posterior mediastinum.
d. The right brachiocephalic veins may be in the
surgical field and could be ligated and divided if
absolutely necessary. But it is better not to. Inferior
 ENDOCRINE SURGERY

Com. carotid a.

A B

Vagus n.

L. in!. jugular v.

L. subclavian v.

PARATHYROID CYSTADENOMA

Sup. vena cava

FIGURE 18-20
 ENDOCRINE SURGERY
thyroid veins may be in the surgical field and are
doubly ligated and transected just above where
they enter the left or right brachiocephalic veins.
e. If the dissection proceeds farther inferior, care is
taken not to injure the azygos vein.
11. The adenoma is identified attached to the esophagus
and the thoracic vertebrae.
12. Vascular supply to the adenoma is ligated and the
tumor is transected and removed intact taking care
not to break the capsule or injure the esophagus. If
the capsule is broken and fragmentation occurs, all
fragments must be removed.
13. A Jackson-Pratt drain is inserted through a stab
wound in the chest flap or cervical incision taking
care not to have it abutted or closely related to any
of the major vessels. Surgicel may offer some pro-
tection and decrease serous collection.
Complications of Surgery for Parathyroid
Adenomas
• Persistent hyperparathyroidism (5 % to 6 %)
• Hypoparathyroidism: temporary (up to 4 months)
(McGarity et aI., 1981); permanent
• Vocal cord paralysis: injury to the recurrent laryngeal
nerve and/or the external branch of the superior
laryngeal nerve
• Hematoma with or without airway obstruction
• Partial blindness (Petti and Linda, 1982) associated
with hemorrhage into an unknown pituitary adenoma.
This problem is related to MEN I.
• Pancreatitis (Reeve and Delbridge, 1982)
• Hemothorax, pneumothorax, or chylothorax.
• Some patients after removal of a parathyroid adenoma
may have a precipitous drop in the serum calcium con-
centration. It is checked within several hours of the
surgery and again in 4 hours. If the serum calcium level
drops to 6 mg/dL or below, administer a continuous
intravenous infusion of 5 g of calcium gluconate in
500 mL of intravenous solution at the rate of 100 mL/hr,
thus delivering 150 to 200 mg of elemental calcium.
• Median sternotomy dehiscence with demineralization
in long-standing hyperparathyroidism
• Hypomagnesemia with bone disease: tremors, con-
vulsions, and other neurologic signs (similar to those
of hypocalcemia). The treatment is magnesium.
• Hypocalcemic cardiomyopathy-idiopathic hypopara-
thyroidism. This may not necessarily be related to
previous surgery and may well be idiopathic (Bashour
et aI., 1980).
• Hypercalcemia is a result of overtreatment of hypocal-
cemia. This also can follow a complication of transient
hypocalcemia after thyroidectomy. It is due to over-
treatment with calcium and must be corrected
immediately with intravenous fluids to dilute the
calcium. The danger is cardiac and could be serious
with hypertension and heart block. It is interesting
to note that some hypertension patients may have a
decrease in their hypertension after parathyroidec-
tomy for hyperparathyroidism.
• Refer to Complications of Thyroid Surgery, page 963.
Postoperative Care
Osteoporosis
Many patients will have improvement in their bone
density after successful surgical treatment of primary
hyperparathyroidism. A reassessment of bone density
should be undertaken after a certain time interval (e.g.,
6 months to 1 year). One should consider use of calcium
supplementation with or without vitamin D to aid the
patient in the bone rebuilding process. Some patients may
require more aggressive medical treatment, depending
on the severity of bone loss. Measurement of the serum
calcium concentration is not an adequate evaluation of
bone loss. Hence, at selected times a follow-up DEXA
bone densitometry study will be indicated.
Hypocalcemia
Hypocalcemia after operations for parathyroid adenoma
may have a varied course, which may depend on whether
the other three parathyroid glands have been sampled,
thus possibly interfering with their blood supply, on the
fact that they are hypoplastic, or on whether the patient
has the "hungry bone syndrome." Therefore, careful
evaluation of the patient for several days is imperative.
Intravenous calcium gluconate (10 mL of 10%) adminis-
tered very slowly is used for the immediate relief of
significant symptoms. If hypocalcemia is severe and/or
persistent, concurrent use of oral calcium supplements
and a vitamin D analogue is often necessary. The primary
considerations involved when choosing a given form of
vitamin D include potency, the time interval for onset
and offset of action, the acute or chronic nature of the
hypocalcemia, and cost. The dosages of both medica-
tions should be checked to avoid hypercalcemia. In
severe cases, hypomagnesemia may be the problem and
should be corrected, because magnesium in adequate
amounts is necessary for optimal parathyroid function.
Tables 18-11 to 18-13 are comparative tables of various
calcium supplements and vitamin D analogues.
 ENDOCRINE SURGERY

TABLE18-11 Calcium PreparatiODllOV and PO) Used in the Management of Acute and Chronic Hypocalcemia

Salt Elemental Calcium Content per Gram (%) Trade Names

IV Preparations
Calcium gluconate 90 mg/I g (9%)
Calcium chloride 360 mg/I g (36%)
Oral Preparations
Calcium glubionate 64 mg/I g (6.5%) Neo-Calglucon syrup, 1.8 g/5 mL
Calcium gluconate 90 mg/I g (9%) 500-mg and I-g tablets
Calcium lactate 130 mg/I g (13%) 325-mg and 650-mg tablets
Calcium citrate 210 mg/I g (21%) Citracal, 950-mg and 1.5-g tablets
Calcium carbonate 400 mg/I g (40%) Turns, 500-mg, 750-mg, and 1.25-g tablets
Oscal, 650-mg and 1.25-g tablets
Titralac tablets, 420 mg, 750 mg; suspension,
I g/IO mL
Caltrate, 1.5-g tablets

TABLE 18-12 Vitamin D Analogues

Potency Relative to Dose Range in Time of

Preparation Vitamin O2/0, Trade Name Hypoparathyroidism Onset Time of Offset

Vitamin Orisdol 50,000-200,000 IU/d 10 days- Weeks to

D2-ergocalciferol 2 weeks months
Vitamin Delta D3 10 days- Weeks to
D,-cholecalciferol 2 weeks months
Dihydrotachysterol 5-10 DHT 0.2-1 mg/d 4-7 days 1-3 weeks
Hytakerol
25-Hydroxyvitamin 10-15 Calderol 50 mg/d 7-10 days Weeks to
D,-calcifediol months
1,25-Dihydroxy- 1000 Rocaltrol 0.25 mg/d 1-2 days 2-3 days
vitamin
D,-calcitriol

TABLE 18-13 Calcium Replacement

Form Total Calcium Carbonate Elemental Calcium Dose

Oral suspension (generic) I mg 400 mg 5 mL

Tablet
Generic 650 mg 260 mg I tablet
Thms 500 mg 200 mg I tablet

Potential benefits of successful surgical treatment of primary hyperparathyroidism:

1. Decreased risk of loss of cortical bone density.
2. Elimination of hypercalcemia (if present) and reduction of risk of renal calculi.
3. Improvement of the neuropsychiatric symptoms.
4. General well-being-"feeling better."
5. Improved mood.
 ENDOCRINE SURGERY

BI BLiOG RAPHY Beierwaltes WH: The diagnosis and treatment of endemic goiter, the
most common thyroid disease in the United States: A challenge to
Thyroid
physicians. Washtenaw County Med Soc Bull 39(2), 1987b.
Aggarwal SK, Jayaram G, Kakor A, et al: Fine needle aspiration Beierwaltes WH, Rabbani R, Dmuchowski C, et al: An analysis of abla-
cytologic diagnosis of the solitary cold thyroid nodule. Acta Cytol tion of thyroid remnants with 1311 in 511 patients from 1947-1984:
33:41, 1989. Experience at the University of Michigan. J Nucl Med 25:1287-1294,
Albores-Saavedra J, Gould E, Vardaman C, Vuitch F: The microfol- 1984.
Iicular variant of papillary thyroid carcinoma: A study of 17 cases. Bengtsson A, et al: Measurement of nuclear DNA content in thyroid
Hum PathoI22:1195-1205, 1991. diagnosis. World J Surg 8:481-486, 1984.
Albores-Saavedra J, Housini I, Vuitch F, Snyder WH: Macrofollicular Bergholm U, Bergstrom R, Ekbom A: Long term follow-up of patients
variant of papillary thyroid carcinoma with minor insular com- with medullary carcinoma of the thyroid. Cancer 79: I 32-138,
ponent. Cancer 80: II 1O-1116, 1997. 1997.
Albores-Saavedra J, LiVolsi VA, Williams ED: Medullary carcinoma. Berlin DO: The recurrent laryngeal nerves in total oblation of the
Semin Diagn Pathol 2:137-145, 1985. normal thyroid gland. Surg Gynecol Obstet 60:20, t935.
Allo MD, Christianson W, Koivunen D: Not all "occult" papillary Billano RA, Ward WQ, Little WP: Minocycline and black thyroid.
carcinomas are ··minimal." Surgery 104:971-976, 1988. JAMA 249:1887, 1983.
Alpers DH: Calcium absorption and malabsorption. Viewpoints Digest Block GE: An appraisal of the hormonal control of carcinoma of the
Dis 6(January), 1974. thyroid gland. Surg Gynecol Obstet, February 1971.
Altavilla G, Pascale M, Nenci I: Fine needle aspiration cytology of Block MA: Management of carcinoma of the thyroid. Ann Surg
thyroid gland disease. Acta Cytol 34:251, 1990. 185:133-144, 1976.
American Cancer Society: 1976 Cancer Facts and Figures. CA 26: Block MA, Horn HC, Brush BE: The place of total thyroidectomy in
150-196,1976. surgery for thyroid carcinoma. Arch Surg 81 :236, 1960.
Andersson T, Biorklund A, Landberg T, et al: Combined therapy for Block MA, Horn RC Jr, Miller JM: Hazards in the diagnosis and
undifferentiated giant and spindle cell carcinoma of the thyroid. management of certain thyroid nodules in children. Am J Surg
Acta Otolaryngol 83:372-377, 1977. 120:447-451, 1970.
Arnstein NB, Juni JE, Sisson JG, et al: Recurrent medullary carci- Block MA, Jackson CE, Greenawald KA, et al: Clinical characteristics
noma of the thyroid demonstrated by thallium-201 scintigraphy. distinguishing hereditary from sporadic medullary thyroid carci-
Nucl Med 27:1564-1567,1986. noma: Treatment implications. Arch Surg 115:142-148, 1980.
Asp A, Georgitis W, Waldron E, et al: Fine needle aspiration of the Block MA, Miller JM, Horn RC Jr: Carcinoma of the thyroid after external
thyroid. Am J Med 83:489-491, 1987. radiation to the neck in adults. Am J Surg 118:764-769, 1969.
Atkinson B, Ernst CF, liVolsi VA: Cytologic diagnosis of follicular Block MA, Miller JM, Horn RC Jr: Medullary carcinoma of the
tumors of the thyroid. Diagn Cytopathol 12:1-3, 1986. thyroid: Surgical implications. Arch Surg 96:521-526, 1968.
Attie IN, Khafif RA, Stecker RM: Elective neck dissection in papillary Block MA, Miller JM, Horn RC Jr: Thyroid carcinoma with cervical
carcinoma of the thyroid. Am J Surg 122:464-471, 1971. lymph node metastasis: Effectiveness of total thyroidectomy and
Backdahl M, Tallroth E, Auer G, et al: Prognostic value of nuclear node dissection. Am J Surg 122:458-463, 1971.
DNA content in medullary thyroid carcinoma. World J Surg 9: Block MA, Wylie JH, Patton RB, Miller JM: Does benign thyroid tissue
980-987, 1985. occur in the lateral part of the neck? Am J Surg 112:476-481, 1966.
Baker HW: Anaplastic thyroid cancer twelve years after radioiodine Blum M, Tothschild M: Improved nonoperative diagnosis of the
therapy. Cancer 23:885-890, 1969. solitary "cold" thyroid nodule. JAMA 243:242-245, 1980.
Baker RR, Hyland J: Papillary carcinoma of the thyroid gland. Surg Bondeson L, Bondeson A, Ljunberg 0, Tibblin S: Oxyphil tumors of
Gynecol Obstet 16:546-550, 1985. the thyroid. Ann Surg 194:677-680, 1981.
Bashour T, Basha HS, Cheng TO: Hypocalcemic cardiomyopathy. Bondeson L, Ljunberg 0: Occult thyroid carcinoma at autopsy in
Chest 78:663-665, 1980. Malmo, Sweden. Cancer 47:319-323,1981.
Beahrs OH: An Atlas of the Surgical Techniques of Oliver H. Beahrs. Brennan MF, Brown EM, Spiegal AM, et al: Autotransplantation of
Philadelphia, WB Saunders, 1985. cryopreserved parathyroid tissue in man. Ann Surg 189:139-142,
Bechner ME, Heffess CS, Oertel JM: Oxyphilic papillary thyroid 1979.
carcinomas. Am J Clin PathoI103:280-287, 1995. Brewster DC, Jensen SR, Noveline RA: Reversible renal artery stenosis
Becker OV: Current status of radioactive iodine treatment of hyper- associated with pheochromocytoma. JAMA 248:1094-1096, 1982.
thyroidism. Thyroid Today 2(7): November 1979. Brooke PK, Hameed M, Zakowski M: Fine needle aspiration of
Becker DV: Choice of therapy for Graves' hyperthyroidism. N Engl J anaplastic thyroid carcinoma with varied cytologic and histologic
Med 311:464-466, 1984. patterns: A case report. Diagn Cytopathol 11:60-63, 1994.
Becker KL, et al: Calcitonin heterogeneity in lung cancer and Brown PM, Judd ES: Thyroglossal duct cysts and sinuses. Am J Surg
medullary thyroid cancer. Acta Endocrinol 89:89-90, 1978. 102:494-501, 1961.
Becker KL, et al: The surgical implications of hypercalcitonemia. Surg Bryant LR, Spencer FC, lfinkle JK: lfeatment of median sternotomy
Gynecol Obstet IS4:897-908, 1982. infection by mediastinal irrigation with an antibiotic solution. Ann
Becker WF: Presidential address: Pioneers in thyroid surgery. Ann Surg 169:914-920, 1969.
Surg 185:493-504, 1977. Buckwalter JA, Thomas CG, Freeman JB: ts childhood thyroid cancer
Beemer RK, Baker HW: Anaplastic cancer of the thyroid. Northwest a lethal disease? Ann Surg 181:632-639, 1975.
Med 69:417-420, 1970. Burman KD, Adler RA, Wartofsky L: Hemiagenesis of the thyroid
Beierwaltes WH: The treatment of thyroid carcinoma with radioactive gland. Am J Med 58:143-146, 1975.
iodine. Semin Nucl Med 8:79-94, 1978. Burt AD, et al: Lymphoid and epithelial markers in small cell
Beierwaltes WH: Controversies in the treatment of thyroid cancer: anaplastic thyroid tumor. J Clin Pathol 38:893-896, 1985.
The University of Michigan Approach. Thyroid Today 6:Sept.-Oct. Busnardo B, Girelli ME, Simioni N, et al: Nonparallel patterns of
1983. calcitonin and carcinoembryonic antigen levels in the follow-up of
Beierwaltes WH: The most common thyroid disease in the state of medullary thyroid carcinoma. Cancer 53:278-285, 1984.
Michigan is endemic goiter not due to iodine deficiency. Washtenaw Cady B: Management of tracheal obstruction from thyroid disease.
County Med Soc Bull 39(1), 1987a. World J Surg 6:696-701, t982.

Calmettes C, Caillou B, Moukhtar MS, et al: Calcitonin and carci-
noembryonic antigen in poorly differentiated follicular carcinoma.
Cancer 49:2342-2348, 1982.
Cance WG, Wells SA Jr: Multiple endocrine neoplasia type lIa. Curr
Probl Surg 22:1-56, 1985.
Caplan RH, Pagliara AS, Wickus G: Thyroxine toxicosis: A common
variant of hyperthyroidism. JAMA 244:1934-1938,1980.
Caraway NP, Sneige N, Samaan NA: Diagnostic pitfalls in thyroid fine
needle aspiration: A review of 394 cases. Diagn Cytopathol 9:
345-350, 1993.
Carcangiu ML, Bianchi S: Diffuse sclerosing variant of papillary
thyroid carcinoma: Clinicopathologic study of 15 cases. Am J Surg
Pathol 13:1041-1049, 1989.
Carcangiu ML, Steeper T, Zampi G, Rosai J: Anaplastic thyroid carci-
noma: A study of 70 cases. Am J Clin Pathol 83:135-158, 1985.
Carcangiu ML, Zampi G, Pupi A, et al: Papillary carcinoma of the
thyroid: A clinicopathologic study of 241 cases treated at the
University of Florence, Italy. Cancer 55:805-828, 1985.
Carcangiu ML, Zampi G, Rosai J: Poorly differentiated ("insular")
thyroid carcinoma: A reinterpretation of Langhans' "wuchernde
Struma." Am J Surg Pathol 8:655-668, 1984.
Carcangiu ML, Zampi G, Rosai J: Papillary thyroid carcinoma: A study
of its many morphologic expressions and clinical correlates. Pathol
Annu 1:1-46, 1985.
Caswell HT, Maier WP: Results of surgical treatment for hyperthy-
roidism. Surg Gynecol Obstet 134:218-220, 1972.
Catalona WJ, Engelman K, Ketcham AS, Hammond WG: Familial
medullary thyroid carcinoma, pheochromocytoma, and parathy-
roid adenoma (Sipple's syndrome): Study of a kindred. Cancer
28: 1245-1254, 1971.
Cavo JW Jr: True vocal cord paralysis following intubation.
Laryngoscope 95:1352-1359,1985.
Catz B, Perzik SL: Total thyroidectomy in the management of thyro-
toxic and euthyroid Graves' disease. Am J Surg 118:434-438, 1969.
Chak LY,Hoppe RT, Burke JS, Kaplan HS: Non-Hodgkin's lymphoma
presenting as thyroid enlargement. Cancer 48:2712-2716, 1981.
Chan JK, Saw D: The grooved nucleus: A useful diagnostic criterion
of papillary carcinoma of the thyroid. Am J Surg PathollO:672-679,
1986.
Chen KT, Rosai J: Follicular variant of thyroid papillary carcinoma: A
clinicopathologic study of 6 cases. Am J Surg Patholl :123-130, 1977.
Ching T, Warden J, Fefferman RA: Thyroid surgery in children and
teenagers. Arch Otolaryngol 103:544-546,1977.
Chonkich GA, Petti GH, Goral W: Total thyroidectomy in the treat-
ment of thyroid disease. Laryngoscope 97:897-900, 1987.
Clark OH: Endocrine Surgery of the Thyroid and Parathyroid Glands.
St. Louis, CV Mosby, 1985.
Clark OH, Gerend PL, Nissenson RA: Mechanisms for increased
adenyl ate cyclase responsiveness to TSH in neoplastic human
thyroid tissue. World J Surg 8:466-473, 1984.
Clark RL, et al: Cancer of the Head and Neck. Baltimore, Williams &
Wilkins, 1967.
Clark RL. Hickey RC, Butler JJ, et al: Thyroid cancer discovered inci-
dentally during treatment for an unrelated head and neck cancer:
Review of 16 cases. Ann Surg 163:665-671, 1966.
Cline RE, Shingleton WW: Long-term results in the treatment of
carcinoma of the thyroid. Am J Surg 115:545-551, 1968.
Clinical Staging System for Carcinoma of the Thyroid Gland. American
Joint Committee for Cancer Staging and End Results Reporting.
February 1967.
Cody HS, Shah JP: Locally invasive, well-differentiated thyroid cancer.
Am J Surg 142:480-483, 1981.
Conley J: Proceedings of the International Workshop on Head and
Neck Cancer. Washington, DC, Butterworth, 1967, p 423.
Conrad RA, Dobyns BM, Sutow WW: Thyroid neoplasia as late effect
of exposure to radioactive iodine in fallout. JAMA 214:316-324,
1970.
ENDOCRINE SURGERY
Constine LS, Donaldson SS, McDougalllR, et al: Thyroid dysfunction
after radiotherapy in children with Hodgkin's disease. Cancer
53:878-883,1984.
Crile G Jr, Rumsey EW: Subacute thyroiditis. JAMA 142:458, 1950.
Cuello G, Correa P, Eisenberg H: Geographic pathology of thyroid
carcinoma. Cancer 23:230-238, 1969.
Cunningham MP, Slaughter DP: Surgical treatment of disease of the
thyroid gland in pregnancy. Surg Gynecol Obstet 131:486-488, 1970.
Curtin CT, McHeffy B, Kolarsick AJ: Thyroid and breast cancer
following childhood radiation. Cancer 40:2911-2913, 1977.
Curtis GM: The blood supply of the human parathyroids. Surg Gynecol
Obstet 51:805, 1930.
Czech JM, Lichtor TR, Carney JA, van Heerden JA: Neoplasms
metastatic to the thyroid gland. Surgery 155:503-505, 1982.
Dembrow VD: Multiple endocrine adenomatosis type liB. Am J Surg
134:498-501, 1977.
De Mendonica WC, Espat PA: Pheochromocytoma associated with
arterial fibromuscular dysplasia. Am J Clin Pathol 75:749-754,
1981.
DeSanto LW: The total rehabilitation of Graves' ophthalmopathy.
Laryngoscope 90:1652-1678,1980.
Dobyns BM, Bertozzi G: Identification of cold thyroid lesions at
operation and its place in the surgical management of carcinoma
of the thyroid. Ann Surg 172:703-710, 1970.
Donis-Keller H, Shenshen D, Chi D, et al: Mutations in the RET proto-
oncogene are associated with MEN 24 and FMTC. Hum Mol Genet
2:851-856,1993.
Donohue JH, Goldfien SD, Miller TR, et al: Do the prognoses of papil-
lary and follicular thyroid carcinoma differ? Am J Surg 148:168-173,
1984.
Eckert C, Byars LT:The surgery of papillary carcinoma of the thyroid
gland. Ann Surg 136:83-89, 1952.
Egdahl RH: Some recent advances in endocrine surgery. Am J Surg
118:363-367, 1969.
Elias AN, Kyaw T, Winikoff J, Gwinup G: Acute suppurative thyroiditis.
J OtolaryngoI14:17-l9, 1985.
Elliott RHE Jr, Frantz VK: Metastatic carcinoma masquerading as
primary thyroid cancer: A report of authors' 14 cases. Ann Surg
151:551,1960.
Elner A, Fex S, Ingelstedt S: Nerve injury in thyroid surgery. Acta Chir
Scand 134:103-105, 1968.
Emerick GT, Duh QY,Siperstein AE, et al: Diagnosis, treatment and out-
come of follicular thyroid carcinoma. Cancer 72:3287-3295, 1993.
Eraker SA, Wickamasekaran R, Goldman S: Complete heart block
with hyperthyroidism. JAMA 239:1644-1646, 1978.
Ericsson N, Berg M, Ingemansson S, et al: Basal and pentagastrin-
stimulated levels of calcitonin in thyroid and peripheral veins
during normocaJcemia and chronic hypercalcemia in humans.
Ann Surg 194:129-133, 1981.
Esselstyn CB, Crile G: Evaluation of various types of needle biopsies
of the thyroid. World J Surg 8:452-457, 1984.
Evans HC: Follicular neoplasms of the thyroid. Cancer 54:535-540,
1984.
Evans HL: Columnar cell carcinoma of the thyroid: A report of two
cases of an aggressive variant of thyroid carcinoma. Am J Clin
Pathol 85:77-80, 1986.
Evans HL: Encapsulated papillary neoplasms of the thyroid: A study
of 14 cases followed for a minimum of 10 years. Am J Surg Pathol
11:592-597,1987.
Exelby PE, Frazell EL: Carcinoma of the thyroid in children. Surg Clin
North Am 49:249-259, 1969.
Fachnie JD, Rao SD: Painless thyroiditis with hyperthyroidism follow-
ing external irradiation to the neck. Henry Ford Hosp Med J
28:149-151,1980.
Falk SA, Birken EA, Ronquillo AH: Graves' disease associated with
histologic Hashimoto's thyroiditis. Otolaryngol Head Neck Surg
93:86, 1985.
 ENDOCRINE SURGERY

Feind CR: Autogenous parathyroid transplantation. Presented at the Greene BM, Goilladay ES, Mollitt DL: Multiple endocrine adenopathy.
Society of Head and Neck Surgeons Meeting, Vancouver, British Surg Gynecol Obstet 156:665-678, 1983.
Columbia, May 1971. Guansing AR, Klink DO, Engbring N, et al: Graves' disease following
Fjalling M, Tisell L-E, Carlsson S, et al: Benign and malignant tumor the occurrence of hypothyroidism. Henry Ford Hosp Med J 28:
nodules after neck irradiation. Cancer 58: 1219-1224, 1986. (2 & 3), 1980.
Fleming 10, Black TL, Thompson EI, et al: Thyroid dysfunction and Hales M, Rosenau W, Okerlund MD, Galante M: Carcinoma of the
neoplasia in children receiving neck irradiation for cancer. Cancer thyroid with a mixed medullary and follicular pattern. Cancer
55: 1190-1194, 1985. 50:1352-1359, 1982.
Foote F: Personal communication, 1970. Hall TL, Layfield U, Philippe A, Rosenthal DL: Source of diagnostic
Fortner JG, et al: Lymphocytic thyroiditis. Postgrad Med J 49:235-237, error in fine needle aspiration of the thyroid. Cancer 63:718-725,
1971. 1989.
Frable MA, Frable WJ: Thin needle aspiration biopsy of the thyroid Halsted WS: The operative story of goiter: The author's operation.
gland. Laryngoscope 90:1619-1625,1980. Johns Hopkins Hosp Rep 19:71, 1920.
Franklin WA, Mariotti S, Kaplan 0, DeGroot U: Immunofluorescence Hamburger B, Gharib H, Melton U, et al: Fine needle aspiration
localization of thyroglobulin in metastatic thyroid cancer. Cancer biopsy of thyroid nodules: Impact on thyroid practice and cost of
50:939-945, 1982. care. Am J Med 73:381. 1982.
Franssila QO, Ackerman LV, Brown CL, Hedinger CE: Follicular Hamilton CR Jr, Adams LC, Maloof F: Hyperthyroidism due to
carcinomas. Semin Diagn PathoI2:101-122, 1985. thyrotropin·producing pituitary chromophobe adenoma. N Engl J
Frazell EL, Foote FW Jr: The natural history of thyroid cancer: Review Med 283:1077-1080,1970.
of 301 cases. J Clin Endocrinol 9:1023, 1949. Hapke MR, Dehner LP: The optically clear nucleus: A reliable sign of
Frazell EL, Schottenfeld 0, Hutter RVP: The prognosis and insura- papillary carcinoma of the thyroid. Am J Surg PathoI3:31-38, 1979.
bility of thyroid cancer patients. CA 20:270-275, 1970. Harach HR, Fransila KO, Wasenius VM: Occult papillary carcinoma of
Friedman M, Skolnik EM, Bairn HM, et al: Thyroid carcinoma. the thyroid: A "normal" finding in Finland: A systematic autopsy
Laryngoscope 90:1991·2003, 1980. study. Cancer 56:531-538, 1985.
Gagel RF: Calcitonin in thyroid carcinoma and other diseases. Lab Harada T, Ito K, Shimaoka K, et al: Fatal thyroid carcinoma: Anaplastic
Manage, June 1982, pp 35-48. transformation of adenocarcinoma. Cancer 39:2588-2596,1977.
Garrett HE, Howell JF, DeBakey ME: Pheochromocytoma and renal Harada T, Nishikawa Y, Suzuki T, et al: Bleomycin treatment for
artery stenosis. Arch Surg 90:97-100, 1965. cancer of the thyroid. Am J Surg 122:53-57, 1971.
Geddie WR, Bedard YC, Strawbridge HTG: Medullary carcinoma of Hashimoto H: Zur Kenntnis der Lymphomatosen Veranderung der
the thyroid in fine needle aspiration biopsies. Am J Clin Pathol Schilddrtise (struma Iymphomatosa). Arch Klin Chir 97:219,1912.
82:552-558, 1984. Hassard AD, Holland JG: Benign thyroid disease and upper airway
Geola F, Chopra I): Hyperthyroidism and hypothyroidism: The current obstruction. J Otolaryngoll1:77-82, 1982.
status of diagnosis and treatment. Resident Staff Physician, July Hawk WA, Hazard JB: The many appearances of papillary carcinoma
1979. of the thyroid. Cleve Clin Q 43:207-216, 1976.
Getaz EP, Shimoska K, Rao U: Anaplastic carcinoma of the thyroid Hawkins MM, Kingston JE: Malignant thyroid tumors following
following external radiation. Cancer 43:2248-2253, 1979. childhood cancer. Lancet 2:804, 1988.
Gharib B, Goellner JR, Zinsmeister AR, et al: Fine needle aspiration Hay 10, Grant CS, van Heerden JA, et al: Papillary thyroid microcar-
biopsy of the thyroid. Ann Intern Med 101:26-28, 1984. cinoma: A study of 535 cases observed in a 50-year period. Surgery
Gharib H, McConahey WM, Tiega RD, et al: Medullary thyroid 112:1139·1146; discussion 1146-1147, 1992.
carcinoma: Clinicopathologic features and long-term follow up of Hazard JB, Crile G, Dempsey WS: Nonencapsulated sclerosing tumors
65 patients treated during 1946 through 1970. Mayo Clin Proc of the thyroid. Read at the annual meeting of the American Goiter
67:934-940, 1992. Association, Madison, Wisconsin, May 27,1949.
Gikas PW, Labow SS, DiGiulio W, Finger JE: Occult metastasis from Hazard JB, Hawk WA, Crile G Jr: Medullary (solid) carcinoma of the
occult papillary carcinoma of the thyroid. Cancer 20:2100·2104, thyroid: A clinicopathologic entity. J Clin Endocrinol 19: 1252-\26\,
1967. 1959.
Goellner JR, Gharib H, Grant CG, Johnson DA: Five needle aspiration Hazard B, Kenyon R: Encapsulated angioinvasive cell carcinoma
cytology of the thyroid. Acta Cytol 31:587, 1987. (angioinvasive adenoma) of thyroid gland. Am J Clin Pathol
Goldfarb WB, Bigos TS, Eastman RC, et al: Needle biopsy in the 24:755-766, \954.
assessment and management of hypofunctioning thyroid nodules. Hedley AJ, et al: Prevalance of hyperthyroidism after subtotal thy-
Am J Surg 143:409-412, 1982. roidectomy for Graves' disease. BMJ 4:258, 1971.
Golouh R, Us-Krasovec M, Auersperg M, Lamovec J: Fine needle Heitz P, Moser H, Staub J: Thyroid cancer: A study of 573 tumors and
aspiration biopsy (AB) and frozen section (FS) versus final histo· 161 autopsy cases observed over a thirty-year period. Cancer
logical diagnosis in malignant tumors of thyroid gland (meeting 37:2329-2337, 1976.
abstract). Pathology 165:98, 1979. Hershman JM: Clinical application of thyrotropin-releasing hormone.
Gonzalez JL, Wang HH, Ducattnan B: Fine needle aspiration biopsy N Engl J Med 290 April 1974.
of Htirthle cell lesions: A cytomorphic approach to diagnosis. Hill CS Jr: The "bad" thyroid cancers. GP Press, November·December,
Am J Clin Pathol 100:231-235, 1993. 1969, pp 9·]2.
Gordon JH, McCabe BF: The effect of accurate neurorrhaphy on Hines RC, Scheuermann HA, Royster HP, Rose E: Invasive fibrous
reinnervation and return of laryngeal function. Laryngoscope (Riedel's) thyroiditis with bilateral fibrous parotitis. JAMA
78:236-250, 1968. 213:869·871. 1970.
Gorman WA: Temporal relationship between onset of Graves' ophthal· Hoffman DP, Surks M1, Oppenheimer JH, Weitzman ED: Response
mopathy and diagnosis of thyrotoxicosis. Mayo Clin Proc 58: to thyrotropin-releasing hormone: An objective criterion for the
515-519, 1983. adequacy of thyrotropin suppression therapy. J Clin Endocrinol
Gottlieb JA, Hill CS: Chemotherapy of thyroid cancer, with Adriamycin. Metab 44:892-901, 1977.
N Engl J Med 290:193-197, 1974. Hoffman DA, McConahey WM, Diamond EL, Kurland LT: Mortality in
Green W, Wessler S, Avioli LV: Management of juvenile hyperthy- women treated for hyperthyroidism. Am J Epidemiol 115:243-254,
roidism. JAMA 213:1652·]655,1970. 1982.
 ENDOCRINE SURGERY

Holck S: Plasma cell granuloma of the thyroid. Cancer 48:830-832, Kini SR: Guide to Clinical Aspiration Biopsy: Thyroid. New York,
1981. 19aku Shoin, 1996.
Holl-Allen RTJ: Haemorrhage following thyroidectomy for thyro- Kini SR, Miller 1M, Hamburger JI, et al: Cytopathology of papillary
toxicosis. Br J Surg 54:703-706, 1967. carcinoma of the thyroid. Acta Cytol 24:511-512, 1980.
Holl-Allen RTJ: Laryngeal nerve paralysis and benign thyroid disease. Kini SR, Miller 1M, Hamburger JI, et al: Cytopathology of follicular
Arch Otolaryngol 85:335-337, 1967. lesions of the thyroid gland. Diagn CytopathoI1:123-132, 1985.
Hollenberg CH: Medullary carcinoma of the thyroid. Arch Otolaryngol Kline TS: Handbook of Fine Needle Aspiration Biopsy, 2nd ed.
109:103-106,1983. New York, Livingstone, 1988, pp 153-198.
Hollinshead WH: Anatomy for Surgeons, Vol I, Head and Neck. Klopp CT, Kirson SM: Therapeutic problems with ectopic non-
New York, Hoeber-Harper, 1954. cancerous follicular thyroid tissue in the neck: 18 case reports
Holt GR, McMurry GT, Joseph DJ: Recurrent laryngeal nerve injury according to etiologic factors. Ann Surg 163:653-663, 1966.
following thyroid operations. Surg Gynecol Obstet 144:567-570, Kocher T: Zur Pathologie und Therapie des Kropfes. Dtsch Z Chir
1977. 4:417-440, 1874.
Horn RC Jr: Carcinoma of the thyroid: Description of a distinctive Konrad HR, Canalis RF: Lethal thyroid carcinoma. Arch Otolaryngol
morphologic variant and report of seven cases. Cancer 4:697-707, 104:454-455, 1978.
1951. Kovacs CS, Mase RM, Kovacs K, et al: Thyroid medullary carcinoma
Howard RB, Truels WP: Thyroid cancer: 30 year review of 201 cases. with thyroglobulin immunoreactivity in sporadic multiple endocrine
Am J Surg 138:934-938, 1979. neoplasia type 28. Cancer 74:928-932, 1994.
Hutter RVP, Frazell EL, Foote FW Jr: Elective radical neck dissection: Lahey FH, Hare HF, Warren S: Carcinoma of the thyroid. Ann Surg
An assessment of its use in the management of papillary thyroid 112:977-1005, 1940.
cancer. CA 20:86-92, 1970. Lang W, Choritz H, Hundeshagen H: Risk factors in follicular thyroid
Hutter RVP, Tollefsen HR, De Cosse JJ, et al: Spindle and giant cell carcinoma: A retrospective follow-up study covering a 14-year
metaplasia in papillary carcinoma of the thyroid. Am J Surg period with emphasis on morphologic findings. Am J Surg Pathol
110:660-668, 1965. 10:246-255, 1986.
Ishihara T, Kikuchi K, Ikeda T, et al: Resection of thyroid carcinoma Lavelle RJ: Thyroid function after radiotherapy and total laryngectomy
infiltrating the trachea. Thorax 33:378-386, 1978. in the treatment of carcinoma of the larynx. Ann Otol 80:593-598,
Itoh H, et al: Detection of metastatic medullary thyroid cancer with 1971.
1311-MIBGscans in Sipple's syndrome. Eur J Nucl Med 11:502-504, Lawson VG: The management of airway involvement in thyroid
1986. tumors. Arch Otolaryngol 109:86-90, 1983.
Jacobson AP, Plato PA, Toeroek D: Contamination of the home Lawson W, Biller HF: The solitary thyroid nodule: Diagnosis and
environment by patients treated with iodine-131: Initial results. management of malignant disease. Am J OtolaryngoI4:43-73, 1983.
Am J Public Health 68:225-230, 1978. Lee TC, Coffey RJ, Mackin J, et al: The use of propranolol in the sur-
Jacques DA, Chambers RG, Oertel JE: Thyroglossal tract carcinoma. gical treatment of thyrotoxic patients. Ann Surg 177:643-647, 1973.
Am J Surg 120:439-446, 1970. Lee TC, Coffey RJ, Currier BM, et al: Propranolol and thyroidectomy
Jansson S, Hansson G, Salander H, et al: Prevalence of C-cell hyper- in the treatment of thyrotoxicosis. Ann Surg 195:766-773, t982.
plasia and medullary thyroid carcinoma in a consecutive series of Lennquist S: The thyroid nodule: Diagnosis and surgical treatment.
pheochromocytoma patients. World J Surg 8:493-500, 1984. Surg Clin North Am 67:213, 1987.
Jeevanram RK, Shah DH, Kumar A, et al: Synthesis of thyroglobulin Lewis MI, Holleran WM: Ectopic thyroid gland in children. Am J Surg
in thyroid carcinoma patients after radioiodine therapy. Cancer 115:688-690, 1968.
52:2240-2244, 1983. Liddle GW, Heyssel RM, McKenzie JM: Graves' disease without hyper-
Johannessen JV, Sobrinho-Simoes M: The origin and significance of thyroidism. Am J Med 30:845-848, 1965.
thyroid psammoma bodies. Lab Invest 43:287-296, 1980. Liechty RD, Graham M, Freemeyer P: Benign solitary thyroid nodules.
Johnson TL, Lloyd RV, Thompson NW, et al: Prognostic implications Surg Gynecol Obstet 121:571-573, 1965.
of the tall cell variant of papillary thyroid carcinoma. Am 1 Surg Lindsay S, Nichols CWo Medullary thyroid carcinoma and parathy-
Pathol 12:22-27, 1988. roid hyperplasia in rats. Arch Pathol 88:402-406, 1969.
Joppich I, Roher HD, Hecker WC, et al: Thyroid carcinoma in child- Liston SL: Hypercalcemia in head and neck cancer. Bony metastases
hood. Kinderchirurgische Klinik, Fakultat fUr Klinische Medizin from tongue cancer. Arch OtolaryngoI104:597-600, 1978.
Mannheim, Universitat Heidelberg, Federal Republic of Germany. liVolsi VA: Medullary carcinoma. In: Surgical Pathology of the Thyroid.
Prog Pediatr Surg 16:23-28, 1983. Volume 22 of Major Problems in Pathology Series. Philadelphia,
Kakudo K, Carney JA, Sizemore GW: Medullary carcinoma of the WB Saunders, 1990, pp 213-252.
thyroid: Biologic behavior of the sporadic and familial neoplasms. liVolsi VA, LoGerfo P, Feind CR: Co-existent parathyroid adenomas
Cancer 55:2818-2821, 1985. and thyroid carcinoma-can radiation be blamed? Arch Sueg
Kameda Y, Harada T, Ito K, Ikeda A: tmmunohistochemical study of 113:285-286, 1978.
the medullary thyroid carcinoma with reference to C-thyroglobulin Ljungberg 0, Bondeson L, Bondeson AG: Differentiated thyroid
reaction of tumor cells. Cancer 44:2071-2082, 1979. carcinoma intermediate type: A new tumor with features of
Kapadia SB, Dekker A, Cheng VS, et al: Malignant lymphoma of the follicular and parafollicular carcinoma. Hum Pathol t5:218-228,
thyroid gland: A clinicopathologic study. Head Neck Surg 4: 1984.
270-280, 1982. Ljungberg 0, Ericsson U, Bondeson L, Thorell J: A compound fol-
Katz AD: Thyroid and associated polyglandular neoplasms in patients licular parafollicular cell carcinoma of the thyroid: A new tumor
who received head and neck irradiation during childhood. Head entity. Cancer 52:1053-1061, 1983.
Neck Surg 1:417-422,1979. LoGerfo P, Colacchio D, Stillman T, Feind C: Serum thyroglobulin and
Kellum JM, Spratt JS, Perez-Mesa CM: Prognostic significance of recurrent thyroid cancer. Lancet 1:881-882, 1977.
individual host-cancer-treatment variables associated with cancer Lore JM Jr: Atlas of Head and Neck Surgery, 1st ed. Philadelphia, WB
of the thyroid. Am J Surg 134:496-497, 1977. Saunders, 1962.
Kim JH, Leeper RD: Treatment of anaplastic giant and spindle cell Lore JM Jr: Thyroid cancer. ORL Digest 34: 10, 1972.
carcinoma of the thyroid gland with combination Adriamycin and Lore JM Jr: The diagnosis and management of thyroid disease: III
radiation therapy. Cancer 52:954-957, t983. and IV. lCE ORL Allergy, April 1979.
 ENDOCRINE SURGERY

Lore JM Jr: Surgery of the thyroid gland. Otolaryngol Clin North Am McArthur RG: Hyperthyroidism in children. Thyroid Today I (January),
13:69-83, 1980. 1978.
Lore JM Jr: The ligament of Berry in total thyroid lobectomy. In McConahey WM, Hay 10, et al: Papillary thyroid cancer treated at the
Wilson JSP (ed): Operative Surgery of the Head and Neck. Part II, Mayo Clinic, 1946-1970: Initial manifestations, pathologic find-
3rd ed. Woburn, MA, Butterworth, 198!. ings, therapy, and outcome. Mayo Clin Proc 61 :978-996, 1986.
Lore JM Jr: Cancer of the thyroid. In Gates GA (ed): Current Therapy McDermott MT, Kidd GS, Dodson LE, Hofeldt FD: Radioiodine-
in Otolaryngology: Head and Neck Surgery 1982-83. SI. Louis, CV induced thyroid storm. Am J Med 75:353-359, 1983.
Mosby, 1982. McDougalllR, Coleman CN, Burke JS, et al: Thyroid carcinoma after
Lore JM Jr: Practical anatomical considerations in thyroid tumor high dose external radiotherapy for Hodgkin's disease: Report of
surgery. Arch Otolaryngol 109:568-574, 1983a. three cases. Cancer 45:2056-2060, 1980.
Lore JM Jr: Technique of thyroidectomy. J Otolaryngol 12:2, 1983b. Melvin KE, Miller MH, Tashjian AH: Early diagnosis of medullary
Lore JM Jr, Banyas J, Kaufman S: Follow-up report-laryngeal nerves carcinoma of the thyroid by means of calcitonin assay. N Engl J
following thyroidectomy (in press). Med 285:1115-1120, 197!.
Lore JM Jr, Banyas JB, Niemiec ER: Complications of total thy- Mendelsohn G, Wells SA Jr, Baylin SB: Relationship of tissue carci-
roidectomy. Arch Otolaryngol Head Neck Surg 113:1238, 1987. noembryonic antigen and calcitonin to tumor virulence in medullary
Lore JM Jr, Kim OJ, Elias S: Preservation of laryngeal nerves during thyroid carcinoma. Cancer 54:657-662, 1984.
total thyroidectomy. Ann Otol Rhinol LaryngoI84:777, 1977. Meyer JS, Steinberg LS: Microscopically benign thyroid follicles in
Lore JM Jr, Kokocharov SI, Kaufman S, et al: Thirty-eight-year cervical lymph nodes. Cancer 24:302-311,1969.
evaluation of a surgical technique to protect the external branch Michaelson ED, Young RL: Hypothyroidism with Graves' disease.
of the superior laryngeal nerve during thyroidectomy. Ann Otol JAMA 211:1351-1354,1970.
Rhinol Laryngol 107:1015-1022, 1998. Michel RG, Hall OM, Woodard BH: Gas-forming suppurative
Lore JM Jr, Perry RJ: The diagnosis and management of thyroid thyroiditis. Ear Nose Throat J 60:127-130, 1981.
disease: III and IV. JCE ORL Allergy 41:13-25,1979. Miller JM, Hamburger JI, Kini SR: The impact of needle biopsy on the
Lore JM Jr, Pruet CW: Retrieval of the parathyroid glands during preoperative diagnosis of thyroid nodules. Henry Ford Hosp Med
thyroidectomy. Head Neck Surg 5:268-269, 1983. J 28:145-148, 1980.
Lore JM Jr, Staggers-Deberny J, Castillo NB, et al: Prognosis of tall Miller JM, Hamburger JI, Kini SR: The needle biopsy diagnosis of
cell variant papillary thyroid carcinoma. Presented at the Fifth papillary thyroid carcinoma. Cancer 48:989-993, 198!.
International Conference for Head and Neck Surgeons, San Francisco, Miller WW, Delivoria-Papadopoulos M, Miller L, Oski FA: Oxygen
August 2000. releasing factor in hyperthyroidism. JAMA 211:1824-1826,1970.
Maceri 0, Babyak J, Ossahow J: Lateral neck mass. Arch Otolaryngol Mills SE, Allen MS Jr: Congenital occult papillary carcinoma of the
112:47-49, 1986. thyroid gland. Hum Pathol 17:1179-1181, 1986.
Maceri 0, Sullivan M, McClotchney K: Autoimmune thyroiditis: Mizukami Y, Nonomura A, Michigishi T, et al: Mixed medullary
Pathophysiology and relationship to thyroid cancer. Laryngoscope follicular carcinoma of the thyroid: A clinicopathologic variant of
96:82-86, 1986. medullary thyroid carcinoma. Mod Pathol 9:631-635, 1996.
Maheshwari YK, Hill CS, Haynie TP, et al: 1311 therapy in differential Moosemen DA, De Weese MS: The external laryngeal nerve as related
thyroid carcinoma: MD Anderson Hospital experience. Cancer to thyroidectomy. Surg Gynecol Obstet 12:1011-1016, 1968.
47:664-671. 198!. Mountain JC, Stewart GR, Colcock BP: The recurrent laryngeal
Makiuchi M, Miyakawa M, Sugenoya A, Furihata R: An evaluation of nerve in thyroid operations. Surg Gynecol Obstet 133:978-980,
several prognostic factors in the surgical treatment for thyrotoxicosis. 197!.
Surg Gynecol Obstet 152:639-641, 198!. Mulligan LM, Kivok JBJ, Healey CS, et al: Germline mutations of the
Marchetta FC, Krause L, Sako K: Interpretation of scintigrams obtained RET proto-oncogene in multiple endocrine neoplasia type 2A.
after thyroidectomy. Surg Gynecol Obstet 116:647-649, 1963. Nature 363:458-460,1993.
Marchetta FC, Sako K: Successful reimplantation of autogenous Murphy E, Cervantes QFBC: Atypical changes in thyroid follicular
parathyroid tissue. Am J Surg 118:779-782, 1969. cells secondary to radioiodine. AJR Am J Roentgenol 109:724-728,
Marchetta FC, Sako K, Matsuura H: Modified neck dissection for 1970.
carcinoma of the thyroid gland. Am J Surg 120:452-455, 1970. Myers RT, Bhatti A: Peptic ulcer and parathyroid adenoma. Ann Surg
Marcus IN, Dise CA, LiVolsi VA: Melanin production in a medullary 17] :647-655, 1970.
thyroid carcinoma. Cancer 49:2518-2526, 1982. Nagataki S, Nystrom E: Epidemiology and primary prevention of
Marquez A: Surgical treatment of post-thyroidectomy tracheomalacia. thyroid cancer. Thyroid 12:889-896,2002.
Arch Otol 81:608-615, 1965. Naib ZM: Cytopathology, 4th ed. Boston, Little, Brown, 1996,
Martin JW, Dozier WE: Carcinoma of the thyroid gland: A IS-year pp 517-534.
survey in private hospitals in Sacramento. Calif Med 108: 166-171, Naidich TP, Sprayregen S, Goldman AG, Siegelman SB: Renal artery
1968. alterations associated with pheochromocytoma. Angiology
Martis C, Athanassiades S: Postthyroidectomy laryngeal edema: A 23:488-499,1972.
survey of fifty-four cases. Am J Surg 122:58-60, 197!. Nathan AR, Raines KB, Lee Y-T, et al: Fine needle aspiration biopsy
Massin J, Savoie J, Garnier H, et al: Pulmonary metastases in differ- of cold thyroid nodule. Cancer 62:1337-1342, 1988.
entiated thyroid carcinoma. Cancer 53:982-992, 1984. Nemiroff PM, Katz AD: Extralaryngeal divisions of the recurrent
Matsuura H, Sako K, Marchetta FC: Successful reimplantation of laryngeal nerve. Surgical and clinical significance. Am J Surg 144:
autogenous parathyroid tissue. Am J Surg 118:779-782, 1969. 466-469, 1982.
Maxon HR, Saenger EL, Thomas SR, et al: Clinically important Nicastri AD, Foote F, Frazell E: Benign thyroid inclusion in cervical
radiation-associated thyroid disease. JAMA 244:1802-1805, 1980. lymph nodes. JAMA 194:113, 1965.
Mazzaferri EL: Management of a solitary nodule. N Engl J Med Nielsen B, Zetterlund B: Malignant thyroid tumors at autopsy in a
328:553-559, 1993. Swedish goitrous population. Cancer 55: 1041-1043, 1985.
Mazzaferri EL, Young RL: Papillary thyroid carcinoma: A 10 year Nikiforov Y, Gnepp DR: Pediatric thyroid cancer after the Chernobyl
follow-up report of the impact of therapy in 576 patients. Am Med disaster: Pathomorphological study of 84 cases (\991-1992) from
70:511-518, 198!. the Republic of Belarus. Cancer 74:748-766, 1994.

Nikiforov Y, Heffner CS, Korzenko AV, et al: Characteristics of
follicular tumors and nonneoplastic thyroid lesions in children
and adolescents exposed to radiation as a result of the Chernobyl
disaster. Cancer 76:900-909, 1995.
Nishiyama RH, Dunn EL, Thompson NW: Anaplastic spindle-cell and
giant cell tumor of the thyroid gland. Cancer 30:113-127,1972.
Nixon OW, SarnoIs E: Acral changes associated with thyroid diseases.
JAMA 212:1175-1180, 1970.
Nofal MM, Beierwaltes WH, PaInO ME: lfeatment of hyperthyroidism
with sodium iodide 1131.JAMA 197:605-610, 1966.
Nussbaum M, Buchwald RP, Ribner A, et al: Anaplastic carcinoma
arising from median ectopic thyroid (thyroglossal duct remnant).
Cancer 48:2724-2727, 1981.
Olanow CW, Lane RJM, Hull KL, Roses AD: Neonatal myasthenia
gravis in the infant of an asymptomatic thymectomized mother.
Can J Neural Sci 9:85-87,1982.
Pacini F, Antonelli A, Lari R, et al: Unsuspected parathyroid cysts
diagnosed by measurement of thyroglobulin and parathyroid. Ann
Intern Med 102:793-794, 1985.
Paloyan E, Scanu A, Straus FH, et al: Familial pheochromocytoma,
medullary thyroid carcinoma, and parathyroid adenomas. JAMA
214:1443-1447, 1970.
Papotti M, Botto Micca F, Favero A, et al: Poorly differentiated thyroid
carcinomas with primordial cell component: A group of aggressive
lesions showing insular, trabecular and solid patterns. Am J Surg
Pathol 17:291-301, 1993.
Park HM, Tarver RD, Siddiqui AR, et al: Efficacy of thyroid scintigraphy
in the diagnosis of intrathoracic goiter. Am J Radial 148:527-529,
1987.
Perry RJ, Lore JM Jr: The diagnosis and surgical management of
thyroid disease. JCE ORL Allergy 41: 17-28, 1979.
Perry RJ, Spaulding MB, Milley PS, Lore JM Jr: The diagnosis and
surgical treatment of thyroid disease: II: Management. JCE ORL
Allergy 41:13-27,1979.
Perzik SL: Total thyroidectomy. Am J Surg 106:744, 1963.
Perzik SL: Total thyroidectomy in the management of Graves' disease.
Am J Surg 131:284-287, 1976.
Piersol GA: Human Anatomy, 3rd ed. Philadelphia, JB Lippincott,
1930.
Pietyibiasi F, Sapino A, Parotti M, et al: Cytologic features of poorly
differentiated "insular" carcinoma of the thyroid as revealed by
fine needle aspiration biopsy. Am J Clin Pathol 94:687-692, 1990.
Pilch BZ, Kahn CR, Ketchan AS, Henson 0: Thyroid cancer after
radioactive iodine diagnostic procedures in childhood. Pediatrics
51:898-902, 1973.
Pilotti S, Collini P, Manzari A, et al: Poorly differentiated forms of
papillary thyroid carcinoma: Distinctive entities or morphological
patterns? Semin Diagn PathoI12:249-255, 1995.
Pollack RS: Cervical lymph node metastasis of thyroid cancer, Am J
Surg 102:388, 1961.
Pretorius HT, Katikineni M, Kinsella TJ, et al: Thyroid nodules after
high-dose external radiotherapy. JAMA 247:3217-3220, 1982.
Provan JG: The 'anterior' lobe of the thyroid. Br J Surg 54:1001-1003,
1967.
Rafla S: Anaplastic tumors of the thyroid. Cancer 23:668-677, 1969.
Ram MD, Hyde G, Griffen WO: Thyroidography in evaluation of
thyroid disease. Arch Surg 115:588-592, 1980.
Ramanna L, Waxman AD, Brachman MB, et al: Correlation of thy-
roglobulin measurements and radioiodine scans in the follow·up
of patients with differentiated thyroid cancer. Cancer 55: 1525-1529,
1985.
Rapoport B, Greenspan S, Filetti S, Pepitone M: Clinical experience
with human thyroid cell bioassay for thyroid-stimulating immuno-
globulin. J Clin Endocrinol Metab 58:332-338, 1984.
Razack MS, Lore JM Jr, Lippes HA, et al: Total thyroidectomy for
Graves' disease. Head Neck 19:378-383, 1997.
ENDOCRINE SURGERY
Reeve TS, Delbridge L, Cohen A, Crummer P: Total thyroidectomy,
Ann Surg 206:782-787, 1987.
Reeve TS, Hales IB, White MB, et a1:Thyroidectomy in the management
of thyrotoxicosis in the adolescent. Surgery 65:694-699, 1969.
Refetoff S, Lever EG: The value of serum thyroglobulin measurement
in clinical practice. JAMA 250:2352-2357, 1983.
Riedel BMCL: Die chronische, zur Bildung eisenharter Thmoren
fiihrende Entzundung der Schilddruse. Verh Dtsch Ges Chir 25
(Part 1):101, 1896.
Riedel BMCL: Ober Verlauf und Ausgang der Strumitis chronica.
Munch Med Wochenschr 57:1946,1910.
Riedel BMCL: Vorstellung eines Kranken mil chronischer Strumitis.
Verh Dtsch Ges Chir 26(Part 1):127, 1897.
Ritter FN: The effects of hypothyroidism upon the ear, nose and
throat. Laryngoscope 77:1427-1479, 1967.
Roediger WEW: The oxyphil and C cells of the human thyroid gland.
Cancer 36:1758-1770,1975.
Rosai J, Carcangiu ML, Delellis RA: Medullary carcinoma. In Tumors
of the Thyroid Gland. Washington, DC, Armed Forces Institute of
Pathology, 1990, pp 207-241.
Rosai J, Carcangiu ML, DeLellis R: Atlas of Tumor Pathology.
Washington, DC, Armed Forces Institute of Pathology, 1990.
Rosai J, Saxen EA, Woolner C: Undifferentiated and poorly differen-
tiated carcinomas. Semin Diagn Pathol 2:123-139,1985.
Rosenberg J, Orlando R III, Ludwig M, Pyrtek U: Parathyroid cysts.
Am J Surg 143:473-480, 1982.
Rougier P, Calmettes C, Laplanche A, et al: The values of calcitonin
and carcinoembryonic antigen in the treatment and management of
nonfamilial medullary thyroid carcinoma. Cancer 51:855-862, 1983.
Rush BF, Swaminathan AP, Patel R: A medical approach to thyroidec-
tomy. Am J Surg 130:430-432, 1975.
Russel WO, Ibanez ML, Clark RL, White EC: Thyroid carcinoma:
Classification, intraglandular dissemination and clinicopathological
study based on whole organ sections of 80 glands. Cancer 16:1425,
1963.
Russell CF, Van Heerden JA, Sizemore GW, et al: The surgical manage-
ment of medullary thyroid carcinoma. Ann Surg 197:42-48, 1983.
Rustard WH: The Recurrent Laryngeal Nerves in Thyroid Surgery.
Springfield, IL, Charles C Thomas, 1956.
Safa AM, Skillern PG: Treatment of hyperthyroidism with a large initial
dose of sodium iodine I 131. Arch Intern Med 135:673-675, 1975.
Saito K, Kuratomi Y, Yamamoto K, et al: Primary squamous cell
carcinoma of the thyroid associated with marked leukocytosis and
hypercalcemia. Cancer 48:2080-2083, 1981.
Samba de MC, Goncalves VS, Dias M, Sobrinho-Simoes MA: High
relative frequency of thyroid papillary carcinoma in northern
Portugal: Cancer 51:1754-1759,1983.
Sampson RJ, Key CR, Buncher CR, lijima S: Thyroid carcinoma in
Hiroshima and Nagasaki. JAMA 209:65-70, 1969,
Sanfelippo PM, Beahrs OH, Hayles AB: Indications for thyroidectomy
in the pediatric patient. Am J Surg 122:472-476, 1971.
Sansa GE, Domene HM, Garcia R. et at: Very early detection of RET
proto-oncogene mutation is crucial for preventive thyroidectomy
in multiple endocrine neoplasia type 2 children: Presence of C-cell
malignant disease in asymptomatic carriers. Cancer 94:323-330,
2002.
Sarkar SO, Beierwaltes WH, Gill SP, et al: Subsequent fertility and
birth histories in children and adolescents treated with 131J for
thyroid cancer. J Nucl Med 17:460-464, 1976.
Sataloff TR: Professional Voice, 2nd ed. San Diego, Singular
Publishing Group, 1997.
Schindel J: Surgery in malignant tumors of the thyroid gland: A review
of 15 years experience with 225 cases. Ann Otol 80:61-66, 1971.
Schmidt MC, Klatch OM, Lore JM Jr: Localizing functioning thyroid
following total thyroidectomy by use of a combination scanning
technique. Clin Nucl Med 5:415-416, 1980.
 ENDOCRINE SURGERY
Schneider AB, Pinsky S, Bekerman C, Ryo UY: Characteristics of 108
thyroid cancers detected by screening in a population with a history
of head and neck irradiation. Cancer 46:1218·1227, 1980.
Schroder S, et al: The encapsulated papillary carcinoma of the thyroid:
A morphologic subtype of papillary thyroid carcinoma. Cancer
54:90-93, 1984.
Schwartz AE, Nieburgs HE, Davies TF, et al: The place of fine needle
biopsy in the diagnosis of nodules of the thyroid. Surg Gynecol
Obstet 155:54-58, 1982.
Schweitzer VA, Olson NR: Thyroid abscess. Otolaryngol Head Neck
Surg 89:226-229, 1981.
Scopsi L, Sampietro G, Borranchi P, et al: Multivariate analysis of
prognostic factors in sporadic medullary carcinoma of the thyroid:
A retrospective study of 109 consecutive patients. Cancer 78:
2173·2183,1996.
Selzer G, Kahn LB, Albertyn L: Primary malignant tumors of the
thyroid gland. Cancer 40:1501-1510,1977.
Senior RM, Birge SJ, Wessler S, Avioli LV: The recognition
management of myxedema coma. JAMA 217:61-65, 1971.
Shapiro S, Slone 0, Kaufman OW, et al: Use of thyroid supplements
in relation to the risk of breast cancer. JAMA 244: 1685-1687, 1980.
Shimaoka K, Bakri K, Sciascia M, et al: Thyroid screening program.
NY State J Med 82:1184-1187,1982.
Shimaoka K, Tsukada Y: Squamous cell carcinomas and adenosqua-
mOllS carcinomas originating from the thyroid gland. Cancer
46:1833-1842, 1980.
Silva OL, Snider RH Jr, Moore CF, Becker KL: Urine calcitonin as a
test for medullary thyroid cancer. Ann Surg 189:269, 1979.
Silver BJ, Kyner JL, Dick AR, Chang CHJ: Primary hypothyroidism.
JAMA 246:364-365, 1981.
Silverberg E, Lubera J: Cancer statistics. Cancer 36:9-25, 1986.
Simpson WJ, McKinney SE: Canadian survey of thyroid cancer. Can
Med Assoc J 132:925·931, 1985.
Simpson WJ, Palmer JA, Rosen IB, Mustard RA: Management
medullary carcinoma of the thyroid. Am J Surg 144:420-422,1982.
Sipple JH: The association of pheochromocytoma with cancer of the
thyroid gland. Am J Med 31 :163, 1961.
Sisson JC: Applying the radioactive eraser. J Nucl Med 24:743-745,
1983.
Sistrunk WW: The surgical treatment of cysts of the thyroglossal
tract. Ann Surg 71:121,1920.
Sizemore GW, Carney A, Heath H Ill: Epidemiology of medullary
carcinoma of the thyroid gland: A 5-year experience (1971·1976).
Surg Clin North Am 57:633-645, 1977.
Slag MF, Morley JE, Elson MK, et al: Hypothyroxinemia in critically
ill patients as a predictor of high mortality. JAMA 245:43-45,1981.
Snyder J, Gorman C, Scanlon P: Thyroid remnant ablation: Question·
able pursuit of an ill-defined goal. J Nucl Med 24:659-665, 1983.
Sobrinho-Simoes M, Nesland JM, Johannessen JV: Columnar cell
carcinoma: Another variant of poorly differentiated carcinoma of
the thyroid. Am J Clin Pathol 89:264, 1988.
Sobrinho-Simoes M, Soares J, Carneiro F, et ai: Diffuse follicular variant
of papillary carcinoma of the thyroid: Report of eight cases of a
distinct aggressive type of thyroid tumor. Surg Pathol 3:189-203,
1990.
Solomon DH, Chopra IJ, Chopra U, Smith FJ: Identification of subgroups
of euthyroid Graves' ophthalmopathy. N Engl J Med 296:181-185,
1977.
Spanos GA, Wolk 0, Desner MR, et al: Preoperative chemotherapy
for giant cell carcinoma of the thyroid. Cancer 50:2252·2256, 1982.
Spiro RH, Daniello N: Spindle and giant cell carcinoma of the thyroid:
Report of a five*year survival after lobectomy and postoperative
irradiation. J Surg OncoI12:385-389, 1979.
Sterling K, Refetoff S, Selenkow HA: T3 thyrotoxicosis: Thyrotoxicosis
due to elevated serum triiodothyronine levels. JAMA 213:571-575,
1970.
Stith JA, Johnson JT: Papillary adenocarcinoma in ectopic thyroid.
Otolaryngol Head Neck Surg 89:84-87, 1981.
Strickland AL, Macfie JA, Van Wyk JJ, French FS: Ectopic thyroid
glands simulating thyroglossal duct cysts. JAMA 208:307·310,
1969.
Suen KC, Quenville NF: Fine needle aspiration biopsy of the thyroid
gland: A study of 304 cases. J Clin Pathol 36: 1036-1045, 1983.
Sutton JP, McSwain B, Diveley WL: Carcinoma of the thyroid. Ann
Surg 167:839-846, 1968.
Szijj I, Caspo Z, Laszlo FA, Kovacs K: Medullary cancer of the thyroid
gland associated with hypercorticism. Cancer 24:167-173,1969.
Tamoney HJ Jr: Surgery for thyroid cancer. Am J Surg 119:699-701,
1970.
Tamura K, Shimaoka K, Friedman M: Thyroid abnormalities associated
with treatment of malignant lymphoma. Cancer 47:2704-2711, 1981.
Tashjian AH Jr, Howland BG, Melvin KEW, Hill CS Jr: Immunoassay
of human calcitonin: Clinical measurement, relation to serum
and calcium and studies in patients with medullary carcinoma. N Engl
J Med 283:890-895, 1970.
Taylor WE, Myer CM, Hays LL, Cotton RT: Acute suppurative
thyroiditis in children. Laryngoscope 92: 1269·1273, 1983.
Tennvall J, Biorklund A, Moller T, et al: Prognostic factors of papil-
lary, follicular and medullary carcinomas of the thyroid gland.
Acta Radiol Oncol 24:Fasc. 1, 1985.
Tennvall J, Biorklund A, Moller T, et al: Is the EORTC prognostic
index of thyroid cancer valid in differentiated thyroid carcinoma?
Cancer 57:1405-1414, 1986.
Tennvall J, Palmer J, Biorklund A, et al: Kinetics of thallium-201 uptake
in adenomas of well-differentiated carcinomas of the thyroid. Acta
Radiol Oncol 23:Fasc. I, 1984.
Tennvall J, Andersson T, Aspergren A, et al: Undifferentiated giant
and spindle cell carcinoma of the thyroid. Acta Radiol Oncol
18:408-416, 1979.
of Tennvall J, Olsson T, Akerman M, et al: Thyroid tissue characteriza-
tion by proton magnetic resonance relaxation time determination.
Acta OncoI26:Fasc. 1, 1987.
Tennvall J, Palmer J, Cederquist E, et al: Scintigraphic evaluation and
dynamic studies with thallium-201 in thyroid lesions with sus-
pected cancer. Eur J Nucl Med 6:295-300, 1981.
Thomas GG, Rutledge RG: Surgical intervention in chronic (Hashimoto's)
thyroiditis. Ann Surg 193:769·776, 1981.
Thompson NW, et al: Htirthle cell lesions of the thyroid gland. Surg
Gynecol Obstet 139:555-560, 1974.
Thompson NW, Harness JK: Complications of total thyroidectomy for
carcinoma. Surg Gynecol Obstet 131 :861-868, 1970.
Tisell LE, Hansson G, Lindberg S, Ragnhult 1: Occurrence of previous
neck radiotherapy among patienrs with associated non-medullary
thyroid carcinoma and parathyroid adenoma or hyperplasia. Acta
Chir Scand 144:7-11, 1978.
Tollefsen HR, DeCosse JJ: Papillary carcinoma of the thyroid: Recurrence
in the thyroid gland after initial surgical treatment. Am J Surg
106:728-734, 1963.
Tollefsen HR, DeCosse JJ: Papillary carcinoma of the thyroid: The
case for radical neck dissection. Am J Surg 108:547·551, 1964.
Tollefsen HR, DeCosse JJ, Hutter RVP: Papillary carcinoma of the
thyroid: A clinical and pathological study of 70 fatal cases. Cancer
17:1035·1044,1964.
Tollefsen HR, Shah JP, Huvos AG: Htirthle cell carcinoma of the
thyroid. Am J Surg 130:390·394, 1975.
Tubiana M, Haddad E, Schlumberger M, et al: External radiotherapy
in thyroid cancers. Cancer 55:2062-2071, 1985.
Utiger RD: Treatment of Graves' disease. N Engl J Med 298:681-682,
1978.
Van Den Berg CV, Edis EJ: Multicentric thyroid carcinoma, parathy-
roid adenomas, and vagal neurilemmoma in a young man with
antecedent tonsillary radiation. Mayo Clin Proc 55 (October), 1980.
 ENDOCRINE SURGERY

Verdon TA, Holmes ER, Hale AS: What nuclear medicine can do for and tracheal obslruction to external-beam radiotherapy. Am J Med
you and your patients: A scientific exhibit. Dept. of Nuclear Medicine, 90:753-757,1991.
Penrose Hosp. Colorado Springs, Colorado. Williams ED, Doniach I, et al: Thyroid cancer in an iodide-rich area.
Vickery AL: Thyroid papillary carcinoma: Pathological and philosophical Cancer 39:215-220,1997.
controversies. Am J Surg Pathol 7:797-807, 1983. Winship T, Rosvoll RV: Childhood thyroid carcinoma. Cancer 14:
Vickery AL Jr, Carcangiu ML, Johannessen JV, Sobrinho-Simoes M: 734-743, 1961.
Papillary carcinoma. Semin Diagn Pathol 2:90-100, 1985. Woolner LB: Thyroid carcinoma: Pathologic classification with data
Vieira AE, Mello MP, Elias LL, et al: Molecular and biochemical on prognosis. Semin Nucl Med 1:481-502, 1971.
screening for the diagnosis and management of medullary thyroid Woolner LB, et al: Classification and prognosis of thyroid carcinoma:
carcinoma in multiple endocrine neoplasia type 2A. Horm Metab A study of 885 cases observed in a thirty-year period. Am J Surg
Res 34:202-206, 2002. 102:354-387, 1961.
Volpe R: The thyroid nodule: An approach to management. J Otolaryngol Work WP: Unusual position of the right recurrent laryngeal nerve.
12:107-108, 1983. Ann Otol 50:769-775, 1941.
Volpe R, Johnston MW: Subacute thyroiditis: A disease commonly Wyse EP, Hill CS, Ibanez NL, Clark RL: Other malignant neoplasms
mistaken for pharyngitis. Can Med Assoc J 77:297, 1957. associated with carcinoma of the thyroid: Thyroid carcinoma
Wagner DH, Recant WM, Evans RH: A review of 150 thyroidectomies multiplex. Cancer 24:701-708,1969.
following prior irradiation to the head, neck and upper part of the Yagi Y, Yagi S, Saku T: The localization of cytoskeletal proteins and
chest. Surg Gynecol Obstet 147:903-908, 1978. thyroglobulin in thyroid mucocarcinoma in comparison with clini-
Wanebo HJ, Andrews W, Kaiser DL: Thyroid cancer: Some basic cally manifested thyroid carcinoma. Cancer 56: 1967-1971, 1985.
considerations. Am J Surg 142:474-479, 1981. Young JL, Percy CL, Asire AJ: Surveillance, epidemiology, and end
Ward GE, et al: The surgical treatment of lingual thyroid. Ann Surg results, incidence and mortality data, 1973-1977. Natl Cancer Inst
139:546,1954. Monogr 57:1-1082, 1981.
Ward PH: Complications of thyroid surgery: Their prevention, recog-
Parathyroid
nition and management. Head Neck Cancer 1:247-251. 1985.
Ward PH, Strahan RW, Acquarelli M, Harris PF: The many faces of Ackerman NB, Winer N: Evaluation of methods for localizing
cysts of the thyroglossal duct. Trans Am Acad Ophthalmol Otolaryngol parathyroid tumors. Am J Surg 122:669-673, 1971.
74:310-318, 1970. Ackerstrom G, Malmaeus J, Bergstrom R: Surgical anatomy of human
Wegelin C: Malignant disease in thyroid gland and its relation to parathyroid glands. Surgery 95:14-21,1984.
goiter in man and animals. Cancer Rev 3:297, 1928. Ackerslrom G, Rudberg C, Grimelius L, et al: Histologic parathyroid
Wells SA Jr, Baylin SB, Gann OS, et al: Medullary thyroid carcinoma: abnormalities in an autopsy series. Hum Pathol 17:520-527, 1986.
Relationship of method of diagnosis to pathologic staging. Ann Albertson DA, Marshall RB, Jarman WT: Hypercalcemic crisis
Surg 188:377-383, 1978. secondary to a functioning parathyroid cyst. Dept of Surg Bowman
Wells SA Jr, Haagensen DE, Linehan WM, et al: The detection of Gray School of Med 141:175-177, 1981.
elevated plasma levels of carcinoembryonic antigen in patients Aldinger KA, Hickey RC, Ibanez ML, Samaan NA: Parathyroid carci-
with suspected or established medullary thyroid carcinoma. Cancer noma: A clinical study of seven cases of functioning and two cases
42:1498-1503, 1978. of nonfunctioning parathyroid carcinoma. Cancer 49:388-397,-
Wells SA Jr, Baylin SB, Johnsrude IS, et al: Thyroid venous catheterization 1982.
in the early diagnosis of familial medullary thyroid carcinoma. AI-Jurf A, Esselstyn CB, Crile G Jr: Thyroid lesions in patients with
Ann Surg 196:505-511, 1982. hyperparathyroidism. Int Surg 64(4):33-36, 1979.
Wells SA Jr, Baylin SB, Leight GS, et al: The importance of early diag- Anderson BJ, Samaan NA, Vassilopoulou-Sellin R, et al: Parathyroid
nosis in patients with hereditary medullary thyroid carcinoma. carcinoma: Features and difficulties in diagnosis and management.
Ann Surg 195:595-599, 1982. Surgery 94:906-915, 1983.
Wells SA Jr, Baylin SB, Linehan WM, et al: Provocative agents and Arici C, Cheah WK, Ituarte PH, et al: Can localization studies be used
the diagnosis of medullary carcinoma of the thyroid gland. Ann to direct focused parathyroid operations? Surgery 129:720-729,
Surg 188:139-141, 1978. 2001.
Wells SA Jr, Ontjes DA, Cooper CW, et al: The early diagnosis of Attie IN, Khafif RA: Preservation of parathyroid glands during total
medullary carcinoma of the thyroid gland in patients with multiple thyroidectomy. Am J Surg 130:399-404, 1975.
endocrine neoplasia type II. Ann Surg 182:362-370, 1975. Axelrod OM, et al: Distinguishing features of primary hyperparathy-
Wenig BM, Thompson LOR, Adair CF, et al: Thyroid papillary carci- roidism in patients with breast cancer. Cancer 60: 1620-1624, 1987.
noma of columnar cell type: A clinicopathologic study of 16 cases. Barnes B, Cope 0: Carcinoma of the parathyroid glands. JAMA
Cancer 82:740-753, 1998. 178:556-559, 1961.
Werk E, Vernon 8M, Gonzalez J, et al: Cancer in thyroid nodules. Bashour T, Basha HS, Cheng TO: Hypocalcemic cardiomyopathy.
Arch Intern Med 144:474-475, 1984. Chest 78:663-665, 1980.
Wessler S, Avioli LV (eds) and Ogura J (discussant): Surgical approach Beahrs OH, Edis AJ, Purnell DC: Unusual problems in parathyroid
to the ophthalmopathy of Graves' disease. JAMA 216:1627-1631. surgery. Am J Surg 134:502-504,1977.
1971. Beahrs OH, Kiernan PO, Hubert JP: An Atlas of the Surgical Tech-
White IL: Total thyroid ablation: A prerequisite to orbital decompression niques of Oliver H. Beahrs. Philadelphia, WB Saunders, 1985.
for Graves' disease ophthalmopathy. Laryngoscope 84:1869-1875, Biller HF, Strashun A, Goldsmith SJ, Bergman 0: Preoperative parathy-
1974. roid adenoma localization by the technetium-thallium subtraction
Whybrow PC, Prange AJ Jr, Treadway CR: Mental changes accompany scan. Laryngoscope 96: 1363-1365, 1986.
thyroid gland dysfunction. Arch Gen Psychiatry 20:48-63, 1969. Bland KI, Tidwell S, von Fraunhofer JA, et al: Intraoperative localiza-
Widstrom A, Megnusson P, Hallberg 0, et al: Adenocarcinoma tion of parathyroid glands using methylthionine chloride/tetra-
originating in the thyroglossal duct. Ann Otol Rhinol Laryngol methylthionine chloride in secondary hyperparathyroidism. Surg
85:286, 1976. Gynecol Obstet 160:42-48, 1985.
Wilford MR, Chertow BS, Lepanto PB, Leidy JW Jr: Dramatic response Block MA: Hyperparathyroidism: Progress in meeting the surgical
of follicular thyroid carcinoma with superior vena cava syndrome challenge. Am J Surg 120:332-333, ]970.
 ENDOCRINE SURGERY
Block MA, Frame B, Jackson CEoThe efficacy of subtotal parathy-
roidectomy for primary hyperparathyroidism due to multiple gland
involvement. Surg Gynecol ObstetI47:1-5, 1978.
Block MA, Jackson CE, Tashjian AH: Management of parathyroid glands
in surgery for medullary thyroid carcinoma. Arch Surg 110:617-624,
1975.
Bohannan NJ, Reitz RE, Hauer SO, Wang C: Management of acute
hyperparathyroidism in a community hospital. JAMA 246:1334-1336,
1981.
Bondeson AG, Bondeson L, Ljungberg 0, Tibblin S: Fat staining
in parathyroid disease-diagnostic value and impact on surgical
strategy: Clinicopathologic analysis of 191 cases. Hum Pathol
16:1255-1263, 1985a.
Bondeson AG, Bondeson L, Ljungberg 0, Tibblin S: Surgical strategy
in non-familial primary parathyroid hyperplasia: Long-term
follow-up of thirty-nine cases. Surgery 97:569-573, 1985b.
Brennan MF, Brown EM, Spiegel AM, et al: Autotransplantation of cryo-
preserved parathyroid tissue in man. Ann Surg 189:139-143, 1979.
Brewer WH, Walsh JW, Newsome HH: Impact of sonography on
surgery for primary hyperparathyroidism. Am J Surg 145:270-272,
1983.
Buckwalter JA, Soper RT, Davies J, Mason EE: Postoperative hypo-
parathyroidism. Surg Gynecol Obstet 101:657-666, 1955.
Bukowski RM, Sheeler L, Cunningham J, Esselstyn C: Successful
combination chemotherapy for metastatic parathyroid carcinoma.
Arch Intern Med 144:399-400, 1984.
Burnett HF, Thompson BW, Barbour GL: Parathyroid autotransplan-
tation. Arch Surg 112:373-379, 1977.
Cabatin AR, Young RL, Schenk 0: Parathyroid cysts, medical diagnosis
and therapy. South Med J 75:1138-1140, 1982.
Calandra DB, Chejfec G, Foy BK, et al: Parathyroid carcinoma:
Biochemical and pathologic response to OTIC.Surgery 96:1132-1137,
1984.
Calandra DB, Shah KH, Frinz RA, et al: Parathyroid cysts: A report of
eleven cases including two associated with hyperparathyroid crises.
Surgery 94:887-892, 1983.
Carnevale N, Samson R, Bennett BP: Multiple parathyroid adenomas.
JAMA 246: 1332-1334, 1981.
Carroll PR, Clark OH: Milk alkali syndrome: Does it exist and can it
be differentiated from primary hyperparathyroidism? Ann Surg
197:427-433, 1983.
Castleman B, Roth SI: Thmors of the parathyroid glands. In: Atlas of
Tumor Pathology. Washington, DC, Armed Forces Institute of
Pathology, 1978, pp 74-82.
Castleman B, Schantz A, Roth SI.: Parathyroid hyperplasia in primary
hyperparathyroidism. Cancer 38:1668-1675, 1976.
Chahinian AP: Chemotherapy for metastatic parathyroid carcinoma.
Arch Intern Med 144:1889, 1984.
Chakrabarti S, Murugesan A. Arida EJ: The association of neurofibro-
matosis and hyperparathyroidism. Am J Surg 137:417-420, 1979.
Chan JC, DeLuca HR: Calcium and parathyroid disorders in children:
Chronic renal failure and treatment with calcification. JAMA
241:1242-1243, 1979.
Clark OH: Endocrine Surgery of the Thyroid and Parathyroid Glands.
St. Louis, CV Mosby, 1985.
Coffey RJ, Lee TC, Canary JJ: The surgical treatment of primary hyper-
parathyroidism: A 20-yearexperience. Ann Surg 185:518-523, 1977.
Cohn K, Silverman M, Corrado J, Sedgwick C: Parathyroid carcinoma:
The Lahey Clinic experience. Surgery 98:1095-1099,1985.
Collier VU, Mitch WE: Accelerated progression of chronic renal insuf-
ficiency after parathyroidectomy. JAMA 244:1215-1218,1980.
Cope 0: Hyperparathyroidism: Diagnosis and management. Am J
Surg 99:394, 1960.
Cordell U, Maxwell JG, Warden GO: Parathyroidectomy in chronic
renal failure. Am J Surg 138:951-956, 1979.
Curtis GM: The blood supply of the human parathyroids. Surg Gynecol
Obstet 51:805, 1930.
Davis PJ, Davis FB: Diagnosis of hyperparathyroidism. Otolaryngology
93:62-64, 1985.
Diethelm AG, et al: Treatment of secondary hyperparathyroidism in
patients with chronic renal failure by total parathyroidectomy and
parathyroid autograft. Ann Surg 193:777-793, 1981.
DiGiulio W, Morales JO: The value of the selenomethionine Se 75
scan in preoperative localization of parathyroid adenomas. JAMA
209:1873-1880,1969.
Doppman JL, Hammond WG, Nelson GL, et al: Staining of parathy-
roid adenomas by selective arteriography. Radiology 92:527,1969.
Doppman JL, Marx SJ, Spiegel AM, et al: Treatment of hyperparathy-
roidism by percutaneous embolization of a mediastinal adenoma.
Radiology 115:37-42, 1975.
Dorman EB, Yang FH, Vaughan CW, et al: The incidence of hypercal-
cemia in squamous cell carcinoma of the head and neck. Head
Neck Surg 7:95-98, 1984.
Dubost C, Jehanno C, Lavergne A, Charpentier YL:Successful resection
of intrathoracic metastases from two patients with parathyroid
carcinoma. World J Surg 8:547-551, 1984.
Earll JM, Cohen A, Lundberg GO: Functional cystic parathyroid
adenoma. Am J Surg 118:100-103, 1969.
Egdahl RH: New methods in the diagnosis and treatment of hyper-
parathyroidism. CMD, April 1969, pp 277-289.
Egdahl RH: Surgery of the parathyroid glands. Surg Gynecol Obstet
130:901-909, 1971.
Esselstyn CB Jr: Personal communication, 1971.
Fahey TJ, Myers WPL: Documented hyperparathyroidism of thirty-six
years' duration. Cancer 35:803-807, 1975.
Fahraeus B, Anderson L, Bergdahl L, Westling P: Postoperative hypo-
parathyroidism. Acta Chir Scand 139:437-441, 1973.
Fallon MD, Hames JW, Teitelbaum SL: Cystic parathyroid gland hyper-
plasia, hyperparathyroidism presenting as a neck mass. Am J Clin
Pathol 77:104-107, 1982.
Feind CR: Autogenous parathyroid transplantation. Presented at the
Society of Head and Neck Surgeons Meeting, Vancouver, British
Columbia, May 1971.
Fitko R, Roth Sl, Costa JC, Marx SJ: Parathyromatosis in hyper-
parathyroidism. Hum Pathol 21:234-237, 1990.
Flye MW, Brennan MF: Surgical resection of metastatic parathyroid
carcinoma. Ann Surg 193:425-435, 1980.
Friedman M, Mafee MF, Shelton VK, et al: Parathyroid localization
by computed tomographic scanning. Arch Otolaryngol 109:95-97,
1983.
Fujimoto Y, Obara T, Ito Y, et al: Surgical treatment of ten cases of
parathyroid carcinoma: Importance of an initial en bloc tumor
resection. World J Surg 8:392-400, 1984.
Fujimoto Y,Obara T, Ito Y,et al: Localization and surgical resection of
metastatic parathyroid carcinoma. World J Surg 10:539-547, 1986.
Fujimoto Y, Obara T: How to recognize and treat parathyroid carci-
noma. Surg Clin North Am 67:343, 1987.
Gavilan J, Gavilan C, Thomas MD: Methylene blue infusion for intra-
operative identification of the parathyroid glands. Laryngoscope
96:1389-1390,1986.
Gilmour JR: The embryology of parathyroid glands, thymus and certain
associated remnants. J Pathol Bacteriol 45:507-522, 1937.
Gordon A, Harcourt-Webster IN: Parathyroid cysts: A report of two
cases. J Pathol BacterioI89:374-377, 1965.
Granberg P, Johansson G, Lindvall N, et al: Reoperation for primary
hyperparathyroidism. Am J Surg 143:296-300, 1982.
Gray SW, Skandalakis JE: Embryology for Surgeons. Philadelphia,
WB Saunders, 1972.
Gremillion DH, Kee JW, Mcintosh DA: Hyperparathyroidism and
medullary sponge kidney: A chance relationship? JAMA 237:
799-800, 1977.
Grimelius L, Ackerstrom G, Johansson H, Bergstrom R: Anatomy and
histopathology of human parathyroid glands. Pathol Annu 16:
1-24,1981.

Haar JG, Boulos EJ: Primary hyperparathyroidism and laryngeal carci-
noma: A cause of associated hypercalcemia. Laryngoscope 91:
1937-1940,1981.
Haff RC, Black WC, Ballinger WF II: Primary hyperparathyroidism:
Changing clinical, surgical and pathologic aspects. Ann Surg
171:85-92, 1970.
Halsted WS, Evans HM: The parathyroid glands: Their blood supply
and their preservation in operations upon the thyroid gland. Ann
Surg 46:489, 1907.
Hardy 10, Snavely JR, Landford HG: Low intrathoracic parathyroid
adenoma. Ann Surg 159:310, 1964.
Harold CC, Wright J: Management of surgical hypoparathyroidism.
Am J Surg 112:482-487, 1966.
Harris MN, Basuk R, Rosses DF, et al: Mixed parathyroid thymic cyst.
NY StateJ Med 81:1657-1659,1981.
Harrison TS, Duarte B, Reitz R, et al: Primary hyperparathyroidism:
4- to 8-year postoperative follow-up demonstrating persistent
functional insignificance of microscopic parathyroid hyperplasia
and decreased autonomy of parathyroid hormone release. Ann Sueg
194:429-437, 1981.
Hayes JF, Gross GF, Schuman ES: Surgical management of renal hyper-
parathyroidism in the dialysis patient. Am J Surg 143:569-571, 1982.
Hedley AJ, et al: Prevalence of recurrent hyperthyroidism after sub-
total thyroidectomy for Graves' disease. BMJ 4:258, 1971.
Hedman I, Tisell L: Autotransplantation of fresh diseased parathyroid
tissue in primary and radiation-induced hyperparathyroidism. Am
J Surg 143:614-618, 1982.
Hoehn JG, Beahrs OH, Woolner LB: Unusual surgical lesions of the
parathyroid gland. Am J Surg 118:770-778, 1969.
Hollinshead WH: Anatomy for Surgeons, Vol 1, The Head and Neck,
4th ed. New York, Hoeber-Harper, 1985.
Holmes EC, Morton DL, Ketcham AS: Parathyroid carcinoma: A
collective review. Ann Surg 169:631, 1969.
Hutter RVP,Frazell EL, Foote FW: Elective radical neck dissection: An
assessment of its use in the management of papillary thyroid
cancer. CA 20:86-93, 1970.
Irvin GL Ill, Dembrow VD, Prudhomme DL: Operative monitoring
of parathyroid gland hyperfunction. Am J Surg 162:299-302, 1991.
Isaacson SR, Lowry LD, Snow JB: Hypoparathyroidism secondary to
surgery for carcinoma of the pharynx and larynx. Trans Am Acad
Ophthalmol Otolaryngol 84:0RL584-59I, 1977.
Johnson JW, Hattner RS, Hampers C, et al: Secondary hyperparathy-
roidism in chronic renal failure. JAMA 215:478-482, 1971.
Johnson RD, Conn JW: Hyperparathyroidism with a prolonged period
of normocalcemia. JAMA 210:2063-2066, 1969.
Joseph MP, Nadol JB, Pilch BZ, Goodman ML: Ectopic parathyroid
tissue in the hypopharyngeal mucosa (pyriform sinus). Head Neck
Surg 5:70-74,1982.
Katz AD: Parathyroid autotransplantation in patients with parathy-
roid disease in total thyroidectomy: Indications in 117 cases. Am J
Surg 142:490-493, 1981.
Kelly TR, Falor WH: Hyperparathyroid crisis associated with pancreatitis.
Ann Surg 168:917-920, 1968.
Klein E, YelinA, Ben-Ari G: Parathyroid cyst and hyperparathyroidism.
Int Surg 64:79-81, 1979.
Krementz ET, Race JL, Sternberg WH, Hawley WD: Parathyroid ade-
noma: Problems in diagnosis and management. Ann Surg 165:
681-695,1967.
Krementz ET, Yeager R, Hawley W, Weichert R: The first 100 cases of
parathyroid tumor from Charity Hospital of Louisiana. Ann Surg
173:872-883,1971.
Krull GH, et al: Venous-compression test in hyperparathyroidism.
Lancet 2:174-177,1969.
Kurtay M, Crile G Jr: Aberrant parathyroid glands in relationship to
the thymus glands. Am J Surg 117:705,1969.
Latimer RG, Renning J, Stevens LE, et al: Tertiary hyperparathyroidism
following successful renal allografting. Ann Surg 172:137-141,1970.
ENDOCRINE SURGERY
Le HN, Norton JA: Surgical management of hyperparathyroidism. In
DeGroot U, Jameson JL (eds): Endocrinology, 4th ed, vol 2.
Philadelphia, WB Saunders, 2001, chap 79.
Linos DA, van Heerden JA, Edis AJ: Primary hyperparathyroidism
and nonmedullary thyroid cancer. Am J Surg 143:301-303, 1982.
Lore JM Jr, Chakar S, Montes M: Parathyroid adenomas causing vocal
cord paralysis. Trans Am Acad Ophthalmol OtolaryngoI76:1397-140l,
1972,
Lore JM Jr, Pruet CW: Retrieval of the parathyroid glands during
thyroidectomy. Head Neck Surg 5:268-269, 1983.
Lore JM Jr, Staggers-Deberney J, Farrell M, et al: Approach to supe-
rior mediastinal parathyroid adenomata via resection of the medial
third of the clavicle: Operative techniques. Otolaryngol Head Neck
Surg 11:216-220, 2000.
MacFarlane SD, Hanelin LG, Taft DA, et al: Localization of abnormal
parathyroid glands using thallium-201. Am J Surg 148:7-13, 1984.
McGarity WC, Goldman AL: Reoperation for primary hyperparathy-
roidism. Ann Surg 194:134-139, 1981.
McGarity WC, Matthews WH, Fulenwider JT, et al: The surgical man-
agement of primary hyperparathyroidism: A personal series. Ann
Surg 193:794-804, 1981.
McKeown PP, McGarity WC, Sewell CW: Carcinoma of the parathy-
roid gland: Is it overdiagnosed? Am J Surg 147:292-297, 1984.
Mallette LE, Eisenberg KL, Schwaitzberg SD, Noon GP: Factors that
influence the assessment of parathyroid graft function. Ann Surg
199:192-196, 1984.
Mallette LE, Eisenberg KL, Schwaitzberg SD, et al: Total parathy-
roidectomy and autogenous parathyroid graft placement for treat-
ment of hyperparathyroidism due to chronic renal failure. Am J
Surg 146:727-733, 1983.
Mannix H Jr, Loehr WJ: Unusual aspects of hyperparathyroidism. Surg
Gynecol Obstet 126:347-351, 1968.
Marks C: Hyperparathyroidism and its clinical effects. Am J Surg
116:40-48, 1968.
Marx SJ, Spiegel AM, Brown EM, et al: Circulating parathyroid hor-
mone activity: Familial hypocalciuric hypercalcemia versus typical
primary hyperparathyroidism. J Clin Endocrinol Metab 47: 1190-1196,
1978.
Matsuura H, Sako K, Marchetta FC: Successful reimplantation of
autogenous parathyroid tissue. Am J Surg 118:779-782, 1969.
Max MH, Flint LM, Richardson JD, et al: Total parathyroidectomy
and parathyroid autotransplantation in patients with chronic renal
failure. Surg Gynecol Obstet 153:177-180, 1981.
Maxwell DB, Horn RCJr, Rhoads JE: Cysts of parathyroid. Arch Surg
64:208-213, 1982.
Miyauchi A, Kakudo K, Fujimoto T, et al: Parathyroid cyst: Analysis
of the cyst fluid and ultrastructural observations. Arch Pathol Lab
Med 105:497-499, 1981.
Myers RT, Bhatti A: Peptic ulcer and parathyroid adenoma. Ann Surg
171:647-655,1970.
Nathaniels EK, Nathaniels AM, Wang C-A: Mediastinal parathyroid
tumors: A clinical and pathological study of 84 cases. Ann Sueg
171:165-170,1970.
Neumann DR, Esselstyn CB, Eastwood J, et al: Localization of medi-
astinal parathyroid adenoma in recurrent postoperative hyper-
parathyroidism with Tc-99 Sestamibi (SPECT). Clin Nucl Med
20:175,1995.
Neumann DR, Esselstyn CB, Go RT,et al: Comparison of double-phase
99m-Tc sestamibi with 123199mTc-sestamibi subtraction SPECT in
hyperparathyroidism. AJR Am J RoentgenoI169:1671-1674, 1997.
Norman J, Denham D: Minimally invasive radio-guided parathy-
roidectomy in the reoperative neck. Surgery 124:1088-1093, 1998.
Pacini F, et al: Unsuspected parathyroid cysts diagnosed by measure-
ment of thyroglobulin and parathyroid hormone concentrations in
fluid aspirates. Ann Intern Med 102:793-794, 1985.
Page AV,Burke ML, Melzger WT: Parathyroid cysts. Am Surg 50:29-32,
1984.
 ENDOCRINE SURGERY

Paloyan E: Endocrine Surgery. Chicago, Year Book Medical, 1976. Sivula A, Ronni-Sivula H: Natural history of treated primary hyper-
Paloyan E, Lawrence AM: Primary hyperparathyroidism: Pathology parathyroidism. Surg Clin North Am 67:329, 1987.
and therapy. JAMA 246: 1344, 1981. Spiegel AM, et al: Parathyroid function after parathyroidectomy:
Payne JE, Tanenberg RJ: Hyperparathyroid crisis and acute necro- Evaluation by measurement of urinary and cAMP clinical
tizing pancreatitis presenting as diabetic ketoacidosis. Am J Surg endocrinology. 15:65-73,1981.
140:698-702, 1980. Sudhaker DR, et al: Hyperparathyroidism following head and neck
Petersen P: Psychiatric disorders in primary hyperparathyroidism. irradiation. Arch Intern Med 140:20S-207, 1980.
J Clin Endocrinol 28:1491-]495, 1968. Tashjian AH, Wolfe HJ, Voelkel EF: Human calcitonin. Am J Med
Pelti GH, Linda L: Hyperparathyroidism: A study of 100 cases. 56:840-849, 1974.
Otolaryngol Head Neck Surg 90:413-418, 1982. Thacker WC, Wells VH, Hall ER Jr: Parathyroid cyst of the medi-
Prinz RA, et al: Radiation-associated hyperparathyroidism: A new astinum. Ann Surg 174:969-975, 1971.
syndrome? Surgery 82:296-302, ] 977. Thompson GB, Mullan BP, Grant CS, et al: Parathyroid imaging with
Prinz RA, Paloyan E, Lawrence AM, et al: Unexpected parathyroid technetium-99m-sestamibi: An initial institutional experience.
disease discovered at thyroidectomy in irradiated patients. Am J Surgery 116:966-973, 1994.
Surg 142:355-357, 1981. Tibblin S, et al: Surgical strategy in hyperparathyroidism due to
Rastad J, Johansson H, Lindgren PG, et al: Ultrasonic localization solitary adenoma. Ann Surg 280:776-784, 1984.
and cytologic identification of parathyroid tul1)ors. World J Surg Tibblin S, Bondeson A, Ljungberg 0: Unilateral parathyroidectomy
8:501-508, 1984. in hyperparathyroidism due to single adenoma. Ann Surg 195:
Reeve TS, Delbridge LW: Pancreatitis following parathyroid surgery. 245-252, 1982.
Ann Surg 195:158-162, 1982. Van Heerden JA, James EM, Karsell PR, et al: Small-part ultrasonog-
Rienhoff WF Jr, Rienhoff WF III, Brawley RK, Shelly WM: The sur- raphy in primary hyperparathyroidism. Ann Surg 195:774-780, 1982.
gical treatment of hyperparathyroidism. Ann Surg ] 68: 1061-1074, Wang C: The anatomic basis of parathyroid surgery. Ann Surg 183:
1968. 271-275, 1975.
Rogers LA, Felter BA, Piete PJ: Parathyroid cyst and genetic degenera- Wang C: Parathyroid re-exploration. Ann Surg 186:140-145, 1977.
tion of parathyroid adenoma. Arch Pathol 88:476-479, 1979. Wang C: Hyperparathyroid crisis. Ann Surg 190:782-790, 1979.
Rosen IB, et al: A case of hyperparathyroidism associated with radia- Wang C, Castleman B, Cope 0: Surgical management of hyperparathy-
tion to the head and neck area. Cancer 36:1111-1114,1975. roidism due to primary hyperplasia. Ann Surg 195:384-392, 1982.
Rosenberg J, Orlando R, Ludwig M, Pyrtek U: Parathyroid cysts. Am Wang C, Randall DG: Natural history of parathyroid carcinoma, diag-
J Surg 143:473-480, 1982. nosis, treatment and results. Am J Surg 149:522-527, 1985.
Rothmund M, Wagner PK: Assessment of parathyroid graft function Wang C, Reitz RE, Pollard JJ, et al: Localization of hyperfunctioning
after autotransplantation of fresh and cryopreserved tissue. World parathyroids: The surgeon's riddle. Am J Surg 119:462-464, 1970.
J Surg 8:527-533, 1984. Wang C, Rieder SV: A density test for the intraoperative differentiation
Rothmund M, Wagner PK: Total parathyroidectomy and autolrans- of parathyroid hyperplasia from neoplasia. Ann Surg 187:63-67,
plantation of parathyroid tissue for renal hyperparathyroidism: A 1978.
1- to 6-year follow-up. Ann Surg 197:7-16, 1983. Wang C, Vickery AL Jr, Maloof F: Large parathyroid cysts mimicking
Russell CF, Edis AJ, Scholz DA, et al: Mediastinal parathyroid tumors. thyroid nodules. Ann Surg 175:448-453, 1972.
Ann Surg 193:805-809,1981. Warren MM, Utz DC, Kelalis PP: Concurrence of hypernephroma and
Sadeghi-Nejad A, Wolfsdorf JI, Senior B: Hypoparathyroidism and hypercalcemia. Ann Surg 174:863-865, 1971.
pregnancy. JAMA 243:254-255, 1980. Weiland LH, Garrison RC, Remine WH, Scholz DA: Lipoadenomas of
Schantz A, Castleman B: Parathyroid carcinoma-A study of 70 cases. the parathyroid gland. Am J Surg Pathol 2:3-7,1978.
Cancer 31 :600-605, 1973. Wells SA: The parathyroid glands. In Sabiston DB Jr (ed): Textbook
Schweitzer VG, Thompson NW, Clark KA, et al: Sarcoidosis, hypercal- of Surgery. Philadelphia, WB Saunders, 1981.
cemia and primary hyperparathyroidism. Am J Surg 142:499-503, Wells SA, Farndon JR, Dale JK, et al: Long-term evaluation of patients
1981. with primary parathyroid hyperplasia managed by total parathy-
Seldinger SI: Localization of parathyroid adenomata by arteriography. roidectomy and heterotopic autotransplantation. Ann Surg 192:
Acta Radiol 42:353, 1954. 451-458, 1980.
Setton HV, Kupperman HS: Normal parathyroid hormone levels with Wells SA, Gunnells JC, Gutman RA, et al: The successful transplan-
primary hyperparathyroidism. NY State J Med 79:2071-2072, 1979. tation of frozen parathyroid tissue in man. Surgery 81 :86-90, 1980.
Shane E, Belezikian jp: Parathyroid carcinoma: A review of 62 patients. Wells SA Jr, Leight GS, Ross AJ: Primary hyperparathyroidism. CUfr
Endocr Rev 3:218-226,1982. Probl Surg 17:1,1980.
Sharp CF, Rude RK, Terry R, Singer FR: Abnormal bone and parathy- Wells SA, Ross AS, Dale JK, et al: Transplantation of the parathyroid
roid histology in carcinoma patients with pseudohyperparathy- glands: Current status. Surg Clin North Am 59:167-177,1979.
roidism. Cancer 49:1449-1455,1982. Wolpert HR, Vickery AL Jr, Vang CA: Functioning oxyphilic adenomas
Sisson GA, Vander Aarde SB: Control of hypoparathyroidism after of the parathyroid gland-A study of 15 cases. Am J Surg Pathol
extensive neck surgery. Arch OtolaryngoI93:249-255, 1971. 13:500-504,1989.
 19 THE TRACHEA AND
MEDIASTINUM

Tracheoscopy is visualization of the lumen of the

trachea; a tracheotomy is opening the trachea for
whatever reason and then closing it at the same time;
tracheostomy is performing a semi-permanent or per-
manent opening into the tracheal lumen.
Tracheoscopy
The trachea can be examined using a rigid (see Fig. 4-3A
to C) or flexible (see p. 192) bronchoscope, but specific
magnified visualization and biopsy of tracheal lesions
may be better achieved utilizing the instruments depicted
in Figures 4-1 and 4-7. In addition, tracheoscopy can
be performed through a preexisting tracheostomy site
utilizing the 70-degree Lore-Karl Storz Hopkins rod
scope, which is used for endoscopic visualization of
the nasopharynx (see Fig. 4-1B; the scope is removed
from the biopsy forceps). This type of instrument can
be rotated 180 degrees for visualization of the trachea
both proximal and distal to the site of the tracheostomy.
The vocal cords can likewise be seen proximally. This
is a very handy method for evaluation of vocal cord
function when the supraglottic airway is compromised.
The 70-degree sinus endoscope can also be used.
Tracheostomy (Fig. 19-1)
Selection of Tracheostomy Tube (Table 19-1)
Various types and sizes of tracheostomy tubes are
available: metal, in silver or stainless steel, plastic, and
rubber. These last two have the advantage of being able
to be shortened easily if necessary. Each has its own
advantages and disadvantages. Most are available with
an inner tube with anesthesia adaptors (see Fig. 20-18A
to E). It is most important, especially in children, that
the proper length and proper curve be chosen.
There are potential problems with plastic tubes in
infants and children because the smaller-diameter tubes
cannot be manufactured with an inner tube to allow for
proper cleaning. Hence, for children, the author prefers
the assorted sizes of Holinger silver tubes over the plastic
Portex tubes. The Holinger silver tubes are all equipped
with inner tubes for proper cleaning.
In an emergency a small endotracheal tube can be
split vertically down to the cuff or near the cuff. These
two halves can then be turned and folded laterally,
right and left, to serve as an emergency tracheostomy
tube.

TABLE 19-1 Guide for Selection of Suitable Thacheostomy 'fubes and Bronchoscopes

Instrument Child's Age Size of Instrument

Holinger Premature ( < 4 Ib) No. 000 x 26 mm

tracheostomy tube Premature (> 4 Ib) No. 00 x 26 to 33 mm
a to 6 mo No. ax 33 to 40 mm
6 to 12 mo No. 1 x 40 to 46 mm
12 to 18 mo No.1 x 46 mm
18 mo to 4 to 5 yr No.1 or No.2 x 46 to 50 mm
4 to 5 yr to 10 yr No.2 or No.3 x 50 to 55 mm
10 yr + No.3 or No.4 or No.5 x 50 to 68 mm
Bronchoscope < 5 Ib 3 mm
a to 6 mo 3.5 mm
6 mo to 3yr 4mm
3 to 12 yr 5 mm
12 yr + 6 mm

From Fearon B, Ellis 0: The management of the long-term airway problem in infants and children. Ann Olal Rhinal
Laryngol 669:80, 1971.

1015
 THE TRACHEA AND MEDIASTINUM
Another emergency adaptation of endotracheal
tubes occurs when the obstruction is in the region of
the mediastinal trachea and the "cane" tracheostomy
tube does not suffice because of a tortuous trachea. In
this case the use of two endotracheal tubes, one inside
the other, can serve as a very adequate arrangement as
a tracheostomy tube. The inner endotracheal tube can
be removed for cleaning.
Another problem associated with tracheostomy
tubes is the possibility that they may rest against an
anomalous great vessel. This can be readily detectable
after the tracheostomy tube is inserted by the marked
pulsations of the tracheostomy tube. Such a situation
can lead to a potential disaster because erosion of the
trachea and thence the great vessel may occur. Some-
times shortening the length of the tracheostomy tube
may alleviate this problem. If this does not suffice, the
metal tube must be replaced by a plastic or rubber
tube. If pulsations transmitted to the tracheostomy tube
continue, the use of a very soft nasopharyngeal tube
works admirably. This tube, however, does not have an
inner tube, and it must be cleaned very carefully and
may have to be changed every 24 to 48 hours to prevent
crusting.
Cuffs on tracheostomy tubes should only be inflated
when closed systems are necessary to ventilate a patient.
The inflated cuffs on either a tracheostomy tube or an
endotracheal tube are the main sources of tracheal
stenosis, and although various low-pressure cuffs and
devices have been designed, an ideal cuff is lacking.
The cuffs should be periodically deflated and, when
inflated, should be inflated with only enough pressure
to close the leak-the minimal leak technique (Lajos,
1971). This pressure varies from patient to patient and
may vary from hour to hour in the same patient. To
determine the minimal leak, place a stethoscope above
the site of the tracheostomy tube. This method allows
for the minimal leak to be easily detected.
Size diameters, although marked with the same
number, may actually vary from manufacturer to manu-
facturer. The Portex tube has a certain amount of flexi-
bility and in addition has various types of adaptation
that are so often needed in a tracheostomy. For example,
the tracheostomy related to an external compression of
the trachea by an anomalous great vessel is best handled
with a tube with some flexibility because of the danger
of erosion and fatal hemorrhage. The Portex tube is
numbered different than the basic metal tracheostomy
tubes. For example, a NO.8 Portex is comparable to a
NO.6 metal tube. When possible, a metal tube often is
preferable to any type of a plastic tube because the
inside diameter is comparably larger in reference to the
outside diameter, because the metal is much thinner
than the plastic tubes available at this time. An advan-
tage of a plastic tube is that it can be modified in length
by simply cutting off the excess portion and then care-
fully rounding the cut edges with heat. The exposure in
the accompanying plates is copious for the purpose of
clarity. Ordinarily, a much more limited exposure is
utilized.
"Anterior cricoid split" (Cotton, 1980) in infants and
children to avoid tracheostomy after extubation has
been reported by Holinger and colleagues (1987) with
a 77 % success rate. In this procedure an anterior inci-
sion is made through the thyroid cartilage commencing
2 mm distal to the thyroid notch and then through
the cricoid cartilage and the first and second tracheal
rings.
Highpoints
I. Hyperextend the head and neck except in patients
with cervical spine injuries and following suboc-
cipital craniectomy.
2. Enter the trachea through the second, third, or
fourth tracheal ring.
3. Always remove a small section of the tracheal ring
before insertion of the tracheostomy tube.
4. Always suture the flange of tube to skin.
5. In a dire emergency (see the section in Chapter 2
on management of acute respiratory emergencies)
other methods of establishing an airway are faster,
depending on equipment available. For example,
direct laryngoscopy with insertion of an endotra-
cheal tube or bronchoscope is usually more rapid
and then permits a more leisurely tracheostomy. A
nasotracheal tube made of any type of tubing can
be utilized when nothing else is at hand. Flexion of
head and neck usually aids in the introduction of
the tube into the larynx. If available, placement of
a laryngeal-mask airway can be used. Other emer-
gency procedures include cricothyroidotomy (see
p. 82), which is the author's preference, or the inser-
tion of a large-bore needle into the trachea. Try to
avoid a cricothyroidotomy in airway compromise
associated with carcinoma of the larynx because
there may be violation of the neck owing to implan-
tation of carcinoma. Obviously, establishment of
the airway is paramount and that takes precedence.
When an airway has been established by such ancil-
lary methods, an operative tracheostomy is usually
necessary. The attempt to maintain an airway with
an endotracheal tube beyond several days is usually
not advisable because adequate tracheal toilet may
be difficult and also the endotracheal tube does little
to reduce the respiratory dead space. Cricothyroi-
dotomy tubes are left in place by thoracic surgeons
for longer periods of time after median sternotomy.
There is a potential danger of subglottic stenosis
with this practice. A tracheostomy reduces this dead
space from 150 to 50 mL-a decided advantage in
all cases of respiratory distress.

FIGURE 19-1
6. When in doubt, perform an elective tracheostomy
rather than depend on the success of an emergency
tracheostomy.
7. Never suture the skin incision tightly-leave the
wound open to allow for any air to leak out.
8. The trachea courses posteriorly as it descends. The
approach is at a right angle to the trachea, not the
skin, for otherwise in a short-necked patient the
dissection will lead into the mediastinum and great
vessels.
9. The innominate artery or right common carotid
artery may cross the trachea above the supraster-
nal notch. Be careful especially in emergency
tracheostomy.
10. Obtain a postoperative chest radiograph.
A Surface anatomy landmarks from above to down-
ward are the thyroid cartilage notch and the slight
prominence of the cricoid cartilage. About 1 or 2 cm
THE TRACHEA AND MEDIASTINUM
ThyroidCart. Notch
Ant.
Suspensory
Lig. of
Thyroid
below the cricoid cartilage, a 4- to 6-cm long horizon-
tal incision is made. The vertical skin incision may be
advantageous in the infant because it may minimize
an up-down motion of the tube. In approximately 25%
of patients (Harrison, 1977) the innominate artery may
be above the sternal notch.
B The skin incision is carried through the platysma
muscles, and the upper and lower skin flaps are retract-
ed. A vertical incision is then made in the fascia in the
midline between the strap muscles.
C The cricoid cartilage is thus exposed above, and
the thyroid isthmus is exposed below. Between these
two structures is a. portion of the anterior suspensory
ligament of the thyroid gland. There is no need to open
the planes lateral to the trachea. Doing so invites addi-
tional contamination.
Continued
 THE TRACHEA AND MEDIASTINUM

Tracheostomy (Continued) (Fig. 19-1) Plastic

a. With and without low pressure cuff

D It is usually possible to retract the thyroid isthmus
superiorly with a Cushing vein retractor, as depicted
in Dl. The second, third, and fourth tracheal rings are
thus exposed. If retraction of the thyroid isthmus upward
proves difficult or cumbersome, the anterior suspen-
sory ligament of the thyroid is incised horizontally
along the dotted line shown in C. Two curved clamps
are then inserted through this incision across the
isthmus, and the isthmus is transected.
Types of Tracheostomy Tubes
1. Selection in children (see Fig. 4-4)
2. Selection in adults
Metal
a. Jackson
b. Holinger
c. Martin: extension of inner tube to facilitate bulky
dressing
d. Lore Jr.: (see Fig. 20-18C1): extension of outer
tube with universal anesthesia adapter of the inner
cannula to connect to ventilation equipment
e. "Cane'"-shaped tube: inner cannula only in
curved portion
f. Cuffed: original cuff was placed on the metal tube
by a surgeon. This is time consuming and is no
longer available.
b. Rigid
c. Soft, slightly flexible plastic, able to be shortened
with the knife, round the edges with heat. A Portex
tube is preferred by the author (JML) because it is
more flexible and adaptable to avoid pressure on
the trachea; the low pressure has less folds and is
easier to insert through the tracheostomy site at the
time of surgery. The plastic has less propensity for
crusting. The flexible flange is less likely to cause
pressure sores around the site of the tracheostomy.
d. T tube: developed by Montgomery
e. Y tube: first described by Meyers (European) and
further modified by Healy/Montgomery as a stent
system for reconstructed trachea and laryngotra-
cheal stenosis and acute injuries (see Fig. 20-25
for other laryngeal stents). (There are many other
modifications of tracheostomy tubes.)
E The transected ends of the isthmus are secured
with suture ligatures.
F Using a one-half inch hypodermic needle, 1 to 2 mL
of 10% cocaine (or 2% tetracaine) is injected into the
lumen of the trachea. Air is first drawn into the syringe
to be sure that the needle point is located in the
lumen.
Continued
 THE TRACHEA ANO MEOIASTINUM

FIGURE 19-1 Continued

 THE TRACHEA AND MEDIASTINUM
Tracheostomy (Continued) (Fig. 19-1)
G A No. 11 blade knife is then used to cut a window
out of the trachea by first making a 5- to 8-mm hori-
zontal incision directly above the tracheal ring of choice.
This should be either the second, third, or fourth ring.
A nylon suture may be placed in the trachea distal to
the opening as a holding and identification marker. This
suture is left long and brought out through the skin
incision. With infants and children, two nylon sutures
may be inserted, one on the right side and one on the
left side, and marked accordingly. These sutures serve
as guides in an emergency if the tube becomes dis-
lodged. The sutures are taped to the skin on the right
and left side, respectively. Montgomery has devised a
useful instrument that forms a round hole for insertion
of the tracheostomy tube as it cuts through the
trachea.
H The incision is carried downward across the ring'
and then back horizontally directly below the ring. An
Allis clamp is gently affixed to the cut end of the carti-
laginous ring, which is then transected. A small por-
tion of the ring is thus removed. (If preferred, a small
skin hook may be used in lieu of the Allis clamp; how-
ever, this may tear and fragment a section of cartilage
with the danger of aspiration.) The airway is now estab-
lished and, if necessary, tracheal toilet is begun even
before insertion of the tracheostomy tube. If an emer-
gency establishment of airway was previously performed
using an endotracheal tube or bronchoscope (which
is often used in children), the tube or bronchoscope
is now removed. By making such a window, several
advantages are gained in addition to the fact that an
airway is established even before insertion of the tube.
Such a window minimizes the danger of fragmented
cartilage being pushed into the tracheal lumen and
reduces the hazard of narrowing the lumen from
inverted portions of the trachea when the
tracheostomy is no longer necessary and the tube is
removed. This is especially true in children. Another
advantage lies in the greater ease of establishing an
airway in the event of accidental dislodgment or
removal of the tracheostomy tube during the first 48
to 72 postoperative hours.
A suture through the edge of the tracheal window
can be placed as a marker to identify the window if the
tube is accidentally dislodged. Two marking sutures
can be used-one through each lateral border-to
act as "retractors" for the strap muscles if the tube
becomes dislodged.
I The previously prepared tracheostomy tube (No.6
or NO.8 Portex for adults) is now inserted into the
trachea and the obturator quickly removed. The end
of the tube should never reach the carina. Difficulty
may be encountered when a cuffed tube is used. The
cuff becomes snagged on the edges of the tracheal
window. When this occurs a tracheal three- or two-
pronged dilator is utilized to enlarge the opening. Care
must be taken not to tear the trachea, especially in
infants and children. Be sure the tube is in the lumen
of the trachea and not alongside the trachea or has not
perforated the lateral or posterior wall of the trachea.
J The skin edges are usually left wide open or only
partially approximated with nylon. A small space must
be left at either side of the tube to minimize the danger
of tension emphysema. The tube is both sewn to the
skin with nylon and affixed with tape tied with a square
knot behind the neck. The inner tube is then inserted.
A moist piece of plain gauze is folded over the tube
orifice. This gauze has had a 1.5-cm strip removed
from the mid portion of the deep half of the fold, the
edges having been guarded by a strip of adhesive.
Postoperative chest radiography is always performed.
In infants and young children, this radiograph is done
in the operating room to rule out pneumothorax.
 THE TRACHEA AND MEDIASTINUM 1021

FIGURE19-1 Continued
 THE TRACHEA AND MEDIASTINUM
Tracheostomy (Continued) (Fig. 19-1)
A semi-permanent tracheostomy has been described
by Fee and Ward. The skin incision is I shaped and the
tracheal incision is H shaped. The lateral skin flaps
form the lateral sides of the tracheostomy and the
tracheal flaps form the superior and inferior margins.
Postoperative Care for Tracheostomy
1. Keep flap dressing moist.
2. Use aerosol oxygen, cold steam, or ultrasonic mist
20 minutes every 1 to 2 hours or continually as
required.
3. Remove and cleanse inner tube every 30 minutes
to 1 hour. Use pipe cleaners or test tube brush.
4. Perform deep rapid suction every hour for the
first few hours and as necessary with inner tube
in place. Overzealous suctioning is to be avoided,
especially in children, unless absolutely neces-
sary. The suction catheter should be temporarily
occluded when being inserted. Negative pressure
suctioning should be limited to intervals of 2 to
4 seconds; otherwise, potentially dangerous hypoxia
can occur.
S. Instill several drops to 2 mL of sterile normal saline
and soda bicarbonate solution every hour and as
necessary when secretions become thick.
6. Change flap dressing as necessary.
7. Guard edges of dressing with adhesives to avoid
frayed edges on dressing.
8. Avoid leaving suction catheter in tracheostomy tube
beyond a few seconds.
9. Use the smallest catheter (with a side arm) commen-
surate with adequate suctioning.
10. Hyperventilate with 100% oxygen for 2 to 3 minutes
before suctioning.
11. Use separate suction catheter for oral cavity as
necessary.
12. Provide instructions early to patient for self-
care.
13. If a tube requires changing within 24 to 48 hours,
special care must be taken to ensure that the new
tube can be easily inserted. If there is any doubt, a
small catheter is inserted through the lumen of the
tracheostomy tube and this acts as a guide for the
reinsertion of the new tube as well as an emergency
airway. With an infant, a change of tube within the
first few days can be a serious procedure and must
be accompanied by appropriate surgical instruments
and personnel available in the proper setting-not
at the bedside in the regular hospital room.
14. See the following section for tracheostomy care at
home for the pediatric patient.
The Child With a Tracheostomy: Management
Hints. A Guide for Parents (Ruben et aI., 1982)
Home Environment
1. Keep all tracheostomy care equipment in one place.
2. Keep dusty items away from the child.
3. Humidify the room if you use an air conditioner.
4. Instruct baby sitter in tracheostomy care.
Bathing and Hair Washing
1. Do not leave the child alone in the tub.
2. For hair washing, place the child on the back on the
vanity or kitchen counter, with the head hanging
over the sink.
Clothing
I. Do not dress in turtleneck shirts.
2. Do not wear clothing made of a fabric that sheds.
Feeding
1. Prevent food or liquids from entering the tracheostomy.
2. Suction the child and do tracheostomy cleaning before
feeding the child.
Traveling
1. Bring a DeLee suction catheter on short trips (store,
doctor's office). For long trips, take a battery-powered
suction device, replacement tube, and suction and
cleaning equipment.
Report the Following to the Otolaryngologist
1. Change in color, consistency, or odor of mucus
2. Skin breakdown around the stoma
3. Child's admittance to the hospital
Emergency Telephone Numbers
1. Otolaryngologist
2. Pediatrician
3. Local hospital
4. Local police, fire, or rescue squad, depending on
which has the equipment and the personnel to aid
with resuscitation
5. Utility company
6. Neighbor
We suggest that if the patient is an infant, a cardiac
monitor should be sent home with the patient. In this

way, bradycardia or tachycardia can be detected. An
alarm signals problems, and this alerts the parents.
Postoperative Advantages
1. Ease of tracheobronchial toilet
2. Ease of oxygen administration
3. Ease of instillation of antibiotic directly into trachea
4. Conscientious but not skilled medical personnel
necessary
5. Both bronchi can be suctioned. By rotating the flange
on the tracheostomy tube counter-clockwise the
catheter can be inserted into the left mainstem
bronchus.
Warning and Recommendations
1. High morbidity and mortality in infants younger
than 9 months of age
a. Difficult to keep tube patent
b. Tendency to obstruction with granulomas of
trachea
c. Almost impossible to extubate until older than
1 year of age
2. Not a panacea for all airway problems
3. Perform as elective rather than as emergency pro-
cedure.
4. Be certain tubular structure selected is trachea and
not large vessel.
5. Be aware of tracheal casts or plugs distal to tra-
cheostomy tube-remove tube immediately to extri-
cate cast or plug. Be prepared to retract skin and
strap muscle.
6. Suture skin loosely around tube-if tight may cause
mediastinal emphysema.
7. Tube must not reach carina.
FIGURE 19-2
THE TRACHEA AND MEDIASTINUM 1023
8. Sew tube to skin.
9. Use deep suction beyond end of tube-remove
rapidly.
10. Follow emergency establishment of airway with
operative tracheostomy.
11. A nasogastric tube in place for any length of time in
an infant may contribute to aspiration. Hence, con-
sider a gastrostomy and remove the nasogastric tube.
12. Aerophagia can lead to severe gastric dilatation in
infants who have a tracheostomy. In one infant, a
perforated prepyloric ulcer occurred related to the
use of corticosteroids. A tension pneumoperitoneum
(Fig. 19-2) occurred that caused life-threatening
respiratory distress by pressure on the diaphragm.
Immediate, yet slow decompression of the pneu-
moperitoneum was accomplished by the insertion
into the peritoneal cavity of a needle connected to
a 50-mL syringe. Respiratory distress was immedi-
ately relieved. The patient was taken to the operating
room, and the perforated ulcer was closed. Gastros-
tomy was then performed.
13. When a tracheostomy is performed over an endo-
tracheal tube, the endotracheal tube should be
removed only to the superior or proximal edge of
the window in the trachea until the tracheostomy
tube is inserted into the tracheal lumen. Then, the
endotracheal tube can be removed.
14. When an infant or a child is extubated, more often
than not it is a good plan to take the patient to the
operating room so that tracheoscopy via a broncho-
scope can be performed to visualize and to confirm
the patency of the trachea. This is especially true if
a window was not performed at the time of the
original tracheostomy. Infolding of the tracheal wall
by a horizontal or cruciate incision and/or granu-
lation tissue at the site of the tracheostomy can
 THE TRACHEA AND MEDIASTINUM
cause obstruction and death if it is not evaluated.
In such instances the tracheostomy tube must then
be reinserted.
Complications
1. Operative
a. Injury to esophagus, recurrent laryngeal nerves,
great vessels (common carotid and innominate
arteries)
b. Pneumothorax-unilateral or bilateral-tension
or non tension
c. Apnea
d. Cardiac arrest
e. Perforation of lateral or posterior wall of trachea
when inserting tracheostomy tube through opera-
tive site
2. Postoperative
a. Erosion of major vessel-this is suspect when
tracheostomy tube moves unduly with each
heartbeat. This must be evaluated immediately;
arteriograms may be necessary.
b. Tracheoesophageal fistula
c. Tracheal stenosis-this is almost always due to
accompanying inflated cuff or to granulation tissue
in children and infants. Bronchoscopy should be
performed when extubating such patients.
d. Erosion of carina due to too long a tube
e. Emphysema
f. Aerophagia in infants and young children
g. Erosions at distal tip of tube
h. Infection: tracheitis due to Staphylococcus
1. Displaced tube
J. Atelectasis
k. Aspiration
1. Persistent stoma
m. Accidental removal of tube and plugging of the
tube by children undergoing tracheostomy are
the primary causes of death in children.
3. A vagovagal reflex occurred in one patient with a
serious head injury, resulting in cardiac arrest.
See the section on tracheal resection regarding "cuff
factors" in the etiology of tracheal stenosis (p. 1026).
Cricothyrotomy is described in Chapter 2 (p. 82).
Cervical Mediastinotomy and
Tracheomediastinotomy (Fig. 19-3)
Indications
Cervical Mediastinotomy
Perforation of the upper thoracic and cervical esophagus
can occur with abscess formation. Mediastinitis can also
be secondary to other sources of infection in the head
and neck (e.g., Bezold's abscess, an abscess overlying
the mastoid process).
Tracheomediastinotomy (Combined Tracheostomy
and Cervical Mediastinotomy)
Traumatic injuries of the neck and thorax may result in
the escape of air from perforations of the larynx, trachea,
bronchi, esophagus, or pharynx. With the former three,
primarily, there is the danger of air forced under tension
beneath the fascial planes that envelop the air passages
and the great veins of the neck and superior mediasti-
num. These injuries may be due to high-velocity impact
from accidents occurring in industry or on the highway
as well as simple accidents such as striking the trachea
or larynx on a table or chair. If this tension is allowed
to increase unrecognized and untreated, death may
result either from airway obstruction or from venous
tamponade or a combination of both. Another possi-
bility is the progression of the tension mediastinal
emphysema to the extent that the mediastinal pleura
may rupture unilaterally or bilaterally and cause unilat-
eral or bilateral pneumothorax.
In the neck, the initial trauma may cause edema of
the larynx or abductor cord paralysis and set the stage
for increased intratracheal pressure, thereby forcing the
exhaled air out through even the smallest perforation.
As the tension beneath the fascial planes increases, this
compresses the walls of the great veins draining the
neck. The resulting venous obstruction in turn causes
an increase in laryngeal edema and leads to complete
glottic obstruction. Death may be the result of either
airway obstruction or venous tamponade.
A similar pathologic process may ensue at the hili of
the lungs if the tension mediastinal emphysema pro-
gresses. Here, too, there may be venous and airway
obstruction and death. This whole process can occur in
a matter of several hours or several days.
Highpoints
1. Use horizontal incision.
2. Avoid injury to inferior thyroid veins, thyroid ima, or
recurrent laryngeal nerves.
3. Use blunt dissection, keeping close to esophagus and
trachea.
4. Avoid injury to internal jugular and innominate veins
and major arteries of the aortic arch. The innomi-
nate artery or the right common carotid artery may
cross the trachea above the suprasternal notch.

Recurrent laryngeal n.
Thyroid
isthmus
Bifurcation of trachea
A B
FIGURE 19-3
A Schematic anatomic drawing depicting the site of
tracheostomy and the course of the cervical mediasti-
notomy. These procedures are performed through the
same horizontal incision as for a tracheostomy alone
(see Fig. 19-1A to D). If an abscess alone is present or
if there is a perforation of the cervical esophagus, the
mediastinotomy is performed without a tracheostomy.
Any perforation is closed and drained.
B With the neck extended, the cricoid cartilage is
palpated. About one or two fingerbreadths below the
cartilage a short horizontal incision is made through
skin, superficial fascia, and platysma muscles. Flaps are
thus developed exposing the strap muscles. A vertical
incision is then made in the midline separating the
strap muscles. The thyroid isthmus and trachea are
thus exposed. The isthmus is either retracted upward
or transected, and a small section of the second, third,
THE TRACHEA AND MEDtASTlNUM
or fourth tracheal ring is excised. The airway is now
established. Before the tracheostomy tube is inserted,
the mediastinum is entered on either side of the trachea.
A moderate-sized curved hemostat or finger is inserted
with care alongside the trachea bilaterally for a distance
of 3 to 6 em. The instrument must be in exactly the
same plane as the trachea so as not to injure either the
innominate or jugular veins. Two small Penrose drains
are inserted, one on either side of the trachea, and sewn
securely to the skin. The tracheostomy tube is inserted
and likewise sewn to the skin. Both the tracheostomy
tube and the drains are brought out through the same
skin incision. The skin is not closed, to allow the escape
of air. This approach is a simple and more direct route
to the superior mediastinum than the more lateral
cervical approach. The illustration demonstrates a liberal
exposure for the purpose of clarity. The usual exposure
is less extensive.
 THE TRACHEA AND MEDIASTINUM
Tracheal Resection (Figs. 19-4 and
19-5) (After Grillo, 1964, 1965)
Indications
• Tracheal stenosis
• Tracheal tumors: primary trachea, thyroid, stomal
recurrence, esophageal tumors
• Tracheomalacia
• Congenital deformities (e.g., long-segment tracheal
stenosis)
Sites of Stenosis and Etiology
1. Trauma
2. Granulomas at tracheostomy site. This is especially
dangerous in infants and young children at the time
of removal of the tracheostomy tube. Infants have
died of obstruction at this site, and it is best for
infants 1 year or younger if the surgeon checks the
area with a bronchoscope at the time of extubation.
3. Cuff sites of both tracheostomy tubes and endotra~
cheal tubes. Stenosis can occur secondary to pro-
longed use of an endotracheal tube, with a moderate
size pedunculated polyp located just below the
stenosis. This would be removed surgically via a
bronchoscope.
4. Site of tracheostomy tube tip anywhere along the
trachea but especially at carina if the tracheostomy
tube is too long
S. Vocal cord and cricoid injuries by endotracheal tubes
and high tracheostomy are covered in Chapter 20.
Discussion
In addition to tracheal resection, other methods are
available to treat tracheal stenosis depending on the
location and extent of the stenosis, as outlined in the
following:
1. Endoscopic removal of small noncircumferential
scar
a. Surgical forceps
b. CO2 laser. Ossoff et al. (1985) described three stages
of tracheal stenosis: granulation stage, limited
scarring, and extensive scarring. He believes the
CO2 laser is useful in the first and second stages
but not the third stage. It is of virtually no value
in complete, thick, circumferential scars of the
trachea. Failure is possible if the stenotic scar is
circumferential and firm despite the four-quarter
use of the CO2 laser.
2. Modified technique of Evans and Todd (1974). The
trachea is exposed via an external cervical horizon-
tal incision. The trachea is then explored by transect-
ing each tracheal cartilage ring alternating from right
to left laterally. This results in an alternating long
cartilage ring at each ring level. The scar tissue is
resected. The long ends of the cartilaginous rings
are now sutured end to end; that is, the long end of
tracheal ring one is sutured to the long end of tra-
cheal ring two. The short ends are not approximated.
This method is especially adaptable to the short-
necked individual with an existing tracheostomy.
The patency of the tracheal reconstruction can be
evaluated with a flexible bronchoscope or ultrathin
nasolaryngoscope. If a tracheostomy is present, and
it should be avoided if at all possible in tracheal
resection but virtually is necessary in cricotracheal
reconstruction, visualization of the anastomosis can
be with a 70-degree rigid endoscope through the tra-
cheostomy site.
Prevention of Stenosis
1. When performing a tracheostomy, always remove a
small portion of the anterior presenting portion of
one tracheal ring. This will help prevent infolding of
cartilage and soft tissue of trachea, which could be
a nidus of granulation tissue and obstruction, espe-
cially in infants.
2. The prevention of stenosis at the cuff site, whether
it be associated with tracheostomy tube or endotra-
cheal tube, is rather complex, because an ideal cuff
is yet to be devised. Lajos (1971) has performed a
number of clinical trials that have shown that the
minimal leak technique using a low-pressure cuff
is the best method at this time to prevent tracheal
damage. The important principle in assisted respira-
tions with a respirator is air exchange with adequate
Po2levels. It is much better to have a minimal leak-
thus minimal to negligible cuff pressure on tracheal
wall-and to maintain the P02 with increased pres-
sure via the respirator. The advantage of the low-
pressure cuff over the high-pressure cuff is that the
former is able to conform to the slightly oval config-
uration of the tracheal lumen without the pressure
points of the latter.
Of all the etiologic factors, it seems that the cuff
is the most common cause of the problem. Before the
advent of the cuff and assisted respirations, tracheal
stenosis was quite rare. It is likewise very important
when using cuffed tubes or tubes made of plastic that
are gas sterilized to allow a minimum amount of
time to lapse before their use. (Consult a local hos-
pital's central service department regarding stan-
dards.) The gas has been shown to cause a harmful
tissue reaction.
3. Tracheostomy tube tip problems:

a. Check the curve of the tracheostomy tube clini-
cally and by radiography. It should conform to the
configuration of the trachea. Holinger tracheostomy
tubes are made in various curvatures. More flexible
tracheostomy tubes are now available.
b. Check the length of the tracheostomy tube clini-
cally and by radiography regarding the length of
the tube so that it does not reach the carina. Most
tracheostomy tubes are made in varying lengths
in the various lumen sizes.
Management of Acute Trauma
1. Laryngoscopy, indirect and direct
2. Bronchoscopy and endotracheal tube
3. Tracheostomy. The need for this procedure may be
very urgent and it should usually be performed
through the site of injury to avoid additional trauma
to the trachea, thus preserving as much of the trachea
as possible. An exception to this dictum is separa-
tion or avulsion at the tracheocricoid level in which
a tracheostomy tube could be inserted as a lifesaving
measure but not as a semipermanent location because
of the hazard of cricoid chondritis and subglottic
stenosis.
4. Primary end-to-end anastomosis when necessary
and when debridement is not extensive. Distal tra-
cheostomy mayor may not be required depending
on circumstances (e.g., usually required with high
tracheal injuries and certainly at the cricotracheal
level). At this site the repair must be extremely
meticulous because of the tendency for the develop-
ment of subglottic stenosis.
If the wound is severely contaminated or asso-
ciated with esophageal perforation or laryngeal injury,
THE TRACHEA AND MEDIASTINUM
a tracheostomy through the injured trachea site may
be the better part of valor. Secondary reconstruction
is then performed.
S. Carefully evaluate the possibility of associated injuries:
a. Larynx and recurrent laryngeal nerves
b. Pharynx
c. Esophagus
d. Pneumothorax (nontension and tension)
e. Mediastinum (emphysema)
All associated injuries must be treated concomitantly.
Refer to the section on laryngeal trauma. Esophageal and
pharyngeal perforations require immediate repair. Chest
injuries require underwater drainage (see Figs. 2-3G to
2-60). Tension pneumothorax is life threatening and
requires drainage immediately. Mediastinal emphysema
of any significant degree requires an adequate proce-
dure for escape of air (see Fig. 19-3B). The skin around
the tracheostomy must be left loose and not closed tight
around the tube. Recurrent nerve injuries are referred
to under Highpoints (item 4).
We have seen tension pneumoperitoneum in one
child associated with a perforated stress gastric ulcer.
This requires immediate peritoneal decompression with
a needle and then abdominal exploration and closure
of perforated ulcer with feeding gastrostomy.
Seldom do standard radiographs of the neck or chest
visualize tracheal stenosis nor do computed tomographic
(CT) scans, because only axial "cuts" are available. The
"cut" may not depict the stenosis. Besides, it affords no
indication of the length of the stenosis. Magnetic reso-
nance imaging (MRI) with sagittal and coronal views is
ideal. Tomography is also very useful and cost effec-
tive, especially for repeated views and follow-up after
initial and immediate follow-up with MRI.
 THE TRACHEA AND MEDIASTINUM

Tracheal Resection (Continued) size, and origin. The right bronchial artery (one)
(Figs. 19-4 and 19-5) (After Grillo) arises from the first aortic intercostal or from the
upper left bronchial artery. The left bronchial
arteries (usually two) arise from the thoracic
Illustration of trachea vis-a-vis method of resection. aorta.
2. Resectable lengths of trachea in relationship to
Highpoints cervical and thoracic mobilization are as follows:

1. Preserve blood supply to the trachea. Upper Trachea

a. Cervical portion from the branches of the infe-
rior thyroid artery enters the trachea laterally, a. Cervical and cervicomediastinal mobilization
hence the lateral pedicle should be preserved. anteriorly and posteriorly (preserve lateral
Complete circumferential mobilization is extremely pedicles with blood supply) (after Grillo,
hazardous and will surely jeopardize the proxi- 1969)
mal area of such a distally mobilized trachea i. Comfortable flexion (15 to 35 degrees) of
unless these lateral pedicles are preserved. The head and neck yields 4.5 em (range: 3.5 to
inferior thyroid arteries anastomose with the 6.0 em).
bronchial and internal mammary arteries ii. Increased flexion of head and neck yields an
inferiorly. additional gain of 1.3 em. It is obvious as
b. Thoracic portion includes carina from branches flexion is increased that the rate of gain is
of bronchial arteries, which vary in number, increased, with a total yield of 5.8 em.

2.5 em - -SUPRALARYNGEAL RELEASE

0.5 em DIVISION OF THYROHYOID MUSCLES
AND SUPERIOR CORNUA THYROID
CARTILAGE
2.0 em DIVISION OF THYROHYOID MEMBRANE

REC. LARYNGEAL N.

4.5 em NECK FLEXED (15° - 35°)

(3.5-6 em)
RANGE

1.3em-- INCREASED FLEXION

1.4em-- MOBILIZATION RT. HILUS AND INF. PUL. L1G.

3.0em--· FULL MOBILIZATION RT. HILUS

DISSECTION PUL. ARTERY AND VEIN INTRAPERICARDIALLY
REIMPLANTATION OF LT. MAINSTEM BRONCHUS

FIGURE 19--4

b. Supralaryngeal release (Dedo and Fishman, 1969)
yields 2.5-cm gain (see Fig. 19-5A to C). This is
accomplished by dividing the thyrohyoid muscles
and superior cornua of the thyroid cartilage,
yielding a gain of 0.5 cm. An additional gain of
2.0 cm is achieved by dividing the thyrohyoid
membrane without entering the lumen of the
pharynx and by avoiding injury to the superior
laryngeal nerves (see Fig. 20-9A and B). The
sternohyoid and omohyoid muscles are not
transected, because they have a tendency to pull
the hyoid bone downward. An example of this
technique is resection of the upper cervical
trachea and lower edge of the cricoid cartilage
for invasion of these structures by Hiirthle cell
carcinoma of the thyroid. A distal tracheostomy
is advisable. Another technique might be transec-
tion of the suprahyoid muscles. Still another tech-
nique to facilitate tracheal anastomosis is an
intralaryngeal release through the thyroid carti-
lage just above the level of the vocal cords. The
intrinsic laryngeal structures are not exposed.
c. Mobilization of hilus of the right lung and infe-
rior pulmonary ligament yields 1.4 cm.
Lower Half of Trachea and Carina
a. Full mobilization of the right hilum and division
of the pulmonary ligament yields 3 cm (range: 2
to 4.2 cm).
b. Dissection of pulmonary artery and vein
intrapericardially yields 0.9 cm (range: 0.3 to
1.8 cm).
c. Division of left mainstem bronchus with implan-
tation into bronchus intermedius (after Barclay
et aI., 1957) yields 2.7 cm. Grillo (1963) has
stated that "this maneuver is best reserved for
carinal reconstruction because of the complexity
of the suture lines." It is also obvious that
cervical mobilization is a great aid in obtaining
tracheal length for lower tracheal reconstruction
procedures.
3. Tension on anastomotic suture lines: standard
tension is 1000 to 1200 g. Cantrell and Folse (1961)
demonstrated in dogs that the top safety tolerance
of tension was below 1700 g.
4. Avoid injury to a recurrent laryngeal nerve in tracheal
resection for stenosis. Because of the associated
scar tissue surrounding the trachea, it is best not to
attempt to expose these nerves. Realize their loca-
tion near the tracheoesophageal sulcus and keep
medial to this area. In acute trauma it may be
worthwhile to expose the nerves, especially if there
is an associated vocal cord paralysis. When the
THE TRACHEA AND MEDIASTINUM
resection is performed for neoplasia, exposure of
the nerves is done if they are not involved by tumor.
Although the author (JML) has had no success with
recurrent nerve anastomosis in humans (in dogs,
yes), it is worthwhile to attempt an anastomosis
using an operative microscope and 6-0 to 8-0
Prolene.
5. When mobilizing the trachea, avoid circumferen-
tial dissection, if feasible, to preserve blood supply
to the trachea.
6. Anterior wedge resection of the trachea can end in
buckling and infolding of the posterior wall of the
trachea and lead to partial obstruction.
7. Nasoesophageal tube aids in the dissection when
the scar tissue extends from the trachea to the
esophagus.
8. Approach the chest through the standard right pos-
terolateral thoracotomy if the lesion involves the
lower one third of the trachea; otherwise, a median
sternotomy extended into the third or fourth right
interspace suffices (see Fig. 19-1OAto L). Another
approach to the upper portion of the thoracic
trachea is resection of the medial third of the
clavicle. At least 2.5 cm of the thoracic trachea can
be adequately visualized through this approach
(see Fig. 19-9).
9. Avoid injury to the innominate artery, which may
be adherent to the trachea and innominate veins.
10. The line of transection of the trachea must be sharp
and neat circumferentially without fraying of mucous
membrane or fragmenting of cartilage. If a section
of cartilage is bare, this is of no concern.
11. The endotracheal tube for anesthesia is best via the
larynx, if feasible; however, intubation through the
lumen of the distal trachea may be necessary at
various stages. When this is necessary, a suture
through the distal end of the intraoral tube will aid
in the passage of the tube down through the larynx
if the tube is withdrawn above this level.
12. Suture technique:
a. 4-0 Tevdek
b. 3 to 4 mm apart plus retention sling sutures
placed around tracheal rings staggered one to
two rings superior and inferior to anastomosis
(see Fig. 19-50 to G)
c. Knots on outside of tracheal lumen
d. Posterior and lateral sutures are inserted through
the cartilage initially and then tied when all are
inserted with the neck flexed. The anterior sutures
are then inserted and tied.
e. Do not telescope the ends of the trachea.
L Test suture line with saline.
13. Patient should be breathing spontaneously at close
of operation.
 THE TRACHEA AND MEDIASTINUM
Tracheal Resection (Continued)
(See Fig. 19-5)
Complications
• Injury to the internal branch of the superior laryngeal
nerves
• Aspiration
• Recurrent laryngeal nerve injury
Supralaryngeal release is performed if necessary
(after Oedo and Fishman, 1969).
A Through a horizontal incision (dotted line in C),
the thyrohyoid area is exposed. Both thyrohyoid muscles
are transected. This achieves a gain of 0.5 em by drop-
ping the larynx. The superior cornua of the thyroid
cartilage are exposed and transected using narrow bone-
cutting forceps with a serrated blade. Extreme care must
be taken to avoid injury to the superior laryngeal nerve,
especially its internal branch. Lore Sr. has demon-
strated that a good norm for identification of the
internal branch as it pierces the thyrohyoid membrane
is a horizontal line drawn across the superior edge of
the uppermost part of the thyroid cartilage, stopping
within 1 em of the superior cornua of the thyroid
cartilage (Al).
B An additional 2.0-cm gain in tracheal length is
achieved by further dropping the larynx by transection
of the thyrohyoid membrane and the superior cornua
of the thyroid cartilage, with care being taken not to
injure the internal branch of the superior laryngeal
nerve or the hypoglossal nerves.
C A horizontal cervical incision is depicted by the
solid line. If the stenosis is below the superior level of
the manubrium, a median sternotomy is necessaryalong
the vertical dotted line (see Fig. 19-10A to Land 0
to Q). If a tracheostomy is present, one long horizontal
incision through the tracheostomy site can achieve
exposure for both the tracheal resection and the
laryngeal release or two separate horizontal incisions
can be used. When a suprahyoid release is performed,
the cornua of the hyoid bone are transected, with care
again taken not to injure the hypoglossal nerves.
Continued
 THE TRACHEA AND MEDIASTINUM 1M 1

B c
FIGURE 19-5
 THE TRACHEA AND MEDIASTINUM

Tracheal Resection (Continued)

The retention sutures are used to help in the approxi-
(See Fig. 19-5)
mation and are then tied along with the shorter
anastomotic sutures.

D The stenotic area is exposed. Avoid injury to the

G The anastomosis is completed. Three retention or
recurrent nerves. This can be accomplished by not
sling sutures are now placed approximately two rings
exposing the nerves and by keeping the plane of
above and below the anastomosis (Tyagi) to reduce
dissection close to the trachea when there is consid-
the tension on the anastomosis. This has been shown
erable scar tissue. If there is no scar tissue-which is
to aid in the prevention of secondary stenosis. It is
unlikely-then the nerves may be exposed. A
imperative to leave the head and neck flexed during
nasoesophageal tube aids in the dissection from the
the postoperative. healing period. This can be main-
esophagus. Preserve the lateral pedicle blood supply
tained by a well-padded posterior cervical molded
from the inferior thyroid arteries while mobilizing the
plaster splint. All of the knots are on the outside.
trachea. Refer to Highpoints (items 1 and 2) for mobi-
Tracheostomy is to be avoided except in a cricotracheal
lization data. Keep pleura intact. Do not mistake non-
anastomosis or in the presence of recurrent nerve
obstructing scars at the previous tracheostomy site with
injury when a tracheostomy is necessary with a crico-
actual stenosis. tracheal anastomosis (e.g., with recurrent nerve
Lateral retention or stay sutures are placed 1 cm
paralysis, a soft nasopharyngeal airway rubber tube
proximally and distally to the lines of transection. An
cut short is ideal). Otherwise, a nasoendotracheal tube
endotracheal tube (Boyan) is inserted into the lumen
can be left in situ for 12 to 36 hours.
of the trachea. This facilitates easier dissection from
The same basic technique is applicable to benign
the esophagus in that the stenotic area is free of any
tumors of the trachea. The resection of malignant neo-
tube passing through its lumen.
plasm is a different matter, because adequate margins
superiorly and inferiorly as well as laterally and poste-
E The stenotic area has been resected. The oral endo-
riorly are necessary. A mediastinal tracheostomy is more
tracheal tube is in place. Using 4-0 Tevdek (3 to 4 mm
often necessary than not as well as mediastinal node
apart and through the cartilages of the rings), the
dissection, thyroidectomy, possibly neck dissection, and
posterior and lateral sutures are inserted, first with
laryngectomy. The reader is referred to the mono-
knots to be tied on the outside. If it is not possible to
graph by Grillo (1970) as well as the writing of Sisson
pass the sutures through the cartilage, they are placed
(1969) relative to tracheal stoma recurrence resection.
around the cartilage.

F The Boyan tube is removed, and the oral endo- Complications

tracheal tube is advanced. The patient is breathing
spontaneously. The head and neck are now flexed for • Injury to recurrent laryngeal nerves
added gain in tracheal length. Release of larynx or • Hypoparathyroidism if resection is for neoplasia
sternotomy with extension into third or fourth inter- • Avulsion of anastomotic suture line
space (see Fig. 19-1 OA to L) may have been necessary • Stenosis at anastomotic suture line
for added mobilization and increased tracheal length. • Airway problems
 THE TRACHEA AND MEDIASTINUM

,
/

! FIGURE 19-5 Continued

 THE TRACHEA AND MEDIASTINUM

Closure of Cutaneous Tracheal 2. Left arytenoidectomy and cordectomy

Fistula (Fig. 19-6)
For the technique of construction of large tracheal
stoma, see Figure 20-19.
A tracheostomy located between the cricoid carti-
lage and first tracheal ring runs the risk of chondritis of
the cricoid cartilage, with subsequent calcification and
tracheal or subglottic stenosis. Circumferential resection
of the stenotic area and anastomoses of the distal trachea
to the remaining portion of the cricoid cartilage would
be preferred ideally. However, the resulting scar tissue
can extend laterally, posteriorly, and inferiorly so that
such a resection may be extremely difficult with almost
certain injury to the recurrent laryngeal nerves. In such
a problem, resection of the anterior constricting portion
of the cricoid cartilage and trachea is performed, lining
the anterolateral walls of the defect first with skin flaps,
replacing the skin with mucosal grafts from the buccal
wall, and then finally closing the fistula with local tissue.
The procedure must be carefully staged, with constant
evaluation of the airway.
Described here is a patient with a very short heavy-
set neck who had an emergency tracheostomy for cer-
vical cellulitis with laryngeal edema following a tooth
extraction. Complications as mentioned previously
occurred along with a left vocal cord paralysis, follow-
ing an initial surgical attempt for correction of the
stenosis. The neck was so short that a tracheostomy
below the stenotic area was not possible. Staged sub-
sequent management was necessary and was as follows:
1. Resection of the anterolateral area of stenosis with
laterally advanced skin flaps to temporarily cover the
defect using a custom-made tracheal tracheostomy tube
3. Extended period (1 year plus) of evaluation of glottic
airway, using a custom-made collar to facilitate tem-
porary closure of the tracheal fistula
4. Excision of epidermal lining of lateral skin flaps to
tracheal defect and application of buccal mucosal
grafts on each side
5. Turn-in flaps of the buccal mucosal grafts with a
second layer of the fat flip graft and third layer of an
advanced skin flap
6. A secondary tracheostomy is not performed. Careful
evaluation of glottic and tracheal airway is done over
a long period, utilizing the cervical collar.
A Anterolateral cricoid and tracheal defect is depicted
after Tesection of the stenotic scar tissue and ossified
cartilage. The lateral edges are covered with horizontal
skin flaps, advanced medially in the direction of the
arrows. A left arytenoidectomy and cordectomy are
performed for the left abductor cord paralysis, since
the glottic airway was severely compromised.
A custom-made tracheostomy tube is then inserted
for a period of several months. After healing has occurred
with no subsequent scar contracture, the tracheostomy
tube is removed and a sponge rubber pad attached to
a cervical collar is used temporarily to occlude the
tracheal fistula, thus allowing evaluation of the glottic
and tracheal airway.
B The epidermal surfaces (X) of the lateral skin flaps
are excised and replaced with buccal mucosal grafts
using 5-0 nylon sutures with knots buried. The cervical
collar is continuously used. The epidermis is replaced
with mucosa, because epidermis can be the source of
sebaceous excretion and result in airway obstruction.

A B
FIGURE 19-6

F
FIGURE 19-6 Continued
C After 3 months, the size of the tracheal fistula has
become smaller. The anterior margins of the mucosal
grafts are mobilized and rotated to the midline, and'
edges are approximated with 5-0 nylon sutures, as
depicted.
D A unilateral cervical rectangular skin flap is elevated
with the outline of two Burow triangles, as depicted by
the dotted lines. A fat flip flap (Y) is then turned over
the mucosal closure (X) in such a fashion that the
suture lines are not overlying each other. Y then is
approximated to yl.
THE TRACHEA AND MEDIASTINUM
SKIN
FATFLIP FLAP
MUCOSAL GRAFT
E The unilateral cervical rectangular skin flap is thus
mobilized, excising the two Burow triangles. The verti-
cal skin closure is as far lateral as possible so that it
does not overlie the fat flip flap vertical closure line.
F Cross-sectional schematic view depicts the offset
planes of the three-layer closure. Cartilaginous support
anteriorly was not necessary. If it had been, it could
have been achieved by burying autogenous cartilage
with perichondrium at a previous stage. The cartilage
source is either costal or septal (with perichondrium on
one side).
 THE TRACHEA AND MEDIASTINUM
Closure of Cervical
Tracheoesophageal Fistula
Closure of a tracheoesophageal fistula secondary to
trauma or iatrogenic causes can be performed by use of
one or more strap muscles detached superiorly and
rotated between the trachea and esophagus at the site
of the fistula. Alternatively, a portion of the sternoclei-
domastoid muscle is rotated as a pedicle, based either
superiorly or inferiorly. Care is taken not to injure the
recurrent laryngeal nerves or the blood supply to the
muscle.
Mediastinum Anatomy (Fig. 19-7)
The mediastinum is the space between the two pleural
spaces extending from the superior border of the
manubrium inferiorly to the diaphragm. It is bounded
anteriorly by the posterior surface of the sternum and
posteriorly by the anterior aspect of the vertebrae. The
division of the mediastinum is quite arbitrary and varies
from author to author. Depicted is a lateral view of the
mediastinum that is divided into superior and inferior
portions at an imaginary horizontal line at or slightly
below the sternal angle at the site of the demi-facets of
the second costal cartilages. The sternal angle is the
junction of the manubrium with the body of the
sternum (gladiolus). This imaginary line as it extends
posteriorly approximates the fifth thoracic vertebra.
The superior mediastinum is divided into anterior and
pos-terior portions, whereas the inferior mediastinum
is divided into anterior, middle, and posterior portions.
It is obvious that these distinctions are artificial and are
only for the convenience of locating the various impor-
tant structures when describing surgical procedures.
They are likewise helpful in understanding the extent
of a specific surgical procedure. It must be pointed out,
however, that neither inflammatory nor malignant
disease respects these divisions.
Access to the Mediastinum
1. Suprasternal via the superior thoracic inlet with
transection of the interclavicular ligament with or
without a vertical skin incision over the manubrium
sterni
2. Resection of medial third of the clavicle (see Fig. 19-9)
3. Median sternotomy-partial or complete (see Fig.
19-1OAto D)
4. Resection of the manubrium sterni
From the head and neck surgeon's point of view, the
anatomic structures in the superior mediastinum are
very important during mediastinoscopy and superior
mediastinal dissection. It is obvious that the surgeon
must likewise have a knowledge of the anatomy of the
entire mediastinum and the pleural cavities as well as a
knowledge of the management of any ensuing compli-
cations (e.g., pneumothorax, mediastinal emphysema,
hemorrhage from any of the major vessels, and perfora-
tions of the trachea and esophagus).
Although in most textbooks of anatomy, the superior
mediastinum is not divided into anterior and posterior
portions, this type of division is believed helpful to the
surgeon (e.g., in the search for a mediastinal parathy-
roid adenoma). The anterior portion of the superior
mediastinum would be concentrated on when the infe-
rior parathyroid gland is suspected to be the missing
gland, and the posterior mediastinum would be concen-
trated on when the suspected missing gland is the supe-
rior parathyroid gland.
The superior anterior mediastinum contains the great
vessels: arch of the aorta, innominate artery, and left
common and left subclavian arteries. Their counter-
parts-the right common carotid and right subclavian
arteries-may be in the mediastinum or in the neck.
The right common carotid artery may overlie the trachea,
superior vena cava, and the brachiocephalic veins,
thymus, adipose tissue, and lymph nodes, whereas the
superior posterior mediastinum contains the trachea,
esophagus, thoracic duct, azygos vein (right side), lymph
nodes, and portions of the roots of the lungs. The vagus
and phrenic nerves traverse from anterior to posterior.
The left recurrent laryngeal nerve swings around the
arch of the aorta from an anterior to posterior position.
The right recurrent laryngeal nerve swings around the
right subclavian artery from anterior to posterior, thus
passing posterior to both the subclavian and common
carotid arteries. It must be emphasized that the innom-
inate artery within the anterior mediastinum may well
cross the trachea above the superior border of the
manubrium and thus may be located in the lower
cervical region. Hence, it is in jeopardy during proce-
dures such as tracheostomy and other operations on
the trachea, thyroidectomy, searching for parathy-
roids, and thymectomy. Additional anatomy of the
mediastinum is depicted during the following specific
surgical procedures:
1. Mediastinoscopy (see Fig. 19-8)
2. Total thyroidectomy with superior mediastinal node
dissection (see Fig. 19-1OAto L)
 THE TRACHEA AND MEDIASTINUM

POSTERIOR ANTERIOR

ESOPHAGUS
a::
Q TRACHEA
a::
w
a..
::;) SUPERIOR VENA CAVA
en
ARCH OF AORTA

ANTERIOR

a::
Q MIDDLE
a::
w
u..
z

POSTERIOR

FIGURE 19-7

3. Cervical mediastinotomy and tracheomediastinotomy 8. Gastric pull up (see Fig. 21-11)

(see Fig. 19-3) 9. Resection of medial third of the clavicle (see Fig.
4. Resection of cervical esophagus at the thoracic inlet 19-9)
(see Fig. 21-12) 10. Tracheal resection (see Fig. 19-4)
5. Exposure of the innominate artery (see Fig. 22-18) 11. Excision of mediastinal parathyroid adenoma and
6. Transcervicaltotalthymectomy (see Fig. 19-12) cystadenoma (see Fig. 18-20)
7. Mediastinal dissection for tracheostoma recurrence
(see Fig. 19-11)
 THE TRACHEA AND MEDIASTINUM
Mediastinoscopy (Fig. 19-8)
Although the prime object of mediastinoscopy is the
evaluation of superior mediastinal lymph node involve-
ment in the resectability of bronchogenic carcinoma, it
has application in other selected diagnostic problems.
These include primary superior mediastinal masses,
primary and secondary tumors of the trachea and of
the upper one third of the esophagus, and occasionally
carcinoma of the subglottic region of the larynx and
thyroid when superior mediastinal extension is sus-
pected. Diagnosis of mediastinal masses associated with
tuberculosis, sarcoidosis, metastatic mammary cancer,
and bronchogenic cysts is also possible. The two valuable
aspects of mediastinoscopy are basic tissue diagnosis
and evaluation regarding resectability. The anterior
portion of the superior mediastinum, however, is not
visualized, because the scope is inserted in a plane
posterior to the arch.
In the evaluation of mediastinal disease (e.g., left
recurrent nerve paralysis and nodal disease), in addi-
tion to a standard chest radiograph, a CT scan and, if
sagittal and coronal views are needed, an MRI are
excellent (see Chapter 1).
In 1991, visualization of the anterior mediastinum
was achieved with the mediastinoscope. A left inferior
parathyroid gland was identified. Biopsy proved that
this was a normal parathyroid gland located in the
region of the arch of the aorta. The indication for this
search and identification was that this patient had a
papillary carcinoma of the thyroid associated with
hypercalcemia, all being due to exposure to ionizing
radiation in childhood. Endoscopic biopsy was per-
formed utilizing the telescopic endolaryngeal forceps
(Lore-Storz) (see Fig. 4-1C).
Highpoints
1. CT scan is mandatory-preferably MRI for vascular
relationships.
2. General anesthesia is preferred with controlled
respiration via an endotracheal tube.
3. The plane of introduction is in the midline along
the anterior aspect of the trachea posterior to the
innominate artery and the aortic arch to the tracheal
bifurcation. The innominate veins lie anterior to
the arch and are thus protected. The innominate
artery or the right common carotid artery may be
above the thoracic inlet where it crosses the
trachea.
4. Palpation with finger and blunt dissection is advan-
tageous in this plane before insertion of the medi-
astinoscope. This is most important.
S. Obviously, no biopsy is made of a pulsating mass
or any vascular structure.
6. Fine-needle aspiration is performed on any unknown
mass before biopsy as a check regarding vascular
structure.
7. Bronchoscopy precedes mediastinoscopy in most
situations.
8. Postoperative chest radiography is done for pneu-
mothorax or widening of mediastinum.
9. Special caution is required because lymph nodes
are often located close to major vessels (e.g., left
pulmonary artery that crosses the left mainstem
bronchus and on the right the azygos vein).
10. Laryngeal instruments (e.g., alligator forceps, micro-
laryngeal forceps, and the Lore-Storz laryngeal tele-
scope with or without the biopsy forceps) are ideal
for dissection, biopsy, and visualization.
11. Always be cognizant of necessity to perform a
median sternotomy-although very rare-to control
persistent bleeding.
A A small transverse incision, 3 to 4 em, is made in
the suprasternal notch with the patient's neck hyper-
extended. The anterior wall of the trachea is exposed
by separating the strap muscles in the midline and by
sectioning the pretracheal fasciaverticallybelow the level
of the thyroid isthmus. The thyroid may require division
and ligation. Take care not to injure the thyroid gland
and the inferior thyroid veins. The anterior jugular veins
may cross the trachea just below the thyroid isthmus. The
right common carotid artery and/or the innominate artery
may cross the trachea above the suprasternal notch.
B Using blunt dissection with a large curved clamp
and finger, the plane anterior to the trachea is opened
down to the tracheal bifurcation. Careful and thorough
evaluation is first performed with finger exploration.
Pulsating structures are then identified. The medi-
astinoscope is introduced in the midline. Portions of
the following structures can then be visualized, depend-
ing on the disease present, keeping the tracheal rings
in view at all times:
1. Anterior tracheal and paratracheal regions
2. Anterior subcarinal area
3. The takeoff of the right and left mainstem bronchi
and the right upper lobe branches
4. Major vessels: innominate artery, aortic arch, right
pulmonary artery, and azygos vein
C Nodes accessible and inaccessible for biopsy are
listed in Band C (Pearson et aI., 1968).
 THE TRACHEA AND MEDIASTINUM

A NODES
INACCESSIBLE

( LIMITED ,
I NT. MEDIASTINAU
I (Inf.Parathyroid) I
,------_/
NODES ACCESSIBLE
ANT SUBCARINAL

SUBAORTIC

POST. SUBCARINAL

NODES ACCESSIBLE

:A.RATRACHEAL }RIGHT
PRE TRACHEAL &LEFT
,/--------"
I LIMITED POSTERIOR I
I MEDIASTINAL I
\ _ (~ue: ~a~t~yr.:>i~_ )
c

FIGURE 19-8

Various types of laryngeal biopsy forceps are ideally structure. When a biopsy is deemed safe, a sharp forceps
suited. If a biopsy of a mass that is not obviously a lymph is utilized to avoid pulling or tearing a specimen loose.
node is contemplated, aspiration with a special long- An excellent forceps is the telescopic endolaryngeal for-
angulated needle is first performed to rule out a vascular ceps (Lore -Storz) depicted in Figure 4-7.
 THE TRACHEA AND MEDIASTINUM
As pointed out by Pearson, the right pretracheal
lymph nodes may be missed at mediastinoscopy unless
a deliberate digital examination is made in the anterior
location. This admonition also applies to a large right
para tracheal node. To visualize this node, overlying adi-
pose tissue is carefully dissected with laryngeal alligator-
type forceps. Care and patience as well as slow progress
is important to prevent injury to large and small vessels
and to the mediastinal pleura.
If the pleural space is entered, the resulting pneu-
mothorax is aspirated via a catheter through the open-
ing in the pleural space, the lung is inflated, and then
the catheter is removed at the time of closure. A post-
operative chest radiograph should be done to evaluate
the status of the lung expansion. The neck incision is
then closed without drainage.
Complications
• Bleeding: treat with cautery (e.g., silver nitrate stick
grasped with laryngeal alligator forceps, silver clips,
hemostatic gauge, or packing).
• Pneumothorax: treat with aspiration and inflation of
lung.
• Left recurrent nerve injury
• Possible implantation and dissemination of malignant
tumor: treat with radiation therapy.
• Possible injury to thoracic duct
Mediastinal Dissection
Various types of mediastinal dissection are described in
this atlas. A summary of the types of approaches to the
mediastinum and the indications are listed below.
Suprasternal Approach via the Superior
Thoracic Inlet (Limited Dissection)
Indications
• Substernal extension of thyroid tissue
• Thymectomy (see Fig. 19-12); in the search for
mediastinal parathyroid adenoma (see Fig. 18-19)
• Evaluation and removal of the most superior
mediastinal nodes for whatever cause
Substernal extension of a goiter can usually be
removed by this approach. On the other hand, a true
substernal goiter has its blood supply within the
mediastinum; and although this, too, can be removed
by the suprasternal approach, one must nevertheless be
prepared to use one of the other methods of exposure.
Improvement of the suprasternal approach can be
achieved by a vertical incision extending inferiorly through
the lower skin flap of a thyroidectomy incision. This extends
for approximately 4 cm over the midline of the manubrium
sterni and exposes horizontalligamen-tous bands attached
to the superior edge of the manu-brium. These bands
make up the interclavicular liga-ment which unites the
sternal ends of the two clavicles, extending across the
suprasternal notch. These bands are then transected
under full view, facilitating several additional centimeters
of exposure into the portion of the superior thoracic
inlet. The transection can be done with a finger under
the ligament plus using a Bovie cutting mode. The addi-
tional exposure is excellent to visualize and protect the
innominate artery and the right common carotid artery.
Resection of the Medial Third of the
Clavicle on One Side (See Fig. 19-9)
(Lore and Szymula, 1980)
Indications
• Thyroid disease. Nodal disease in malignant thyroid
neoplasia as well as true substernal goiter is removed
when the suprasternal approach is inadequate.
• Removal of more extensive nodal disease from what-
ever cause. The exposure is limited on the contralat-
eral side of the resected clavicle.
Mediastinal Thyroid Disease
The study included 53 patients:
Suprasternal approach: 27 patients
Mediastinal approach: 26 patients
Medial third clavicular resection: 15 patients
Median sternotomy: 6 patients
Combination: 4 patients
Resection of manubrium sterni: 1 patient
Histopathology
A thyroid specimen was obtained in 26 patients:
Benign goiter: 17 patients
Follicular adenoma: 3 patients
Hashimoto's disease: 1 patient
Graves' disease: 1 patient
Hlirthle cell carcinoma: 2 patients
Mixed follicular-papillary carcinoma: 1 patient
Predominant papillary carcinoma: 1 patient
Results
Surgical Complications
Paralysis of the one recurrent laryngeal nerve with
normally functioning vocal cords preoperatively:
temporary, 5; permanent, 0

Paralysis of external branch of superior laryngeal nerve:
temporary, 0; permanent, 0
Hypoparathyroidism: temporary before discharge, 7;
temporary resolved at home, 2; permanent, 1 (patient
now being weaned off calcium)
Tracheostomy: temporary, 2; permanent, 0
Pneumothorax, hemothorax, hemomediastinum, 0
Tracheal and/or esophageal perforation, 0
Respiratory failure, 0
Tracheomalacia, 0
Seroma,5
Mediastinitis, 0
Hemorrhage, 0
Conclusion
Resection of mediastinal thyroid disease, benign or
malignant, can be performed using the approaches des-
cribed. There was no intraoperative nor postoperative
mortality related to these techniques (1 patient died at
home 22 days postoperatively of cardiac disease). Using
a median sternotomy, transclavicular approach, resec-
tion of manubrium sterni, or a combination of these,
thoracotomy has not been necessary to successfully
perform a total mediastinal thyroidectomy (Lore et a!.,
1994).
Median Sternotomy
Indications
• Extensive malignant thyroid disease
• Whenever additional exposure is necessary and not
achieved by either of the two previous methods (e.g.,
mediastinal parathyroid adenoma) (see Fig. 18-19)
If there is some question as to whether a midline
sternotomy is necessary (e.g., in the resection of a true
substernal thyroid), the anterior cortex of the manubrium
and the sternum can be transected with a sagittal plane
saw via a vertical incision. Then if bleeding does occur
during a suprasternal approach, the inner cortex can be
quickly transected to accomplish the complete midline
sternotomy.
Resection of the Manubrium With or
Without a Portion of the Sternum and
Medial Portion of the Clavicle
(See Fig. 19-11)
This is a method that facilitates a lower location for a
tracheostomy below the level of the suprasternal notch.
Indications
• Tracheostomal recurrence after total laryngectomy
THE TRACHEA AND MEDIASTINUM
• Extensive subglottic tumors extending inferiorly into
trachea. This can be combined with a totallaryngec-
tomy (Harrison, 1977).
• Malignant neoplasms of the cervical trachea
and/or the cervical esophagus depending on the
extent of disease and the type of reconstruction
necessary
If at all possible, radiation therapy should be avoided
before this type of operative procedure. Radiation therapy
can devitalize tissue and set the stage for rupture of
major vessels, thus making any surgical procedure diffi-
cult or contraindicated. Mediastinal dissection is prefer-
ably avoided in the presence of a tracheostomy because
of the possibility of mediastinitis.
Exposure of the Mediastinum
by Resection of the Medial Third
of the Clavicle (Fig. 19-9) (Lore and
Szymula, 1980)
Diseases Amenable to the Approach
With Medial Third Clavicle Resection
(Table 19-2)
1. Substernal thyroid
2. Resection of carcinoma at the tracheal stoma area
combined with resection of the mediastinum
3. Cervical thoracic esophageal surgery
4. Transposition of the pectoralis major flap into the
cervical area for additional flap length and to avoid
pressure on the pedicle vessels as well as eliminat-
ing the supraclavicular dead space
5. Approach and exposure of the subclavian arteries
6. Exposure of the upper thoracic vertebrae (Sundaresan
et a!., 1984)
Access to the superior mediastinum can be achieved
by using anyone of a number of methods. The method
of access depends on the pathologic process as well as
the location and extent of the disease. For example, sub-
sternal extension of thyroid disease can often be removed
with careful blunt dissection via the suprasternal inlet.
On the other hand, tracheostomal recurrence of carci-
noma requires resection of the manubrium and a portion
of both clavicles, as depicted in Figure 19-11. Between
these two approaches lies resection of the medial third
of the clavicle, which affords visualization of the
superior mediastinum, often sufficing for an ipsilateral
resection of disease. Good to excellent exposure of the
great vessels, trachea, and esophagus can thus be
accomplished with minimum deformity and minimum
operating time.
 THE TRACHEA AND MEDIASTINUM

Exposure of the Mediastinum

by Resection of the Medial Third
of the Clavicle (Continued)
(Fig. 19-9) (Lore and Szymula, 1980)
Resection of one half of the clavicle is utilized in
transposing the pectoralis major myocutaneous flap
when additional length is necessary. Hence, when intra-
operative inspection warrants a superior mediastinal
entry, this is first attempted from above by careful blunt
dissection. If the disease is adherent to the mediastinal
structures, if exposure is inadequate, or if the recurrent
laryngeal nerves are in jeopardy, a resection of the
medial one third of the clavicle is then performed. This
resection can be accomplished on either side depend-
ing on the origin of disease.
The procedure is performed usually unilaterally but
can be bilateral. Although excellent exposure of the
ipsilateral side of the mediastinum is achieved, expo-
sure of the contralateral side may be somewhat limited.
Hence, if a complete mediastinal dissection or explora-
tion is necessary, the surgeon must consider a midline
mediastinotomy (see Figs. 19-1OA to Land 19-11)
relative to mediastinal dissection for tracheostomal
recurrence.
A Schematic anatomy is depicted for resection of
the medial third of the left clavicle. Exposure can be
achieved at times through the usual horizontal incision
for a thyroidectomy. If on the other hand this is inade-
quate, a vertical inferior midline incision can be made
through the lower skin flap of the thyroidectomy inci-
sion. This incision extends over the sternum. If a neck
dissection is performed, the exposure is achieved by
further mobilization of the inferior skin flap of the neck
dissection. The dotted lines outline the portion of the
medial third of the clavicle to be resected and the site
of the transection of the sternocleidomastoid muscle.
The sternal head of the muscle is transected 2 to 3 cm
above its origin. This allows adequate length distally to
reapproximate the sternal head at the close of the
operation if a radical neck dissection has not been
performed. The other alternative is a combination of
both resection of the medial third of the clavicle and
median sternotomy. This approximation of the sternal
head of the muscle is not possible, obviously, if a por-
tion of the manubrium sterni is removed. This type of
approximation ensures normal topographic placement
of the sternal head and thus decreases some of the
cosmetic deformity. The pectoralis major muscle is
sectioned along its attachment to the inferior border
of the clavicle.
B Alexander and Doyen elevators are utilized to
elevate, where possible, the periosteum of the clavicle
5 cm from the sternoclavicular joint. At this point, a
malleable retractor is inserted beneath the clavicle
over the subclavius muscle, which has been separated
from the undersurface of the clavicle. The retractor
protects the subclavian vein and artery and the apical
pleura from the Gigli saw that is then passed beneath
the clavicle to transect the bone. The sternohyoid and
the sternothyroid muscles are transected near their
origins at the sternum. The nerve supply to these mus-
cles may be interrupted, because the ansa cervicalis
has penetrating branches at the inferior extent of these

TABLE 19-2

Advantages Disadvantages

Resection of Medial Third
of Clavicle
Median Sternotomy
Easier approach to both the anterior and
posterior mediastinum.
Good exposure in obese patients,
particularly laterally in the anterior
mediastinum.
Usually a good exposure in the entire
anterior mediastinum bilaterally except
in the very obese patient.
Contralateral side; has limited exposure.
Exposure to substernoclavicular joint area
may be limited.
It is also limited for the posterior mediastinum.
If need be:
1. The median sternotomy can be combined
with resection of the medial third of the
clavicle.
2. Bilateral resection of the medial third of the
clavicle is possible.

STERNOCLEIDOMASTOID
STERNOHYOID M. EXTERNAL JUGULAR V.
STERNAL HEAD
S!
,
l
FIGURE 19-9
muscles. If the strap muscles have been transected more
superiorly during the initial part of the procedure, they
do not have to be transected inferiorly. In fact, the
longer ends of the muscle can be inverted into the
mediastinum at the close of the procedure to reduce
the dead space.
When all the muscular attachments to the medial
one third of the clavicle have been removed, the clavicle
is disarticulated at the sternoclavicular joint after the
anterior sternoclavicular, interclavicular, and costoclavicu-
lar ligaments have been transected using a scalpel plus
Bovie cutting current.
The portion of manubrium sterni indicated by diag-
onal lines can be resected for additional exposure if
necessary. This can increase the diameter of the tho-
racic inlet when gastric pull-up is performed into the
cervical area. This also will afford additional visualiza-
tion of the mediastinum, if necessary.
THE TRACHEA AND MEDIASl1NUM
M.
DELTOID BRANCH OF
THORACOACROMIAL A.
In addition, this can be utilized for exposure of the
upper thoracic vertebrae as described by Sundaresan
and colleagues (1984). This approach is directed at the
bodies of the vertebrae for the treatment of primary
cancers and occasionally metastatic disease, especially
when there is compression of the spinal cord. The tribu-
taries of the innominate artery and the left brachio-
cephalic vein are ligated and transected, with retraction
of the vein inferiorly. The carotid sheath is retracted
laterally, while the trachea, esophagus, and the left
recurrent laryngeal nerve are retracted medially beyond
the midline. This affords exposure of C7 and Tl and T2.
After resection of the bodies of the vertebrae, the resected
portion of the clavicle is utilized as a strut graft with
implantation of bone chips tightly packed to augment
the fusion. An orthotic support must be used for post-
operative immobilization to prevent spinal cord injury.
Continued
 THE TRACHEA
AND MEDIASTINUM
Exposure of the Mediastinum
by Resection of the Medial Third
of the Clavicle (Continued)
(Fig. 19-9) (Lore and Szymula, 1980)
C The anatomy after the medial third of the left
clavicle has been removed viewed from below.
Possible Complications (These Have Not
Occurred)
• Pneumothorax
• Mediastinitis
• Hemorrhage
There has been minimal functional deformity as a
result of the resection of the medial third of the clavicle.
There is virtually complete range of motion of the upper
extremities. The only cosmetic deformity is a slight
depression over the resected clavicle.
D The superior mediastinum after the medial third
of the left clavicle has been removed is viewed from
above from the left side. At times, the arch of the aorta
can be visualized by gentle retraction of the left bra-
chiocephalic vein (left innominate vein). Either a
Langenbeck or small Deaver retractor is placed beneath
the manubrium to retract it to the contralateral side,
thus enhancing the exposure beyond the midline.
SUPERIOR
..-J.-
,
/~.\ •.-( EXTERNAL JUGULAR V.
. SCALENUS ANTERIOR M.
\
c INFERIOR
FIGURE 19-9 Continued
Complete exposure of the contralateral side is, how-
ever, somewhat limited.
The esophagus, which is usually slightly to the left
of the midline, is easily exposed by retracting the
trachea to the right and retracting the left common
carotid artery, jugular vein, and vagus nerve to the left.
The left recurrent laryngeal nerve is best visualized and
protected as it passesthrough the operative field.
E The superior mediastinum after the medial third of
the right clavicle has been removed is viewed from
above from the right side. Further exposure is achieved
as is described under the resection of the clavicle on
the left side. Excellent visualization of the brachio-'
cephalic (innominate) artery is achieved. The right
recurrent laryngeal nerve is shown as a dotted line as
it passesaround and behind the subclavian artery and
the common carotid artery. The right recurrent laryn-
geal nerve, when associated with a posterior medi-
astinal goiter, may pass anterior to the right thyroid
lobe. The nerve can thus be placed in extreme jeopardy
when removing the right thyroid lobe. The esophagus
is exposed by retracting the trachea to the left and the
right common carotid artery and jugular vein to the
right.
After the definitive procedure has been completed in
the mediastinum, two Penrose drains are inserted. One
of these drains is brought out through a stab wound
made in the inferior skin flap at its lowest point of
STERNOCLEIDOMASTOID M.
, .----CLAVICLE
INTERNAL JUGULAR V.
SUBCLAVIUS M. LEFT SIDE
~; SUBCLAVIAN A.
SUBCLAVIAN V.
THORACIC DUCT
 THE TRACHEA AND MEDIASTINUM

INFERIOR

LT. BRACHIOCEPHALIC V.

MANUBRIUM
SUBCLAVIAN V. i \ VAGUS N.

SUBCLAVIAN A. SUBCLAVIAN V.
LEFT I
VAGUS N.
INTERNAL JUGULAR V.
LT.CLAVICLE

INTERNAL JUGULAR V.
COMMON CAROTID A.
COMMON CAROTID A.

SUPERIOR D

INFERIOR

BRACHIOCEPHALIC A.
(INNOMINATE)

R;r. BRACHIOCEPHALIC V.
\
LT. BRACHIOCEPHALIC V. ; LARYNGEAL N.
VAGUS N.
LT. SUBCLAVIAN V.
INTERNAL JUGULAR V.

LT. INT. JUGULAR V.

COMMON CAROTID A.

E
SUPERIOR
FIGURE 19-9 Continued

mobilization. The other drain is brought out through a
cervical incision. There is considerable dead space in
the mediastinum. A suction catheter would be ideal in
this dead space and could be utilized if it is placed in
such a fashion that it is not in contact with any of the
vessels, for fear of vessel erosion. Such a suction
catheter is not utilized if a tracheostomy is performed,
because it would suction tracheal secretions into the
mediastinum. If at all possible, a tracheostomy is best
avoided, because it could invite mediastinitis. A cricothy-
roidotomy might be the procedure of choice if indicated.
If a radical neck dissection has not been performed,
the sternal head of the sternocleidomastoid muscle is
reapproximated, as are the strap muscles. If the strap
muscles were transected high in the neck, their distal
ends can be turned into the mediastinal dead space.
 THE TRACHEA AND MEDIASTINUM
Median Sternotomy, Total
Thyroidectomy, With Superior
Mediastinal Node and Radical Neck
Dissection (Fig. 19-10)
Highpoints
I. Superior mediastinal node dissection is indicated with
evidence of gross or microscopic disease extending
below the thoracic inlet.
2. Approach to mediastinal dissection depends on acces-
sibility of the mediastinal disease. This can be accom-
plished by the following:
a. Suprasternal approach via the superior thoracic
inlet
b. Resection of the medial third of the clavicle (see
Fig. 19-9) on the side of most significant disease
c. Midline sternotomy when there is extensive disease
requiring more exposure, precluding either of the
above approaches. Midline sternotomy is almost
always necessary when complete superior mediasti-
nal node dissection is indicated. It is mandatory
when there is any question of adequate exposure
because of adherence to the great vessels and when
smaller vessels extending inferiorly beneath the
sternum cannot be seen after resection of the
middle third of the clavicle.
d. Resection of manubrium sterni
3. Pneumothorax must be recognized and treated by
intercostal underwater drainage (see Fig. 2-6).
A 1 The incision is made as outlined starting with the
standard horizontal thyroidectomy incision. This is
extended as depicted (Lahey) for the radical neck dis-
section. A vertical extension is made in the midline
over the sternum to the level of the lower edge of
the third costochondral cartilage. The attachrnents of
the pectoralis major muscles to the sternum are not
dis-turbed except to clear a 1.S-cm path in the
midline.
A The right lobe of the thyroid has been dissected
leaving behind no remnant of thyroid tissue. The tech-
nique is similar to the operation of total thyroidectomy
and radical neck dissection (see Fig. 18-12). The recur-
rent nerve is preserved if no gross disease is evident in
this area. The same is true of the parathyroid glands.
They may subsequently be removed from the specimen
if no gross disease is evident in their locale and reim-
planted in an available muscle (see Fig. 19-1 OK and L).
The anterior edge of the trapezius muscle on the
homolateral side is preferred. The thyroid ima vein or
veins may be ligated at this stage.
B The substernal space is entered carefully by blunt
dissection using the index finger and keeping close to
the manubrium and sternum. Heavy fascia will be
encountered at this point running in horizontal fashion.
The dissecting finger is kept between this fascia and the
manubrium. The fascia is sectioned after the manubrium
and sternum are split.
C The sternum is split with a sternal Stryker saw or
Lebsche knife, taking care that the flange on the saw
or knife hugs the sternum. (If explosive anesthetic gases
are used, a nonmetallic mallet head should be employed.
This precaution is virtually nonexistent with today's
anesthetic agents-an interesting historical point.) This
is ensured by having the assistant practically lift the
patient off the operating table. Another precaution is
to tilt the saw or knife so that its tip is always pointed
upward. These two maneuvers will protect the sub-
sternal vessels. Opposite the second or third interspace
the knife is utilized to prevent breaking the saw blade,
and it is turned laterally. Care is exercised so that the
internal mammary vessels and parietal pleura are not
injured. If necessary, these vessels may be ligated. If
additional mobilization is necessary, the manubrium is
cut horizontally opposite the first intercostal space on
the opposite side. (Alternate approach is a complete
sternotomy, which is very seldom indicated.)
D A preferred method of opening the mediastinum
is with a Stryker sternal-splitting saw. A flexible ribbon
retractor is inserted substernally after the blunt finger
dissection. Cautery is utilized to control bleeding from
the cut edges of the sternum.
Continued
 THE TRACHEA AND MEDIASTINUM

Stump info
thyroid a.

In!. jug. v.

Thyroid ima v.

FIGURE 19-10
 THE TRACHEA AND MEDIASTINUM
Median Sternotomy, Total
Thyroidectomy, With Superior
Mediastinal Node and Radical Neck
Dissection (Continued) (Fig. 19-10)
E The left sternocleidomastoid muscle and the sternal
origins of the left sternohyoid and sternothyroid muscles
are transected after identification of the contents of
the carotid sheath.
El A curved Kelly clamp is carefully inserted beneath
the substernal transverse fascia and the fascia is cut
with a No. 15 blade knife. This releases the two cut
halves of the manubrium and sternum.
F A small Finochietto rib spreader or special sternal
retractor exposes the mediastinum. Dissection is
begun on the right side along the reflection of the
parietal pleura and over the superior vena cava. Lymph
nodes (see Fig. 16-2A on the anatomy of the lymph
nodes), along with the encountered portion of the
thymus gland, are reflected en masse toward the left.
Small thymic arteries usually arise from the internal
mammary arteries, and the right-sided one may be
encountered at this stage. It is ligated and transected.
Additional blood supply to the thymus arises from
branches of the inferior thyroid arteries and enters the
upper poles of the thymus. The thymus gland is
roughly H shaped with the upper poles sometimes in
the cervical region. The larger lower extensions overlie
the aorta and pericardium. If the parathyroid glands
are not identified, preserved, or reimplanted, make
every effort to preserve the thymus, because parathy-
roid tissue may be within it. If the thymus must be
removed, search for parathyroid glands and reimplant
them.
G As the dissection proceeds from right to left, the
superior vena cava is exposed along with its tributaries,
the right and left innominate veins. Small veins from
the thymus gland are encountered on the inferior sur-
face of the left innominate vein. These are all ligated
and transected. Additional thymus veins drain into the
thyroid veins. It will be noted that the left innominate
vein is much longer than the right, because it crosses
the mediastinum, overlying the origin of the innom-
inate artery from the arch of the aorta.
Continued
 THE TRACHEA AND MEDIASl1NUM

Jhyroid ima v.

Sternohyoid m.

In!. jugular v.

AI. innominate v.

Pleura, rl. lung

Sup. vena cava

FIGURE 19-10 Continued

 THE TRACHEA AND MEDIASTINUM
Median Sternotomy, Total
Thyroidectomy, With Superior
Mediastinal Node and Radical Neck
Dissection (Continued) (Fig. 19-10)
H The superior mediastinal node dissection is com-
pleted with the contents either left in continuity with
the cervical portion of the specimen or removed sepa-
rately. On the left lateral border of the mediastinum,
the parietal pleura is evident with the arch of the aorta
and its ascending branches: the left common carotid
artery and the barely visible left subclavian artery. The
left vagus nerve is seen deep to the left innominate
vein overlying the arch of the aorta. The origin of the
left recurrent nerve from the vagus nerve will probably
not be visualized because it sweeps behind the lower
edge of the aortic arch and ascends deep to the arch.
Its ascent deep to the left common carotid artery will
be noted above the level of the left innominate vein.
The right vagus nerve crosses the right subclavian
artery at its origin from the innominate artery. At this
point the right recurrent nerve takes origin and sweeps
behind the subclavian artery. It reaches the right
tracheoesophageal region by passing deep to the right
common carotid artery near its origin from the
innominate artery.
The thyroid ima vein is ligated and divided as is the
left internal jugular vein just above the latter's junction
with the left subclavian vein. The thoracic duct empties
into the venous system at this juncture and should not
be injured.
I, J The left lobe of the thyroid and the isthmus are
now dissected upward, transecting the ligament of
Berry and sacrificing, in this particular case, the left
recurrent laryngeal nerve, becausethe nerve was affixed
to the left lobe by grossly diseased tissue. On preoper-
ative mirror laryngoscopy there was left abductor vocal
cord paralysis. Under such circumstances, no attempt
is made to identify and to preserve parathyroid tissue
on this side, provided the right parathyroids were iden-
tified and preserved or implanted. All the paraglandular,
paratracheal, and tracheoesophageal lymph nodes are
removed. It may be necessary to remove a section of
trachea. Up to three tracheal rings can be excised with
primary end-to-end anastomosis by mobilization of
the trachea (Grillo; Som) or release of the larynx (Dedo
and Fishman, 1969) or both. Flexing the head forward
will aid in this maneuver. The head should be kept
flexed during the healing period.
K Technique of parathyroid gland implant in the
anterior border of the base of the left trapezius muscle
is shown. Slicing parathyroid tissue in portions 0.3 mm
or lessafforded a good take when implanted in muscle.
Feind has also substantiated this concept by using
small sections of parathyroid tissue for implantation.
L The thin slices of parathyroid tissue are embedded
in the muscle. The edges of the muscle pocket are
approximated with interrupted silk. The site is marked
with a metallic clip.
Continued
 THE TRACHEA AND MEDIASTINUM

Int.jug. v. \\

/7~.:i@1.JG. BERR~
d'-:?'~
/: I"
. /Com. carotid a.

i
H I
¥- ...- ....
I

Esophagus
Stump int. thyroid a.
Parathyroids

Proximal end
rec. laryngeal n.
Com. carotid a.
Vagus n.

L. innominate v.

FIGURE 19-10 Continued

 THE TRACHEA AND MEDIASTINUM

Median Sternotomy, Total

Thyroidectomy, With Superior muscles) is carefully identified and preserved. The
Mediastinal Node and Radical Neck superior thyroid artery is ligated and transected close
Dissection (Continued) (Fig. 19-10) to its origin from the external carotid artery. The
accompanying vein may be resected in continuity with
Complete Median Sternotomy the internal jugular vein after superior tributaries
are divided. The remainder of the radical neck dissec-
Partial median sternotomy as depicted may not afford tion is completed in the usual fashion (see
adequate exposure to the following disease processes: Fig. 16-3L to W).
1. Mediastinal parathyroid adenomas Continued
2. Thymomas
Occasionally, the carcinoma of the thyroid has grossly
In these circumstances, a complete median sternotomy invaded the larynx-the thyroid alar and/or the cricoid
to the xiphoid is warranted. Exposure is a sine qua non. cartilage. If the tumor, because of its histology (e.g.,
A temporary chest tube is utilized to drain the medi- medullary carcinoma or some Hiirthle cell carcinomas
astinum usually for 24 hours. The tube must avoid or squamous cell carcinoma) is not anticipated to pick
contact with any vessel. up postoperative iodine-131, a partial laryngectomy
(see Fig. 20-11) or very rarely a total laryngectomy (see
Fig. 20-18) may be necessary. Partial pharyngectomy
M The standard radical neck dissection (see Fig. 16-3) and esophagectomy may also be necessary.
is continued along the median plane by cleaning the
submental space. The insertions of the sternohyoid, Complications
sternothyroid, and omohyoid muscles are cut, including
these strap muscles with the resected specimen. The • Infection: sternal incision, mediastinum and empyema,
thyrohyoid muscle is not removed. Some surgeons, cervical region
depending on the absence of gross metastatic disease, • Hypoparathyroidism
leave the contents of the submaxillary triangle intact. • Hypothyroidism
• Pneumothorax
N The superior laryngeal nerve with its internal branch • Pain
(sensory to the larynx) and external branch (motor to • Dehiscence of sternotomy and major skin slough of
the cricothyroid and inferior pharyngeal constrictor chest wall
 THE TRACHEA AND MEDIASTINUM

Ant. belly digastricus m.

Mylohyoid m.

Hyoid bone
Omohyoid m.

;;J
Sternohyoid m.
Ext. br. sup. laryngeal n.

Cricothyroid m. Cricopharyngeus m.

Stump infothyroid a.

/
Stump int. jug. V.

Hyoid bone

Int. br. sup. laryngeal n.

Inf. pharyngeal constrictor m.
Ext. br. sup. laryngeal n.
Int. jugular vein
N Vagus n.
Esophagus

Com. carotid a.
Phrenic n.
Prox. end of rec. laryngeal n.

FIGURE 19-10 Continued

 THE TRACHEA AND MEDIASTINUM
Median Sternotomy, Total
Thyroidectomy, With Superior
Mediastinal Node and Radical Neck
Dissection (Continued) (Fig. 19-10)
o The median sternotomy is closed by drilling small
holes or using a sternal punch through and through
with a ribbon retractor for protection of the underlying
great vessels. Malleable silver wire or stainless steel
wire is first threaded outside-in through the left-sided
hole. The eyelet end of a curved needle is then passed
outside-in through the right-sided hole, and the wire
is inserted through the needle hole by using a clamp
or needle holder. The wire is pulled through the right-
sided hole with the needle. Another method is to use
a pull-through fine wire on the right side, which forms
a loop. The heavy wire is passed through the loop and
withdrawn.
P This technique is repeated as pictured for the
remainder of the sternal approximation. Some opera-
tors do not believe such through-and-through sutures
are necessary. They use periosteal and perichondrial
sutures with supporting sutures through the fascia.
Q A tracheostomy is performed if indicated, and two
drains are inserted, one in the cervical region and one
in the mediastinum. If a small portion of trachea is
excised with the thyroid tumor, depending on its loca-
tion, the resulting defect could serve as the site of the
tracheostomy. If a complete circumferential portion is
excised, refer to the section on tracheal resection (see
Fig. 19-4). If the pleural cavity was entered, an inter-
costal tube with underwater drainage is mandatory
(see Figs. 2-3G to J and 2-4 to 2-6). If the upper
respiratory or pharyngoesophageal tract was entered,
it is best to insert tube drainage into the mediastinum
because of the danger of fistula formation in the cervi-
cal region, which would then drain into the mediastinum.
Such tubes must not come in contact with any major
vessel for fear of vessel erosion. Catheters with nega-
tive pressure may be used in place of the cervical drain.
 THE TRACHEA AND MEDIASTINUM

, 01
~/a~

FIGURE 19-10 Continued

 THE TRACHEA AND MEDIASTINUM
Mediastinal Dissection for
Tracheostoma Recurrence
(Sisson Procedure) (Fig. 19-11)
(After Sisson) (Harrison, 1977)
Although tracheostoma recurrence was more common
some years ago, currently the incidence appears to be
decreasing. This is most likely due to a number of factors,
not the least of which are adequate tracheoesophageal
dissection at the time of laryngectomy, the use of pre-
operative adjuvant chemotherapy aiding in the avoid-
ance of tracheostomy associated with airway compro-
mise secondary to laryngeal carcinoma, and emergency
laryngectomy with airway resection. The etiology of tra-
cheostoma recurrence is a moot point. This may be related
to nodal disease in the tracheoesophageal and superior
mediastinal areas, or it may be due to tracheostomy as
an emergency or semi-emergency procedure associated
with airway obstruction related to carcinoma of the
larynx. Initial steps of the surgical procedure of medi-
astinal dissection are directed to evaluate resectability;
for example, involvement of the major arteries in the
mediastinum would preclude resectability.
This step involves resection of the medial one third
or medial one half of the clavicle on the side of major
involvement by the neoplasm (see Fig. 19-9). The
costoclavicular ligament between the first rib and the
clavicle is transected, and the medial one half or medial
one third of the clavicle is excised. This affords an
excellent view and facilitates evaluation of the left com-
mon carotid artery and subclavian artery on the left
side and the innominate artery with the right common
carotid artery and the subclavian artery on the right
side. The thoracic esophagus (with an esophageal tube
in place) and the extent of the disease inferiorly involv-
ing the trachea are evaluated. The decision can then be
made as to whether an ablative procedure is indicated,
with a reasonable expectation of cure or palliation.
Preoperative CT scans and MRI and a pharyngoesopha-
gram are helpful, but precise evaluation regarding
resectability still depends on visualization and palpa-
tion of the superior mediastinum.
After tracheostoma recurrence, it is our admonition
not to utilize preoperative radiation therapy but rather
to use adjuvant preoperative chemotherapy. Surgery
after radiation therapy is not only difficult but increases
the risk of postoperative hemorrhage and esophageal
slough. Sisson (personal communication) believes that
if radiation therapy has failed to control the patient's
disease, the surgeon should consider esophageal resec-
tion and replacement with a gastric pull-up procedure
(see p. 1200) when there is significant dissection around
the esophagus. This will obviate an esophageal slough.
Highpoints
I. Evaluate the extent of the neoplasm and clinically
stage the types as to 1,2,3, and 4 (see Fig. 19-IIA).
2. Insert esophageal feeding tube.
3. Perform wide resection of skin and soft tissue
surrounding the sternal recurrence.
4. Depending on extent of disease, evaluate major
arteries, esophagus, and trachea.
S. Resect a portion of the clavicles with the manubrium
sterni to the level of the second rib or lower, if
required.
6. Preserve the major arteries: the innominate and its
branches, the left common carotid, and the left
subclavian. The left brachiocephalic vein (innomi-
nate) may be sacrificed if absolutely necessary. It is
better to preserve this vessel, if at all possible.
7. Preserve the vagus nerves and the phrenic nerves,
at least one of each.
8. Relocate the trachea lateral and caudad to the innom-
inate artery if necessary to obtain additional length
of the trachea.
9. Protect the innominate artery and the other vessels
in contact with the trachea by invagination of a
portion of a pectoralis major myocutaneous flap
between the trachea and the vessels.
10. Ensure adequate mediastinal drainage postopera-
tively, using very soft catheters to avoid erosion of
vessels.
II. Debulk the portion of the pectoralis major flap that
surrounds the location of the new stoma, especially
superiorly.
12. Do not use any type of metal laryngectomy or tra-
cheostomy tube because of the danger of pressure
necrosis of the trachea from pulsations of the innom-
inate artery or the aorta. Use a small length of cut
endotracheal tube if necessary. Occasionally, no
tube is necessary at all.
A The various types of stoma recurrence as out-
lined by Sisson (1969): (1) localized and usually
presents as a discrete nodule in the superior aspect of
the stoma. The prognosis is very good if detected
early; (2) indicates an esophageal involvement but no
inferior involvement (prognosis for type 2 is fair to
good depending on the amount of esophagus involve-
ment); (3) originates inferior to the tracheostoma and
usually has direct extension into the mediastinum.
Prognosis is fair to poor (4) if there is an extension
laterallyand often under either clavicleand may involve
the great vessels and be nonresectable. Prognosis is
very poor.

CLAVICLE
B
FIGURE 19-11
B The skin incision (the solid line) extends at least
2 to 3 cm beyond the gross evidence of disease
surrounding the stoma. A large skin defect is of little
concern, because a pectoralis major myocutaneous
flap (the dotted line) will be utilized for reconstruction
of the skin; the muscle portion of this flap will be used
to protect the great vessels.If feasible, the periosteum
THE TRACHEA AND MEDIASTINUM
over the sternum is left attached to the skin flaps. If
necessary,a contralateral pectoralis major flap could
be used for only its muscle portion to further protect
the innominate artery and also to reinforce a pharyn-
geal closure of the hypopharynx if a laryngectomy is
performed.
Continued
 THE TRACHEA AND MEDIASTINUM
Mediastinal Dissection for
Tracheostoma Recurrence
(Sisson Procedure) (Continued)
(Fig. 19-11) (After Sisson)
(Harrison, 1977)
C Outline of the sternal resection is shown with one
third to one half of the clavicles and the medial portion
of the first and second ribs. The level of transection
of the sternum depends on the extent of the lesion
(anatomically, the sternum is composed of three parts:
manubrium, body, and the xiphoid process). The ster-
num is transected between the attachments of the
second and third ribs. The sternal Stryker saw is utilized
to transect the ribs and sternum, whereas a Gigli saw
is utilized to transect the clavicles (see Fig. 19-9). Rib
cutters can be used to transect the ribs and possibly
the clavicles. Malleable retractor is placed underneath
the sternum for protection, as well as pleura and
internal mammary arteries. If the pleura are opened,
repair is done with the lung inflated. A chest tube is
not usually necessary unless the lung itself is lacerated.
Care is taken relative to the thoracic duct.
D This illustration is viewed from below looking
superiorly. Caudal edge of the transected sternum is
retracted upward in a plane between the sternum and
the periosteum, exposing the left and right brachio-
cephalic veins, the left and right internal jugular veins,
the superior vena cava, and the arch of the aorta. The
right internal jugular vein is retracted laterally. The
locations of both subclavian veins are identified.
Continued
The pectoralis major flap, which will be utilized to
obliterate the defect, can be mobilized now or after the
mediastinum dissection. With a large flap, the lateral
thoracic artery along with the pectoral branch of the
thoracoacromial artery is preserved. To free the lateral
thoracic artery, a portion of the pectoralis minor may
require transection on its lateral border. The midline
incision over the sternum for the mediastinum
dissection is the medial border of the pectoralis major
myocutaneous flap.
Complications
• Hemorrhage
• Mediastinitis
• Recurrence
• Slough of esophagus
 THE TRACHEA AND MEDIASTINUM

RT. COMMON CAROTID A.

INT. JUGULAR V.

RT. SUBCLAVIAN A.

INNOMINATE A.

D
SUPERIOR VENA CAVA' LT. RECURRENT LARYNGEAL N.
LT. BRACHIOCEPHALIC V.

AORTA
FIGURE 19-11 Continued
 THE TRACHEA AND MEDIASTINUM
Mediastinal Dissection for
Tracheostoma Recurrence
(Sisson Procedure) (Continued)
(Fig. 19-11) (After Sisson)
(Harrison, 1977)
E The mediastinal dissection consists of removing all
of the lymph nodes, adipose tissue, and thymus gland
remnants in the superior mediastinum. In the illus-
tration the left (innominate) brachiocephalic vein has
been resected along with the mediastinal dissection.
This mayor may not be necessary. The trachea has
been relocated laterally and inferiorly to the innom-
inate artery to gain additional length. This maneuver
depends on the extent of disease <:Indthe local anatomy.
Resection of the esophagus depends on the extent
of the disease and the type of the lesion. If the
esophagus requires resection, reconstruction depends
on the amount of resected esophagus. The reader is
referred to Chapter 21 for the various approaches to
resection and reconstruction of the esophagus (see
Fig. 21-12).
F This demonstrates the pectoralis major myocuta-
neous flap used in the reconstruction of the skin
defect. A deep portion of the pectoralis major myocu-
taneous flap is placed between the trachea and
innominate artery to protect the great vessels from any
pressure erosion. Soft suction catheters are placed in
the mediastinum for adequate drainage. Great care
must be used in placing these catheters to avoid con-
tact with major vessels, whether artery or veins. Ade-
quate drainage must be obtained and maintained for
7 to 10 days postoperatively.
A metal laryngectomy tube cannot be used. A 5- to
7-cm pliable plastic laryngectomy tube would be ideal
(Bivona) or a soft endotracheal tube cut to the desired
length. If the endotracheal tube is utilized, this is secured
to a tongue depressor in horizontal fashion, which acts
as a flange. This is padded with soft gauze. Be certain
a portion of the endotracheal tube is securely fastened
to the tongue depressor; otherwise the tube may become
dislodged and slip into the trachea and obstruct one of
the bronchi. Only use as a temporary measure.
 THE TRACHEA AND MEDIASTINUM

INT. JUGULAR V.
COMMON CAROTID,A.
SUBCLAVIAN V.
VAGU
RT. INNOMINAJ'E
,.
K' .

F
FIGURE 19-11 Continued
 THE TRACHEA AND MEDIASTINUM
Transcervical Total Thymectomy
(Fig. 19-12)
Discussion
The transcervical route for thymectomy was described
by Parker in 1913 for management of myasthenia gravis,
but with the advances of thoracic surgery, the sternal-
splitting approach became the one of choice (see
Fig. 19-1OA to G). The trans cervical approach was
revived (Crile, 1966; Kirschner et a!., 1969). The signif-
icant advantage of this latter approach is the relative
absence of pain, which is so characteristic following
the sternal-splitting incision. Thus, the postoperative
period is smoother and calmer. The problems may be
inadequate exposure for total removal of the thymus
and bleeding.
Contraindications to Transcervical Approach
• Large mediastinal mass (thymoma) may be adherent
to pleura, pericardium, and vessel walls, and tumors
of the thymus may be malignant. Median sternotomy
(see Fig. 19-1OA to 0) complete to the xiphoid is
required.
• Mediastinal mass located low in the superior medi-
astinum, beyond reach of the cervical approach.
This requires median sternotomy.
• Preexisting low tracheostomy 2 em or less above
contemplated cervical incision. The danger is medi-
astinal infection if sufficient space does not exist
between tracheostomy and suprasternal notch.
Consider cricothyrotomy (see Chapter 2).
Highpoints
1. General endotracheal anesthesia is used: no muscle
relaxants and no morphine.
2. Plane of dissection is just deep to sternum. Blunt
dissection is used.
3. Avoid injury to major vessels, especially left innom-
inate vein, by keeping plane of dissection close to
gland.
4. Avoid dissection too far laterally so as not to tear
mediastinal pleura.
S. Be prepared to convert to sternal-splitting incision
if necessary to perform total thymectomy.
6. After the operation, check the mediastinum for any
bleeding or pleural tears; obtain chest radiograph
in operating room to rule out pneumothorax.
7. Continue endotracheal tube with mechanical venti-
lation postoperatively.
8. If there is a preexisting tracheostomy, take extreme
care not to contaminate the mediastinal wound.
9. Ensure complete familiarity with physiology of
myasthenia gravis and cholinergic crisis.
10. Surgery should not be attempted unless the team
concept is available-medical, neurologic, surgical,
and nursing-to manage sudden respiratory and
supplementary drug problems.
Figure 19-1OAto L describes the median sternotomy
approach.
There is currently substantial evidence that the
thymus does in fact produce true hormones that are
secreted into the circulation and have effects on remote
tissues. Thymic tumors include thymoma, thymolipoma,
carcinoid tumor of the thymus, germ cell tumor, malig-
nant lymphoma, and oat cell carcinoma of thymus (Wick
and Scheithauer, 1982).
Malignant thymomas may be associated with a num-
ber of systemic syndromes, including (1) myasthenia
gravis, (2) pure red cell aplasia, and (3) hypogamma-
globulinemia, and may metastasize to the liver, kidneys,
extrathoracic lymph nodes, and central nervous system.
Resection of Thymoma
Complete sternotomy to the xiphoid process affords a
complete exposure and is necessary for the adequate
resection of a thymoma that may be adjacent to the
pericardium. The capsule of a thymoma should not be
violated, because it may be malignant. Both the tumor
and the entire thymus are resected along with pleural
metastasis. It is important that the entire tumor and the
thymus are removed to decrease the incidence of post-
operative myasthenia gravis. If a portion is left behind,
myasthenia gravis, which may accompany a thymoma,
is more likely to occur. Late myasthenia gravis, although
rare, may follow resection of a thymoma. By the same
token, biopsy of a thymoma is not performed because
of the danger of implantation of malignant cells. On the
other hand, biopsy may be indicated With extremely
large tumors that may be considered to be nonresectable
or non operable because of the increased surgical risk.
When the tumor involves the pericardium, left bra-
chiocephalic vein, and the superior vena cava, portions
of these involved structures may require resection.
Although resection of a phrenic nerve may be necessary,
it should, if at all possible, be preserved because of the
postoperative respiratory problems that may ensue. With
malignant lesions, if there is any question of residual
nonresectable disease, postoperative radiation therapy
may be indicated as well as chemotherapy (Wilkins,
1984). A temporary chest tube is utilized to drain the
mediastinum, usually for 24 hours.
Preparation for Thymectomy in Myasthenia Gravis
1. Medical improvement of myasthenia gravis
2. Plasmapheresis. If unsuccessful, then consider corti-
costeroids; they may induce myasthenic deterioration.

3. Pulmonary function studies
4. Arterial blood gas analysis
S. Patient must stop smoking for at least 2 weeks prior
to surgery. This improves pulmonary status.
6. Pulmonary toilet
7. Reassurance to patient to avoid any emotional upset
Myasthenia gravis can be aggravated by any of the
following:
1. Antiarrhythmic drugs: quinidine, quinine, and pro-
pranolol
2. Antibiotics: streptomycin, kanamycin, gentamicin,
neomycin, bacitracin, and polymyxin. Adverse reac-
tions to these may respond to calcium.
3. Ether anesthesia and curare-like and muscle-relaxing
agents
4. Central nervous system depressants such as morphine
and barbiturates
S. Atropine
6. Hypocalcemia
7. Renal disease
The surgeon is reminded of the possible coexistence
of myasthenia gravis and thyroid disease, especially of
the autoimmune type.
Postoperative Care
1. Ventilatory function is most important. Assisted ven-
tilation may be necessary along with respiratory inten-
sive care.
2. Chest radiograph, to rule out pneumothorax
3. Corticosteroids and plasmapheresis, as indicated
4. Emergency drugs
S. Postural drainage and bronchoscopy to treat atelectasis
6. It is usually possible to extubate the patient within a
few hours if there is mild myasthenia gravis; other-
wise leave the tube in for a longer period of time.
Adequate vital capacity should be the guide.
7. Avoid antibiotics.
Complications
• Respiratory: pneumonitis, atelectasis, pneumothorax
• Mediastinitis
• Myasthenic crises
THE TRACHEA AND MEDIASTINUM
Postoperative Phases (After Kreel et aI., 1967)
1. Free period (average is 1 day; range is 4 hours to
5 days)
a. No myasthenic symptoms
b. Excellent muscle strength and breathing
c. Anxiety pronounced
d. No cholinergic drugs necessary
2. Unstable period (average is 5 days; range is 2 to
7 days)
a. Reappearance of myasthenic symptoms: peripheral
and bulbar muscle weakness and respiratory weak-
ness
b. Cholinergic drugs necessary in varying and at times
unpredictable amounts, as indicated by the man-
agement edrophonium (Tensilon) test.
c. Cholinergic crisis with respiratory paralysis
3. Stabilization period (range is long)
a. Response to medication more stable and pre-
dictable
b. Improved handling of secretions and greater ease
of respirations
Factors responsible for improvement of post-
thymectomy morbidity and mortality include:
1. Cholinergic drug restriction
2. Medical-surgical-nursing team management
3. Tracheobronchial toilet
a. Tracheostomy: endotracheal tube has for most part
replaced tracheostomy
b. Aseptic suction
c. Bronchoscopy
d. Postural drainage
4. Mechanical support of ventilation
Current Postoperative Management
1. Respiratory intensive care including endotracheal
tube
2. Plasmapheresis
3. Corticosteroids
 THE TRACHEA AND MEDIASTINUM
Transcervical Total Thymectomy
(Continued) (Fig. 19-12)
A Depicted is the cervical incision just at the superior
edge of the suprasternal notch. The dotted line indi-
cates the site of the high tracheostomy incision, which
will be performed after the first incision is closed and
sealed. An alternate to the tracheostomy is a cricothy-
rotomy (see Chapter 2).
B Upper and lower skin flaps are minimally elevated,
especially superiorly to avoid communication with the
tracheostomy. The strap muscles-sternohyoid and
sternothyroid-are separated in the midline. The ante-
rior jugular veins at their communications may require
ligation and transection. Beneath the sternothyroid
muscles, the cervical portion of the thymus (pinkish-
tan color) will be located. Small fibrous strands or small
veins often extend from the inferior pole of the thyroid
gland to the superior pole of the thymus. This aids in
the identification of the thymus.
C With anterior traction on the manubrium, careful
blunt dissection with a "peanut" gauze clamp is per-
formed, staying initially in the plane just beneath the
sternum. Gentle traction is placed on the exposed
presenting portion of the thymus. Tender grip forceps
can be used to grasp the gland. Usually the thymus, of
rather tough tissue, is encased in only a thin layer of
fascia and is easily separated from adjacent structures.
If a thymoma is present, adherence or actual invasion
of pleura, pericardium, or other structures can occur.
This is an indication for conversion to a sternal-splitting
incision (see Fig. 19-1 OA to L). As the blunt dissection
proceeds, the line of cleavage is maintained close to
the gland, avoiding injury to the great vessels, espe-
cially the left innominate vein, and mediastinal pleura.
The thymic vessels are identified, clamped, ligated,
and divided. The usual course of these vessels is depict-
ed in the anatomic drawing in D. The veins on the pos-
terior aspect of the gland empty into the left innom-
inate vein.
D Anatomy of the arterial supply and venous
drainage is depicted. The main arteries are from the
internal mammary and inferior thyroid or innomi-
nate artery and the veins drain into both innominate
veins and thyroid veins. The gland is essentially
bilobed. The inferior parathyroid gland may be closely
related or actually within the thymus, because both
structures arise from the third pharyngeal pouch.
During the inferior migration of the thymus gland in
the embryo, portions may split off the main gland
and be located as high as the thyroid cartilage, hyoid
bone (Bien), or under the angle of the mandible
(Harman) (from Hollinshead). The usual lower extent is
at the level of the fourth costal cartilage. An anatomist
(Piersol) has described portions as low as the
diaphragm.
The dissection is then completed. The operative
wound is carefully inspected for any bleeding site or
mediastinal pleural tear. A mediastinoscope may be
utilized. A small drain is inserted and the wound is
closed in layers using an adhesive antiseptic spray over
the incision. Leave the endotracheal tube in place and
attach it to the ventilator. If the tube is to be left in
place for extended periods, the cuff is only inflated to
the degree of the "no-leak technique."
 THE TRACHEA AND MEDIASTINUM

FIGURE 19-12
 THE TRACHEA AND MEDIASTINUM
BIBLIOGRAPHY
Alvarado A: Tracheal fenestration. Arch Surg 119:235-239, 1984.
Ardito JM, Tucker GF, Ossoff RH, Deloon SY:Innominate artery com-
pression of the trachea in infants with reflex apnea. Ann Otol Rhinol
Laryngol 89:401-405, 1980.
Arnold GE: Alleviation of aphonia or dysphonia through intrachordal
injection of Teflon paste. Ann Otol Rhinol Laryngol 72:384-395, 1963.
Bahn CH, Vitikainen KJ: Repair of tracheal intubation injuries. Am J
Surg 141:528-530, 1981.
Bailey BJ, Kosoy J: Observations in the development of tracheal pros-
theses and tracheal transplantation. Laryngoscope 80:1553-1565,
1970.
Baker HW, Wise RA: Tracheostomy: Indications and technique in sur-
gical practice. Am J Surg 92:416-422, 1956.
Barclay RS, McSwan R, Welsh TM: Tracheal reconstruction without
the use of grafts. Thorax 12:177, 1957.
Biller HF, Ebert PA: Innominate artery hemorrhage complicating tra-
cheotomy. Ann Otolaryngol 69:301-306, 1970.
Bonanno PC: Swallowing dysfunction after tracheostomy. Ann Surg
174:29-33, 1971.
Brunings W: Uber Cine Neve Behandlunge methode der Rekureenslah-
mung Werhaudl. Dtsch Laryngol16:933 and 151, 1911.
Bryant LR, Spencer FC, Trinkle JK: Treatment of median sternotomy
infection by mediastinal irrigation with an antibiotic solution. Ann
Surg 169:914-920, 1969.
Bryant LR, Trinkle JK, Dubilier L: Reappraisal of tracheal injury from
cuffed tracheostomy tubes: Experiments in dogs. JAMA 215:625-628,
1971.
Butler RM, Moser FH: The padded dash syndrome: Blunt trauma to
the larynx and trachea. Laryngoscope 78: 1172-1182, 1968.
Cantrell JR, Folse JR: The repair of circumferential defects of the
trachea by direct anastomosis: Experimental evaluation. J Thorae
Cardiovasc Surg 42:589, 1961.
Catlin D: Making a large tracheal stoma during laryngectomy. Eye Ear
Nose Throat Monthly 45:87-90, 1966.
Chalon J, Loew DAY,Orkin LR: Tracheobronchial cytologic changes
during the menstrual cycle. JAMA 218:1928-1931, 1971.
Cheng WF, Takagi H, Akutsu T: Prosthetic reconstruction of the
trachea. Surgery 65:462-469,1969.
Chew JY, Cantrell RW: Tracheostomy. Arch Otol 96:538, 1972.
Chodosh PL: Cricoid fracture with tracheal avulsion. Arch Otolaryngol
87:461-467, 1968.
Cohen SR: The diagnosis and surgical management of congenital
tracheoesophageal fistula without atresia of the esophagus. Ann
Otol 79:1101, 1970.
Cooper JD, Grillo HC: The evolution of tracheal injury due to venti-
latory assistance through cuffed tubes: A pathologic study. Ann
Surg 169:334-348, 1969.
Cotton RT, Seid AS: Management of the extubation problem in the
premature child. Ann Otol Rhinol Laryngol 89:508-511, 1980.
Crile G Jr: Thymectomy through the neck. Surgery 59:213-215, 1966.
Oedo HH, Fishman NH: Laryngeal release and sleeve resection for
tracheal stenosis. Ann 0101 78:285, 1969.
Downey MJ, Kane LA, Secord LC: Nasotracheal intubation in infants
and children. NY J Med 72:2521-2523, 1972.
Dye JP: Special problem patients have with a tracheostomy. JAMA
249:702, 1983.
Dykstra CL: Tracheotomy in infants and children. Eye Ear Nose Throat
Monthly 45:84, 1966.
Edis AJ, Purnell DC, Van Heerden JA: The undescended "parathy-
mus": An occasional cause of failed neck exploration for hyper-
parathyroidism. Ann Surg 190:64-68, 1979.
Eliachar I, Zohar S, Golz A, et al: Permanent tracheostomy. Head
Neck Surg 7:99-103,1984.
Evans JNG, Todd GB: Laryngotracheoplasty. J Leg Med 88:589-597,
1974.
Fearon B, Cinnamond M: Tracheotomy in acute supraglottitis (epiglot-
titis): The treatment of choice. Laryngoscope 87:879-883,1977.
Fearon B, Whalen JS: Tracheal dimensions in the living infant. Ann
010176:964, 1967.
Feneck RO, Scott WE: Misconnection of a cuffed "speaking" tra-
cheostomy tube. Anaesthesia 38:47-51, 1983.
Fonkalsrud EW, Hermann C Jr, Mulder DG: Thymectomy for myas-
theniagravis in children. J Pediatr Surg 5:157-165,1970.
Fraser K, Bell PRF: Distal tracheal stenosis following tracheostomy.
Br J Surg 54:302-303, 1967.
Frenkiel S, Assimes I, Rosales JK: Congenital tracheal diverticulum.
Ann Otol Rhinol Laryngol 89:406-408, 1980.
Geffin B, Grillo HC, Cooper JD, Pontoppidan H: Stenosis following
tracheostomy for respiratory care. JAMA 216:1984-1988,1971.
Gerhardt HJ: Transtracheal microsurgical closure of tracheoesophageal
fistulas. Head Neck Surg 4:64-68, 1981.
Greenberg SD, Williams RK: Tracheal prostheses. Arch Otolaryngol
75:335-341,1962.
Grillo HC: Circumferential resection and reconstruction of the mediasti-
nal and cervical trachea. Ann Surg 162:374-387, 1965.
Grillo HC: Management of cervical and mediastinal lesions of the
trachea. JAMA 197:1085-1090, 1966.
Grillo HC: Terminal or mural tracheostomy in the anterior mediastinum.
J Thorac Cardiovasc Surg 51:422-427,1966.
Grillo HC: Surgical approaches to the trachea. Surg Gynecol Obstet
129:347-352, ] 969.
Grillo HC: The management of tracheal stenosis following assisted
respiration. J Thorac Cardiovasc Surg 57:52-71, 1969.
Grillo HC: Surgery of the trachea. Curr Probl Surg July:3-59, 1970.
Grillo HC: Management of tracheal tumors. Am J Surg 143:697-700,
1982.
Grillo HC, Bendixen HH, Gephart T: Resection of the carina and lower
trachea. Ann Surg 158:889-893, 1963.
Grillo HC, Dignan EF, Miura T: Experimental reconstruction of cervi-
cal trachea after circumferential resection. Surg Gynecol Obstet
122:733-738, 1966.
Grillo HC, Dignan EF, Miura T: Extensive resection and reconstruction
of mediastinal trachea without prosthesis or graft: An anatomical
study in man. J Thorac Cardiovasc Surg 48:741-749,1964.
Harris HH, Tobin HA: Acute injuries of the larynx and trachea in
49 patients (observations over a 15-year period). Laryngoscope
80:1376-1384, 1970.
Harrison DFN: Resection of the manubrium. Br J Surg 64:374-377, 1977.
Hatcher CR Jr, Calvert JR, Logan WD Jr, et al: Prolonged endotracheal
intubation. Surg Gynecol Obstet 127:759-762, 1968.
Hedden M, Ersoz CJ, Donnelly WH, Safar P: Laryngotracheal damage
after prolonged use of orotracheal tubes in adults. JAMA207:703-708,
1969.
Holinger LD, Stankiewicz JA, Livingston GL: Anterior cricoid split:
The Chicago experience with an alternative to tracheotomy.
Laryngoscope 97:19-24,1987.
Hughes M, Kirchner JA, Branson RJ: A skin-lined tube as a compli-
cation of tracheostomy. Arch Otolaryngol 94:568-570, 1971.
James AE Jr, MacMillan AS Jr, Eaton SB, Grillo HC: Roentgenology of
tracheal stenosis resulting from cuffed tracheostomy tubes. AJR
Am J Roentgenol 109:455-466, 1970.
Johnston JB, Wright JS, Hercus V: Tracheal stenosis following tra-
cheostomy. J Thorae Cardiovasc Surg 53:206-217, 1967.
Jurkiewicz MJ, et al: Infected median sternotomy wound: Successful
treatment by muscle flaps. Ann Surg 191:738-744, 1980.
Kapur TR: Tracheal injury and reconstruction. Br J Surg 54:689-694,
1967.
Keim WF, Shapiro MJ, Rosin HD: Study of postlaryngectomy stomal
recurrence. Arch Otolaryngol 81:183-186, 1965.
Keynes G: Surgery of the thymus gland, second (and third) thoughts.
Lancet 2(June 12):1197-1202, 1954.

Kilman JW, Klassen KP: Thymoma. Am J Surg 121:710-711,1971.
Kirchner FR, Toledo PS, Svoboda OJ: Studies of the larynx after Teflon
injection. Arch Otol 83:350-354, 1966.
Kirchner PA: Tracheotomy and its problems. Surg Clin North Am,
60: 1093-1104, 1980.
Kirchner PA, Osserman KE, Kark AE: Studies in myasthenia gravis:
Transcervical total thymectomy. JAMA 209:906-910, 1969.
Kreel I, Osserman KE, Genkins G, Kark AE: Role of thymectomy in
the management of myasthenia gravis. Ann Surg 16S:111-117,
1967.
Krespi YP, Biller HF, Baek S: Tracheal reconstruction with a pleuro-
periosteal flap. Otolaryngol Head Neck Surg 91:610-614, 1983.
Kuehn P: Surgical treatment of stomal recurrence in cancer of the
larynx. Am J Surg 122:445, 1971.
Lajos TZ: Inflatory peak pressure-a forgotten parameter. Presented
before the Upstate Thoracic Society Meeting, Rochester, New York,
June 1971.
Lajos TZ: Personal communication, 1971.
Lee Keun Y, Lore JM Jr: Two modifications of the pectoralis major
myocutaneous flap (PMMF). Laryngoscope 96:363-367, 1986.
LeMay SR Jr: Penetrating wounds of the larynx and cervical trachea.
Arch Otolaryngol 94:558-565, 1971:
Levinger L: Safer tracheostomy tube reinsertion Am J Surg 136:284,
1978.
Lewit T, Karman S, Terracina S, Beamer AM: Malignant tumor of the
trachea. Chest 60:498-499,1971.
Lewy RB: Responses of laryngeal tissue to granular Teflon in situ.
Arch Otolaryngol 83:355-359,1966.
Lewy RB: Increased safety in tracheotomy tube replacement. Arch
OtolaryngoI108:327, 1982.
Loeb WJ: Experiences with a modified cuffed tracheotomy tube. Ann
Otol 80:549-555, 1971.
Loewy A, Laker HI: Tracheal stoma problems. Arch Otolaryngol
87:477-481, 1968.
Lore JM Jr: Tracheostomy. Arch Ololaryngol 68:727-736, 1958.
Lore JM Jr: Tracheo-mediastinotomy. Am J Surg 97:324-325, 1959.
Lore JM Jr, Martin PT, Koch RJ, et al: Access to the superior
mediastinum. Am J Surg 169:348-354, 1995.
Lore JM Jr, Szymula NJ: Superior mediastinal exposure. Arch
Otolaryngol 106:6-7, 1980.
Lund T, et al: Upper airway sequelae in burn patients requiring
endotracheal intubation or tracheotomy. Ann Surg 201:374-382,
1985.
Mathog RH, Kenan PO, Hudson WR: Delayed massive hemorrhage
following tracheostomy. Laryngoscope 81:107-119, 1971.
McCall VW, Whitaker CW: The use of prostheses in the larynx and
trachea. Ann Olol 71:397-403, 1962.
McGovern FH, Fitz-Hugh GS, Edgemon LJ: The hazards of endo-
tracheal intubation. Ann Otol 80:556-564, 1971.
Michelson H, Sender B: Cervical thymus. Arch Surg 72:275-276, 1956.
Miller DR, Sethi G: Tracheal stenosis following prolonged cuffed
intubation: Cause and prevention. Ann Surg 171:283-293,1970.
Miscall L, et al: Stenosis of trachea, resection and end-ta-end anasto-
mosis. Arch Surg 87:726-731, 1963.
Miura T, Grillo HC: The contribution of the inferior thyroid artery to
the blood supply of the human trachea. Surg Gynecol Obstet
123:99-102,1966.
Modlin B, Ogura JH: Post-laryngectomy tracheal stomal recurrences.
Laryngoscope 79:239-250, 1969.
Montgomery WW: Reconstruction of the cervical trachea. Ann Otol
Rhinol Laryngol 73:5, 1964.
Montgomery WW: Silicone tracheal cannula. Ann Otol Rhinol Laryngol
89:521-528, 1980.
Montgomery WW: Stenosis of tracheostoma. Arch Ololaryngol 75:62-65,
1962.
Montgomery WW: T-tube tracheal stent. Arch Otolaryngol 82:320-321,
1965.
THE TRACHEA AND MEDIASTINUM
Myers RS, Pilch YH: Temporary control of tracheal-innominate artery
fistula. Ann Surg 170:149-151, 1969.
Needles B, Kemeny N, Urmacher C: Malignant thymoma, renal metas-
tases responding to cis-platinum. Cancer 48:223-226, 1981.
Neufeld 0, Anagnost BD, Navarre JR, et al: Condensation of "tra-
cheostomy in acute respiratory failure: Effects assessed by arterial
blood gases." J Am Geriatr Soc 16:930, 1968.
Nordin U, Ohlsen L: Prevention of tracheal stricture in end-to-end
anastomosis. Arch OtolaryngoI108:308-314, 1982.
Odell PF, LeBrun CJ: Tracheo-esophageal disruption. J Otolaryngol
9:433-437, 1980.
Oppenheimer P, Quinn FB: Sudden death following tracheotomy.
Arch Otolaryngol 82:292-293, 1965.
Ossoff RH, Tucker GF Jr, Duncavage JA, Toohill RJ: Efficacy of
bronchoscopic carbon dioxide laser surgery for benign strictures
of the trachea. Laryngoscope 95:1220-1223, 1985.
Oswalt CE, Gates GA, Holmstrom MG: Pulmonary edema as a com-
plication of acute airway obstruction. JAMA 238:1833-1835,1977.
Parker CA: Surgery of the thymus gland: Thymectomy. Report of fifty
operated cases. Am J Dis Child 5:89-122, 1913.
Pearson FG, Goldberg M, Da Silva AJ: A prospective study of tracheal
injury complicating tracheostomy with a cuffed tube. Ann Otol
77:867-882, 1968.
Petersen GM, Pierson OJ, Hunter P: Arterial oxygen saturation during
nasotracheal suctioning. Chest 76:283-287, 1979.
Pettit PK, Butcher RB, Bethea MC, King TO: Surgical correction
of complete tracheoesophageal cleft. Laryngoscope 89:804-811,
1979.
Pratt LW: Postoperative care of the tracheostomy. J Maine Med Assoc
58:35-39, 1967.
Pratt LW:Complications of tracheotomy. Eye Ear Nose Throat Monthly
48:119-127, 1969.
Pruet CW, Kornblut AD, Kaliner MA, et al: Management of the airway
in patients with angioedema. Laryngoscope 93:749-755, 1983.
Rabuzzi DO, Reed GF: Intrathoracic complications following tra-
cheostomy in children. Laryngoscope 81:939-946, 1971.
Ramming KP, Roth JA, Mulder DG: Surgical management of exten-
sive tracheal lesions. Am J Surg 138:80-88, 1979.
Rockey EE: Detailed surgical technique of tracheal fenestration, with
report of 26 cases. Arch Surg 79:875-888, 1959.
Rockey EE, Thompson SA, Blazsik CF, Ahn KJ: Tracheal fenestration
as a new method of treatment for advanced emphysema. N Y State
J Med 58:3607-3614, 1958.
Rosnagle RS, Yanagisawa E: Aerophagia. Arch Ololaryngol 89: 121-123,
1969.
Rosnagle RS, Yanagisawa E: An unrecognized complication of tra-
cheotomy. Arch Otolaryngol 89:S37-539, 1969.
Ruben RJ, Newton L, Chambers H, et al: Home care of the pediatric
patient with a tracheotomy. Ann Otol Rhinol Laryngol 91:633-640,
1982.
Rubin HJ: Misadventures with injection Polytef (Teflon). Arch Otol
101:114-116,1975.
Sanada Y, Kojima Y, Fonkalsrud EW: Injury of cilia induced by tracheal
tube cuffs. Surg Gynecol Obstet 154:648-652, 1982.
Sasaki CT,Suzuki M, Horiuchi M, Kirchner JA: The effect of tracheostomy
on the laryngeal closure reflex. Laryngoscope 87:1428-1433,
1977.
Schuller DE: Long-term stenting for laryngotracheal stenosis. Ann
Otol Rhinol Laryngol 89:515-520, 1980.
Schuller DE, Hamaker RC, Gluckman JL: Mediastinal dissection.
Arch Otolaryngol 107:715-720, 1981.
Schwab RS, Leland CC: Sex and age in myasthenia gravis as critical
factors in incidence and remission. JAMA 153:1270-1273, 1953.
Shadd DP, Gata JF: In vivo staining of larynx and pharynx cancer.
Arch Surg 102:442-446, 1971.
Shapiro RS, Martin WM: Long custom-made plastic tracheostomy
tube in severe tracheomalacia. Laryngoscope 91:355-362, 1981.
 THE TRACHEA AND MEDIASTINUM
Sharp EH, Chambers RG: Surgical use of pancreatic dornase. JAMA
176:144-146,1961.
Silen W, Spieker 0: Fatal hemorrhage from the innominate artery
after tracheostomy. Ann Surg 162:1005-1012, 1965.
Sisson GA: Extended radical surgery for cancer of the head and neck:
Mediastinal dissection for stomal recurrences. Otolaryngol Clin
North Am, October 1969, pp 617-630.
Sisson GA: Mediastinal dissection for recurrent cancer after laryn-
gectomy. Trans Am Acad Ophthalmol Otolaryngol 74:767-776, 1970.
Sisson CA, Bytell DE, Becker SP: Mediastinal dissection-1976: Indica-
tions and newer techniques. Laryngoscope 87:751-759,1977.
Sisson CA, Bytell DE, Edison BD, et al: Transdermal radical neck
dissection for control of stomal recurrences~end results.
Laryngoscope 85:1504-1510,1975.
Sisson GA, Edison BD, Bytell DE: Transsternal radical neck dissec-
tion. Arch OtolaryngollOl:46-49, 1975.
Smith WF, De WallRA, Krumholz RA:Ciant thymoma. Chest 58:383-385,
1970.
Snyderman N, et a1: Extracapsular spread of carcinoma in cervical
lymph nodes. Impact upon survival in patients with carcinoma of
the supraglottic larynx. Cancer 56:1597-1599, 1985.
Souadjian JV, Silverstein MN, Titus JL: Thymoma and cancer. Cancer
22:1221-1225,1968.
Stool SE, Campbell JR, Johnson DG: Tracheostomy in children: The
use of plastic tubes. Pediatr Surg 3:402-407, 1968.
Stuart WD: The otolaryngologic aspects of myasthenia gravis.
Laryngoscope 75:112-121, 1965.
Sulek M, Miller RH, Mattox KL: The management of gunshot and
stab injuries of the trachea. Arch OtolaryngolI09:56-59, 1983.
Sundaresan N, Shah J, Feghali JG: A transsternal approach to the
upper thoracic vertebrae. Am J Surg 148:473-477, 1984.
Tovi F, Gittot A: Sternocleidomastoid myoperiosteal flap for the repair
of laryngeal and tracheal wall defects. Head Neck Surg 5:447-451,
1983.
Trail ML, Chambers R, Leonard JR: Z-plasty of tracheal stoma at
laryngectomy. Arch Otolaryngol 88:110-112,1968.
Veau V, Oliver E: Ablation du thymus. Presse Med 18:257-260, 1910.
Verley JM, Hollman JH: Thymoma: A comparative study of clinical
stages, histologic features and survival in 200 cases.
55:1074-1085,1985.
Vonfraenkel PH: Indications for tracheostomy. Eye Ear Nose Throat
Monthly 45:68-75, 1966.
Walker FW, Salley AJ: A drainage tube for mediastinal abscesses.
Surg Cynecol Obstet 152:831-832, 1981.
Welsh FM, Costelli JB: Polytef granuloma clinically simulating carci-
noma of the thyroid. Arch OtollOl:262-263, 1975.
Westgate HD, Roux KLJr: Tracheal stenosis following tracheostomy:
Incidence and predisposing factors. Anesth Analg (Cleveland]
49:393-401, 1970.
Wetmore RF, Handler SO, Potsic WP: Pediatric tracheostomy: Expe-
rience during the past decade. Ann Otol Rhinol Laryngol 91:628-632,
1982.
Yanagisawa E, Kirchner JA: The cuffed tracheotomy tube. Arch
Otolaryngol 79:80-87, 1964.
Thymus
Bryant LR, Spencer FC, Trinkle JK: Treatment of median sternotomy
infection by mediastinal irrigation with an antibiotic solution. Ann
Surg 169:914-920, 1969.
Crile G Jr: Thymectomy through the neck. Surgery 59:213-215, 1966.
Fonkalsrud EW, Herrmann C Jr, Mulder DG: Thymectomy for myas-
thenia gravis in children. J Pediatr Surg 5:157-165, 1970.
Keynes G: Surgery of the thymus gland: Second (and third] thoughts.
Lancet 2(June 12):1197-1202, 1954.
Kilman JW, Klassen KP: Thymoma. Am J Surg 121:710-711,1971.
Kirschner PA, Osserman KE, Kark AE: Studies in myasthenia gravis:
Transcervical total thymectomy. JAMA 209:906-910, 1969.
Kreel I, Osserman KE, Genkins G, Kark AE: Role of thymectomy in
the management of myasthenia gravis. Ann Surg 165:111-117,1967.
Michelson H, Sender B: Cervical thymus. Arch Surg 72:275-276,1956.
Parker CA: Surgery of the thymus gland: Thymectomy. Report of fifty
operated cases. Am J Dis Child 5:89-122, 1913.
Schwab RS, Leland CC: Sex and age in myasthenia gravis as critical
factors in incidence and remission. JAMA 153:1270-1273, 1953.
Smith WF, DeWall RA, Krumholz RA: Giant thymoma. Chest 58:383-385,
1970.
Souadjian JV, Silverstein MN, Titus JL: Thymoma and cancer. Cancer
22:1221-1225,1968.
Stuart WD: The otolaryngologic aspect of myasthenia gravis.
Laryngoscope 75:112-121,1965.
Veau V, Oliver E: Ablation du thymus. Presse Med 18:257-260, 1910.
Wick MR, Scheithauer BW: Oat-cell carcinoma of the thymus. Cancer
Cancer 49:1652-1657,1982.
Wick MR, et al: Malignant, predominantly lymphocytic thymoma
with central and peripheral nervous system metastases. Cancer
47:2036-2043, 1981.
Wilkins EW Jr: Thymic tumors: Management of thymoma. Surgical
Rounds, January 1984, p 84.
 20

Indirect Mirror Laryngoscopy Anatomy of Superior Laryngeal Nerve

(Fig. 20-1)
Highpoints
The various relationships of the important nerves extrin-
See Chapter 4 for additional discussion relative to
sic to the larynx with relationship to the greater vessels
peroral endoscopy.
are shown. The internal branch of the superior laryn-
geal nerve passes through the thyrohyoid membrane
1. Equipment:
on a line horizontal to the superior corner of the thy-
a. Laryngeal mirror
roid cartilage approximately 1 cm medially (Lore, Sr.).
b. Head mirror with light source or headlight
c. Gauze
d. Hot glass head device; hot water or forced hot air
from small hair dryer
2. Reassure patient: have him or her relax by drooping
shoulders, easing neck muscles, and using moderate
deep breathing.
3. Properly position the patient by having him or her
sit erect, not slouch backward.
4. Topical anesthesia is required in 30% to SO% of
patients: use a cotton swab moistened with 10%
cocaine, 2 % tetracaine, or 4 % lidocaine. Avoid use
of compressed air spray, because too large a dose
with cocaine may be administered. Lidocaine 4% is
probably the agent with the least side effects.
S. Perform orderly visualization of:
a. Larynx with epiglottis, especially base of epiglottis
b. Hypopharynx, especially the pyriform sinuses
and posterior wall
c. Base of tongue and vallecula
6. Realize the optical illusions of the mirror:
a. Anterior commissure appears to be posterior (i.e.,
reversal of anterior and posterior regions).
b. There is no reversal of right and left sides.
c. Overhang of epiglottis tends to obscure anterior
commissure and base of epiglottis, a serious blind
area.
d. Overhang of ventricular bands tends to obscure
ventricles.
e. Overhang of vocal cords tends to obscure sub-
glottic space.
FIGURE20-1

1069
 Mirror laryngoscopy is a very important means of
evaluation of the larynx, because it affords a full view
of the entire presenting portion of the larynx,
hypopharynx, base of tongue, and inferior tonsillar
pillars. Next in line are optical and direct rigid laryn-
goscopy with telescopic instruments or the operation
microscope, followed by external palpation of the larynx.
Finally, radiographic examination, purely as an adjunct,
is of aid in estimating subglottic extension of disease.
Plain soft tissue radiography, computed tomography
(CT), and laminograms (planigrams) and laryngograms
can be used and should be obtained before a biopsy
sample is taken.
All patients with hoarseness must have a pathologic,
anatomic, or physiologic reason for their symptoms.
However, tumors arising away from the free edges of
the vocal cords may not and often do not produce any
voice changes in the early stages of the disease. By the
same token, recurrent laryngeal nerve paralysis is not
necessarily associated with hoarseness. For example, to
say that a patient has no injury to the recurrent nerve,
after thyroidectomy, simply because his or her voice
is satisfactory is entirely fallacious. The normal vocal
cord many times compensates for and adapts itself to
the paralyzed cord. The only subjective complaint may
be failure to control the pitch of the voice. On the other
hand, paralysis of the external branch of the superior
laryngeal nerve is almost always associated with hoarse-
ness. The vocal cord is bowed and may be at a lower
level than the normal vocal cord. Paralysis of the
recurrent laryngeal nerve can occur after endotracheal
intubation.
Technique (Fig. 20-2)
A The patient is placed in an erect sitting position,
preferably with the base of his spine resting against the
back of a straight-backed examining chair. The head
should be free of any headrest, because the head and
neck are usually not hyperextended.
The next step is to achieve complete relaxation. The
patient is instructed to let his or her shoulders, neck,
and arms become limp. Regular and moderately deep
breathing aid in minimizing the gag reflex and spasm
in the throat.
A suitable-sized laryngeal mirror-a selection from
NO.3 to NO.6 is ideal-is chosen, depending on the
oropharyngeal width. The mirror is warmed either with
a hot glass bead sterilizer (Premier Dental Products),
hot water, or warm air from a blower, and its temper-
ature is tested on the back of the examiner's hand. The
examiner, using an opened piece of 2 x 2-inch gauze
gently grasps the tongue between the thumb and
middle finger, using the index finger to retract the
upper lip.
The use of topical anesthesia will depend on the
patient's ability to relax. Diazepam (Valium), 10 mg,
orally 30 minutes before examination aids relaxation
significantly. Complete visualization of the vocal cords
will require phonation. The vowel "E" is ideal. If this
fails to expose the vocal cords, have the patient attempt
to laugh or sound "hah-hah-hah." Phonation is also
necessary to check the function of the laryngeal struc-
tures as well as "open" the pyriform sinuses. This is
necessary to evaluate the mucosa of the pyriform
sinuses. The apex (inferior) portion of the pyriform
sinus may not be visualized. If suspicious results are
found, direct rigid laryngoscopy will be necessary.
B Labeled parts are as follows: 1, epiglottis; 2, ante-
rior commissure; 3, ventricular band; 4, posterior com-
missure; 5, corniculate cartilage overlying arytenoid
cartilage; 6, cuneiform cartilage; 7, aryepiglottic fold;
8, glossoepiglottic fold; 9, ventricle; 10, base of tongue;
and 11, pyriform sinus.
Some type of routine checklist should be followed to
perform a complete evaluation, for example, the follow-
ing:
1. Larynx
a. Vocal cords (free edges and superior surfaces) and
their motion and whether they are straight
b. Arytenoid cartilages and their motion
c. Ventricles and ventricular bands
d. Anterior and posterior commissures
e. Subglottic space; wall of trachea
f. Aryepiglottic folds
g. Lingual and laryngeal surfaces and free edges and
base of epiglottis
h. Glossoepiglottic folds
2. Hypopharynx
a. Pyriform sinuses-especially the inferior extent,
the apex; constant filling with saliva indicates
esophageal obstruction (Jackson's sign).
b. Posterior and lateral walls-the more superior
portions can be visualized with a tongue depres-
sor and an examining finger.
3. Tongue (must also be evaluated with an examining
finger), especially base of tongue
a. Vallecula (space between epiglottis and base of
tongue)
b. Juxtaposed inferior tonsillar pole
C Bowing of the vocal cords. This is best demon-
strated during phonation of "E." It is usually caused by
a prominent vocal process of the arytenoid cartilages
(which can be amputated with stripping forceps) (see
Fig. 20-5) or paralysis or weakness of the cricothyroid

FIGURE 20-2
muscle, which is innervated by the external branch of
the superior laryngeal nerve. The vocal cord may be at
a lower plane than the normal vocal cord.
D Bilateral adductor cord paralysis. This indicates
paralysis of either the cricoarytenoideus lateralis, inter-
arytenoideus, or thyroarytenoideus or all these muscles
bilaterally. The nerve supply is via the adductor division
of the recurrent laryngeal nerve. The interarytenoideus
muscle may have a motor supply via the internal
branch of the superior laryngeal nerve. This is dubious.
E Bilateral abductor cord paralysis. This indicates paral-
ysis of the cricoarytenoideus posterior muscles bilater-
ally. Innervation is via the abductor division of the
recurrent laryngeal nerve.
A way to remember easily the action of the signifi-
cant intrinsic muscles of the larynx is to divide them
into two groups: adductor or sphincteric group and
abductor or dilator group.
THE LARYNX
Sphincteric Group
An analysis of this group shows that it can be reduced
to simple terms and can be described so it is easily
remembered. All these muscles pull on or are inserted
into the arytenoids. The cartilages of origin are the
cricoid, arytenoids, and thyroid. Hence, the letters C, A,
and T may be used to designate the cricoid, arytenoid,
and thyroid cartilages, respectively.
Dilator Group
This is composed of a simple pair of muscles, namely,
cricoarytenoid posterior, or CAP. This pair abducts the
cords.
Admittedly, this is an oversimplification of the diver-
sity of opinion regarding the motor function of the
intrinsic muscles of the larynx. Details are beyond the
scope of this atlas.
 THE LARYNX

Instruments (Fig. 20-3)
The Lore head light (Karl Storz) with observation side
arm attachment is shown. It was utilized with mirror
laryngoscopy and nasopharyngoscopy both for exam-
ination and as a light source during surgery.The observer
could see exactly what the examiner and operator
visualized. Its only drawback for the observer was the
somewhat smaller image seen through the side arm.
This has been replaced with fiberoptic laryngoscopes
that have either observer arms or video capabilities.
Direct optical, both flexible and inflexible, and direct
rigid laryngoscopy and hypopharyngoscopy are described
and depicted in Chapter 4. The images seen on the
optical instruments are in the same position as they are
anatomically and are not reversed as they are with the
mirror; that is, the anterior portion of the larynx and
hypopharynx are visualized anteriorly while with the
mirror the anterior portion of the larynx and hypo-
pharynx are visualized posteriorly. On both optical and
mmor laryngoscopy the right and left sides are seen as
they are in the anatomic position.

FIGURE 20-3

Punch Biopsy of lesions of larynx
and Hypopharynx (Fig. 20-4)
Additional endolaryngeal and microlaryngeal procedures
are described in Chapter 4.
Highpoints
1. Use topical anesthesia or general anesthesia plus
topical anesthesia. A small endotracheal tube (No.6)
can be used.
2. Insert laryngoscope from the contralateral position
through the mouth.
3. Stripping is preferred for lesions of the vocal cord
except for bulky tumors, which are obviously malig-
nant.
For details, see the section on direct laryngoscopy in
Chapter 4 and Figure 4-2.
-FIGURE 20-4
THE LARYNX
With either a Holinger or a Jackson anterior commis-
sure speculum or a standard laryngoscope introduced
from the contralateral oral position, the lesion is exposed
on the opposite side of the larynx. Microlaryngoscopy
is utilized for small lesions (see Fig. 4-5D and E). With
a sharp basket or cup forceps, the biopsy of the
suspected area is performed in one or two locations,
depending on the size of the tumor. Postoperative
bleeding is usually of no concern except with lesions
involving the lingual side of the vallecula. One such
case of carcinoma had uncontrollable bleeding,
necessitating an emergency laryngectomy.
Whenever general anesthesia is used, topical
anesthesia is strongly recommended. This permits a
repeat mirror examination, prevents laryngospasm, and
reduces the amount of general anesthetic agent and the
danger of cardiac arrhythmias. Toluidine blue, 1%,
topically applied to suspicious lesions that are first
cleansed with 1 % acetic acid, has been demonstrated
to be of some aid in localizing early carcinoma (Shedd
and Gaeta, 1971; Strong et aI., 1968).
 THE LARYNX
Stripping (De-Epithelialization) of
a Vocal Cord (Fig. 20-5)
(Lore Sr., 1934)
Indications
Stripping of a vocal cord is preferred for virtually all
lesions that involve primarily the true vocal cord. Two
exceptions are the bulky, obviously malignant tumor in
which a simple punch biopsy suffices for diagnosis and
the pedunculated, single, small polyp that may be
removed with cup forceps. The stripping operation is
ideally suited for the removal of other polyps with or
without associated edematous cords. The polyp and
edematous tissue are removed usually in one maneu-
ver. Papillomas, hypertrophic vocal cords (polypoid
edematous cords), and almost any benign lesion may
be thus removed. The resulting free edge of the cord
remains straight, and re-epithelialization occurs in 2
to 4 weeks. Usually, only the surface epithelium
needs to be removed; however, if necessary, one may
go as deeply as the thyroarytenoid muscle or may
operate several times if some diseased tissue has been
left.
Stripping a vocal cord is particularly suited to suspi-
ciously malignant disease (e.g., leukoplakia or keratosis),
which extends over a greater part of the cord or the
entire length of the cord. By stripping the entire cord,
the entire lesion may be removed and serial sections
taken by the pathologist for microscopic examination.
Hence, a complete evaluation of malignancy is pos-
sible. If the lesion turns out to be benign, satisfactory
removal has been achieved and no additional operation
is necessary. Miller has shown that this technique
appears to be satisfactory for carcinoma in situ. The
author agrees; others believe that a simple cordectomy
is warranted.
Lengthy lesions of the ventricular bands or in the
floor of the ventricles are also well suited to the strip-
ping procedure. Subglottic tumors are easily sampled
with the child-sized stripping forceps. Essentially, this
is the lmperatori subglottic forceps, which was modi-
fied by Lore, Sr. by making the anterior two thirds very
sharp and the posterior third somewhat duller. A sub-
sequent modification (Lore, Jr.) utilizing a telescope is
manufactured by Karl Storz (see Chapter 4).
Bowing of a vocal cord by a prominent vocal process
of the arytenoid cartilage may be improved by inclu-
sion of the vocal process in the stripping forceps.
Carbon dioxide (C02) laser removal of these lesions
is preferred by some surgeons (Strong and Jako, 1972).
This author is concerned about the possibility that some
cells, which may be precancerous or cancerous, could
be vaporized or destroyed and thus missed on histo-
logic examination.
Highpoints
1. General anesthesia supplemented with topical anes-
thesia is preferred. Indiscriminate use and overdosage
of a muscle relaxant is definitely contraindicated,
because the cord will be so relaxed when stripped
that bowing or an irregular free edge of the cord will
result. This danger cannot be overemphasized. A
small endotracheal tube at the posterior commissure
is ideal for an unhurried procedure.
2. Contralateral approach with anterior commissure
speculum is usually necessary.
3. Be certain that the amount of tissue grasped is to the
desired depth and extent. Attempt to complete the
operation in a single maneuver.
4. Strip only one vocal cord at a time. One month should
elapse before stripping the opposite side in bilateral
disease; otherwise webbing at the anterior commis-
sure may occur. This admonition applies where the
de-epithelialization extends to the anterior commis-
sure. If intact mucosa remains for several millimeters
at the anterior commissure, then bilateral stripping
may be done.
5. Microlaryngoscopy is advantageous, especially for
small lesions suspected to be malignant (see Fig.
4-50 and E).
A If the left vocal cord is being operated on, the
anterior commissure speculum is introduced from the
right side of the mouth. The beak of the instrument
extends to the anterior commissure and may be slightly
rotated so that the beak is against the right cord. The
left cord is thus fully exposed and fixed. With the
instrument in this position a full view of the cord is
obtained and the floor of the ventricle, in most cases,
is brought into view. Byinserting the instrument slightly
between the cords, a subglottic lesion may be seen
and a biopsy of it performed. The free edge of the vocal
cord can be "rolled" laterally. This may also facilitate
stripping the inferior portion of the vocal cord.
The left-sided stripping forceps (the lower or medial
blade fixed, the upper or lateral blade hinged) is inserted
with the long axis of the blade parallel to the long axis
of the cord. An adult (9 mm) or child (6 mm) blade is
selected as required.

A B
FIGURE 20-5
B The blade is opened and the growth and subja-
cent cord are engaged gently. The blade is placed
between the anterior commissure and the vocal process
of the arytenoid. The vocal process is usually not included
unless the procedure is performed for bowing of the
vocal cord due to a prominent vocal process. Slight
traction is made toward the free edge until the growth
itself is felt in the forceps. Then the forceps is closed
tighter. At this stage it is important to visualize the
cord to make sure thilt not too much is being removed.
If too much tissue is engaged, the forceps is opened a
little until the proper amount of tissue is included. The
stripping is then begun anteriorly by tilting the handle
of the forceps posteriorly. The entire stripping is per-
formed with a brisk, rapid, single motion.
C The position of the forceps at the end of the single
stripping motion is shown.
D A schematic lateral view is similar to the stage
depicted in C.
THE LARYNX
Gross examination of the tumor will reveal a thin
small strip of cord tissue attached to it anteriorly and
posteriorly.
Postoperatively, the patient is allowed to speak in a
normal manner. Excess speech, whispering, shouting,
and singing are contraindicated for 3 to 5 weeks. Normal
speech is allowed. The voice is usually very clear imme-
diately postoperatively. Some hoarseness may occur
several days later for a short period of time.
In hypertrophic laryngitis (polypoid involvement of
the entire vocal cord), caution should be taken not to
leave a tab of polypoid tissue either at the anterior por-
tion of the vocal cord or in the vicinity of the vocal
process of the arytenoid. Extreme caution must be taken
in this disease not to de-epithelialize the anterior portion
of the contralateral vocal cord; otherwise webbing may
occur.
 THE LARYNX
Endoscopic Removal of Congenital
Cyst of Ventricle in Newborn
(Internal Laryngocele) (Fig. 20-6)
Cysts of the larynx may be congenital or acquired. The
congenital cyst that arises in the ventricle is often indis-
tinguishable clinically from a laryngocele. A true laryn-
gocele is a diverticulum of the mucosa of the ventricle
lined with respiratory epithelium, usually with a com-
munication to the laryngeal lumen. Thus, a laryngocele
may fill with air or mucus and may be internal, entirely
within the lumen of the larynx and presenting as a cystic
mass from the ventricle, or external, extending through
the thyrohyoid membrane and presenting as a com-
pressible cystic mass in the lateral side of the neck
between the hyoid bone and the thyroid cartilage. The
internal laryngocele can usually be deflated and removed
through an endoscope, whereas the external laryngocele
is excised through an external cervical approach. A
horizontal skin incision is made over the cystic mass,
which is dissected down to the thyrohyoid membrane.
Extreme care must be exercised not to injure the internal
branch or external branch of the superior laryngeal
nerve (see Fig. 20-25).
For all practical purposes the congenital ventricular
cyst and internal laryngocele in the newborn present
the same clinical picture of varying degrees of respira-
tory obstruction and absent or poor cry at birth. The
treatment is the same and often is very urgent.
Highpoints
1. All newborns with respiratory difficulty and abnormal
or absent cry must undergo laryngoscopy.
FIGURE 20-6
2. Attempt immediate removal of laryngocele through
the laryngoscope. If this is not possible, aspirate and
deflate cyst with needle or punch.
3. Avoid tracheostomy in a newborn; however, do not
hesitate to perform one if endoscopic methods fail.
Tracheostomy in infants younger than 1 year of age
is associated with high morbidity and mortality. The
alternative is endotracheal intubation. Extubation
may require the anterior cricoid split of Holinger and
colleagues (see p. 1016).
A The larynx is exposed with a wide lumen laryngo-
scope. A laryngeal grasping forceps is inserted through
the loop of a very fine snare. An ideal snare is the type
used in rectal surgery for the removal of rectal polyps
in infants. The cyst is grasped firmly and pulled upward
while the snare engages the neck or base of the cyst.
Speed is essential, especially because the cyst may break
and mucus may be extruded. The snare is closed, cut-
ting the neck of the cyst, and the forceps are with-
drawn with the cyst. Tracheal suction may be neces-
sary if aspiration of mucus occurs. This procedure
requires the aid of an assistant who holds either the
laryngoscope or preferably the forceps after the operator
has grasped the cyst. A Lewy laryngoscope holder,
although large, may be of help.
B A schematic cross-sectional view demonstrates the
technique.

CO2 Laser in Laryngeal and
Endobronchial Surgery (See Fig. 4-6)
The CO2 laser has innumerable applications in head
and neck surgery. It can be utilized via the microscope
or a hand-held adapter. All of the various adaptations
of this modality are beyond the scope of this atlas but
have been described by many authors. Ossoff and Karlan,
in Ballenger's Diseases of the Nose, Throat, Ear, Head
and Neck (1985, chap. 42), give an excellent overview
of this subject (see also Chapter 4 of this atlas).
Basically, this form of energy can be used to vapor-
ize tissue or for dissection purposes. The device can be
utilized in two modes, either pulsed or continuous, and
operates at a wavelength of 10.6 flm, producing light in
the invisible range of the spectrum.
Microlaryngoscopy Using the CO2 Laser
Indications
• Papillomatosis
• Various degrees of keratosis
• Other benign and premalignant lesions
• Selected patients with verrucous carcinoma who
refuse surgery
• Soft and/or edematous tissue and some localized
fibrosis that is causing obstructions
• Capillary hemangiomas
Other Indications Reported by Other Authors
• Debulking large malignant lesions to improve the
airway (the present authors would opt for preopera-
tive chemotherapy as an initial step). Debulking is
not a definitive treatment (JML).
• Webs and noncircumferential scars
• Carcinoma in situ-no specimen margins-not recom-
mended (JML)
• T1 carcinomas of the true vocal cord and epiglottis-
no specimen margins-not recommended (JML)
• Arytenoidectomy
Endoscopic Removal of Small Noncircumferential
Tracheal Scar
Ossoff et al. (1985) described three stages of tracheal
stenosis:
1. Granulation stage
2. Limited scarring
3. Extensive scarring
They believe the CO2 laser is useful in the first and
second stages but not in the third stage. It is of virtually
no value in treatment of complete thick circumferential
scars of the trachea.
THE LARYNX
Highpoints and Precautions
Fire is an ever-present complication that must always
be kept in mind in any application of the CO2 laser. Fire
may act as a blowtorch from the trachea and larynx.
The endotracheal tube must be immediately removed
and the procedure terminated; then a new endotracheal
tube is introduced. In the presence of increasing con-
centration of oxygen, the heat produced by this laser
can result in the ignition of any combustible material.
Prevention of this catastrophic sequela is based on the
following:
1. Provide special training for surgeons and all
personnel.
2. Use a specially coated "laser" endotracheal tube;
alternatively, use a tube (preferably red rubber)
carefully wrapped in overlapping fashion with pro-
tective V2-inch metallic tape. Water or methylene
blue rather than air is used to inflate the cuff of the
endotracheal tube. Care must be taken that the
tape used is in fact metallic rather than plastic tape
with the appearance of metallic tape. The authors
have noticed that one flexible metal endotracheal
tube that we have tried actually leaks.
3. Use a nonflammable anesthetic agent.
4. Use water-saturated cottonoid pledgets over the
wrapped endotracheal tube in the laser field and in
the subglottic space. These pledgets are to be kept
moist during the entire procedure. Retrieval sutures
are secured to these pledgets. The sutures, how-
ever, may be vaporized with the laser; hence, an
accurate count of the pledgets at the close of the
operation is mandatory.
5. Protect all exposed skin and mucous membrane of
the patient with wet towels and sponges even out-
side the operative field.
6. Protect the patient's eyes with glasses and two
layers of wet towels. Corneal and scleral burns can
. occur both to the patient and to operating room
personnel.
7. Protect all personnel in the operating room with
glasses.
8. Place a notice on the operating room doors stating
that a laser is in use and that personnel should not
enter unless glasses are worn.
9. Be cognizant that the laser beam is absorbed by
soft tissues and bone but that it may be reflected
by metal objects.
10. Check that the laser beam exactly coincides with
the target light on a wooden block just before the
use of the laser.
11. When using the CO2 laser on a bilateral lesion, it is
advisable to treat one side at a time.
12. During laryngeal surgery, the subglottic area is
completely occluded around the endotracheal tube
 THE LARYNX
with soaking wet cotton sponges and sutures to
facilitate retrieval.
Comments
Basically, this form of energy can be used to vaporize
tissue or for dissection purposes. It can be utilized in
two modes, either pulsed or continuous, and operates
at a wavelength of 10.6 nm, producing light in the
invisible range of the spectrum.
Although many authors use the CO2 laser for exci-
sional biopsy purposes, this author has not followed
this procedure for fear of possibly destroying tissue for
histologic examination. Surgical biopsy is preferred. This
is a personal preference. There is little doubt that minute
areas are best sampled surgically either using telescopic
biopsy forceps (see Chapter 4) or the microscopic laryn-
geal set-up. Only vessels less than 1 mm in diameter
should be attempted to be coagulated with the laser;
hence, care must be taken when excising larger lesions
that may have large vessels. Under these circumstances
electrocautery and/or pistol grip-type hemostatic sur-
gical applicator clips should be available.
Although the use of the CO2 laser usually requires
the larger lumen laryngoscope, as used in microlaryn-
goscopy, occasionally it is well nigh impossible to insert
these large laryngoscopes. The authors h"ve occasionally
used the standard Holinger hourglass speculum or the
Jackson anterior commissure speculum with monocular
vision. This adaptation requires a careful preoperative
trial to be certain that the laser beam is aligned with
the target spot on a block of wood.
The one area that the authors find very difficult to
treat with the laser is posterior to the vocal process of
the arytenoid and the posterior commissure because of
the posterior location of the endotracheal tube. One
solution is the use of a 1.3-cm segment of a plastic tooth
guard that is firmly secured with heavy silk sutures to
the anterior aspect of the laryngoscope. The concave
portion of this segment is faced anteriorly to hold the
endotracheal tube at the anterior commissure. This seg-
ment is then completely covered with a water-saturated
cottonoid pledget to prevent ignition. Another adapta-
tion of this concept would be the use of a metallic clip
shaped similar to a portion of the tooth guard to hold
the endotracheal tube anterior to the laryngoscope.
Despite the reports of minimal postoperative edema
that may cause airway obstruction, it is best to observe
the patient very carefully after extubation. The patient
may be kept in the hospital overnight to be observed
for 18 hours if there is any suspicion of edema, in
which case corticosteroids are used.
Pain and scarring are reported as uncommon or
entirely absent after the use of the CO2 laser. Although
we have not seen pain as a complication of endolaryn-
geal laser use, scarring forming a web at the anterior
commissure has occurred when papillomatosis crosses
the anterior commissure. This has not been of any
significance or concern, but it can occur. Pain with
scarring has occurred with the use of the CO2 laser in
the floor of the mouth in at least one patient.
With a hand-held CO2 laser, debulking of massive
lymphohemangiomas of the tongue has been utilized
to vaporize the lesions with varying success. Whether
these lesions arise in the tongue or larynx their treat-
ment usually requires surgical excision along with laser
surgery.
Complications
• Fire
• Edema-usually 1 to 6 hours postoperatively
• Postoperative bleeding after vaporization of large
lesions
• Recurrence of lesions
• Corneal, mucous membrane, and skin burns
• Tracheal perforation and burns
• Glottic web
• Vocal cord fibrosis from vaporizing the underlying
vocalis muscle
• Subglottic stenosis
• Arytenoid perichondritis-use antibiotics if cartilage
is exposed.
• Delayed airway obstruction
• Foreign bodies from metallic tape or dislodged
cottonoid pledgets
It is obvious from this list of complications that sig-
nificant expertise and care is necessary with the use of
the CO2 laser. This procedure is not recommended for
the occasional operator or the occasional anesthesiologist.
Endoscopic Intracordal Injection
of Teflon Paste (Fig. 20-7)
When there is a glottic gap of 4 mm or more resulting
in dysphonia and/or aspiration, intracordal injection of
various types of materials has been described to narrow
this gap. The most common indication is adductor
vocal cord paralysis in which the normal vocal cord is
unable to approximate the fixed abducted vocal cord.
The timing of performing the intracordal injection varies
with the underlying etiology and whether sufficient time
has elapsed for spontaneous recovery of the paralyzed
vocal cord (usually 9 to 12 months) and also whether
other procedures are indicated. In general, the treat-
ment of dysphonia can be delayed whereas the treatment
of aspiration may be urgent. Then again other methods
of management of aspiration may be indicated, such as
cricopharyngeal myotomy (which has varied success)
and closure of the glottis.

\
THYROID
CART.
2-4mm
THYROARYTENOID M.
CRICOID
CART.
FIGURE 20-7
Teflon paste injections were very popular in the
1980s. They have been abandoned because of their
propensity to migrate. Gelfoam paste and finely minced
fat are used today for an initial trial because they are
absorbable. Therefore, these absorbable materials could
possibly be used in the treatment of temporary aspira-
tion. The author's experience is limited to only one
patient in whom Gelfoam was injected in both vocal
cords to alleviate aspiration. Unfortunately, this measure
failed, because closure at the posterior commissure could
not be adequately achieved. Gelfoam paste absorbs in
3 to 4 months, depending on the amount injected.
The technique consists of the use of a direct laryngo-
scope and a laryngoscope holder (e.g., a Holinger ante-
rior commissure speculum and Lewy holder or a
Kleinsasser and a Riecker holder), along with a central
ratchet-type syringe with a long laryngeal 18- or 19-
gauge needle (e.g., the Briinings syringe and accom-
panying needles). Anesthesia is topical 10% cocaine
with intravenous supplement of meperidine (Demerol)
and droperidol (Inapsine) administered by an anesthe-
siologist who is also monitoring the patient for any
cardiac irregularities.
The procedure technique and operating room set-up
are similar to those used for micro laryngoscopy (see
Fig. 4-5D and E) except that the contralateral introduc-
tion of the laryngoscope is usually used.
The topical anesthesia facilitates evaluation of the
glottic gap as the patient is asked to phonate during the
procedure, thus indicating the amount of Teflon to be
injected. Depending on the configuration of the glottic
gap, one or two, or possibly three, injection sites are
THE LARYNX
utilized. The usual sites are in the middle third and
posterior third (juxtaposed to the vocal process of the
vocal cord) of the membranous vocal cord. From 0.3 to
0.4 mL is the usual amount injected at each site, again
depending on the glottic gap. The injection is carefully
made lateral to the free edge of the vocal cord and lateral
to the vocalis muscle. Depth of injection varies from 2
to 4 mm, with care being taken not to go too deep into
the infraglottic tissue of the vocal cord nor too super-
ficial to cause a localized bulge. A metal or plastic guard
(Rubin) located 2 to 4 mm from the tip of the needle
can be used as a guide. The free edge of the vocal cord
should be displaced medially as evenly and uniformly
as possible. At times, 0.1 to 0.2 mL of the Teflon paste
may be required between the two major sites of injection.
Some endoscopists perform this procedure on an
outpatient basis; yet, it is preferred to observe the
patient overnight for any significant edema that might
compromise the glottic airway. Associated edema can
be managed with corticosteroids. If necessary, repeat
injections can be performed in 1 or more months.
Teflon injections have been performed to improve
the "breathy" voice after frontolateral laryngectomy,
with little to no success, depending on the amount of
soft pliable tissue that is present.
The procedure is not without complications, how-
ever. A complication rate of 33 % has been reported by
Lewy (1983), indicating that extreme care must be taken
in the selection of patients as well as in the technique
of injection.
Myasthenia laryngis and hypogenesis vocalis are not
indications for these injections. Again, if there is any
question regarding the indication, injection of an
absorbable substance is far better than the injection of
Teflon, which is permanent. Some voices have been
made permanently worse despite the attempt to remove
the Teflon.
The following complications have been reported:
1. Granulomas of the intrinsic larynx as well as of the
neck when the paste extrudes through the cricothy-
roid membranes. Such a complication can stimulate
a cold nodule of the thyroid or cause a neck mass.
2. Draining sinus tract
3. Airway obstruction necessitating tracheostomy
4. Resulting vocal cord margins at different levels
causing a weak and breathy voice
Oppenheimer has implicated Teflon sheeting as
carcinogenic in the mouse; however, Kirchner and co-
workers (1966) have shown no carcinogenic effect of
the powdered Teflon as used in these injections. It
seems that the physical properties rather than the
chemical properties of Teflon are the deciding factor.
 THE LARYNX
Thyroplasty /Vocal Cord
Medialization (Fig. 20-8)
Highpoints
1. Equipment:
a. Silas tic block
b. Periosteal elevator
c. Fiberoptic laryngoscope
2. Medialization is preferably done under local anes-
thesia. However, it can also be done under general
anesthesia in patients in whom vocal cord paralysis is
anticipated as a result of resection of the vagus nerve
(base of skull surgery or oncologic surgery in the neck].
3. To minimize swelling, intravenous corticosteroids are
administered at the time of the procedure and for a
few doses postoperatively.
Medialization of the vocal cord is the preferred method
to restore glottic competence in cases of unilateral vocal
cord paralysis, since the use of Gelfoam or Teflon injec-
tion of the vocal cord has for the most part been aban-
doned. Of all the different phonosurgery procedures,
the thyroplasty type 1, initially described by 1sshiki, is
the most commonly done. The operative technique has
been modified by different surgeons.
The technique described here is Netterville's modifi-
cation of 1sshiki's technique.
Technique
The patient is placed in the semi-sitting position. A
transverse incision is outlined at about the level of the
middle third of the thyroid cartilage. It measures 6 to
7 em long, and it is located to the side of the paralysis.
It usually extends slightly over the midline. Alternatively,
the incision used in the neck for a neck dissection or a
base of skull procedure can be extended appropriately
to expose the thyroid ala. Flaps are elevated superiorly
and inferiorly for a short distance to expose the entire
height of the thyroid cartilage. The dissection is carried
in the midline down to the level of the thyroid cartilage.
The perichondrium of the lateral ala of the thyroid car-
tilage is incised vertically in the midline. It is then ele-
vated from the midline to the oblique line of the thyroid
cartilage or near the posterior edge. It is important to
expose the thyroid ala completely so that the inferior
and superior borders of it can be delineated.
A A rectangular window in the thyroid ala is out-
lined. There are many descriptions of how to place this
window precisely. A reliable way to place it is to locate
it 5 to 8 mm back from the midline and 4 mm superior
to the inferior border of the thyroid cartilage. The
dimensions of the window average 5 to 6 mm in
height and 13 to 14 mm in length.
B With a scalpel or a drill with a 2- to 3-mm bur, the
cartilage is removed in the outlined window. Keep in
mind that the cartilage is thicker anteriorly than in the
most posterior part of the window.
C The interperichondrium of the thyroid ala is bluntly
elevated. At this point, an assistant introduces a fiber-
optic scope through one nostril that has been
previously anesthetized topically with 2% tetracaine.
Preferably the scope is connected to a camera and a
monitor that the surgeon can visualize directly. Alter-
natively, the assistant can communicate the findings to
the surgeon. Whereas some surgeons believe that it is
possible to obtain good medialization of the cord by
extensive mobilization of the perichondrium, in most
instances it is necessary to incise the perichondrium
superiorly, posteriorly, and inferiorly to facilitate medial-
ization. The position of the window is checked by
visualizing the vocal cord, and not the false cord, being
mobilized when the perichondrium is pushed medially.
The extent of the medialization necessary to correct
the glottic incompetence is monitored directly by
asking the patient to phonate. Obviously this is not
possible when the patient is under general anesthesia.
D1, D2 A Silastic implant is carved from a Silastic
block. A commercially available Dow-Corning block
with a block holder is available and it facilitates the
carving. The proper shape and size of the implant is a
key for a good result. The implant is obviously thinner
anteriorly (about 2 mm in thickness) and thicker pos-
teriorly (6 to 7 mm). The dimensions of the implant
can be varied, according to the shape of the thyroid
cartilage and the needs of each individual case. It is
important to avoid overmedialization of the anterior
commissure.
E1, E2 Once the implant's shape has been finalized
it is inserted and it should be self-retaining.
D1

FIGURE 20-8
 THE LARYNX

Laryngofissure (Thyrotomy)
(Fig. 20-9) bone and the cricoid cartilage, and the upper and
lower skin flaps including the platysma muscles are
developed. Extension into the lateral areas of the neck
Indications
is kept to a minimum, yet adequate visualization is still
possible. The lower edge of the hyoid bone is exposed
A laryngofissure, thyrotomy, or laryngotomy is a mid-
above and the cricoid cartilage below.
line anterior incision through the thyroid cartilage that
allows an excellent view of the interior of the larynx,
B The fascia enveloping the strap muscles is incised
permitting intralaryngeal surgery. Cordectomy, certain
in the midline, exposing the body of the thyroid carti-
vertical laryngectomies, and arytenoidectomy for both
lage and the thyrohyoid membrane. The location of
bilateral abductor cord paralysis and neoplasms are
the internal branch of the superior laryngeal nerve
performed through this approach. This exposure is well
is kept in mind as it enters the larynx through the
suited for various types of partial laryngectomy (except
thyrohyoid membrane. If a horizontal line is drawn
supraglottic) as well as more precise determination of
across the upper level of the thyroid cartilage to a
the extent of a transglottic or subglottic neoplasm.
point within 1 em of the superior cornu of this carti-
Excision of webs, correction of strictures, wide resec-
lage, this point localizes fairly accurately the site of
tion of large areas of chronic leukoplakia and hyper-
entrance of the nerve through the thyrohyoid mem-
keratoses, benign growths, and impacted foreign bodies
brane (X in A). This guide is important because the
that resist removal by peroral endoscopic procedures
midline incision through the thyroid cartilage may
are suitable for the laryngofissure approach.
then be converted to a Y incision as it transects the
thyrohyoid membrane. This modification permits a
Highpoints
much'wider and clearer visualization of the larynx and
avoids fracture of the thyroid cartilage when it is
1. Two horizontal skin incisions are preferred.
retracted. It also avoids injury to the epiglottis. This
2. Do not skeletonize the larynx.
incision is depicted by the dotted line.
3. Preliminary tracheostomy is performed.
4. Internal branch of superior laryngeal nerves should
C Through a small initial incision at the thyroid notch,
not be injured unnecessarily.
a pair of angulated heavy scissors is inserted under the
5. Use a V extension of a Y incision through the thyro-
cartilage in the midline, with an attempt to stay sub-
hyoid membrane for better exposure.
perichondrially on the under side. That is, the lumen of
6. Attempt preliminary visualization of a malignant
the larynx is not entered at this time.
tumor through the thyrohyoid incision before section
of the anterior commissure. This will permit resec-
Cl An alternate method of sectioning the thyroid
tion of the anterior commissure if it is deemed neces-
cartilage is with the use of an oscillating saw, as depicted,
sary by the extent of tumor.
or a sagittal plane saw or a Clerf saw.
7. Always drain the wound.
D The V incision through the thyrohyoid membrane
A Two separate horizontal skin incisions are made as begins at the thyroid notch and is carried upward and
indicated: the upper one for the laryngofissure and the outward toward the greater cornu of the hyoid bone.
lower one for the tracheostomy. If so desired, the upper The previously described location of the internal branch
incision may be midline vertical but it should be kept of the superior laryngeal nerve is noted. With both
separate from the tracheostomy incision if possible. sides of the V incision made, a preliminary survey of
The tracheostomy is performed under local anesthesia, the inside of the larynx is performed. Depending on
and then general anesthesia can be used or the opera- these findings, the anterior commissure is transected
tion continued under local anesthesia. The upper inci- either in dead center or off to one side.
sion is made midway between the level of the hyoid Continued
 THE LARYNX

Hyoid bone
Thyrohyoid
membrane
Thyroid cart.

FIGURE 20-9
 THE LARYNX
Cordectomy and Arytenoidectomy for
Bilateral Abductor Cord Paralysis
(Lore Sr., 1936)
Highpoints
1. Excise internal portion of thyroarytenoideus muscle.
2. Excise portion of the cricoarytenoideus lateralis
muscle.
3. Remove entire arytenoid.
4. The pedicle of the elevated and preserved mucosa
can be based either anterior or posterior.
5. Perform a tracheostomy.
Complications
• Hematoma, bleeding, and subcutaneous emphysema
• Failure of adequate airway
• Edema
• Remember, as the airway improves (glottic chink
wider), the voice becomes poorer. The patient should
be made aware of this fact preoperatively.
Thornell (1948) has described an intralaryngeal tech-
nique for the treatment of bilateral abductor vocal cord
paralysis. The author has no experience with this
method.
E Schematic frontal section through the larynx shows
the submucosal excision of a vocal cord for laryngeal
stenosis after bilateral abductor cord paralysis. First
one cord is operated on and then, if necessary, the
other cord can be operated on after evaluation of the
airway. It must be remembered, however, that as the
airway increases the voice will become worse.
F The initial incision consists of separation of the
mucosa with a No. 11 blade knife from the underlying
thyroarytenoid muscle, leaving, however, an anterior
pedicle. Posteriorly, the incision is carried medial to the
vocal process and body of the arytenoid cartilage to
the posterior commissure and thence over the ary-
tenoid cartilage following the dotted line. If desired,
this mucosal flap may be left partially or completely
attached along its inferior margin as suggested by
Lawson.
G With the mucosal flap turned forward, the ary-
tenoid cartilage is dissected using a nasal mucosal freer
and fine long scissors and removed. Care must be exer-
cised not to leave any part of the arytenoid cartilage.
H Through the denuded area, the tissues lateral to
the vocal cord are excised down to but not including
the perichondrium. The excised tissues are the internal
portion of the thyroarytenoideus muscle and part of
the cricoarytenoideus lateralis muscle. The upper part
of the conus elasticus (lateral cricothyroid membrane)
is now undermined for about 1 cm to permit closure.
It may be necessary to electro coagulate the raw area
to control oozing of blood and thus prevent postopera-
tive hematoma. The glottic chink is checked by direct
laryngoscopy. The opening at the posterior commissure
must be about 5 mm wide. Four millimeters is the
minimum required after wound healing has occurred.
If not, additional tissue should be excised.
I The mucosal flap is sutured back in place using 5-0
chromic gut sutures. If there is any persistent ooze, a
1-inch gauze strip impregnated with antibiotic oint-
ment is used as packing and brought out through the
cricothyroid membrane. Closure of the laryngofissure
is shown in Figure 20-13T. Tracheostomy care is dis-
cussed on page 116. A laryngeal keel is usually not
necessary unless the opposite vocal cord is denuded at
the anterior commissure. A small Penrose drain is used
to prevent spreading emphysema.
J A mirror laryngoscopy image shows the lateral
position of operated vocal cord.
 THE LARYNX

Epiglottis

F Ant. pedicle preserved G

Thyroarytenoideus m.

FIGURE 20-9 Continued

 THE LARYNX
Lateralization of Arytenoid
Cartilage (Arytenoidopexy)
for Bilateral Abductor Vocal Cord
Paralysis (Fig. 20-10) (After King,
1945, as modified by Clerf, 1950;
Woodman, 1946)
Highpoints
1. Correct evaluation of level of cricoarytenoid articu-
lation.
2. Complete mobilization of arytenoid cartilage:
a. Transect interarytenoid and posterior cricoary-
tenoideus muscles.
b. Transect cricoarytenoid ligament (joint capsule).
c. Maintain vocal cord attachment to the vocal pro-
cess of the arytenoid.
3. Keep all mucosa intact during dissection and place-
ment of arytenoid sutures.
4. Handle arytenoid cartilage with very fine hooks to
avoid fragmentation.
S. Mobilize the arytenoid cartilage and fix it hard
against the thyroid ala and slightly lower than its
normal position. Fixation may be too far lateral for
some patients (follow Highpoint No.6).
6. Check position of vocal cord with direct laryngo-
scope before closure of wound. Space at posterior
commissure should be at least 5 mm at the end of
the operation. (Four millimeters is the ideal final
result after the healing has occurred.)
7. Perform careful hemostasis.
8. Remember to inform the patient that as airway is
improved, voice may well become poor.
9. A cordectomy and arytenoidectomy may be the
better choice than arytenoidopexy when the patient
has had a malignant lesion (e.g., carcinoma of the
thyroid). The cordectomy and arytenoidectomy
would avoid violation of the lateral neck, which
could make detection of early metastasis difficult
and neck dissection even more difficult. Also, ary-
tenoidopexy can be very difficult to perform after
neck dissection because of scarring and lack of
protection for the common carotid artery. Hence,
the cordectomy and arytenoidectomy may be the
operations of choice (see Fig. 20-9E to J).
10. Dissect along the inner aspect of the thyroid car-
tilage to reach the arytenoid. Keep posterior and
somewhat superior; otherwise, the cricoid cartilage
will be unnecessarily exposed too much.
A Schematic lateral view depicts topographic anatomy.
The skin incision is either made through a previous
thyroidectomy scar (if one exists) or placed horizon-
tally in a natural skin crease at the level of the cricoary-
tenoid joint (solid line).
B Detailed relationship is shown of the arytenoid
cartilage to the cricoid and thyroid cartilages. The level
of the vocal cord is along the long horizontal broken
line in the adult male, which is located at the mid-
portion of the thyroid cartilage anteriorly. In the female
or small male, the level is one third of the distance
from the thyroid notch.
C Upper and lower skin flaps have been developed.
The omohyoid muscle is retracted or may be tran-
sected, exposing the inferior pharyngeal constrictor
muscle as it crosses the posterior edge of the thyroid
ala. An incision is made along the edge of the thyroid
ala transecting the inferior pharyngeal constrictor
muscle along the dotted line.
D With careful blunt dissection, using a moist peanut-
type sponge, the posterior cut edge of the inferior
pharyngeal constrictor muscle is retracted posteriorly
and the thyroid ala is retracted anteriorly, exposing the
inner anterior aspect of the slightly bulging mucosa of
the pyriform sinus. This mucosa should not be incised
or torn. The inferior cornu of the thyroid cartilage may
be separated from the cricoid cartilage or resected for
additional exposure.
E Continuing with blunt dissection, the mucosa is
now freed from the underlying arytenoid muscles and
retracted posteriorly and laterally. The two important
muscles to be transected are exposed: the interary-
tenoideus and the posterior cricoarytenoideus. The
smaller lateral cricoarytenoideus muscle may either be
left intact or cut.
Continued
 THE LARYNX

INF. PHARYNGEAL CONSTRICTOR M.

POSTERIOR EDGE
THYROID ALA

c
POST. CRICOARYTENOID

E
LAT. CRICOARYTENOID M.
FIGURE 20-10
 THE LARYNX

Lateralization of Arytenoid the other hand, the tracheostomy is absolutely

Cartilage (Arytenoidopexy) for necessary in bilateral abductor cord paralysis. Closure
of the wound is in layers with a small Penrose drain. Be
Bilateral Abductor Vocal Cord
sure to approximate the transected inferior pharyngeal
Paralysis (Continued) (Fig. 20-10) constrictor muscle. In I to 2 weeks the airway is
(After King, 1945, as modified by C1er( evaluated; and if the airway is satisfactory, the
1950; Woodman, 1946) tracheostomy tube is removed.

Complications

• Postoperative hematoma causing edema TABLE 20-1 Incidence of Cancer of the

• Breakage or slipping of arytenoid cartilage sutures Larynx in the United States, 1992-1998
• Chondritis if mucosa is torn
• Cicatrization with gradual narrowing of glottic chink. Age-Adjusted Rates
If necessary, this procedure can then be repeated on
the opposite side or an arytenoidectomy can be per-
formed (see Fig. 20-9E to J) on the opposite side via Sex
thyrotomy. Year of
Diagnosis Male and Female Male Female

F Detailed view of the muscles. The dotted lines indi-

1992 4.1714 7.5500 1.4410
cate the sites of transection. A pair of small angulated
1993 3.7037 6.7649 1.2577
scissors is used to cut the interarytenoideus muscle,
1994 3.9650 6.8814 1.5817
taking care not to violate the mucosa. 3.7909 6.7387 1.3599
1995
1996 3.6679 6.3641 1.4656
G The joint capsule is now transected circumferen- 1997 3.4879 6.1806 1.2988
tially. The arytenoid cartilage must not be fragmented. 1998 3.2436 5.6070 1.3153
A very fine double-pronged hook is used for traction
on the cartilage. Again, take care not to open the mucosa Crude Rates
overlying the cartilage.
Sex
Two sutures of 3-0 Tevdek or 4-0 braided nylon or
Age at
Mersilene are carefully placed around the vocal process Diagnosis Male and Female Male Female
and body of the arytenoid cartilage. If the arytenoid
cartilage is not calcified, a fine needle may be used to 00-04 0.0050 0.0000 0.0103
pass the suture through the cartilage. Clerf has designed 05-09 0.0000 0.0000 0.0000
special needles for this purpose. The needles must be 10-14 0.0112 0.0109 0.0115
stout enough so that they will not break. Two holes 15-19 0.0114 0.0222 0.0000
slightly lower than the level of the arytenoid cartilage 20-24 0.0332 0.0431 0.0228
are made in the thyroid cartilage to secure these lateral- 25-29 0.0548 0.0689 0.0404
izing sutures, thus dropping and tensing the vocal cord. 30-34 0.2031 0.2784 0.1270
Depending on the consistency of the thyroid cartilage, 35-39 0.4827 0.6313 0.3340
40-44 1.3744 2.1783 0.5887
a 19-9auge needle can be hand-drilled through the car-
45-49 2.8614 4.6134 1.1518
tilage and used as a guide to pass the securing suture.
50-54 6.1889 10.3436 2.1892
The arytenoid cartilage is tacked firmly against the inner 55-59 11.4793 18.9683 4.4506
aspect of the thyroid ala. This is best for men, whereas 60-64 16.1877 27.1383 6.3640
for women, the glottic chink can be somewhat smaller. 65-69 19.6324 34.5380 7.2717
The position of the vocal cord is now checked with 70-74 20.7099 38.0920 7.3302
direct laryngoscopy. The glottic chink should be about 75-79 18.7289 36.3899 6.4203
5 mm at the vocal processes. A slightly wider opening is 80-84 15.0734 33.0439 4.6692
more desirable, because scarring can narrow the glottic 85 + 9.4967 25.0200 3.1012
chink. When healing is complete, the usual4-mm width
Rates are expressed as cases per 100,000; race/ethnicity = all races;
will then be achieved. A tracheostomy, if not already
age at diagnosis ~ all ages.
present, should be performed. Tracheostomy may not Statistics are provided by the SEER Program for research purposes
be necessary if there is unilateral vocal cord paralysis. only, available at http://canques.seer.cancer.gov / Accessed
Actually, it is rarely used under such circumstances. On January 9, 2002.

INTERARYTENOID M.
F POSTERIOR CRICOARYTENOID
INTERARYTENOID M.
POSTERIOR CRICOARYTENOID
FIGURE 20-10 Continued
H Posterior view of basic anatomy depicts relation-
ship of arytenoid cartilage and the transected muscles.
Cancer of the Larynx
Incidence
The incidence (age adjusted) of carcinoma of the larynx
is 3.2 (SEER, 1998) (age-adjusted rates) patients per
100,000 population in the Un~ted States. This is the
lowest incidence since 1973 (females,1.3; males, 5.6).
When based on age at diagnosis, in those younger than
65 the incidence is 6.9; in those 65 and older it is 2.3.
THE LARYNX
M.
INTACT MUCOSA
ARYTENOID CART.
JOINT SURFACE
CRICOID CART.
M. '
This accounts for approximately 25 % of all head and
neck cancers and 1.5% of all cancers. The trend during
the period 1992-1998 appears to be somewhat
downward: 4.2 to 3.2. The bulk of patients are in the
sixth and seventh decades of life with a few patients
younger than the age of 20. Incidence data are shown
in Table 20-1.
Etiology
The major etiologic factors for carcinoma of the larynx
are the extended use of tobacco and/or alcohol, with
cigarette smoking as the primary etiologic agent. Any
patient with a history of smoking of one pack of ciga-
rettes per day for 10 or more years must be carefully
 THE lARYNX
evaluated and followed when there are any signs or
symptoms relative to the voice or suspicious changes in
the laryngeal mucosa.
Carcinoma of the larynx may be seen rarely in the
nonsmoker. There appears to be a relationship of these
patients to an environment of tobacco smoke inhala-
tion. Examples of this exposure to secondary smoke are
demonstrated in the three following patients: One was
an 18-year-old girl whose parents were exceedingly
heavy smokers, another was an elderly lady who spent
considerable time playing bridge with companions who
were heavy smokers, and a third patient was a middle-
aged woman whose husband was a heavy smoker and
who developed carcinoma of the larynx.
There is some evidence that early exposure to thera-
peutic radiation as well as industrial exposure to smoke
and toxic fumes may be contributing agents.
Pathology
Malignant tumors of the larynx arise from the mucous
membrane as well as the supporting related structures.
From 85% to 90% of the malignant epithelial tumors
are squamous cell carcinoma, ranging from the well
differentiated through the undifferentiated, with the
majority being at least moderately well differentiated.
Glottic lesions tend to be well differentiated. Verrucous
carcinoma is a distinct clinicopathologic entity, with an
incidence of approximately 1% to 2 % of laryngeal car-
cinomas. The remaining (less than 10%) malignant
tumors include fibrosarcoma, chondrosarcoma, chemo-
dectoma, rhabdomyosarcoma, malignant minor salivary
gland tumors, adenocarcinoma, oat cell carcinoma,
adenosquamous cell carcinoma, and giant cell and
spindle cell carcinoma.
Discussion of the precancerous lesions of the larynx
is limited to those of epithelial origin. The gross appear-
ance may range from a whitish and/or reddish patch,
slight roughness, and irregularity of the mucosa, to a
minimally detectable break or minor ulceration of the
mucosa, to a thick pile-up of whitish irregular mucosa.
Although clinical diagnosis indicates suspicion, histologic
examination is the only way to be certain. However, it
is emphasized that biopsy must consist of complete
removal of the suspected area when frank carcinoma is
not obvious. The histologic changes of these precan-
cerous lesions include dysplasia and cytological atypia
(see Chapter 3).
The clinician is cautioned that when the clinical diag-
nosis is malignant, but the biopsy does not confirm this,
the clinician should review the slides with the pathol-
ogist and, if necessary, repeat the biopsy. If the lesion
involves the membranous true vocal cord and it is not
obvious squamous cell carcinoma, a stripping biopsy of
the entire edge of the vocal cord is more fruitful than
multiple small biopsies of the area.
Natural History
The natural history of larynx cancer varies widely,
depending on the anatomic site of the origin of the
tumor. The larynx is divided into supraglottic, glottic,
and subglottic. These divisions are very useful; how-
ever, in advanced disease they may not be precise. The
supraglottis of the larynx extends from the tip of the
epiglottis to the apex of the ventricle. This includes the
ventricular bands or false vocal cords and the superior
wall of the ventricle. The glottis extends from the apex
of the ventricle inferiorly to the area beneath the true
vocal cord where the squamous epithelium changes to
respiratory epithelium. The subglottis extends from the
junction of the squamous and respiratory epithelium to
the inferior edge of the cricoid cartilage. Patients with
tumors arising from other than the true vocal cord
usually do not experience any voice changes until a
neoplasm becomes so large that it interferes with the
glottis. Even then, voice changes may not be apparent
or significant. Surprisingly enough, very large bulky
lesions of the epiglottis occur that defy an explanation
of the paucity of symptoms. Although dysphagia can
occur in these large tumors, the real threat is airway
embarrassment, leading to obstruction. Although more
common in glottic tumors, airway problems are the
terminal symptoms of virtually all stage IV malignant
lesions. Table 20-2 outlines the symptoms.
Supraglottic carcinomas are generally more aggres-
sive both in direct extension (e.g., into pre-epiglottic
space [adipose tissue] and lymph node metastases).
Approximately one third to one half will have positive
nodes. Lymphatic channels drain into the jugulodi-
gastric, middle, and inferior levels of the internal jugular
chain. All adjacent structures may become involved.
This includes the lateral wall of the hypopharynx along
the glossoepiglottic fold as well as the base of the tongue.
Yet extension to the true vocal cords or subglottically is
TABLE20-2 Symptoms of Carcinoma of the
Larynx
Hoarseness or change in the voice
Irritation or tickle in the throat
Lump in the neck
Dysphagia and/or odynophagia
Sore throat
Dyspnea or orthopnea leading to airway obstruction
Hemoptysis
Stridor
Cough
'Earache
Asymptomatic

relatively rare except for those tumors that involve the
base of the epiglottis.
Kirchner (1969) has pointed out in serial sections of
over 50 supraglottic cancers that when the tumor is
limited to the supraglottic portion of the larynx, the thy-
roid cartilage is not destroyed or even invaded. However,
when the fixed growth does involve the true cord and
the ventricle, the thyroid ala is invaded, particularly in
growths over 2 cm in diameter. If lymph nodes are
positive on one side of the neck, then the possibility of
contralateral node metastases is high.
In the clinical evaluation of supraglottic carcinoma,
the inferior wall of the ventricle should not be involved.
Once this becomes involved, then the disease has spread
to the glottis, and as noted previously, the thyroid ala
can then become involved.
These tumors arising from the laryngeal surface of
the epiglottis tend more to lead toward potential airway
embarrassment. When a tumor reaches such a size,
however, it is often quite difficult to ascertain the exact
site of origin. After preoperative adjuvant chemother-
apy when there is some residual disease, this location
seems to indicate the site of origin.
Glottic carcinomas tend to be well differentiated, grow
slowly, and metastasize late, with metastases usually
occurring only when the disease has spread beyond the
limits of the true cord. This characteristic is related to
the limited lymphatic drainage of the vocal cords. Sub-
mucosal extension of the anterior third of the vocal
cord toward the anterior commissure may be a rela-
tively early occurrence; and, subsequently, the lesion
may extend across the midline to the opposite side,
invade the thyroid cartilage specifically at the anterior
commissure, and then extend superiorly into the walls
of the ventricle, the ventricular bands and aryepiglottic
fold, and/or inferiorly into the subglottic space, although
rarely below the superior border of the cricoid arch.
Significant invasion and breakthrough of the thyroid
cartilage may be characterized by broadening of the
thyroid cartilage. Posterior extension of the posteriorly
situated cord lesions is to the cricoarytenoid articula-
tion and into the arytenoid region. Ten to 20 % of glottic
carcinomas with fixed vocal cords present as lymph
node metastases. These fixed vocal cords are usually a
result of local extension rather than nerve involvement,
although the latter can occur. Fixation of the vocal
cords usually indicates invasion of the thyroarytenoid
muscle. On the other hand, limitation of motion of the
vocal cord may be due to the bulk of the tumor, with
surface extension rather than direct invasion of the
thyroarytenoid muscle. Nevertheless, it should be
emphasized that with impaired mobility of either the
true cord or, for that matter, the ventricular band in
supraglottic carcinomas, one must be suspicious of a
deeply invasive lesion that may well have started in the
ventricle.
THE lARYNX
True subglottic carcinomas are uncommon (perhaps
5% of all laryngeal carcinomas); however, subglottic
extension does occur with glottic carcinoma; and when
it does occur, the disease progresses rapidly and is an
ominous sign. Lymphatics from the subglottic area drain
to the middle and inferior levels of the internal jugular
chain, to the prelaryngeal (cricothyroid or delphian)
nodes (from which lymph vessels pass to the pretracheal
and supraclavicular nodes), and tothe paratracheal and
tracheoesophageal nodes and then into the mediasti-
num. Dye studies have demonstrated the existence of a
plexus of lymphatics at the surface of the cricothyroid
membrane, with channels leading bilaterally to the deep
cervical nodes. This supports the observation that carci-
nomas with subglottic extension have a greater tendency
toward bilateral cervical metastases and have a poorer
prognosis. Hence, these tumors require extensive para-
tracheal and tracheoesophageal node dissection as well
as superior mediastinal node dissection. In addition, an
ipsilateral thyroid lobectomy is performed. As a matter
of routine, an ipsilateral thyroidectomy is recommend-
ed in all total laryngectomies. Glottic carcinomas with
subglottic extension have a higher incidence of stomal
recurrence, probably owing to the nodal spread.
It is significant that in more recent years, tracheal
stoma recurrence after total laryngectomy has signifi-
cantly decreased. Tracheal recurrence could be the result
of a number of factors. Three possibilities are:
1. Tumor implantation in the tracheal wound. Tra-
cheostomies years ago were more common because
of airway obstruction. Today, if a patient arrives at a
hospital in airway distress, there are three options:
a. Immediate commencement of chemotherapy with
Decadron
b. Debulking of the lesion with the CO2 laser provid-
ing a temporary airway
c. Emergency laryngectomy
2. Untreated paratracheallymph node metastases
3. Undetected presence of tumor at the tracheal margin
of resection. This was a significant possibility with
the so-called narrow field laryngectomy, which vir-
tually is skeletonization of the thyroid cartilage and
all the surrounding tissue, which constituted a "shelled
out" larynx with no contiguous tissue and positive
margins. If there is any question regarding margins
in any operation, frozen sections are utilized. This
likewise would be true if there is extension of the
laryngeal carcinoma into any portion of the hypo-
pharynx, particularly the pyriform sinus.
Diagnostic Methods
1. Inspect and palpate the neck for cervicallymphade-
nopathy and broadening of the thyroid cartilage
(broadening of the thyroid cartilage is suspicious of
 THE lARYNX
neoplasm of larynx). Always palpate the base of the
tongue.
2. Perform laryngoscopy (see Chapter 4).
a. Indirect mirror. This is probably the most impor-
tant overall diagnostic measure. It gives an overall
view of not only the larynx but also the base of
the tongue and hypopharynx.
b. Direct optical laryngoscopy. This includes the use
of the various types of fiberoptic and opticallaryn-
goscopes. There are a number of these available;
one of them is the Bercie-Ward, which utilizes
Hopkin's rod principle (Karl Storz). It affords an
excellent view of the larynx, particularly the ante-
rior commissure and the base and petiolus of the
epiglottis. The instrument must be defogged using
a chemical defogger or by dipping the end in "hot
beads" or in hot water. This water should be
changed from patient to patient.
c. Another instrument is the flexible fiberoptic laryn-
goscope, which is inserted through one of the
nares and facilitates an overall view not only of
the nasopharynx but also of the base of the tongue,
hypopharynx, and larynx. This instrument gives
a much less magnified view, and it may be diffi-
cult to detect very small lesions. It is excellent for
visualizing the motion of the vocal cords and is
usually very well tolerated by the patient.
d. Direct rigid laryngoscopy. The Holinger hourglass
anterior commissure speculum is excellent. Another
instrument, interestingly enough, is the Jesberg
short adult esophagoscope. Both this and the
Holinger anterior hourglass speculum can be in-
serted well into the intrinsic structures of the
larynx for careful visualization of the walls of the
ventricle as well as the pyriform sinus of the hypo-
pharynx. Evaluation of the medial wall of the
pyriform sinuses is most important in all moder-
ately and advanced carcinomas of the larynx.
e. Microlaryngoscopy. This can be done utilizing a
standard operating microscope or an optical tele-
scope inserted through a rigid laryngoscope.
3. Diagnostic radiology
a. Soft tissue radiographs
b. Pharyngoesophagogram
c. CT and magnetic resonance imaging (MRI) are
used when additional soft tissue detail is neces-
sary. Some clinicians prefer MRI in the evaluation
of larynx cancers because it provides excellent
actual (not computer reconstructions as in CT)
coronal and sagittal views of the larynx.
d. Laryngogram and tomograms are not utilized and
are very selective.
4. Esophagoscopy and bronchoscopy
5. Photography of the larynx and hypopharynx. These
photographs can quite easily be obtained using a
Hopkin rod type of fiberoptic laryngoscopy (e.g., the
Bercie-Ward scope). These photographs afford a very
careful and leisurely examination of the larynx and
hypopharynx and serve as a record for the extent of
the tumor prior to preoperative chemotherapy.
6. Video recordings are excellent, not only for record-
ing the extent of the neoplasm but also for the evalu-
ation of the mobility of the vocal cords. Combined
with voice evaluation-stroboscopy-additional data
are obtained regarding voice function and compara-
tive analysis with vocal cord motion. Video record-
ings are excellent for presentation at tumor confer-
ences, and this combined with video presentation of
the histopathology is a sine qua non for an up-to-
date head and neck tumor conference, as well as a
record regarding the extent of disease if chemother-
apy is to be used (e.g., before operation or chemoir-
radiation) .
After these various diagnostic modalities, a biopsy is
then performed, usually through a direct laryngoscope.
If there is some question as to the site of biopsy,
particularly with multiple suspicious areas, staining of
the mucous membrane can be performed with the use
of 1% toluidine blue. Acetic acid (1 % solution) is used
to cleanse the lesion before and after staining (see
Chapter 3, p. 91). Although there is some difference of
opinion regarding the validity of the staining, never-
theless, it is believed to be of help with multiple suspi-
cious areas. In lesions of the membranous vocal cord in
which clinical diagnosis is not clear cut, stripping of
the entire edge of the free vocal cord is preferred over
small multiple punch biopsies. This stripping specimen
corresponds to the free membranous cord, and hori-
zontal multiple small sections can then be obtained.
With a large lesion, a simple punch biopsy will suffice.
A variant of direct laryngoscopy is the operation
microscope, which is utilized for small lesions, particu-
larly multiple suspicious areas. Telescopic instruments
designed by the author and manufactured by Karl Storz
are ideal for careful scrutiny of the entire intrinsic larynx
(see Chapter 4).
Anesthesia
Many indirect laryngoscopies can adequately be per-
formed without any form of anesthesia. If anesthesia is
necessary, there are basically three types of agents: 2 %
tetracaine (Pontocaine), 10% cocaine, and 4% lidocaine.
Side effects can occur with any of these agents. Careful
history of any untoward reaction is important. More
laryngoscopies using the various types of opticallaryngo-
scopes do require some type of anesthesia, although the
Hopkin rod type may be used without any anesthesia.
The Machida optical scope requires anesthesia and
decongestion of the nasal mucous membrane as well as
of the oropharynx and hypopharynx.
 THE LARYNX

When direct rigid laryngoscopy is done, anesthesia
is always necessary, and although in the past topical
anesthesia was used primarily, at the present time
general anesthesia through a small endotracheal tube is
preferred. This allows the surgeon to make a careful
evaluation of the areas of the larynx and hypopharynx.
In the large, bulky lesions in which there may be some
compromise of the airway, topical anesthesia alone is
utilized because of the danger of airway obstruction
after general anesthesia and intubation.
Staging
Staging that involves the TNM classification (Tables 20-3
and 20-4) is based on a pretreatment diagnostic evalua-
tion of the extent of disease and is classified according
to the supraglottic, glottic, and subglottic larynx. There
are a number of problems with staging, not the least of
which are the various methods of TNM classification
and the change in the TNM classification in anyone
system. It is suggested to the clinician that a very care-
ful delineation of the tumor is made so that if there is
a change in the TNM classification from one system to
another, or within one system, this can be easily inter-
preted and cross-referenced. Kaufman and Lore (1978)
have described a TNM classification and disease descrip-
tion that accomplishes this type of TNM classification
and can be converted from one system to another. The
stage relates only to the site of the lesion and to a
clinical estimate of the extent of the disease. It does not

TABLE20-3 TNM Classification of Cancer of the barynx

Primary Thmor (T)

TX Minimum requirements to assess the primary tumor cannot be met.
TO No evidence of primary tumor
Tis Carcinoma in situ
Supraglottis
Tl Tumor limited to one subsite of supraglottis with normal vocal cord mobility
T2 Tumor involves mucosa of more than one adjacent subsite of supraglottis or glottis or
region outside of supraglottis (e.g., mucosa of base of the tongue, vallecula, medial wall
of pyriform sinus) without fixation of the larynx
T3 Tumor limited to larynx with vocal cord fixation and/or invades any of the following:
postcricoid area, pre-epiglottic tissues, paraglottic space, and/or minor thyroid cartilage
erosion (e.g., inner cortex)
T4a Tumor invades through the thyroid cartilage and/or invades tissues beyond the larynx
(e.g., trachea, soft tissues of neck including deep extrinsic muscle of the tongue,
strap muscles, thyroid, or esophagus)
T4b Thmor invades prevertebral space, encases carotid artery, or invades mediastinal structures
Glottis
Tl Tumor limited to the vocal cord(s) (may involve anterior or posterior commissure) with
normal mobility
Tla Tumor limited to one vocal cord
Tlb Tumor involves both vocal cords
T2 Thmor extends to supraglottis and/or subglottis, and/or with impaired vocal cord mobility
T3 Tumor limited to the larynx with vocal cord fixation and/or invades paraglottic space,
and/or minor thyroid cartilage erosion (e.g., inner cortex)
T4a Tumor invades through the thyroid cartilage and/or invades tissues beyond the larynx
(e.g., trachea, soft tissues of neck including thyroid deep extrinsic muscle of the tongue,
strap muscles, thyroid, or esophagus)
T4b Tumor invades prevertebral space, encases carotid artery, or invades mediastinal structures
Subglottis
Tl Tumor limited to the subglottis
T2 Thmor extends to vocal cord(s) with normal or impaired mobility
T3 Tumor limited to larynx with vocal cord fixation
T4a Tumor invades cricoid or thyroid cartilage and/or invades tissues beyond the larynx
(e.g., trachea, soft tissues of the neck including deep extrinsic muscles of the tongue,
strap muscles, thyroid, or esophagus)
T4b Tumor invades prevertebral space, encases carotid artery, or invades mediastinal structures

From American Joint Committee on Cancer, 2003.

 THE LARYNX

by stripping (see Fig. 20-5) the entire lesion (removal of

Stage Grouping for Cancer of the the epithelium of the vocal cord) and multiple section
evaluation for histopathology. Carcinoma in situ is
treated in the same manner with a deeper stripping if
Stage 0 Tis NO MO suspected preoperatively. The CO2 laser can also be uti-
Stage I Tl NO MO lized to achieve virtually the same results. The author
Stage II T2 NO MO
is concerned regarding the adequacy of the histologic
Stage III T3 NO MO
examinations of the specimen with the CO2 laser. The
Tl or T2 or T3 Nl MO
Stage IVA T4a NO MO CO, laser may destroy active cancer cells on the margins
T4a Nl MO and give a false sense of security and is not utilized for
Tl or T2 or T3 or T4a N2 MO biopsy purposes. Early superficial cancers without fixa-
Stage IVB T4b Any N MO tion or lymph node involvement can be treated by
Any T N3 MO radiotherapy alone. In this group of patients, it appears
Stage Ive Any T Any N Ml that radiotherapy or surgery offer the same high cure
rate, namely, 85 % to 95 %. Yet there are some statistics
From American Joint Committee on Cancer, 2003. that do place surgery slightly higher than radiotherapy.
There are pros and cons. For example, radiotherapy usu-
take into account the other aspects relative to prog- ally affords a better post-treatment voice. After surgery,
nosis, namely, the immune competency of the patient, the voice may be breathy after frontolateral laryngec-
the actual histologic spread of the disease, the duration tomy or there may be aspiration after a supraglottic
of symptoms, or the rapidity of growth. All of these laryngectomy. All this depends on the success or failure
factors obviously influence the survival. of reconstructive procedures. Conversely, radiotherapy
Nevertheless, clinical staging is most important in requires more time than surgery, but surgery affords a
assessing the type of treatment and the outcome of better evaluation of the extent of the disease.
treatment. With large tumors, the exact classification More locally advanced lesions may be successfully
based on the site of origin is extremely difficult, and managed by surgery, radiotherapy, or a combination
this compounds the evaluation of the end results. of both in either sequence. When mobile lymph node
The author believes that stage IV actually may be involvement is present, surgery is the predominant
misleading, because within stage IV both resectable and management with or without adjunctive radiation
nonresectable lesions are included and there is cer- therapy.
tainly an expected difference in survival of patients who Surgery is the prime modality in extensive carcinoma,
are resectable and nonresectable. It is suggested that namely, stage III and stage IV disease. Several combi-
stage V be recognized to designate the stage IV disease nation options are available:
that is nonresectable. This would be most important in
reporting statistics. The other problem arises with the 1. Surgery may be combined with radiotherapy either
determination of resectability, because this is a very preoperatively or postoperatively.
subjective evaluation by the physician. 2. Preoperative adjuvant chemotherapy with or without
postoperative radiotherapy and/or chemotherapy.
Treatment This is the preference of one of the authors (JML).
Currently (JEM), however, it appears that concurrent
Treatment of carcinoma of the larynx involves multiple chemotherapy and radiation therapy yields the best
modalities, used either independently or in combination. results in terms of local regional control and larynx
One point must be made clear regarding the termi- preservation (RTOG, ECOG, and SWOG protocol
nology of operable versus resectable. This is especially R91-11). If there is failure of chemotherapy and radia-
important in reporting end results. Operability refers to tion therapy or chemoirradiation concomitantly, the
the patient's ability, usually medical status, to tolerate tumor is then treated by salvage surgery. With the
anesthesia and a major surgical procedure. Resectability, larynx this usually means a total laryngectomy (JML).
on the other hand, refers to the surgeon's impression as In addition, this type of surgery is associated with
to whether the tumor can be entirely resected and complications seen years ago when advanced squa-
reconstruction performed. Obviously both are subjective mous cell carcinoma of the head and neck was
and change from physician to physician. rather routinely treated with preoperative radiother-
apy. These complications include severe crusting of
Basic Concepts secretions in the supraglottic area, poor and delayed
wound healing, fistula formation, and the worst,
Premalignant and SUSpICIOUSepithelial lesions of the carotid artery blowout. At the present time, at least
membranous vocal cord are usually treated surgically one author (JML) has not seen any patients with

carotid artery blowout. Also associated with the
radiotherapy are dysphagia and esophageal stricture.
Each modality as it applies to site and extent of
disease is as follows:
Surgery
1. Carcinoma in situ. Deep stripping (de-epithelializa-
tion) of the membranous portion of the true vocal
cord is done. Radiotherapy plays no part in the
treatment of carcinoma in situ. The CO2 laser may
achieve the same results as a stripping operation but
may render the specimen useless for histologic
examination.
2. Tl disease at all sites and T2 lesions. The vocal
cord and other involved structures must be mobile,
indicating limited invasion. Impaired mobility of
either the vocal cord or ventricular band raises
serious doubt as to the validity of a partial laryn-
gectomy.
Partial Laryngectomy
1. Cordectomy for very small Tl lesions of the middle
third of the membranous vocal cord (see Fig. 20-12)
2. Vertical or frontolateral laryngectomy primarily for
tumors of the true vocal cord with minimal sub-
glottic extension. Lesions involving the inferior wall
of the ventricle with no evidence of deep invasion
may be suitable for this type of conservation surgery
(see Fig. 20-13A to M)
3. Horizontal or supraglottic laryngectomy primarily for
tumors of the supraglottic larynx (see Fig. 20-16D
to 0)
4. A combination and extension of the previous three
incisions with or without involvement of the ven-
tricle, which can be a danger sign, ventricular band,
aryepiglottic folds, and juxtaposed limited portion of
the medial wall of the pyriform sinus
5. Advanced carcinoma: some T2 and all T3 and T4
lesions
Total Laryngectomy
Total laryngectomy is usually indicated with vocal cord
fixation and certain lesions classified as T2 or T2b
(more than one region), depending on the extent of the
tumor. T3 and T4 lesions require total laryngectomy.
Total laryngectomy is combined with an ipsilateral thy-
roid lobectomy and isthmusectomy, especially with those
lesions that involve the subglottic region, which in addi-
tion require paratracheal and tracheoesophageal node
dissection. The basic recommended technique of total
laryngectomy includes resection of a major portion of
the juxtaposed strap muscles. Careful evaluation of
THE LARYNX
the extent of the lesion, not only by prior endoscopic
examination but also at the time of surgery, is essential.
When preoperative chemotherapy is utilized with a
response, endoscopic examination at the time of surgery
is not to be used to delineate the extent of the surgical
procedure. This basically involves an approach, for
visualization of the larynx, from the side opposite the
gross extent of the disease. In other words, if the lesion
involves the left side of the larynx, a contralateral
approach via the right pyriform sinus is utilized. If the
lesion is primarily glottic, a trans hyoid or suprahyoid
approach for evaluation may be utilized. However, an
initial trans hyoid or suprahyoid exposure is contraindi-
cated in those lesions that involve the epiglottis for fear
of cutting into the tumor. Depending on this evaluation
of the extent of the disease, a portion of the hypo-
pharynx should be at least 2 cm because of the sub-
mucosal spread of squamous cell carcinoma once it
reaches the pharynx. Liberal use of frozen section to
ascertain free margins is recommended. With chemo-
therapy it is important to search the deep structures for
viable tumor cells because the mucosa can be intact,
hence the importance of pretreatment tattoo. Partial or
total hypopharyngectomy is thus included depending
on the extent of the disease. When anything but mini-
mal involvement of the hypopharynx is detected, a total
hypo pharyngectomy is advised. Reconstruction in a
one-stage manner using a posterior tongue flap and
dermal graft is performed (see Fig. 21-7), or if the
defect is larger than 6 to 8 cm a pectoralis major flap is
used with a dermal graft (see Fig. 8-2G).
If the lesion encroaches on the airway, do a tra-
cheostomy first under local anesthesia and then con-
vert to general anesthesia through the tracheostomy.
There may be a real hazard in endotracheal intubation
through the glottis of implanting a large number of
tumor cells dislodged by the endotracheal tube. Care
must be exercised in performing a tracheostomy to be
sure that the site in the trachea is well below any sub-
glottic extension. Preoperative CT and MRI (especially
sagittal and coronal MRI views) and soft tissue radio-
graphs are of value in determining this subglottic exten-
sion. Bronchoscopy and tracheoscopy are most impor-
tant. Another option is immediate commencement of
chemotherapy with corticosteroids (see Chapter 3,
p. 132). This usually reduces bulk, improves airway,
and may obviate a tracheostomy. There must be no
compromising the extent of the surgical procedure rela-
tive to the preoperative chemotherapy response. Pre-
treatment tattoo to delineate the extent of the disease is
most important to guide the surgeon (it is very impor-
tant to refer to p. 132 relative to the entire technique of
this management).
Local recurrence, after the application of the preced-
ing principles for total laryngectomy, has been mini-
mal. The problems of failure are mainly uncontrollable
 THE LARYNX
neck and mediastinal disease, tracheostomal recurrence,
and, in some patients, distant metastases.
Neck Dissection
Radical or modified radical neck dissection is indicated
with clinically positive nodal disease. This includes an
ipsilateral thyroid lobectomy, isthmusectomy, and
removal of tracheoesophageal and para tracheal lymph
nodes. In the absence of clinically palpable nodes,
patients with carcinomas classified as T2, especially
subglottic and supraglottic carcinomas, may need either
a modified radical neck dissection (JEM) (with preser-
vation of the sternocleidomastoid muscle, internal
jugular vein, and spinal accessory nerve) or a lateral
neck dissection (including nodal regions II, III, and IV).
In addition, those patients with disease classified as T3
and T4 should have the regional lymph nodes treated
electively with a neck dissection, radiation therapy, or
both (when there are multiple histologically positive
nodes or there is evidence of extracapsular spread of
tumor).
One author (JML) believes very strongly that a
standard radical neck dissection, including levels I, II,
III, IV, and V, should be performed when there is stage
III or stage IV disease, even though the neck is clini-
cally negative. In virtually all instances, a modified or
selected neck dissection is not performed. One excep-
tion is the preservation of the 11th cranial nerve if level
II is free of disease. In level V disease, the involved
portion of the 11th cranial nerve can be resected and
reconstructed with a sural nerve graft (see Fig. 3-8) or
the nerve may be sectioned and then reanastomosed,
depending on the location of the disease and the neces-
sity to transect part of the sternocleidomastoid muscle
to free the 11th cranial nerve.
In T2 lesions of the oral cavity, a suprahyoid neck
dissection is often performed when the neck is NO. On
the other hand, the T2 lesion of the subglottic area can
be a bad actor and it is the tendency of one author
(JML) to perform a standard radical neck dissection, or
at least a dissection of the tracheoesophageal nodes
with the ipsilateral lobe of the thyroid and with the
paratracheallymph nodes.
When a radical neck dissection is combined with
preoperative chemotherapy and selective postoperative
radiotherapy, the results of this treatment plan reveal
that neck recurrence can be reduced to 0% when using
cisplatin and 5-fluorouracil (see Chapter 3, p. 132).
It is the belief of one author (JML) that once the
lateral neck is entered, rather than modifying this opera-
tion, the standard radical neck dissection be performed,
because the neck is actually "violated" and any subse-
quent surgical procedure is extremely difficult and almost
fruitless. The admonition to use postoperative radio-
therapy to compensate for the radical neck dissection is
not believed to achieve the results of no recurrence in
the neck in a 5-year period of follow-up.
At the time of neck dissection, evidence of gross
disease in the low internal jugular lymph nodes is an
indication to sample top superior mediastinal nodes using
mediastinoscopy (see Fig. 19-8). If the nodes are posi-
tive, then consider performance of superior mediastinal
dissection if the patient's medical status is good (for
various approaches to the mediastinum, see pp. 1041to
1061). The approach to the superior mediastinum (see
Chapter 19) can be achieved by either median sternotomy
or more simply by resection of the medial third of the
clavicle on the homolateral side or by resection of the
manubrium sterni. These latter approaches afford good
exposure without some of the drawbacks of a sternal
splitting incision.
Radiation Therapy for Laryngeal Cancer
Dhiren K. Shah
At diagnosis, about two thirds of glottic tumors are
confined to the cords (usually one cord). The anterior
portion of the cord is the most common site. In most
centers, irradiation is the initial treatment for Tl and T2
lesions. Surgery is reserved for salvage after radiation
therapy failure. Radiation consists of 66 Gy to the glottis
only in Tl lesions and 68 to 70 Gy for T2 lesions with
consideration to include the first echelon lymph nodes.
For more advanced T3 and T4 lesions, the Veterans
Administration Larynx Preservation Study randomized
patients to either standard therapy with surgery and
postoperative irradiation or two to three cycles of induc-
tion chemotherapy followed by radiation therapy, with
laryngectomy as a planned salvage procedure. There
was no difference between the two arms in the study.
Of patients receiving chemotherapy, 64% did not
undergo laryngectomy. Long-term survival data from
this study have not been published. There was also a
European study investigating a similar approach for
patients with pyriform cancer. Induction chemotherapy
resulted in similar survival data while allowing organ
preservation; 42 % of patients in the chemotherapy arm
were alive with a functional larynx at 3 years of follow-
up and 35 % were alive at 5 years.
More recently, the RTOG, ECOG, SWaG Protocol
R91-11compared induction chemotherapy (5-fluorouracil
and cisplatin) followed by radiation therapy, concur-
rent chemotherapy and radiation therapy (cisplatin,
110 mg/m2, on days 1, 22, and 43 of irradiation), and
irradiation alone. The results (JEM) indicate that there
were no differences in overall survival, that in terms
of laryngeal preservation, induction chemotherapy has
no advantage over irradiation alone, and that concur-
rent chemoradiation results in a higher larynx preser-
vation rate.

Radiation Therapy: Surgeon's Viewpoint
An in-depth discussion of this modality is beyond the
scope of this atlas. However, a few suggestions are in
order:
1. The radiation ports should be discussed with the
head and neck surgeon and the outline of the ports
be likewise supplied.
2. In general, glottic carcinoma without vocal cord
fixation generally requires limited ports confined to
the larynx.
3. For more advanced glottic and most supraglottic carci-
nomas, regional nodes should be treated even though
they are clinically negative. Full therapeutic doses
are suggested to avoid subsequent radiotherapy with
the problem of overlapping ports. It is the belief of this
author (JML) that patients whose disease is operable
and resectable should have radical neck dissections
rather than radiotherapy. On the other hand, nonre-
sectable, huge masses in the neck have been seen
to respond to radiotherapy even though they are
fixed.
4. The controversy regarding surgery versus radiotherapy
will probably go on forever until a "real" management
occurs. The patient should be aware of the options
as well as the advantages and disadvantages of each
modality. This includes during the treatment course
as well as the post-treatment period, which goes on
indefinitely. Cross consultation on an individual basis
is suggested. Presentation of findings at head and
neck tumor conferences is also very beneficial for
divergent views. However, do not get caught in the
trap of "treatment by committee," so aptly expressed
by Helmuth Goepfert.
5. Planned preoperative radiotherapy followed by sur-
gery is virtually never advocated by the authors.
6. The use of routine postoperative radiotherapy in
stage III and stage IV carcinoma is open to question.
What are the reasons? To be sure if the surgeon
believes there may be tumor left behind and if the
margins are positive on the final histologic review,
then postoperative radiotherapy is indicated. (For
additional indications for radiotherapy, see item 7.)
The frightening aspect is the possibility that the
surgeon advocating postoperative radiotherapy does
it for the purpose of "covering up" incomplete surgi-
cal resection, with no frozen sections of margins
during the operation.
7. When preoperative adjuvant chemotherapy is utilized
followed by uncompromised surgery and selective
radiotherapy, the decision for radiotherapy is based
on:
a. Highest superior or lowest inferior neck dissection
nodes positive
b. Margins positive
THE LARYNX
c. Tumor extending through the lymph node capsule
(extracapsular spread)
d. Extension of disease beyond the fascial planes of
the neck
e. Invasion of the deep cervical musculature
f. Significant multiple nodal metastasis on a selective
basis (Lore and Hendrickson, 1979).
Laser
CO, laser treatment of cancer of the larynx is limited to
three pathologic processes, namely, carcinoma in situ,
very early invasive carcinoma of the middle third of the
vocal cord (Tl lesion) (which is amenable to cordec-
tomy), and verrucous carcinoma. The basic technique
with the carcinoma in situ and the Tl lesion involves
the use of the CO, laser with the operation microscope
as a cutting modality and not as vaporization. With
verrucous carcinoma, the cutting modality is ideal;
however, vaporization of bulky lesions may be neces-
sary. This disease, depending on its extent, may be suit-
able for partial laryngectomy. When both vocal cords
are involved, the CO, laser may be the modality of
choice. With the more extensive lesions, totallaryngec-
tomy is indicated. Verrucous carcinoma does not usu-
ally metastasize. It should be mentioned, however, that
trans oral endoscopic resection of tumors of the larynx,
including T3 and selected T4 tumors, as advocated by
Wolfgang Steiner is being done with growing frequency
in Europe and in the United States (Steiner and
Ambrosch, 2000). In any case done with the laser,
careful continued observation is essential and repeated
laser therapy may be necessary. One author (JML) does
not recommend this methodology, which often includes
sectioning the tumor into smaller pieces to facilitate
removal through the endoscope. Another admonition
regarding the use of CO, laser is the problem of evalu-
ation of margins. Catastrophic failures have been seen
in three patients treated elsewhere for a carcinoma of
the tongue and floor of the mouth with the CO, laser.
The CO, laser can likewise be used to vaporize endo-
tracheal extension of disease as a palliative procedure
to improve the airway patency. This has been efficacious
in one patient in whom there was radiation failure
and salvage surgery was impossible. This patient was
initially treated elsewhere; the preference would have
been to perform a tracheal resection and medi-astinal
node dissection before the radiation therapy. The
surgical procedure would have been a mediastinal
dissection for tracheostomal recurrence as described in
Figure 19-11A.
Chemotherapy (see Chapter 3)
This modality alone has not been successful in the cure
of any patient with squamous cell carcinoma of the
 THE LARYNX
larynx, until recently. It has been utilized with palliation
of up to 2 years in several patients who have refused
either surgery or radiation. However, Laccourreye and
co-workers have reported data that contradict the old
dogma of noncurability of squamous cell carcinoma
with chemotherapy alone. They treated a group of 36
patients with glottic carcinoma (Tl-T4NOMO) with a
median of seven courses of cisplatin and 5-fluorouracil.
Surprisingly, 85 % of the patients were alive and free of
disease at 5 years.
Chemotherapy has a distinct advantage of often
significantly reducing the bulk of tumor within 24 to
48 hours. In patients with a compromised airway, this
is a very important facet, because it may well allow for
avoidance of tracheostomy. Chemotherapy must not be
used as a substitute for tracheostomy when it is obvi-
ously necessary. Nevertheless, patients with some air-
way compromise, if they can be carefully observed,
will often have improved airway patency as time goes
on. If dysphagia was present, this will likewise improve.
Corticosteroids as combined with (and if necessary
their dosage is increased) chemotherapy and a temporary
endotracheal tube can improve the airway patency.
Combined Modalities
1. Surgery and radiotherapy. Adjuvant postoperative
irradiation should include all potential sites of
cancer. The author does not use preoperative
radiotherapy except in unusual circumstances, such
as hemoptysis and dyspnea associated with tracheal
lumen invasion by Hiirthle cell carcinoma of thyroid
that has no uptake of 1311. The radiotherapy in less
than the "curative" dose has halted the bleeding
and improved the airway before definitive tracheal
resection.
It is believed that planned radiotherapy com-
mencing 3 weeks postoperatively should be con-
sidered in a number of circumstances before there is
clinical evidence of disease:
a. Disease at line of resection
b. Significant subglottic extension in patients who
have had a tracheostomy performed before the
time of laryngectomy
c. Inferior tracheoesophageal and/or mediastinal
lymph nodes positive for carcinoma. The radia-
tion ports would include the mediastinum and the
tracheostome. Surgical mediastinal node dissec-
tion is recommended before radiotherapy to the
mediastinum, because radiation failure in this area
is very likely to preclude any salvage after radio-
therapy. The neoplasm may invade the trachea
and cause deep ulceration juxtaposed to any of the
great vessels in the mediastinum. If the patient
has had radiotherapy before this unfortunate event,
mediastinal dissection is usually impossible in a
contaminated field associated with radiation arteri-
tis. Vessel replacement is then virtually impossible,
thus setting the stage for major vessel blowout.
d. Histologic or gross disease at the superior and/or
inferior margins of the neck dissection, extension
of disease beyond the usual fascial planes of the
neck dissection and/or significant involvement of
the deep surface of the sternocleidomastoid muscle,
and/or gross breakthrough of the capsule of
lymph nodes that lie on the margins of the neck
dissection.
e. Histologic extracapsular spread, as reported by
Snow and colleagues (1982), Johnson and asso-
ciates (1985), and Snyderman and co-workers
(1985), is a very ominous finding in neck dissec-
tion specimens and an "indicator of poor prog-
nosis in patients with squamous cell carcinoma of
the upper aerodigestive tract." To further quote
Snyderman and co-workers: "Radiation therapy
after surgical excision has become standard therapy
for patients with large primary tumors or tumors
metastatic to the neck." This recommendation for
postoperative radiotherapy follows a proposal by
Lore and Hendrickson (1979), in which break-
through of a capsular lymph node and/or inva-
sion of muscle was detected on radical neck dis-
section. Other recommendations for postoperative
radiotherapy are enumerated in the section on
preoperative chemotherapy in Chapter 3 and also
on page 1096 of this chapter. However, routine
postoperative radiotherapy is not utilized (JML)
but rather selective radiotherapy (see Chapter 3,
p.132).
f. Spillage of tumor at time of resection or open
biopsy and if surgeon is doubtful regarding com-
plete resection of tumor
2. Preoperative chemotherapy, uncompromised surgery,
and selective radiotherapy. The plan of treatment is
outlined in Chapter 3 in the section on preoperative
chemotherapy. Several points are very important
with this regimen, all of which must be performed
before biopsy:
a. The precise protocol should be understood and
then followed as closely as possible.
b. Extremely careful pretreatment evaluation of the
extent of disease must be performed. Included are
various forms of mirror, optical, and direct laryn-
goscopies with photographs as well as video
documentation and tattoo with India ink mark-
ing the borders of the primary neoplasm to facil-
itate surgical resection that is not compromised
by the response to chemotherapy; these are fol-
lowed by direct rigid laryngoscopy, esophagoscopy
when feasible, and biopsies. Bronchoscopy is
ideal but often not feasible because of airway
embarrassment.

c. A precise outline of the extent of the anticipated
surgery is needed, for example, whether the base
of the tongue is to be included and all or a portion
of the hypopharynx. If there is any significant
involvement of the hypopharynx, a total hypopha-
ryngectomy must be performed. There should be
very careful evaluation of any unexplained promi-
nence of the lateral wall of the hypopharynx or the
posterolateral wall of the oropharynx or hypophar-
ynx. There is a possibility of parapharyngeal and
retropharyngeal metastatic lymphadenopathy
(Ballantyne). The exact extent of all of this dis-
ease should be tattooed with India ink. This is a
sine qua non. Reconstruction is usually simple in
a one-stage procedure using posterior tongue flap
and dermal graft or pectoralis major myocutaneous
flap with a dermal graft (see Figs.8-2G and 21-7).
Alternatively, a radial forearm free flap or a jejunal
free flap is preferred by some surgeons for the
reconstruction of the pharynx after total laryn-
gopharyngectomy.
d. The extent of surgery, regardless of the good to
excellent response to chemotherapy, must include
all structures as determined before the chemother-
apy. This often becomes difficult for both the
surgeon and the patient. This admonition must be
explained to the patient before chemotherapy is
done, because there is no evidence at this time
that chemotherapy alone cures the cancer, except
as noted on page 1097 to 1098 or, for that matter,
justifies a conservative procedure. This point can-
not be overemphasized. Mucosal biopsies are
worthless after chemotherapy, because in surgi-
cally resected specimens, although the mucosa
may show no histologic disease, viable tumor cells
can be seen deep to the mucosa and submucosa
and within the muscle. If the patient refuses the
planned ablative surgery, then radiotherapy is
utilized. Statistical analysis must be clear on this
point; otherwise, analysis of the evaluation of
preoperative chemotherapy becomes adulterated
and poor end results can be expected.
3. Induction chemotherapy and radiotherapy: "organ
preservation." Patients with complete response to
two or three cycles of chemotherapy (e.g., cisplatin
and 5-fluorouracil) are then treated with radiation.
When patients thus treated develop relapses or recur-
rences, salvage surgery is performed. This regimen
is used primarily for advanced carcinoma of the larynx
and hypopharynx in which total laryngectomy would
ordinarily be performed, thus preserving the func-
tion of speech. The problems are the patients who
are classified as failing treatment who require the
salvage surgery, which is discussed next. Complete
evaluation of the successes and failures is still in
THE LARYNX
progress. The "jury" is still out. Such an evaluation
is beyond the scope of this atlas.
One of the problems may be that patients who are
classified as having complete responses to chemother-
apy in fact do not have complete response even though
the mucosa is intact, as mentioned in other parts of this
atlas. When these organs are surgically removed, viable
tumor cells are found deep within the associated muscle.
If complete response is the sine qua non for organ
preservation, then some better method is necessary by
which to come to the conclusion that there is, in fact,
a complete response to the chemotherapy.
Treatment Failures
Salvage Surgery
In patients in whom radiotherapy has failed, surgery
can play an important role. Usually this involves total
laryngectomy, although Norris (1966) reports reason-
able results with partial laryngectomy. Partiallaryngec-
tomy has the problem of assessing the extent of disease
plus the higher incidence of fistula formation. Fistula
formation after surgery is always an ominous sign,
because it often portrays recurrent disease.
Salvage surgery is well named because it replays the
serious surgical complications that occurred four to five
decades ago when preoperative radiotherapy was the
method of treating advanced squamous cell carcinoma
of the head and neck. These complications caused a
high morbidity and mortality rate: carotid artery blow-
out, skin slough, osteoradionecrosis, poor healing and
breakdown of wounds, high incidence of fistula, infec-
tion, dysphagia, and esophageal stricture, and, in general,
a very difficult postoperative period that made life for
both the patient and the surgeon grueling. The length
of hospital stay was longer and nurses were faced with
frequent changes of dressing and complicated wound
care. The other problem for the surgeon was the diffi-
culty of evaluation of how much tissue to resect, because
the effect of radiation often masked the actual extent of
disease. This calculation of the extent of disease versus
radiation effect led to additional surgical procedures. Cost
containment with multiple and prolonged hospital stays
further complicated the picture.
In the reconstruction of skin and soft tissue loss and
bone loss, reconstruction techniques could be difficult:
microvascular technique can be hampered by the effect
of the fibrosis of radiotherapy on local vessels, which
are needed for this type of reconstruction
This is basically the problem associated with radia-
tion failure and organ preservation treatment plans. With
more modern radiotherapy equipment and advanced
radiotherapy techniques, these horror pictures of salvage
 THE LARYNX

may well be less when compared with the planned
preoperative radiotherapy of decades ago. But, they
still do exist and the replay can also be horrible when
the final evaluation of the organ-sparing treatment is
made. The effect of salvage surgery must be taken into
account. There is no doubt that organ-sparing manage-
ment has a place, but exactly where and how is a
moot question. One thought is to require the radiation
oncologist to assist at the salvage surgery and also take
an active part in the postoperative management of
these patients.
This must not be taken as a condemnation of radio-
therapy in the management of squamous cell carcinoma
of the head and neck. It definitely has a place, and at
times the responses are very encouraging. For an anec-
dotal example, a patient had a 2.5-cm, fixed, metastatic
node from an oropharyngeal carcinoma that was deemed
inoperable for surgery after chemotherapy. This patient
received radiotherapy, and all clinical evidence of disease
has disappeared. He is now 9 years 9 months post treat-
ment with no evidence of disease, no dysphagia, and
excellent voice.
Stomal Recurrence
best used before surgery and not as a "last resort"
modality. Survival rates are shown in Table 20-5.
Partial Laryngectomy (Outline)
(Fig. 20-11)
Resection of a portion of the larynx for carcinoma has
been designated by various terms. The main objective
is adequate cancer surgery coupled with conservation
of the main function of the larynx (i.e., speech, airway,
and prevention of aspiration), hence the overall generic
term of conservation surgery (Alonzo, 1947; Ogura and
Som, 1971). This basic concept was developed by Press-
man (1961). To simplify the understanding of the more
common surgical procedures performed on the larynx,
a basic classification is outlined as follows:
I. Partial laryngectomy (permission for totallaryngec-
tomy should be obtained before operation)
A. Cordectomy via laryngofissure
B. Vertical or frontolateral
C. Horizontal

Although stomal recurrence carries an extremely poor

prognosis, it is believed that in certain patients, aggres-
sive therapy is indicated. This may be surgery alone, a TABLE20-S Cancer of the Larynx: 5-Year
combination of chemotherapy plus surgery, or radio- Survival Rates
therapy. Radiotherapy is not advisable as the initial
modality if the tumor is resectable. The surgery would All Races
consist of mediastinal node dissection and resection of
the major portion of the thoracic trachea with or with- Total Males Females
out juxtaposed esophagus. Sisson has described four
types of disease and the indicated surgical procedures Year of Diagnosis
(see Chapter 19, p. 1056). 1960-1963
1970-1973
Salvage Radiotherapy 1974-1976 65.6 65.3 67.2
1977-1979 67.0 67.9 63.0
In addition to planned (before clinical recurrence) post- 1980-1982 68.1 68.0 68.5
1983-1985 67.0 68.1 61.7
operative radiotherapy as previously outlined, radiother-
1986-1988 66.7 67.3 64.2
apy has a place in the surgical failures when the disease 1989-1995 64.6 66.2 58.6
is no longer resectable.
1989-1995
All stages 64.6 66.2 58.6
Salvage Chemotherapy
Localized 81.0 82.5 74.0
Regionalized 52.9 54.1 49.0
After surgery and radiotherapy failures, chemotherapy Distant 40.8 40.0 43.6
utilizing paclitaxel (Taxo!), cisplatin, and 5-fluorouracil Unstaged 44.4 45.0 42.9
may be worthwhile as a purely palliative measure in
Stage Distribution (%) 1989-1995
selected patients. No cures have been reported, and one No. of cases 6,170 4,959 1,211
must be careful to evaluate the quality of life, time in Percent 100% 100% 100%
the hospital, cost, and other sociologic and psychologic Localized 51 52 44
factors in the determination of the use of chemotherapy Regional 29 28 33
in such circumstances. At times, a combination of Distant 15 15 16
chemotherapy, surgery, and/or radiation can be utilized Unstaged 5 5 7
in treatment failures. By and large, chemotherapy is

1. Supraglottic
2. Supracricoid
D. Combinations and extensions of A, B, and C with
or without involvement of the ventricle, ventric-
ular bands, aryepiglottic fold, and juxtaposed
limited portion of medial wall of pyriform sinus
II. Total laryngectomy
A. Narrow field
B. Wide field
The author has no experience with near-totallaryn-
gectomy (Pearson, 1981). Hemilaryngectomy-a true
and complete removal of one half of the entire larynx-
is actually seldom performed and will not be described.
Supracricoid laryngectomy is also believed to have a
very limited application and will be omitted. The narrow
field total laryngectomy in which the strap muscles are
preserved is not performed by the author and will not
be described.
The validity of the vertical and horizontal partial
laryngectomies as adequate cancer operations is now
established. The spread of carcinoma of the larynx
depends on the various sites as depicted by whole
organ sections (Kirchner, 1969; Tucker, 1962) that aid
in the selection of patients. Kirchner voices concern
regarding carcinoma arising in the walls of the ven-
tricle, because these lesions may extend beyond the areas
of a partial laryngectomy. CT and MRI for additional
soft tissue detail are of aid in delineation of the extent
of the disease. With thyroid cartilage invasion, total
laryngectomy is the treatment of choice.
In Figure 20-11, the basic portions of the larynx
removed in the first two types of partial laryngectomy
(i.e., cordectomy and vertical or frontolaterallaryngec-
CORDECTOMY
A
FIGURE 20-11
THE LARYNX
tomy) are shown. Details of these operations are in
Figures 20-12 and 20-13A to H. In Figure 20-16A to C,
the supraglottic laryngectomy is outlined, with details
in Figure 20-16G to P. Combinations and extensions
of the vertical or frontolateral and horizontal or supra-
glottic laryngectomies are not detailed, because limited
combinations (ventricle, ventricular bands, and ary-
epiglottic folds) are quite obvious to the operator, while
the more extensive combinations (involvement of pyri-
form sinus and hypopharyngeal wall) raise the serious
question as to whether a total laryngectomy may not
be the operation of choice, except with minimal or
small lesions of the pyriform sinus or hypopharynx.
Other details of the treatment of primary carcinoma
of the hypopharynx and esophagus are discussed in
Chapter 21.
A The simple cordectomy via a laryngofissure (midline
thyrotomy) approach is limited to a carcinoma of 1 to
2 mm on the free edge of the membranous vocal cord
at its middle one third with microinvasion. The resec-
tion is carried down to the thyroid cartilage, removing
the inner perichondrium. No cartilage is removed,
this being the main criticism of those who find fault
with the operation, because invasion of the vocalis
muscle may be present. There is a legitimate difference
of opinion regarding the treatment of this lesion
with radiotherapy, with the final decision resting on
the availability of adequate radiotherapy facilities. This
procedure is also useful in situations in which the
diagnosis is in doubt. Details of the operation are in
Figure 20-12A to C.
Continued
 THE LARYNX
Partial Laryngectomy (Outline)
(Continued) (Fig. 20-11)
Vertical or frontolaterallaryngectomy may be divided
into three basic types depending on the extent of the
tumor along the edge of the membranous vocal cord.
One modification may be applied to any of the three
basic types if there is subglottic extension of not more
than 2 to 3 mm. A second modification may likewise
be applied if the vocal process of the arytenoid cartilage
is involved. Kirchner (1969) emphasizes the importance
of evaluation of the walls of the ventricle in conjunc-
tion with mobility of the true vocal cord and the ven-
tricular band. If there is impaired mobility of either of
these structures, deep invasion with involvement of the
thyroid ala is suspected and partial laryngectomy is
usually contraindicated.
Basic Type 1
B Carcinoma is limited to membranous vocal cord at
its middle third. The entire vocal cord with the vocal
process of the arytenoid cartilage and adjacent thyroid
ala is resected except for a posterior 3-mm-wide
vertical strip of thyroid cartilage. The anterior line of
resection is in the midline. If the lesion extends into
the posterior one third of the vocal cord, the arytenoid
cartilage is resected. The subglottic tissue is resected to
the superior border of the cricoid cartilage (a variation
of this technique is depicted in Figure 20-13N to T).
Caution
An obvious point of caution about partial laryngectomy
procedures is the delineation of millimeters in the extent
and lines of resection. Selection of patients is critical.
Experience and follow-up statistics have firmly demon-
strated that these procedures are justified. All patients
having a partial laryngectomy must have exceedingly
careful and continuous follow-up examination.
Other Modifications
Bailey (1971) has described partial laryngectomy and
laryngoplasty as a further modification of a vertical
partial laryngectomy (see Fig. 20-15). The author's
method of reconstruction to improve the voice is
depicted in Figures 20-14 and 20-15 as an omohyoid
muscle flap.
Basic Type 2
C Carcinoma of membranous vocal cord extends to
the anterior commissure. The tissue resected is the
same as that in B except that 2 to 3 mm of thyroid
cartilage and juxtaposed true and false cords and
subglottic soft tissue are resected on the contralateral
side. The frontal section is at the anterior commissure
region and depicts the thyroid ala resected on the
contralateral side as well as on the side of the lesion.
Basic Type 3
D Carcinoma of membranous vocal cord extends
into the anterior one third of an opposite or a contra-
lateral vocal cord. The tissue resected is the same as
that in B except that 4 to 5 mm of thyroid cartilage
and juxtaposed true and false cords and subglottic soft
tissue are resected on the contralateral side. The frontal
section is through the bulk of the tumor anteriorly and
shows the resected thyroid alae (see Fig. 20-13D to K).
Continued
 THE LARYNX

VERTICAL

o
FIGURE 20-11 C ontlnued
.. j
 THE LARYNX

Partial Laryngectomy (Outline)

(Continued) (Fig. 20-11)
Modification 1
E Carcinoma of the membranous vocal cord with 2
to 3 mm of subglottic extension. The tissue resected is
the same as in B, C, or D, depending on the extent of
the tumor along the edge of the vocal cord except
that the upper half of the cricoid cartilage is resected
posteriorly to the arytenoid cartilage on the involved
side and across the midline on the contralateral side
(see Fig. 20-13D to K).
Modification 2
F Carcinoma of the membranous vocal cord involves
a portion of the vocal process arytenoid cartilage. The
tissue resected is the same as that in Figure 20-11 B
except that the entire arytenoid cartilage is resected.
Modification 3
Carcinoma of both membranous vocal cords with nor-
mally functioning vocal cords can be resected as depict-
ed with preservation of both arytenoid cartilages. Severe
stenosis can occur, however. All margins must be care-
fully checked by frozen section. A transposed omohyoid
muscle flap (see Figs. 20-14 and 20-15) is utilized on
the side of the thyroid cartilage resection with a free
buccal mucosal graft or bipedicle sternohyoid muscle
flap (Bailey, 1971) (see Fig. 20-16A to C) on the contra-
lateral side. It is not advisable to use any type of free
skin graft or skin flap placed in the reconstructed intrin-
sic larynx. Sebum can occur and cause obstruction to
the airway.

(MODIFICATION 1) E

F
(MODIFICATION 2) (MODIFICATION 3)

FIGURE 20-11 Continued

 THE LARYNX

Cordectomy for Small Carcinoma

of the arytenoid cartilage, juxtaposed soft tissue, and
of True Vocal Cord (Fig. 20-12)
inner perichondrium of thyroid cartilage (see Fig. 20-
11 A). The approach is via a laryngofissure (see Fig. 20-
Highpoints
9A to D).
1. The lesion must not be larger than 2 mm.
C The free edges of the mucosa are approximated
2. The lesion must be limited to the middle one third
with interrupted sutures of 4-0 chromic catgut.
of the vocal cord and localized to the free margin of
the vocal cord.
3. There must be full and complete mobility of the
The illustrations demonstrate the scope of the pro-
vocal cord.
cedure from the posterior aspect. This is for clarity pur-
4. Margins must be carefully checked for extension of
poses. A laryngofissure approach is utilized; hence the
tumor.
approach would be anterior. The other approach would
5. Tracheostomy is advised.
be endoscopically utilizing microsurgical instruments.
Some surgeons might use the CO2 laser, but the author
A, B Area of resection is outlined, which includes the (JML) would nbt. One reason is the problem of evalua-
entire true vocal cord encompassing the vocal process tion of margins, especially on frozen section.

A B c

FIGURE 20-12
 THE LARYNX
Vertical or Frontolateral
Laryngectomy (Fig. 20-13)
Surgical procedure depicts the resection for a type 3,
modifications 1 and 2, as delineated in Figure 20-11C
to F.
Highpoints
Of all the following highpoints, probably the most
important is the very careful evaluation of the extent of
the disease. This is performed preoperatively and con-
firmed during the surgical procedure. The tattooing is a
sine qua non if adjuvant preoperative chemotherapy is
decided on.
1. Complete evaluation of extent of tumor is accom-
plished by indirect and direct laryngoscopy, micro-
laryngoscopy, CT, and MRI (planograms and/or
laryngogram are seldom used by the author-JML).
Permission should be obtained for a totallaryngec-
tomy.
2. Vocal cords must be mobile: a slightly sluggish vocal
cord in itself may not be a contraindication.
3. Lesion is limited to membranous vocal cord with
subglottic extension no more than 2 to 3 mm. Carti-
lage invasion as demonstrated by a radiograph or
by widening of the thyroid cartilage is a contra-
indication.
4. Extension into the ventricle may be a limiting factor;
however, a primary small neoplasm of the ventricle
is usually suitable for this type of resection.
5. Severe to moderate chronic pulmonary disease (e.g.,
emphysema) is another limiting factor.
6. One arytenoid cartilage along with one half to two
thirds of its vocal cord should remain on the con-
tralateral side. An exception to this is as shown in
modification 3 (see Fig. 20-11C to F).
7. Regardless of the procedure, entrance into the larynx
must be as far away from the tumor as possible,
preferably on the contralateral side and from above.
8. A 3-mm vertical strip of cartilage is preserved along
the posterior portion of the thyroid cartilage on the
involved side.
9. The resected specimen includes the following:
a. True vocal cord
b. Ventricular band (false vocal cord) and walls of
ventricle
c. Either the vocal process or arytenoid cartilage
d. Thyroid cartilage except for a 3-mm posterior
vertical strip on the involved side and a portion
of the opposite thyroid ala, depending on the
extent of tumor
e. Anterior and lateral subglottic tissue, and if there
is gross subglottic extension, the upper one half
of the cricoid cartilage
10. Tracheostomy is necessary. A laryngeal keel is
usually used when both sides are operated upon.
Drains are utilized.
11. The procedure can be performed in patients in
whom radiotherapy has failed. However, extreme
care must be exercised because of difficulty of
evaluation of the extent of disease.
12. A nasopharyngeal feeding tube is inserted preoper-
atively and the position verified before closure of
the wound. A percutaneous endoscopic gastrostomy
is seldom indicated in this operation, but it might
be a consideration in the event of a patient with
very poor nutrition.
13. Do not compromise the area of resection; there is
really not much more surgery for a frontolateral
laryngectomy than a chordectomy. However, if the
medical status is problematic, then consider radio-
therapy as a primary choice.
Discussion
Details of a vertical or frontolateral laryngectomy are
described by depicting the procedure for a carcinoma
of the right membranous true vocal cord with exten-
sion across the anterior commissure involving 2 mm of
the opposite vocal cord with 2 mm subglottic extension
and involvement of the arytenoid area. This is an exam-
ple of type 3 as outlined in Figure 20-11D, with resec-
tion of the upper one half of the cricoid cartilage (modi-
fication 1) as in Figure 20-11E, and removal of the
arytenoid cartilage as Figure 20-11F (modification 2).
This combination is chosen to show what is considered
the virtual maximum of a vertical or frontolaterallaryn-
gectomy short of a total laryngectomy. The operation
can be extended farther to include a portion of the pyri-
form sinus and posterior pharyngeal wall.
A Optical and/or mirror image of the extent of the
carcinoma with a schematic representation of resected
tissue. Note that aryepiglottic folds are not usually
included in the vertical laryngectomy. Nevertheless,
great care must be taken that these folds are not
redundant and thereby overhang the glottis. This is
most important. They can become edematous post-
operatively for long periods of time and cause glottic
obstruction. Needle cauterization at multiple sites may
induce desirable scarring and contracture and prevent
this complication.

c D
FIGURE 20-13
B Frontal section depicts the depth of the resection
to include the true vocal cord, ventricular band and
walls of ventricle, lateral subglottic tissue with cricothy-
roid membrane and upper one half of cricoid cartilage,
and thyroid ala, as depicted, preserving its outer
perichondrium.
C Anterior schematic drawing depicting the extent
of the thyroid cartilage resected as delineated by the
broken line. A modification superiorly is along the solid
line. Because the lesion crosses the anterior commis-
sure to the opposite vocal cord, 4 to 5 mm of the ante-
THE LARYNX
rior portion of the contralateral thyroid ala is resected.
A 3-mm posterior vertical strip of thyroid ala remains
on the side of the primary lesion. The upper half of the
cricoid cartilage is resected, because the lesion extends
2 mm beneath the glottis. The portion of cartilage,
thyroid, and cricoid resected is depicted by the diag-
onal lines. The stippled cartilage mayor may not be
resected.
D Cross section (axial) depicts extension of resection
as described previously.
Continued
 THE lARYNX
Vertical or Frontolateral
Laryngectomy (Continued)
(Fig. 20-13)
E Two horizontal skin incisions are made. The lower
one is made for temporary tracheostomy, and the upper
one is between the hyoid bone and the upper border
of the thyroid cartilage for exposure of the larynx for
the definitive surgery. The upper flap of the upper inci-
sion is elevated to the level of the hyoid bone, while the
lower flap is elevated to expose the cricoid cartilage.
F The strap muscles have been separated in the mid-
line and retracted laterally with the perichondrium,
which is left attached to the strap muscles, if feasible.
The perichondrium of the thyroid cartilage is incised
vertically in the midline and elevated on the primarily
involved side to within 3 mm of the posterior border.
On the contralateral side, the perichondrium is elevated
4 to 5 mm from the midline to the site of the line of
resection of the contralateral thyroid ala as depicted by
the dotted line.
G, G 1 The thyroid cartilage is transected either with
a knife or, if calcified, with a sagittal plane saw. Because
there is subglottic extension, a horizontal incision is
made along the anterior aspect of the cricoid cartilage
equidistant from the superior and inferior edges. (If
there were no subglottic extension, this lower horizontal
line of resection would be along the superior edge of the
cricoid cartilage.) The cricoid resection extends across
the midline to correspond to the thyroid ala line of
resection. Posteriorly, on the primarily involved side, the
cricoid resection approaches the corresponding vertical
thyroid ala line of resection. The superior incision may
be along the superior aspect of the thyroid cartilage (solid
line), transecting the attachment of the thyrohyoid
membrane to the thyroid cartilage. An alternate incision
is in an oblique direction (dotted line), preserving the
superior projecting portion of the thyroid cartilage.
H Visualization of the intrinsic larynx to fully evaluate
the extent of the disease must be combined from
above through the thyrohyoid membrane incision (Gl)
as well as laterally via the vertical transected edges of
the thyroid cartilage. Entrance into the larynx is
accomplished both from above and by the separation
of the transected edges of the thyroid cartilage on the
contralateral side with a curved clamp and then
incising the underlying soft tissue or by retraction of
the superior and inferior portions of the transected
cricoid cartilage with three-pronged fine retractors or
by a combination of both. In any event, it is at this
stage that careful confirmation of the extent of the
tumor is made. If there is any question regarding
adequate margins, a total laryngectomy may well be
the procedure of choice.
Continued
It is important to visualize the vocal cords at the
anterior commissure before the incision is made at the
anterior commissure. This can be accomplished by
opening the larynx close to the level of the thyroid
notch. Slowly extend the incision inferiorly toward the
anterior commissure. If disease is suspected at the
anterior commissure, then the incision at the level of
the anterior commissure is made through the contralat-
eral vocal cord to avoid an incision into the tumor. A
useful alternative in these cases is to enter the larynx
through the cricothyroid membrane; then, a large
hemostat aimed superiorly is used to separate the vocal
cords, as they are visualized from below (this maneuver
is facilitated by placing the patient in Trendelenburg
position). As the tumor is visualized the decision is
made to proceed with the incision through the anterior
commissure or through the anterior portion of the
opposite vocal cord.
Intracartilaginous vessels do exist and are carefully
cauterized with Bovie current. The entire transected edge
of the cartilaginous incision is likewise cauterized.
 THE lARYNX

G1
FIGURE20-13 Continued
 THE LARYNX
Vertical or Frontolateral
Laryngectomy (Continued)
(Fig. 20-13)
I The thyroid cartilage is retracted laterally with two
fine three-pronged retractors. Superiorly, the thyroid
cartilage has been freed from the thyrohyoid mem-
brane and the epiglottis. At this point, the superior
laryngeal vessels are ligated. Lesser areas of bleeding
are usually satisfactorily controlled by cauterization.
Inferiorly, the superior portion of the cricoid cartilage
has been transected to the cricoarytenoid articulation.
With Metzenbaum scissors, the joint capsule is entered
and transected, thus separating the arytenoid cartilage
from the cricoid cartilage. The inferior line of resection
now hugs the superior transected edge of the cricoid
cartilage. The interarytenoid muscles and overlying
mucosa are incised. The specimen is thus removed. (If
the arytenoid cartilage is not removed, the line of
resection crosses the vocal process.)
J The remaining portion of the larynx is shown after
removal of the specimen.
K The surgical sped men is shown. Frozen sections
are performed on all margins.
L A very thin flap of mucous membrane (arrow)
mobilized from the medial wall of the pyriform sinus is
swung inward and downward to cover a portion of the
bare operative site resulting from removal of the ary-
tenoid cartilage. Any remaining bare area is left bare.
It is best to use absorbable sutures. If the arytenoid
cartilage has not been removed, a mucous membrane
flap is usually not used. Occasionally, mucous mem-
brane from the subglottic space can be mobilized and
brought upward.
Extreme care must be taken to ensure that the flap
of pyriform sinus mucosa is thin and not redundant. To
reduce the possibiJity of hematoma formation under
the flap, several mattress sutures of absorbable material
are placed, as shown in Figure 20-13M. In addition,
electric cautery using a needle inserted in several areas
through the mucosal flap and aryepiglottic fold will
help prevent edema. A bulky thick flap can easily cause
so much postoperative airway obstruction that it is often
more prudent to leave the area uncovered or use a free
graft of buccal mucosa. Never use a free skin or pedicle
skin graft to cover an endolaryngeal defect because of
the possibility of sebaceous secretions, which can cause
obstruction.
Rather than an advanced flap of pyriform sinus
mucosa, the defect can be partially filled with an omo-
hyoid muscle flap (see Fig. 20-14) or strap muscle (see
Fig. 20-15), which helps form a replacement for the
resected vocal cord and thus reduces the postoperative
breathy voice.
M The base of the epiglottis is sutured to the lower
edge of the thyrohyoid tissue and, where possible, to
the perichondrium of the thyroid ala, which is to be
reflected forward. The transected end of the remaining
left true vocal cord is sutured anteriorly to the perichon-
drium and/or the strap muscles using chromic catgut.
Because the anterior one third of the contralateral vocal
cord has been removed, a McNaught keel of tantalum
or silicone (Montgomery) is used (see Fig. 21-1 A to B)
that is left in place for 3 weeks.
Continued
The keel must be securely sutured in place. With the
silicone keel, nylon sutures are placed through the flange
portion of the keel and the overlying strap muscles with
at least one nylon suture brought through the skin. This
is an aid in localizing the keel at the time of removal of
the keel under local anesthesia.
The thyrotomy incision is closed by approximation of
the two leaves of the right and left perichondrial flaps.
The strap muscles are closed in similar fashion. This
muscle closure helps support the keel. There may be
difficulty in closure of the thyrotomy. The strap muscles,
especially the sternohyoid, are then utilized. One of two
Y.-inch drains is necessary to release any subcuta-
neous leakage of air. Postoperative feeding is through a
nasoesophageal tube. Trials with swallowing water may
be begun at 1 week, and if these are satisfactory the
feeding tube is removed. Removal of the tracheostomy
tube depends on the amount of edema relative to the
glottic airway. At times, removal of the tracheostomy
tube is necessary to facilitate swallowing without aspi-
ration. It is recommended that the tracheostomy tube
be left in place until the keel is removed.
 THE LARYNX

BASE OF EPIGLOTTIS
_-----."
- ..

FALSE CORD

ANT. ONE THIRD LT. FALSE CORD

ANT. ONE THIRD LT.TRUE CORD

ANT. ARYTENOID CART. RT.
K
TRUE CORD RT.

UPPER ONE HALF CRICOID CART/

FIGURE20-13 Continued
 THE LARYNX

Vertical or Frontolateral
Laryngectomy (Continued) Q The perichondrium over the external surface of the
(Fig. 20-13) cartilage is elevated. The area of resection is depicted
by the dotted lines.
Complications
R With scissors or knife, the thyroid cartilage is tran-
• "Breathy" voice sected along with the soft tissue on the inside of the
• Stenosis larynx. The ventricular band is removed, including the
• Fistula rarely entire lining of the ventricle. The vocal process or the
• Aspiration less common as compared with horizon- entire arytenoid cartilage is excised with the vocal cord.
tal or supraglottic laryngectomy Small angulated scissors or a knife is ideal for posterior
• Dislocation of the keel excision.
• Edema, which may cause airway obstruction, espe-
cially when a bulky pyriform mucosal flap is utilized. S The mucosa is approximated as much as possible
This has been treated with a CO2 laser with some with simple interrupted sutures of 4-0 chromic catgut.
promising results. Deep vaporization or excision may The upper mucosal margin may be mobilized to facil-
be required as well as multiple procedures. itate closure. Complete approximation of the mucosal
• Subcutaneous emphysema. Use one or two drains to margin is not necessary. An intralaryngeal stent may
prevent this complication. The drains are best left in be used. Farrior has described the use of a finger cot
place for 4 to 6 days until the thyrotomy heals. filled with Ivalon sponge and secured with wire sutures
• Postoperative bleeding from transected edge of as a stent.
cartilage

If extensive or suspicious leukoplakia exists on the

Depicted is a slightly variant method of partial laryn-
opposite vocal cord, this diseased area can be excised and
gectomy type 1, as outlined in Figure 20-11 B.
mucosal edges approximated with 5-0 chromic catgut.
A laryngeal keel (see Fig. 20-29) is used to prevent web
N, 0 The malignant tumor is located on the middle formation or stenosis when both sides are operated on.
third of the right vocal cord. The dotted lines indicate
the extent of the resection, which includes the entire
T The external perichondrium is approximated with
true cord, the lining of the ventricle, a portion of the
interrupted 4-0 catgut. The fascia enveloping the strap
ventricular band, and juxtaposed thyroid cartilage.
muscles is then closed. The skin is closed with subcu-
taneous catgut and cutaneous 5-0 nylon. Tracheostomy
P The thyroid cartilage has been transected in the
care is discussed on page 116. A small Penrose drain is
midline with the V extension in the thyrohyoid mem-
utilized to prevent spreading emphysema.
brane, preserving the mucosa of the larynx. This mucosa
is incised slightly to the left of the midline along the
dotted line. This is especially advisable when there may Complications
be some question of extension of the tumor toward
the anterior commissure. These are the same as described previously for parts A
to M.
 THE LARYNX

Epiglottis

N 0
Ventricular
band
Thyroid cart
'Ventricle

FIGURE 20-13 Continued

 THE LARYNX
Omohyoid Muscle Laryngoplasty
(Fig. 20-14)
One of the functional sequelae of a frontolaterallaryn-
gectomy is the breathy voice due to the gap or "dead
space" at the glottic level. Bailey (1971) has described
a method of filling in the "dead space" using transposi-
tion of the sternohyoid muscle in vertical fashion (see
Fig. 20-16A to C). In the following text is the author's
method of utilizing a transposed omohyoid muscle flap.
Stenosis is a possible complication. A completely normal
voice is unlikely, but significant reduction in the breathy
voice is very gratifying. There are two methods of uti-
lizing the omohyoid muscle flap.
1. Suturing the superior transected end of the omohyoid
muscle to the posterior commissure
2. Suturing the superior transected end of the omohyoid
muscle to the anterior commissure
Another method of reducing the "dead space" is the
use of a free buccal mucosal graft with its underlying
muscle. This also has aided in minimizing, but not com-
pletely eliminating, postoperative breathy voice. This is
used with or without the omohyoid muscle transfer.
Highpoints
1. Preserve the blood supply and the nerve supply to
the omohyoid muscle.
2. Omohyoid muscle on the ipsilateral side is transected
from its attachment to the hyoid bone.
3. The omohyoid muscle is passed through a tunnel lateral
and deep to the thyrohyoid and sternohyoid muscles.
4. Cut end of the omohyoid muscle is sutured to either
the anterior or posterior commissure.
S. Optional: Cover muscle flap with free buccal mucosal
graft and be sure not to include any underlying
muscle in the graft. Avoid bulk, especially above the
level of the glottis.
6. A keel is used if any portion of the contralateral vocal
cord has been excised.
7. A tracheostomy and two Penrose drains are mandatory.
Complications
• Edema. This resolves with time, occasionally requiring
steroids or CO2 laser vaporization of the overhang-
ing aryepiglottic fold.
• Partial atrophy of omohyoid muscle
• Stenosis
• Subcutaneous emphysema
A The omohyoid muscle is transected from its attach-
ment to the hyoid bone on the ipsilateral side. A stab
wound is made along the lateral border of the remain-
ing strap muscles, the thyrohyoid muscle, and the
sternohyoid muscle; and a tunnel is made by blunt
dissection deep and posterior to the muscles, bringing
the cut end of the omohyoid muscle into the surgical
defect of the larynx. If the entire perichondrium that
was elevated from the resected portion of the thyroid
cartilage is intact, a horizontal incision is made through
the perichondrium to facilitate passage of the omohyoid
muscle flap into the larynx. The omohyoid muscle is
identified beneath the skin incision used for the fron-
tolaryngectomy by a slight tug on the muscle, which
indicates its course above the outer third of the clavicle.
Approximately 1.5 to 2 em of the muscle is mobilized
distal to its attachment to the hyoid bone. Care is
taken to preserve the muscle blood supply from the
superior thyroid artery and the motor supply from the
ansa hypoglossi. Sufficient mobilization is required to
avoid tension on the muscle; however, the neck is not
violated. The transected superior end of the omohyoid
muscle is sutured to the bed of the previously removed
arytenoid using 3-0 and 4-0 Vicryl sutures. The omo-
hyoid muscle is thus placed along the location of the
surgically removed vocal cord.
B That portion of the muscle that reaches the ante-
rior commissure is now sutured in place to the region
of the anterior commissure using 4-0 Vicryl. No attempt
is made to cover the entire muscle with advanced
mucosa from the pyriform sinus, although a portion of
it may be so covered. To cover the entire muscle may
well result in edematous mucosa, which can cause
postoperative glottic obstruction. An alternate covering
can be achieved with a free buccal mucosal graft. Do
not include any muscle with the mucosal graft, because
this may add too much bulk to the already transposed
omohyoid muscle. If the entire contralateral vocal cord
is intact up to the anterior commissure, the muscle can
be sutured to the anterior commissure and no keel is
necessary. If an anterior portion of contralateral vocal
cord has been excised, a Montgomery Silastic keel at
the anterior commissure is utilized. The keel is tagged
with a nylon suture brought out through the wound
to facilitate ease of removal. Closure of the wound is
similar to that described under frontolateral laryngec-
tomy.

THYROID
CARTILAGE
FIGURE 20-14
C An alternate method of utilizing the omohyoid
muscle flap is to reverse its location in the bed of the
resected vocal cord and arytenoid. The superior cut
end of the omohyoid muscle is sutured anteriorly with
the bend in the muscle sutured posteriorly at the site
of the resected arytenoid cartilage. The choice of the
method utilized depends on the length of the omo-
hyoid muscle and its adaptation to the surgical defect,
THE LARYNX
CRICOID CARTILAGE
again taking care to preserve its neurovascular supply.
The method depicted in A and B is more suitable when
the entire arytenoid is removed.
Although Teflon injection has not been utilized to
enhance the bulk of the muscle, it is conceivable that
this could be used at a later date if significant atrophy
of the muscle has occurred.
 THE LARYNX
Strap Muscle Laryngoplasty
(Fig. 20-15) (After Bailey, 1971)
Bailey (1971) has described a type of laryngoplasty
following frontolaterallaryngectomy in which the "dead
space" is filled with a bipedicle flap of one or more strap
muscles (sternohyoid, sternothyroid, and/or thyrohyoid
muscles). This method can be used bilaterally depend-
ing on the extent of the partial laryngectomy.
Highpoints
1. Leave the external perichondrium of the thyroid ala
cartilage attached to the muscle complex. This forms
the inner lining of the reconstructed larynx.
2. The muscle complex is left intact superiorly and
inferiorly and repositioned to the inner aspect of the
thyroid ala cartilage.
3. Utilize an abundant amount of muscle complex,
because a certain degree of atrophy and contracture
occurs (30% to 40%).
4. Suture the external perichondrium loosely to the
juxtaposed mucosa superiorly, posteriorly, and infe-
riorly.
5. A laryngeal Silastic keel is optional with unilateral
reconstruction; a keel is recommended with bilateral
reconstruction to prevent web formation anteriorly.
Depicted is a unilateral laryngoplasty.
Complications
• Laryngeal stenosis
• Weak voice
• Recurrence
Additional information and modifications of this
procedure are depicted in Surgery of the Larynx by
Bailey and Biller (1985, pp. 270-274).
A The sternothyroid muscle (the sternohyoid and/or
thyrohyoid muscles can be included depending on the
size of the dead space) with the attached perichon-
drium of the thyroid ala cartilage forms the inner lining
of the larynx. The muscle or muscles have been sepa-
rated by a vertical incision along the posterolateral
attachment of the muscle or muscles from approxi-
mately 1 cm above to 1 cm below the superior and
inferior margins of the thyroid cartilage. The superior
and inferior continuity of the muscle or muscles are
preserved, thus forming a bipedicle flap of muscle and
external perichondrium. Note that the entire thyroid
cartilage has been preserved during the partial laryn-
gectomy. This is a modification of the procedure as
shown in Figure 20-13N to T. The external perichon-
drium is loosely sutured to the juxtaposed remaining
mucosa superiorly, inferiorly, and posteriorly. The ante-
rior row of sutures secures the perichondrium to the
muscle. These sutures stabilize the perichondrium before
careful closure of the larynx.
B The closure of the larynx without a keel is shown.
A keel is recommended when bilateral reconstruction
is necessary, depending on whether a bilateral resec-
tion has been performed.
C Depicted is a cross-sectional diagram showing the
muscle and external perichondrium mobilized before
the transposition of the bipedicle flap.
D The arrow shows the transposition of the muscle-
perichondrial flap. Temporary tracheostomy and bilat-
eral placement of drains are mandatory. The drains help
prevent emphysema and are left in situ until complete
healing has occurred.
Bailey's technique has been combined with the
authors' omohyoid muscle flap technique. The latter is
used for the side in which a frontolaterallaryngectomy
has been performed when the major portion of the
hemithyroid cartilage has been resected. Bailey's
technique is used on the contralateral side on which
the hemithyroid cartilage has been preserved. A Silastic
keel is necessary.
 THE LARYNX

STERNOHYOID M.

EXT. PERICHONDRIUM

c D

FIGURE 20-15
 THE LARYNX
Horizontal or Supraglottic
Laryngectomy (Fig. 20-16) (After Alonzo,
1947; LeRoux, 1956; Ogura and Sam, 1971)
Indications
Supraglottic laryngectomy (horizontal partiallaryngec-
tomy) is primarily limited to malignant lesions of
the epiglottis either on the laryngeal or the lingual
surface. Extension of the lesion to the aryepiglottic fold
or superior aspect of the false cords with tumor on the
laryngeal surface or extension to the base of the tongue
(1 to 1.S em) with tumors on the lingual surface can
also be included in this type of resection. Others have
extended the procedure, in selected situations, to
juxtaposed portions of the pyriform sinus, hypopha-
ryngeal wall, one arytenoid, and even the ventricle and
superior aspect of one vocal cord. These latter exten-
sions appear tenuous and open to serious debate. In
any event, one arytenoid must be preserved; if one
arytenoid is removed, the posterior end of the vocal
cord must be fixed in the midline by passing a suture
through the vocal process portion and the cricoid
cartilage to aid in the prevention of aspiration, which is
the most significant postoperative complication.
Proximity to anterior commissure is a critical area for
careful evaluation.
If stage III or IV is present, the author uses preopera-
tive adjuvant chemotherapy.
Contraindications
• Fixed or significantly sluggish true vocal cord
• Elderly patients with chronic pulmonary disease or
debilitation
• Extension of tumor to the base of the epiglottis on its
laryngeal side to within I to 1.S em to the anterior
commissure. This clearance may not suffice, and a
total laryngectomy is indicated. Frozen section should
be utilized in borderline situations.
• Extension of tumor on the lingual side of the
epiglottis to the area of circumvallate papillae of the
tongue
• Procedure can be performed in patients in whom
radiation therapy has failed; however, extreme care
must be exercised because of the difficulty of evalu-
ating the extent of the disease plus the rise in com-
plications. It may be best to perform a totallaryngec-
tomy .
• Extension of tumor into ventricle, with involvement
of interarytenoid area or arytenoid cartilage itself,
pyriform sinus apex, postcricoid region, or thyroid
cartilage. The thyroid cartilage is not involved in
supraglottic carcinoma alone but can be involved if
the tumor has spread to the true cord and walls of
the ventricle (Kirchner).
Highpoints
1. Complete evaluation of the extent of the tumor must
be done before any treatment. In addition to the
epiglottis and the intrinsic larynx (the vocal cord,
ventricle, and ventricular band), the aryepiglottic
fold, the arytenoid cartilage, and the lingual epiglottic
fold must be scrutinized using indirect and direct
laryngoscopy or microlaryngoscopy with flexible as
well as rigid scopes. CT and MRI and pharyngoesoph-
agography are utilized, the last especially if there is
any dysphagia. Permission for total laryngectomy
should be obtained. In addition, careful evaluation
of the juxtaposed hypopharynx must also be done.
2. Exposure of the lesion must be excellent at the
early stage of resection.
3. The approach for this exposure must be as far from
the primary lesion as possible. Do not enter the
vallecula through the suprahyoid approach if the
lesion extends to the base of the epiglottis on the
lingual side of the epiglottis.
4. With the basic resection, the following structures
are removed:
a. Entire epiglottis and pre-epiglottic tissue
b. Aryepiglottic folds
c. False vocal cords-ventricular bands
d. Major portion of hyoid bone
e. Entire upper one half or upper one third of thyroid
cartilage on involved side and portion on the
contralateral side
f. Thyrohyoid membrane
g. Portion of base of the tongue as indicated
S. Always perform cricopharyngeal myotomy to aid in
deglutition. This is difficult if neck dissection is not
done (see Figs. 20-16N to P and 21-3).
6. Sacrifice the internal branch of the homolateral
superior laryngeal nerve and contralateral nerve if
necessary to perform adequate resection. Preserve
the external branch of the superior laryngeal nerve
to the cricothyroid muscle.
7. Avoid suturing mucosa of tongue to remaining
laryngeal structure, because this type of closure
may act as a chute for food, thus dumping food
directly into the glottis. Instead, place the suture
through tongue musculature.
8. Avoid sacrificing hypoglossal nerve because of inter-
ference with deglutition.
9. Tracheostomy is necessary.
10. Use a feeding tube or percutaneous endoscopic
gastrostomy.
11. Perform frozen section on margins.
12. Obtain preoperative permission for total laryngectomy.
13. Optional but recommended: Suspension of remain-
ing portion of thyroid cartilage to midportion of
mandible to aid in prevention of aspiration (Calcaterra,
1971) (see Fig. 20-17).

'1'-"'
FIGURE 20-16
Bocca (1979) leaves the hyoid bone in place, resect-
ing the periosteum of the hyoid bone inferiorly. He is
also emphatic in not mobilizing pyriform sinus mucosa to
close any bare areas, leaving them to heal by secondary
intention. The normal configuration of the pyriform sinus
should be preserved or reconstructed if necessary.
(Leaving the hyoid bone in place cannot be done when
a portion of the base of the tongue is removed. The
hyoid bone must be removed when the lingual side of
the epiglottis or the base of the tongue is involved.)
Tumor on Laryngeal Surface
A Depicted is a lesion of the laryngeal side of the
epiglottis. This is the ideal type for supraglottic resec-
tion. The base of the tongue is free of disease. The
THE LARYNX
ANT. COMMISSURE
lesion is well above the anterior commissure. The area
of resection is outlined in this supraglottic view, which
includes the entire epiglottis, aryepiglottic fold, and
false vocal cords.
B Anterior view outlines the line of resection, which
includes the upper one half (upper one third in women
and small men) of the thyroid cartilage on the side of
the lesion and somewhat less on the contralateral side.
A major portion of the hyoid bone is removed except
for a small portion on the contralateral side.
C lateral view outlines the line of resection that
passes through the base. of the tOngue above and
through the ventricle below.
Continued
 THE LARYNX
Horizontal or Supraglottic
Laryngectomy (Continued) (Fig. 20-16)
(After Alonzo, 1947; LeRoux, 1956; Ogura
and Sam, 1971)
Tumor on Lingual Surface
D TO F Depicted is a lesion of the lingual side of the
epiglottis with extension to the base of the tongue.
The lines of resection are outlined. In D the relation-
ship of the epiglottis to the thyrohyoid membrane and
hyoid bone is outlined. The danger of cutting into the
neoplasm through an initial anterior approach through
the thyrohyoid membrane is obvious and must be
avoided. A larger portion of the base of the tongue is
resected.
Simultaneous Radical Neck Dissection
Highpoints
1. Always perform simultaneous radical neck dissec-
tion in the presence of clinically diseased lymph
nodes.
2. In the absence of clinically diseased lymph nodes, a
simultaneous neck dissection is usually performed
under the following conditions:
a. Primary lesion of 2 cm or more in diameter
b. Smaller lesions with evidence of deep infiltration
c. Lesions extending into the base of the tongue,
aryepiglottic fold, false cord, or base of epiglottis
d. The side chosen is the side of greater involvement.
If nodes are positive, the opposite neck is dissect-
ed in 4 to 6 weeks.
3. Always remove false vocal cords with neck dissec-
tion because of the high incidence of edema of false
cords if they are preserved.
4. In general, there is a higher incidence of nodal involve-
ment as the distance of the primary lesion from the
true vocal cord increases.
Depicted in steps G to P is the technique for a
horizontal or supraglottic partial laryngectomy with a
simultaneous right neck dissection for cancer of the
laryngeal side of the epiglottis.
G The skin is outlined for a combined right radical
neck dissection and supraglottic laryngectomy for the
lesion shown in A to C. A preliminary tracheostomy
has been performed, preferably with the patient under
local anesthesia.
H The radical neck dissection has been performed
(see Fig. 16-3) in such a fashion that the contents of
the neck dissection are left attached to the right side
of the thyrohyoid membrane and to the right side of
the hyoid bone. The ipsilateral thyroid lobe with any
tracheoesophageal nodes and isthmus are included in
the specimen. Care is taken not to injure the recurrent
laryngeal nerve. An attempt is made to preserve or
reimplant the parathyroid glands if they are not con-
tiguous with metastatic disease. The omohyoid muscle
is also left attached to the hyoid bone. All the remain-
ing strap muscles on the right side are now transected
along the level of the superior margin of the thyroid
cartilage. The attachments of the sternothyroid muscle
to the superior and lateral edge of the thyroid cartilage
are freed. Those strap muscles on the left side as far
laterally to a point midway between the midline of the
thyroid cartilage and its posterior border are either
retracted or transected. The dotted line outlines the
incision through the perichondrium.
I The perichondrium of the thyroid cartilage has been
incised along its superior border and reflected inferiorly
to just below the halfway distance between the superior
and inferior margins of the thyroid cartilage. With a
suitable dye, the thyroid cartilage line of incision is out-
lined. With relatively large larynges, the horizontal line
is midway between the superior margin at the thyroid
notch and the inferior margin. In smaller larynges, this
horizontal line is somewhat higher to a level one third
of the distance between the superior and the inferior
margins of the thyroid cartilage. The object is to be
above the anterior commissure level of the true vocal
cords. On the right side-the side of the lesion-this line
is kept horizontal until it reaches the posterior margin
of the thyroid cartilage. On the left side, the line is
curved superiorly to meet a point midway between
the anterior border and the posterior border on the
superior margin of the thyroid cartilage. This line on
the cartilage is then incised using a sagittal plane saw,
taking care to avoid cutting the underlying soft tissue.
The superior laryngeal nerve on the right side is
sacrificed; the opposite nerve is likewise sacrificed if its
preservation would compromise the resection.
Continued
 THE LARYNX I r 1121

PERICHONDRIUM
REFLECTED

FIGURE 20-16 Continued

 THE LARYNX
Horizontal or Supraglottic
Laryngectomy (Continued) (Fig. 20-16)
(After Alonzo, 1947; LeRoux, 1956; Ogura
and Sam, 1971)
J The. suprahyoid muscles are transected above the
hyoid bone with care taken not to enter the pre-
epiglottic space at this time. The hyoid bone is tran-
sected on the left side just lateral to the lesser corner.
It is at this point that the pharynx is entered. Some
difficulty may be encountered, because the soft tissue
has a tendency to face posteriorly. An assistant can help
by placing a finger into the oral cavity and then into
the hypopharynx, exerting gentle pressure anteriorly
at the site of the transected hyoid bone. A change of
glove and gown should then be done by the assistant.
It may be easier at times to enter the hypopharynx
from the ipsilateral side, thus avoiding additional dissec-
tion and exposure on the contralateral side. Regard-
less, the point of entrance into the hypopharynx must
be very carefully planned, depending on the extent of
the disease so that the tumor is not violated. For the
lesion depicted in A to C, without involvement of the
lingual side of the epiglottis, the incision is carried
along the anterior wall of the vallecula juxtaposed to
the base of the tongue. For clarity, the contents of the
neck dissection are not depicted in this and the follow-
ing steps.
K If the lesion involves the lingual surface of the
epiglottis (see D to F) with or without extension to the
base of the tongue, the point of entrance into the
pharynx on the left side is extended downward along
the lateral wall of the hypopharynx toward the pyri-
form sinus (dashed line).The internal branch of the
superior laryngeal nerve is sacrificed; the external
branch is preserved. Entrance through a suprahyoid
approach must be avoided for fear of cutting through
the tumor. The extent of the lesion is carefully evaluated
before extending the horizontal incision across the
base of the tongue. Gross margins should be a mini-
mum of 1 to 1.5 cm. Frozen sections must be obtained
from the base of the tongue. If results are positive,
additional base of the tongue must be resected with
frozen sections repeated until margins are clear.
Regardless of the location of the lesion, extreme care
must be taken to completely evaluate the extent of
the lesion. Variations in approach and extension of
incision may be required to avoid cutting too near the
tumor.
L The operator should now move to the head of the
patient. It is at this stage that visualization of the extent
of the tumor may be difficult and frustrating. Extreme
care and patience and slow progress are mandatory.
The suprahyoid musculature having been transected,
incision through the lateral laryngopharyngeal walls is
now made, again maintaining at least 1.0- to 1.5-cm
margins from the gross tumor. Traction on the epiglot-
tis itself, if at all possible, is avoided. Use a tenaculum
on the hyoid bone for traction. If this fails to give ade-
quate exposure, the tenaculum is placed on the epiglot-
tis, with care taken to avoid the tumor and fragmen-
tation. If necessary, the arytenoid cartilage opposite the
lesion may be held in abduction for improved visual-
ization. Using Metzenbaum scissors and countertrac-
tion on the right aryepiglottic fold, the supraglottic
resection is begun posteriorly in the region of the ary-
tenoid cartilage. The mucosa overlying the arytenoid
may be excised. However, avoid exposing the cartilage.
The entire arytenoid can be excised, but if this is per-
formed, the vocal process should be left attached to
the vocal cord for suturing to the cricoid cartilage pos-
teriorly in the midline. This is necessary to prevent
aspiration. On the other hand, if the lesion is this exten-
sive, consideration for a total laryngectomy is in order.
M The line of resection is advanced anteriorly along
a plane horizontal to and through each ventricle, thus
removing the false cords with the specimen.
If visualization is poor, the side opposite to the
lesion is transected first.
When the tumor extends along the glossolingual fold
to the lateral border of the base of the tongue, the resec-
tion must be extended to include this area with adequate
margin. Care must be taken not to injure the 12th nerve
unless extension of tumor requires otherwise.
N A cricopharyngeal myotomy is then performed by
incising the muscle over an inserted index finger using
a knife to start the incision and then Metzenbaum
scissors to carry the incision more inferiorly as far as
6 cm along the solid line (see Fig. 21-3). This incision
is made as far posteriorly as possible. The approach may
be either posterior or medial to the common carotid
artery. The mucosa should not be incised. If it is, it must
be repaired.
Continued
 THE lARYNX

J L

FIGURE 20-16 Continued

 THE LARYNX

Horizontal or Supraglottic
Laryngectomy (Continued) (Fig. 20-16) strap muscle. The skin is closed in two layers. Penrose
drains or suction-type drains are used, depending on
(After Alonzo, 1947; LeRoux, 1956; Ogura
the preference of the surgeon.
and Sam, 1971)
Postoperative Management
o If feasible, a thin flap of pyriform sinus mucous
membrane is utilized to cover a portion of the bare pre- 1. Antibodies
senting superior portion of the posterior aspect of the 2. Feeding tube (short: not a nasogastric tube nor a
larynx. This step is controversial because of the danger of Levin tube)-preoperative percutaneous endoscopic
postoperative edema and distortion of the pyriform sinus. gastrostomy
3. Careful tracheostomy
P Closure consists of the approximation of the mus- 4. To initiate adequate deglutition, the tracheostomy
culature of the tongue to the reflected perichondrium tube is best removed, and usually the feeding tube is
of the thyroid cartilage and the remaining strap muscles. removed as well. Trial with various types of food will
This can be quite troublesome, because tension may be necessary to rehabilitate the patient. If possible,
result. This can be somewhat alleviated by suspension teach the patient to inhale before deglutition and then
of the thyroid cartilage to the symphysis of the mandible, exhale after deglutition. This may prevent aspiration.
using two 3-0 nylon sutures passed through drill holes
in both structures (Calcaterra, 1971; jabaley and Hoopes, Complications
1969). Ogura (1979) emphatically avoids placing the
sutures through the tongue mucosa, because he states • Aspiration is the most troublesome, leading to pneu-
that this will provide a chute for food to land directly monia and debilitation. Cricopharyngeal myotomy
on the vocal cords and lead to aspiration. By filleting and suspension of the larynx as described under N
the tongue 2 to 2.5 em thick in a horizontal plane (see and P are helpful in the prevention of aspiration.
Fig. 20-22), additional tongue musculature can be mobi- Also refer to the surgical technique of suspension of
lized for closure. However, the tongue musculature, the larynx (see Fig. 20-17).
not the mucosa, is sutured to the remaining portion of • Fistula
the larynx. This results in an overhang of the mucosa • Possible recurrence of disease
that helps prevent aspiration. The lateral pharyngeal • Cricoid chondritis resulting from long-standing use
defect is closed. The supraglottic closure, especially on of feeding tube
the side of the neck dissection, can be reinforced by • Dysphagia
transposition of the digastric muscle or any remaining

FIGURE 20-16 Continued

 THE LARYNX

Laryngeal Suspension (Fig. 20-17)

(After Calcaterra, 1971) A Anterior view depicts placement of 3-0 nylon sutures
through a drill hole in the symphysis of the mandible.
Indication Calcaterra places a wire suture through the drill hole and
inserts the suspension sutures through the loop. Two
• After supraglottic laryngectomy and hypopharyngec- sutures are then inserted through the perichondrium
tomy with preservation of the larynx to help prevent and the thyroid cartilage near the midline on the edge
aspiration of the transected cartilage. One or two additional sutures
are inserted through the thyroid cartilage near the
Highpoints inferior edge of the cartilage in the midline. All sutures
are tightened to raise the larynx approximately 2 em.
1. Nonabsorbable sutures are recommended.
2. The larynx is raised and tilted forward. B Lateral view depicts the location of the suspension
sutures.

FIGURE 20-1 7
 THE LARYNX
Total Laryngectomy (Fig. 20-18)
Highpoints
1. Do not skeletonize the thyroid cartilage.
2. Include at least the midportion of the hyoid bone
and epiglottis in the resection.
3. Enter the hypopharynx on the side opposite the
primary tumor.
4. In postcricoid tumors, full-length pharyngoesopha-
gography and esophagoscopy are indicated preoper-
atively to determine the extent of involvement. Such
lesions are tantamount to esophageal cancer, and a
portion of the cervical esophagus must be resected.
Frozen sections are performed on the esophageal
cuff (see Chapter 21).
5. Include on the ipsilateral side (the side with the pre-
dominate disease) the thyroid lobe and isthmus and
the para tracheal, paraesophageal, and tracheoesopha-
geallymph nodes. Spare the parathyroid glands either
in situ or reimplant them (see Chapter 18).
6. Extreme care should be taken in the evaluation of the
extent of tumor, with frozen section done as indi-
cated, especially in any hypopharyngeal involvement.
7. If significant hypopharyngeal involvement is found,
then perform total hypopharyngectomy (see Fig. 21-7
and Chapter 8 for reconstruction).
8. Take care not to injure the hypoglossal nerve.
9. Insert feeding tube through the nose into the orophar-
ynx before operation. It should not be inserted
farther, because it may impinge on the tumor and
thus cause implantation of tumor cells.
10. A preoperative and postoperative mouthwash with
1 % neomycin or clindamycin is used.
A A single midline incision is made with a circular
portion of skin and superficial fascia excised at the site
of the tracheostomy. As an alternate, two separate
horizontal incisions have been used: a small lower one
at the site of the tracheostomy and a larger upper one
over the larynx. This latter incision may be objection-
able, because it can violate the neck.
B If the malignant tumor is bulky and especially if
the endotracheal intubation is likely to traumatize the
tumor, the operation is begun by first performing a
tracheostomy under local anesthesia. The thyroid
isthmus is sectioned in the midline. The thyroid lobe is
removed on the side of the primary laryngeal tumor.
This facilitates the removal of the lymph nodes in the
paratracheal and tracheoesophageal sulcus. This is most
important with tumors extending into the subglottic
space and involving the anterior commissure. In such
instances, the thyroid isthmus is transected close to
the contralateral thyroid lobe. The precricoid tracheal
lymph node (delphian) must always be excised. The
site of election for entering the trachea is based on the
extent of the tumor. If there is any suspicion of sub-
glottic extension, at least three or four tracheal rings
are included with the resected specimen. The lumen of
the trachea should be carefully inspected at this stage,
and frozen sections should be obtained.
C, C1 A suitable anesthesia tube, either a short,
flexible, wire-supported rubber or plastic tube (a right-
angled preformed tube is ideal, e.g., Boyan) or a lore-
lawrence tracheostomy tube with universal anesthesia
adaptor (el), is inserted into the trachea. Regardless, a
cuffed tube is mandatory. The patient is then anes-
thetized, and the incision is extended to the suprahyoid
space. The patient should be awake and able to cough
at the end of the procedure. lateral skin flaps are
developed superficial to the strap muscles. The lateral
dissection should not go beyond the strap muscles,
because scarring beyond this point would obscure later
neck metastases. However, palpation of the internal
jugular chain of lymph nodes is done to ascertain the
presence of any suspicious lymphadenopathy. If any
exists, a radical neck dissection is performed in conti-
nuity with the larynx (see Figs. 16-3 and 20-21). The
sternohyoid muscles are transected between clamps
below the level of the cricoid cartilage. In similar fashion,
the sternothyroid muscles are transected. The thyroid
and cricoid cartilages are not skeletonized.
D The omohyoid muscle is sectioned near its inser-
tion on the hyoid bone. In this step and the following
steps the anesthesia tube in the distal trachea has been
omitted for the sake of clarity.
E The superior poles of the thyroid gland are exposed.
The resected larynx includes the ipsilateral lobe along
with all adjacent lymph nodes, with preservation, if
feasible, of the parathyroid glands or reimplantation
(frozen section to be certain not metastatic lymph
node) of them in the base of the sternocleidomastoid
muscle or pectoralis major muscle. The location is
marked with black silk suture and metallic clip. With
sharp and blunt dissection, the contralateral thyroid
lobe is separated from the cricoid cartilage and the
upper rings of the trachea. The anterior suspensory
ligaments of the thyroid are cut. The inferior laryngeal
vessels are clamped and transected. The recurrent
laryngeal nerve is likewise sacrificed. This may be done
at this step or later (see D. The superior thyroid vessels
usually can be retracted laterally. This exposes the
inferior constrictor muscles on each side.
Continued
 THE LARYNX

FIGU RE 20-1 8
 THE LARYNX
Total Laryngectomy (Continued)
(Fig. 20-18)
F Just above the top level of the thyroid cartilage, the
superior laryngeal vessels and nerves are identified,
clamped, and transected. The external branch of the
superior laryngeal nerve will be seen descending to
supply motor power to the inferior pharyngeal con-
strictor and cricothyroid muscles, whereas the internal
sensory division continues with the superior laryngeal
vessels to enter the larynx through the thyrohyoid
membrane.
G With the hyoid bone exposed, the attachments of
the mylohyoid and geniohyoid muscles are transected.
The intermediate tendon of the digastric muscle is like-
wise separated from the hyoid bone. The hyoglossus,
stylohyoid, and middle pharyngeal constrictor muscles
are separated either at this stage or later on during the
operation, depending on the amount of hyoid bone
included with the resected specimen. Bear in mind the
proximity of the hypoglossal nerve and the lingual
veins, which may cause troublesome bleeding if the
dissection is carried too far laterally.
H The hyoid bone is transected with small bone
cutters if only the mid portion is to be removed. Usually
the entire hyoid bone is removed with the larynx.
Again care must be taken not to injure the hypoglossal
nerve.
I With all major attachments to the thyroid cartilage
and hyoid bone now transected, except for the inferior
constrictors of the pharynx, the trachea is transected
at the site of the tracheostomy. The posterior, noncar-
tilaginous portion of the trachea is sectioned over a
curved clamp or catheter that has been inserted in the
plane between the trachea and esophagus, with care
taken not to enter the esophagus. A Lahey clamp is
then used to retract the upper resected portion of
trachea and cricoid cartilage.
J With sharp dissection, the esophagus is further sepa-
rated from the posterior aspect of the trachea up to
the lower edge of the cricoid cartilage. This point marks
the junction of the upper end of the esophagus with
the lower end of the hypopharynx. The dissection should
not be carried much beyond this point, and certainly
not up to the superior border of the cricoid cartilage,
because this would lead to the mucosa at the arytenoid
area. The tumor thus could be very easily exposed and
entered. The inferior pharyngeal constrictor muscles are
transected (along the dotted line) with Metzenbaum
scissors as they are put on stretch. The anesthesia tube
is reinserted if it was removed to perform this step.
Gauze is placed about the anesthesia tube to help
prevent leakage of blood into the trachea. In the draw-
ings, the anesthesia tube is omitted so as not to
obscure the surrounding anatomy.
Continued
When the endotracheal tube is removed (if a prelim-
inary tracheostomy was not performed) do not with-
draw the endotracheal tube through the glottis until the
new airway is well established. When the tube is inserted
into the lumen of the trachea it is prudent to secure it in
place to the cut edge of the trachea. The same suture can
then be placed through the lower skin flap anteriorly to
prevent retraction of the trachea into the mediastinum.
 THE LARYNX

Mylohyoid m.
Thyrohyoid membrane

Inferior
pharyngeal constrictor m.

Ext. br. sup.

laryngeal n.

FIGURE20-18 Continued
 THE LARYNX
Total Laryngectomy (Continued)
(Fig. 20-18)
K If the laryngeal tumor is in the postcricoid area,
the anterior wall of the esophagus is included with the
resected larynx. If there is gross disease in the wall of
the esophagus, an entire section of apparently normal
esophagus is excised, because esophageal cancer spreads
submucosally. Frozen section of the resected edges of
the esophageal mucosa is performed to ascertain the
extent of disease. There also may be skipped areas of
disease in the esophagus. Because the tumor arose
from the right side, the right lobe of the thyroid along
with paratracheal and tracheoesophageal nodes are
removed with the specimen.
L The superior cornu of the thyroid cartilage is brought
into view. The lateral thick band of the thyrohyoid liga-
ment attached to the superior cornu usually requires
transection. If the cornu is long, it may be cut.
M The hypopharynx is entered on the side opposite
the tumor so that accurate assay of the extent of disease
is possible. Extreme care must be taken at this stage to
evaluate the extent of disease accurately. If preopera-
tive chemotherapy has been used, the surgeon must
then base the resection on the extent of disease that
existed before chemotherapy. Photography, radiographs
(full-length pharyngoesophagograms), MRI and CT,
and endoscopy are the methods used. This is most
important, because the mucosa can be free of disease,
yet there can be and often are viable tumor cells beneath
the mucosa. Frozen sections are a must. Never enter
the pre-epiglottic space when the tumor involves the
epiglottis. The lateral hypopharyngeal wall is then
incised upward to the level of the hyoid bone using
Metzenbaum scissors. The incision is carried inferiorly
across the anterior wall of the origin of the esophagus
and thence up the opposite side. With the larynx
almost upside down and slightly drawn to one side,
the final attachments in the suprahyoid area are cut.
This may include a portion of the base of the tongue,
depending on the extent of the tumor.
When the tumor involves the pyriform sinus, a large
portion of the hypopharyngeal wall is removed. When
entering the pyriform sinus, be sure to extend the line
of transection posterolaterally and not along the pos-
terior edge of the thyroid cartilage. Otherwise, the "cut"
may be too close to the aryepiglottic fold. The medial
wall of the pyriform sinuses should be removed with
the larynx.
When the pyriform sinus is involved, for example,
the medial and lateral wall and the apex, then depend-
ing on the extent of this disease, a total hypopharyn-
gectomy should be considered. If on the other hand
just the medial wall is involved, then a total hypophar-
yngectomy is not necessary. However, frozen sections
in this area are very important to be certain at least a
1.0- to 1.S-cm margin free of disease is obtained.
Reconstruction in this area under such circumstances,
although time consuming, can be achieved by flexing
the head forward and using high hypopharyngeal and
some oropharyngeal mucosa. If there is significant
involvement of the hypopharynx, a total hypopharyn-
gectomy is preferred. Reconstruction utilizes a tongue
flap and dermal graft (see Fig. 21-7). If a significant
portion of the cervical esophagus has been resected,
reconstruction is performed with a pectoralis major
myocutaneous flap and dermal graft (see Chapter 8).
Frozen section is most important in this area of the
surgical procedure. The surgeon must realize that
although the mucosa appears intact and free of disease,
unfortunately once the tumor invades the hypophar-
ynx, its submucosal spread can occur both superiorly
into the oropharynx or inferiorly into the cervical
esophagus.
N A nasal feeding tube previously inserted through
one naris is now further inserted into the esophagus,
and closure of the hypopharyngeal and esophageal
defect is begun using 3-0 chromic gut intestinal suture
material. A preoperative percutaneous endoscopic
gastrostomy may be preferred. A separate suture is
started at each lateral end of the defect utilizing a
continuous through-and-through horizontal Connell-
type stitch with inversion of the mucosal edges. Along
the superior edge, the mucosa and portions of the
musculature of the tongue are included. This closure is
most important to help prevent fistula. The mucosa
must be inverted. There should be no tension on the
suture lines.
Continued
 THE LARYNX 1131
.

Esophagus

Post. wall of
esophagus
K

M N
FIGURE 20-18 Continued
 THE LARYNX
Total Laryngectomy (Continued)
(Fig. 20-18)
o Any vertical defect in the hypopharynx or esoph-
agus is closed with a similar suture starting at the lower
end of the opening. The ends of these sutures are left
long as markers for the location of the second layer of
the closure. If the closure is difficult, use a tongue flap
(see Fig. 20-22). It is emphasized again that the mucosa
must be inverted without tension.
01 Completion of the first layer shows the inversion
of the mucosa. This closure has approximated the
hypopharyngeal or esophageal defect with a vertical
line meeting the horizontal line in T fashion.
02 A similar type of horizontal closure is used when
the hypo pharyngeal defect is smaller or when there is
no esophageal defect. When the defect is larger, a
horizontal incision through the base of the tongue is
used to develop a posterior tongue flap. This flap is
then brought down into the pharyngeal defect for
closure (see Fig. 20-22). Reconstruction of the entire
hypopharynx can be performed by a number of
methods: deltopectoral flap (see Fig. 8-4A and B);
dermal or split-thickness skin graft (see Fig. 21-9F to I);
Wookey cervical flaps (see Fig. 21-9A to E), not used
frequently at this time; and a combined tongue flap
and dermal graft (see Fig. 21-7). The latter method is
the one preferred by the author. If a significant portion
of the esophagus has been resected with postcricoid
carcinoma, and the tongue flap is not long enough (an
8-cm anterior defect is about the maximum), then a
pectoralis major flap with dermal graft is the choice
(see Chapter 21).
P If possible, a second layer of closure is performed
with approximation of the edges of the inferior pha-
ryngeal constrictor muscle and fascia as well as portions
of the suprahyoid muscles.
Q The tracheal edges are approximated to the skin
edge with through-and-through 3-0 or 4-0 nylon. A
circular portion of skin is first excised to adapt the skin
margins to the trachea. This helps avoid stenosis of the
tracheostomy.
Two suction catheters have been inserted through
two separate, laterally placed, stab wounds. The skin
incision has been closed in two layers, the deep layer
approximating the cervical fascia and platysma muscles
where possible. The catheters are connected to a suc-
tion apparatus (see Fig. 3-10 and entire section on pre-
operative and postoperative suction care). The catheters
must not be in contact or near the carotid arteries to pre-
vent pressure erosion. They must not cross the carotids.
Q1 If there is disparity between the anterior and
posterior walls of the trachea in the adaptation of the
trachea to the skin, a portion of the anterior wall (X) of
the trachea is excised.
Q2 A lateral view of the trachea showing the portion
of the anterior wall (X) excised to adapt the out-turned
trachea to the plane of the skin.
R If stenosis of the tracheostomy occurs, a Z-plasty is
performed following the basic technique shown in
Figure 3-2.
S The completed Z-plasty is shown. See Figures 20-19
and 20-20 for additional tracheostomy procedures.
Myers suggests that steps Rand S be performed at
the initial operation to prevent stenosis.
Complications
• Fistula and wound infection
• Tracheostomal recurrence. This is believed by Harris
to be due primarily to a previous tracheostomy per-
formed for obstructing carcinoma. It could also be
due to positive tracheoesophageal nodes. It is seen
especially with subglottic extension of the cancer.
Hence, more trachea should be excised in such
instances. The reader is referred to the technique of
Sisson for resection of tracheostomal recurrence (see
section on tracheal resection in Chapter 19).
• Hypoparathyroidism and hypothyroidism (rarely and
then usually when total thyroidectomy was indicated)
• Stress peptic ulcer-bleeding
• Pharyngoesophageal stenosis: treat with dilation using
Maloney dilators and be certain that there is no
recurrence.
• If fistula develops after 10 to 14 days postoperatively,
suspect early recurrence.
• Tracheitis
 THE LARYNX

R s

FIGURE 20-18 Continued

 THE LARYNX
Tracheostomal Problems
Complkations
• Crusting and plugs. In the immediate postoperative
period, an obstructing tracheal plug of mucus and
blood can become lodged just proximal to the laryn-
gectomy tube and cause complete airway obstruc-
tion. The laryngectomy tube must be immediately
removed and the plug grasped with clamp or forceps
and extricated by the nursing staff. Crusting that occurs
later on (days, months, or years) is usually associated
with poor care, excessively dry air, stenosis, infec-
tion, and possible recurrent carcinoma. Treatment is
based on the cause.
• Stenosis. The best management is the prevention of
stenosis at the time of laryngectomy (see Fig. 20-I 9
for corrective measures).
• Recurrence of carcinoma
• Pseudo epitheliomatous hyperplasia can occur along
the stoma margin. This must be differentiated from
an early recurrence of the carcinoma by excisional
biopsy and very careful follow-up.
• Overhang of skin superiorly-simple excision
Highpoints
I. Excision of circular or oval portion of skin is slightly
larger than the diameter of the trachea.
2. Meticulous approximation of mucosa to skin is done
using 5-0 nylon interrupted sutures.
3. Good nursing care can prevent local infection.
B c
FIGURE 20-19
4. Other predisposing factors are a short tracheal stump
with limited mobilization, tension, and keloid formation.
5. The larger the stoma, the better.
6. Some surgeons (Catlin and Harrold, 1966) advise
construction of a large tracheal stoma at the time of
laryngectomy.
Technique of Construction of
Large Tracheal Stoma (Fig. 20-19)
(After Catlin and Harrold, 1966)
Split Tracheal Stoma
A The tracheal incision is shown. The lateral tracheal
walls are split through three or four tracheal rings, thus
forming posterior (x) and anterior (y) "tracheal lips."
B Twoopposing triangles of skin-superior (1) and infe-
rior (2)-are excised, leaving two lateral skin flaps (3 and
4) that have wide obtuse angles larger than 90 degrees.
C The completed closure is done using 5-0 nylon
interrupted sutures. The resulting stoma has a figure-
eight configuration. Flapsx and yare the tracheal "lips"
or flaps; flaps 3 and 4 are the two lateral skin flaps.
Oval Tracheal Stoma
See Figure 20-18Q and QI.

Correction of Tracheal Stomal
Stenosis (Fig. 20-20)
Single Z-Plasty
See Figure 20-18R and S.
Double Z-Plasty
A The scar contracture has been excised and two Z-
plasties are outlined on each lateral border. Simple
circumferential excision of the scar and approximation
of the mucocutaneous junction usually does not suf-
fice. Examine all removed tissue for possible recurrent
carcinoma. Triple or quadruple Z-plasty may be required,
depending on the degree of stenosis.
B Following the basic technique of a Z-plasty (see
Fig. 3-2A to G), the interdigitating flaps of mucosa and
skin are rotated and reapproximated using 5-0 nylon
interrupted sutures.
A B
D E
FIGURE 20-20
THE LARYNX
C The completed closure is shown.
Lateral Skin Flap Technique
(After Montgomery, 1963)
This method is particularly applicable to the vertical slit-
like stenosis usually associated with collapsed tracheal
rings.
D Excision of stenotic vertical slit. The lateral skin
flaps are outlined by the solid lines. The dotted lines
represent the excised scar and adjacent skin.
E On one side is depicted the elevation of the lateral
skin flap. By shortening the skin flap with excision of
excess skin, the lateral walls of the trachea are pulled
laterally. On the other side is the completed closure.
c
 THE LARYNX
Recurrence at the Tracheal Stoma
The reported incidence of recurrent carcinoma at the
tracheal stoma varies between 3 % and 15 %.
There is likewise a wide difference of opinion regard-
ing the etiologic factors relative to the recurrence. Modlin
and Ogura, in their review of 12 patients with stomal
recurrence out of 243 laryngectomies, could not arrive
at any definite conclusion. However, a number of factors
may be involved, as follows:
1. Preoperative tracheostomy
2. Subglottic extension of the primary tumor
3. Involvement of paratracheal, tracheoesophageal, or
cricothyroid (delphian) lymph nodes
4. Large primary tumors
5. Surgical implant
6. Endotracheal tube implants when the tube is inserted
through a large transglottic tumor (a tumor that
traverses the ventricle in vertical fashion invading
both the supraglottic and infraglottic portion of the
larynx with a high incidence of metastatic lymph
nodes). Many surgeons prefer a tracheostomy first
performed under local anesthesia at the time of
laryngectomy. Preoperative adjuvant chemotherapy
with a significant response may help prevent implan-
tation of tumor when an endotracheal tube is used.
This is purely speculative.
7. Vascular and nerve sheath invasion
Treatment
It appears that the best technique for managing this
serious complication is the mediastinal resection of the
trachea (Sisson; see Fig. 19-I1A and B). Postoperative
over preoperative radiation therapy is preferred; radia-
tion therapy alone has limited success.
Possibly emergency laryngectomy should be per-
formed rather than simply a tracheostomy when there
is airway obstruction secondary to a large carcinoma of
the larynx (Baluyot et aI., 1971). Emergency laryngec-
tomy has been performed by the author (JML) for
intractable bleeding after laryngeal biopsy.
Total Laryngectomy and Radical
Neck Dissection (Fig. 20-21)
Highpoints
1. Do not skeletonize the thyroid cartilage.
2. Include at least the midportion of hyoid bone and
epiglottis in the resection.
3. Enter the hypopharynx on the side opposite the
primary tumor.
4. In postcricoid tumors, full-length pharyngoesopha-
gography and esophagoscopy are indicated preoper-
atively to determine the extent of involvement.
Such lesions are tantamount to esophageal cancer,
and a portion of the cervical esophagus must be
resected. Frozen sections are performed on the
esophageal cuff (see Chapter 21).
5. Include on the ipsilateral side (the side with pre-
dominant disease) the thyroid lobe and isthmus
and the paratracheal, paraesophageal, and tracheo-
esophageal lymph nodes. Spare the parathyroid glands
either in situ or reimplant them (see Chapter 18).
6. Extreme care should be taken in the evaluation of
the extent of tumor, with frozen sections done as
indicated, especially in any hypopharyngeal
involvement.
7. If significant hypopharyngeal involvement is found,
then perform total hypopharyngectomy (see Fig. 21-9A
to D and Chapter 8 for reconstruction).
8. Take care not to injure the hypoglossal nerve.
9. Insert feeding tube through the nose into the orophar-
ynx before operation. It should not be inserted
farther, because it may impinge on the tumor and
thus cause implantation of tumor cells.
10. For additional details of radical neck dissection, the
reader is referred to Figure 16-3.
11. With subglottic extension, a mediastinoscopy may
be of help to ascertain the presence of mediastinal
disease (see Fig. 19-8).
12. Review data under total laryngectomy (see Fig. 20-18A
to E) and radical neck dissection (see Fig. 16-3).
13. Do not separate neck dissection contents from
laryngectomy specimen.
14. Preoperatively and postoperatively neomycin or
clindamycin mouthwash is used.
A The skin incision is made as pictured with the
excision of a circular portion of skin at the site of the
tracheostomy. The skin flaps include the platysmal
muscle. The dotted line depicts a larger superior skin
flap that is less likely to become necrotic and thus
protects the carotid bifurcation.
B The anatomy as seen after elevation of the skin
flaps. The lower flap may be sutured down to the chest
wall for retraction. An incision is made along the
anterior border of the sternocleidomastoid muscle at
its inferior end. Through this incision, the carotid
sheath is identified. Another similar incision is made at
the posterior border. Care must be exercised that the
external jugular vein is not avulsed from the subclavian
vein, which lies just under the clavicle. A Kelly-type
clamp is then inserted under the sternocleidomastoid
muscle, and both heads of the muscle are sectioned.
 THE LARYNX

B Ext. Jugular V.

Common Carotid A.

Vagus N.

rapezius M. chial Plexus

c D
FIGURE 20-21

C The external jugular vein is doubly ligated with tie
and suture ligature and transected. The internal jugular
vein is isolated from the common carotid artery and vagus
nerve. A small Mixter clamp is excellent for this step.
D A proximal suture ligature and distal tie of silk is
placed above and below the line of transection of the
internal jugular vein, which is then sectioned. The
sternocleidomastoid muscle with internal jugular vein,
associated lymph nodes,. and adipose tissue is reflected
upward, using the fascia covering the scalenus muscles
as the deep plane to follow. The omohyoid muscle is
sectioned at its lowest point. The subclavian vein is
carefully preserved. If injury to the subclavian vein
does occur, the wound must be immediately occluded
with pressure against the clavicle to avoid an air
embolism. The defect is usually closed easily by the
technique of lateral venorrhaphy using continuous fine
silk. Injury to the pleura may occur and must be recog-
nized and treated with an intercostal tube and under-
water drainage system.
Continued
 THE lARYNX
Total Laryngectomy and Radical
Neck Dissection (Continued)
(Fig. 20-21)
E The procedure now differs from other radical neck
dissections in that the strap muscles on the side of the
neck dissection are sectioned at the sternum and retract-
ed upward. The strap muscles on the opposite side are
transected (see dotted line) between the level of the
cricoid cartilage and the thyroid isthmus or slightly
caudad. A hemithyroidectomy and isthmusectomy are
likewise performed, sectioning the isthmus along the
dotted line at the edge of the opposite thyroid lobe.
On the side opposite the neck dissection, the technique
of total laryngectomy as depicted in Figure 20-18£ to I
is followed.
F The inferior thyroid artery and recurrent nerve are
sectioned; the thyroid lobe, strap muscles, and internal
jugular vein with associated lymph nodes are retracted
upward and included in the resected specimen. It is
most important to remove all the pretracheal and
paratracheal and tracheoesophageal lymph nodes
including the cricothyroid lymph node (delphian). A
search is made for the ipsilateral parathyroid glands. If
feasible, their blood supply is preserved; if not, the
glands are sectioned in small portions and reimplanted
in the trapezius muscle and marked with a metallic
clip. Frozen section is done to be certain metastatic
cancer is not reimplanted. The most superior mediasti-
nal lymph nodes are removed with frozen section. If
positive, a superior mediastinal node dissection is per-
formed (see pp. 1096 to 1097 for indications for radio-
therapy). A total thyroidectomy is occasionally neces-
sary. Under this circumstance, hypoparathyroidism is a
distinct possibility. The trachea is now entered if a
previous tracheostomy was not performed. If the lesion
is supraglottic, only one or two tracheal rings are included
in the specimen. If subglottic extension exists, an ade-
quate margin of trachea must be excised, with frozen
sections. Rotated, turned-in skin flaps are used to
facilitate a serviceable tracheostomy (see Fig. 21-12W)
if sufficient trachea does not remain to reach the usual
skin margins.
G The trachea is obliquely sectioned farther by retrac-
ing the upper border, making the incision somewhat
more cephalad along the posterior plane. The endo-
tracheal tube has been withdrawn by the anesthetist.
The esophagus should not be entered at this time.
H Endotracheal anesthesia is now directed into the
trachea if a previous tracheostomy has not been per-
formed. The fitting into the trachea must be entirely
closed, using an inflatable cuff. A Boyan endotracheal
tube with cuff is ideal. The distal end of the larynx is
reflected upward.
I The radical neck dissection is carried upward con-
comitantly with the laryngectomy. An alternate method
that is preferable in certain respects is to perform the
lower, the posterior, and the upper stages of the neck
dissection, leaving the mid-anterior portion attached
to the larynx, before the dissection of the larynx. In
any event do not separate or dissect the contents of
the neck from the larynx.
J With the larynx retracted upward and the inferior
pharyngeal constrictor on the stretch, this latter struc-
ture is cut with scissors on the side opposite the neck
dissection.
J1 The lateral wall of the pyriform sinus is now entered
as shown by the dotted line. This point of entry is
made at an area away from the known extension of
the tumor.
This is most important. This stage of the surgery must
be performed very slowly, with extreme care, so that at
least 1- to 2-cm margins are obtained. Again, frozen sec-
tions should be performed as indicated. With these pre-
cautions, recurrence in the pharyngoesophageal region as
well as stomal recurrence can be reduced to a minimum.
 THE LARYNX

FIGURE20-21 Continued
 THE LARYNX
Total Laryngectomy and Radical
Neck Dissection (Continued)
(Fig. 20-21)
K The incision is extended superiorly along the
lateral wall of the hypopharynx up to the hyoid bone.
Either the entire hyoid bone or its middle two thirds is
included and left attached to the resected larynx and
neck dissection.
L, M Before the left lateral hypopharyngeal wall is
sectioned, any remaining areas of the neck dissec-
tion are completed. These steps are diagrammatic,
because all tissue is removed in continuity with the
larynx.
N Depicted is the nasoesophageal feeding tube that
was inserted into the oropharynx before the surgical
procedure. The tube should not be inserted into the
hypopharynx until the tumor-bearing specimen has
been removed because of fear of implantation of
tumor cells. Approximation of the pharyngeal defect is
in the shape of a T or horizontal line unless extension
into the hypopharyngeal wall has necessitated resec-
tion of more mucous membrane and muscle. Three
separate intestinal chromic 3-0 catgut sutures are
used, starting at the outer corners of the defect. A
runningtype Connell stitch is employed with the
mucosa inverted. The sutures are placed through-and-
through mucosa and submucosa (see Fig. 20-18N).
The technique is similar to an open intestinal anas-
tomosis except that the serosa is absent. When more
hypopharyngeal wall or a portion of the cervical
esophagus has been excised, primary closure is
achieved by flexing the head forward (Martin) and
using pharyngeal mucous membrane judiciously.
Very rarely, special reconstructive procedures are
necessary (see Figs. 21-9 and 21-10) unless a pha-
ryngectomy or esophagectomy has been necessary.
Refer to page 1142 and Figure 20-22 for pharyngoe-
sophageal reconstruction.
There is little indication to preserve a narrow strip of
posterohypopharyngeal mucosa for reconstructive pur-
poses. If the disease is this extensive, it is far better to
perform a total hypopharyngectomy along with the
laryngectomy and to reconstruct the gullet using a
tongue flap and dermal graft (see Fig. 21-7). If a portion
of the cervical esophagus has been resected, the tongue
flap may not be long enough for reconstructive pur-
poses. Reconstruction can then be accomplished using
a pectoralis major myocutaneous flap with a dermal
graft posteriorly. Gastric pull-up is not necessary unless
the submucosal spread in the esophagus extends
beyond the thoracic inlet (see Fig. 21-11).
o Using interrupted sutures of 3-0 chromic gut, a
second muscular layer is approximated over the mucosa
closure. This is not always feasible and not necessary to
prevent a postoperative fistula. The important points
to help prevent fistula formation include no tension on
the suture line and careful inversion of all mucosal edges.
Preoperative adjuvant chemotherapy does not predis-
pose the patient to fistula formation. The skin flaps are
approximated as in a radical neck dissection alone.
Either drains or suction may be used, as preferred. If
catheters are used, they must be placed and fixed with
loose gut sutures away from the great vessels.
P The tracheostomy is constructed by using inter-
rupted nylon sutures. The anterior portion of the trachea
may be removed obliquely to fit the skin margins more
accurately. The ellipse of skin removed at the tracheostomy
site helps prevent stomal stricture (see Fig. 20-180
to 5). Other tracheostomy procedures are found in
Figures 20-19 and 20-20.
At the time of skin closure of the neck dissection
flaps, a 1.0-cm margin of skin along the vertical edges
of the anterior and posterior flaps is excised. This aids
in primary wound healing. If there is redundant skin in
the flap above the tracheostomy, additional skin is
excised to prevent drooping of the skin, which can
obstruct the tracheostomy.
 THE LARYNX

Submaxillary Salivary GI.

Mylohyoid M.

Tongue

Inf. Constrictor M.

N o

".
P
".. J,

\tJ~l:>fUIL
FIGURE 20-21 Continued
 THE LARYNX
Tongue Flap (Myomucosal)
for Reconstruction of Portion
of Hypopharynx Associated With
Total Laryngectomy (Fig. 20-22)
(Extended after Sisson, 1956;
Hiranandani, 1967)
Highpoints
1. This is an ideal procedure for anterior and lateral
hypopharyngeal defects after laryngopharyngectomy.
2. It is a one-stage operation.
3. Stricture formation is minimized.
4. It does not interfere with tongue function.
S. Tension of suture lines is avoided in closure of
hypopharynx.
6. It does not interfere with voice prosthesis surgery
(see Fig. 20-23).
A After laryngopharyngectomy, when the posterior
wall of the hypopharynx remains, closure of this defect
is achieved with the aid of a horizontal posterior tongue
flap. The hyoid bone has been removed with the resect-
ed specimen along with a radical neck dissection. All
redundant pharyngeal mucosa is mobilized as depict-
ed by the arrows. The posterior tongue flap is then
developed with a horizontal incision through the base
of the tongue-a fish mouth incision. The incision is
SUPERIOR LONGITUDINAL M.
GENIOGLOSSUS M.
FIGURE 20-22
made posterior, so that a tongue flap containing mucous
membrane with papillae and a narrow layer of intrinsic
lingual muscles is formed. The incision is carried
forward into the tongue so that point 1 easily reaches
point 2 without tension.
B Lateral view depicts the placement of the incision.
The blood supply of the tongue is copious, with preser-
vation of the lingual arteries, and there is little danger
of flap necrosis. Point 1, which is the distal end of the
tongue flap, is advanced (arrow) to point 2.
C The edges of the tongue flap are approximated to
the mobilized edges of the mucous membrane of
the hypopharynx using interrupted or semicontinuous
Connell-type sutures of 3-0 chromic gut. The tip of the
tongue flap (1) is approximated to the distal end of
the hypopharyngeal defect (2). This V-type approxi-
mation is preferred to the V-type closure. If possible, a
second layer of sutures is used to reinforce the closure.
See Figure 21-7 for extension of this technique to
reconstruct the entire hypopharynx and a portion of
the cervical esophagus when combined with total
laryngectomy. A tongue flap with a dermal graft for
replacement of the entire hypopharynx combined with
total laryngectomy is preferred when only a narrow
portion of the posterior wall of the hypopharynx is
contemplated for preservation. It is far better to resect
the entire hypopharynx under these circumstances.
\Nabnn.;

Voice Prostheses: Post-Total
Laryngectomy
Tracheal Esophageal Puncture (TEP)
(Fig. 20-23)
Shortly after the first laryngectomy by Billroth in 1873,
innumerable methods were described to develop post-
laryngectomy speech. This speech can be obtained in a
number of ways, namely, the utilization of esophageal
speech, various types of electric larynges, and different
ways of diverting air from the trachea to the esophagus,
hypopharynx, or oral cavity. In addition, there have
been modifications of the total laryngectomy to facilitate
diversion of the tracheal air column into the esophagus,
hypopharynx, or oral cavity. In a publication by Shedd
(1980), the historical background is reviewed. More
recently, Sisson (1962) has contributed a significant
amount of research and development in the field of
postlaryngec-tomy speech.
If training in esophageal speech fails after several
months, and the electric larynx is not acceptable to
FIGURE 20-23
THE lARYNX
the patient, a shunt or fistula between the trachea and
esophagus is believed the best choice for voice rehabil-
itation. Nevertheless, a number of serious complications
can occur.
A As time goes on, patients who desire voice pros-
thesis devices using a tracheoesophageal fistula
become more selective. Actually, few of the authors'
patients desire the prosthesis. Some who have had
the procedure performed are not entirely satisfied.
Others are very satisfied and elated and have become
well rehabilitated. A number of patients have developed
successful esophageal speech after total laryngec-
tomy and total hypopharyngectomy reconstructed
with a tongue flap and dermal graft. Hence, careful
selection of patients is necessary. Previous radio-
therapy may be a contraindication to performing a
tracheoesophageal fistula because of the possibility of
necrosis of the posterior wall of the trachea and the
esophagus.
Continued
 THE LARYNX
Tracheal Esophageal Puncture (TEP)
(Continued) (Fig. 20-23)
Two techniques that both utilize a plastic one-way
valve prosthesis are described in the following text:
1. Singer-Blom prosthesis with a flanged plastic device
0.3 to 0.5 em from the posterior rim of the stoma
2. Panje device with a button configuration prosthesis
1.0 em from the posterior rim of the stoma
Common to both techniques is a prepharyngo-
esophageal air retention evaluation, which can be per-
formed to assess whether the patient can in fact develop
speech'by the introduction of air into the lumen of the
esophagus. This test is performed by inserting a soft
rubber nasoesophageal catheter and then instilling some
air into the esophagus and evaluating the patient's ability
to expel the air into the hypopharynx and oral cavity.
Failure to do so may be due to the lack of relaxation of
the cricopharyngeus muscle and/or the esophageal
constricting musculature. Some surgeons perform a
cricopharyngeal myotomy extending inferiorly through
the upper cervical esophageal mucosa at the time of
the total laryngectomy to obviate this problem. Some
even suggest the insertion of the prosthetic device at
the time of a total laryngectomy. The author, however,
believes that the attempted use and development of
esophageal speech is in fact worthy before the insertion
of any prosthetic device. As far as the sacrifice of the
sphincteric action of the cricopharyngeal and esophageal
constricting musculature is concerned, this sacrifice may
in fact be detrimental to the development of esophageal
speech. This mayor may not be so. The myotomy can
also be performed after the total laryngectomy when
the esophageal air retention study indicates that spasm
in this musculature hampers the development of
adequate speech.
Singer-Blom Technique (Modified)
Highpoints
1. Tracheoesophageal shunt is created 0.3 to 0.5 em
distal to the superior posterior rim of the tracheostomy.
2. Use of esophagoscope facilitates the passage of an
l8-gauge needle threaded with 2-0 silk or nylon, the
needle being passed through the tracheal mucosa
into the esophageal lumen.
3. Retrieval of the suture is done through the esophago-
scope.
4. Pull-through is performed of a NO.14 French soft
rubber catheter attached to the suture.
5. The catheter is replaced on the second day with a
valve voice prosthesis.
6. If unable to puncture the esophagus because of scar-
ring with angulated lumen, use the Panje technique
(see F to L).
A tracheoesophageal puncture kit (Singer-Blom) is
available.
Another alternative method is the use of a straight 18-
or 20-gauge hollow needle with a stylette in place of the
curved needle with the attached 2-0 silk or nylon as in
B. The advantage of the straight needle is that its position
and direction will not be altered as with the curved needle
if it rotates slightly. The straight needle is inserted in a
slightly superior oblique plane to enter the esophagoscope
as depicted in B. After the needle is in the esophago-
scope, the stylette is removed and then Prolene is inserted
through the lumen into the esophagoscope and grasped
as in C. The needle is removed and a Bard urethral
dilator No. 18 is threaded over the Prolene and used to
dilate the fistula for the insertion of the feeding tube.
B AJesberg esophagoscope is inserted into the lumen
of the esophagus and passed beyond any remnant of
the cricopharyngeal muscle to the point at which the
light and pressure of the esophagoscope is noted within
the posterior wall of the trachea. The esophagoscope
is rotated 180 degrees so that the bevel of the lumen
is facing anteriorly. The lumen is now just posterior to
the superior posterior rim of the stoma. An l8-gauge
needle curved in C fashion and threaded with 2-0 silk
or nylon is passed through the posterior membranous
wall of the trachea 0.3 to 0.5 em distal to this posterior
rim and then into the beveled lumen of the esophago-
scope. Care must be taken, with direct vision through
the esophagoscope, in the exact placement of this
needle. The rotated esophagoscope prevents injury to
the posterior wall of the esophagus. Rather than using
a curved bent needle, a trocar has been developed by
Nijdam and colleagues to facilitate this puncture. As
the needle isvisualizedwith its suture in place the suture
is then grasped with forceps through the esophago-
scope and drawn superiorly. The needle is now with-
drawn with the suture passing through the tracheal
and esophageal mucosa. Utilizing a fine clamp, either
curved or the Mixter type, the tracheoesophageal shunt
or fistula is now opened and widened to facilitate the
passage of a No. 14 French soft rubber catheter. A
Bard urethral dilator can be used for this purpose.
C The catheter is attached to the suture. The suture
is grasped with alligator forceps.
D The catheter is then drawn by the suture through
the tracheoesophageal fistula.
Continued
 THE LARYNX

FIGURE 20-23 Continued

 THE LARYNX
Tracheal Esophageal Puncture (TEP)
(Continued) (Fig. 20-23) . 4. This site should be visible to the patient for ease in
E The distal end of the catheter that has been drawn
into the oral cavity is sutured through another catheter
passed through the nose. Both catheters are then
withdrawn through the nose. The second catheter is
detached. The proximal and distal ends of the catheter,
which is through the tracheoesophageal fistula, are
connected with a suture, thus forming a loop from the
nose to the tracheoesophageal fistula. On the second
day the catheter is removed and replaced with the
prosthesis.
El The prosthesis is in place.
E2 An alternate technique is the insertion of the
catheter directly into the distal esophagus, thus avoid-
ing the discomfort of the feeding tube through the
nasal cavity. This is preferred.
Complications
These are the same as those listed on page 1150.
Panje Voice Button Prosthesis
Highpoints
1. Topical and local anesthesia is used.
2. Diameter of the tracheal stoma must be at least
1.5 em.
3. Fistula site is 1 em distal to the posterior edge of
the tracheal stoma.
insertion of the voice button and thus be slightly
proximal (superior) to the lower or anterior edge of
the tracheal stoma.
5. Esophageal dilator (e.g., Maloney type without
mercury), chest tube, or endotracheal tube is used
to ascertain the maximal bulge and vertical midline
of the esophagus at the fistula site.
6. Insertion of an 18- to 22-gauge spinal needle is
done through the fistula site into the esophageal
tube.
7. The needle acts as a guide for the incision through
the tracheoesophageal wall.
8. If feasible, suture tracheal mucosa to esophageal
mucosa with absorbable sutures.
9. A No. 14 catheter is inserted through the fistula
from the tracheal side down into the esophagus
distally.
10. The tube must be securely fastened to the patient
to avoid displacement.
F, F1 The valve voice prosthesis is now placed in the
tracheoesophageal fistula and secured by tape across
the flanges of the prosthesis. The skin is protected with
tincture of benzoin. Depicted is a Singer-Blom
prosthesis with a one-way valve that when functioning
properly requires that the patient temporarily occlude
the tracheostomy with his finger to divert the exhaled
air through the prosthesis.
G Depicted is the site of the Panje tracheoesophageal
fistula as compared with the Singer-Blom fistula.
Continued
 THE lARYNX

FIGURE20-23 Continued
 THE LARYNX
Tracheal Esophageal Puncture (TEP)
(Continued) (Fig. 20-23)
Procedure
H After careful evaluation of the pharyngoesophageal
area utilizing a Jesberg esophagoscope to be certain
that there is no evidence of any recurrent tumor, a
Maloney-type esophageal dilator without mercury, a
chest tube, or an endotracheal tube is then inserted
through the reconstructed cricopharyngeal area. The
largest diameter tube able to be passed is utilized.
Anesthesia is with a topical anesthetic agent, both to
the oral cavity, hypopharynx, and tracheal mucosa. As
the tube is advanced into the esophagus, its bulge is
noted in the posterior wall of the membranous trachea.
This bulge may not be in the center of the posterior
wall of the trachea; however, the important point is
that the site for the fistula must be placed where the
maximum bulge is noted in the midline of the esophagus
rather than in the midline of the trachea. This site is
approximately 1 cm inferior to the posterior edge of
the tracheal stoma. Again, it must be emphasized that
the diameter of the tracheal stoma must be at least
1.5 cm in diameter. An 18- to 22-gauge spinal type
needle is then inserted through this point (H) of maxi-
mum bulge, and the needle isthrust through the tracheal
mucosa, through the party wall, between the trachea
and esophagus, and thence into the esophageal lumen
and into the rubber tube. Supplemental anesthesia in
the posterior wall of the trachea is obtained by the
injection of several milliliters or 1% lidocaine without
epinephrine. It is to be noted that the fistula site is
clearly visible to the patient and hence must be placed
superior or proximal to the inferior edge of the tracheal
stoma. This is to facilitate the insertion of the voice
button by the patient. The voice button is inserted with
an inserter that introduces the button in the future
fistula. The voice button (Panje) in all probability would
not be suitable for a Singer-type fistula that is much
closer to the posterior edge of the tracheal stoma,
because the thickness,of the tracheoesophageal wall is
much greater than at the fistula site for the voice
button.
I This depicts a lateral view of the needle through
the tracheoesophageal wall into the esophageal tube,
which may be the Maloney dilator, a chest tube, or an
endotracheal tube.
Total laryngectomy and Radical Neck
Dissection
J By moving the esophageal tube slightly cephalad
and caudad, the movement of the needle will indicate
that it is properly inserted into the esophageal tube. By
using the needle as a guide, an incision is then made
through the posterior wall of the trachea in vertical
fashion using either a No. 15 or a No. 11 blade. The
length of this incision is 7 to 10 mm and is carried down
ideally through the esophageal mucosa. However,
although an incision may be made in the esophageal
mucosa, the exact opening into the lumen of the
esophagus may not be apparent.
K If the opening into the esophagus is not apparent,
esophageal mucosa can then be exposed by blunt
dissection using a mosquito-type clamp or a long
tonsillar-type clamp, thus exposing the submucosa of
the esophagus. The submucosa is then grasped, and a
vertical incision is made under direct vision through
the submucosa and the mucosa of the esophagus. The
esophageal tube can now be clearly visualized. Ideally,
3-0 or 4-0 absorbable sutures are then used to approx-
imate the tracheal mucosa to the esophageal mucosa.
It is very easy to insert the catheter, which acts as a
stent. Also if the catheter becomes dislodged, it is very
easy for the patient to reinsert it. It also serves to form
a very narrow tracheoesophageal wall.
Continued
 THE LARYNX

FIGURE 20-23 Continued

 THE LARYNX
Tracheal Esophageal Puncture (TEP)
(Continued) (Fig. 20-23)
L A No.14 soft red rubber feeding-type catheter is
then inserted through the fistula from the tracheal side
down into the esophagus and is passed distally. This
tube must be securely fastened to the skin of the patient.
This can be achieved by using adhesive tape as well as
a 2-0 silk tie, which occludes the catheter to prevent
regurgitation. This is secured to the patient at an appro-
priate location. The only function of the tube is to act
as a stent during the healing period of the tracheo-
esophageal fistula. There may be some leakage of
fluids surrounding the catheter for the first few hours
or a few days, and the patient is advised to keep the
posterior wall of the trachea as clean as possible and to
eat solid foods as much as possible.
M Inserter is being utilized to place the prosthesis in
the fistula.
N, Nl The voice button prosthesis in place. The
valve tip of the voice button prosthesis is available in
two varieties: one is the short type that projects 6 mm
from the inner flange, has a four-flutter flap, and is a
one-way valve. The other one is a long-type voice
button advised for patients who cannot generate suffi-
cient lung pressure for good long-term vocalization
and is somewhat easier to insert than the short
type.
Postoperatively, the patient is placed on antibiotics
for 1 week. One to 2 weeks after the surgery the voice
button is inserted. The prosthesis should be cleaned
once a day, and the patient should also be under the
care and management of a speech pathologist.
Complications (Relative to Both Types of Voice
Prostheses)
• Dislodgement and/or aspiration of prosthesis with
inability to reinsert the device
• Closure of the fistula
• Leakage through the fistula and aspiration
• Massive breakdown of tissue between the trachea and
the esophagus with surrounding necrosis. This com-
plication can be extremely serious and life threaten-
ing. It is more likely to occur in those patients who
have had radiotherapy.
• Infection and abscess formation
• Skin problems associated with the repeated use of
various types of adhesive to hold the Singer-Blom
prosthesis in place
• Failure and no voice
• Pseudo epitheliomatous hyperplasia
 THE LARYNX

N1
FIGURE20-23 Continued
 THE LARYNX
Resection of External Laryngocele
(Fig. 20-24)
Highpoints
1. Carefully evaluate the larynx for any internal
laryngocele.
2. The entire cyst (external type) should be resected
through an external approach.
3. Unless there is a compromise of the airway, a
tracheostomy is usually unnecessary.
4. Avoid injury to the internal and external branches
of the superior laryngeal nerve.
5. Any communication with the interior portion of the
larynx should be excised completely.
6. External and internallaryngoceles, both of signifi-
cant size, can coexist.
7. Excision of external laryngocele can facilitate removal
of an internal laryngocele.
8. A small connecting duct should be excised down to
the muscular layer (see Fig. 20-24E1).
9. Excision of a portion of the thyroid lamina can help
in tracing a duct inferiorly.
10. The 12th cranial nerve can be in jeopardy during
resection of an external laryngocele.
11. There may be swelling in the supraglottic larynx
(e.g., the ventricular band, aryepiglottic fold).
12. An external laryngocele can be confused with a
branchial cleft cyst-"cervical cyst."
A A horizontal incision following a natural skin crease
is made over or under the cystic mass. This mass is
compressible and located in the area of the thyrohyoid
membrane. When compressed, a gurgling and hissing
sound may occur (Bryce's ~ign). The mass may change
in size from time to time.
B Upper and lower skin flaps including the platysma
muscle are developed. The cystic mass is seen displacing
the strap muscles anteriorly and the carotid sheath
posterolaterally.
C The common facial vein has been doubly ligated
and divided. The ansa hypoglossi may be adherent to
the cyst wall and is easily preserved. The strap muscles
may be transected for exposure, but in this patient
retraction sufficed, because the cyst was rather large
and had stretched the muscles effectively.
D Further dissection of the laryngocele is shown. Its
neck at the thyrohyoid membrane is now identified.
The superior laryngeal nerve is identified with its internal
and external branches as it passes deep to the carotid
vessels. The hyoid bone is identified and preserved.
The medial border of the cyst was closely adherent to
the lateral lamina of the thyroid cartilage and the infe-
rior constrictor muscle (Iaryngopharyngeus), requiring
a careful and sharp dissection to avoid injury to the
superior laryngeal nerve and its branches. The superior
laryngeal artery arising from the superior thyroid artery
is likewise identified and preserved, if feasible.
E The neck and base of the cyst have been removed
intact from the thyrohyoid membrane without enter-
ing the lumen of the larynx. Whether the larynx is
entered depends on the type of laryngocele (see F). At
this site, two layers of fascia are incised, between which
lies the adipose tissue of the thyrohyoid membrane.
This site is slightly more anterior to the entrance point
of the internal branch of the superior laryngeal nerve
and superior laryngeal artery and vein. If a horizontal
line is drawn across the upper border of the thyroid
cartilage to a point within 1 em of the superior corner
of this cartilage, this point localizes fairly accurately at
the site of entrance of the internal branch of the supe-
rior laryngeal nerve through the thyrohyoid membrane
(Lore, Sr.). The two layers of fascia are sutured (El),
and the wound is closed with a small Penrose drain.
Evaluation of the laryngeal airway should be made
at the close of the operative procedure. The airway
should be excellent; otherwise, a tracheostomy must
be performed.
F Frontal section through the larynx depicts the
various types of laryngoceles. 1, Internal laryngocele
(see Fig. 20-6). It arises in the ventricle. 2, External
laryngocele. 3, Communication of external laryngo-
cele with ventricle. This communication may be
absent. 4, Thyrohyoid membrane. 5, Hyoid bone.
6, Thyroid cartilage. 7, Vocal cord. 8, Thyrohyoid
muscle. 9, Ventricular band.
There may be a combination of internal and external
laryngoceles. In addition, carcinoma of the ventricle of
the larynx can coexist with this and can possibly be the
etiologic factor of a laryngocele. Therefore, a careful
histologic examination must be done for any specimen
removed, and preoperative biopsy should be performed
as indicated.
Internal Laryngocele
Small internal laryngoceles can usually be resected or
"uncapped" endoscopically (see Fig. 20-6). Large internal
laryngoceles or recurrent ones usually require a laryngo-
fissure approach (see Fig. 20-9). Any communicating
tract should be excised.
 THE LARYNX

J
'/
E~~ERNAL BR.
SUPERIOR LARYNGEAL N.

FIGURE 20-24
 THE LARYNX

Laryngeal Trauma (See Figs. 20-25 to

c. Low tracheostomy as indicated
20-28) (After Fitz-Hugh et aI., 1962; Ogura, d. lntralaryngeal stent as indicated (see A). Varieties
1971; Montgomery, 1963; and Pennington, of stents are shown in AI.
1964) 3. Severe
a. Low tracheostomy. Tracheomediastinotomy is per-
Objectives formed if mediastinal emphysema is present (see
Fig. 19-3).
• Adequate airway b. Direct rigid laryngoscopy, pharyngoscopy, bron-
• Satisfactory voice choscopy, and esophagoscopy
• Prevention of aspiration with satisfactory deglutition c. Reposition of displaced cartilages through direct
• Prevention of infection-chondritis laryngoscopy, if feasible, plus use of laryngeal stent
d. If "c" fails, then open operation:
Associated Injuries 1) Exploration of thyroid and cricoid cartilages and
trachea as indicated
• Pharynx 2) Approximation and wire or nylon fixation of
• Trachea fractured cartilages
• Soft tissue of neck 3) Thyrotomy and repair of lacerated mucous
• Chest: pneumothorax (tension, nontension) membrane lacerations and reposition of dis-
• Esophagus placed arytenoid cartilage if feasible; otherwise,
• Vascular arytenoidectomy with fixation of vocal process
• Mediastinum: emphysema laterally to thyroid ala.
4) Cover bare areas with local mucosal flaps if
Complete Radiographic Evaluation possible or free mucosal grafts (buccal wall
primary closure of donor site); nasal septal
The neck, larynx, trachea, mediastinum, and lungs mucosa (donor site covered with dermal graft)
should be examined. can be used as well. Do not use epidermal grafts
because of danger of future airway obstruction
Acute (Fig. 20-25) due to sebum.
5) Insert laryngeal stent (the mucosal graft can be
Pathologic Anatomy-Classification directly sewn in defect or fixed around stent)
(Montgomery, 1963).
1. Minimal 6) Use laryngeal keel as indicated to prevent ante-
a. Ecchymosis rior commissure web (see Fig. 20-29).
b. Slight edema
2. Moderate Highpoints
a. Hematoma
b. Increased edema 1. Keep debridement of laryngeal structures to a mini-
3. Severe mum.
a. Fracture or avulsion of thyroid cricoid or arytenoid 2. Use horizontal skin incisions or use preexisting
cartilages lacerations through the skin if feasible.
b. Epiglottis, vocal cord, or pharyngeal and esophageal 3. Reapproximate to normal anatomy as possible with
injuries meticulous concern for detail.
c. Tracheocricoid avulsion and separation 4. Perform a low tracheostomy.
d. Emphysema: subcutaneous or mediastinal 5. Carefully evaluate all possible injuries as previously
listed.
Management 6. Obstruction to airway and tension pneumothorax
must be immediately corrected: they are life threat-
1. Minimal ening.
a. Antibiotics 7. Laryngeal stent is left in situ from 3 to 5 weeks and
b. Proteolytic enzymes? up to 6 months depending on degree of deformity.
c. Steroids 8. If open operation is indicated, operate as soon as
d. Close observation possible except in the presence of extensive edema,
2. Moderate which obscures the anatomy.
a. Antibiotics 9. Best results are obtained when surgery is done early,
b. Direct rigid laryngoscopy with or without aspira- at least within the first week and preferably within
tion of hematoma 24 hours.

c
FIGURE 20-25
A Endolaryngeal stent is in place and fixed with
through-and-through wire sutures secured through a
piece of Silastic over the skin. Low tracheostomy is
performed (after Pennington, 1964).
A 1 Depicted are various types of laryngeal stents.
From top to bottom: Knight, Conley, and Montgomery.
Additional stents have been described by Pennington
and others. A section of Portex endotracheal tube can
be fashioned by heating a tube in the autoclave and
flattening the anterior portion with a clamp, thus
shaping it to the configuration of the intrinsic larynx.
B Reduction and fixation with wire or nylon is done
of fractured thyroid and cricoid cartilages. This is
approached through a horizontal incision. Low
tracheostomy is performed through a separate hori-
zontal incision.
C Repair of laceration of mucous membrane of larynx
is done using fine absorbable sutures. The approach is
THE lARYNX
D
through a standard laryngofissure (see Fig. 20-9A to
D); a low tracheostomy is performed through a
separate horizontal incision.
D Avulsion of cricotracheal continuity with fracture
of cricoid cartilage is shown (after Chodosh, 1968).
The cricoid fracture is repaired with stainless steel wire.
Reapproximation of cricotracheal continuity can be
made using wire. A stent (Portex or Silastic) is placed
across the anastomoses. AT-tube stent (Montgomery)
can also be used, thus obviating a tracheostomy tube.
The problem with this tube is suctioning to maintain
patency. The site of the tracheostomy must be as low
as possible and preferably through a separate hori-
zontal incision. Meyer has designed a T tube with the
horizontal arm curved as a standard tracheostomy
tube. It is made of Portex, which can be warmed and
made thus quite pliable for ease of insertion. The
curved horizontal arm facilitates suctioning in the
distal vertical arm. The proximal arm, however, cannot
be suctioned.
 THE LARYNX
Laryngeal Trauma (Continued)
(See Figs. 20-25 to 20-28) (After Fitz-Hugh
et ai., 1962; Ogura, 1971; Montgomery,
1963; and Pennington, 1964)
The top of such stents can be pinched closed to
prevent aspiration.
Chronic
Pathologic Anatomy-Classification
1. Supraglottic
a. Epiglottis displaced posteriorly: lacerated
b. Aryepiglottic fold lacerations with cicatrix
c. Cricoarytenoid dislocation or fixation (This could
be classified under glottic.)
2. Glottic
a. Scarring and webs of vocal cords or ventricular
bands (Ventricular bands could be included under
supraglottic.)
b. Vocal cord paralysis
3. Subglottic
a. Web: incomplete, complete
b. Cricoid or tracheocricoid stenosis
4. Combination of above, especially 1 and 2 and 2
and 3.
Management
1. Supraglottic (see Fig. 20-26)
a. lnfrahyoid or trans hyoid exposure is used.
b. Resect scar tissue and reshape anatomy as nearly
normal as possible. This may require:
1) Excision of part or all of epiglottis or aryepiglot-
tic fold
2) Arytenoidectomy if dislocated and fixed: eval-
uation of motility may not be possible pre-
operatively; hence, lightening anesthesia may
give some clue as to motility. If there is the
slightest motion on indirect laryngoscopy, do
not remove arytenoid at this time. Fix remain-
ing portion of vocal cord (vocal process)
laterally to thyroid ala if arytenoidectomy is
performed.
3) Cover bare areas with thin local mucosal flaps
if possible or free mucosal grafts (buccal wall,
nasal septal mucosa). Do not use epidermal
grafts. Avoid bulk, which could cause obstruc-
tion.
4) Laryngeal stent with or without tracheal exten-
sion is almost always necessary except possi-
bly in posterior commissure web. The mucosal
graft can be directly sewn in the defect or fixed
around a sten!.
5) Laryngeal keel is used as indicated. A keel may
be necessary after removal of a sten!.
2. Glottic
a. A horizontal skin incision is used.
b. Explore thyroid and cricoid cartilage: if badly
deformed, correct and realign with No. 32 stain-
less steel wire or nylon.
c. Laryngofissure (thyrotomy) is done for explora-
tion and operative approach.
d. Resect scar tissue.
1) Close with local mucous membrane flaps if
possible, for example, at posterior commis-
sure using superiorly based mucosal flap
(Montgomery, 1963) (see Fig. 20-29).
2) Free mucosal grafts (buccal or septal) may be
sutured directly into the defect or fixed around
a sten!, or vein grafts can be used (Tabb and
Kirk, 1962).
e. Laryngeal stent or keel is used depending on defor-
mity. Pennington (1964) has designed a stent with
horizontal fins to fit into the ventricle in cicatriza-
tion of ventricular bands. Anterior commissure web
requires a keel; posterior commissure may not
require a stent if mucous membrane flap is used.
f. Arytenoidectomy is done with or without fixation
of vocal process to thyroid ala.
g. Low tracheostomy is performed.
3. Subglottic (see Fig. 20-28)
a. Approach is endolaryngeal, transtracheal, or trans-
cricoid, depending on pathologic anatomy.
b. Use en dolaryngeal approach for subglottic incom-
plete webs: remove with forceps and use stent.
Dilations are usually required.
c. Transtracheal or trans cricoid approach is used if
there is stenosis and it is circumferential or nearly
so. Excision is done of a major portion of the lower
section of the cricoid or the upper one or two
tracheal rings as indicated. Trachea or larynx is
mobilized for end-to-end anastomoses. Stent and
low tracheostomy are necessary (see Fig. 19-6).
d. If only a small area of the anterior portion of the
cricoid is deformed, this can be resected and the
area can be closed with thyroid cartilage flap
(Lapidot) (see Fig. 20-28F). Stent and low tra-
cheostomy are necessary.
 THE lARYNX

A B

FIGURE 20-26

e. Arytenoidectomy: approach can be external or via Supraglottic (Fig. 20-26)

laryngofissure depending on approach used for
other deformities. A Mirror laryngoscopy view of supraglottic stenosis
f. Laryngotracheal stent is necessary. These may have
caused by injury of epiglottis and wall of hypophar-
to be fashioned from Portex or silicone. T tube
ynx. The epiglottis is displaced posteriorly and
(Montgomery, 1963) is useful, as is the Meyer tube.
adherent to the pharynx. The dotted area is to be
excised.
Highpoints
B Lateralview of the pathologic change shows dotted
1. Essentially, management of the sequelea of
area to be excised.
laryngeal trauma is similar to that for acute trauma. Continued
2. Subperichondrial dissection of cricoid cartilage is
done to avoid injury to recurrent laryngeal nerves.
3. Mobilization of trachea or release of larynx is done
as necessary for subglottic resection (see Figs. 19-4
and 19-5A to C).
 THE lARYNX

Laryngeal Trauma (Continued)

(See Figs. 20-25 to 20-28) (After Fitz-Hugh
et aI., 1962; Ogura, 1971; Montgomery,
1963; and Pennington, 1964)
C Approach is shown through a transhyoid or
infra hyoid pharyngotomy (see Fig. 21-4A and B). The
area of scarring, major portion of epiglottis, and por-
tion of pharynx are to be excised (area encompassed
by dotted line).
D Excised bare area is shown. As much of this bare
area is closed by thin local flaps or thin free mucosal or
vein graft as possible (Tabb and Kirk, 1962). Caution:
Minimal mobilization or no mobilization of pyriform
sinus mucosa is preferred; do not use any type of
skin graft because of danger of obstruction due to
sebum.

c o
FIGURE 20-26 Continued
 THE LARYNX

Glottic (Fig. 20-27)

B The scar has been excised and a superiorly based
Correction of anterior commissure web with the use of mucous membrane flap is mobilized from the poste-
a laryngeal keel is depicted in Figure 20-29. rior aspect of interarytenoid area and cricoid (after
Montgomery, 1963). A stent is usually not necessary.

A Posterior commissure scar is shown.

FIGURE 20-27
 THE LARYNX
Laryngeal Trauma (Continued)
(See Figs. 20-25 to 20-28) (After Fitz-Hugh
et aI., 1962; Ogura, 1971; Montgomery,
1963; and Pennington, 1964)
Subglottic (Including Cricoid- Tracheal Region)
(Fig. 20-28)
A Depicted is a subglottic web secondary to an
endotracheal tube. The scar tissue is excised endo-
laryngeally along the dotted line. A stent is inserted,
and a tracheostomy is performed. Subsequent dilations
are usually required.
B Complete subglottic stenosis is associated with
severe tracheal and cricoid injury.
C Lateral schematic view of stenotic area is shown.
D, E Area to be resected is the circumferential lower
portion of the cricoid cartilage and the first tracheal
ring. It is important that a subperichondrial dissection
of the cricoid cartilage be performed to avoid injury to
the recurrent nerves. Mobilization of the trachea is
performed anteriorly and posteriorly. The lateral
attach-ments are associated with the blood supply and
should not be interrupted (see Fig. 19-4). If too much
scar tissue prevents this maneuver, the larynx may be
dropped with supralaryngeal release (see Fig. 19-5A to
C) (Dedo and Fishman, 1969). Approximation of trachea
to the remaining cricoid and thyroid cartilages is done
with No. 32 stainless steel wire.
F Depicted is the technique of Lapidot, used in one
patient with the isolated injury of an anterior portion
of the cricoid cartilage. The deformed anterior portion
of the cricoid is excised, and a thyroid cartilage (with
perichondrium) inferiorly hinged flap is dropped into
position to close the defect.
Another technique is the use of a portion of the
hyoid bone as a free or a muscle-pedicled hyoid bone
graft to fill in a defect of the cricoid cartilage and/or
the first and/or the second tracheal ring anteriorly. The
muscle-pedicled graft is designed so that the portion
of the hyoid bone utilized is left attached to the sterno-
hyoid muscle. The blood supply to the muscle should
be preserved as much as possible. The problem with
free bone or cartilage grafts and even pedicled grafts
is infection along with avascular necrosis.
In addition to cricoid-tracheal resection, other methods
are available to treat cricoid-tracheal stenosis, depend-
ing on the location and extent of the stenosis. Two such
techniques are the following:
I. Endoscopic removal of small noncircumferential scar
a. Surgical forceps
b. CO2 laser
Ossoff et al. (1985) described three stages of tracheal
stenosis:
1) Granulation stage
2) Limited scarring
3) Extensive scarring
He believes that the CO2 laser is useful in stages I
and 2 but not in stage 3. It is of virtually no value in
complete thick circumferential scars of the trachea.
2. Modified technique of Evans and Todd
3. The trachea is exposed via an external cervical hori-
zontal incision. The trachea is then explored by
transecting each tracheal cartilage ring alternating
from right to left laterally. This results in an alter-
nating long cartilage ring at each ring level. The scar
tissue is resected. The long ends of the cartilaginous
rings are now sutured end to end (e.g., the long end
of tracheal ring No. I is sutured to the long end of
tracheal ring No.2). The short ends are not
approximated. This method is especially adaptable
to the short-necked individual with an existing
tracheostomy.
4. For techniques of tracheal resection see Chapter 19.
5. The patency of the cricoid-tracheal reconstruction
can be evaluated with a 70-degree Hopkin rod (Karl
Storz) passed through the tracheostomy site.
 THE LARYNX

A B

o E

FIGURE 20-28
 THE LARYNX
Correction of Laryngeal Web
(Fig. 20-29)
Technique of McNaught (1950)
A Webbing of the anterior commissure of the true
vocal cords is shown. The larynx is exposed through
the laryngofissure approach, and the web is incised. If
large, it is excised.
B To prevent re-formation, a laryngeal keel made of
tantalum plate or Silastic is inserted according to the
technique of McNaught. A tracheostomy is preferred.
C The keel in position between the vocal cords. The
posterior edge of the keel is 1.0 to 1.5 em short of the
posterior commissure, which it must not reach.
D The thyrotomy incision is closed, and the keel is
anchored to the outer perichondrium of the thyroid
cartilage with several sutures of 3-0 chromic catgut. The
Silastic keel (Montgomery, 1963) is removed through
an external approach when endolaryngeal healing is
entirely complete. A nylon suture that secures the keel
in place is left protruding through the skin for ease of
location at the time of removal.
The COzlaser (with a small spot size) has been utilized
via a laryngoscope, as described by Ossoff et al. (1985).
The author has experienced the formation of a web after
CO2 laser treatment of papillomatosis at the anterior
commissure. The resulting web has been very small
and did not bother the patient.
Technique of Frazer (1968)
Highpoints
1. External incision is not necessary.
2. Tracheostomy is usually not necessary.
3. Be sure plastic sheet fits through the laryngoscope.
This method of treating a small web at the anterior
commissure utilizes a straight piece of tantalum or prefer-
ably a flat plastic material such as a Teflon sheet or
Silastic. Although this basic technique has been described
by others, the technique of Frazer seems to be the sim-
plest method. The anteroposterior width of the sheet of
Teflon is determined on a laryngogram with a metallic
ruler over the thyroid cartilage on the outside of the
neck, which serves to estimate the correction factor.
This width is also calculated on measurement obtained
at the time of direct laryngoscopy. In any event, the
sheet does not reach the posterior commissure. The
cephalocaudad length of the sheet is from 2 to 3 mm
longer than the distance between the cricothyroid liga-
ment below and the thyrohyoid membrane above. Holes
are made in the sheet corresponding to the site of
needle puncture in the cricothyroid and thyrohyoid
membrane.
E An anterior commissure web has already been
removed either with a Holinger knife or by a laryngeal
web forceps. With a laryngoscope in place, two 20-
gauge needles are inserted through the cricothyroid
and thyrohyoid membrane. Through the needles are
passed No. 25 stainless steel wires, which in turn are
grasped and pulled through the laryngoscope. It is
important to identify and to separate the upper and
lower wires and to secure them properly in the upper
and lower ends of the Teflon sheet. Care must be taken
that the wire does not cut or tear the sheet. The needles
are then removed, and the wire is gently but firmly
secured over a gauze pad soaked with suitable antibiotic
ointment or over a Silastic guard. During this maneu-
ver, positioning is checked through the laryngoscope.
F The Teflon sheet is in position. Evaluation of progress
of epithelialization as well as position of the sheet is
checked frequently by indirect laryngoscopy. Removal
of the sheet is performed through direct laryngoscopy
when healing is complete, usually in 6 weeks.
G Tracheostomy is usually not necessary. However, if
there is any question regarding airway patency, a con-
comitant tracheostomy is performed and then may be
corked postoperatively as conditions warrant.
Persistent granulation tissue may be vaporized by
laser.
Aspiration
Of all the complications and rehabilitation problems
associated with head and neck surgery and trauma,
aspiration and dysphagia are among the most formi-
dable. Both of these are at times closely related, and
their treatment is interrelated and dependent on the
cause.
Aspiration is thus a complication of direct trauma,
neuromuscular dysfunction, surgery of the upper aero-
digestive tract, radiotherapy, tracheostomy, tracheo-
esophageal fistula planned or unplanned, esophageal
obstruction, and other innumerable causes.
The management is diverse and depends on the
cause, the anticipated duration of the symptoms, and
the cooperation and abilities of the patient as well as
whether reversibility might be possible. Surgical judg-
ment is as important as the cause.
 THE LARYNX

A B c

FIGURE 20-29
 THE LARYNX
Rehabilitation using the aid of a deglutition expert
may be the initial step. Evaluation with a barium
swallow on video fluoroscopy is a sine qua non before
most of the following procedures. This follows the
technique of Logemann.
Prevention of aspiration when anticipated with a con-
comitant surgical procedure (e.g., a horizontal partial
laryngectomy or resection of the hypopharynx and/or
base of the tongue with preservation of the larynx) can
at times be achieved by performing a number of the
procedures that are listed as follows.
Methods
1. Cuffed tracheostomy tube: temporary, can induce
esophageal obstruction and in turn aggravate the
aspiration at times
2. Supraglottic closure
a. Suture the epiglottis to the posterior part of the
hypo pharyngeal wall.
b. Epiglottic flap sutured to the arytenoids.
c. Approximation of aryepiglottic folds: closure can
break down and leak.
3. Glottic
a. A stripping of the vocal cords and suture approxi-
mation (see Fig. 20-5). This author has had excel-
lent results when this is combined with the resec-
tion of the hypopharynx and base of the tongue,
because exposure was excellent. However, it has
failed on two occasions via a laryngoscope uti-
lizing Kleinsasser's special ligature carriers. The
sutures pulled through. Montgomery's approach
is through a laryngofissure. Sasaki and colleagues
(1980) added to Montgomery's procedure a supe-
rior based sternohyoid muscle flap for closure at
the posterior commissure.
b. Teflon or Gelfoam is injected into the vocal cords.
Relatively poor results occur because of difficulty
in closure at the posterior commissure when both
cords are paralyzed or fixed in the abducted position.
c. A specially designed stent with a one-way valve
for the trachea and larynx is inserted. Experience
is limited to one patient, who, although the pro-
cedure appeared to function satisfactorily, was
not satisfied with the device owing to alleged
infection.
4. Cricopharyngeal myotomy. Reasonably good results
are obtained when spasm or failure of this muscle to
function normally is the etiologic factor.
5. Suspension of larynx (Calcaterra)
6. Tracheal diversion
a. Tracheoesophageal fistula (Lindeman, 1975). The
author has no experience with this procedure.
b. Separation of the larynx and trachea. Baron and
Dedo (1980) describe this as being performed
through the first tracheal ring by incising the ring
anteriorly in the midline, with approximation of
the two lateral portions of the sectioned ring with
a midline closure. The distal trachea via the second
tracheal ring is sutured to the skin as a trache-
ostomy. The author has utilized this procedure on
one patient with a preexisting tracheostomy, and
the procedure has worked satisfactorily. The only
modification was the selection of the second tra-
cheal ring rather than the first tracheal ring, thus
sparing the cricoid cartilage of possible chondritis.
The theoretical contradiction to the procedure is a
blind pouch. Dissection of the posterior mem-
branous wall of the trachea may not be feasible
because of scarring, and this need not be done if
the lining mucosa of the posterior wall is scari-
fied. Leakage will occur until scarring occurs.
7. Laryngectomy. This is rather drastic unless all else
has failed.
8. A feeding gastrostomy or feeding tube is indicated
if the patient can handle saliva and is not able to
swallow food.
In any of these procedures, which conceivably could
be reversible, preservation of the recurrent laryngeal
nerve is of paramount importance. Undesirable and
unintentional tracheoesophageal fistula is likewise to
be avoided.
Carbon Dioxide Laser (See p. 1077)
This modality can be used in the treatment of limited
types of obstructive scars and webs, provided there is
adequate structural support for the remaining soft
tissue. Vaporization with ablation or the use of a small
spot excision technique can be used depending on the
size, location, and extent of the deformity. The CO2
laser has no application in the treatment of 360- degree
circumferential stenosis, for example, of the trachea or
esophagus, and it is only of limited use when the obstruc-
tion is 180 degrees. The problem with this modality is
that it, in itself, can form scar tissue, especially when a
scar is the object of the treatment. A good substitute for
the CO2 laser is the standard Bovie cauterizing current,
which has been used successfully in ablating small
areas of hypertrophic mucosa but not for circumfer-
ential scar.
BIBlioe RAPHY
Abelson TI, Tucker HM: Laryngeal findings in superior laryngeal nerve
paralysis: A controversy. Otolaryngol Head Neck 5urg 89:463-470,
1981.
Abramowski CR, Witt W: Sarcoma of the larynx in a newborn. Cancer
52:1726-1730,1983.
Abramson AL, Parisier 5C, Zamansky MJ, 5ulka M: Distant metas-
tases from carcinoma of the larynx. Laryngoscope 81:1503-]511,
1971.

AJCC Cancer Staging Handbook, Sth ed. Philadelphia, Lippincott-
Raven, 1998.
Alonzo JM: Conservative surgery of cancer of the larynx. Trans Am
Acad Ophthalmol Otolaryngol 51:633-642,1947.
Arnold GE: Some complications of intracordal Teflon injection.
Excerpta Medica International Congress Series No. 206, Oto-Rhino-
Laryngology. Proceedings of the Ninth International Congress,
Mexico City, August 1969.
Aronson AE, DeSanto LW: Adductor spastic dysphonia: One and one
half years after recurrent laryngeal nerve resection. Ann Otol Rhinol
Laryngol 90:2-6, 1981.
Aronson AE, DeSanto LW: Adductor spastic dysphonia: Three years
after recurrent laryngeal nerve resection. Laryngoscope 93:1-8,1983.
Asai R: Asai's laryngoplasty: A technique permitting voice production
after laryngectomy. Eighth International Congress of Olo-Rhino-
Laryngology. Tokyo, Japan, October, 1965.
Bailey BJ: Partial laryngectomy and laryngoplasty. Laryngoscope
81:1742-1771,1971.
Bailey BJ: Partial laryngectomy and laryngoplasty. Presented at the
74th Annual Meeting of the American Laryngological, Rhinological
and Otological Society. San Francisco, May 25, 1971.
Bailey BJ, Biller HF: Surgery of the Larynx. Philadelphia, WB Saunders,
1985, pp. 270-274.
Bailey BJ, Calcaterra TC: Vertical, subtotal laryngectomy and laryngo-
plasty: Review of experience. Arch Ololaryngol 93:232-237, 1971.
Baker DC Jr: Chronic laryngeal stenosis. Ann 010178:751,1969.
Baker HW: Surgical management of recurrent laryngeal cancer after
irradiation. Cancer 16:774, 1963.
Baker SR, Ross J: Sleep apnea syndrome and supraglottic edema. Arch
Otolaryngol 106:486-491, 1980.
Ballantyne AJ: Significance of retropharyngeal nodes in cancer of the
head and neck. Am J Surg 108:500-504, 1964.
Baluyot ST Jr, Shumrick DA, Everts EC: "Emergency" laryngectomy.
Arch Ololaryngol 94:414-417, 1971.
Bardwil JM: Cancer of the vocal cord. Cancer 29:31-34, 1972.
Baron BC, Dedo HH: Separation of the larynx and trachea for intract-
able aspiration. Laryngoscope 90: 1927-1932, 1980.
Bartalemeo JR: The argon and CO2 lasers in otolaryngology: Which
one, when and why? Laryngoscope SuppI26:1-16, 1981.
Baxter 10: Acute epiglottitis in children. Laryngoscope 77:1358-1367,
1967.
Benjamin B: Technique of laryngeal photography. Ann 0101 Rhinol
Laryngol 93:1-11, 1984.
Benjamin B, Carter P: Congenital laryngeal hemangioma. Ann Otol
Rhinol Laryngol 92:448-455,1983.
Bennett M: Laryngeal blastomycosis. Laryngoscope 74:498-512,1964.
Bennett SH, Futrell JW, Roth JA, et al: Prognostic significance of
histologic host response in cancer of the larynx or hypopharynx.
Cancer 28:1255-1265, 1971.
Biller HF, Davis WH, Ogura JH: Delayed contralateral cervical metas-
tases with laryngeal and laryngopharyngeal cancers. Laryngoscope
81:1499-1502, 1971.
Biller HF, Harvey JE, Bone RC, Ogura JH: Laryngeal edema: An
experimental study. Ann Otol 79:1084, 1970.
Biller HF, Ogura JH, Bauer we: Verrucous cancer of the larynx.
Laryngoscope 81:1323-1329, 1971.
Biller HF, Ogura JH, Davis WH, Powers WE: Planned pre-operative
irradiation for carcinoma of the larynx and laryngopharynx treated
by total and partial laryngectomy. Laryngoscope 79:1387-1395,
1969.
Biller H, Ogura JH, Pratt LL: Hemilaryngectomy for T2 glottic cancers.
Arch Otolaryngol 93:238-243, 1971.
Sirek HG: Endoscopic repair of laryngeal stenosis presentation. Am
Acad Ophthalmol Otolaryngol, October 1969.
Blair RL, Berry H, Briant TOR: Laryngeal electromyography-
techniques, applications, and a review of personal experience.
J Otolaryngol 6:496-504, 1977.
THE LARYNX
Blom ED, Singer MI, Hamaker RC: Tracheostoma valve for postlaryn-
gectomy voice rehabilitation. Ann Otol Rhinol Laryngol 91:576-578,
1982.
Boles R, Fritzell B: Injury and repair of the recurrent laryngeal nerves
in dogs. Laryngoscope 79:1405-1418, 1969.
Bolivar R, et al: Aspergillus epiglottitis. Cancer 51:367, 1983.
Booth lB, Birck HG: Operative treatment and postoperative management
of saccular cyst and laryngocele. Arch Ololaryngol 107:500-502,
1981.
Boyle WF, McCoy EG, Fogarty WA: Electron microscopic identification
of virus-like particles in laryngeal papilloma. Ann Otol 80:693,
1971.
Boyles JH Jr: Lacerations of the larynx. Arch OtolaryngoI87:422-424,
1968.
Brandenburg JH: Vocal rehabilitation after laryngectomy. Arch
Otolaryngol 106:688-691, 1980.
Briant TOR: Spontaneous pharyngeal fistula and wound infection
following laryngectomy. Laryngoscope 85:829-834, 1975.
Brodofsky OM: Laryngeal tuberculosis in an age of chemotherapy.
Can J OtolaryngoI4:168-176, 1975.
Brophy JW, Scully PA, Stratton CJ: Argon laser use in papillomas of
the larynx. Laryngoscope 92:1164-1167, 1982.
Brummitt WM, Fearon B, Brama I: Anesthesia for laryngeal laser sur-
gery in the infant and child. Ann Otol Rhinol Laryngol 90:475-477,
1981.
Bryce DP, Rider WD: Preoperative irradiation in the treatment of
advanced laryngeal carcinoma. Laryngoscope 81:1481-1490,1971.
Burgess GE, Lejeune FE: Endotracheal tube ignition during laser sur-
gery of the larynx. Arch OtolaryngoI105:561-562, 1979.
Buschke F, Vaeth JM: Radiation therapy of carcinoma of the vocal cord
without mucosal reaction. AJR Am J Roentgenol 89:29-34, 1963.
Butler RM, Moser FH: The padded dash syndrome: Blunt trauma to
the larynx and trachea. Laryngoscope 78:1172-1182,1968.
Calcaterra TC: An evaluation of the treatment of subglottic heman-
gioma. Laryngoscope 78: 1956-1964, 1968.
Calcaterra TC: Laryngeal suspension after supraglottic laryngectomy.
Arch Ololaryngol 94:306-309, 1971.
Calearo CV, Caroggio A: Total laryngectomy with tracheopharyngeal
fistula (neoglottis). Ann Otol Rhinol Laryngol 90:217-221,1981.
Canalis RF, Jenkins HA, Osguthorpe 10: Acute laryngeal abscesses.
Ann Otol Rhinol Laryngol 88:275-279, 1979.
Catlin D, Harrold C: Making a large tracheal stoma during laryngec-
tomy. Eye Ear Nose Throat Monthly 45:87-90, 1966.
Chodosh PL: Cricoid fracture with tracheal avulsion. Arch Ololaryngol
87:46] -467, 1968.
Clerf LH: The surgical treatment of bilateral posticus paralysis of the
larynx. Laryngoscope 60:142,1950.
Cocke EW Jr (moderator), Tardy ME Jr, DeSanto LW, Strong MS
(panelists]: Microscopic laryngeal surgery. Presented before the
Fifty-Seventh Annual Clinical Congress, American College of
Surgeons, Atlantic City, ] 971.
Cody CC III: Laryngocele: Diagnosis and management with case report.
Eye Ear Nose Throat Monthly 44:68-72, ]965.
Cohen SR: Congenital atresia of the larynx with endolaryngeal sur-
gical correction: A case report. Presented at the 74th Annual Meet-
ing of the American Laryngological, Rhinological and Otological
Society, San Francisco, May 1971.
Colman MF, Schwartz I: The effect of vocal cord paralysis on the
cricoarytenoid joint. Otolaryngol Head Neck Surg 89:419-422, 1981.
Conley JJ: Vocal rehabilitation by autogenous vein graft. Ann Otol
Rhinol Laryngol 68:990-995, 1959.
Conley JJ: The use of mucosal flaps for wound rehabilitation in par-
tiallaryngectomy. Arch Otolaryngol 69:700-703, 1959.
Cotton RT, Evans JNG: Laryngotracheal reconstruction in children.
Ann Otol Rhinol Laryngol 90:516-520, ]981.
Crumley RL, McCabe BF: Regeneration of the recurrent laryngeal nerve.
Otolaryngol Head Neck Surg 90:442-447, 1982.
 THE LARYNX
Cummings CW, Montgomery WW, Balogh K Jr: Neurogenic tumors
of the larynx. Ann Otol 78:76, 1969.
Daly JF: Relapsing polychondritis of the larynx and trachea. Arch
Ololaryngol 84:570-573, 1966.
Dayal VS, Bahri H, Stone PC: Preepiglottic space: An anatomic study.
Arch Ololaryngol 9S:130-133, 1972.
Dayal VS, Joy MLG, Moon RE, et al: Endotracheal artificial larynx.
Ann Otol Rhinol Laryngol (Suppl) 95:1-32, 1982.
Dedo HH: Supraglottic laryngectomy, indications and techniques.
Laryngoscope 78:1183-1194, 1968.
Dedo HH: The paralyzed larynx: An electromyographic study in dogs
and humans. Laryngoscope 80:1455-1517,1970.
Dedo HH, Fishman NH: Laryngeal release and sleeve resection for
tracheal stenosis. Ann 0101 78:285-296, 1969.
Dedo HH, lzdebski K: Intermediate results of 306 recurrent laryngeal
nerve sections for spastic dysphonia. Laryngoscope 93:9-16,1983.
DeSanto LW,Carney FMT:Microlaryngoscopic surgery. Arch Otolaryngol
91:324-326, 1970.
Devine KD: Laryngectomy. Arch Otolaryngol 78:100, 1963.
Devine KD: Sarcoidosis and sarcoidosis of the larynx. Laryngoscope
75:533-569, 1965.
Diamant H, Schiratzki H: Chronic fibrosis of the subglottic space and
possibly the paranasal sinuses and tympanic cavities. Laryngoscope
79:355-367, 1969.
Donegan JO, Strife JL, Cotton RT, et al: Internal laryngocele and sac-
cular cysts in children. Ann Otol Rhinol LaryngoI89:409-413, 1980.
Doyle PJ: Repair of supraglottic laryngeal stenosis with postcricoid
involvement. Ann Otol Rhinol Laryngol 89:576-577, 1980.
Doyle PJ, Brummett RE, Everts EC: Results of surgical section and repair
of the recurrent laryngeal nerve. Laryngoscope 77:1245-1254,1967.
Dubick MN, Wright BD: Problems with prolonged endotracheal intu-
bations. Chest 74:479-480, 1978.
Dworkin JP, Sparker A: Surgical vocal rehabilitation following total
laryngectomy: A state-of-the-art report. Clin 0l0IaryngoI5:339-350,
1980.
Eisenman TS, Ossoff R: Anesthesia for bronchoscopic laser surgery.
Otolaryngol Head Neck 5urg 94:45, 1986.
Eliachar I, Moscona AR: Reconstruction of the laryngotracheal complex
in children using the sternocleidomastoid myocutaneous flap. Head
Neck Surg 4:16-21, 1981.
Feder BH, Schaeflein JW, Stein JJ: Early carcinoma of the vocal cords.
Kilovoltage results; Telecobalt 60 dosimetry (a preliminary report).
AJR Am J Roentgenol108:269-277, 1970.
Finn DG, Farmer JC: Management of amyloidosis of the larynx and
trachea. Arch Otolaryngol 108:54-56, 1982.
Fitz-Hugh GS: Management of recent injuries to the larynx and cervical
trachea. Instruction section. Presented before the American Academy
of Ophthalmology and Otolaryngology, Las Vegas, 1971.
Fitz-Hugh GS, Wallen born WM, McGovern F: Injuries of the larynx
and cervical trauma. Trans Am Laryngol Assoc 83:43, 1962.
Fletcher GH, Jesse RH, Lindberg RD, Koons CR: The place of radio-
therapy in the management of the squamous cell carcinoma of the
supraglottic larynx. AJR Am J Roentgenol108:19-26, 1970.
Fletcher GH, Lindberg RD, Jesse RH Jr: Radiation therapy for cancer
of the larynx and pyriform sinus. Eye Ear Nose Throat Dig 31:
58-67,1969.
Flores TC, Wood BG, Koegel L, et al: Factors in successful deglutition
following supraglottic laryngeal surgery. Ann 0101 Rhinol Laryngol
91:579-583, 1982.
Frazer JP: Treatment of thin laryngeal webs with suspended metallic
plates. Trans Am Acad Ophthalmol Otolaryngol 72:581-587, 1968.
Fried MP: Complications of CO2 laser surgery of the larynx. Presented
at the Postgraduate Course on Complications Honoring Dr. Joseph
H. Ogura, Washington University School of Medicine, St. Louis,
March 26, 1981.
Friedman M, Toriumi 0, Grybauskas V, Katz A: Nonrecurrent laryngeal
nerves and their clinical significance. Laryngoscope 96:87-90, 1986.
Futrell JW, Bennett SH, Hoye RC, et al: Predicting survival in cancer
of the larynx or hypopharynx. Am J Surg 122:451-457, 1971.
Gates GA, Fernandez AT:Laryngotracheoplasty for acquired subglottic
stenosis in infants and children. Presented at the Southern Section
Meeting of the American Laryngological, Rhinological, and Otological
Society, Inc. Houston, January 13, 1978.
Gilmer WS, Arnold GE, Stephens CB: Vocal cord position in laryngeal
paralysis. Arch OtolaryngoI91:575-580,1970.
Gindhart TD, Johnston WH, Chism SE, Dedo HH: Carcinoma of the
larynx in childhood. Cancer 46:1683-1687, 1980.
Giovanniello J, Grieco RV, Bartone NF: Laryngocele. AJR Am J
RoentgenoI108:825-829, 1970.
Gnepp DR, Ferlito A, Hyams V: Primary anaplastic small cell (oat cell)
carcinoma of the larynx. Cancer 51:1731-1745, 1983.
Goldman JL, Gunsberg MJ, Friedman WH, et al: Combined therapy
for cancer of the laryngopharynx. Arch Otolaryngol 92:221-225,
1970.
Gordon JH, McCabe BF: The effect of accurate neurorrhaphy on rein-
nervation and return of laryngeal function. Laryngoscope 78:236-250,
1968.
Griffiths CM: Neoglottic reconstruction after total laryngectomy. Arch
0l0IaryngoI106:77-79, 1980.
Griffiths CM, Love JT: Neoglottic reconstruction after totallaryngec-
tomy. Ann 0101 Rhinol Laryngol 87:180, 1978.
Gross CW, Crocker TR: Current management of juvenile laryngeal
papillomata. Laryngoscope 80:532-543, 1970.
Gross CW, Gros JC: Rare complications after prolonged translaryngo-
tracheal intubation. Ann Otol 80:582-584, 1971.
Habal MA: Surgical treatment of life endangering chronic aspiration.
J Plast Reconstr Surg 49:305-311, 1972.
Haglund S, Lundquist P, Cant ell K, Strander H: Interferon therapy in
juvenile laryngeal papillomatosis. Arch Otolaryngol 107:327-332,
1981.
Hahn FW Jr, Martin JT, LillieJC: Vocal-cord paralysis with endotracheal
intubation. Arch Otolaryngol 92:226-229, 1970.
Haraguchi S, Sasaki CT, Fung RQ: Effect of hyperthermia on the
laryngeal closure reflex. Implications in the sudden death syndrome.
Ann 0101 Rhinol Laryngol 92:24-28, 1983.
Harrer WV, Lewis PL: Carcinoma of the larynx with cardiac metas-
tases. Arch Otolaryngol 91:382, 1970.
Harris CS, et al: Childhood asphyxiation by food. JAMA 251:2231-2235,
1984.
Harris HH, Ainsworth JZ: Immediate management of laryngeal and
tracheal injuries. Transactions of the American Laryngology,
Rhinology and Otology Society, 1965, p 207.
Harris HH, Butler E: Surgical limits in cancer of the subglottic larynx.
Arch Otolaryngol 87:490-493, 1968.
Harris HH, Tobin HA: Acute injuries of the larynx and trachea in 49
patients (observations over a IS-year period). Laryngoscope
80:1376-1384,1970.
Harris HS Jr, Watson FR, Spratt JS Jr: Carcinoma of the larynx: A
retrospective study of 144 cases. Am J Surg 118:676-684, 1969.
Harrison OFN: The pathology and management of subglottic cancer.
Ann 0101 80:6-12,1971.
Harrold CC: Personal communication cited by Catlin D: Making a large
tracheal stoma. Eye Ear Nose Throat Monthly 45:87-90, 1966.
Hawkins DB, Luxford WM: Laryngeal stenosis from endotracheal
intubation. Ann Otol Rhinol Laryngol 89:454-458, 1980.
Hayes TP, Atkins JP, Raventos A: Carcinoma of the larynx: Diagnosis
and treatment by surgery or irradiation. Ann Otol 80:627,1971.
Hedden M, Ersoz CJ, Donnelly WH, Safar P: Laryngotracheal damage
after prolonged use of orotracheal tubes in adults. JAMA 207:703-708,
1969.
Helsper J: Helsper laryngectomy stoma button. Personal communica-
tion.
Hendrickson FR: Radiation therapy treatment of larynx cancers.
Cancer 55:2058-2061, 1985.

Hilding AC: Laryngotracheal damage during intratracheal anesthesia:
Demonstration by staining the unfixed specimen with methylene
blue. Ann Otol 80:565-581, 1971.
Hiranandani LH: Tongue as pedicle flap for reconstruction of pharynx
in one-stage laryngopharyngectomy. Rev Laryngol (Bordeaux] 1-2:
February i967.
Hirano M: A technique for glottic reconstruction following vertical
partial laryngectomy. Auris Nasus Larynx 5:63-70, 1978.
Hiroto I, Hirano M, Tomita H: Electromyographic investigation of
human vocal cord paralysis. Ann Otol 77:296, 1968.
Holinger LD: Etiology of stridor in the neonate, infant and child. Ann
Otol Rhinol Laryngol 89:397-400, 1980.
Holinger PC, Vuckovich DM, Holinger LD, Holinger PH: Bilateral
abductor vocal cord paralysis in Charcot-Marie-Tooth disease. Ann
Otol Rhinol Laryngol 85:205-209,1979.
Holinger PH, Brown WT: Congenital webs, cysts, laryngoceles and
other anomalies of the larynx. Ann Otol 76:744-752, 1967.
Holinger PH, Johnston KC, Schiller F: Congenital anomalies of the
larynx. Ann Otol 63:581, 1954.
Holinger PH, Schild JA, Maurizi DG: Laryngeal papilloma: Review of
etiology and therapy. Laryngoscope 78:1462-1474,1968.
Holley HS, Gildea JE: Vocal cord paralysis after tracheal intubation.
JAMA 215:281-284,1971.
Hoover WB: Bilateral abductor paralysis: Operative treatment by sub-
mucous resection of the vocal cords. Trans Am Laryngol Assoc
53:247-276,1931; Arch OtolaryngoI15:339-355, 1932.
Howell TR, Gildersleeve GA, King ER: The role of roentgenographic
studies in the evaluation and staging of malignancies of the larynx
and pharynx. AJR Am J Roentgenol102:138-144, 1968.
Imbrie JD, Doyle PJ: Laryngotracheoesophageal cleft: Report of a case
and review of the literature. Laryngoscope 79:1252-1274, 1969.
Jabaley ME, Hoopes JE: A simple technic for laryngeal suspension
after partial or complete resection of the hyomandibular complex.
Am J Surg 118:685-690, 1969.
Jako GJ, Kleinsasser 0: Endolaryngeal micro-diagnosis and micro-
surgery. Scientific Exhibition, 115th Annual Meeting of the American
Medical Association, Baltimore, June 1966.
Jesse RH, Lindberg RD, Horiot J-C: Vocal cord cancer with anterior
commissure extension: Choice of treatment. Am J Surg 122:437-439,
1971.
Johns ME, Farrior E, Boyd JC, Cantrell RW: Staging of supraglottic
cancer. Arch Otolaryngol 108:700-702, 1982.
Johnson JT, Chang J, Myers EN: "How I do it "-Head and neck and
plastic surgery: A targeted problem and its solution: Jet ventilation
for operative laryngoscopy. Laryngoscope 92:1194-1195,1982.
Johnson JT, et al: Cervical lymph node metastases. Arch Otolaryngol
111:534-537,1985.
Johnson TH Jr, Feist JH: Laryngography: The procedure of choice for
benign laryngeal lesions. AJR Am J RoentgenoI111:109-114, 1971.
Jones DG, Gabriel CE: The incidence of carcinoma of the larynx in
persons under twenty years of age. Laryngoscope 79:251-255,
1969.
Kaplan MJ, et al: Glottic carcinoma. Cancer 53:2641-2648, 1984.
Kartan MC, Ossoff RH: A new laser-laryngoscope coupler. Otolaryngol
Head Neck Surg 92:717-719,1984.
Kaufman S, Lore JM Jr: Classification and disease description: Head
and neck cancer. Am J Surg 136:469, 1978.
King BT:Improved technic in the King operation for relief of bilateral
vocal cord paralysis. In Jackson C, Jackson CL (eds): Diseases of
the Nose, Throat and Ear. Philadelphia, WB Saunders, 1945.
Kirchner FR:Suturing techniques in endolaryngeal surgery. Laryngoscope
91:1860-1864, 1981.
Kirchner FR, Smith SA, Toledo PS: Micro cryocauterization of papil-
lomas of the larynx. Trans Am Acad Ophthalmol Otolaryngol
75:S13-518,1971.
Kirchner FR, Toledo PS, Svoboda DJ: Studies of the larynx after
Teflon iniection. Arch Otolaryngol 83:350-3S4, 1966.
THE LARYNX
Kirchner JA: One hundred laryngeal cancers studied by serial section.
Ann Otol 78:689, 1969.
Kirchner JA, Cornog JL, Holmes RE: Transglottic cancer. Arch
Otolaryngol 99:247-251,1974.
Kirchner JA, Som ML: Clinical and histological observations on supra-
glottic cancer. Ann Otol 80:638-64S, 1971.
Kirchner JA, Som ML: Clinical significance of fixed vocal cord.
Laryngoscope 81:1029-1044, 1971.
Kitajima K, Tanabe M, Isshiki N: Cricothyroid distance and vocal pitch.
Ann Otol Rhinol Laryngol 88:52-55, 1979.
Kitamura T, et al: Supracricoid laryngectomy. A new technique for
vocal rehabilitation. From the Department of Otolaryngology, Chiba
University School of Medicine, Chiba, Japan.
Kleinsasser 0: Microlaryngoscopy and Endolaryngeal Microsurgery.
Philadelphia, WB Saunders, 1968.
Knight JS: Further effort for correction of severe, acute or chronic
laryngeal stenosis: Double post Teflon tube utilization. Ann Otol
75:392, 1966.
Knudson RJ, Hatch HB, Ochsner A, Lejeune FE: Multiple carcinomas
of the lung and upper respiratory tract. Dis Chest 48:140-144, 1965.
Kuehn PG, Tennant R: Surgical treatment of stomal recurrence in
cancer of the larynx. Am J Surg 122:445-450, 1971.
Laccourreye 0, Veivers D, Hans S, et al: Chemotherapy alone with
curative intent in patients with invasive squamous cell carcinoma
of the pharyngolarynx classified as Tl-T4 NOMOcomplete clinical
responders. Cancer 92: 1504-1511, 2001.
LambertJA: Microlaryngeal surgery. Arch LaryngoI94:1S1-152, 1971.
Lambert PR, Ward PM, Berci G: Pseudosarcoma of the larynx. Arch
Otolaryngol106:700-708, 1980.
Larson DL, Maxell R, Abston S, Dobrkovsky M: Zinc deficiency in
burned children. Plast Reconstr Surg 46:13-21, 1970.
Lawson HP: Bilateral abductor paralysis of the vocal cords. In Rob C,
Smith R (eds]: Operative Surgery: Eyes, Ears, Nose and Throat.
Philadelphia, FA Davis, 1959.
Lee SY: Surgical reconstruction with long-term stenting in the treat-
ment of chronic laryngotracheal stenosis. J Otolaryngol Soc Republic
China 18(Suppl I), December 1983.
Lefebvre JL, Chevalier D, Luboinski S, et al: Larynx preservation in
pyriform sinus cancer: Preliminary results of a EORTC phase lIt
trial. J Natl Cancer Inst 88:890-899, 1996.
Lejeune FE: Laryngotracheal separation. Laryngoscope 88:1956-1961,
1978.
Lell WA: Laryngeal tuberculosis. Arch Otolaryngol 60:350-366, 1954.
LeMay SR Jr: Penetrating wounds of the tarynx and cervical trachea.
Arch Otolaryngol 94:558-565, 1971.
Leopold DA: Laryngeal trauma: A historical comparison of treatment
methods. Arch Otolaryngol 109:106-112, 1983.
LeRoux RJ: Indications for radical surgery, partial surgery and com-
bined surgery for cancer of larynx. Ann Otol 6S:137, 1956.
LeRoux RJ: Indications for radical surgery, partial surgery, radiotherapy
and combined surgery and radiotherapy for cancer of the larynx
and hypopharynx. Ann Otol 65:137-153, 19S6.
Lewy RB: Teflon injection of the vocal cord: Complications, errors,
and precautions. Ann Otol Rhinol Laryngol 92:473-474, 1983.
Lewy RB: Responses of laryngeal tissue to granular Teflon in situ.
Arch Otolaryngol 83:355-359, 1966.
Lichti EL, Turner M, Henzel JH, DeWeese MS: Wound fluid zinc levels
during tissue repair: Sequential determination by means of surgi-
cally implanted Teflon cylinders. Am J Surg 121:665-667, 1971.
Lindeman R: Diverting the paralyzed larynx. Laryngoscope 35:152-180,
1975.
Lore JM: Practical anatomical considerations of the larynx.
Laryngoscope, September 1933.
Lore JM: Suggested modification of the laryngofissure operation. Ann
OtoI42:1205, 1933.
Lore JM: Stripping of the vocal cords. Laryngoscope 44:803-816,
1934.
 THE LARYNX
Lore JM: A suggested operative procedure for the relief of stenosis in
bilateral abductor paralysis: An anatomic study. Ann Otol 45:679,
1936.
Lore JM: Stripping of the vocal cords. Arch Otolaryngol 42:378-383,
1945.
Lore JM Jr: Experimental section and reanastomoses of recurrent
laryngeal nerve in dogs. Unpublished data.
Lore JM Jr: A set of instruments designed for stripping the vocal
cords. Arch Otolaryngol 59:604-605, 1954.
Lore JM Jr: Radical surgery of the larynx and laryngopharynx. In
Treatment of Head and Neck Cancer. New York, Excerpta Medica,
1975.
Lore JM Jr: Stripping of vocal cords. Laryngoscope 44:802-816, 1984.
Lore JM Jr, Hendrickson FR: Management Guidelines for Head and
Neck Cancer, publication No. 80-2037. Bethesda, MD, National
Institutes of Health, 1979, pp 1-17.
Lore JM Jr, Klotch OW: Cancer of the larynx, how to find it, what to
do. J Respir Dis, Jan.-Feb. 1982.
Lore JM Jr, Klotch DW, Lee KY: One stage reconstruction of
hypopharynx using myomucosal tongue flap and dermal graft. Am
J Surg 144:473-476, 1982.
Lore JM Jr, Lawrence J: Modified tracheostomy tube. Anesthesiology
21:567-568, 1960.
Lulenski GC: Laryngeal closure and glottic reconstruction. Ear Nose
Throat J 59:23-30, 1980.
MacComb WS: Cancer of the larynx. Cancer 19:149-156, 1966.
McCall VW, Whitaker CW: The use of prostheses in the larynx and
trachea. Ann Otol 71:397-403, 1962.
McGrail JS, Oldfield DL: One-stage operation for vocal rehabilitation at
laryngectomy. Trans Am Acad Ophthalmol Otolaryngol 75:510-512,
1971.
McNaught RC: Surgical correction of anterior web of the larynx.
Laryngoscope 60:264-272, 1950.
McNelis FL: Laryngeal carcinoma classified by clinical staging. Arch
Otolaryngol 82:173-180, 1965.
Malmgren LT, Gacek RR: Histochemical characteristics of muscle
fiber types in the posterior cricoarytenoid muscle. Ann Otol Rhinol
Laryngol 90:423-429, 1981.
Malmgren LT, Gacek RR: Acetylcholinesterase staining of fiber com-
ponents in feline and human recurrent laryngeal nerve. Acta
Otolaryngol 91:337-352,1981.
Maniglia AJ: Vocal rehabilitation after total laryngectomy: A flexible
fiberoptic endoscopic technique for tracheoesophageal fistula.
Laryngoscope 92:1437-1439, 1982.
Marks RD Jr, Fitz-Hugh GS, Constable We: Fourteen years' experience
with cobalt-60 radiation therapy in the treatment of early cancer
of the true vocal cords. Cancer 28:571-576,1971.
Mendenhall WM, Parsons JT, Stringer SP, et al: Tl-TZ Vocal cord
carcinoma: A basis for comparing the results of radiotherapy and
surgery. Head Neck Surg 10:373-377, 1988.
Mendenhall WM, Parsons JT, Stringer SP, et al: Management of Tis,
Tl and T2 squamous cell carcinoma of the glottic larynx. Am J
OtolaryngoI15:250-257,1994.
Micheau C, et al: Relationship between laryngocele and laryngeal
cancer. Laryngoscope 88:680-688, 1978.
Miller AH: Carcinoma in situ of the larynx. Am J Surg 120:492-494,
1970.
Miller AH: First experiences with the Asai technique for vocal
rehabilitation after total laryngectomy. Ann Otol 76:829-833, 1967.
Miller AH, Fisher HR: Clues to the life history of carcinoma in situ of
the larynx. Laryngoscope 81:1475-1480,1971.
Mitta! B, Marks JE, Ogura JH: Transglottic carcinoma. Cancer 53:151-161,
1984.
Montgomery WW: Cricoarytenoid arthritis. Laryngoscope 73:801-836,
1963.
Montgomery WW: Surgery to prevent aspiration. Arch Otolaryngol
101:679-682, 1975.
Murakami Y, Kirchner JA: Vocal cord abduction by regenerated
recurrent laryngeal nerve. Arch Otolaryngol 94:64-68, 1971.
Myers EM, Ogura JH: Completion laryngectomy. Ann Otol Rhinol
Laryngol 88:172-177,1979.
Myers MB, Cherry G: Zinc and the healing of chronic leg ulcers. Am
J Surg 120:77-81, 1970.
Neal GD, Cummings CW, Sutton D: Delayed reinnervation of unilateral
vocal cord paralysis in dogs. Otolaryngol Head Neck Surg 89:608-612,
1981.
Norris CM: Technique of extended fronto-Iateral partial laryngectomy.
Laryngoscope 68:1240-1250, 1958.
Norris CM, Peale AR: Partial laryngectomy for irradiation failure.
Arch Otolaryngol 84:558-562, 1966.
Norris CM, Peale AR: "Untreated" carcinoma of the larynx. Ann Otol
77:468, 1968.
Norris CM, Kuo BF, Tucker GF Jr, Pitser WF: A correlation of clinical
staging, pathological findings and five year end results in surgically
treated cancer of the larynx. Presented at the Meeting of the
American Laryngological Association. Hollywood Beach, Florida,
April 1970.
Nuutinen J, Karja J: Bilateral vocal cord paralysis following general
anesthesia. Department of Otolaryngology, University of Kuopio,
Kuopio, Finland.
Oberleas D, Lenaghan R, Wilson RF, et al: Effect of zinc deficiency
on wound-healing in rats. Am J Surg 121:566-568, 1971.
Ogura JH: "How I do it"-Head and neck. A targeted problem and its
solution. Hyoid muscle flap reconstruction in subtotal supraglottic
laryngectomy: A more rapid rehabilitation of deglutition.
Laryngoscope 89:1522-1524, 1979.
Ogura JH, Biller HF: Conservation surgery in cancer of the head and
neck. Otol Clin North Am October 1969.
Ogura JH, Biller HF: Reconstruction of the larynx following blunt
trauma. Ann Otol 80:492-506, 1971.
Ogura JH, Mallen RW: Partial laryngopharyngectomy for supraglottic
and pharyngeal carcinoma. Trans Am Acad Ophthalmol Otolaryngol
69:832-845, 1965.
Ogura JH, Marks JE, Freeman RB: Results of conservation surgery for
cancers of the supraglottis and pyriform sinus. Laryngoscope
90:591-600, 1980.
Ogura JH, Powers WE: Functional restitution of traumatic stenosis of
the larynx and pharynx. Laryngoscope 74: 1081-1110,1964.
Ogura JH, Powers WE, Holtz S, et al: Laryngograms: Their value in
the diagnosis and treatment of laryngeal lesions. Laryngoscope
70:780-809, 1960.
Ogura JH, Salzstein SL, Spjut HJ: Experiences with conservation 'sur-
gery in laryngeal and pharyngeal cancer. Laryngoscope 71:258-276,
1961.
Ogura JH, Som ML: Conservation surgery of the larynx and pharynx.
Instruction Course, American Academy of Ophthalmology and
Otolaryngology, 1971.
Olofsson J, Bielkenkrantz K, Grontoft 0, Nordstrom G: Juvenile
laryngeal papilloma displaying malignant degeneration-a spec-
trophotometric investigation. J Otolaryngol 7:353-365, 1978.
Olofsson J, Bielkenkrantz K, Grontoft 0: Malignant degeneration of
a juvenile laryngeal papilloma-a follow-up study. J Otolaryngol
9:329-333,1980.
Olson NR, Miles WK: Treatment of acute blunt laryngeal injuries.
Ann Otol 80:704, 1971.
Ono J, Saito S: Endoscopic microsurgery of the larynx. Ann Otol
80:479-486, 1971.
Ossoff RH, Barnes DR, Goldman ME, Sisson GA: Silastic surgical
sten! and dilator for use with the Singer-810m voice restoration
procedure. Otolaryngol Head Neck Surg 90:223-225, 1982.
Ossoff RH, Karlan MS: Safe instrumentation in laser surgery. Otolaryngol
Head Neck Surg 92:456-460, 1984.
Ossoff RH, Karlan MS, Sisson GA: Endoscopic laser arytenoidectomy.
Lasers Surg Med 2:293-299, 1983.

Ossoff RH, Tucker GF Jr, Duncavage JA, Toohill RJ: Efficacy of
bronchoscopic carbon dioxide laser surgery for benign strictures
of the trachea. Laryngoscope 95:1220-1223,1985.
Paes BA, De Sa DJ, Hitch DA: Fatal malformations of the larynx and
upper trachea. Laryngoscope 94:1447-1481, 1984.
Panje WR: Prosthetic vocal rehabilitation following laryngectomy.
Ann Otol Rhinol Laryngol 90:116-120,1981.
Parnell FW, Brandenburg JH: Vocal cord paralysis: A review of 100
cases. Presented at the Meeting of the Middle Section, American
Laryngological, Rhinological and Otological Society, Chicago,
January 1970.
Parnes SM, Saty-Murti S, Crane S: Laryngeal electromyography. NY
State J Med 83:329-333, 1983.
Pashley NR: Anterior cricoidotomy for congenital and acquired sub-
glottic stenosis in infants and children. J Otolaryngol13:187-190,
1984.
Pearson BW: Laryngeal microcirculation and pathways of cancer spread.
Laryngoscope 85:700-713,1975.
Pearson BW: Subtotal laryngectomy. Laryngoscope 91:1904-1911,
1981.
Pearson BW, Woods RD, Hartman DE: Extended hemilaryngectomy
for T3 glottic carcinoma with preservation of speech and swallow-
ing. Laryngoscope 90: 1950-1961, 1980.
Pennington CLJr: Glottic and supraglottic laryngeal injury and stenosis
from external trauma. Laryngoscope 74:317-345, 1964.
Polayes 1M, Kirchner JA: Reconstruction of a stenosed and crushed
laryngeal airway. Plast Reconstr Surg 46:568-571,1970.
Powell RW, Redd BL, Wilkins SA Jr: An evaluation of treatment of
cancer of the larynx. Am J Surg 110:635-643, 1965.
Powers WE, Holtz S, Ogura J: Contrast examination of the larynx and
pharynx. Inspiratory phonation. AJR Am J Roentgenol 92:40-42,
1964.
Pratt LW: Laryngostomy for acute airway obstruction. J Maine Med
Assoc 53:237-238,1962.
Pressman JJ: Anatomic studies related to the dissemination of cancer
of the larynx. Cancer 14:1131-1138, 1961.
Pressman JJ, Simon MB: Evaluation of subtotal laryngectomy based
upon studies of the lymphatics of the larynx and neck. Laryngoscope
71:1019,1961.
Pullen FW II, Pories WJ, Strain WH: Delayed healing: The rationale
for zinc therapy. Laryngoscope 81:1638-1649, 1971.
Pullen FW II, Smith LA: Laryngotracheal trauma. Presenting a new
method of conservative therapy. An exhibit. From the Department
of Otolaryngology, University of Miami School of Medicine.
Putney FJ: Elective versus delayed neck dissection in cancer of the
larynx. Surg Gynecol Obstet 112:736, 1961.
Putney FJ, Bagley CS: The two stage Asai technique of laryngectomy.
Ann Otol 79:1057, 1970.
Putney FJ, Clerf LH: Treatment of chronic hypertrophic laryngitis.
Arch Otolaryngol 31:925-929, 1940.
Quarantillo EP Jr: Effect of supplemental zinc on wound healing in
rats. Am J Surg 121:661-664, 1971.
Quick CA, Krzyzek RA, Watts SL, Faras AJ: Relationship between
condylomata and laryngeal papillomata. Ann Otol Rhinol Laryngol
89:467-471,1980.
Quinn HJ: Glottic reconstruction after hemilaryngectomy. Laryngoscope
80:599-609, 1970.
Rice DH, Coulthard SW: The growth of cartilage from a free perichon-
drial graft in the larynx. Laryngoscope 88:517-521, 1978.
Roggli VL, Greenberg D, McLarty JL, et al: Asbestos body content of
the larynx in asbestos workers. Arch OtolaryngoI106:533-S35, 1980.
Rosenberg HS, Vogler C, Close LG, Warshaw HE: Laryngeal fibro-
matosis in the neonate. Arch Otolaryngol 107:513-517, 1981.
Rueger RS:The superior laryngeal nerve and the interarytenoid muscle
in humans: An anatomic study. Laryngoscope 82:2008,1972.
Sachs ME, Conley J, Rabuzzi DD: Intralaryngeal release for tracheal
anastomosis. Ann Otol Rhinol Laryngol 92:482-484, 1983.
THE LARYNX
Sanders G, Uyeda RY, Karlan MS: Nonrecurrent inferior laryngeal
nerves and their association with a recurrent branch. Am J Surg
146:501-503,1983.
Sasaki C: Surgical closure of the larynx. Arch OtolaryngoI106:422-423,
1980.
Sasaki CT, Ikari T, Horiuchi M, Kirchner JA: Vocal cord positioning
by selective denervation. Ann Otol Rhinol Laryngol 89:541-546,
1980.
Sasaki CT, Milmoe G, Yanagisawa E, et al: Surgical closure of the larynx
for intractable aspiration. Arch OtolaryngoI106:422-423, 1980.
Satoh I: Evoked electro myographic test applied for recurrent laryngeal
nerve paralysis. Presented at the Japan Broncho-Esophagological
Society, Tokyo, December 10, 1976.
Schramm VL, Mattox DE, Stool SE: Acute management of laser-
ignited inlratracheal explosion. Laryngoscope 91:1417-1425,1981.
Schramm VL, May M, Lavorato AS: Gelfoam paste injection for vocal
cord paralysis: Temporary rehabilitation of glottic incompetence.
Laryngoscope 88:1268-1273,1978.
Schuller DE: Long-term stenting for laryngotracheal stenosis. Ann
Otol Rhinol Laryngol 89:515-520,1980.
Schwartz IS, Grishman E: Rheumatoid nodules of the vocal cords as
the initial manifestation of systemic lupus erythematosus. JAMA
244:2751-2752, 1980.
Shaia FT, Cassady CL: Laryngeal trauma. Arch OtolaryngoI95:104-108,
1972.
Shapshay SM, Davis RK, Vaughan CW, et al: Transoral management
of pharyngeal diverticula after laryngectomy. Otolaryngol Head
Neck Surg 90:193-197,1982.
Shedd D: Surgical and Prosthetic Approaches to Speech Rehabilita-
tion. Boston, GK Hall Medical Publishers, 1980.
Shedd DP, Gaeta JF: In vivo staining of pharyngeal and laryngeal
carcinoma. Arch Surg 102:442-446, 1971.
Shibata K, Komune S: Laryngeal angiomyoma (vascular leiomyoma):
Clinicopathological findings. Laryngoscope 90: 1880-1886, 1980.
Shumrick DA: Trauma of the larynx. Arch Otolaryngol 86:691-696,
1967.
Shumrick DA: Partial laryngectomy. Am J Surg 122:440-444, 1971.
Silver CE, Rosen RG, Dardik I, et al: Transplantation of the canine
larynx. Ann Surg 172:142-150, 1970.
Silver FM, Gluckman JL, Donegan JO: Operative complications of
tracheoesophageal puncture. Laryngoscope 95: 1360-1362, 1985.
Singer MI, Blom ED: Tracheoesophageal puncture: A surgical pros-
thetic method for postlaryngectomy speech restoration. Third
International Symposium on Plastic and Reconstructive Surgery of
the Head and Neck, New Orleans, May 1979.
Singer MI, Blom ED: An endoscopic technique for restoration of voice
after laryngectomy. Ann Otol Rhinol Laryngol 89:529-S33, 1980.
Singer MI, Blom ED: Selective myotomy for voice restoration after
total laryngectomy. Arch Otolaryngol107:670-673, 1981.
Singh J, Black MJ, Fried I: Cartilaginous tumors of the larynx: A
review of literature and two case experiences. Laryngoscope
90:1872-t879,1980.
Sisson GA: Reconstruction of the hypopharyllX and cervical esophagus
after radical excisional surgery. Laryngoscope 66: 1268-1290, 1956.
Sisson GA, Straehley CJ Jr, Johnson NE: Mediastinal dissection for
recurrent cancer after laryngectomy. Laryngoscope 72:1064-1077,
1962.
Sisson GA: Extended radical surgery for cancer of the head and neck:
Mediastinal dissection for stomal recurrences. Otolaryngol Clin
North Am, October 1969.
Sisson GA: Mediastinal dissection for recurrent cancer after laryngec-
tomy. Trans Am Acad Ophthalmol Otolaryngol 74:767-777, 1970.
Sisson GA, et al: Transsternal radical neck dissection for control of
stomal recurrence-end results. Laryngoscope 85:1504-1510,1975.
Smith HG, Vaughan CW, Healy GB, Strong MS: Topical chemotherapy
of recurrent respiratory papillomatosis. Ann Otol Rhinol Laryngol
89:472-478, 1980.
 THE LARYNX
Smith II, Bain AD: Congenital Atresia of the Larynx. Edinburgh,
Scotland.
Smith RO, Hemenway WG, English GM, et al: Post-intubation sub-
glottic granulation tissue: Review of the problem and evaluation of
radiotherapy. Laryngoscope 79:1227-1251, 1969.
Snow GB, et al: Prognostic factors of neck node metastasis. Clin
Otolaryngol 7:] 85-192, 1982.
Snyderman NL, et al: Extracapsular spread of carcinoma in cervical
lymph nodes. Cancer 56:1597-1599,1985.
Sofferman RA: Management of laryngolracheal trauma. Am J Surg
]41:412-4]7, 1981.
Som ML: Conservation surgery for carcinoma of the supra-glottis.
J Laryngol Otolaryngol 84:655-678, 1970.
Som ML: Hemilaryngectomy-a modified technique for cordal carci-
noma with extension posteriorly. Arch 01OIaryngoi54:524-533, 1951.
Spaulding MB, Khan A, Sundquist N, Lore JM Jr: Preoperative
chemotherapy for hypopharyngeal carcinoma. Laryngoscope
93:346-349, 1983.
Staffieri M, Serafini I, Capretti C, et al: La Riabilitazione Chirurgica
delia Voce e delia Respirazione dopo Laringectomia Totale. Bologna,
Italy, Associazione Otologi Ospedialieri Italiani, 1976.
Steiner W, Ambrosch P: Endoscopic Laser Surgery of the Upper
Aerodigestive Tract. Stuttgart, Thieme, 2000.
Stone JW, Arnold GE: Human larynx injected with Teflon paste. Arch
01OIaryngoi 86:550-561,1967.
SlOne JW, Arnold GE, Stephens CB: Intra-cordal Polytef (Teflon)
injection. Arch 01OIaryngoi 91:568-574,1970.
Strome M, Norris CM, Brodsky G, et al: An assessment of grafts in
the posterior cricoid lamina. Laryngoscope 92:1120-1125, 1982.
Strong MS: Natural history and management of premalignant lesions
of the glottis. Presented at 5th Annual Spring Head and Neck
Workshop, Snowbird, Utah, April 2-9, 1983.
Strong MS: Microscopic laryngoscopy. A review and appraisal.
Laryngoscope 80: 1540-1552, 1970.
Strong MS, Jako GT:Laser surgery in the larynx. Ann 010181:791, ]972.
Strong MS, Vaughan CW: Vocal cord nodules and polyps: The role of
surgical treatment. Laryngoscope 81:911-923, 1971.
Strong MS, Vaughan CW, Incze JS: Toluidine blue in the management
of carcinoma of the oral cavity. Arch Ololaryngol 87:527, 1968.
Strong MS, Vaughan CW, Incze JS: Toluidine blue in diagnosis of
carcinoma. Arch Ololaryngol 91:515-5]9, 1970.
Stutsman AC, McGavran MH: Ultraconservative management of super-
ficially invasive epidermoid carcinoma of the tfue vocal cord. Ann
Otol 80:507-512, 1971.
Sues OW, Powell OB Jr: Congenital cyst of the larynx in infants.
Laryngoscope 77:654-662, 1967.
Suzuki M, Kirchner JA, Murakami Y: The cricothyroid: Its character-
istics in bilateral recurrent laryngeal nerve paralysis as a respira-
tory muscle. Ann Otol 79:976, 1970.
Tabb HG, Kirk RL: Vein grafts in the management of laryngeal papil-
loma. Presented at the 65th Annual Meeting of the American
Laryngological, Rhinological and Otolaryngological Society,
Dallas, May 1962.
Tarnai 5, lei H, Maruyama T, et al: Laryngeal carcinoid tumor: Light
and electron microscopic studies. Cancer 48:2256-2259, 1981.
Taub S, Bergner LH: Air bypass voice prosthesis for vocal rehabili-
tation of laryngectomies. Am J Surg 125:748-756, 1973.
The Department of Veterans Affairs Laryngeal Cancer Study Group:
Induction chemotherapy plus radiation compared with surgery
plus radiation in patients with advanced laryngeal cancer. N Engl
J Med 324:1685-1690,1991.
Thornell we: Intralaryngeal approach for arytenoidectomy in bilateral
abductor paralysis of the vocal cords: A preliminary report. Arch
0l0IaryngoI47:505-508,1948.
Thornell we: Transoral intralaryngeal approach for arytenoidectomy
in bilateral vocal cord paralysis with inadequate airway. Ann Otol
66:364, 1957.
Trail ML, Chambers R, Leonard JR: Z-plasty of tracheal stoma at
laryngectomy. Arch Otolaryngol 88:84-86, 1968.
Treyve E, Yarington CT, Thompson GE: Incendiary characteristics of
endotracheal tubes with the carbon dioxide laser. Ann 0101Rhinol
Laryngol 90:328-330, 1981.
Trotter W: Operation for malignant disease of the pharynx. Br J Surg
16:485-487,1929.
Tsui HN, Lore JM Jr: Congenital subglottic fibroma in the newborn.
Laryngoscope 86:571-576,1976.
Tucker G Jr: A histological demonstration of the development of
laryngeal connective tissue compartments. Trans Am Acad
Ophthalmol Otolaryngol 66:308-318, ] 962.
Tucker G: Some clinical inferences from the study of serial laryngeal
sections. Laryngoscope 73:728-748, 1963.
Tucker H: Management of incompetent larynx. Am J Otolaryngol
1:47, 1979.
Tucker HM: Double-barreled (diversionary) tracheostomy in the
management of juvenile laryngeal papillomatosis. Ann 0101Rhinol
Laryngol 89:504-507, 1980.
Vaeth JM, Green JP, Schroeder AG: Radiation therapy of cancer of the
vocal cord and NSD implications. AJR Am J RoentgenoI114:63-64,
1972.
von Essen CF, Shedd DP, Connelly RR, Eisenberg H: Cancer of the
larynx in Connecticut, 1935-1959. Cancer 22:1315-1322,1968.
Wagenfeld DJH, Harwood AR, Bryce DP, et al: Second primary respira-
tory tract malignancies in glottic carcinoma. Cancer 46:1883-1886,
1980.
Wang CC, Schulz MD, Miller D: Combined radiation therapy and
surgery for carcinoma of the supraglottis and pyriform sinus. Am
J Surg 124:551-554, 1972.
Ward PH: Observations on central neurologic etiology for laryngeal
dysfunction. Ann Otol Rhinol Laryngol 90:430-441, 1981.
Ward PH, Berci G: Observations on the pathogenesis of chronic non-
specific pharyngitis and laryngitis. Laryngoscope 92:1377-1382,
1982.
Ward PH, Berci G: Observations on so-called idiopathic vocal cord
paralysis. Ann Otol Rhinol Laryngol 9]:558-563, 1982.
Ward PH, Engel E, Nance WE: The larynx in the cri du chat (cat cry)
syndrome. Laryngoscope 78:] 716-1733, 1968.
Weaver AW,Fleming SM: Partial laryngectomy: Analysis of associated
swallowing disorders. Am J Surg 136:486-489, 1978.
Wetmore RF, Tronzo RD, Lane RJ, Lowry LD: Nonfunctional para-
ganglioma of the larynx: Clinical and pathological considerations.
Cancer 48:2717-2721, 1981.
Wilson OK: Voice re-education of children with vocal nodules.
Laryngoscope 72:45-53, 1962.
Woodman DeG: A modification of the extralaryngeal approach to
arytenoidectomy for bilateral abductor paralysis. Arch Otolaryngol
43:63-65, t946.
Woodman DeG: Bilateral abductor paralysis: A study of 521 cases of
arytenoidectomy via the open approach as reported by ninety
surgeons. Arch Otolaryngol 58:150-153, 1953.
Woodman DeG: Laryngeal stenosis. Laryngoscope 63:714-720,1953.
Woodman D, Pennington CL: Bil;teral abductor paralysis. Ann 0101
Rhinol Laryngol 85:437, 1976.
Woodson GE, Miller RH: The timing of surgical intervention in vocal
cord paralysis. Otolaryngol Head Neck Surg 89:264-267,1981.
Work WP: Unusual position of the right recurrent laryngeal nerve.
Ann 0101 50:769-775, 1941.
Wortham DG, Hoover LA, Lufkin RB, Fu YS: Magnetic resonance
imaging of the larynx-correlation with histologic sections.
Otolaryngol Head Neck Surg 94: 123-133, 1986.
Yanagisawa E, Christmas OA, Wilson GL: Superior laryngeal nerve
section for odynophagia. Arch Otolaryngol 91:387-388, 1970.
Yarington CT Jr: Immediate repair of blunt and penetrating trauma to
the larynx and trachea. Arch Surg 96:403-404, 1968.
 21 THE HYPOPHARYN
AND THE ESOPH
Repair of Pharyngoesophageal
Diverticulum (Fig. 21-1)
Pulsion diverticula in the cervical region may arise in
the hypopharynx, in the pharyngoesophageal vestibule,
or in the cervical esophagus. For the most part, they are
all false diverticula, because they do not include all
layers of the gut. They are numbered 1, 2, and 3 from
superior downward.
The first type is the hypo pharyngeal diverticulum
known as the Killian type. It may arise laterally or in the
midline, posterior or posterolaterally, or in the hypopha-
ryngeal wall. One explanation for its etiology is the site
of perforation of the vascular supply to the hypopharynx.
This diverticulum is usually small and may appear as a
small bulge-l.O to 1.5 em-on a pharyngoesopha-
gogram. They mayor may not be symptomatic and are
rare and are seen usually as an incidental finding on the
barium swallow. Searching for this diverticulum with
only an exterior approach can be quite futile. If the diver-
ticulum is asymptomatic no treatment is indicated.
The second type (Zenker), the most common, arises
in the posterior wall usually in the midline, sometimes
laterally to the lower portion of the pharyngoesophageal
vestibule. In any event the diverticulum sac usually
presents laterally on the left side. This type has a more
pharyngeal than esophageal origin, because it presents
superior to the transverse fibers of the cricopharyngeus
muscle (lowermost part of the inferior pharyngeal con-
strictor) and inferior to the oblique fibers of the inferior
pharyngeal constrictor muscle. However, muscularis
mucosae of the esophagus may accompany this diver-
ticulum. It usually presents itself in the left side of the
neck, although in the following illustrations, the diver-
ticulum appears on the right side.
The causative mechanism appears to be spasm of
the cricopharyngeus muscle, which narrows the lumen
of the esophagus at its origin, causing dysphagia, and
this predisposes to the formation of the diverticulum.
This extends from the posterior edge of the muscle into
the retro- or lateral paraesophageal space. In this area
the recurrent laryngeal nerve can be placed in signifi-
cant jeopardy. It may be adherent to the wall of the
diverticulum. As the diverticulum enlarges and extends
inferiorly into the posterior thoracic mediastinum, the
enlarged diverticulum presses on the esophagus, thus
aggravating the esophageal obstruction more. Never-
theless, even small diverticula of 1.0 to 1.5 em can be
associated with significant dysphagia, the prime culprit
being the spasm of the cricopharyngeus muscle. Hence
the basis of all treatment is the transection of this
muscle. It appears that not only is transection of the
main muscle, which may be only 1.0 to 1.5 em in
width, important but also transection of other horizontal
fibers extending inferiorly along the posterior wall of
the esophagus for several centimeters (see p. 1178 and
Fig. 21-3). Barium swallow after just a cricopharyngeus
myotomy may be rather disheartening because the
diverticulum is still present, but the patient's dysphagia
has disappeared both radiologically and clinically.
The point that has to be stressed to the primary care
physician is that these diverticula should be treated
surgically and as early as possible. If not, the patient
can lapse into a progressive debilitating picture: loss of
weight, regurgitation, aspiration, pneumonia, and then
even lung abscess. There is not a course of treatment of
watch and wait. Although endoscopic cricopharyngeus
myotomy is "less" of an operation than open operation,
with larger diverticulum the Lahey first-stage procedure
is well tolerated even in the older age group.
The third type, which arises in the cervical
esophagus proper, is not common but when it does
occur, it is usually in the lower third of the cervical
esophagus. It almost always arises from the anterior
surface of the esophagus, presenting itself laterally.
Indications for Treatment of Zenker Diverticulum
When the diverticulum is 1.0 to 1.5 em or smaller, a
cricopharyngeal myotomy will usually suffice. With the
larger diverticula, cricopharyngeal myotomy is combined
with resection of the diverticulum and transverse closure
of the muscularis layer (not the cricopharyngeal muscle).
The Dohlman and Mattson procedure in which the
septum between the esophageal lumen and the diver-
ticulum is cauterized through a bivalved esophago-
scope can be associated with leakage and mediastinitis.
The concept of transection of the "septum"-the
cricopharyngeus muscle and mucosa of esophagus and
diverticulum-is valid but not with cautery or with the
CO2 laser. This transection can be accomplished with a
stapler (see p. 1174); otherwise, there is danger of
mediastinitis. It is not believed that this procedure
using the stapler is warranted. In the extremely poor-
1171
 THE HYPOPHARYNX AND THE ESOPHAGUS
Repair of Pharyngoesophageal
Diverticulum (Continued) (Fig. 21-1)
risk patient, particularly the patient with pulmonary
complications associated with aspiration, the procedures
suggested are the stapler method or the cricopharyngeal
myotomy; and if the sac is large, then this can be
sutured superiorly as in the original first stage of the
Lahey operation (see Fig. 21-IEl). Rarely, there may be
more than one sac or pouch associated with the
diverticulum.
The Zenker pharyngoesophageal diverticulum
most likely related to an incoordination of relaxation
and contraction of the cricopharyngeal muscle. At times
the sac may be very difficult to isolate, and these sacs
are usually the smaller ones that only require a cricopha-
ryngeal myotomy. An attempt to resect these small sacs
can present a problem; adequate closure of the neck of
the sac can be difficult and hence another reason why
resection of the sac is usually not indicated.
External Anatomy of Larynx and Laryngeal
Nerves (See Fig. 20-1)
In Figure 20-1, note the site at which the internal
branch of the superior laryngeal nerve perforates the
lateral hyoid membrane. This is located at approxi-
mately a horizontal line with the superior corner of the
thyroid cartilage, about I em medially.
Highpoints
I. A horizontal incision follows the natural skin
crease.
2. The recurrent laryngeal nerve is identified if the
sac is large and extends inferior to the lower border
of the thyroid cartilage.
3. Careful dissection around neck of sac is done.
4. Cricopharyngeal myotomy is performed for a
minimal distance of 3 to 4 em (see Fig. 21-3). Be
certain that all muscle fibers are transected on the
posterior aspect.
5. Remember that carcinoma may occur in these
diverticula, and all patients should be examined by
esophagoscopy. The diverticulum is cleansed of all
food. The food may be impacted and up to I hour
can be taken for complete removal of debris.
Extreme care is needed to avoid perforation of the
diverticulum. A soft, large-base rubber catheter is
ideal to remove the debris. At this time a short
feeding tube can be inserted into the lumen of the
esophagus.
6. In poor-risk patients, the two-stage procedure may
be the one of choice or simply the first-stage
procedure with cricopharyngeal myotomy.
7. There is a danger of perforation with esophagoscopy.
8. Recurrent nerve injury can result in paralysis of the
vocal cord, which can further complicate the pre-
existing dysphagia.
9. Horner's syndrome is secondary to cervical
sympathic nerve injury.
10. The better approach is anterior to the carotid sheath
rather than posterior to the sheath.
Il. The "neck" of the diverticulum is at the level of the
cricoid cartilage.
A A horizontal incision, if possible, follows a natural
is skin crease and is made 2 to 3 fingerbreadths above
the clavicle, depending on the size of the diverticulum.
The larger the diverticulum, the lower the incision; the
smaller the diverticulum, the higher the incision. With
very small diverticula, the incision is made at the level
of the cricoid cartilage. The side chosen depends on
the presenting side of the diverticulum as shown by
radiographic and clinical examination. An incision cross-
ing natural skin creases along the anterior border of
the sternocleidomastoid muscle is not cosmetic. This
latter incision is used in the elderly because elevation
of skin flaps then becomes unnecessary.
A 1 Schematic representation is shown of esophageal
obstruction caused by large diverticulum (as seen from
the left side) exerting pressure on the esophagus.
Danger of esophageal perforation with esophagoscopy
is obvious, because the esophagoscope passes into the
diverticulum rather than the esophagus. Large diver-
ticula may extend into the mediastinum. It is worth-
while to insert a soft red rubber catheter via the nostril
into the diverticulum for clarification of the anatomy.
The cricopharyngeal muscle is depicted between the
esophagus and the neck of the diverticulum.
A2 Findings on esophagoscopy indicate that the
larger opening posteriorly is the diverticulum, whereas
the more anterior orifice is the esophagus. Lying between
the two is the cricopharyngeal muscle. Again, the danger
of esophageal perforation is emphasized, because the
esophagoscope often is directed into the diverticulum
rather than into the esophageal lumen.
A3 Treatment of a Zenker diverticulum with the
stapler technique. A disposable stapler (Endo GIA 30,
US Surgical Corporation, Norwalk, CT) with shorter anvil
that allows tissue stapling and sectioning down to the
bottom of the septum, that is, the entire width of the
cricopharyngeus muscle, is shown.
B The incision is carried through the platysma muscle
and liberal superior inferior skin flaps containing the
platysma muscle are developed. Stay sutures through
the platysma muscle are used for traction. In the elderly,
 THE HYPOPHARYNX AND THE ESOPHAGUS

Sup. belly
omohyoid m.

Sternocleido-
mastoid m.

A B

...L- PHARYNX

DIVERTICULUM

CRICOPHARYNGEUS M.

FIGURE 21-1

• Recurrence of diverticulum andjor dysphagia

especially a debilitated patient the skin incision is made • The preoperative esophagoscopy can result III
along the anterior border of the sternocleidomastoid perforation of the diverticulum.
muscle. This is quicker and does not involve develop-
ing flaps. An incision is then made along the anterior Management of Perforation of Zenker's
border of the sternocleidomastoid muscle. The Diverticulum
omohyoid muscle is noted in the upper half of the
wound as it passes behind the sternocleidomastoid 1. Immediate
muscle. a. Broad-spectrum antibiotic, for instance, ampicillinj
Continued sulbactam (Unasyn), 3.0 g every 6 to 8 hours IV.
b. NPO
c. Careful clinical evaluation along with soft tissue
Complications radiographs of the neck and mediastinum; CT is
preferred.
• Fistula and infection (mediastinitis) 2. Late (and if above fails) open operation down to the
• Recurrent laryngeal nerve injury perforation of the diverticulum with continuous suction-
 THE HYPOPHARYNX AND THE ESOPHAGUS
Repair of Pharyngoesophageal
Diverticulum (Continued) (Fig. 21-1)
type drain (Jackson-Pratt). The surgical approach to
the perforation is the same as for the resection of the
diverticulum. A diversion operation of the esophagus
is of no value.
When the diverticulum and perforation is in the
mediastinum and conservative treatment fails, surgical
approach depends on location in the mediastinum.
If the location is superior, resection of the left median
third of clavicle may suffice (see Fig. 19-9A to D). If
the location is in the lower mediastinum, thoraco-
tomy is the approach.
Although the author (JML) has no experience with
the stapler technique, treatment of Zenker's diverticu-
lum with a stapler appears to be very valid in diver-
ticula large enough (estimated by Collard to be 3 em or
larger in length) to staple the entire thickness of the
cricopharyngeus muscle. The Weerda diverticuloscope
(Karl Storz) or smaller modification, along with a 5-cm
wide angle O-degree telescope for magnified vision, is
used. A disposable stapler (Endo GIA 30, United States
Surgical Corporation, Norwalk, CT) with shorter anvil
that allows tissue stapling and sectioning down to the
bottom of the septum, that is, the entire width of the
cricopharyngeus muscle, is depicted in Figure 21-1A3.
This stapler procedure appears a valid option; however,
the open operation is still a very basic, sound surgical
procedure and is certainly indicated when the diver-
ticulum is small and is less than 2 to 3 em in length. The
reader is referred to two articles that are very important
to review.
1. Collard JM, et al: Endoscopic stapling technique of
the esophagodiverticulostomy for Zenker diverticulum.
Ann Thorac Surg 56:573-576, 1993.
2. Peracchia A, et al: Minimally invasive surgery for
Zenker diverticulum. Arch Surg 133:695-700, 1998.
C The carotid sheath containing the common carotid
artery, internal jugular vein, and vagus nerve is then
exposed by retracting the sternocleidomastoid muscle
laterally. The descending hypoglossal nerve (ansa) (fibers
actually from the cervical plexus) usually is also in this
sheath close to the internal jugular vein or in front of
the sheath. This nerve (motor supply to the strap mus-
cles) may be sacrificed if necessary for exposure's sake,
or it may be retracted. The same can be said of the
omohyoid muscle. With a large diverticulum, the muscle
is best transected and each end tagged with stay
sutures to facilitate approximation at the close of the
procedure. This muscle repair can then act as a sling to
support a large diverticulum, which has been inserted
(Lahey: first stage). The middle thyroid veins draining
into the internal jugular vein are then exposed,
ligated, and divided.
D The thyroid lobe is retracted medially, and at its
inferior pole the recurrent nerve is first identified. This
is not necessary in diverticula that do not extend
inferior to the lower edge of the thyroid cartilage. This
is important, because the nerve may soon divide into
abductor and adductor fibers, and the identification of
a nerve structure higher in the wound will not ascertain
whether other vulnerable branches are still hidden.
This step may require ligation and division of the inferior
thyroid veins. As the nerve is traced upward, the inferior
thyroid artery will be exposed. Depending on the
mobility of the thyroid lobe for full medial retraction,
this vessel may be preserved or sacrificed. With all
important structures identified, the distal end of the
diverticulum is now separated from the neighboring
structures. Blunt dissection is usually ideal. Care must
be taken not to rupture large diverticula extending into
the mediastinum. Care is also taken not to injure the
recurrent laryngeal nerve, which may be adherent to
the wall of the diverticulum. Also avoid injury to the
cervical sympathetic nerves, which are more vulnerable
if an approach posterior to the carotid sheath is used.
After the neck of the diverticulum is meticulously dis-
sected and the lowest fibers of the inferior pharyngeal
constrictor muscle (cricopharyngeal muscle) are clearly
identified, a stay suture is placed at the superior aspect
of the neck of the diverticulum. The cricopharyngeal
muscle (El) is sectioned along with any other fibers for
a distance of at least 3 to 4 cm (see Fig. 21-3).
E The diverticulum is retracted upward with a
Tendergrip (Lore) clamp, and the inferior aspect of the
neck of the diverticulum (1 cm wide area of submucosa)
is checked for thoroughness of dissection. The larynx
may be slightly elevated forward and rotated if possible
to check the dissection and exposure posteriorly and
toward the opposite side of the pharyngoesophagus.
Another stay suture is then placed at the inferior border
of the neck of the diverticulum. A Mixter forceps is
pla.ced across the neck of the diverticulum distal to the
stay' sutures, allowing enough proximal mucosa for
inversion; the neck is transected between the Mixter
forceps and the stay sutures. An alternate method
(Payne and Reynolds, 1982) utilizes the TA-30 stapling
device to effect closure. The diverticulum is then
removed.
El In the markedly debilitated patient with a large
diverticulum associated with diverticulitis, simple treat-

Ansa hypoglossus n.
Com. carotid a.
Esophagus
E F
FIGURE 21-1 Continued
ment of the diverticulum may be indicated. This consists
of turning the diverticulum upside down by taking the
most dependent end of the sac and suturing it high
along the anterior border of the sternocleidomastoid
muscle (Lahey: first-stage operation). This is combined
with the cricopharyngeal myotomy (see Fig. 21-3).
This keeps the diverticulum emptied of food particles
and relieves the symptoms of esophageal obstruction
and regurgitation. The esophageal obstruction is due
to spasm of the cricopharyngeal muscle and is aggra-
vated by the dilatation of the diverticulum, which in
turn presses on the esophagus distal to the neck of the
sac. This fact should also be kept in mind during
esophagoscopy of these patients; that is, the scope is
more likely to find its way into the sac than into the
distal esophagus. This can result in perforation of the
diverticulum. At a subsequent date the diverticulum
can then be resected or simply left sutured upside
down. This procedure can readily be performed with
the patient under local anesthesia.
THE HYPOPHARYNX AND THE ESOPHAGUS
F Closure consists of continuous or interrupted
inverting Connell sutures of 4-0 chromic gut placed if
possible in the horizontal plane.
G The muscularis is then closed with interrupted
mattress sutures of 3-0 silk. A small Jackson-Pratt drain
is inserted low in the wound. The platysma muscle is
approximated with 4-0 chromic catgut, and the skin is
sutured with interrupted sutures of fine nylon. It is
important not to suture the cricopharyngeus muscle,
depicted here schematically as laterally transected
bundles. If there is a question regarding this muscular
layer it is best to delete this step.
When the diverticulum remains in the midline, as seen
on the pharyngoesophagogram, this external surgical
approach is somewhat more difficult relative to exposure
of the neck of the diverticulum. The stapler method
may be the better technique for the management of this
type of diverticulum.
 THE HYPOPHARYNX AND THE ESOPHAGUS
Exposure of the Superior Portion
of the Thoracic Esophagus
(Fig. 21-2)
This approach is useful for two purposes:
I. Repair of injuries to the lower cervical esophagus
whether due to trauma or iatrogenic
2. Resection of neoplasm of the cervical esophagus
when additional distal length of the esophagus is
necessary
Repair of Iatrogenic Injury to the
Esophagus
The patient in this case showed what not to do for a
perforation of a Zenker's diverticulum. After perforation,
transection and external diversion of the proximal
esophagus was performed and then the blind end of the
distal esophagus was turned in at the thoracic outlet and
a gastrostomy was done. The patient had a cutaneous
esophagostomy for months. The surgeon suggested
reconstruction of the esophagus with a gastric pull-up.
The author's suggestion was direct anastomosis of the
two ends of the transected esophagus if possible.
Before open operation, retrograde flexible optical
esophagoscopy as well as retrograde gastrographic studies
were performed to identify the closed end of the distal
esophagus. This closed end was in the vicinity of the
suprasternal notch. Hence, a transcervical approach
was performed.
A A horizontal cervical incision was made 1
fingerbreadth above the sternoclavicular junction with
an inferior 6-cm vertical incision. The strap muscles,
left lobe of the thyroid gland, trachea, carotid sheath,
and the sternocleidomastoid muscle were all encased
in scar tissue and carefully identified. The trachea was
retracted medially, and all else was retracted laterally
with exposure of the superior thoracic inlet posteriorly.
At this point, a retrograde flexible optical repeat
esophagoscopy was performed; with the operating
room lights off, the closed end of the distal esophagus
was identified. The esophagus was able to be exposed
1.0 to 1.5 em. Additional exposure was obtained by
resection of the medial third of the'c1avicle with tran-
section of the sternocleidomastoid muscle and strap
muscles (see Fig. 19-9).
Extreme care was taken not to cut into the scar
tissue in the vicinity of the left recurrent laryngeal
nerve. The left vocal cord had been immobile after the
initial diversion operation.
B The trachea was retracted medially and the carotid
sheath and internal jugular vein, vagus nerve, and the
common carotid artery were retracted laterally.
The proximal esophagus was detached from the
skin, and stay sutures were secured and mobilized up to
the cricoid cartilage. The recurrent laryngeal nerve was
now exposed and carefully preserved. No attempt was
made to perform a cricopharyngeus myotomy because
of the scar tissue. The closed end of the esophagus was
opened very carefully and secured with stay sutures.
C The proximal end of the esophagus, when detached
from the skin, resulted in slight obliquity. The anasto-
mosis was performed with two-layer interrupted 4-0
silk for the muscle layer and 4-0 Vicryl inverting inter-
rupted sutures for the mucosal layer. The anastomosis
areas was buttressed by the longitudinal portion of the
right sternocleidomastoid muscle, which was passed
into the mediastinum. Cervical fascia and left strap
muscles covered the left internal jugular vein. A Valsalva
maneuver was performed. Slight bleeding on the
lateral aspect of the thyroid lobe was controlled. A
Jackson-Pratt drain was inserted on the left side, which
was free and clear of any vessels. The wound was
closed in layers.
Immediately after the operation, with the patient
reactive and able to phonate, an optical laryngoscope
revealed that the left vocal cord was immobile in a
slightly abducted position with a very good airway.
Tracheostomy was not necessary.
The postoperative course was excellent until the
fifth day when the bleeding occurred from the right
side of the upper neck where the skin was reflected for
the sternocleidomastoid muscle flap. The wound was
exposed. The branch of the external jugular vein was
ligated. There was no anastomotic leak.
Long-term follow-up showed that swallowing was
well except for one minor episode of dysphagia that
lasted over 30 minutes. The left vocal cord was mobile.
Resection of Adenocarcinoma From the
Cervical Esophagus
The patient in this case had a known adenocarcinoma
of the esophagus extending into the superior thoracic
esophagus with indication that this was arising in a polyp.
The approach was similar to the previously described
operation for iatrogenic injuries: a T-type incision and
resection of the medial third of the clavicle. It was also
similar on the left side of the trachea with the retraction
of the trachea medially and the carotid sheath laterally.
The left recurrent laryngeal nerve was located and

Inferior
Clavicular
stump,
Vagus n.
Rt. common
carotid a.
Leftthyroidlobe
Common carotid a.
FIGURE 21-2
displaced 1.5 cm from the usual tracheoesophageal groove.
Beneath the nerve was a firm mass, which proved to be
the mass within the cervical esophagus. Associated lymph
nodes were sent for frozen section and were negative
for metastatic carcinoma. The recurrent laryngeal nerve
was carefully retracted for its protection.
Stay sutures were used in the esophageal muscula-
ture and then a vertical esophagotomy was performed.
Marked distention in the esophagus in doing this type of
approach would not narrow the lumen. Esophagotomy
extended 4 cm, and the mass was well visualized. The
mass was identified, and it was found to be attached to
an elongated length of esophageal mucosa and not to a
polyp as originally thought.
Stay sutures were placed superiorly and inferiorly
approximately 1 cm away from the gross tumor, which
appeared to extend for a distance of about 3 cm. 11was
able to stretch the esophageal mucosa so that an Ethicon
linear stapler 30 mm was able to be inserted from above
downward. This facilitated a margin of 5 to 7 mm between
gross tumor and what appeared to be normal esophagus.
THE HYPOPHARYNX AND THE ESOPHAGUS
The lesion was thus resected and sent for frozen
section. The margins were free; however, at the deep
resection edge there was tumor that was very close to
the margin. As a result, an additional 8 mm of esophageal
mucosa was able to be removed again using the stapler,
this time from below upward. Extreme care was taken
to avoid injury to the recurrent laryngeal nerve, which
was adherent to the esophageal musculature. This pos-
terior wall of the esophagus where the tumor arose was
oversewn with continuous 4-0 Vicryl. Resection and clo-
sure was in vertical fashion. There was no significant
narrowing of the lumen of the esophagus at the actual
closure site because of the previous dilatation due to the
mass. 11was estimated to be at least 1.5 cm in diameter.
The original esophagotomy was now closed with con-
tinuous 4-0 Vicryl for the mucosa and muscle, and then
a second layer of interrupted 4-0 black silk was used
for the muscular layer. 11was decided to leave distal
silk sutures about 1 cm in length from the closure site in
the event that another exploration and further surgical
procedure might be necessary.
 THE HYPOPHARYNX AND THE ESOPHAGUS

Exposure of the Superior Portion The surgical approach is similar to that described
of the Thoracic Esophagus under repair of pharyngoesophageal diverticulum
except that the horizontal incision is made close to the
(Continued) (Fig. 21-2)
level of the cricoid cartilage following, if possible, a
natural skin crease.
Closure consisted of approximation of the strap muscles
that were previously transected. The sternocleidomastoid,
which had been separated from the resected portion of A The anatomy of the cricopharyngeal muscle, which
the clavicle, was reapproximated to the remaining perios- is either a separate muscle or the inferior portion of the
teum of the resected clavicle. A Jackson-Pratt drain was inferior pharyngeal constrictor muscle, is shown.
inserted at the head of the clavicle, and another one
was inserted deeper into the wound. Care was taken B A short jesberg esophagoscope has been inserted
not to malign any vessel. into the lumen of the esophagus for a distance of several
A Valsalva maneuver was performed. There was no centimeters. This distends the lumen, stretching the
bleeding. The continuity of the recurrent laryngeal nerve cricopharyngeal muscle. By carefully angulating the
was reaffirmed. After the patient was extubated and able esophagoscope toward the operator, the muscle fibers
to phonate, an optical laryngoscopy was performed to are better delineated. The larynx is rotated in the oppo-
evaluate the status of the left vocal cord. Both vocal site direction to expose the posterior aspect of the
cords were straight and fully mobile. muscle. Care is taken to avoid injury to the recurrent
The postoperative diagnosis was adenocarcinoma laryngeal nerve and the external branch of the superior
arising in a fold of the cervical esophagus at the tho- laryngeal nerve. These nerves, along with branches
racic inlet. Treatment consisted of radiotherapy with a from the superior cervical ganglion (sympathetic) and
tumor dose 5,040 cGy to the upper thoracic and lower sensory branches of the glossopharyngeal nerve,
cervical esophagus, combined with S-fluorouracil innervate the muscle (after Blakeley et aI., 1968). The
administered concomitant with the radiotherapy. At solid line depicts the extent of the myotomy.
5 years 6 months later with no dysphagia or other
problems, the patient was free of tumor. C The thyroid gland and larynx are retracted
medially, while the carotid sheath is retracted laterally.
With the jesberg esophagoscope in place, a small
Cricopharyngeal Myotomy curved clamp may be inserted under the fibers of the
(Fig. 21-3) cricopharyngeus muscle, carefully elevating the fibers
from the underlying mucosa. The fibers are then tran-
Highpoints sected with Metzenbaum scissors or a No. 15 blade
knife. It is important to transect all fibers of the muscle
1. Indications include dysphagia associated with both in depth and in their extent superiorly and inferiorly.
aspiration and, with surgical treatment of Zenker The upper end of the esophagus may have a func-
diverticulum, any significant resection of the tioning sphincter muscle as well. This mayor may not
hypopharynx. be so; nevertheless, close scrutiny may reveal additional
2. Dysphagia may be secondary to cerebrovascular horizontal muscle fibers that then should be transected.
accident or to spasm of the cricopharyngeal muscle The operation microscope has been used to visualize
or may occur after partial laryngectomy or pharyngeal and to transect these additional muscle fibers up to a
muscular dystrophy. total distance of 5 to 6 em. At this point, the mucosa
3. Transect all fibers as close to posterior median raphe should bulge through the opening in the muscle
as possible (minimal distance: 3 to 4 cm). fibers. Care must be taken not to incise the mucosa. If
4. Do not incise mucosa. this is done, it must be recognized and repair per-
5. This is not a panacea for all patients with dysphagia. formed with inverting sutures of 4-0 chromic gut. A
drain is used only if the mucosa has been opened. The
operation is similar in principle to a Ramstedt
pyloromyotomy and a Heller procedure.
 THE HYPOPHARYNX AND THE ESOPHAGUS

(~
I.
THYROID GLAND
CRICOPHARYNGEUS M.

CAROTID SHEATH
SUP CERVICAL GANGLION

1 B

INF. PHARYNGEAL
CONSTRICTOR M.

CRICOPHARYNGEUS M.

ACCESSORY M.
AREA OF LAIMER
LONGITUDINAL MUSCLE
OF ESOPHAGUS

FIGURE 21-3
 1180 THE HYPOPHARYNX AND THE ESOPHAGUS
Transhyoid Pharyngotomy
(Fig. 21-4) (After Cocke, 1961) and
Anterior Pharyngotomy
(Martin et aI., 1980)
Discussion
A somewhat similar approach to the transhyoid, but
easier to perform than trans hyoid pharyngotomy, is
suprahyoid pharyngotomy. This affords virtually the
same degree of exposure as transhyoid pharyngotomy.
When this is performed, it is best to leave 5 to 10 mm
of muscle attached to the superior edge of the hyoid bone
to facilitate closure. In addition to excellent exposure of
the posterior hypopharyngeal wall by extending the
incisions laterally, with care taken to avoid injury to the
hypoglossal nerve, this also affords an excellent approach
to the base of the tongue, which can be combined with
a radical neck dissection. It also facilitates exposure of
the posterior oropharyngeal wall up into the nasopharynx
and inferiorly to the postcricoid area. When the inci-
sion is extended farther laterally, the proximity of the
cornu of the hyoid bone to the 12th nerve is empha-
sized. The tendon of the digastric muscle will aid in the
identification of the hypoglossal nerve. The submandibular
gland may be elevated to facilitate increased exposure
in this area. When the suprahyoid approach is used, it
is not necessary to identify the internal branch of the
superior laryngeal nerve.
Highpoints
1. Remove central portion or entire hyoid bone.
2. Identify and preserve superior laryngeal nerves.
3. Avoid injury to hypoglossal nerves. This is very
important when extending incision laterally to the
cornu of the hyoid bone.
4. Excellent exposure of posterior hypo pharyngeal wall
and base of tongue is achieved.
5. Perform cricopharyngeal myotomy with large
resection of hypopharynx.
A A horizontal incision is made over or slightly above
the hyoid bone extending from one sternocleido-
mastoid muscle to the other. Upper and lower skin
flaps with the platysma muscles are developed.
B, C Specific identification of both superior laryngeal
nerves is performed (see Fig. 16-15). Each nerve arises
from its respective vagus nerve above the level of the
bifurcation of the common carotid artery and courses
downward and medially behind the internal and
external carotid arteries, where it divides into internal
and external branches. The internal branch enters the
larynx through the thyrohyoid membrane, being
joined by the superior laryngeal artery, which is a
branch of the superior thyroid artery. Its site of
entrance through the thyrohyoid membrane is
localized by a horizontal line drawn across the top level
of the thyroid cartilage to a point within 1 em of the
superior cornu of this cartilage. The internal branch is
the main sensory nerve for the larynx, with possible
motor supply to the interarytenoid muscle. The external
branch courses downward lateral and external to the
inferior pharyngeal constrictor muscle, of which it is
one of the motor nerves. (The recurrent laryngeal
nerve also sends a motor branch to this muscle.) The
external branch has an important motor branch to the
cricothyroid muscle (tensor of the vocal cord), which
accompanies the superior thyroid vessels.
The central portion or entire hyoid bone is then
excised by freeing the suprahyoid and infrahyoid
muscular attachments. The hypoglossal nerves must
not be injured, because they pass deep to the lateral
portion of the hyoid bone (cornu).
D With four retractors, the hypopharynx is exposed.
This approach and exposure is ideal for resection of
large benign lesions and small malignant lesions of the
posterior wall of the hypopharynx. With larger malignant
lesions of the hypopharynx, oropharynx, and base of
tongue, the median labiomandibular glossotomy (see
Fig. 15-4) or lateral pharyngeal approach is used (see
Fig. 21-5), with the transhyoid, transthyrohyoid mem-
brane transection and a radical neck dissection being
alternate approaches. The latter is preferred (see
Chapter 15, pp. 720 and 732).
Larger defects (associated with benign disease) in
the posterior hypo pharyngeal wall, if not amenable to
primary closure by mobilization of the mucosa, can be
covered with dermal graft sutured to the prevertebral
fascia. If a portion of the lateral hypopharyngeal wall
has been resected, a tongue flap can be mobilized as
shown in Figure 21-7. A significant portion of the
posterior and lateral hypopharyngeal wall can thus be
resected with preservation of the larynx. Dysphagia is
a problem, but with patience and time the patient can
learn to swallow. With these more extensive resections,
a cricopharyngeal myotomy is advisable. Running or
interrupted Connell-type sutures are used for approxi-
mation of the mucosa. Two drains are inserted, one on
each side.
 THE HYPOPHARYNX AND THE ESOPHAGUS

Mylohyoid raphe

Ant. belly digastricus m.

Hyoid bone

Sup. thyroid a.
Ext. br. sup. laryngeal n.
Sup. laryngeal a.
D Int. br. sup. laryngeal n.

FIGURE21-4

Resection of Carcinoma at
Posterior Wall of Hypopharynx
and Oropharynx and Radical Neck
Dissection (Lateral Pharyngotomy
Approach) (Fig. 21-5)
Discussion
Carcinoma of the hypopharynx (except for extremely
small lesions and unicentric lesions) without involve-
ment of the larynx presents a management problem
in that it appears that the best survival is achieved by
performing a total hypopharyngectomy associated with
preoperative adjuvant chemotherapy (see Chapter 3,
p. 132 and Chapter 15, pp. 720 and 732). The surgeon's
choice rests on whether a concomitant total laryn-
gectomy should be performed only to facilitate ade-
quate deglutition without aspiration. To preserve the
uninvolved larynx can result in serious problems in
deglutition. In one patient (although this result is
anecdotal), a near-total hypopharyngectomy preserv-
ing the larynx was performed preserving a narrow strip
(1.5 to 2.0 em) of hypopharynx along the contralateral
wall, one pyriform sinus, and the postcricoid mucosa.
Reconstruction consisted of the use of a dermal graft
for the posterior wall, and one half of a posterior
tongue flap (see Fig. 21-7) was used to reconstruct
the resected ipsilateral wall of the hypopharynx. After
11f2 months, this patient was able to swallow without
aspiration. A cricopharyngeal myotomy is advised if in
fact this muscle is not removed during the ablative
procedure. A laryngeal suspension is also advisable
(see Fig. 20-17).
Another patient with a subtotal hypopharyngectomy
preserving one pyriform sinus, the postcricoid area,
and the larynx, with the reconstruction consisting of
a tongue flap and dermal graft, has had more diffi-
culty swallowing. Now the patient is finally able to
digest enough food without weight loss. A cricopha-
ryngeal myotomy was not performed, and it is believed
the myotomy made the difference between the two
patients.
 THE HYPOPHARYNX AND THE ESOPHAGUS
Resection of Carcinoma at
Posterior Wall of Hypopharynx
and Oropharynx and Radical Neck
Dissection (Lateral Pharyngotomy
Approach) (Continued) (Fig. 21-5)
Highpoints
1. Lesions approximately less than 2 em in diameter
without palpable cervical lymphadenopathy are
usually resectable via an anterior transhyoid
pharyngotomy (see Fig. 21-4) or a median labio-
mandibular glossotomy (see Fig. 15-4). With larger
lesions and with all lesions associated with
palpable cervical lymphadenopathy, a transhyoid
pharyngotomy and lateral pharyngotomy approach
combined with neck dissection, or the mandibular
swing, is preferred.
2. Carcinoma of the hypopharynx and oropharynx
and of the palate, in addition to metastasizing to
the internal jugular chain of lymph nodes, also has
a propensity to spread to the parapharyngeal or
lateral lymph nodes in both a downward and an
upward plane. Also these neoplasms may spread to
retropharyngeal lymph nodes (Ballantyne, 1971).
(See Chapter 15 and Chapter 23 regarding the
parapharyngeal space.) Pharyngeal carcinoma can
behave like carcinoma of the esophagus with sub-
mucosal spread as well as be multicentric in origin.
Hence, the neck dissection should usually encom-
pass these areas. Resection of the primary lesion
must have wide margins of at least 2.5 to 3.0 em.
A frozen section should be freely used along the
margins of the primary resection. Total hypophar-
yngectomy may be indicated, but the problem is in
preservation of the uninvolved larynx when the
entire hypopharynx is removed. It is better to remove
the larynx.
3. Preoperative induction chemotherapy (see Chapter
3) is used for lesions over 2 em in diameter.
4. Protection of the carotid artery with a rotated
levator scapulae muscle flap (see Fig. 22-36) is
advisable.
5. Closure of the pharyngeal defect is achieved with
either a dermal graft and a pectoralis major myocu-
taneous flap (PMF) or a tongue flap if the base of
the tongue is preserved.
6. The larynx is preserved if not involved. If it is
involved, a laryngopharyngectomy is performed.
In the latter procedure, continuity of the orodiges-
tive tract can be reconstructed in a number of
ways, depending on the extent of the defect:
a. Tongue flap is used with dermal graft (see
Fig. 21-7).
b. A PMF with dermal graft is used for the
posterior wall (see Fig. 8-2G).
c. Dermal graft with stent (see Fig. 21-10). This is
primarily of historical interest.
d. Deltopectoral flap (see Fig. 8-4). There is a
problem of planned fistula.
e. Colon transplant or gastric pull-up when cervical
esophagus has been resected (see Figs. 21-11
and 21-14).
f. Wookey flap (see Fig. 21-9). This is occasionally
used but is mainly of historical interest.
g. A free jejunal graft is placed.
7. Tracheostomy is mandatory.
8. Take care not to injure the internal carotid artery
while resecting the primary lesion when lateral
extension is performed.
9. Perform cricopharyngeal myotomy.
10. Postoperative radiotherapy is used in selected
circumstances (see Chapter 3, p. 132).
A Cross-sectionalview shows tumor 3 em in its vertical
length extending from oropharynx to hypopharynx.
The dotted line outlines the area of resection of the
primary tumor. Minimal margin resections are 2 em
because of the problem of submucosal spread.
B Intraoral view of lesion shows its extent from just
to the right of the midline extending toward the left
lateral wall to the edge of the posterior tonsillar pillar.
The solid line outlines the area of resection. The dotted
line indicates that portion of the nasopharyngeal wall
behind the soft palate, which is resected. The lateraledge
of the soft palate is removed along with the lefttonsil and
its pillars. A radical neck dissection is to be performed.
C A radical neck dissection has been performed with
resection of the posterior belly of the digastric and
stylohyoid muscles. The contents of the neck dissec-
tion have been removed for clarity; yet it may be quite
impractical and even unnecessary to maintain conti-
nuity with the primary lesion except possibly in the
region of the tonsil.
The mandible has been transected in stepwise fashion
utilizing a Gigli saw (see Fig. 15-9A to F). The ends of
the mandible are retracted, exposing the lingual
nerve, which may require transection for adequate
exposure. More inferiorly are the 9th and 12th nerves,
as well as the superior laryngeal nerve with its internal
and external branches. The 12th and superior laryn-
geal nerves should be preserved if compatible with
adequate ablative surgery. The dotted line indicates
the incision for the lateral pharyngotomy.
Continued
 THE HYPOPHARYNX AND THE ESOPHAGUS

FIGURE 21-5
 THE HYPOPHARYNX AND THE ESOPHAGUS
Resection of Carcinoma at
Posterior Wall of Hypopharynx
and Oropharynx and Radical Neck
Dissection (Lateral Pharyngotomy
Approach) (Continued) (Fig. 21-5)
Complications
1. There is a high recurrence rate with the large tumors,
which is improved with use of preoperative adjuvant
chemotherapy.
2. Fistula formation may occur.
3. Carotid artery blowout may occur.
4. Loss of any flap is extremely dangerous in this opera-
tion, because it is usually used to cover the carotid
artery and hence may contribute to artery blowout.
5. Dysphagia and aspiration can be extremely serious
when the resection and reconstruction extend to the
cervical esophagus with preservation of the larynx.
This complication has required the suture approxi-
mation of the vocal cords after stripping of both
vocal cords. The tracheostomy is then permanent. A
laryngectomy may even be necessary. A cricopha-
ryngeal myotomy (see Fig. 21-3) may be of some
help. Sisson (1956) has described suturing the lip of
the epiglottis to the posterior pharyngeal wall to
alleviate the aspiration.
D The exposure is shown after the lateral pharyn-
gotomy. The lingual nerve can be reapproximated at
the time of closure. The tumor is well visualized except
for that portion hidden by the epiglottis. The corner of
the hyoid bone and its attachments have been
transected, as well as the hyoglossus muscle and the
lingual artery.
E Additional retraction exposes the entire tumor.
This can be accomplished by performing a suprahyoid
incision (suprahyoid pharyngotomy). The area resected
is depicted by the solid line. A Bovie or hot knife can
be utilized to outline the extent of the mucosal incision.
Its main drawback is the possible interference with
frozen section evaluation of the margins, in which any
question of the extent of the tumor arises. The prever-
tebral fascia is the usual extent of the depth of resection.
In this plane a cold knife is utilized. If there is any ques-
tion regarding involvement of the fascia, it is resected.
The parapharyngeal, retropharyngeal, and lateral
pharyngeal lymph nodes are removed, as well as the
palatine tonsil and at least the posterior pillar. In the
lateral extent of the resection, care must be exercised
not to injure the internal carotid artery. If there is
lateral extension, the sympathetic chain may require
resection.
F After resection, the cut margins of the mucosa are
sutured to the underlying fascia with moderate trac-
tion toward the defect. A dermal graft is then sutured
into the posterior wall defect. Although chromic gut is
probably used by most surgeons, continuous 5-0 or
4-0 nylon can be utilized. If nylon is used, the knots
must be buried, because the suture will remain
permanently. A PMF can also be used. Some surgeons
use no covering and allow the pharyngeal defect to
granulate and close by secondary intention. A lateral
posterior-based tongue flap can be used, but this may
contribute to marked dysphagia and lead to an oral
cripple.
The carotid artery is covered with a muscle flap of the
levator scapulae muscle or by the PMF. The pharyn-
gotomy is closed using 3-0 chromic gut continuous
sutures for the mucosal layer and interrupted gut for
the hyoglossus muscle and the pharyngeal constrictors.
Repair mandibulotomy is performed with Steinmann
pin and tie wires (see Fig. 14-1lN).
 THE HYPOPHARYNX AND THE ESOPHAGUS

FIGURE 21-5 Continued

 THE HYPOPHARYNX AND THE ESOPHAGUS

Introduction to Reconstruction of
Pharynx and Esophagus (Fig. 21-6)
Depicted is a schematic illustration of the various types
of reconstruction techniques for replacement of the
nasopharynx, oropharynx, hypopharynx, and esophagus.
This is a rule of thumb with a certain amount of overlap.
Modifications are performed depending on the surgical
approach, especially with reference to the nasophar-
ynx and oropharynx. The important points are the
following:
1. The hypopharynx does not require the use of gastric
pull-up or colon interposition for reconstruction.
2. The dermal graft combined with the tongue flap (see
Fig. 21-7) or with the PMF (see Fig. 8-2G) forms the
posterior wall of the entire pharynx and is able to
reach the vault of the nasopharynx. The PMF is used
for anterior and lateral areas (270 degrees) but not
for the entire reconstruction (360 degrees) because
of too much bulk. Neither the stomach nor the colon
is practical for use in extension this far superiorly
and is not necessary.

TONGUE FLAP & DERMAL GRAFT

NASOPHARYNX PECTORALIS MAJOR
MYOCUTANEOUS FLAP
& DERMAL GRAFT

OROPHARYNX

GASTRIC PULLUP

HYPOPHARYNX
COLON
INTERPOSITION

FIGURE 21-6

Carcinoma of the Hypopharynx and
Cervical Esophagus
There should be a distinction between the management
of carcinoma of the hypopharynx and that of the cervical
esophagus. The latter requires a total cervical esophagec-
tomy and excision of a portion of the thoracic esophagus
depending on the location of the neoplasm. With large,
long lesions the preferred operation is total esophagec-
tomy. Advanced hypopharyngeal carcinoma limited to
the hypopharynx and the larynx requires a totallaryn-
gectomy and a total hypopharyngectomy (see Discus-
sion, later). The reconstruction of this latter portion of
the food passage can be accomplished by other than a
major intra-abdominal operation and a total esophagec-
tomy. There are a number of other methods of recon-
struction. Among these are local and chest flaps and
combinations of these flaps with skin grafts. Possible
methods are listed on pages 1182 and 1199. Granted,
there is no one method that is always perfect, and this
is attested to by the number of methods described.
When there is sufficient base of the tongue remaining, a
tongue flap with a dermal graft is very suitable. It is a
one-stage procedure and, if done properly, can usually
be accomplished without the problems of fistula for-
mation, either planned or unplanned. The important
points of this operation are the fixation of the transected
proximal end of the esophagus, the dermal graft, the
tongue flap to the prevertebral fascia, and the immobi-
lization of the head and neck in a flexed position for a
period of approximately 10 days. The main complication
is varying degrees of stenosis, which usually responds
to several outpatient dilatations. There has been one
patient who has required resection of a stenotic keloid.
The tongue flap must not be utilized when either
lingual artery is sacrificed, as might be the case when
the base of the tongue is resected.
Cervical esophageal carcinoma does by and large
merit a total esophagectomy, and gastric pull-up or a
colon interposition is the treatment of choice. The
exception might be a tumor confined to the proximal
several centimeters of the cervical esophagus, if there
is no submucosal spread.
When the gastric pull-up operation with total
esophagectomy is done for the convenience of recon-
struction of the hypopharynx, it is not warranted unless
the surgeon has resected esophageal tissue because of
spread of disease. The debatable area is postcricoid
carcinoma of the hypopharynx, which may extend into
the esophagus. Frozen sections must be performed on
the margins. If there is minimal extension (1 em or less)
into the cervical esophagus, then in addition to the tongue
flap, other methods of reconstruction are available. The
PMF with dermal graft is the first choice. If there is
significant involvement of the esophagus, then total
esophagectomy is the treatment of choice. Reconstruc-
THE HYPOPHARYNX AND THE ESOPHAGUS
tion is then with gastric pull-up or colon interposition.
Free-jejunal transplant is not recommended because of
the failure rate, which in turn is a result of ischemia-
either wet or dry gangrene and the additional time
required for the vascular anastomosis to be accom-
plished. Failure is associated with high morbidity and
mortality.
The literature is replete with various data relative to
mortality and morbidity of the various types of recon-
struction for the hypopharynx and cervical esophagus.
The ranges are shown in Table 21-1.
Discussion
In advanced carcinoma of the hypopharynx and larynx,
stages III and IV, the ideal ablative operation is total
hypopharyngectomy and total laryngectomy with
radical neck dissection. Total laryngectomy is described
(see Fig. 20-18). To include a total hypopharyngectomy
is relatively easy and makes for a clear-cut operation.
There does not appear to be any reason to leave a small
strip of posterior hypopharyngeal wall to facilitate recon-
struction of the gullet, because the entire hypopharynx
can be reconstructed in a one-stage operation in most
patients with a tongue flap and dermal graft. By using
the concept of Sisson and Hiranandani (see Figs. 20-22
and 21-7) to close anterior pharyngeal defects, the
tongue flap has been extended with a combination of a
dermal graft with some mobilization of the cervical
esophagus to facilitate a one-stage reconstruction. To
perform a total esophagectomy and reconstruction with
a gastric pull-up simply for the purpose of reconstruc-
tion of the hypopharynx appears unjustified. If for some
reason the tongue flap is too short (e.g., when there is
significant involvement of the base of the tongue, thus
shortening the availability of the tongue flap), alternate
TABLE21-1 Mortality and Failure Reported
With Reconstruction of the Hypopharynx and
Cervical Esophagus
Type Mortality Failure
Gastric pull-up Up to 8% to Most reports: a
18%
Up to 8% to
Jejunum Up to 6%
15%
Pectoralis major a a
myocutaneous
flap and
posterior tongue
flap with dermal
graft
 THE HYPOPHARYNX AND THE ESOPHAGUS
Introduction to Reconstruction of
Pharynx and Esophagus (Continued)
(Fig. 21-6)
local methods of reconstruction are available: combina-
tion of cervical flaps (see Figs. 21-9 and 21-10); deltopec-
toral flap (see Fig. 8-4); and the PMF combined with a
dermal graft (see Fig. 21-8). This latter procedure (pre-
ferred by the author (JML) when the base of tongue is
resected, which precludes the use of a tongue flap)
utilizes the PMF to form the anterior and lateral walls
of the gullet and a dermal or epidermal split-thickness
graft to form the posterior wall of the gullet. This has
proved very satisfactory in situations requiring the base
of tongue to be resected. By utilizing the dermal or
epidermal graft for the posterior wall, the objectionable
bulk of the PMF is reduced.
After total laryngectomy and total hypopharyngectomy
with or without radical neck dissection for stage III and
stage IV carcinoma of the hypopharynx, the one-stage
immediate reconstruction of the surgical defect can be
achieved with local flaps using a dermal graft. This
section of the reconstruction surgery primarily depends
on the extent of disease and the size of the surgical
defect.
Two methods of reconstruction of the hypopharynx
and cervical esophagus are depicted:
I. Tongue flap with dermal graft (see Fig. 21-7).
2. PMF with dermal graft (see Fig. 21-8).
Myomucosal Tongue Flap and
Dermal Graft for Reconstruction
of Entire Hypopharynx, Posterior
Wall of Oropharynx, and
Nasopharynx Associated With
Total Laryngectomy and Total
Hypopharyngectomy (Fig: 21-7; see
Fig. 20-22)
Highpoints
I. This is a one-stage operation.
2. Liberal use of frozen sections on margins IS
required.
3. Anterior defect that is closed can be up to 6 to 8 cm
in length.
4. Mobilize esophagus for 1 to 2 cm.
S. Suture all mobilized oropharyngeal and esophageal
mucosa and underlying muscle to prevertebral
fascia. This avoids tension on mucosa-to-mucosa
sutures.
6. Suture dermal graft to prevertebral fascia. This
forms posterior wall of new gullet.
7. Tongue flap forms anterior and lateral walls of new
gullet.
8. Vertical incision is made in anterior and/or posterior
wall of esophagus to widen lumen and anastomotic
suture line.
9. Radical neck dissection is easily combined with the
resection to include the parapharyngeal and
retropharyngeallymph nodes.
10. Care should be taken not to injure either the lingual
arteries or, if possible, the hypoglossal nerves while
developing the tongue flap.
11. Immobilize the head and neck in a flexed position
for 10 days postoperatively with a plaster posterior-
molded splint that is well padded.
12. Resection can include the posterior wall of the
oropharynx and nasopharynx. This defect is covered
with the dermal graft.
13. Extreme care is taken regarding the internal carotid
artery in nasopharyngeal resection.
14. CT of the neck and mediastinum is done; and if there
is any question regarding the extent of disease,
then MRI should be performed.
15. If there is significant mediastinal node disease,
perform a mediastinoscopy (see Fig. 19-8).
A A total laryngectomy and a total hypopharyn-
gectomy have been performed. The oropharynx and
esophagus have been mobilized, and their free edges
have been sutured to the prevertebral fascia. This fixes
these structures and minimizes the tension on the
mucosa to dermal graft sutures. The dermal graft is
sutured laterally and distally to the prevertebral fascia,
and the upper and lower ends are sutured to the mucosa
of the oropharynx and esophagus. The anterior and
posterior walls of the esophagus are split vertically in
the midline for a distance of 1 or 2 em to enlarge its
lumen. The tip of the tongue flap is sutured into the
anterior split while the dermal graft is sutured into the
posterior split. The horizontal dotted line across the
base of the tongue indicates the incision to form the
tongue flap. (See Fig. 20-22 for the technique to
develop the tongue flap.)
B Lateral view depicts mobilization of the tongue
flap.
C The tongue flap has been tubed about 270 degrees
to form the anterior and lateral walls of the newly con-
structed gullet. The dermal graft forms the posterior
wall. The tongue flap is sutured not only to the dermal
graft but also to the prevertebral fascia. Distally, it is
sutured to the esophagus and the prevertebral fascia

FIGURE 21-7
with through-and-through sutures, using either inter-
rupted or continuous Connell sutures. If continuous
sutures are used, it is best that they be in two sections,
right and left, to avoid a purse-string effect and thereby
narrow the lumen. The distal top of the tongue flap is
pulled into the vertical esophageal incision, thereby
widening the lumen. The same is performed with the
dermal graft posteriorly. A second layer of three inter-
rupted sutures through esophageal and tongue mus-
culature may be used for reinforcement, although the
initial mucosa-to-mucosa 'sutures are by far the more
important. Superiorly, the dermal graft can be extended
to cover a posterior defect from associated resection of
the oropharynx and nasopharynx to just above the
level of the eustachian tubes.
When the dissection includes the lateral wall of the
nasopharynx, the internal carotid artery can be placed
in serious jeopardy because it may be only several
millimeters deep to the mucosa. Hence, take extreme
care in this dissection. When the vessel is exposed, it
should be protected with either a transposed muscle
THE HYPOPHARYNX AND THE ESOPHAGUS
flap or a turned-in flap of prevertebral fascia. The fascia
is then covered with a dermal graft, which likewise covers
the posterior wall of the nasopharynx. Preoperative
evaluation of intracranial blood flow is advised, as is
digital subtraction angiography, CT, MRI, and MR
angiography (MRA) with enhancement to localize the
internal carotid artery.
o Cross section through the new gullet demon-
strates the tongue flap forming the anterior and lateral
walls and the dermal graft forming the posterior wall.
The so-called prevertebral fascia is actually the
posterior cervical fascia and is made up of two layers:
the alar fascia and the true prevertebral fascia being
separated by loose connective tissue. Each layer is
attached to the ends of the transverse processes of the
vertebrae. When portions of the prevertebral fascia are
resected with the posterior pharyngeal wall, the dermal
graft is then sutured to the anterior longitudinal
ligament. This ligament is a band extending along the
anterior surface of the bodies of the vertebrae.
 THE HYPOPHARYNX AND THE ESOPHAGUS
Myomucosal Tongue Flap and
Dermal Graft for Reconstruction
of Entire Hypopharynx, Posterior
Wall of Oropharynx, and
Nasopharynx Associated With
Total Laryngectomy and Total
Hypopharyngectomy (Continued)
(Fig. 21-7; see Fig. 20-22)
The classic radical neck dissection is performed with
primary ablative surgery. However, the neck dissection
is extended to include the parapharyngeal and retropha-
ryngeal nodes. Pharyngeal nodes lying along the side
of the entire pharynx-naso-, oro-, and hypopharynx-
and the retropharyngeal nodes behind the entire
pharynx are a group of nodes that are not encompassed
in the standard neck dissection and must be removed
in operations involving any portion of the pharynx.
Ballantyne (1971) has emphasized the importance of
removing the retropharyngeal nodes involved in some
patients with other primary sites (e.g., base of the
tongue, tonsil, soft palate, retromolar trigone, cervical
esophagus, and gum).
Limitations of this technique after total laryngectomy
and hypopharyngectomy are as follows: (1) extension
of disease into the cervical esophagus, (2) anterior
defect larger than 8 em, and (3) tumor extension to
significant portion of the base of the tongue. When the
tumor extends beyond the hypopharynx significantly
into the cervical and thoracic esophagus, total esophagec-
tomy is necessary. Limited extension into the cervical
esophagus can be resected and reconstructed with a
PMF and dermal graft. The PMF is rotated 270 degrees,
as is the tongue flap, and the dermal graft is used pos-
teriorly as in the tongue flap (Lee and Lore, 1986). In
females, especially those with large pendulous breasts,
the pectoralis major muscle alone can be used without
breast tissue and without skin. The bare muscle is then
covered with a dermal graft or a skin graft to eliminate
bulk. The margins must be free of disease, as con-
firmed by frozen section.
Although radiotherapy is not utilized preoperatively,
it is used in selected circumstances postoperatively as
follows:
• The highest and/or lowest nodes are positive.
• Disease involves the deep muscles of the neck or
extends beyond the usual fascial plane of the neck
dissection.
• Disease has broken the capsule of the cervical nodes.
• Margins are positive.
• Disease is left behind, or the surgeon is not satisfied
that the operation has been a "clean dissection."
For results, see the section in Chapter 3 on preopera-
tive chemotherapy, uncompromised surgery, and selective
radiotherapy.
Cervical Esophagoscopy
Cervical esophagoscopy is done after total laryngectomy
or cervical esophageal surgery. Examination of the
pharyngoesophageal area and the cervical esophagus
can be performed with the use of a flexible nasopharyn-
goscope, which has a suction port and a second port for
instillation of medication by attaching a short section
of tubing with a bulb for inflation (similar to the bulb
used on a sphygmomanometer) to inflate and distend
the esophagus (see Chapter 3).
Reconstruction of Hypopharynx
and Cervical Esophagus Using PMF
With Dermal Graft (Fig. 21-8)
A This is an excellent method of reconstruction of
the entire hypopharynx after total laryngectomy and
total hypopharyngectomy as well as excision of a
portion of the cervical esophagus when the defect is
too large for a tongue flap and dermal graft (see
Fig. 21-7). The PMFis tubed 270 degrees, forming the
anterior and lateral walls of the reconstructed gullet,
just as a tongue flap is used. The dermal graft forms
the posterior wall of the hypopharynx and esophagus.
The dermal graft can be extended superiorly to recon-
struct the posterior wall of the oropharynx and naso-
pharynx to just above the level of the eustachian tube.
It is important that the flap and dermal graft be
sutured to the prevertebral fascia to prevent tension
on the mucosal closure suture lines. This method
reduces the bulk of an entirely tubed PMF, which is
detrimental to adequate deglutition.
When the dissection includes the lateral wall of the
nasopharynx, the internal carotid artery can be jeop-
ardized because it may only be several millimeters
deep to the mucosa. Hence, take extreme care in this
dissection. When the vessel is exposed, it should be
protected with either a transposed muscle flap or a
turned-in flap of prevertebral fascia. The fascia is then
covered with a dermal graft, which likewise covers the
posterior wall of the nasopharynx. Preoperative evalua-
tion with MRI and MRA is used to evaluate the internal
carotid artery, its location, and any distortion.
 THE HYPOPHARYNXAND THE ESOPHAGUS

ESOPHAGUS

DERMAL GRAFT

POSTERIOR

SKIN OF
FLAP ~
AI
ANTERIOR

FIGURE 21-8

A 1 This is a cross section of the reconstructed
hypopharynx utilizing the PMFwith the posterior dermal
graft. If additional length is necessary, the medial' one
half of the clavicle is resected (see Fig. 19-9). In addition,
this is admirably suited to fill in the dead space in the
supraclavicular region after a radical neck dissection. It
also avoids the bulk of the muscle over the clavicle and
minimizes compression of the axial vessels on the
clavicle. This additional length is particularly useful in
total tongue replacement with this flap.
 TH~HWmHARYNXANDTH~~m~~AGU~
Reconstruction After Partial
"Cuff" Cervical Esophagectomy,
Hypopharyngectomy, and Total
Laryngectomy Above the Thoracic
Inlet Using Local Cervical Flaps
Cancer of the esophagus whether cervical and/or thoracic
usually requires a total esophagectomy. The disease
can spread submucosally and can be multicentric. In
addition, cancer of the cervical esophagus above the
thoracic inlet usually necessitates removal of the larynx
as well. With involvement of the hypopharynx and
cervical esophagus, preservation of the larynx is impos-
sible. One exception to the dictum of total esophagec-
tomy might be minimal involvement (1 to 2 cm) of the
cervical esophagus by extension from a primary carci-
noma of the postcricoid region of the larynx (classified
as part of the hypopharynx). In this latter event, limited
cervical esophagectomy with total laryngectomy and
total hypopharyngectomy and radical neck dissection
may be justified rather than total esophagectomy. A total
esophagectomy with gastric pull-up or bowel interpo-
sition does not appear justified solely for the purpose
of reconstruction of the hypopharynx and several cen-
timeters of the cervical esophagus. Reconstruction can
be facilitated by a number of methods utilizing local
flaps and/or chest flaps.
Some of these methods, albeit, are mainly of a his-
torical interest. Nevertheless, the knowledge of these
methods and modifications thereof are of interest to the
head and neck oncologic surgeon:
1. Lateral skin flap (Wookey) (historical interest;
occasionally used) (see Fig. 21-9)
2. Free-skin graft over tantalum (historical interest)
(see Fig. 21-10)
3. Thoracic skin flap (primarily historical interest) (see
Fig. 21-10)
4. Deltopectoral flap (see Fig. 8-4) (problem of planned
fistula)
5. PMF with a dermal graft
6. Tongue flap with a dermal graft (may have limitation
as to length of tongue flap) (see Fig. 21-7)
7. Free jejunal transplant for reconstruction of the
hypopharynx and cervical esophagus. This is not
warranted for reconstruction of the hypopharynx
alone, because the tongue flap or PMF and dermal
graft is an easier and very satisfactory procedure.
Methods NO.5 and NO.6 are preferred by the author
(JML).
Highpoints
1. Perform adequate preoperative evaluation.
2. The prime consideration is adequate resection of
tumor and its avenue of spread.
3. Do not hesitate to revise a' preoperative conception
of the spread of disease during the procedure and
extend resection of cervical esophagus to include the
thoracic esophagus.
4. Avoid the use of a hair-bearing flap, if possible. Hair
within the reconstructed gullet can cause obstruction.
Nevertheless, the adequacy of the reconstruction
takes precedence over the problem caused by hair.
The patient can be so informed only if the surgeon
believes that the information may be helpful.
Lateral Skin Flap (Wooker) (Fig. 21-9)
This procedure is seldom utilized now; however, its
description is warranted not only from a historical point
of view but also from the basic principles portrayed. It
has been modified in such a fashion that simply a
cervical flap has been used to form the posterior lining
and a deltopectoral flap used as the anterior covering.
Montgomery (1963) and others have described other
variations of cervical flaps to reconstruct the cervical
esophagus. One criticism of any cervical flap derived
from the unoperated neck is the obscurity in the
detection of early lymph node metastasis on the donor
flap side of the neck.
A A laterally based skin flap is outlined in which the
base is significantly wider than the distal free margin.
The base of the flap is situated on the side opposite the
bulk of the disease so that a radical neck dissection
may be performed on the side opposite the base of the
flap. It is not feasible to perform a bilateral neck dissec-
tion, because the skin flap derives a considerable
amount of its blood supply from the upper portion of
the sternocleidomastoid muscle.
B The skin flap with the platysma muscle is elevated.
The lower half of the sternocleidomastoid muscle on
the side of the base of the flap is resected while the
upper half is preserved. Following the technique of
total laryngectomy (see Fig. 20-18), the larynx,
cervical esophagus, a portion of the hypopharynx, and
the right lobe of the thyroid gland are removed.
 THE HYPOPHARYNX AND THE ESOPHAGUS

Sternal head
A B
sternocleidomastoid m.

c D
FIGURE 21-9

( The skin flap is now placed across the prevertebral
fascia, and the posterior margin of the pharynx is
sutured to the upper margin of the skin flap.
D With the posterior margins of pharynx and
esophagus sutured to the respective margins of the
flap, the flap is now folded back, suturing the anterior
margin of the pharynx to the flap. At this stage a nasal
feeding tube is inserted.
Continued
 THE HYPOPHARYNX AND THE ESOPHAGUS

Lateral Skin Flap (Wookey) (Continued)

(Fig. 21-9)
F After at least 5 weeks have elapsed following com-
plete wound healing, the right-sided fistula is closed
E The same procedure is now performed with the by turning in the skin edges. Two vertical incisions are
esophageal margin, and the flap is again folded on made along the folds of the fistula.
itself so that the raw surfaces of the flap approximate
one another. Any remaining bare area on the left side G The inner flaps are approximated to one another.
that cannot be closed with a left-sided advanced flap
is covered with split-thickness skin. A right-sided lateral H The outer flaps are then sutured to one another,
fistula is allowed to remain until the final stage. An ellipse closing the fistula.
of skin is excised as far below the lower skin margin
and as far to the left as possible for the tracheostomy. The completed operation is shown.
It is important that as wide an area of skin as possible
remains between the tracheostomy and the skin flap.
The farther away the tracheostomy is from the fistula
the better.
 THE HYPOPHARYNX AND THE ESOPHAGUS

F G

FIGURE 21-9 Continued

 THE HYPOPHARYNX AND THE ESOPHAGUS
Free Skin Graft Over Tantalum Gauze
(Fig. 21-1 OA to C)
The main drawback of this procedure, first described by
Rob in 1941 and later used by Edgerton (1952), is the
resulting scarring and stenosis. Some difficulty may be
encountered in the removal of the tantalum mesh.
Scarring may be reduced by using a dermal graft rather
than an epidermal split-thickness graft.
A A split-thickness skin graft is sutured around the
outside of a suitable length of tantalum gauze, with
the raw surface of the skin graft facing out.
B The completed funnel-shaped tube of skin and
tantalum is then sutured to the pharynx above and the
esophagus below. This reconstructive procedure is
performed at the time of the definitive surgery.
The tantalum may be left in situ permanently or
removed through an esophagoscope.
C The manner of anastomosis is depicted.
Thoracic Skin Flap (Conte, 1958)
(See Fig. 21-1 OD to H)
D As a secondary procedure on a patient with a
pharyngostomy, esophagostomy, and tracheostomy,
reestablishment of continuity of the oroesophageal
tract can be achieved with a single-pedicle thoracic
skin flap. The thoracic skin flap forms the anterior wall
of the reconstructed esophagus while the existing skin
of the neck extending from the pharyngostomy to the
esophagostomy forms the posterior wall. A delay should
not be necessary when the base of the flap is at least one
third of the length. If there is any question regarding
viability, a 2-week delay is advised. Two parallel vertical
incisions extending from the pharyngostomy to the
esophagostomy are made to receive the edges of the
skin flap.
E The distal free end of the skin flap is sutured to the
anterior mucous membrane rim of the pharyngostomy.
Continued
 THE HYPOPHARYNX AND THE ESOPHAGUS

A B

Ant. mucous membrane

wall of pharyngostome

Distal free end of skin flap

Pharyngostome

Esophagostome
D E

FIGURE 21-10
 THE HYPOPHARYNX AND THE ESOPHAGUS

Thoracic Skin Flap (Continued) (Conte,

1958) (See Fig. 21-1 OD to H) G After both sides of the skin flap are sutured, two
lateral skin flaps are mobilized to cover the raw exposed
skin flap.
F The sides of the skin flap are sutured to the inner
skin edges formed by the vertical incisions.
H The completed reconstruction is shown. A
modification of this concept would be the use of a
deltopectoral flap (see Fig. 8-4A and B) rather than the
thoracic flap shown.

Distal free end of skin flap

.: Side of skin flap

Inner cervical skin edge

Lateral cervical skin flap

FIGURE 21-10 Continued


Resection for Cancer of the
Cervical Esophagus
Cancer of the cervical esophagus has been discussed
(see p. 1187) and usually requires a total esophagectomy.
When the cancer is in the cervical region, another
consideration is the clearance between the tumor and
the cricoid cartilage of the larynx. This must be of such
a length that adequate ablative surgery is feasible and
enough suitable proximal esophagus for tension-free
and tumor-free anastomosis is available. Hence, the
preservation of the larynx is considered only when the
lesion is located at the thoracic inlet and has no superior
extension. Otherwise, a total laryngectomy with total
esophagectomy is needed. Another consideration is
metastases to regional lymph nodes-cervical and/or
mediastinal-as well as infradiaphragmatic spread to
celiac nodes and the liver. Bronchoscopy preoperatively
must be done to evaluate the membranous portion of
trachea. CT and MRI to further evaluate the extent of
disease with video pharyngoesophagography may furnish
additional data.
The choices of total esophagectomy are either transtho-
racic or extra thoracic. Depending on the condition of
the patient, a one- or two-stage procedure is possible.
Induction chemotherapy with radiotherapy has a place
in multimodality treatment and appears to be the treat-
ment of choice. Radiotherapy is not utilized preoperatively
when surgery is planned but is used selectively post-
operatively. Another regimen for consideration would
be preoperative chemotherapy, uncompromised surgery,
and selective radiotherapy (see Chapter 3, p. 132).
Reconstruction after total esophagectomy is by gastric
pull-up or by colon interposition (see Figs. 21-[[ and
21-14) or occasionally by jejunum. When jejunum is
transposed, it may not reach above the aortic arch,
owing to the limitation of the length of the vessels. The
esophageal neoplasm may extend through the wall to
be in contact with the descending aorta. When jejunum
is used as a free graft requiring microvascular anasto-
mosis, it is usually limited to replacement of the cervical
esophagus, although total replacement has been reported
by Nakayama and colleagues (1962) and Chang and
associates (1980).
Pathologic Outline for Cervical Esophageal
Disease
1. Squamous cell carcinoma
2. Barrett's esophagus
3. Adenocarcinoma
4. Polyp (may have adenocarcinoma)
5. Ectopic gastric mucosa
6. Scleroderma
THE HYPOPHARYNX AND THE ESOPHAGUS
Colon Interposition (See Fig. 21-14A to Pl)
Advantages, disadvantages, and suggestions include
the following:
1. Both the transverse and the descending colon are
preferred over the ascending colon because of the
thicker wall and better blood supply, although the
selection depends on preoperative angiographic studies,
the intra-abdominal findings, and the presence of
significant diverticula as seen on barium enema.
2. Good adequate length is required. Scanlon and Staley
(1958) have brought the colon up to the base of the
tongue.
3. Blood supply is usually good.
4. Either isoperistaltic or antiperistaltic segment is feasible
(see Fig. 21-14E to K).
5. Reflux seldom occurs, especially with an isoperistaltic
segment.
6. Possible necrosis and cervical anastomotic leak are
disadvantages.
7. Three anastomoses are necessary:
a. Cervical colostomy
b. Cologastrostomy
c. Colocolostomy
8. Approach can be either substernally or via the
posterior mediastinum or subcutaneously.
Gastric Interposition
These are two types of interpositions. Advantages,
disadvantages, and suggestions include the following:
Gastric Pull-Up of Intact Stomach (see Fig. 2'-")
1. Fundus will reach the hypopharyngeal-oropharyngeal
junction.
2. Blood supply is excellent via the right gastric and
right gastroepiploic vessels.
3. One anastomosis is required.
4. Previous gastric resection is a contraindication-
colon is then utilized.
5. Gastric reflux may occur.
6. Dumping syndrome may occur.
7. Tissue is isoperistaltic.
Greater Curvature Gastric Tube
1. Either antiperistaltic or isoperistaltic tissue is used.
2. Tube must reach the hypopharynx.
3. Blood supply is reasonably good but not as good as
with a gastric pull-up.
4. One anastomosis is required but extensive closures
are needed to form the gastric tube and to close the
edges of the retained stomach.
5. Cervical anastomotic leak may occur.
6. Reflux is possible.
 THE HYPOPHARYNX AND THE ESOPHAGUS
In summary, the gastric pull-up appears to be preferred
over the gastric tube and is depicted in Figure 21-11.
Gastric Pull-Up (Fig. 21-11)
Resection of cancer of the cervical esophagus at the
thoracic inlet requires a total extrathoracic esophagectomy
and immediate reconstruction using either gastric pull-
up or colon. Gastric pull-up precludes any previous gastric
surgery; under such circumstances the colon would be
the choice.
The cervical approach is through a horizontal incision
similar to that used for thyroidectomy with or without
a vertical midline superior extension when laryngectomy
is performed. The approach can be either from the left
side (see Fig. 21-13A to D) or from the right side (see
Fig. 21-12A to Pl. The left-sided approach is preferred,
with the extrathoracic total esophagectomy, because the
esophagus is usually slightly to the left of the trachea.
Very careful blunt dissection is utilized to separate
the esophagus from the trachea. It is here that the
membranous trachea can be vulnerable, because the
esophagus and trachea may be adherent from fibrous
reaction to the tumor or from invasion by tumor. If the
latter exists, then two alternatives are available: either
terminate the resection and (1) bypass the tumor with
substernal colon plus chemotherapy and radiotherapy
or radiotherapy alone or (2) transect the tumor, thus
separating the trachea from the esophagus and leaving
some of the neoplasm attached to the trachea, and follow
with postoperative radiotherapy. Resection of the trachea
has been reported but seems hardly justified and worth
the additional risk. If the membranous trachea is entered,
for example as a result of adhesions, the closure may
be possible through the suprasternal approach, depending
on the distance involved. Otherwise, better exposure
can be obtained through a right thoracotomy, as shown
in Figure 21-12A to P. Reflected pleura, if possible, can
be of some aid in the closure but is not absolutely
necessary if an air-tight approximation is obtained. If
transposed stomach or colon is brought up through the
posterior mediastinum, these structures, too, will
reinforce the closure.
Gastric Pull-Up With Extrathoracic
Esophagectomy
Indications and Discussion
For the head and neck surgeon gastric pull-up has its
application when total esophagectomy is indicated to
accomplish adequate tumor resection. It is also indi-
cated for tracheal stomal recurrence that involves the
cervical esophagus (e.g., the Sisson type II). Ochsner
(1978) points out that extrathoracic esophagectomy is
not new, having been described by Denk in the 1920s
and Clairmont in 1924. Its application for carcinoma of
the thoracic esophagus is not without significant con-
troversy because of its complications and the fact that
the mediastinal nodes by and large are not removed.
Orringer and Orringer (1983) indicate an 8% operative
mortality (within 30 days of the surgery), with a
hospital mortality of 12% in 143 patients, 128 (93%) of
whom had gastric interposition and 10 of whom had
reconstruction with colon transposition. Thirty-one
patients had resection of the cervi cothoracic esophageal
carcinoma, and, of these, 8 patients (26%) died while
in the hospital. It appears that in light of this article
there is a higher mortality when the procedure is com-
bined with total laryngopharyngectomy. Hence, the
choice of this operation must be carefully decided and
cannot be justified simply to reconstruct the hypopharynx
after total laryngopharyngectomy (see p. 1142).
Highpoints
1. Two surgical teams are needed-one for the
abdominal and inferior mediastinum and one for
the cervical and superior mediastinum.
2. Preserve the blood supply-right gastric artery and
right gastroepiploic artery.
3. Ligate and divide left gastroepiploic vessels, left
gastric artery, and short gastric vessels.
4. Transect the gastrocolic ligament and gastrohepatic
ligament.
S. Perform pyloromyotomy or pyloroplasty.
6. Kocher maneuver is used to obtain the additional
length of the mobilized stomach.
7. Expose the esophagogastric junction with an incision
through the overlying peritoneum and encircle the
junction with a Penrose drain.
8. Blunt mediastinal dissection is done with the volar
aspect of the fingers close to the esophagus to
avoid either entering pleural cavity or injury to the
tracheobronchial tree, especially in the area of the
carina. The membranous trachea is the danger area
when the esophagus is being dissected from the
trachea.
9. With retraction at the diaphragmatic hiatus, the
esophageal vessels can be visualized and clipped
almost to the level of the carina.
10. Care must be taken not to exert too much traction
on the stomach until it is well mobilized.
11. Transect the esophagogastric junction with a GIA
stapler, and oversuture the cardia.
12. Anastomosis of the hypopharynx to the fundus of
the stomach with supporting sutures of the stomach
to the prevertebral fascia is performed.
13. Continual monitoring of the intra-arterial blood
pressure is required to avoid prolonged hypotension
from cardiac displacement.
14. A stapler is utilized wherever adaptable.

A The abdomen has been entered with an upper
midline incision. The liver and lymph nodes, especially
those in the celiac axis, are checked for any evidence
of metastasis. Positive disease is not necessarily a con-
traindication to proceed. Nevertheless, if the intra-
abdominal disease is present, consideration must be
given to other forms of bypass procedures (e.g., if
there is obstruction at the thoracic inlet, a substernal
colon interposition may be the procedure of choice,
leaving the esophagus in place). The distal end of any
esophageal segment should not be closed without
decompression of the esophagus proximally.
The left gastric artery and the left gastroepiploic
vessels are transected and ligated, the latter being
transected asfar proximally as possible. The gastrocolic
and gastrohepatic ligaments are transected, and the
FIGURE 21-11
THE HYPOPHARYNX AND THE ESOPHAGUS
greater omentum is separated from the stomach. The
short gastric vesselsare ligated and transected, taking
care not to injure the spleen. The right gastric and the
right gastroepiploic vesselsare preserved. A pylorotomy
or pyloroplasty and a Kocher maneuver (along the
dotted line mobilizing the duodenum) are performed.
The peritoneum overlying the esophagogastric junc-
tion is incised, and the vagus nerves are transected. A
Penrose drain is place-d around the esophagogastric
junction; and with gentle downward traction on the
Penrose drain, the right hand is inserted through the
hiatus of the diaphragm. If necessary, the margin of
the right crus of the diaphragm is sectioned to facilitate
the insertion of the hand behind the esophagus.
Continued
 THE HYPOPHARYNX AND THE ESOPHAGUS
Gastric Pull-Up (Continued) (Fig. 21-11)
8 The hand is inserted with the volar surface facing
the posterior wall of the esophagus, taking care not to
injure the pleura. This blunt dissection must be in the
midline. The blunt dissection is carried up to the carina.
It is at this point that extreme care must be taken to
avoid injury to the membranous portion of the trachea.
It is best not to proceed any farther from below at this
point.
If a total laryngopharyngectomy is to be performed
as depicted, this portion of the procedure is done as
described in Figure 20-18, except that the resection is
commenced at the level of the hyoid bone superiorly,
and the entire hypopharynx is resected with the larynx.
At this point, the trachea is transected just above the
suprasternal notch, and the endotracheal tube is inserted
in the distal end of the trachea to allow for the anes-
thesia to be continued. The resection then proceeds
inferiorly down to the thoracic inlet, mobilizing the entire
larynx and hypopharynx, taking care to include all
parapharyngeal, retropharyngeal, and tracheoesophageal
lymph nodes. The posterior plane of this dissection is
just anterior to the prevertebral fascia. If, however, this
fascia is involved, it, too, is resected. If there is lateral
cervical lymphadenopathy, a radical neck dissection is
performed in continuity with the larynx and hypopharynx
(see Fig. 20-21A to 11), removing the ipsilateral thyroid
lobe and the isthmus. The contralateral thyroid lobe
mayor may not require removal. It may be possible to
preserve at least the contralateral parathyroid glands,
but probably these will be removed with the contralateral
thyroid lobe and the tracheoesophageal nodes. A search
is then conducted within the specimen for parathyroid
glands. Frozen sections of preserved parathyroid glands
are performed to verify their histology to be certain that
no malignant tissue is included. The parathyroid glands
are then sectioned in as small portions as possible and
reimplanted in the muscle as far from the diseased area
as possible (e.g., the anterior border of the trapezius
muscle) and are marked with metal clips or black silk
sutures.
If the larynx and hypopharynx are not involved and
not resected, then the surgical approach is the same as
that depicted on Figure 21-13A to D. Figure 21-13E to K
describes an esophagocolon anastomosis. A similar type
of anastomosis can be performed with the mobilized
stomach. Extreme care is taken to identify and to preserve
the recurrent laryngeal nerves when the larynx is pre-
served. There should be no tension or pressure on these
nerves during the surgical procedure. When additional
space is required at the thoracic inlet, especially if the
stomach is brought substernally, the medial one third
of the clavicle is resected as shown in Figure 19-9.
Blunt dissection is now begun at the superior thoracic
inlet, continuing along the same plane as that for the
mobilization of the hypopharynx and cervical esophagus,
namely, the prevertebral fascia. The anterior plane is
along the tracheoesophageal line, with care taken not
to injure the great vessels that lie anterior and lateral to
the trachea (see Fig. 19-7). During this dissection the
fingers are kept close to the esophagus. Extreme care is
taken not to injure the azygos vein and the membranous
portion of the trachea. If significant bleeding occurs, a
right thoracotomy may be necessary to control the
bleeding (see Fig. 21-121 to R).
81 This illustration depicts the extreme care that
must be taken in the separation of the anterior wall of
the esophagus from the membranous portion of the
trachea. Adhesions may be present, especially if there
has been preoperative radiotherapy. The authors would
not use preoperative radiotherapy but rather preopera-
tive adjuvant chemotherapy, reserving radiotherapy
for postoperative management of any nonresectable
disease or suspected residual disease, especially with
positive mediastinal lymph nodes. This dissection then
reaches the carina and joins the mobilization from
below. The sponge stick inserted through the superior
thoracic inlet may be guided in its inferior extent by
the surgical team via the abdominal route. The intra-
arterial blood pressure is continually monitored during
the mediastinal dissection to detect and thus avoid any
prolonged hypotension resulting from cardiac com-
pression or displacement.
 THE HYPOPHARYNX AND THE ESOPHAGUS

\
\.,
\

r
\

FIGURE 21-11 Continued

 THE HYPOPHARYNX AND THE ESOPHAGUS
Gastric Pull-Up (Continued) (Fig. 21-11)
If the membranous portion of the trachea is entered
(see point x in B), closure of the defect may be accom-
plished through the suprasternal approach. If this is not
feasible, a right thoracotomy is necessary. The stomach,
when brought into the posterior mediastinum, will aid
in buttressing this closure.
C, Cl The larynx, thyroid gland, hypopharynx, and
proximal trachea with parapharyngeal, retropharyn-
geal, and tracheoesophageal lymph nodes, and the
entire esophagus, are delivered through the superior
thoracic inlet. The contents of a radical neck dissection,
if performed, have been omitted for the purposes of
clarity.The cardioesophageal junction is transected and
closed with a GIA stapler along the dashed line. The
closure is reinforced with 3-0 silk or Prolene using a
Lembert-type suture.
The pharyngogastric anastomosis is performed at
the fundus of the stomach by first securing the fundus
just above the opening into the stomach, to the
prevertebral fascia by interrupted sutures (see C1, also
Fig. 21-12V). This helps reduce the tension at the anas-
tomotic line. If there is any possibility of tension an
elective pharyngostomy is necessary. The anastomosis
is completed by interrupted through-and-through sutures
between the pharynx and the stomach. There is a
problem of no serosa on the hypopharynx and esopha-
gus. Decompression of the stomach can be achieved
with either a nasogastric tube or a pharyngostomy tube.
A feeding jejunostomy is optional. One or two suction
catheter drains are utilized in the cervical and thoracic
inlet region, with care taken so that these catheters do
not cross and are not close to any major vessels.
Complications
• Tension pneumothorax
• Hemorrhage
• Innominate artery rupture
• Thoracic duct injury
• Splenectomy
• Anastomotic leaks-pharyngogastrostomy anastomotic
leaks occur 29% of the time (Orringer). Fistula may
occur with trachea in the cervical area.
• Stricture-8% (Orringer)
• Cervical dysphagia-50 % require dilatation (Orringer)
• Postvagotomy diarrhea
• Regurgitation-75 % with laryngopharyngectomy
(Orringer)
• Vocal cord paresis or paralysis when the larynx is
preserved
• Subphrenic abscess
• Dumping syndrome
• Gastric dilatation
• Sepsis
• Hypoparathyroidism-73 % (Krespi et aI., 1985)
• Respiratory failure secondary to chest infection
(Lam et aI., 1981)
• High overall rates of mortality (18%) and com-
plications (40%) (Ujiki et aI., 1987). Hence it is clear
that other reconstructive procedures are preferable.
When reconstructing the hypopharynx and proximal
two thirds of the cervical esophagus a myomucosal
tongue flap and dermal graft (pp. 1188 to 1190) or
PMF and dermal graft (pp. 1190 and 1191) are used
unless total esophagectomy is indicated for adequate
resection.
 THE HYPOPHARYNX AND THE ESOPHAGUS

ANTERIOR BELLY DIGASTRIC M.

FIGURE 21-11 Continued

 THE HYPOPHARYNX AND THE ESOPHAGUS

Resection of Cancer of Cervical

Esophagus at the Thoracic Inlet A The inframammary thoracic incision is made over
(Fig. 21-12) the right fifth rib by elevating the breast. This incision
is made after the steps outlined in Band C have been
Carcinoma of the cervical esophagus at the thoracic performed. The dotted vertical incision is optional,
inlet presents a significant challenge in that adequate depending on whether a sternotomy is necessary for
exposure at the inlet may be limited. Median sternotomy adequate exposure. The reason for the low inframam-
or resection of the medial third of the clavicle may be mary incision is to preserve skin and pectoralis major
necessary for additional exposure (see Fig. 19-9). The muscle for the possible use of a PMF for reconstruction.
spread can be proximal, leading to laryngectomy, or
distally into the thoracic esophagus. Free use of frozen B After upper and lower skin flaps are developed, an
sections on margins of the esophagus is mandatory, incision is made along the anterior border of the ster-
because multicentric disease is not uncommon. This nocleidomastoid muscle exposing the carotid sheath.
leads to the conclusion that by and large total esophagec- The strap muscles (sternothyroid and sternohyoid) are
tomy with colon interposition (see Fig. 2I-I4A to PI) or transected near the sternum; the ansa of the hypoglossus
gastric pull-up (see Fig. 21-11) is indicated. However, at (motor supply to the strap muscles) and middle thyroid
times a patient cannot tolerate this magnitude of sur- vein are divided.
gery, and some compromise is justified, leading to
staged procedures plus radiotherapy. Ideally, at the C The carotid sheath is retracted laterally and the
present time the authors would treat all our patients thyroid lobe and trachea medially and to the left. After
with induction preoperative chemotherapy and total the recurrent laryngeal nerve is identified, the inferior
esophagectomy followed by radiotherapy if margins thyroid artery and veins are ligated and divided. The
were positive or if the surgeon believed there was tumor is then easily located, and the upward extent of
residual disease. the disease is carefully delineated. It may not be pos-
sible at this stage to decide whether a laryngectomy is
Highpoints to be done. This decision can be deferred until the
thorax is explored.
For one- or two-stage reconstruction with colon
interposition: D With the patient supine, an inframammary skin
incision has been made extending from the sternum
1. Adequate exposure is done to remove mediastinal to the anterior axillary line. The upper skin flap has
lymph nodes. been elevated upward to the level of the third rib, and
2. Carefully evaluate the extent of disease with free use the inferior attachments of the pectoralis major muscle
of frozen section at resected margins if less than to the fifth, fourth, and third ribs are transected care-
total esophagectomy is performed. fully to preserve the terminal portion of the thora-
3. A one-stage operation is preferred; nevertheless, a coacromial artery. Counting from above downward,
staged procedure is possible. the third rib is identified, and the pectoralis minor is
4. A one-stage procedure favors two surgical teams: transected, carrying the incision along the midline of
one for the cervical and upper thoracic esophagus the third rib through the periosteum.
and one for preparation of the colon and lower
thoracic esophagus. E The periosteum is then elevated. The attachment
of the serratus anterior is freed with the periosteum
laterally.
A 1 The first incision is made 2 fingerbreadths above
the right sternoclavicular junction. Although the esopha- F Using an Alexander periosteal rib elevator, the
gus is usually slightly to the left, the upper thoracic neurovascular bundle is separated along the inferior
approach is easier on the right side, because the arch margin of the rib.
of the aorta obscures a portion of the esophagus on
the left side. Through this cervical incision, the upward G A Doyen elevator completes the periosteal
spread of the disease is evaluated. Needless to say, the separation.
patient has undergone esophagoscopy, laryngoscopy,
and bronchoscopy. Mediastinoscopy may also be H The third rib is then transected medially and
indicated. laterally with rib cutters and removed.
Continued
 THE HYPOPHARYNX AND THE ESOPHAGUS

Ansa hypoglossi

In!. jug. v.

Pectoralis major m.

Pectoralis minor m.

FIGURE 21-12
 THEHYPOPHARYNX
ANDTHEESOPHAGUS
Resection of Cancer of Cervical
Esophagus at the Thoracic Inlet
(Continued) (Fig. 21-12)
I The underlying pleura is exposed and then
opened.
J Additional exposure is obtained by transecting the
second rib medially. The intercostal vessels are sepa-
rated from the intercostal nerve, ligated, and divided.
The nerve is divided.
K The thoracic cavity is exposed with a suitable rib
retractor. The lung is allowed to collapse and is displaced
downward. The mediastinal pleura is then opened
longitudinally, exposing trachea, esophagus, and right
bronchus down to the level of the azygos vein. This
vein, partially overlapped by the esophagus, crosses
the right lateral border of the esophagus to empty into
the superior vena cava. If the azygos vein interferes
with proper visualization and exposure or if a total
esophagectomy is performed, it is doubly ligated and
divided with suture ligature. The lower edge of the
cancerous tissue of the esophagus is then seen at the
thoracic inlet.
L Depending on the size of the tumor, a decision is
made regarding additional exposure. This is obtained
by connecting the thoracotomy and the cervical inci-
sions with a median sternotomy. Although this extension
is not by any means necessary, the increased exposure
at the site of the tumor aids in a cleaner dissection
under direct visualization in which it is most needed.
This aids in a more complete mediastinal dissection of
lymph nodes bilaterally. If there is adequate exposure
through the superior thoracic inlet, this sternal split
may not be necessary.
M The internal rnammary vessels are ligated and
divided and, with a sternal-splitting saw or Lebsche
knife, the manubrium is split to the level of the second
or third intercostal space (see Fig. 19-10A to D). A
horizontal extension is then made to meet the
thoracotomy incision.
N The tumor is now seen from above and below,
being covered by the innominate artery and its
branches, the common carotid and subclavian arteries,
and the right innominate vein. The vagus nerve lies
between the subclavian artery and the innominate vein,
giving off the right recurrent laryngeal nerve, which
swings around and behind the subclavian artery.
During this dissection the recurrent nerve should be
visualized, and if not involved in the disease process, it
is preserved; otherwise, it is sacrificed.
o The thoracic esophagus is mobilized and retracted
with a Penrose drain. Extreme care must be taken not
to injure or to perforate the membranous portion of
the trachea at which point the tumor or the esophagus
may be adherent. The blood supply to this portion of
the esophagus is from branches of the descending
aorta and the right third intercostal and bronchial
arteries. These vessels are ligated and divided. The
right vagus nerve is beside the trachea, and it is usually
preserved. Stay sutures are placed in the esophagus if
a two-stage operation is performed, and then it is
transected just above the level of the hilus of the lung.
Transection of the esophagus is not performed if total
esophagectomy in one stage is to be performed.
Continued
Alternates are thus now available and three possible
methods are described here:
1. A one-stage total esophagectomy with immediate
reconstruction using colon or stomach. The lower
thoracic esophagus can then be further mobilized
via the intra-abdominal portion of the operation and
pulled superiorly via the thoracotomy and thence
into the cervical region. The azygos vein is doubly
ligated and transected. A gastric pull-up procedure is
then performed (see Fig. 21-11). The cardia is closed.
The anastomosis to the cervical remnant is via the
fundus of the stomach.
2. The distal end of the esophagus can be closed and left
in place, and immediate or delayed reconstruction
utilizing colon substernally can be performed.
3. A two-stage operation can be performed by closing
the distal esophagus. The remaining lower esophagus
can then be removed via the abdominal route at the
time of reconstruction using substernal colon. There
may be some difficulty in freeing the esophagus
from below, owing to adhesions from the first stage.
If so, a repeat thoracotomy may be necessary.
 THE HYPOPHARYNX AND THE ESOPHAGUS

N
R. innominate v.
Sup. vena cava

FIGURE 21-12 Continued

 THE HYPOPHARYNX AND THE ESOPHAGUS
Resection of Cancer of Cervical
Esophagus at the Thoracic Inlet
(Continued) (Fig. 21-12)
A decision regarding the various alternatives is based
on the status of the patient and absence or presence of
disease at the margin of the esophagus. A one-stage total
esophageal resection and immediate reconstruction is
preferred, if feasible.
If a staged procedure is done, the proximal esophagus
near the larynx, or if the larynx has been removed, the
hypopharynx, will require either closure as a temporary
blind end (not advised) or a cervical fistula to the side
of the tracheostomy. A deltopectoral flap or PMF may
be necessary to divert the saliva to the side of the
tracheostomy. This diversion is emphatically preferred
over the blind closure of the proximal esophagus or
hypopharynx, because if a leak occurs, this will lead to
severe mediastinitis and all its sequelae. The second
alternative is depicted in the following figures:
P The distal end of the esophagus is closed, using
two layers of sutures. Continuous 4-0 chromic catgut
is utilized for the mucosa, whereas interrupted hori-
zontal mattress sutures of 3-0 silk are placed deep in
the muscle to invert the end. This closed end of the
esophagus is allowed to drop back in the mediastinum
as a blind end. At this point it is possible to follow the
first alternative as listed in O. The azygos vein is doubly
ligated and transected. The collapsed lung may be
reflected anteriorly. A combined intra-abdominal and
thoracic approach completes the total esophagectomy.
Q With blunt and sharp dissection, the proximal end
of the thoracic esophagus is further mobilized upward,
including as many surrounding lymph nodes as pos-
sible. It is obvious that many of these nodes cannot be
removed en masse with the esophagus and will require
excision after the esophagus has been mobilized. This
proximal end is turned upward through a tunnel formed
behind the great vessels. The stay sutures aid in this
maneuver.
R The thoracic segment of the esophagus is now
delivered into the neck. At this step, upward extension
of disease is further evaluated using gross and frozen
section, and the decision is made regarding the sacrifice
or preservation of the larynx. If the larynx is to be pre-
served, the highest .Ievel of resection that will permit
an adequate esophageal anastomosis is below (3 cm
ideally) the level of the cricoid cartilage. The esophagus
is transected, and reconstruction is accomplished imme-
diately with a colon transplant, as shown in Figure 21-14A
to Pl. This type of resection is difficult to stage because
the proximal end of the esophagus at the cricoid
cartilage is difficult to exteriorize. A planned fistula
could be developed using a chest flap (deltopectoral
flap or PMF) to divert saliva away from the medi-
astinum. Blind closure of the pharynx is not advisable.
The blind closure may leak, and disastrous medias-
tinitis will occur.
The esophagocolostomy is performed as shown in
Figure 21-13A to D. A tracheostomy is advisable.
The cervical wounds are closed using 3-0 chromic
catgut subcutaneously and nylon for the skin. A drain
is inserted. The thoracic incision is closed as shown in
Figure 2-2E to G, with underwater drainage, and the
sternotomy is closed as shown in Figure 19-100 to Q.
S When the tumor extends upward close to the
cricoid cartilage, the larynx must be removed. The
technique is similar to that of a laryngectomy alone
(see Fig. 20-18A to J), except that the cervical esophagus
is removed in continuity with the larynx. The thyroid
lobe on the side of the approach is likewise removed
as is a section of trachea, depending on the extent of
the disease. The hypopharynx is opened just above the
hyoid bone, the middle two thirds of which are to be
included in the resected specimen.
T The hypopharynx, including the pyriform sinuses
and larynx, is dissected and reflected upward.
U The lateral and posterior hypopharyngeal walls are
opened as shown by the dotted lines, connecting this
incision with the suprahyoid pharyngotomy incision.
The same is performed on the opposite side, and the
specimen is removed.
Continued
 THE HYPOPHARYNX AND THE ESOPHAGUS

Cricoid cartilage

Cricopharyngeus m.
(lowest fibers of inferior
pharyngeal constrictor m.)

Post. cricoarytenoid m.

FIGURE 21-12 Continued

 THE HYPOPHARYNX AND THE ESOPHAGUS
Resection of Cancer of Cervical
Esophagus at the Thoracic Inlet
(Continued) (Fig. 21-12)
V The distal descending colon or proximal sigmoid
colon has now been brought up through a substernal
tunnel (see Fig. 21-14A to P1). A two-layer pharyn-
gocolostomy is performed using interrupted 3-0 silk
for the outer layer and continuous 3-0 chromic catgut
for the inner layer. In the drawing, the posterior layer
of interrupted silk has already been inserted. The two
corner sutures remain long for guides. The continuous
catgut suture begins at the center of the posterior wall
and is run as an interlocking suture to the corner,
where it is converted into an inverting continuous
Connell suture. Before the center of the anterior wall is
reached, a similar catgut suture is run from the center
of the posterior wall in the opposite direction until
both meet anteriorly in the midline.
Vl The outer layer of 3-0 silk is then inserted as hori-
zontal mattress sutures, completing the anastomosis.
Mylohyoid m.
FIGURE 21-12 Continued
W If an unusual length of trachea was resected,
advanced turn-in skin flaps from the neck and chest
are used to reach the deeply placed end of the trachea.
A funnel of skin is thus formed. All the cervical incisions
are closed in two layers with one or more drains.
Drainage catheters (suction type) are inserted in the
mediastinum in such a fashion that they avoid contact
with major vessels. The thoracic incision is closed with
an intercostal underwater drainage tube as depicted in
Fig. 2-2E to G. The sternotomy wound is closed as
shown in Figure 19-100 to Q. A gastrostomy may be
desirable (see Fig. 21-14L to V).
Complications
• Fistula formation
• Mediastinal and pleural empyema
• Hemorrhage
• Bowel necrosis
• Membranous tracheal tear
 THE HYPOPHARYNX AND THE ESOPHAGUS

Cervical Esophagocolostomy This technique for the anastomosis is also applicable to

pharyngocolostomy
(Fig. 21-13)
gastric pull-up.
Highpoints
1. Mobilize the inferior thyroid pole.
2. Expose and preserve the recurrent laryngeal nerve.
3. The side of approach depends on other surgery con-
templated. If no other neck surgery is indicated, a
left-sided approach is preferred, because the cervical
esophagus is slightly to left of center.
4. At least 3 cm of proximal esophagus is needed for
anastomosis.
5. A stapler is utilized whenever adaptable.
This operation comprises the anastomosis between
the proximal cervical esophagus and the transposed
substernal colon. It is used as a bypass procedure for
thoracic esophageal cancer, as a first-stage step in the
resection when a subtotal esophagectomy is performed.
in total esophagectomy as well as
A A curved horizontal incision is made about 2
fingerbreadths above the clavicles. The exposure is
similar to that for a left total thyroid lobectomy.
Improved exposure occurs with resection of the medial
third of the left clavicle (see Figs. 19-9B to E and 21-2).
B The left recurrent laryngeal nerve is identified, and
the thyroid ima and inferior thyroid veins are ligated
and divided. It is also advisable to ligate and to divide
the middle thyroid vein; otherwise, it is likely to be
avulsed as the thyroid is retracted upward. If the inferior
thyroid artery is in the way, it, too, is divided. The
esophagus is exposed by blunt dissection, and usually
its left lateral border is easily seen.
Continued

Inf. thyroid V.

Esophagus
A B
Rec. laryngeal n.

Com. carotid a. Middle thyroid V.

FIGURE 21-13
 THE HYPOPHARYNX AND THE ESOPHAGUS
Cervical Esophagocolostomy
(Continued) (Fig. 21-13)
C With gentle retraction on the trachea, taking care
not to damage the recurrent laryngeal nerve, the
esophagus is mobilized by blunt and finger dissection.
A small Penrose drain may be passed around behind
the esophagus for traction.
D The index finger is then inserted substernally,
keeping close to the undersurface of the sternum. If
some resistance by heavy fascia is met, a curved Kelly
clamp is used to start the dissection. Extreme care is
exercised to avoid the innominate veins and any tribu-
taries. This is accomplished by staying in the immediate
substernal plane. Thus, the substernal tunnel is opened
from the cervical end. Colon has been reported to be
transposed subcutaneously.
E With stay sutures placed above and below the site
of transection, the esophagus is cut with a No. 15
blade knife along the dotted line. Ideally, there should
be a proximal esophageal stump of 3 to 4 cm.
F If a staged bypass procedure is performed (rarely),
the distal end of the esophagus is inverted and closed
with two layers, the first layer being continuous 3-0
chromic catgut and the second layer interrupted hori-
zontal mattress sutures of 3-0 silk. The closed distal
end of the esophagus is dropped into the posterior
mediastinum.
lnf. thyroid V.
c Rec. laryngeal n.
FIGURE 21-13
G The colon is now brought into the cervical wound
through the substernal tunnel (see Fig. 21-14L to P1).
H A two-layer anastomosis is performed. The outside
posterior layer of interrupted 3-0 silk is first inserted.
I The inside layer of through-and-through 3-0 chromic
catgut is begun as two separate sutures tied in the center
of the anastomosis posteriorly. Posteriorly, it is run as a con-
tinuous locking suture. At the corner it is converted to
an inverting Connell suture. The sutures then meet in the
center of the anastomosis anteriorly and are tied together,
with care being taken that the mucosa is inverted.
J The outside anterior layer of interrupted 3-0 silk is
now inserted as horizontal mattress sutures.
K The completed anastomosis is shown. Several
sutures are placed between the serosa of the colon and
the deep cervical fascia to help suspend the colon,
thus minimizing stress and strain on the anastomotic
suture line. A rubber tissue drain is placed in the
mediastinum, and the wound is closed.
Complications
• Fistula formation-caused usually by too much
tension on the line of anastomosis
• Ischemia and necrosis of the transposed colon
• Mediastinal empyema
• Recurrent nerve injury
• Aspiration pneumonia-death
D
Continued
 THE HYPOPHARYNX AND THE ESOPHAGUS

FIGURE 21-13 Continued

 THE HYPOPHARYNX AND THE ESOPHACUS
Reconstruction of Esophagus Using
Transverse and Descending Colon
(Fig. 21-14A to Pl)
Highpoints
1. Substernal tunnel is opened by blunt dissection.
2. Preserve the middle colic vessels-usually more
than one artery and vein at this location. There
must be no undue pressure or kinking of the veins.
3. When transecting mesentery of descending colon,
do not injure marginal artery of Drummond.
4. Middle colic vessels with mesentery may pass either
antegastrically or retrogastrically. The retrogastric
method is preferred.
5. Left colon is preferred.
6. Preoperative evaluation:
a. Upper gastrointestinal series for evaluation of
the entire pharyngoesophagus and stomach and
a barium enema
b. Liver scan
c. CT of the mediastinum and upper abdomen for
evaluation of celiac nodes
d. Intra-abdominal angiography of colon vascula-
ture has been recommended, especially in those
patients with a history of significant vascular
disease.
e. Bowel preparation
7. Vulnerable point in dissection is the membranous
trachea-extreme care must be taken not to perforate
it. This has occurred with the use of the so-called
peanut sponge.
8. Extreme care must be taken to preserve the blood
supply, especially veins of transposed colon-no
twisting.
9. Meticulous technique is done at anastomotic sites,
especially the cervical colostomy; since there is no
esophageal serosa, there should be no tension.
10. Avoid compression and redundant loops at the
diaphragm.
11. Perform pyloroplasty.
Discussion
The colon interposition can be utilized as follows:
1. Bypass procedure is done for nonresectable or
inoperable carcinoma of the esophagus.
2. Reconstruct the esophagus:
a. After total esophagectomy
b. After partial esophagectomy
c. Concomitantly with esophageal resection
d. As a second stage
3. Colon can be transposed:
a. Posterior mediastinum at the time of the esophageal
resection
b. Substernally
c. Subcutaneously
The use of transverse and descending colon for
esophageal replacement may be a bypass procedure for
thoracic esophageal cancer before resection of the pri-
mary lesion, or it may follow total cervical esophagec-
tomy with total laryngectomy. In the latter case, Scanlon
has demonstrated anastomosis of colon to the base of
the tongue and oropharyngeal mucosa. The placement
of the colon in a substernal tunnel makes this opera-
tion suitable for single or multiple-staged procedures.
The greatest length is obtained by using the colon as an
antiperistaltic loop with the descending colon brought
into the neck. If this is objectionable, a right ileocolic
transplant may be used.
Preoperative bowel preparation currently consists of
mechanical cleansing and administration of antibiotics.
Polyethylene glycol (PEG) in a balanced salt solution is
the most commonly used bowel preparation. An average
of 4 L of this solution is ingested, over a period of 4 hours,
the day before surgery. In addition, most surgeons use
various combinations of antibiotics. A common regi-
men (Schwartz, 1994) consists of administering oral
antibiotics the day before surgery (neomycin and eryth-
romycin, one g each at 1 PM, 2 PM, and 11 PM) and intra-
venous antibiotics administered immediately before
surgery.
A This patient has had a total laryngectomy and
subtotal resection of the esophagus, the distal end of
the lower third of the thoracic esophagus having been
closed. The hypopharynx has likewise been closed at
the first stage. The colon transplant for esophageal
reconstruction is performed as a second stage. If the
condition of the patient warrants it, two surgical teams
can accomplish both stages at the same time. A mid-
line abdominal incision is made extending from the
xiphoid cartilage to below the level of the umbilicus.
B The incision is then carried through the fascia
between the two rectus muscles. In the upper portion
of the incision considerable adipose tissue may be
encountered before the peritoneal layer is reached.
This actually is a portion of the falciform ligament. To
increase the exposure superiorly and to facilitate the
substernal approach, the incision may be extended
upward alongside the xiphoid cartilage for a distance
of several centimeters. The peritoneum is then opened
in the midline, exposing, from above downward, the
left lobe of the liver, stomach, greater omentum over-
lying the transverse colon, and loops of small bowel.
The abdomen is then explored routinely.
 THE HYPOPHARYNX AND THE ESOPHACUS

A B Xiphoid cart.

Pharyngostome
(CLOSED)

Greater
omentum
overlying
transverse
colon

FIGURE 21-14

C After it is grasped and lifted upward, the greater
omentum is separated from the transverse colon along
its embryonic fusion line. The hepatic and splenic
flexures are also exposed. The greater omentum is left
attached to the greater curvature of the stomach.
D The descending colon is mobilized by incising the
lateral peritoneal fascia fusion layer (white line of
Toldt) with scissors, as shown by the dotted line in.
This incision is extended upward to free the splenic
flexure of the colon by incising the phrenocolic and
splenocolic ligaments. The left kidney is exposed.
Continued
 THE HYPOPHARYNX AND THE ESOPHAGUS
Reconstruction of Esophagus Using
Transverse and Descending Colon
(Continued) (Fig. 21-14A to Pl)
E, El The entire midsection of the colon is now
inspected, and its blood supply is evaluated by palpa-
tion of the middle colic vessels. If there is no obvious
anomaly, the inferior mesenteric artery is exposed near
its origin from the aorta and traced distally to its first
main branch, which is the left colic artery. The left colic
artery divides into ascending and descending branches.
These branches are occluded with bulldog Atraugrip
vascular clamps, while a rubber-shod intestinal clamp
is placed across the lower region of the descending
colon at the elected level of transection. This clamp
occludes the marginal artery of Drummond. While these
occluding clamps are in place, the ascending colon is
mobilized along its lateral attachment to the abdominal
wall, carefully preserving the mesentery with its blood
supply. Behind the ascending colon and its mesentery
lie the right kidney and ureter, the gonadal vessels,
and more medially the inferior vena cava. Another
rubber-shod clamp is placed across the upper third of
the ascending colon.
The main blood supply of the mid portion of the
colon is through the two or three middle colic arteries
arising from a single trunk or multiple trunks of the
superior mesenteric artery where it crosses the upper
border of the horizontal portion of the duodenum.
The middle colic arterial trunk lies just to the right of
the ligament of Treitz in the base of the transverse
mesocolon (El). The middle colic veins empty into the
superior mesenteric vein, which is to the right of the
artery, and usually have connections with the superior
anterior pancreaticoduodenal and right gastroepiploic
veins. The continuity of these middle colic veins must
be carefully preserved, and it is at this site that they
may be injured when the colon is swung upward. The
distal end of the colon graft (J[l] to L) will be brought
up into the neck, and the proximal end (J[2] to L) will
be anastomosed to the stomach.
F Medium-sized intestinal clamps (Payr) or Kocher
clamps replace the rubber-shod intestinal clamps. The
colon is then transected, and gauze or a plastic sheet
is tied around each cut end.
G, H At the sites of election of transection of both
ascending and descending colon, the mesentery is cut
between two rows of small hemostats. The mesentery
of the descending colon is transected upward along
the dotted line as depicted in E. The remaining distal
portion of the ascending branch of the inferior mesen-
teric artery is kept intact, as of course is the marginal
artery. The venous tributaries emptying into the infe-
rior mesenteric vein require transection. The inferior
mesenteric vein curves upward in the base of the
mesentery of the colon, lying in the lateral fold of the
paraduodenal fossa before it empties into the splenic
vein. This dissection is carried up to the middle colic
stalk.
Continued
 THE HYPOPHARYNX AND THE ESOPHAGUS

MIDDLE COLIC ARTERIAL TRUNKS

SUP. MESENTERIC V. .

L1G. OF TREITZ

INF. MESENTERIC V.

FIGURE 21-14 Continued

 THE HYPOPHARYNX AND THE ESOPHAGUS
Reconstruction of Esophagus Using
Transverse and Descending Colon
(Continued) (Fig. 21-14A to Pl)
I The colon is now mobilized and swung upward in
antiperistaltic fashion over the chest to the cervical
region to evaluate length. The permanent position for
the colon transplant is preferably retrogastric, because
additional length is gained and, more importantly, the
antegastric location is likely to result in obstruction.
Therefore, the colon and its vascular pedicle are
brought through the lesser sac and gastrohepatic
ligament.
A longer colon transplant is obtainable by transection
of the ascending colon near the cecum and by preserving
the right colic vessels in addition to the middle colic
vessels. The descending colon is transected at the sig-
moid. This antiperistaltic transplant will then easily
reach the base of the tongue, as demonstrated by
Scanlon (1958).
J An isoperistaltic loop of transverse colon may be
utilized when only limited strength is required, as
demonstrated by Miller and Sherman. This utilizes the
left branches of the middle colic arterial trunk, sacri-
ficing the right branches. Before this technique is used,
careful evaluation of the blood supply in conjunction
with colon length is mandatory.
J1 The right colon also may be used. This loop is
used in isoperistaltic fashion. The appendix is removed,
and the ileocecal area is closed.
K The substernal tunnel is developed from below
upward, hugging the sternum closely. Finger and hand
dissection usually accomplish this. It is not advanta-
geous to attempt simultaneous dissection from above
at the thoracic inlet, because different planes are likely
to be opened.
Continued
Care must be taken to avoid injury to the mediastinal
pleura. Because this possibility always exists, careful
postoperative evaluation with chest radiography is done
for several days to detect any pneumothorax. The
pneumothorax is treated with intercostal underwater
drainage (see Figs. 2-4 to 2-6).
A number of other technical modifications of
esophageal replacement with colon transplant have
been described. Introduction of the colon has been per-
formed (Waterstone) through an opening made in the
diaphragm near the spleen. The cardioesophageal junc-
tion may then be preserved, performing a coloesophageal
anastomosis distally. Nakayama and colleagues (1962)
have utilized free jejunal transplants with vascular
pedicle anastomoses in the neck for replacement of the
cervical and upper thoracic esophagus. The vascular
anastomoses are performed with their specially
designed rings.
 THE HYPOPHARYNX AND THE ESOPHAGUS

Middle colic vessels

Cut edge of mesocolon

Inf. mesenteric v.
Inf. mesenteric a.

FIGURE 21-14 Continued

 THE HYPOPHARYNX AND THE ESOPHAGUS
Reconstruction of Esophagus Using
Transverse and Descending Colon
(Continued) (Fig. 21-14A to Pl)
L If necessary, a sponge stick with folded sponge
may aid in the last few centimeters of the dissection for
the substernal tunnel. The clamp on the distal end of
the colon transplant is removed, and the open end is
tied with an overlying piece of gauze or plastic sheet.
This end is placed in the substernal tunnel and either
gently pushed upward or pulled upward with a suture.
The venous return is more likely to be injured than the
arterial supply, and care must be exercised not to
injure the veins, because they are as important as the .
arteries for sustained viability.
The cervical anastomosis is now performed, resecting
the crushed end and any excess length. The site of the
anastomosis depends on the esophageal or pharyngeal
defect (see Fig. 21-13A to K).
M The cologastrostomy is performed as high as
possible on the anterior wall of the stomach near the
lesser curvature. The crushed end of the colon is resected
as well as any excess length. A hanging loop of colon
is avoided. A two-layer anastomosis is performed using
interrupted 3-0 silk for the outer seromuscular layer.
The posterior layer is inserted first.
M1 With the two corner sutures of the seromuscular
layer left long as guides, the inner mucosal layer of
3-0 chromic catgut is inserted posteriorly as a
continuous interlocking through-and-through suture.
When the corners are reached, it is converted to a
continuous inverting Connell suture. Two sutures are
used, each starting in the midline of the posterior edge
and meeting in the middle of the anterior edge.
M2 The other anterior layer of sutures using 3-0
interrupted silk completes the anastomosis.
N, N1 If a vagectomy was done with the esophagec-
tomy, a Heineke-Mikulicz pyloroplasty is advised. The
stomach is opened just proximal to the pylorus. The
incision is then extended through the pylorus in the
long axis of the bowel into the lumen of the duode-
num. The two ends of the incision are approximated
(Nl) while the midportion of the edges of the incision
becomes the ends of the closure, which is now
horizontal to the long axis of the bowel. A two-layer
closure is performed using continuous 3-0 chromic
catgut for the first or inner layer and 3-0 interrupted
silk for the second or outer layer.
o The colon continuity is reestablished by anasto-
mosing the ascending colon to the sigmoid colon. The
crushed ends of devitalized bowel are resected, and a
two-layer anastomosis is performed similar to the
cologastrostomy.
The posterior row of outside interrupted 3-0 silk
sutures has been inserted with the two corner sutures
left long as guides. One inner 3-0 continuous suture is
in place whereas the other is rounding the corner,
having been converted from a posterior through-and-
through interlocking suture to a Connell suture. This
inverts the edges. The Connell suture is continued
along the anterior edge to the midline, where it meets
its counterpart from the other side. The two sutures are
tied, with care being taken that the mucosa is inverted.
01 The anterior row of 3-0 interrupted silk as the
outer layer completes the colostomy.
Stamm Gastrostomy
Although not necessary, a gastrostomy may be desirable.
Depicted is a Stamm gastrostomy in which the stomach
wall is puckered concentrically to form a cone, the
portion closest to the tube being telescoped inward. A
Glassman gastrostomy follows the same principle
except that the telescoping is reversed, the portion
closest to the tube being sutured to the abdominal wall.
The gastrostomy may be performed through a separate
abdominal incision.
P Three rows of 3-0 silk are placed as separate purse-
string sutures around a No. 22 to No. 26 rubber
catheter that has been inserted into the lumen of the
stomach for a distance of 5 to 7 cm. The inner row of
sutures is first tied, pushing the stomach snugly about
the catheter. The second row is then tied over the first
row and the third row over the second row. A
telescoped cone is thus formed about the catheter.
P1 Several sutures secure the stomach wall to the
parietal peritoneum. The midline abdominal incision is
closed in layers when possible, using 1-0 chromic
catgut for the peritoneum and fatty areolar tissue at
the superior extent of the incision. Inferiorly, the peri-
toneum and fascia are usually so closely adherent that
the simple interrupted 2-0 silk sutures used for the
fascia include the peritoneum.
Continued
 THE HYPOPHARYNX AND THE ESOPHAGUS

FIGURE 21-14 Continued

 THE HYPOPHARYNX AND THE ESOPHAGUS
Reconstruction of Esophagus Using
Transverse and Descending Colon
(Continued) (Fig. 21-14A to P1)
Complications
• Vascular pedicle infarction
• Anastomosis leakage
Janeway Gastrostomy
(See Fig. 21-14Q to V)
Highpoints
1. The anterior stomach wall flap is longer and wider
than anticipated.
2. Suture the peritoneum at the edges of the abdominal
wall. The incision to the anterior gastric wall facili-
tates adherence of the stomach to the peritoneum
around the gastrostomy tube. Percutaneous endoscopic
gastrostomy (Gauderer et aI., 1980; Moss, 1984;
Russell et aI., 1984) is another technique applicable
to gastrointestinal decompression and for feeding.
Miller and associates (1986) described 100 consecu-
tive percutaneous endoscopic gastrostomies in 98
patients with no complications and no mortality.
Q The anterior gastric wall flap is outlined. The flap
should be wide enough to form a tube around the
gastrostomy catheter without tension, thus avoiding
compromise of the blood supply. The flap should
likewise be longer than anticipated. Be certain that the
blood supply is adequate. Enterostomy clamps may be
placed proximally and distally on the stomach to avoid
spillage of gastric contents.
R With the use of Babcock clamps or stay sutures,
the gastric flap is mobilized.
S With the gastrostomy catheter in position, the
mucosa of the flap is approximated with a continuous
suture starting at the lesser curvature.
Continued
 THE HYPOPHARYNX AND THE ESOPHAGUS

\\
,,
\
\

~.f···-
FIGURE 21-14 Continued
 THE HYPOPHARYNX AND THE ESOPHAGUS

Janeway Gastrostomy (Continued)

Complications (Ischemia)
(Fig. 21-14Q to V)
• Wound separation
T The serosa and submucosa are likewise approxi- • Infection-peritonitis
mated with a continuous suture. • Injury to the posterior wall of the stomach
• Injury to other organs
U The anterior gastric wall and gastrostomy is • Hematoma
approximated to the peritoneum of the abdominal • Prolonged paralytic ileus
incision. This secures the gastrostomy to the anterior • Inability to extubate
abdominal wall and prevents leakage, which could be
fatal.

V Closure shows mucosa sutured to the skin.

FIGURE 21-14 Continued


FIGURE 21-14 Continued
Percutaneous Endoscopic
Gastrostomy (Fig. 21-15)
Daniel Sette Camara
Major advances in the techniques for placement of
gastrostomy tubes have occurred in the past 17 years.
The traditional surgical placement utilizing the Janeway
or Stamm technique has been replaced by the endoscopic
technique first described by Gauderer and colleagues in
1980. Percutaneous endoscopic gastrostomy (PEG) is a
simple method that does not require a laparotomy and
has minimal mortality and acceptable morbidity.
Currently, there are over a million patients being fed by
PEG tubes with over 100,000 new patients per year. A
patient undergoing head and neck surgery should be
THE HYPOPHARYNX AND THE ESOPHAGUS
\
considered to undergo a PEG, particularly those patients
facing prolonged periods of dysphagia. A feeding gas-
trostomy avoids complications of parenteral nutrition
and decreases the cost of maintaining the patient's
nutrition by 50 % to 75 %.
Indications
Patients with the inability to maintain nutrition due to
neurologic disorders (e.g., cardiovascular accident,
dementia, degenerative neurologic disease, amyotrophic
lateral sclerosis) have the most common indications for
a PEG. Patients with head and neck tumors associated
with dysphagia preoperatively or postoperatively are
good candidates for a PEG placement.
 THE HYPOPHARYNX AND THE ESOPHAGUS
Percutaneous Endoscopic
Gastrostomy (Continued) (Fig. 21-15)
Technique
Under sedation with midazolam and meperidine, an
endoscope is inserted and the stomach is inflated.
Subsequently, a site for the gastrostomy tube place-
ment is selected by external palpation of the left upper
quadrant and endoscopic transillumination of the
abdominal wall. Once the endoscopist and the assistant
agree on an optimal location by observing an intralu-
minal indentation by applying external pressure and
following the area of transillumination, the assistant
will prepare the skin with a solution of povidone-iodine
(Betadine) and inject a local anesthetic in the area
selected.
A A small incision (approximately 5 mm) is made,
and through this incision an l8-gauge Seldinger
needle is inserted in the stomach. The endoscopist will
inflate the stomach to facilitate the penetration of the
needle. Under endoscopic observation, the stilet is
removed and a guide wire (0.035 cm) is inserted and
captured by an open polypectomy snare. The
endoscope and wire are pulled out.
B Subsequently, a gastrostomy tube connected with
a long tapered dilator is slid over the guide wire and
once it reaches the skin incision in the abdomen is
pulled by external traction to its optimal position.
C The external retention disk is then placed close to
the skin and the patient undergoes endoscopy again
to evaluate the position of the gastrostomy tube and
its relationship to the gastric wall. Care should be taken
to leave enough space so that not too much pressure
is applied to the gastric mucosa, to avoid injury.
Postoperative Care
The patient is usually kept fasting until the next morning
and is maintained initially on intravenously adminis-
tered fluids. If there are no obvious complications such
as fever, pain, bleeding, or signs of peritonitis, the
patient will be started on a full-strength polymeric
formula at the rate of 50 mL an hour. Residual volumes
are checked with a 60-mL syringe. The tube is aspirated
every 2 hours for the first 24 hours and every 8 hours
thereafter. The physician should be notified if residual
volume is greater than 100 mL. Gastroparesis or gastric
outlet obstruction should be diagnostic considerations
in this case. Local cleaning of the gastrostomy site with
peroxide and povidone-iodine should be performed
every 8 hours.
Complications
Complication rates for insertion of the PEG range from
5% to 16%, with a mortality rate of 0.3% to 1%. The
complications and mortality rates are much less than
with standard surgical gastrostomy. Wound infection is
the most common complication, occurring in 5% to 30%
of cases. This is most likely due to contamination of the
gastrostomy tube by oral bacterial flora. This rate can
be significantly reduced by providing antibiotic prophy-
laxis (cefazolin, 1 g, 30 minutes before the procedure)
and by cleaning the gastrostomy site with peroxide and
povidone-iodine solution at least three times per day.
One should also avoid placing the external retention
disk or bumper so close to the skin that ischemic injury
may ensue.
Other complications associated with a PEG insertion
are as follows:
• Aspiration pneumonia
• Bacteremia
• Necrotizing fasciitis
• Gastric hemorrhage
• Gastric perforation
• Peritonitis
• Subcutaneous abscesses
• Subcutaneous migration of PEG dome
• Stomal leak
• Gastrocolocutaneous fistula
• Squamous cell carcinoma implants in the gastric wall
Conclusion
Percutaneous endoscopic gastrostomy is a simple method
for providing nutritional support to patients with pro-
longed periods of dysphagia or potential for severe
aspiration. This technique has replaced the traditional
surgical gastrostomy and can be easily discontinued
once the patient can maintain his or her nutrition by
the oral route (see Chapter 3, Preoperative Care).
 THE HYPOPHARYNX AND THE ESOPHAGUS

r-.
(

~~
,
I

C Retention disk
FIGURE 21-15

BIBLIOGRAPHY Blakeley WR, Grety EJ, Smith DE: Section of the cricopharyngeus
Adler RH: Congenital esophageal webs. J Thorac Cardiovasc Surg muscle for dysphagia. Arch Surg 96:745·762, 1968.
45:175·185,1963. Bracka A: The blood supply of dorsal tongue flaps. Br J Plast Surg
Akakura !, Nakamura Y, Kakegawa T, et al: Surgery of carcinoma of 34:379·384, 1981.
the esophagus with preoperative radiation. Chest 57:47·57, 1970. Bruchin PJ: Foreign bodies of the esophagus. NY State J Med 81:1057,
Alperin KM, Levine HL, Wood BG, Tucker HM: Approach to and 1981.
reconstructions for lesions of the posterior third of the tongue via Burdette WJ: Palliative operation for carcinoma of cervical and
midline labiomandibular gJossotomy. Head Neck Sueg 6:744-750, thoracic esophagus. Ann Surg 173:714·732, 1971.
1984. Cantrell RW: Pharyngeal fistula: Prevention and treatment.
Anderson LL, Lad TE: Autopsy findings in squamous cell carcinoma Laryngoscope 88:1204·1208, 1978.
of the esophagus. Cancer 50:1587·1590,1982. Caracci B, Garvin P, Kaminski DL: Surgical therapy of advanced
Aprigliano F: Esophageal stenosis in children. Ann Otol Rhinal esophageal cancer. Am J Surg 146:704·707, 1983.
Laryngol 89:391·395,1980. Carbone A, Micheau C, Bosq J, et al: Superficial extending carcinoma
Atkins JP: Some aspects of benign esophageal disease in children. of the hypopharynx: Report of 26 cases of an underestimated
Ann Otol 77:883·891, 1968. carcinoma. Laryngoscope 93:1600·1606,1983.
Bains MS, Spiro RH: Pharyngolaryngectomy, total extrathoracic Cardona JC, Daly JF: Current management of corrosive esophagi-
esophagectomy and gastric transposition. Sueg Gynecol Obstet tis: An evaluation of results in 239 cases. Ann 0101 80:521·527,
149:693·696, 1979. 1971.
Ballantyne AJ: Methods of repair after surgery for cancer of the Chang T·S, Ling HO, and Wei W: Reconstruction of esophageal
pharyngeal wall, postcricoid area and cervical esophagus. Am J defects with microsurgically revascularized jejunal segments: A
Surg 122:482A86, 1971. report of 13 cases. J Microsurg 2:83·94, 1980.
Bellinger CG: Classification of pharyngostomes: A guideline for Chrysospathis P: The contribution of vascular surgery to oesophageal
closure. Plast Reconstr Surg 47:54·60, 1971. replacement. Br J Surg 53:122·126,1966.
 THE HYPOPHARYNX AND THE ESOPHAGUS

Coben RM, DiMarino AJ lr: Endoscopic percutaneous gastrostomy Gawande AS, Batiuchok W, Barman AA, Mule lE: Carcinoma with
and jejunostomy. In Dimarino Al lr, Benjamin SB (eds): lower esophageal (epiphrenic) diverticulum. N Y State 1 Med
Gastrointestinal Disease: An Endoscopy Approach. Malden, MA, 72: 1749-1751, 1972.
Blackwell Science, 1997, pp 446-460. Gerami S, Booth A, Pate lW: Carcinoma of the esophagus engrafted
Cocke EW lr: Cavernous hemangioma of the oral and hypopharynges. on lye stricture. Chest 59:226-227, 1971.
Am 1 Surg 102:798-802, 1961. Gluckman lL, McDonough 1, Donegan la, et al: The free jejunal graft
Coia LRet al: A pilot study of combined radiotherapy and chemotherapy in head and neck reconstruction. Laryngoscope 91:1887-1894,1981.
for esophageal carcinoma. Am 1 Clin Oncol 7:653-659, 1984. Goldstein LA, Thompson WR: Esophageal perforations: A 15 year
Collard 1M, et al: Endoscopic stapling technique of the esophago- experience. Am 1 Surg 143:495-503, 1982.
diverticulostomy for Zenker diverticulum. Ann Thorac Surg Goodner JT: Treatment and survival in cancer of the cervical
56:573-576, 1993. esophagus. Am 1 Surg 118:673-675, 1969.
Conley JJ: A one-stage operation for the immediate reconstruction of Graham WP Ill, Royster HP: Simplified cervical esophagostomy for
the pharynx and cervical esophagus following radical resection. long term extraoral feeding. Surg Gynecol Obstet 125:127-]28, 1967.
West 1 Surg 63:344, 1955. Grillo HC: Esophageal perforation. Surgical Rounds Feb. 1983.
Conley JJ: One-stage radical resection of cervical esophagus, larynx, Gullane Pl, Willett 1M, Heeneman H, et al: Zenker's diverticulum.
pharynx, and neck with immediate reconstruction. Arch Otolaryngol 10tolaryngoI12:53-57,1983.
58:546, 1963. Handler SD, Beaugard ME, Canalis RF, Fee WE lr: Unsuspected
Conte AJ: Operations on the esophagus. Personal communication, esophageal foreign bodies in adults with upper airway obstruc-
1958. tion. Chest 80:234-237, 1981.
Cross FS: Esophageal diverticula related neuromuscular problems. Harashina T, Kakegawa T, Imai T, Suguro Y:Secondary reconstruction
Ann Otol 77:914-926, 1968. of oesophagus with free revascularized ileal transfer. Br 1 Plast
Dabbs Dl: Diagnoslic Immunohistochemistry. New York, Churchill Surg 34:17-22,1981.
Livingstone, pp 225-226. Harashina T, et a1: Reconstruction of cervical oesophagus with free
Dawson lH: Subcutaneous placement of the left colon for esophageal double-folded intestinal graft. Br 1 Plast Surg 38:483-487, 1985.
bypass. Am 1 Surg 35:574-579, 1969. Harii K, Ebihara S, Ono I, et al: Pharyngoesophageal reconstruction using
Dillow BM, Neis DO, Sellers RD: Leiomyoma of the esophagus. Am 1 a fabricated forearm free flap. Plast Reconstr Surg 75:463-476,
Surg 120:615-619,1970. 1985.
Dohlman G, Mattsson 0: The endoscopic operation for hypopharyngeal Hester TR, McConnel F, Nahai F, et al: Pharyngoesophageal stricture
diverticula. Arch Otolaryngol 71:744-752, 1960. and fistula. Ann Surg 199:762-769, 1984.
Dorsey 1M, Randolph DA: Long-term evaluation of pharyngo- Hester TR, McConnel FMS, Nahai F, et al: Reconstruction of cervical
esophageal diverticulectomy. Ann Surg 173:680-685, 1971. esophagus, hypopharynx and oral cavity using free jejunal transfer.
Edgerton MT: One-stage reconstruction of the cervical esophagus or Am 1 Surg 140:487-491, 1980.
trachea. Surgery 31:239,1952. Hiranandani LH: Tongue as pedicle flap for reconstruction of pharynx
Edgerton MT: Reconstruction of hypopharynx and the cervical in one stage laryngopharyngectomy. Rev Laryngol (Bordeaux)
esophagus after removal of cancer. Proceedings of the Fourth 88:111-125,1967.
National Cancer Conference, 1960, p 685. Hix WR, Mills M: The management of esophageal wounds. Ann Surg
Ellis FH: Controversies regarding the management of hiatus hernia. 172:1002-1006, 1970.
Am 1 Surg 139:782-788, 1980. Holinger PH: Management of esophageal lesions caused by chemical
Ellis FH, Crozier RE: Cervical esophageal dysphagia. Ann Surg burns. Ann Olol 77:819-829, 1968.
194:279-289,1981. Holinger PH, Schild lA: The Zenker's (hypopharyngeal) diverticulum.
Ellis FH, Gibb SP: Esophagogastrectomy for carcinoma. Ann Surg Ann Olol 78:679, 1969.
190:699-705,1979. Hopkins RA, Postlethwait RW: Caustic burns and carcinoma of the
Ellis FH lr, Schlegel lF, Lynch VP, Payne WS: Cricopharyngeal esophagus. Ann Surg 194:146-148,1981.
myotomy for pharyngo-esophageal diverticulum. Ann Surg Humphrey DM, et al: Immunoperoxidase characterization of a
170:340-350, 1969. pharyngeal plasmacytoma. Arch Otolaryngol 108:362-365, 1982.
Fee WE: Hypopharyngeal reconstruction (Commentary). Arch Isono 1, Onoda S, Ishikawa T, et al: Studies on the causes of deaths
OtolaryngolllO:384-385, 1984. from esophageal carcinoma. Cancer 49:2173-2179, 1982.
Ferguson CF: Esophageal dysfunction and other swallowing Isshiki N, Harita Y, Kawano M: What muscle is responsible for lateral
difficulties in early life. Ann Otol 80:541-548, 1971. pharyngeal wall movement? Ann Plast Surg 14:224-227, 1985.
Ferguson TB, Woodbury 10, Roper CL, Burford TH: Giant muscular lsshiki N, Honjow l, Morimoto M: Cineradiographic analysis of
hypertrophy of the esophagus. Ann Thorac Surg 8:209-218,1969. movement of the lateral pharyngeal wall. Plast Reconstr Surg
Finley Rl, Grace M, Duff lH: Esophagogastrectomy without 44:357-363, 1969.
thoracotomy for carcinoma of the cardia and lower part of the Jamieson WR, et al: Surgical management of primary motor
esophagus. Surg Gynecol Obstet 160:49-56, 1985. disorders of the esophagus. Am 1 Surg 148:36-42, 1984.
Fleischer D, Kessler F, Haye 0: Endoscopic Nd:YAGlaser therapy for Johnson TC, Zarbo RJ, Lloyd RV,Crissman 10: Paragangliomas of the
carcinoma of the esophagus: A new palliative approach. Am 1 head and neck: Immunohistochemical neuroendocrine and
Surg 143:280-283, 1982. intermediate filament typing. Mod Pathol1:216-223, 1988.
Flynn MB, Acland RD: Free intestinal autografts for reconstruction 10nes 1M: Necrotizing Candida esophagitis. lAMA 244:2190-2191,
following pharyngolaryngoesophagectomy. Surg Gynecol Obs!et 1980.
149:858-862, 1979. K'ai WY. Chun HK: Chinese experience in the surgical treatment of
Ford LH, Holinger PH: Hereditary dysphagia: The oculopharyngeal carcinoma of the esophagus. Ann Surg 190:361-365, 1979.
syndrome. Laryngoscope 81:373-378, 1971. Kaiser AB, Herrington JL, Jacobs JL, et al: Cefoxitin versus erythro-
Garvin Pl, Kiminski DL: Extrathoracic esophagectomy in the mycin, neomycin and cefazolin in colorectal operations. Ann Surg
treatment of esophageal cancer. Am 1 Surg 140:771-778, 1980. 198:525-530, 1983.
Gauderer MWL, Ponsky JL, Izant RJ Jr: Gastrostomy without Katsaros J, Tan E: Free bowel transfer for pharyngo-oesophageal
laparotomy: A percutaneous endoscopic technique. ] Pediatr Sueg reconstruction: An experimental and clinical study. Br J Plast Surg
15:872-875, 1980. 35:268-276, 1982.

Keane TJ: Carcinoma of the hypopharynx. J OI0Iaryngolll:227-231,
1982.
Keshishian JM, Smyth NPD, Maxwell DO, Chua L: Dilation of the
difficult strictures of the esophagus. Surg Gynecol Obstet 158:81-85,
1984.
Keszler P, Buzna E: Surgical and conservative management of
esophageal perforation. Chest 80: 158-162, 1981.
Keyes GR, Tenta LT, Schultz RC: Myoepithelial construction of the
thoracic esophagus. Plast Reconstr Surg 69:683-689, 1982.
Killen DA, Greenlee HB: Transcervical repair of H-type congenital
tracheo-esophageal fistula. Ann Surg 162:145-150, 1965.
Krespi YP, Wurster CF, Wang TO, et al: Hypoparathyroidism
following total laryngectomy and gastric pull-up. Laryngoscope
95:1184-1187,1985.
Lahey FH: Technique of the two stage operation for pulsion
esophageal diverticulum. 5urg Gynecol Obstet 43:359-365, 1926.
Lahey FH, Warren KW: Esophageal diverticula. Surg Gynecol Obstet
98: 1-28, 1954.
Lam KH, Wong J, Urn STK, et al: Pharyngogastric anastomosis
following pharyngolaryngoesophagectomy: Analysis of 157 cases.
World J Surg 5:509-516, 1981.
Lee KY, Lore JM Jr: Two modifications of pectoralis major myocu-
taneous flap (PMMF). Laryngoscope 96:363-367, 1986.
Lees W: Colonic replacement after pharyngolaryngectomy. Br J Surg
54:541-547, 1967.
Leonard JR, Maran AGO: Reconstruction of the cervical esophagus
via gastric anastomosis. Laryngoscope 80:849-862, 1970.
Leonard JR, Rossi NP, Blaedel M: Esophageal carcinoma: Palliation
by indwelling tubes. Ann Otol 78:1169-1178,1969.
Leonard JR, Smith H: Cricopharyngeal achalasia. Ann Otol 79:907, 1970.
Lerche W: The Esophagus and Pharynx in Action. Springfield, IL,
Charles C Thomas, 1950.
Levin B, Posner JB: Swallow syncope. Neurology 22:1086-1093,1972.
Levine PA: Hypopharyngeal perforation. Arch Otolaryngol106:578-580,
1980.
Litton WB: Reconstruction of the hypopharynx and cervical esophagus:
Local flap technique after planned preoperative irradiation. Trans
Am Acad Ophthalmol Otolaryngol 72:85-89, 1968.
Lloyd RV:Shapiro B, Sisson JC, et al: An immunohistochemical study
of pheochromocytoma. Arch Pathol Lab Med 108:541-544, 1984.
Lore JM Jr: Cancer of the hypopharynx and cervical esophagus.
Symposium on Malignancies of the Head and Neck, Vol 11.
St. Louis, CV Mosby, 1975.
Lore JM Jr: Total reconstruction of the hypopharynx with tongue flap
and dermal graft. Ann Otol Rhinal Laryngol 83:476-480, 1974.
Lore JM Jr, Klatch OW, Lee KY: One-stage reconstruction of the
hypopharynx using myomucosal tongue flap and dermal graft.
Am J Surg 144:473-476, 1982.
Lynn HB: Colon interposition in pediatric patients with esophageal
varices. Ann Surg 173:706-713, 1971.
MacBeth R: The treatment of carcinoma of the hypopharynx: The
gutter-graft operation. J Laryngol 83:119-132, 1969.
Madden JL, Ravid JM, Haddad JR: Regional esophagitis: A specific
entity simulating Crohn's disease. Ann Surg 170:351-368, 1969.
Marchetta FC, Johnson RT, Riegler HC: Healing potential of the
pharynx and cervical esophagus. Surgery 47:623-630, 1960.
Marchetta FC, Sako K, Creedon PJ: Rolation of the esophageal and
pharyngeal flaps for reconstruction of the cervical esophagus.
Am J Surg 102:854-858, 1961.
Martin SA, Marks JE, Lee JY, et al: Carcinoma of the pyriform sinus:
Predictors of TNM relapse and survival. Cancer 46:1974-1981, 1980.
McConnel FMS, Hester TR, Nahai F, et al: Free jejunal grafts for
reconstruction of pharynx and cervical esophagus. Arch Otolaryngol
107:476-481, 1981.
Mellow MH, Layne EA, Lipman TO, et a1: Plasma zinc and vitamin A in
human squamous carcinoma of the esophagus. Cancer 51:1615-1620,
1983.
THE HYPOPHARYNX AND THE ESOPHAGUS
Menguy R: Near-total esophageal exclusion by cervical esophagostomy
and tube gastrostomy in the management of massive esophageal
perforation: Report of a case. Ann Surg 173:613-616, 1971.
Miller RE, Kummer BA, Kotler DP, Tiszenkel HI: Percutaneous
endoscopic gastrostomy, procedure of choice, Ann Surg 204:543-545,
1986.
Minielly JA, Harrison EG Jr, Fontana RS, Payne WS: Verrucous
squamous cell carcinoma of the esophagus. Cancer 20:2078-2087,
1967.
Mladick RA, Horton CE, Adamson JE: Immediate cricopharyngeal
myotomy: An adjunctive technique for major oral-pharyngeal
restrictions. Plast Reconstr Surg 47:6-11,1971.
Mobarha NS, Trombore L: Enteral tube feeding: A clinical perspective
on recent advances, Nutr Rev 49:129-140,1991.
Montgomery WW: Reconstruction of the cervical esophagus. Arch
Otolaryngol 77:609-620, 1963.
Montgomery WW, Lynch JP: Oculopharyngeal muscular dystrophy
treated by inferior constrictor myotomy. Trans Am Acad Ophthalmol
Otolaryngol 75:986-993, 1971.
Moody FG, Garrett JM: Esophageal achalasia following lye ingestion,
Ann Surg 170:775-784, 1969,
Moss G: Efficient gastroduodenal decompression with simultaneous
full enteral nutrition: A new gastrostomy catheter technique.
J Parenter Enter Nutr 8:203-207, 1984,
Mowschenson PM, Rosenberg S, Pallotta J, Silen W: Effect of hyper-
parathyroidism and hypercalcemia on lower esophageal sphincter
pressure, Am J Surg 143:36-38, 1982,
Mullen DC, Young WG Jr, Sealy WC: Results of twenty years expe-
rience with esophageal replacement for benign disorders. J Sac
Thorac Surg South Thorac Surg Assoc 5:481-488,1968.
Murakami Y, Saito S, Ikari T, et al: Esophageal reconstruction with a
skin-grafted pectoralis major muscle flap. Arch Otolaryngol
108:719-722, 1982.
Nakayama K, Tamiya T, Yamamoto K, Akomoto S: A simple new
apparatus for small vessel anastomosis, Surgery 52:918,1962.
Neville WE, Najem AZ: Colon replacement of the esophagus for
congenital and benign disease. Ann Thorac Surg 36:626-633,1983.
Nicks R: Colonic replacement of the oesophagus, Some observations
on infarction and wound leakage. Br J Surg 54:124-128,1967,
Ogura JH, Biller HF, Wette R: Elective neck dissection for pharyngeal
and laryngeal cancers: An evaluation, Ann Otol 80:646, 1971.
Ogura JH, Salzstein SL, Spjut HJ: Experiences with conservation
surgery in laryngeal and pharyngeal cancer. Laryngoscope 71:258-276,
1961.
Orringer MB, Kirsh MM, Sloan H: Esophageal reconstruction for
benign disease. J Thorac Cardiovasc Surg 73:808-812, 1977,
Orringer MB, Sloan H: Esophagectomy without thoracotomy. J Thorac
Cardiovasc Surg 76:643-654, 1978.
Orringer MB, Orringer JS: Esophagectomy without thoracotomy: A
dangerous operation? J Thorac Cardiovasc Surg 85:71-80, 1983.
Orringer MB, Sloan H: Substernal gastric bypass of the excluded
thoracic esophagus for palliation of esophageal carcinoma. J Thorae
Cardiovasc Surg 70:836-851, 1975.
Parker EF, Gregorie HB Jr: Combined radiation and surgical treatment
of carcinoma of the esophagus. Ann Surg 161:710-722, 1965.
Payne WS, Reynolds RR: Surgical treatment of pharyngoesophageal
diverticulum (Zenker's diverticulum). Surg Rounds, 1982, pp 18-24.
Peracchia A, et al: Minimally invasive surgery for Zenker diver-
ticulum. Arch Surg 133:695-700, 1998,
Peters CR, McKee OM, Berry BE: Pharyngoesophageal reconstruction
with revascularized jejunal transplants. Am J Surg 121:675-678,
1971.
Postlethwait RW: Colonic interposition for esophageal substitution.
Surg Gynecol Obstet 156:377-383, 1983.
Raia A, Gama AH, Pinotti HW, Rodrigues JJG: Diverticular disease in
the transposed colon used for esophagoplasty: Report of two
cases. Ann Surg 177:70-74,1973.
 THE HYPOPHARYNX AND THE ESOPHAGUS
Raschke E, Paquet KT: Management of hemorrhage from esophageal
varices using the esophagoscopic sclerosing method. Ann Surg
177:99-102, 1973.
Reichert n, Faw KD: The cricopharyngeus in the neonate. Ann Otol
Rhinol Laryngol 89:446-449, 1980.
Ritter FN, Gago 0, Kirsh MM, et al: The rationale of emergency
esophagogastrectomy in the treatment of liquid caustic burns of
the esophagus and stomach. Ann 0101 80:513-520, 1971.
Rob CG, Bateman GH: Reconstruction of the trachea and cervical
esophagus. Br J Surg 37:202-205, 1941.
Robertson MS, Robinson JM: Immediate pharyngoesophageal recon-
struction: Use of a quilted skin-grafted pectoralis major muscle
flap. Arch Otolaryngol 110:386-387, 1984.
Rojas FA, Szymanowski RT, Fujita S: Zenker's diverticulum-
carcinoma of the esophagus? J Otolaryngol 8:266-270, 1979.
Ross ER, Green R, Auslander MO, Biller HF: Cricopharyngeal myotomy:
Management of cervical dysphagia. Otolaryngol Head Neck Surg
90:434-441, 1982.
Rusca JA, Bornside GH, Cohn f Jr: Everting versus inverting
gastrointestinal anastomoses: Bacterial leakage and anastomotic
disruption. Ann Surg 169:727-735, 1969.
Russell TR, Brotman M, Norris F: Percutaneous gastrostomy: A new
simplified and cost-effective technique. Am J Surg 148:132-137,
1984.
Sanfey H, Hamilton SR, Smith RRL: Carcinoma arising in Barrett's
esophagus. Surg Gynecol Obstet 161:570-574, 1985.
Scanlon EF: Operations of the esophagus. Personal communication.
Scanlon EF, Morton DR, Walker JM, Watson WL: The case against
segmental resection for esophageal carcinoma. Surg Gynecol
Obstet 101:290-296, 1955.
Scanlon EF, Staley CJ: The use of the ascending and right half of the
transverse colon in esophagoplasty. Surg Gynecol Obstet 187:99-103,
1958.
Schaefer SO, Bucholz RW,Jones RE, et a1:Treatment of transpharyngeal
missile wounds to the cervical spine. Laryngoscope 91:146-148,
1981.
Schwartz S led]: Principles of Surgery, 6th ed. New York, McGraw
Hill,1994.
Shprintzen RJ, Croft C, Berkman MD, Rakoff SJ: Pharyngeal
hypoplasia in Treacher Collins syndrome. Arch Otolaryngol
105:127-131,1979.
Shprintzen RJ, McCall GN, Skolnick ML: The effect of pharyngeal
flap surgery on the movements of the lateral pharyngeal walls.
Plast Reconstr Surg 66:570-573, 1980.
Sieber AM, Sieber WK: Colon transplants as esophageal replacement:
Cineradiographic and manometric evaluation in children.
Ann Surg 168:116-122, 1968.
Silver CE: Gastric pull-up operation for replacement of the cervical
portion of the esophagus. Surg Gynecol Obstet 142:243-245, 1976.
Sisson GA: Reconstruction of the hypopharynx and cervical
esophagus after radical excisional surgery. Laryngoscope 66:1268-I290,
1956.
Sisson GA: The surgical treatment of carcinoma of the cervical
esophagus. NY State J Med 55:201-208, 1955.
Skinner DB: Esophageal reconstruction. Am J Surg 139:810-814, 1980.
Skinner DB, Little AG, DeMeester TR: Management of esophageal
perforation. Am J Surg 139:760-764, 1980.
Skinner DB, Walther BC, Riddell RH, et al: Barrett's esophagus. Ann
Surg 198:554-566, 1983.
Spaulding MB, Kahn A, Sundquist N, Lore JM Jr: Preoperative
chemotherapy for hypopharyngeal carcinoma. Laryngoscope
93:346-349,1983.
Spiro RH, Shah JP, Strong EW, et al: Gastric transposition in head and
neck surgery. Am J Surg 146:483-487, 1983.
Stevens KM, Newell RC: Cricopharyngeal myotomy in dysphagia.
Laryngoscope 81:1616-1620, 1971.
Sugimachi K, Inokuchi J, Kuwano H, et al: Patterns of recurrence
after curative resection for carcinoma of the thoracic part of the
esophagus. Surg Gynecol Obstet 157:537-540, 1983.
Symbas PN, Hatcher CR, Vlasis SE: Esophageal gunshot injuries.
Ann Surg 191:703-707, 1980.
Tenta LT, Keyes GR: Total extrathoracic neoesophageal construction
by combined cutaneous and myoepithelial flaps. Otolaryngol
Head Neck Surg 90:31-36, 1982.
Torek F: First successful case of resection of the thoracic esophagus.
Surg Gynecol Obstet 16:614, 1913.
Tragus ET, Griffith JL: Palliative intubation for malignant strictures of
the esophagus. Am J Surg 119:27-29, 1970.
Trotter W: Method of lateral pharyngotomy for exposure of large
growths of epipharyngeal region. J Laryngol 35:289, 1920.
Trotter W: Method of lateral pharyngotomy for the exposure of large
growths in the epilaryngeal region. J Otolaryngol 35:199-205,1920.
Tryzelaar JF, Neptune WB, Ellis FH: Esophagectomy without thora-
cotomy for carcinoma of the esophagus. Am J Surg 143:486-489,
1982.
Ujiki GT, Pearl GJ, Poticha S, et al: Mortality and morbidity of gastric
"pull-up" for replacement of the pharyngoesophagus. Arch Surg
122:644-647,1987.
van Overbeek JJ, Betlem HC: Cricopharyngeal myotomy in pharyn-
geal paralysis. Ann Otol Rhinol Laryngol 88:596-602, 1979.
van Overbeek JJ, Hoeksema PE, Edens ET: Microendoscopic surgery
of the hypopharyngeal diverticulum using electrocoagulation or
carbon dioxide laser. Ann Otol Rhinol Laryngol 93:34-36, 1984.
Vargas JR, Pino JA, Murad TM: Craniopharyngioma in two siblings.
JAMA 246:1807-1808, 1981.
Vincent RG, Webster JH: Total esophagectomy and descending colon
bypass for squamous cell carcinoma of the esophagus. Am J 5urg
121:527-530, 1971:
Ware L, Garrett WS Jr, Pickrell K: Cervical esophagostomy: A simpli-
fied technic. Ann Surg 165:142-144,1967.
Watson JS, Robertson GA, Lendrum J, et al: Pharyngeal reconstruc-
tion using the latissimus dorsi myocutaneous flap. Br J Plast Surg
35:401-407,1982.
Wichern WAJr: Perforation of the esophagus. Am J Surg II9:534-536,
1970.
Wilkins SAJr: Carcinoma of the posterior pharyngeal wall. Am J Surg
122:477-481,1971.
Wilkins SA Jr: Indications for section of the cricopharyngeus muscle.
Am J Surg 108:533-538, 1964.
Wilson BS, Lloyd RV: Detection of chromogranin in neuroendocrine
cells with monoclonal antibody. Am J Pathol 115:458-468, 1984.
Woodburn BT,Hartwell SW Jr, Anderson R: Cervical esophagostomy:
Technic and use. Cleve Clin Q 31:231-234, 1964.
Wookey H: Surgical treatment of carcinoma of the hypopharynx and
esophagus. Br J Surg 35:249, 1948.
Waakey H: Surgical treatment of neoplasms of the cerviCQ-
esophagus. In Pack GT, Ariel IN (eds): Treatment of Cancer and
Allied Diseases, Vol. III, Tumors of the Head and Neck, 2nd ed.
New York, Paul B. Hoeber, 1959.
Wookey H: The surgical treatment of carcinoma of the pharynx and
upper esophagus. Surg Gynecol Obstet 75:499, 1942.
Work WP: Tumors of the paraphaJyngeal space. XXIVWherry Memorial
Lecture. Trans Am Acad Ophthalmol Otolaryngol 73:389-394, 1969.
Wright C, Cuschieri A: Jejunal interposition for benign esophageal
disease. Ann Surg 205:54-60, 1987.
Wychulis AR, Fontana RS, Payne WS: Noninstrumental perforations
of the esophagus. Dis Chest 55:190-196, 1969.
Young DC: Successful primary anastomosis in oesophageal atresia
after reduction of a long gap between the blind ends by
bougienage of the upper pouch. Br J Surg 54:321-324, 1967.
Zilberstein B, Mishrick A, Kashiwabara H, et al: Use of Teflon
pledgets in esophageal anastomoses. Am J Surg 374-375, 1982.
 22 VASCULAR
PROCEDURES
JOHN M. LORE, JR., JOSEPH ANAIN,
NIEVA B. CASTILLO, L. NELSON HOPKINS

Vascular Surgery in Operations of horizontal incisions, in stepladder fashion after the

Neck, Extracranial Portions of technique of MacFee, are used. If an emergency occurs,
Head, Face, and Thoracic Outlet a vertical extension may be made either superiorly or
inferiorly or an incision along the anterior border of the
Vascular problems in these areas that are amenable to sternocleidomastoid muscle can be made. In operations
surgical management can be grouped into four main on patients who have had previous neck surgery, the
categories: incision may follow the course of the scar.
In case of a high bifurcation or extensive disease of
I. Degenerative vascular disease the internal carotid artery, the skin incision may be
a. Occlusion of vessels extended upward to the mastoid process. Care must be
b. Subclavian steal taken to avoid injury to the spinal accessory nerve. The
c. Arteriosclerotic aneurysm stylomandibular ligament can be sectioned to afford addi-
d. Anomalies of internal carotid (kinking, absence) tional exposure. Extraoral transection of the mandible
e. Fibromuscular dysplasia is rarely needed, but when necessary it can be done
f. Takayasu's arteritis behind the last molar tooth using a Gigli saw (see
g. Radiation arteritis Fig. 22-33). Repair of the mandible is performed by
h. Spontaneous intimal dissection of the carotid artery using an intramedullary Kirschner wire or Steinmann
2. Neoplastic disease pin and tie wires.
a. Invasion of vessel wall In case of trauma in which proximal control is required
b. Displacement of vessel at the base of the neck or near the arch of the aorta
c. Intravascular extension (e.g., to control the left common carotid artery or the
3. Trauma to vessels innominate artery), a midline sternotomy (see Fig. 22-18)
a. Immediate sequelae incision is the most reliable and rapid approach for the
b. Late sequelae exposure of these vessels. For the exposure of the verte-
4. Control of hemorrhage bral artery, a supraclavicular incision or a trans cervical
a. Prevention and management of carotid artery approach and transection of the scalenus anticus
blowout muscle is recommended (see Fig. 22-12). The proximal
b. Ligation of proximal vessel portion of the left subclavian artery is best approached
I) External carotid artery by a left posterolateral thoracotomy incision. If time is
2) Internal maxillary artery not a factor, the carotid and the innominate arteries
3) Ethmoidal arteries and the subclavian arteries can be exposed by resection
of the medial third to the medial half of the clavicle
Basic Principles (see Fig. 19-9).

Exposure Instrumentation and Gentle Care of Vessel Wall

Exposure must be liberal and adequate so that control
of the vessel proximal and distal to the area of surgery
is possible by placement of tapes and vascular clamps
about the vessel. Some vascular surgeons use a long
incision following the anterior border of the sternoclei-
domastoid muscle; this affords excellent exposure.
Nevertheless, a long oblique incision following a natural
skin crease is preferred for cosmetic reasons. If additional
exposure is necessary at another level, one or more
Extreme care must be used in the application of vascular
clamps. No clamp is completely atraumatic. Hence, the
vascular clamp must be placed well away from the area
to be sutured; otherwise, the sutures may pull through
the vessel wall. In the presence of atheromatous plaques,
care must be taken to avoid breaking off a loose fragment.
There is a very extensive variety of vascular instru-
ments. All are designed so they are capable of securely
holding the vessel without extensive trauma or intimal

1233
 VASCULAR PROCEDURES
injury. The small, least traumatic instruments are used
for small vessels, because large vascular instruments
will cause extensive endothelial injury when applied to
small vessels. Vascular forceps without teeth or with small
serration should be used at all times when handling
blood vessels. Forceps without serrations are preferred
for the smaller vessels. The forceps should grasp the
adventitia, thus avoiding unnecessary injury to the intima.
Vascular scissors with 4S- and 13S-degree angles should
be available when the arteriotomy is made in both
directions, namely, proximally and distally. The vas-
cular needles usually have a tapered end. However, the
taper cut can be utilized when calcified atheromatous
plaques are present at the anastomotic site. When pos-
sible, the needle should be introduced from the inside
to the outside. Small needles should be used for a small
vessel anastomosis, and large needles should be used
for a large anastomosis. Vascular needle holders are
lighter and easier to handle with small needles than the
conventional needle holders. They should not cause
any damage to the needle. The preferred suture material
is monofilament. Although there are numerous types of
monofilament sutures on the market, their basic char-
acteristic is that they are essentially nonreactive. They
slip through the vessel wall with a minimal amount of
friction and tearing. When the monofilament sutures
are used, care must be taken when tying the knot that
the vessel wall is not lacerated. In addition, several
(usually five to six) square knots are applied.
Balloon catheters such as the Fogarty catheters and
other similar ones are available for embolectomy and
thrombectomy of an occluded artery. Caution must be
exercised so that the balloon is not overinflated, because
this might cause intimal damage and be a further source
of thrombosis. The amount of pressure applied to the
wall of the vessel must be just "right" to remove a clot
without stripping the endothelial system. Cases of
carotid-cavernous sinus fistula after the use of Fogarty
catheters have been reported.
Vascular Anastomosis
Arterial repair and anastomosis may be accomplished
by a variety of techniques. Simple through-and-through
sutures are used to approximate intima to intima or
intima to graft anastomosis. The needle must go through
the entire thickness of the wall of the vessel and may
be placed from the outside in (adventitia to intima) or
from the inside out (intima to adventitia). Inside out is
especially important at any distal anastomosis, especially
if there is evidence of atherosclerosis and calcification
of the wall of the distal artery, because the blood flow
and the insertion of the needle may cause a dissection
or separation of the intima from the media of the distal
vessel. This can lead to possible occlusion of the lumen
with a type of a dissection of the intima. Whichever
technique is preferred, intima-to-intima approximation
is the technique of choice. The correct tension must be
maintained at all times to prevent leakage or to avoid a
narrowing of the anastomosis.
When the anastomosis between the walls of a vessel
and a prosthesis is required, an end-to-end or end-to-
side or a side-to-side anastomosis can accomplish this
need. The selection of the method depends on the
given circumstances and whichever technique is more
convenient for the surgeon. Another consideration of
the type of anastomosis is the prevention of narrowing
at the anastomotic site. Hence, a side-to-end anastomosis
would be preferred over an end-to-end anastomosis,
especially in a small vessel, to prevent narrowing at the
anastomotic site. In general, end-to-end anastomosis
may be preferred for large vessel anastomosis, but when
such procedures are utilized in small vessels, it is recom-
mended that the vessels be transected obliquely so that
there will be less chance of narrowing at the site of the
anastomosis.
Different techniques of suturing vessels or anastomosis
are available:
1. Through-and-through running sutures are preferred
in closures of vertical or longitudinal arteriotomies.
2. When performing an end-to-end or end-to-side anas-
tomosis, two separate continuous simple over-and-
over sutures are used, each encompassing 180 degrees
of the diameter of the lumen. This is preferred for
large vessel anastomosis.
3. When performing small vessel anastomosis or an
anastomosis of vessels in children, an interrupted
suture technique is the procedure of choice. This is
done in children to allow future growth of the lumen
of the vessel.
4. A combination of interrupted and running sutures is
also utilized for medium-sized vessel anastomosis.
This is accomplished by placing interrupted sutures
in the "toe and heel" of the anastomosis (Fig. 22-1)
and with running sutures for both lateral sides. This
prevents narrowing at the anastomotic site. Whichever
technique is used, careful attention must be given to
intima-to-intima approximation and eversion of the
suture line. This is important, because the endothelial
layer of the intima has an antithrombogenic function
whereas the adventitia of vessels has a thrombogenic
effect.
Vessel anastomoses performed when local infections
exist are in severe danger of leakage and blowout, and
hence this should be avoided if at all possible. This
specifically applies to carotid artery blowout and the
infected wound. When the anastomosis is completed,
the distal vascular clamp is usually removed first. The
anastomosis is then checked for bleeding and patency.
Any active pulsatile major bleeding can easily be

FIGURE 22-1 A and B, Technique of anastomosis.
controlled with a simple temporary pressure dressing
or single interrupted suture.
Adequacy of flow through the anastomosis is best
determined by the use of intraoperative Doppler or
completion angiography or by occluding the proximal
artery and then opening it once again to see if the distal
vessel fills and pulsates properly and promptly. Care
must be taken that the pulsation in the distal vessel is
in fact a true pulsation and is not a transmitted pulsa-
tion from the proximal vessel. If there is evidence that
the pulsations are not adequate, then arteriograms should
be performed in the operating room to see whether the
occlusion is at the site of the arteriotomy or is more
distally located. If the latter situation exists, transverse
arteriotomy and embolectomy with a Fogarty catheter
can correct the problem much more easily than redoing
the vascular anastomosis.
Some of the causes relative to an anastomotic failure
may be related to unhealthy vessels such as those seen
in postirradiation cervical vessels, to inflammatory
processes associated with oropharyngeal fistula forma-
tion, to endothelial changes secondary to more exten-
sive trauma than was clinically appreciated, and finally
to faulty technical vessel repair and/or anastomosis.
Technique of Surgery
After a satisfactory induction of anesthesia and careful
exposure of the vessels, the carotid artery is then mobi-
VASCULAR PROCEDURES
lized. Extreme care must be taken to avoid injury to the
superior laryngeal nerve, hypoglossal nerve, vagus nerve,
and the sympathetic chain whenever possible. Never-
theless, if a malignant tumor encompasses any or all of
these nerves, they should be sacrificed. However, sacrifice
of both vagus nerves high in the neck is to be avoided.
Sacrifice of both sympathetic chains high in the neck in
one patient was associated with orthostatic changes in
blood pressure. Whether these changes were related to
the sacrifice of both cervical sympathetic chains was never
ascertained and is a moot question. If the superior laryn-
geal nerve or the vagus nerve is sacrificed, a cricopha-
ryngeal myotomy may be performed to aid in swallowing
and in the prevention of aspiration. Both vagus nerves
cannot be sacrificed. If the lesion of the carotid artery
is high or extensive, extension of the skin incision for
mobilization of the internal carotid artery must be done.
Care must be taken to avoid injury to the spinal accessory
nerve, which enters the sternocleidomastoid muscle
near the insertion at the mastoid process. Once this has
been accomplished, and the carotid artery is carefully
mobilized and dissected, heparin is given intravenously.
Anticoagulants
The use of anticoagulants is relegated to the vascular
procedure involved in the reconstruction or the reha-
bilitation of the vascular system, as with endarterectomy,
grafting, or most other procedures involving temporary
occlusion. Heparin, 100units/kg, is injected intravenously
just before the occlusive phase. After completion of the
procedure, neutralization of the heparin is no longer
routine, but, if necessary, protamine sulfate in an equal
amount is slowly injected intravenously. One of the
problems in the administration of heparin has been
hemorrhage from the site of the arteriotomy incision, with
possible compression of the endarterectomized segment
or graft. Anticoagulants are not used postoperatively.
Grafts for Arterial Reconstruction
These grafts can be divided into autografts, allografts,
and synthetic grafts.
Autograft
The autogenous vein graft is the most popular and
allegedly has the best clinical results regarding patency
and survival; it remains the standard to which other
grafts (biologic or synthetic) are compared. Some of the
drawbacks of autogenous vein grafts, however, are the
availability of a suitable vein and the histologic changes
that may occur years later related to "arterialization" or
fibrosis of the vein graft. This fibrosis appears more
common in vascular replacements of the neck and may
 VASCULAR PROCEDURES
be related to the late effect of radiotherapy. Hence, syn-
thetic grafts may be more suitable in the neck. Other
types of autografts that can be used for bypass are the
splenic artery and the internal iliac artery. However,
because of their limited availability and length, the use
of these autografts is very restricted.
Allograft
Fresh or preserved vessel segments from human donors
or cadavers were some of the early grafts used in vas-
cular surgery. The most commonly used allograft today
is the glutaraldehyde-treated umbilical vein reinforced
with a Dacron mesh. Umbilical vein grafts are usually
useful for lower extremity bypass grafts. Some of the
drawbacks of this type of graft have been the
disintegration and aneurysmal formation after several
years of implant and the difficulty in performing a
thrombectomy after occlusion in the graft.
Synthetic Graft
Since the initial investigation of Voorhees, who utilized
Vinyon-N, the fabric graft has evolved in such a way
that at the present time different yarn materials and
fabric designs are available. Dacron grafts are available
in two fabric forms: knitted and woven. The difference
in the woven design is that it has a low porosity surface
and preclotting is not required. The woven type consists
of a number of warp threads with a filling thread called
the weft or fill. This type of graft is indicated when mini-
mal blood loss is desired through the interstices. This
is used mainly when a patient has received anticoagulants.
The drawback of this type of fabric is the poor growth
of tissue into the graft. This type of graft is usually used
for large blood vessel bypass or replacements.
The knitted Dacron grafts are more porous and require
preclotting before use and before systemic hepatization.
This type of graft has the advantage of better graft incor-
poration with body tissue. The knitted type is formed
with needles by interloping a single strand of yarn to
form a succession of connected loops. This type of graft
permits permeation through the interstices for subse-
quent growth and attachment of the neointima and is
preferred over the woven type. More recently, Dacron
velour grafts have had an advantage over both the
woven and knitted types because the tiny warp-knitted
loops enmesh fibrin quickly, thus minimizing thrombi
and emboli.
Expanded Teflon (polytetrafluoroethylene [PTFEJ) is
an electronegative graft with a low porosity that requires
no preclotting. This has become the most common
arterial substitute graft for medium-sized arteries. Late
thrombosis, however, has been a frequent complication
of the graft and is probably related to an anastomotic
pseudo intima hyperplasia. PTFE grafts can be placed in
a curved fashion without kinking. They, thus, are ideally
suited for relocation along the anterior border of the
trapezius muscle. Currently, our basic conclusion is that
a prosthetic graft of either Dacron or PTFE is preferred
for replacement in the neck. Lately, albumin- and collagen-
coated knitted graft has been developed that does not
require preclotting before use.
Although initially our experience was extremely favor-
able with Teflon prosthetic grafts, a switch was made to
autogenous saphenous vein grafts. However, pseudoin-
timal stenosis of autogenous saphenous vein grafts has
been reported to occur in approximately 14% of these
peripheral grafts. The same result is suggested by our
experience.
There has been at least one instance when an au-
togenous vein graft over a period of years has com-
pletely fibrosed in a patient who had radiotherapy,
chemotherapy, and a radical neck dissection. In this
circumstance, a prosthetic graft may be the graft of
choice. It is impossible to speculate whether the total
occlusion and fibrosis in this patient were due to
thrombosis of the graft or to the associated radio-
therapy and surgery. There is no doubt that the graft
was patent for many months, and when total fibrosis
did occur, the patient adapted in such a manner that
there was no neurologic deficit. Percutaneous balloon
catheter dilatation can be used to treat autogenous
saphenous vein bypass graft stenosis. Recently,
end avascular stents have been used in clinical experi-
ments to maintain patency and prevent restenosis with
promising results. This technique is still investigational
and should be used with caution in the head and neck
region.
After a radical neck dissection, especially when a
relocation or extra-anatomic bypass graft is indicated
although an autogenous vein graft has been used, a
seamless prosthetic graft of either knitted or woven
Dacron or PTFE may now be the graft of choice in view
of stenosis of autogenous vein grafts.
Vascular Grafts
When end-to-end arteriorrhaphy (patch graft angioplasty
is less often used now) is not possible and the vessel
involved is either the common carotid artery or the
internal carotid artery, reestablishment of continuity is
preferred by use of a vessel graft. In the presence of
infection or oropharyngeal fistula, grafts, regardless of
the type, are not usually feasible because of the likelihood
of breakdown of the vascular anastomosis. Relocation
bypass grafts are sometimes feasible. The risk of hemor-
rhage and death must be weighed against the risk of liga-
tion of the common carotid artery, taking into account
the underlying pathologic change.

Shunt or Temporary Vascular Bypass
The earlier type of temporary bypass consisted of a
section of polyethylene tubing with a large-bore needle
at each end. The needles were placed proximally and
distally to the area of surgery, and vessel bypass was
accomplished. One problem with this arrangement was
that the needles slipped out. Another problem was
the clotting of blood in the needles or tubing. Later,
the intraluminal bypass was introduced. In this tech-
nique, a section of plastic tubing is inserted through an
arteriotomy incision and held in place with tapes
pulled through a cuff or rubber tubing, the tape being
secured by a clamp. The main problem with this
arrangement has been that the tubing has a tendency
to slip out.
Javid (1966) introduced specially cupped holding
clamps with tapered tubing, a bulge being located on
either end of the tubing. The bulge is placed proximal
to the proximal clamp and distal to the distal clamp.
Thus, the tubing cannot inadvertently slip. The distal
bulge may have to be trimmed off if it cannot be fitted
into the narrower distal internal carotid artery. Air
embolism must be avoided by allowing blood to fill the
bypass tube before establishment of blood flow. If a
graft is to be utilized, it can first be threaded over the
tubing before the tubing is inserted into the vessels.
This should be a loose fit. Thus, the anastomoses, both
proximal and distal, can be performed over the tubing
with ease. The tubing is removed through an arteriotomy
incision about 3 em proximal to the proximal anastomosis
or through an arteriotomy in the graft or before com-
pletion of the final anastomosis. This is facilitated by
pushing the tubing proximally until the distal end of
the tubing rests at the arteriotomy site. A suture may be
tied on the tubing to ensure safety, but it is actually vir-
tually impossible to lose the tubing in a proximal direc-
tion because of the blood flow. If an acute thrombosis
occurs in the graft, it can be removed by inserting a
Fogarty catheter through the proximal arteriotomy incision.
Another type of clamp that is well suited for interlu-
minal shunting is the Kraft clamp. It is much smaller
than the Javid clamp. We tend to prefer the Javid clamp
proximally and the Kraft clamp distally. If the Kraft
clamp is used proximally, leakage may occur. Another
type of shunt is the Heyer-Schulte loop shunt, which is
available in three different diameters.
During endarterectomy, the intraluminal bypass is
usually looped, whereas it is used straight (distal excess
length removed) in grflft procedures. Under no circum-
stances should the holding rim or bulge be removed on
the proximal end; otherwise, the tubing will slip out of
the common carotid artery. If this tubing is not available,
a section of ordinary vinyl tubing can be substituted. In
such situations, a silk tie is firmly secured to the mid-
portion of the tubing and held in a caudal direction to
VASCULAR PROCEDURES
prevent the tubing from slipping out. Do not depend on
the Javid or Kraft clamps to keep this tubing from
slipping. If a short intraluminal tube is desirable, simply
cut off the end (3 to S em) of the Javid tube utilizing
the bulge at the proximal end.
Preservation of Vessels
In general, the vessels in the neck that should be
preserved, or the continuity of which should be re-
established, are the common carotid, internal carotid,
and vertebral arteries. The subclavian artery may be
sacrificed if its collateral pathways are intact. In such
instances, interruption of the subclavian artery should
be distal to the origin of the vertebral artery; yet, it is
best to reconstruct the subclavian artery, if possible.
Carotid artery blowout is an exception to this rule.
Because this calamity is almost always associated with
infections, reconstruction is thus virtually impossible
unless a relocation graft is feasible. Stump pressure of
the internal carotid artery is helpful in determining
whether the continuity of the carotid system can be
relatively safely sacrificed. This pressure should be
above 60 mm Hg for sacrifice and can be measured
with a transducer manometer or connected to the intra-
arterial digital or pressure wave manometer used by
the anesthesiologist.
Physical Examination and Diagnostic
Laboratory Tests
Evaluation of the carotid arteries by manual examina-
tion is limited to the presence or absence of a pulse,
which may be difficult to detect, especially in obese
patients. Carotid artery bruit may be present when there
is stenosis between 20 % to 9S % of the lumen. Thrill is
uncommon. A prominent carotid artery bulb on physical
examination is a concern to the head and neck surgeon
regarding its evaluation and diagnosis. When present
and there is suggestion of possible carotid body tumor
or aneurysm of the internal carotid artery, diagnostic
imaging should be considered. The possibility of lymph
node or tumor mass present over the carotid bifurca-
tion sometimes can be better evaluated with enhanced
computed tomography (CT) or magnetic resonance
imaging (MRI).
Oculoplethysmography (Fig. 22-2)
Noninvasive testing of the extracranial portion of the
carotid artery is designed to identify a hemodynamically
significant lesion of the carotid artery of the carotid
bifurcation. Although some of this testing can be utilized
to evaluate the vertebral circulation, this has become
much less precise than that of the carotid artery. The
most common uses of noninvasive testing of the carotid
 VASCULAR PROCEDURES

FIGURE22-3 Carotid phonangiography: top tracing-

normal; middle tracing-minimal bruit; bottom tracing-
marked bruit in the upper cervical region. (Courtesy of
Manfred Asrican, LifeScience Inc.)

FIGURE 22-2 Eye cup of the oculoplethysmograph

placed on the sclera for the measurement of ophthalmic giography is rarely used alone for carotid artery evalua-
artery pressure. tion but rather is combined with other noninvasive
instrumentation. The disadvantage of this instrument
is that it is not useful in severe stenosis when there is
not a detectable bruit, and it fails to discriminate between
artery are those that are classified as the direct tech- the bruit of the internal carotid and the bruit of the
nique of evaluation of the carotid artery flow. Oculo- external carotid artery as well as the degree of stenosis.
plethysmography (OPG) allows for the study of the oph- This technique is rarely used today but rather is com-
thalmic artery, which is the first branch of the internal bined with other noninvasive instrumentation.
carotid artery. The two most common systems used today
are the OPG-Gee, which measures the ophthalmic artery Ultrasound (Fig. 22-4)
pressure, and the OPG Kartchner-Zira, which compares
the arrival time of the arterial pulse of one eye with With the improvement in ultrasonic equipment, it is now
that of the other eye and with the ear. Our experience possible to analyze the characteristics of the arterial wall
has been mainly with the OPG-Gee. The accuracy rate
has been reported between 75% and 95% in lesions
with greater than 50% stenosis. Some of the con-
traindications for OPG include acute glaucoma, recent
eye surgery, retinal detachment, and conjunctivitis.
OPG can also be utilized for preoperative measurement
of carotid stump pressure by ipsilateral compression of
the common carotid artery. Compression of the carotid
artery should be performed low in the common carotid
artery, avoiding compression and manipulation of the
carotid bifurcation, because asymptomatic ulcerative
plaque may be present and thrombic emboli may occur
with subsequent cerebrovascular accident. OPG is of
historical interest only and rarely used at this time.

Carotid Phonangiography (Fig. 22-3)

Designed by Kartchner and McRae (1969) to analyze FIGURE 22-4 Duplex ultrasound imaging shows
the carotid artery bruit quantitatively, carotid phonan- bifurcation of the common carotid artery.
 VASCUlAR PROCEDURES

and the hemodynamics of the carotid flow by means of

ultrasound. The overall accuracy rate has been reported
at between 90 % and 99 %. The duplex scanning (gray
scale ultrasound with Doppler) of the carotid bifurcation
provides an accurate method of detecting significant
carotid artery stenosis. The limitation of this technique
is the need for experienced technicians.

Doppler Imaging

Doppler imaging is one of the most common methods

for evaluation of the patency and stenosis of the carotid
system. This includes transcranial Doppler evaluation
of the intracranial circulation, continuous wave Doppler
imaging, and periorbital Doppler studies. Intraoperative
Doppler imaging is a significant aid in the identification
of the carotid system, especially in patients who have
had radiotherapy and/or previous surgery. It is espe-
cially helpful in operations involving the para pharyngeal
space. In patients who have had previous radiotherapy,
actual exposure of the internal carotid artery should be
avoided because if the patient develops a fistula there FIGURE 22-5 Digital subtraction angiography. Arrow
is a possibility of carotid artery blowout. This has not points to an obstruction in the left internal carotid artery
been experienced, but it is a warning. as depicted using the venous route. (Courtesy of D.
Rowland, Director of Radiology, Sisters of Charity
Angiography (Fig. 22-5) Hospital, Buffalo, New York.)

Conventional angiography, now with usual subtraction

technology, is the most useful single tool for the diag-
nosis and surgical management of a specific vascular
problem. In occlusive extracranial vascular disease,
arch studies and intracranial views are necessary to
visualize the direction of the flow, as in subclavian steal
syndrome, as well as to diagnose other concomitant
occlusive lesions. Arch aortography provides visualiza-
tion of the takeoff of the brachiocephalic vessel, carotid
bifurcation, and proximal internal carotid arteries.
Intracranial visualization requires selective catheteri-
zation and injection of the common carotid artery. A
femoral or axillary route can be used for the insertion
of the catheter. When extensive vascular disease is
present, and a major vessel is not available for the
insertion of the catheter, direct arterial puncture can be
used. Seriographic films are necessary to interpret the
direction and the velocity of the flow, especially for
subclavian steal syndrome. The complications of con-
ventional angiography arise from its invasiveness. It
may produce embolization of plaque, intimal dissection,
and thrombosis and bleeding at the site of the catheter
insertion. Contrast media reaction includes renal failure,
anaphylactic reaction, cortical blindness due to neuro-
toxicity of the drug, and cerebrovascular accident, which
may be permanent or transient. The highest complica-
tion rate has been in patients with acute stroke and
severe occlusive vascular disease.
Magnetic Resonance Angiography
Magnetic resonance angiography (MRA) has been very
accurate in diagnosing the degree and location of
carotid artery stenosis. MRA is not invasive and does
not require the use of contrast material, which makes
this technique very suitable for older patients with
peripheral vascular disease and patients with renal
failure or dye allergy. Although dye can be added to the
basic MRA study, there is no substitute for the
angiogram as far as fine details are concerned relative
to smaller vessels. One problem with MRA is that it
only gives a limited image of the surrounding soft
tissue. An angiogram will afford soft tissue and some
bone detail. An example of this is the evaluation of a
glomus jugulare tumor at the base of the skull. Even
then, one requires CT for bone detail.
Selective Venography
Venograms are useful in evaluating intravenous exten-
sion of neoplasm, such as for Hiirthle cell carcinoma of
the thyroid invading the jugular veins, innominate
veins, and superior vena cava, with extension into the
right atrium (see p. 913); glomus jugulare tumor
invading the internal jugular vein (see Fig. 22-30); and
 VASCULAR PROCEDURES

intravagale chemodectoma compressing the internal
jugular vein at the base of the skull (see Fig. 22-27).
Computed Tomography
CT and MRI will give valuable information differen-
tiating ischemia from infarction and other space-occu-
pying lesions such as malignant or benign brain tumors
as well as a blush associated with chemodectomas.
avoiding a cerebrovascular accident when the ipsi-
lateral internal carotid artery must be sacrificed. Hence,
it is important to perform an internal carotid artery
bypass, when feasible. Arteriography with or without
compression of the common carotid artery is no longer
believed to be helpful in evaluating functional
intracranial blood flow.
Complications

Technetium Flow Studies The reader is referred to page 1251.

These tests can also indicate the presence of a chemo-

dectoma by a concentration of the dye at the site of the Degenerative Vascular Disease
tumor. (See Figs. 22-6 to 22-21)
Evaluation of Intracranial Blood Flow Crossover Within this category, four main types of extra cranial
vascular disease (Fig. 22-6) exist that are amenable
1. OPC is used with compression of the ipsilateral com- under certain conditions to surgical correction:
mon carotid artery. This test is of historical interest
only and seldom used (via ophthalmic artery).
A Occlusive disease (see p. 1259) includes athero-
2. Obtain intraoperative stump pressure.
matous plaques with or without thrombus formation.
3. There is no standard test to evaluate the crossover
circulation from one carotid artery to the other in
B, B1 Subclavian or innominate artery steal (B) (see
case of a need for ligation of the internal carotid
p. 1258)-shunting or diversion of blood from con-
artery except for balloon occlusion of the artery
tralateral vertebral artery into the obstructed vertebral
(incidence of stroke is 1 + %).
artery via the basilar artery and thence into the distal
subclavian artery with blood that was originally
There are several anatomic pathways of crossover
intended for the cerebral circulation or a thyrocervical
circulation. The first branch of the internal carotid.
steal (B1).
artery is the ophthalmic artery, but in cases in which
the external carotid artery must also be sacrificed, this
C Atherosclerotic aneurysm (see p. 1266).
pathway will not exist. The anterior and midcerebral
arteries and the basilar artery are also pathways for
D Kinking of major vessels (see p. 1266).
crossover circulation but cannot be depended on in
 VASCULAR PROCEDURES

BASILAR

EXT. MAXILLARY

LINGUAL

EXT. CAROTID

INT. CAROTID
Int. carotid a.
SUP. THYROID

COMMON CAROTID
Common carotid a.

VERTEBRAL

SUBCLAVIAN

INNOMINATE

FIGURE 22-6
 VASCULAR PROCEDURES
Extracranial Cerebrovascular Disease
With the improvement of techniques of blood vessel
anastomosis and thromboendarterectomy and in pros-
thetic materials, the results of cerebrovascular surgery
have improved considerably. Since the early report of
Carrea and colleagues (1951) and others, cerebrovas-
cular surgery has undergone rapid development and
continues to progress and expand with the advance-
ment of new diagnostic techniques and better under-
standing of the symptoms.
Cerebrovascular accidents rank as the third most
common cause of death in the United States. It has
been estimated that approximately 500,000 new cases
of stroke occur in the United States each year. Patients
with transient ischemic attacks (TIAs) have on average
a 33 % chance of developing a complete stroke. However,
in patients with severe stenosis of the internal carotid
artery, the risk of a stroke rises to 75 %.
The natural history of asymptomatic carotid artery
stenosis is much more difficult to predict. Reported
figures range from 5% to 70%, but with the develop-
ment of noninvasive equipment, the diagnosis of
hemodynamically significant lesions can be made more
accurately.
The most common pathologic lesion of the extracranial
vessels is atherosclerotic plaque. The atheroma affects
the entire wall of the artery and is more prevalent in
large- and medium-sized arteries. The progression of
atheromatous plaque from an asymptomatic to a symp-
tomatic lesion may be related to the development of
intraplaque hemorrhage. This may result in TIAs because
of a decrease in the arterial flow or embolic phenome-
non to the involved cerebral hemisphere. Platelets also
playa important role in the development of atheroma-
tous plaque and in the formation of a hemostatic plug
in response to endothelial injury that triggers a complex
chain of events leading to the thrombus formation. Other
pathologic lesions involving the extracranial vessels
include fibromuscular dysplasia, aneurysm, kinking
and angulation, neoplastic invasion, radiation arteritis,
and trauma.
Carotid Artery Disease
Surgery of the carotid bifurcation for the treatment of
cerebral insufficiency and, it is hoped, to prevent a
stroke is the most common vascular procedure done in
the head and neck region. The symptoms of carotid
artery insufficiency may be valuable in distinguishing a
variety of clinical syndromes.
Transient Ischemic Attacks
Temporary and local cerebral dysfunction of sudden
onset usually lasts less than I minute but occasionally
as long as 24 hours, leaving no permanent neurologic
deficit. The symptoms of TIA may include ipsilateral
monocular vision disturbance (amaurosis fugaxJ, con-
tralateral motor weakness and sensory changes, aphasia,
and speech impairment. Other patients may present
with no localizing hemispheric symptoms, which include
syncope, dizziness, amnesia, and sometimes convulsions.
In some patients, symptoms are so vague that estab-
lishing the diagnosis of carotid artery insufficiency may
be difficult.
The cause of TIAs remains controversial and
unclear. It is generally accepted that they result from
the breaking off of microemboli from the plaque itself
or to a decrease in the flow from reduction of the
arterial lumen by the stenotic plaque. TIA is the most
important warning symptom of impending stroke: 75 %
of patients with complete stroke had a previous TlA.
Once the TIA has cleared, there are no abnormal
physical findings, except for the presence sometimes of
a carotid artery bruit.
Contraindications for Surgery
The main contraindication for surgery is the presence
of an acute cerebrovascular accident. Relative contraindi-
cations are an unstable cardiovascular status, terminal
illness, and completely occluded internal carotid artery.
Indications for Surgery for Carotid Artery
Stenosis
Indications for surgery for symptomatic carotid artery
stenosis are the following:
• TIA referable to the involved hemisphere
• Amaurosis fugax
• Nonhemispheric symptoms with significant carotid
artery lesion
• Cerebrovascular accident with no or minimal
neurologic deficit
• Stroke in evolution or crescendo stroke with significant
carotid artery stenosis
Indications for surgery for asymptomatic carotid
artery lesions include:
• Asymptomatic but hemodynamically significant
carotid artery stenosis

• Large ulcerated plaque
• Patient who must undergo another surgical pro-
cedure that is likely to produce hypotension during
the procedure, such as coronary bypass and aortic
resection (with concomitant significant asymptomatic
carotid artery stenosis)
• When the opposite carotid artery is totally occluded
Intraoperative Considerations
Local anesthesia was originally preferred because
intracranial circulation and oxygenation of vital centers
were easily evaluated. If a trial occlusion in 3 to 5 minutes
was not well tolerated, a bypass was believed necessary.
This principle is still basically sound, but the opposite
is not necessarily true: If the trial occlusion was well
tolerated, all will go well with longer periods of cross
clamping.
There is a consensus that the patients undergoing
cerebrovascular surgery are probably best managed
with the use of general anesthesia. Both hypercarbia
and hypocarbia have been advocated in the past. It was
Wells and colleagues, in 1963, who introduced the com-
bination of general anesthesia, hypercarbia, and induced
hypertension without the use of shunts or hypothermia
in the anesthesia for occlusive vascular disease. Larson
subsequently modified his regimen by substituting
hypocarbia for hypercarbia, using phenylephrine to
produce hypertension. Some believe that hypocarbia
itself will induce mild hypertension. The induced hyper-
tension is delayed and the carotid vessels are exposed,
thus minimizing troublesome bleeding during the expo-
sure. While it was believed that hypercarbia may increase
cerebral perfusion, some investigators have postulated
that a selective steal of blood of the contralateral hemi-
sphere with a decrease in arterial flow to the ischemic
hemisphere may occur when hypercarbia is induced.
White and colleagues (1967) presented evidence to
support the argument for halothane (0.4% to 1.5%) as
the best maintenance agent, with nitrous oxide-oxygen
for cerebral protection during carotid endarterectomy.
Their regimen included hypercapnia (hypercarbia),
spontaneous respiration maintenance of the patient's
normal blood pressure to within 10 to 20 mm Hg, using
0.002 % of phenylephrine if necessary, and monitoring
VASCULAR PROCEDURES
of cerebral venous oxygen rather than carbon dioxide
as an index of adequacy of cerebral flood flow and oxy-
genation. Neither shunts nor hypothermia was used.
It is stated that cerebral blood flow is adequate if
the venous oxygen saturation remains above 60 %.
Others raise doubts regarding this conclusion. Regard-
less, currently it seems that whenever interruption of
the carotid system is contemplated, mild hypertension
and normal tension should be attained along with a
shunt, if feasible. This will apply not only to carotid
endarterectomy but to other carotid artery surgery and
reconstruction as well. Mild hypertension or at least a
normal blood pressure with normal blood volume is
crucial.
Agents for the control of hypertension, such as
sodium nitroprusside, and of hypotension, such as
vasopressor agents, must be immediately available
during anesthesia, because sudden changes in blood
pressure are well known to occur and can be cata-
strophic. Oxygenation is of paramount importance
during carotid endarterectomy.
If a decision has been made to utilize a shunt, then
after the arteriotomy incision has been completed, an
intraluminal shunt is inserted. If the decision is to use
a shunt selectively the stump pressure is recorded before
the arteriotomy incision. The arteriotomy incision is
made in the lateral portion of the common carotid
artery and is extended toward the plaque upward into
the internal carotid artery with a Potts scissors. The
arteriotomy must be extended past the distal end of the
lesion as well as past the proximal end of the athero-
matous plaque. An endarterectomy then is carried out,
and the plaque is removed in toto in the proper plane.
The distal end of the specimen is inspected to be
certain that a clean, smooth distal end is found. After
the endarterectomy is completed, the surface is irri-
gated with normal saline or dextran solution to remove
all the loose fragments and debris. The arteriotomy
incision is then closed with vascular suture material,
and simple through-and-through sutures are utilized to
approximate intima to intima or intima to graft for
anastomosis. Monofilament (Prolene) is the suture of
choice for repair of the arteriotomy incision. In the clo-
sure of a longitudinal arteriotomy, one single continuous
suture is utilized.
 VASCULAR PROCEDURES
Exposure of Bifurcation of Carotid
Arteries and Endarterectomy (Continued)
(Fig. 22-7)
Highpoints
1. Refer to Basic Principles (p. 1233).
2. Operation is based on cleavage plane of atheroma-
tous plaques within the media of vessel wall, hence
the removal of the intima, leaving a smooth surface.
3. Excise all diseased, thickened intima, including tags
up to the point at which the intima is normally
adherent to the media.
4. Take care during exposure and mobilization of
carotid vessels to avoid dislodging a loose plaque.
5. Avoid injury to the mandibular branch of the facial
nerve, the hypoglossal nerve, the superior laryngeal
nerve with its two branches (internal and external),
and the vagus nerve.
6. Place occluding clamps beyond the area of palpable
disease.
7. Be sure all debris and air are flushed out before final
closure.
A A horizontal skin incision is made following a
natural skin crease at the upper third of the neck. A
vertical incision may be the choice of some vascular
surgeons. If additional exposure is necessary cephalad,
the techniques shown in Figure 22-33C to E may be
used. Variations of skin incisions are discussed under
the section on exposure (see p. 1233).
B Upper and lower skin flaps are developed, with
care taken for the mandibular division of the facial
nerve at the upper margin. An incision is then made
along the anterior border of the sternocleidomastoid
muscle.
C The carotid sheath has been opened and the
medial tributaries of the internal jugular vein have
been ligated and divided. The internal jugular vein and
ansa of the hypoglossus are retracted laterally, expos-
ing the bifurcation of the common carotid artery and
vagus nerve. An alternate approach is to retract the
internal jugular vein and ansa medially.
D After adequate exposure of the proximal and
distal vessels, vessel loops are placed around the com-
mon carotid artery and internal carotid artery and the
external carotid artery. The vagus nerve and internal
jugular vein are retracted laterally. The sympathetic
chain lies posteriorly. If bradycardia develops during
dissection, especially around the carotid body, this can
be controlled by injection of 0.5% lidocaine to the
tissue surrounding the carotid body. If so desired,
pressure studies can now be made by the insertion of
manometric needles into the common carotid artery
proximal to the occlusion and into the internal carotid
artery distal to the occlusion. Prominence of the vessels
and firmness and thickening of the vessel wall will
indicate the location and, to some degree, the extent
of the occlusion. The preoperative angiogram delineates
the degree of stenosis and the extent of the lesion. An
electromagnetic flowmeter can also be placed around
the common carotid artery proximal to the obstruction.
This will evaluate blood flow in cubic centimeters per
minute and can be compared with the flow postopera-
tively. Wylie and Ehrenfeld (1970) use mean internal
carotid backpressure of 40 mm Hg or less as an indi-
cation to use an intraluminal shunt. Others use shunts
more frequently. Actually, at this writing, no minimum
safe pressure guidelines have been determined.
Two techniques for the use of intraluminal shunts
are depicted in Figure 22-9. Vascular occlusive clamps
are then placed around the carotid vessels at least
2 cm from the gross detectable disease, taking care to
avoid injury to the superior laryngeal nerve and its two
branches that lie posterior to the internal and external
carotid arteries. The superior thyroid artery may like-
wise require occlusion, depending on its relationship
to the external carotid artery clamp.
E, El Arteriogram of partial occlusion of the internal
carotid artery is shown with a schematic (E1) represen-
tation of the occlusion.
Continued
 VASCULAR PROCEDURES 1245 -'

Ant. jugular v.

A B

Ansa
hypoglossi
Int. jugular v.

FIGURE 22-7
 VASCULAR PROCEDURES
Exposure of Bifurcation of Carotid
Arteries and Endarterectomy (Continued)
(Fig. 22-7)
Complications
The reader is referred to page 1251.
F A longitudinal arteriotomy is begun with a No.15
blade knife and then enlarged with angulated scissors
in the common and internal carotid arteries,
attempting to extend the incision beyond both ends
of the plaque. If it is possible, avoid narrowing of the
internal carotid artery, thus obviating the need for a
patch graft angioplasty. The arteriotomy is made along
the anterolateral wall of the vessels.
G With the major portion of the atheromatous
plaque exposed, stay sutures of 6-0 vascular suture
material are placed to aid in exposure. With a nasal-
type freer, the diseased intima with atheromatous
plaque is first dissected proximally. The cleavage plane
is easily detected lying within the media. This may
extend slightly proximal to the arteriotomy. The intima
is then transected sharply. The extension into the
external carotid artery is handled in similar fashion.
H With extreme care the extent of the diseased
intima into the internal carotid artery is evaluated and
dissected. Slight cephalic traction (after Wylie and
Ehrenfeld, 1970) on the proximal clamp will relax the
arterial segment between the clamps, and this, com-
bined with caudal traction on the diseased intima,
permits further distal dissection with the freer up to
normal intima. It is important that no additional dis-
section be performed into normal intima. The correct
plane must be identified by sharp dissection with a
spatula. The distal end is most critical, and a smooth
tapered end must be obtained.
The traction sutures or a clamp placed within the
arteriotomy and gently opened will aid in exposure. A
clean line of demarcation is necessary with all diseased
tabs of intima removed. Each clamp is then released
independently and briefly to flush out any loose frag-
ments. The clamps are then reapplied. Careful irriga-
tion and washing of the endarterectomized segment is
performed, and all loose fragments and debris are
removed.
I Closure consists of a continuous 6-0 vascular suture.
Before the final suture, the clamp on the internal carotid
artery is briefly released to flush out any air at the
operative arterial segment and reapplied. Initial blood
flow is first established into the external carotid artery
by releasing the common and external carotid artery
clamps simultaneously to obviate the forcing of any
clot or fragment into the internal carotid artery. The
clamp on the internal carotid is then remov.ed.
J If circumferential dissection of the distal intima
margin occurs that occludes the free flow, this can
usually be detected by palpation. Although rare, this
complication requires immediate correction by replacing
the clamps and further exposure of the distal internal
carotid artery. Extraoral transection of the mandible
may be required, depending on the need for addi-
tional distal exposure (see Fig. 22-33). In any event the
internal carotid artery is transected distal to the flap
and the offending intima removed as depicted. End-
to-end anastomosis completes the repair.
K Occasionally, to prevent further dissection by the
blood flow of the free distal margin of the intima, several
7-0 vascular sutures are placed to secure the intima to
the media and adventitia. If this fails, an autogenous
saphenous graft may be necessary with further distal
resection of the internal carotid artery. Before skin clo-
sure, patency of the internal carotid artery can be accom-
plished by completion angiography or intraoperative
duplex scanning or by intraoperative hand-held
Doppler imaging.
 VASCULAR PROCEDURES 1247

J K

FIGURE 22-7 Continued

 VASCULAR PROCEDURES

Endarterectomy With Patch Graft Intraluminal Shunts Used in

(Fig. 22-8) Endarterectomy (Fig. 22-9)

Highpoints
A Although there may be a bulge at the site of the
arteriosclerotic plaque, after its removal and subse- 1. Refer to shunts under Basic Principles (see p. 1237).
quent simple closure a constriction may occur. Such a 2. Atheromatous debris must not enter the lumen of
constriction should be avoided, because this may be the shunt.
the nidus for a subsequent occlusion. This is prevented 3. Be sure all air is cleared out of the shunt and recon-
by using a patch graft composed of either a section of structed vessel. First, the internal carotid artery clamp
vein from one of the jugular or saphenous veins or a is temporarily released.
prosthesis of Dacron or PTFE. 4. Heparin must be used (5000 to 6000 units intra-
venously) as well as irrigation of the tubing with
B Two continuous sutures encircle the patch graft up heparin solution.
to one area in the midportion of the graft. Before this S. Be sure silk retrieving tie is placed on a straight
area is closed, the distal and then the proximal tapes tubing shunt that does not have a bulge on at least
or clamps are removed to flush out the operative site. the proximal end.
6. Advantages
( The completed closure is shown. a. Brain perfusion

FIGURE 22-8

FIGURE 22-9
b. Unhurried endarterectomy
c_ Easy closure of endarterectomy
7_ Disadvantages
a. Difficulty in performing endarterectomy
b. Embolization
c. Possible intimal dissection
javid Technique
A A longitudinal arteriotomy is performed similar to
that shown in Figure 22-7 after adequate exposure and
crossclamping of the carotid vessels_The loose athero-
matous debris is first irrigated away and the smaller
end of the specially designed shunt tube with a bulge
or rim (A2) on either end is carefully inserted into the
internal carotid artery and securedwith the small-sized
ring clamp (Javid)_(The author has used the Kraft
bulldog-type interdigitating clamp at this site, because
it is devoid of the long handles.) The tubing is looped
and flushed with blood flowing retrograde from the
internal carotid artery, and its large proximal end is
VASCULAR PROCEDURES 1249 -
gently inserted into the common carotid artery. Debris
must not be allowed to enter the tubing. The larger
size ring clamp (Javid) then securesthe tube in place,
the clamp being placed distal to the bulge or rim on
the tubing (Al). This prevents the tube from being
forced out of the vessel by flow.
B The endarterectomy is then unhurriedly per-
formed in the usual manner, first proximally. Any distal
intimal tabs are carefully removed up to normal
intima.
C Closure is performed using two continuous 6-0
vascular sutures, one starting at each end of the
arteriotomy. Just before final closure, extreme care
must be taken to flush out the reconstructed vesselof
all debris and air by first releasing the internal carotid
artery clamp temporarily and then establishing
forward blood flow first through the external carotid
artery.
Continued
 1250 VASCULAR PROCEDURES
Intraluminal Shunts Used in
Endarterectomy (Continued) (Fig. 22-9)
Straight Vinyl Tubing Shunt (After DeBakey,
1964)
Complications
• Dissection of the distal internal carotid artery intimal
flap at the time of insertion
• Dislodgment of atheromatous debris causing
cerebral emboli
• Acute clotting in tube or proximally or distally
• With the use of the straight shunt without a cuff
proximally, the tubing can slip out of the common
carotid artery. This can be extremely bothersome.
• The shunt can be a nuisance in that it can get in the
way of the endarterectomy.
See Table 22-1 for ways to prevent complications in
carotid artery surgery.
D TO F A section of vinyl tubing with a retrieving tie
of silk is first inserted into the internal carotid artery
proximally. The precautions taken under the Javid
technique are followed. The silk tie is also utilized to
prevent extrusion of the tube from the common
carotid artery during the endarterectomy by traction
caudad. Kraft or Javid clamps or tapes are utilized to
prevent leakage of blood around the tube. Shown are
FIGURE 22-9 Continued
the Kraft clamps. The Javid clamp is preferred proxi-
mally, because there may be some leakage with the
Kraft clamp at this site. The remaining technique is
similar to that described in Figure 22-88 and C. Intra-
arterial heparin is useful when injected into that
portion of the artery that is completely isolated from
the circulation by clamping.
Danger Maxims
1. Avoid operation when acute neurologic damage exists.
2. Avoid operation when total occlusion is of long
duration.
3. Avoid operation when preexisting neurologic
damage is severe.
Complications of Carotid Artery Surgery
The most tragic and feared complication of any vascular
procedure involving blood supply to the brain is the
possibility of a stroke with varying degrees of neurologic
deficit or death. The dictum of primum non nocere, first
do no harm, is strictly applicable. In the most experienced
hands, death or neurologic deficit will occur in 1 % to
3 % of the cases. There is controversy in the literature
regarding the management of a patient who develops
neurologic deficit on awakening. Do not depend on
continuity of the external-internal carotid artery system
for cranial blood flow when the common carotid artery
 VASCULAR PROCEDURES 1251

TABLE22-1 Prevention of Complications of Carotid Artery Surgery and Specific Therapy

Complication Prevention/Therapy

Hypotension Vasopressordrugs
Hypertension Sodium nitroprusside
Bleedingand hematoma Closed system drainage
Peripheral nerve injury Carefuldissection
Operative stroke due to embolization Carefulinsertion of shunt
Carefulirrigation of the endarterectomized segment
Postoperativestroke Emergencyevaluation of the patency of the internal carotid artery
Myocardialinfarction Careful selection of the patient

is interrupted, because the pressure in the internal and false aneurysm. It has been reported that restenosis
carotid artery may be greater than that in the external occurs in 3% to 10% of the patients and may be related
carotid artery. An external carotid artery steal would then to neointimal formation, especially in the first 2 years
occur. The cause of the operative stroke is thought to after surgery, or to recurrent atherosclerosis that usually
be immediate postoperative hypertension, with cerebral develops after the first 2 postoperative years. False
hemorrhage, intimal dissection, decreased flow, and aneurysm may be related to infection of the suture line.
proximal thrombosis and embolic phenomenon. Reoperation in this situation may be difficult, and the
Another complication of carotid artery surgery is severe cranial nerve becomes more vulnerable to injury.
postoperative hypertension. It has been suggested that
this is due to changes in the neural bundle supplying Complications According to Specific Areas
the carotid baroreceptors. Careful dissection and spar-
ing of the nerves in this area have been recommended. 1. Anesthesia
However, when hypertension is present during the a. Cardiovascular
operation or immediately postoperatively, it must be b. Airway compromise
controlled promptly, especially with the use of sodium 2. Cervical wound
nitroprusside infusion. The incidence of postoperative a. Hematoma
stroke in hypertensive crisis is much higher than in the b. Bleeding
nonhypertensive group (9 %). c. Nerve injury (vagus, hypoglossal)
Hypotension is also a frequent complication of carotid d. Marginal branch of the facial nerve
endarterectomy, is usually benign, and is easily controlled e. Sympathetic chain
with vasopressive drugs. Peripheral nerve injury is also 3. Carotid artery
well known to occur during carotid endarterectomy. The a. Disruption
incidence ranges from 1 % to 16 %. Careful dissection b. Arteriovenous fistula
and recognition of this nerve is important. The most c. Occlusion
common nerve injury is to the hypoglossal nerve, which d. Thrombosis
must be identified, carefully dissected, and preserved. e. Embolism
The superior laryngeal nerve may also be injured as it 4. Postoperatively
passes deep to the external carotid artery. Vocal cord a. Hypertension
paralysis can also occur. This is evidently due to injury b. Hypertension headache
of the vagus nerve. The ansa hypoglossi nerve can be
surgically divided with safety. Table 22-1 discusses ways to prevent complications
Postoperative hematoma may occur because the in carotid artery surgery.
patient has been heparinized during surgery and may
have received preoperative antiaggregate platelet therapy. Specifics in Relation to Complications
In such circumstances, drainage of the hematoma is
recommended. When active oozing and bleeding is • Hypotension and hypertension
present during surgery, the use of a closed drainage • Cerebral emboli
system is recommended. • Cerebral ischemia at time of cross clamping of the
Late postoperative complications may occur. The carotid vessels
two most common are recurrent carotid artery stenosis • Acute carotid thrombosis
 VASCULAR PROCEDURES
• Progression of preexisting ischemia infarction into a
hemorrhage infarction
• Distal intimal dissection causing obstructing flap
• Airway obstruction
• Myocardial infarction
• Separation of arteriotomy suture line
Controversies of Carotid Artery Surgery
Cerebral Protection and Monitoring During
Carotid Endarterectomy
Opinion in this area varies widely depending on the
surgeon-some who never use shunts to those who
always use intraluminal shunts. However, most vascular
surgeons use shunts in a selective population of patients.
The criteria for selective shunting vary also. One group
will use the level of consciousness during carotid cross
clamping in the patient done under local and regional
anesthesia. Another group will use electroencephalo-
graphic changes associated with carotid occlusion. And
a third group will measure the stump pressure of the
distal internal carotid artery as a criterion for shunt-
ing and also uses trans cranial Doppler imaging during
cross clamping.
Controversy also exists as to the accepted "safe" stump
pressure for the prevention of a stroke. This varies from
2S to 60 mm Hg. It is also recommended that the shunt
be routinely used in the presence of contralateral
carotid artery occlusion.
Carotid Artery Surgery and Coronary Artery
Disease
Controversy exists regarding the natural history of patients
with asymptomatic carotid artery disease undergoing
coronary artery revascularization. One group believes that
the incidence of peri operative stroke is not significantly
different from that in patients with no significant carotid
artery disease. However, they recommend no prophy-
lactic carotid artery surgery, except when TrAs develop.
Other groups, however, believe that the patient with an
asymptomatic but hemodynamically significant carotid
artery lesion is at higher risk of perioperative and imme-
diately postoperative stroke; hence, they recommend
endarterectomy before coronary bypass or simultaneously
with the bypass surgery.
Surgery for Acute Carotid Artery Occlusion
Emergency surgery after acute cerebrovascular accident
in the presence of carotid artery disease was advocated
some time ago. Presently, it is generally agreed that
carotid endarterectomy in the presence of acute stroke
is contraindicated because of the risk of converting
an ischemic infarct to a hemorrhagic infarct. However,
some authors recommend surgery for selected cases
of acute arterial occlusion, especially in those patients
with progressive or crescendo cerebrovascular deficit.
Our policy has been not to operate in cases of acute
stroke with carotid occlusion or in cases of completely
occluded internal carotid artery with fixed neurologic
deficit.
External Carotid Endarterectomy
This is a well-accepted procedure for the correction of
external carotid artery stenosis before the superficial
temporal artery jmiddle cerebral artery anastomosis.
However, other surgeons have advocated this procedure
for improvement of cerebral and ocular ischemia, but
such evidence remains unclear.
Management of Asymptomatic Carotid Artery
Ulceration
The literature is divided regarding the management of
asymptomatic nonstenotic ulcerated carotid lesion. One
group recommends the use of platelet anti aggregates as
the preferred choice of therapy. Others have suggested
endarterectomy for this lesion. Our policy has been
platelet antiaggregate therapy for a small lesion and
carotid endarterectomy for large ulcerated plaques.
Management of the Patient With an Acute
Postoperative Neurologic Deficit (Fig. 22-10)
The management of this patient in the immediate post-
operative period remains somewhat controversial.
However, the majority of the vascular surgeons believe
that immediate reoperation in the patient with pro-
found neurologic deficit is indicated. Several criteria
are available in the literature regarding the manage-
ment of this patient. If possible, the assessment of the
patency of the internal carotid artery should be made
with no delay by means of angiography, digital subtrac-
tion angiography, duplex imaging, or oculoplethysmo-
graphy. If the artery is found to be patent, conservative
management is then recommended. If it is occluded or
if a significantly decreased flow exists, reoperation is
recommended.
If the assessment of the patency of the artery cannot
be determined in a reasonable period of time (20 minutes),
then re-exploration is recommended. At the time of the
re-exploration, consideration should be given to intra-
operative arteriography, especially if the artery is found
to be pulsatile.
Asymptomatic Carotid Artery Bruit (Fig. 22-")
The asymptomatic carotid bruit also remains a contro-
versial issue because of the disagreement over the
 VASCULAR PROCEDURES 1253

Carotid Artery Surgery

Postoperative cerebrovascular accident
Postoperative stroke

Emergency assessment
of carotid artery patency

OPG, Doppler ultrasound, subtraction

or conventional angiography

FIGURE 22-10 Algorithm for management of acute postoperative

neurologic deficit.

Completion
angiogram

Carotid Artery Surgery

Asymptomatic carotid artery bruit
(management)
Asymptomatic

Not
FIGURE 22-11 Algorithm for management of significant
asymptomatic carotid artery bruit.

[ Angiogram )
 VASCULAR PROCEDURES
natural history of the carotid artery plaque. However,
several authors have suggested that the patient with
asymptomatic carotid artery bruit should be evaluated
noninvasively. Several protocols have been developed.
The most accepted is by Parker and consists of the
following: If the patient has an asymptomatic carotid
artery bruit, noninvasive testing is done. If the patient
is normal, or has a subclinical stenosis, he or she is
followed by noninvasive testing. If the patient has a
hemodynamically significant lesion, an angiogram is
performed. If the angiogram confirms the diagnosis,
carotid endarterectomy is recommended.
Carotid Artery Stenting: Indications,
Technique, and Results
L. Nelson Hopkins
Extracranial carotid surgery continues to evolve and
evoke debate. Since the first successful surgical recon-
struction of the carotid artery in 1951 by Carrea and
colleagues, issues regarding proper technique, patient
selection, timing of surgery, and the utility of surgical
versus medical therapy have been debated over decades
in the medical literature (Carre a et aI., 1951; Robertson,
1997). The current medical literature supports the role
of carotid endarterectomy on the basis of several large
prospective randomized multicenter national and
international clinical trials. The North American Symp-
tomatic Carotid Endarterectomy Trial (NASCET), the
Asymptomatic Carotid Atherosclerosis Study (ACAS),
and the European Carotid Surgery Trial (ECST) have
shown the durable benefit of this operation as determined
by a reduced risk of stroke in patients with recent
nondisabling stroke, hemispheric TIAs, and amaurosis
fugax in whom the stenosis is greater than 70% as well
as reduced 5-year stroke rates for men with asympto-
matic stenosis of 60% or more (NASCET Collaborators,
1991; ACAS Group, 1995; ECST Collaborative Group,
1991). The recent evolution of carotid artery stenting
has added another technique to the extracranial carotid
revascularization debate.
Results of Carotid Endarterectomy
To determine the current role of carotid artery stenting
relative to carotid endarterectomy, it is important to
recognize that achieving a durable benefit from surgery
is highly dependent on the technical skill of the operating
surgeon. The benefit of carotid endarterectomy is lost if
the perioperative morbidity and mortality exceed 6% in
symptomatic patients and 3 % in asymptomatic patients
(Grotta, 1997). The surgeons in these studies were
carefully screened regarding technical ability; thus, the
results may not be generally applicable to the population
of extracranial carotid surgeons at large. In addition,
the patients were carefully screened for risk factors that
may have introduced confounding variables in the data
analysis. These factors included: older than 79 years;
heart, kidney, liver, or lung failure; cancer likely to cause
death within 5 years; cardiac valvular lesion or rhythm
disorder potentially associated with cardioembolic stroke;
previous ipsilateral carotid endarterectomy; angina or
myocardial infarction in the previous 6 months; pro-
gressive neurologic signs; contralateral carotid endarterec-
tomy within 4 months; or a major surgical procedure
within 30 days (NASCET Collaborators, 1991; Hopkins
et aI., 1998). Thus, the results of the numerous prospec-
tive randomized trials may not be generally applicable
to the population at large. In fact, the mortality among
Medicare beneficiaries undergoing carotid endarterec-
tomy during the same period as NASCET enrollees was
3% versus 0.6%, respectively (Hsai et aI., 1992).
Indications for Carotid Stenting
Endovascular carotid artery stenting has never been sub-
jected to prospective randomized evaluation, and given
the relative infancy of the technique, several more years
may pass before a critical number of endovascular sur-
geons are trained in the technique. Currently, it is unlikely
that endovascular angioplasty-assisted stenting can
achieve the clinical results of NASCETand ACASrelative
to their patient populations. However, recently published
clinical series suggest that for those patients in whom
significant medical and surgical comorbidities exist, sten!-
ing poses a risk of 0.6 % and 6.2 % for major and minor
stroke, respectively (Mathur et aI., 1998). Because of
the exclusion of patients with significant comorbidities
in the NASCET, the role of carcinoembryonic antigen
relative to this population is poorly defined. In a sub-
group analysis of NASCET patients with diabetes, the
rate of perioperative morbidity and mortality was over
10% (Barnett et al., 1998). Additionally, the coexistence
of carotid and coronary artery disease is well estab-
lished, with myocardial infarction as the leading cause
of death in patients undergoing carotid endarterectomy
(Gray et aI., 1997; Hopkins et aI., 1998).
Other high risk candidates for carotid endarterectomy
include patients who are pre-coronary artery bypass
grafting (CABG).The risk of stroke or death of combined
carotid endarterectomy and CABG is 1.5 to 2.0 times
the risk of either operation alone, with patients under-
going carotid endarterectomy as a prelude to CABG at
highest risk (McCrory et aI., 1993). Ipsilateral stenosis
and contralateral occlusion carries a 14.3 % periopera-
tive risk after carotid endarterectomy (Mathur et aI.,
1998). In our recent report of 20 patients undergoing
carotid stenting before CABG, there was 1 cardiac death
and 1 patient suffered transient neurologic deficit post
stenting (Lopes et aI., 1998). Carotid restenosis after pre-
vious carotid endarterectomy is a difficult and challeng-
ing operation even in the most experienced surgeon's

hands and carries a perioperative risk of approximately
10% (Meyer et aI., 1994). Other high-risk patients include
those with high cervical lesions that are technically dif-
ficult to reach via an open surgical approach (Diethrich,
1996). Tandem lesions and radiation-induced carotid
artery stenosis are also associated with an increased
risk of peri operative morbidity and mortality (Hopkins
et aI., 1998). Carotid stenosis with intraluminal clot
typically presents as crescendo TIAs; the 30-day risk of
stroke or death in NASCET patients with intraluminal
clot was 10.7% for those randomized to medical treatment
and 12% for those undergoing carotid endarterectomy
(Villarreal et al., 1997).
Although carotid artery stenting is neither indicated
nor recommended for those patients who meet NASCET
entry criteria, recent clinical carotid stent series suggest
that endoluminal stenting may be a viable alternative
in those patients deemed at high risk, as discussed earlier.
Stenting has several benefits over carotid endarterec-
tomy in high-risk patients. Carotid artery stenting is
typically performed under local anesthesia with intra-
venous sedation, thus negating the risk of general anes-
thesia with its inherent pulmonary complications. In
addition, cerebral blood flow is interrupted for only
seconds during endovascular procedures versus minutes
of carotid occlusion during carotid endarterectomy. The
risk of cranial nerve palsies can be significant during
carotid endarterectomy, particularly with bifurcations
above C3. In cases of recurrent carotid artery stenosis,
the risk is even higher and the need for carotid patch
grafting is generally necessary, adding even more time
to the operation. Such issues are obviated with endolu-
minal reconstruction of carotid stenoses. Additionally,
the occurrence of an embolic complication, although one
of the most feared complications of carotid stenting,
can be recognized during the performance of serial neu-
rologic examinations and identified angiographically,
and thrombolysis can be initiated (Lanzino et aI., 1999).
Preprocedure Patient Evaluation
Patients undergoing angioplasty-assisted stenting pro-
cedures on an elective basis should receive a preproce-
dural medical evaluation to identify any relevant medical
issues. A complete neurologic examination is imperative.
Baseline cognition, language ability, sensation, motor
strength, and cranial nerve function should be determined
before the intervention. This will allow the ready iden-
tification of any peri procedural neurologic changes. A
brain MRI study will identify new or old regions of
infarction and ensure that postprocedural studies do
not attribute preexisting infarction to stent placement.
Before stenting, a complete angiographic study is
obtained, which includes the bilateral carotid arteries
and the posterior circulation. We also obtain complete
intracranial views in standard projections. Information
VASCULAR PROCEDURES 1255
critical to safe performance of the procedure is acquired
from such studies: the presence of coexistent intracra-
niallesions (I.e., aneurysms or stenoses); collateral cir-
culation patterns, both intra- and extracranial; the pres-
ence of preexisting vessel occlusion from prior strokes;
and so on. Intracranial views before and after stenting
are especially helpful in cases of suspected thrombo-
embolic complications.
To minimize the occurrence of perioperative proce-
dure-related embolic complications, patients are begun
on oral anti platelet therapy 3 days before the proce-
dure. Administration of aspirin, 325 mg daily, as well
as ticlopidine, 250 mg twice daily, or clopidogrel,
75 mg daily, is initiated. Aspirin is taken indefinitely
after the procedure, and anti platelet therapy is
continued for 1 month. Patients are admitted to the
outpatient area, and intravenous lines are placed as
well as a Foley catheter. Patients are hydrated to achieve
urine output of approximately 1 mL/kg/hr. Additionally,
patients with diabetes undergo serial monitoring of
blood glucose levels because elevated levels can
potentiate ischemic injury. Intravenous sedation is
administered before and throughout the procedure, in
addition to analgesics. Typically, this includes sedative-
hypnotics for their amnestic effects and synthetic
narcotics for their analgesic properties. All flush lines
are heparinized throughout the procedure. Patients
considered at high risk for stenting procedures (I.e.,
restenosis, contralateral occlusion, tandem lesions, or
recent TIA) are started on intravenous glycoprotein
IIb/IIIa antagonist therapy before the procedure or in
conjunction with heparinization during the procedure
(Coller, 1997).
Technique
Patients are placed supine on the neuroangiography
table. Routine prepping and draping are performed.
Biplane fluoroscopy is utilized, although single plane
fluoroscopy is acceptable. Blood pressure, heart rate,
electrocardiogram, oxygen saturation, and urine output
are continuously monitored. Serial neurologic exami-
nations are performed throughout the procedure. After
access to the femoral artery, a diagnostic angiogram is
performed. If a complete study has recently been per-
formed, we proceed to the diseased vessel immediately.
Angiography is performed, and the lesion measure-
ments are generated. These initial measurements deter-
mine the initial angioplasty balloon size (if necessary)
and stent choice. Once access has been obtained, the
patient is anticoagulated with an initial heparin bolus
of 70 units/kg to maintain an activated clotting time of
approximately 300 seconds. If glycoprotein IIb/IIIa
antagonists are to be utilized, they are administered at
this point and the heparin bolus is scaled back to
50 units/kg.
 VASCULAR PROCEDURES
By using a "road mapping" technique, the diagnostic
catheter guide wire is passed into the external carotid
artery, followed by the diagnostic catheter. An exchange
length wire is passed into the external carotid artery,
and the diagnostic catheter is removed. Performing the
maneuver in this fashion minimizes manipulation of
the carotid bifurcation by the exchange wire. The guide
catheter for stent delivery is then advanced over the
exchange wire to the proximal common carotid artery
approximately 3 em proximal to the lesion. Angiographic
runs are obtained at this point, and the previous meas-
urements are verified. The exchange length wire is
removed, and the previously chosen angioplasty
balloon is passed through the guide catheter with a
0.014- or O.01S-inch exchange length micro-guide wire.
At the distal guide catheter, a "road map" is created,
and the wire is advanced across the lesion to reside in
the distal cervical internal carotid artery. Balloon angio-
plasty is performed with careful attention to blood
pressure and heart rate. In patients without significant
cardiac disease, we routinely administer 0.5 to 1.0 mg
of atropine before balloon inflation. It is important not
to oversize the angioplasty balloon because this may
result in dissection or liberate embolic debris from the
plaque.
After removal of the angioplasty balloon, angiography
is performed to ascertain any morphologic changes in
the lesion. The previously chosen stent is prepared and
advanced over the guide wire. Once again, the "road
map" is used to advance the stent across the lesion.
However, bony landmarks are also important in this
regard because manipulation of the artery by the stent
may make the previously generated "road map" illegible.
The deployed stent should cross the lesion in its entirety.
Multiple angiographic runs are occasionally necessary
before stent deployment to determine the optimalloca-
tion. The stent is deployed under constant fluoroscopic
control. After deployment, angiography is performe,d to
determine the presence of residual stenosis. If necessary,
postdeployment dilatation is performed to approximate
the distal stent diameter. Final angiographic evaluation
of the intracranial circulation is performed and the runs
compared with the prestent intracranial angiograms.
Throughout, the micro-guide wire is maintained across
the stented lesion in the event that distal access is
necessary. If the final intracranial angiograms are normal,
the wire is removed and the guide catheter withdrawn
into the descending aorta.
The heparin is allowed to wear off. If a glycoprotein
IIb/IIIa antagonist was infused, the sheath is either
left in place until the infusion is stopped or a percu-
taneous closure device is utilized for hemostasis. Post-
procedure care is administered in the intensive care
unit. Most patients are discharged to home the follow-
ing morning.
The Future of Carotid Artery Stenting
Technologic advances in catheters and wires have made
access to the extracranial carotid circulation safer and
faster than ever before. Whereas liberation of emboli
remains the most feared of carotid stenting complica-
tions, meticulous technique and, in the future, distal
protective devices will likely minimize this complication.
The use of distal protective devices will likely diminish
peri procedural morbidity due to stroke and result in a
marked decline in its occurrence.
Exposure of Cervical Portion of
Subclavian Arteries and Proximal Portion
of Vertebral Arteries (Fig. 22-12A to D)
Highpoints
1. Exposure of the proximal portion of the right sub-
clavian artery is via a trans cervical approach. Resec-
tion of the medial third of the clavicle with disarticu-
lation of the sternoclavicular junction will aid in the
exposure if necessary.
2. Exposure of the proximal portion of the left subclavian
artery is via a left posterolateral thoracotomy incision,
whereas the more distal portion is via a trans cervical
approach. If at all possible, any transthoracic approach
is to be avoided, because a thoracotomy is usually not
well tolerated in patients with degenerative vascu-
lar disease. A bypass graft with the proximal end
anastomosed to a vessel accessible via a transcer-
vical incision is usually preferred (see Fig. 22-16).
3. Both vertebral arteries are approached through a
trans cervical incision.
4. Avoid injury to the phrenic and vagus nerves, brachial
plexus, subclavian vein, internal jugular vein, and
thoracic duct.
5. Gentle care must be taken when mobilizing and
suturing the subclavian artery, because it is fragile.
6. Recognize pneumothorax if it occurs and treat it
accordingly (see Figs. 2-3 to 2-6).
A The incision is just above the clavicle. The
approach depicted is for the left side. A similar tech-
nique is used for the right subclavian artery. On the left
side, injury to the thoracic duct should be avoided. If
injured, the duct should be carefully ligated to prevent
a chylous fistula. On the right side, any lymphatic
collecting duct into the venous septum, if injured,
should also be doubly ligated.
B, B1 The anterior and posterior borders of the
sternocleidomastoid muscle are identified, and the
external jugular vein is doubly ligated and transected.
 VASCULAR PROCEDURES

,.STERNOCLEIDOMASTOID M

THYROCERVICAL
TRUNK

PHRENIC N,

THORACIC
DUCT
A

VAGUS N,
SUP THYROID A.
VERTEBRAL A. THYROCERVICAL TRUNK

SUBCLAVIAN A.

INT. MAMMARY A. SCALENUS ANTICUS M,

c W~bntb
FIGURE 22-12

The sternocleidomastoid muscle is then transected as
is performed in a radical neck dissection, with
identification and exposure of the carotid sheath (see
Fig. 16-3).
The subclavian and internal jugular veins, the
scalenus anticus muscle with the overlying phrenic
nerve, and the branches of the thyrocervical trunk are
identified. The thoracic duct enters the region of
junction of the subclavian and internal jugular veins
with a tributary from the cervical region (Bl).
C The scalenus anticus muscle is sectioned by
placing a curved clamp under the muscle. The phrenic
nerve and brachial plexus must not be injured. The
contents of the carotid sheath (internal jugular vein,
vagus nerve, and common carotid artery) are retracted
medially at this stage. The thyrocervical trunk and
some of its branches are identified and may require
ligation and division to facilitate mobilization of the
subclavian artery.
Continued
 VASCULAR PROCEDURES

Exposure of Cervical Portion of There are three classic surgical repairs of this lesion
Subclavian Arteries and Proximal Portion when the pathologic process is found at the takeoff
of Vertebral Arteries (Continued) from the subclavian artery:
(Fig. 22-1 2A to D)
1. Subclavian vertebral endarterectomy. This operation
is reserved for situations in which the lesion is well
D To expose the vertebral artery, the internal jugular localized to the origin of the subclavian artery.
vein is now dissected from the vagus nerve and com- 2. Subclavian vertebral endarterectomy with vein patch
mon carotid artery, and the vein is carefully retracted angioplasty. This operation is best designed for situa-
laterally. To mobilize the subclavian artery, the internal tions in which the atheromatous plaque extends
mammary artery may require ligation and division. A more than I em into the vertebral artery.
silicone rubber tube or suitable substitute is placed 3. Ligation and reimplantation of the vertebral artery to
around the subclavian artery to retract and deliver the the common carotid artery. This is the preferred
subclavian and vertebral arteries into the operative procedure when a combined lesion (common and
site. The exposure of the subclavian artery may not be vertebral artery) is present and in patients in whom
achieved as well as depicted and can be enhanced by the dissection and control of the proximal subclavian
resection of the medial third of the clavicle. artery are difficult to accomplish with the supra-
clavicular technique. Complications of vertebral artery
surgery are the same as those for carotid artery
Vertebral Artery Reconstruction surgery. Other complications seen with this proce-
dure are the following:
Vertebral artery reconstruction is less frequently a. Injury to the right recurrent laryngeal nerve as it
performed. The indication for this procedure is severe crosses the right subclavian artery
symptoms of vertebrovascular insufficiency in which b. Thoracic duct injury (left side) or accessory
no other extracraniallesion is identified. thoracic duct injury (right side)
The vertebrovascular TIAs are caused by anoxia to c. Re-thrombosis: vertebral artery surgery has a
the area of the brain that is supplied by the vertebral higher incidence of re-thrombosis than internal
artery. Some of the signs and symptoms are as follows: carotid artery surgery.
d. Phrenic nerve injury-may cause respiratory
1. Visual embarrassment
a. Homonymous hemianopsia e. Brachial plexus neuralgia due to surgical manipu-
b. Blurred vision lation or postoperative scarring
c. Diplopia
2. Equilibrium Surgical Treatment of Occlusion of
a. Vertigo Vertebral Arteries (See Fig. 22-1 2E to 11)
b. Drop attacks
c. Postural disturbances Highpoints
3. Auditory
I. Perform trans-subclavian endarterectomy when
a. Tinnitus
obstruction is limited to the takeoff of the vertebral
b. Deafness
artery.
4. Consciousness
2. When the obstruction lesion is more extensive in the
a. Syncope
subclavian artery, performance of vertebral/common
b. Lapse of consciousness
carotid anastomoses is preferred to endarterectomy.
c. Transitory rigidity
d. Fits
S. Motor E Depicted is an incision in the subclavian artery. Be
a. Pain careful of tears in this vessel, because it may be fragile.
b. Numbness
c. Fatigue F A wide (twice the diameter of vertebral artery)
6. Others circumferential incision is made surrounding the takeoff
a. Headache of the vertebral artery. With a nasal-type freer, the
b. Nausea or emesis endarterectomy is performed by dissecting out a core
c. Noises in head of the intima with gentle traction similar to that used in
d. Convulsions the internal carotid artery technique (see Fig. 22-7H).
Continued
 VASCULAR PROCEDURES

VERTEBRAL A.

VAGUS NERVE

FIGURE 22-12 Continued

 VASCULAR PROCEDURES
Surgical Treatment of Occlusion of
Vertebral Arteries (Continued)
(See Fig. 22-12E to 11)
G Depicted is the transection and anastomosis of the
vertebral artery to the juxtaposed common carotid
artery. The shaded area represents the occlusion of a
portion of the subclavian and proximal vertebral
arteries.
H In an alternative method a thromboendarterec-
tomy is performed with a patch graft (see Fig. 22-8).
I Anatomy of the vertebral artery is shown. The first
branch of the subclavian artery passes deep to the
common carotid artery and then passes through the
foramen of C6, C5, C4, C3, and C2 turning laterally, at
which point it becomes vulnerable. It then passes
through the foramen of C1 (atlas) and then behind the
superior articular process of the atlas.
The vessel is thus vulnerable:
a. Proximal portion at thoracic inlet (e.g., during
radical neck dissection [see Fig. 16-3])
b. Very deep to the superior portion of the sternoclei-
domastoid muscle, between C1 and C2 (e.g.,
during superior extension of radical neck dissection
[see Fig. 16-4] or during deep approach to the
parapharyngeal space [see Chapter 23])
11 Distal vertebral artery is shown from behind. Note
prominence of C1 (atlas), which may be mistaken for
a fixed mass during surgery or at the time of physical
examination.
 VASCULAR PROCEDURES

,r

Post. Belly
of Digastric
Mastoid Process

Vertebral A.

iOccipital
Condylus

Posterior View
FIGURE 22-12 Continued
 VASCULAR PROCEDURES
Exposure of Distal Common Carotid
Artery and Placement of Bypass Graft
(Fig. 22-13)
Highpoints
1. Use multiple horizontal incisions, as necessary.
2. Careful and adequate mobilization is required of the
vessel proximally and distally. This may require resec-
tion of a portion of the clavicle or splitting the sternum.
A Skin incisions are diagrammed.
B Depicted is exposure of the common carotid artery
proximal to its bifurcation for placement of a bypass
graft. Although shown is an end-to-side anastomosis,
an end-to-end anastomosis can also be performed,
depending on circumstances.
C A prosthetic graft is passed through a tunnel
formed by the introduction of a clamp using blunt
dissection. The proximal anastomosis is made to the
subclavian artery through a supraclavicular incision,
and exposure is as depicted in Figure 22-12A to D.
Tangential vascular clamp on the subclavian artery is
omitted for clarity's sake. If the diameter of the vein
graft is small, the ends are cut obliquely.
An adaptation of this type of bypass has been utilized
at the suggestion of Upson for resection of the common
carotid artery along with a recurrent carcinoma and over-
lying skin of a previous deltopectoral flap. The distal
anastomosis was end to end to the internal carotid artery.
An autogenous vein graft was used. The skin defect was
covered with further advancement of a deltopectoral
flap. Initial blood flow was good; however, the ultimate
outcome was a failure, owing to hemorrhage from the
proximal anastomosis secondary to infection. A con-
tributing factor was poor coaptation of the deltopectoral
flap over the anastomosis, because there was a deep
depression just above the clavicle. In retrospect, resec-
tion of one third or one half of the clavicle probably
would have aided in good coaptation of the flap and
in exposure. The patient has been the only postopera-
tive mortality in the author's (JML) series of operations
consisting of elective vascular reconstructions.
Another possibility for reestablishing blood flow
to the internal carotid artery might be the use of a
trans cervical graft from the contralateral external carotid
artery to the ipsilateral internal carotid artery. This has
not as yet been used.
Subclavian Steal Syndrome
(See Figs. 22-6B and 22-16)
Since the initial description of Contorni (1960) of the
angiographic evidence of reverse flow of the vertebral
artery with associated proximal subclavian artery occlu-
sion, the subclavian steal syndrome has become a well-
recognized etiologic factor of cerebrovascular insufficiency
of the vertebral vascular system, with or without arm
claudication.
The symptoms may be produced by partial stenosis
or complete occlusion of the subclavian artery proximal
to the origin of the vertebral artery. The most important
physical finding is the differential blood pressure between
the two arms of at least 20 mm Hg. The patient may
also have a supraclavicular bruit. The pathophysiology
of this phenomenon is usually atherosclerotic but may
also be congenital or surgically induced.
Initially, the lesion was corrected by direct arterial
reconstruction of the subclavian artery through a transtho-
racic approach. At the present time, extrathoracic recon-
struction of the subclavian steal syndrome is preferred,
and five major surgical procedures are available:
1. Direct anastomosis between the carotid artery and the
subclavian artery by ligation of the proximal subclavian
and transection proximal to the vertebral artery is
probably the most commonly utilized procedure.
When the bypass is to be performed, the anastomosis
is between the proximal carotid and the subclavian
artery distal to the origin of the vertebral artery.
2. Carotid subclavian bypass is probably the most com-
mon operation for relief of this clinical entity. Direct
anastomosis between the carotid artery and the sub-
clavian artery distal to the origin of the vertebral artery
has been the most commonly utilized procedure.
The prosthesis of choice for this bypass has been a
Gore-Tex or Dacron prosthesis or an autogenous
vein graft. The argument against this procedure is
the possible compromise of the carotid circulation
and the possible embolization from the suture line.
3. Subclavian-subclavian bypass requires a bilateral
supraclavicular incision but avoids complications to
the carotid circulation.
4. Axillary bypass appears to be the simplest with the
least risk of complication. However, the long-term
result may be inferior to that of the carotid subcla-
vian or subclavian-subclavian bypasses.
5. Lately, endovascular dilatation and stenting of the
occluded segment of the subclavian artery has been
advocated by Diethrich (1996) and others, but this
procedure remains experimental and the long-term
patency is not known.
 VASCULAR PROCEDURES

FIGURE 22-13
 VASCULAR PROCEDURES
Surgical Treatment of Occlusion of
Common Carotid and Subclavian Arteries
and Subclavian Steal (Figs. 22-14 to
22-16) (After Crawford et aI., 1969)
Highpoints
1. Bypass graft is preferred over an extended endarterec-
tomy unless obstruction is due to a thrombus; then
a simple thrombectomy is performed with an arterial
stripper if the thrombus is long, without injury to
the intima.
2. Avoid a thoracotomy for the placement of a proximal
end of graft; rather, use the cervical approach and
utilize the patent vessel available in the neck.
3. Avoid using grafts of excessive length.
4. If feasible, a prosthetic graft is preferred.
5. Do not ligate the vertebral artery for treatment of
subclavian steal; perform a carotid subclavian
bypass.
Figure 22-14 shows an occlusion in a common
carotid artery. Figure 22-15 gives a postoperative view
of a bypass graft (arrow). See Figure 22-13 for the basic
FIGURE 22-14 Arch aortogram of a 56-year-old man
with a complete occlusion (black arrow) of the left
common carotid artery and late filling of the carotid
bifurcation. (Courtesy of Joseph Anain.)
surgical technique of placement of a bypass graft. See
Figure 22-12A to 0 for exposure of subclavian arteries.
A TO H Composite drawing depicts various cervical
bypass procedures for the treatment of common
carotid and subclavian artery obstruction. The grafts
are tunneled under the soft tissue of the neck to the
appropriate location of the more distal portion of the
carotid artery system, avoiding airway and venous
obstruction by a graft overlying the jugular vein or
trachea. An 8-mm prosthetic graft is utilized. Note in
A and B the use of the carotid/subclavian bypass for
treatment of subclavian steal. This same type of bypass
is used for a thyrocervical steal.
Endarterectomy is used primarily only for the bifur-
cation of the innominate artery. In the use of this
procedure for the right subclavian steal-the innomi-
nate artery steal in this case (with total occlusion)-the
left subclavian steal (partially occluded left subclavian
artery) has occurred as a complication (Berger et aI.,
1967). These authors thus emphasize the importance
of repeat aortic arch angiography (see F).
FIGURE 22-15 Postoperative angiogram demon-
strating a patent left subclavian/carotid saphenous vein
bypass (white arrow). (Courtesy of Joseph Anain.)
 VASCULAR PROCEDURES

c D

E F

FIGURE 22-16
"",,~ 1266 VASCULAR PROCEDURES
Atherosclerotic Aneurysm (Fig. 22-17A)
External carotid artery aneurysms are rare. The clinical
manifestations usually include a pulsatile mass in the
neck. Serious complications such as emboli, thrombosis,
or rupture may result. They may be fusiform (the most
common) or saccular and may involve both carotid
arteries or be associated with other arterial aneurysms.
False aneurysms are most common after carotid
endarterectomy and patch graft angioplasty. They are
caused by suture line disruption due to infection. Mycotic
aneurysms of the carotid artery are extremely rare.
A Shown is such an aneurysm of the internal carotid
that presented as a bulging mass in the neck. These
require reconstruction using Javid intraluminal bypass
technique (Eagan). An aneurysm of the inferior thyroid
artery also has been observed, explored, and ligated
(Upson). This patient presented a picture of rather
rapid cervical swelling with ecchymosis of the neck
and upper thoracic region.
The surgical technique requires excision and bypass
by autogenous saphenous vein. However, when the
aneurysm extends very high, it may require extracranial-
intracranial bypass and ligation of the internal carotid
artery.
One of the authors (JML) has seen a patient who
underwent incision and drainage (at another hospital)
for a mass in the neck that proved to be an aneurysm
of the internal carotid artery. Bleeding was controlled,
and the patient was transferred to our institution, where
the artery was reconstructed several hours later.
Anomalies of the Internal Carotid Artery
(See Fig. 22-1 7B and C)
Kinked Internal Carotid Artery
B This internal carotid artery is so severely angulated
that during the systolic impulse severe kinking of the
vessel occurs, causing partial obstruction to the lumen.
Proximal dilatation and distal narrowing are present.
This should be differentiated from a tortuous internal
carotid artery without obstruction. The symptoms of
one patient with kinking consisted of intermittent
headache and intermittent weakness of the contralateral
upper extremity. The only symptom or sign of a tortuous
internal carotid artery may be a prominence of the
vessel in the neck.
See the discussion in Figures 22-20 and 22-21 for
more on kinked internal carotid arteries and their
correction.
C Angiogram demonstrates "coil" deformity of the
internal carotid artery, which, unless recognized at the
time of surgery (e.g., operation on parapharyngeal
space), can be very deceptive. (The Steinmann pin
visible in the image was used in the reconstruction of
the mandible. See Chapter 23 for a more detailed dis-
cussion of the anatomy of the parapharyngeal space.)
Partial or Complete Absence of the Internal
Carotid Artery
Other anomalies of the internal carotid artery include
its absence, referred to as agenesis or aplasia. Absence
of the carotid canal points to agenesis of the vessel.
 VASCULAR PROCEDURES

In!. Carotid A.

B
A

Common Carotid A.

FIGURE 22-17
 VASCULAR PROCEDURES

Exposure of Innominate Artery and

Proximal Portion of Right Subclavian and A The left innominate vein can be retracted
Common Carotid Arteries via Sternal- inferiorly or superiorly for adequate exposure of the
Splitting Incision (Fig. 22-18) innominate artery.

Highpoints B This exposure facilitates the performance of an

endarterectomy of the bifurcation of the innominate
1. Use a sternal-splitting inCIsIOn in preference to a artery and right subclavian artery utilizing a specially
transthoracic approach, because the former is much designed clamp that allows blood flow through the
better tolerated by most patients, especially those arch of the aorta.
with degenerative vascular disease.
2. Pneumothorax is to be avoided; if it occurs, it should C Depicted is the preferred procedure for obstruc-
be treated as necessary by intercostal underwater tion of the innominate artery with a concomitant
drainage. block in the takeoff of the left common carotid artery.
3. Refer to Basic Principles, page 1233. This exemplifies the basic principle of the extrathoracic
approach by utilizing a patent vessel to supply the
The surgical approach and closure is similar to that obstructed vessel distal to its obstruction all within the
described in Figure 19-1OA to L; however, extension into cervical approach. Either an autogenous vein graft or a
the second or third interspace may not be necessary. prosthetic graft is used. The dotted lines represent
another type of bypass graft extending from one axillary
1. Endarterectomy is reserved for partial occlusion at artery to the other. The approach is subclavicular with
the bifurcation of the innominate artery causing the graft placed subcutaneously over the manubrium
obstruction of the right common carotid and sub- sterni.
clavian arteries.
2. Bypass grafts, if possible, via trans cervical approach
are preferred. In Takayasu's artentls-an obliterative idiopathic
arteriopathy primarily causing varying degrees of
obstruction on all the aortic arch vessels-a bypass
graft from the aorta to the carotid vessels can be
performed. This disease is seen in young females and
may involve other vessels.
 VASCULAR PROCEDURES

RT. INTERNAL JUGULAR V.

RT. AND LEFT COMMON CAROTID A.

RT. SUBCLAVIAN A.

INNOMINATE A.
LEFT INT. JUGULAR V.

FIGURE 22-18
 VASCULAR PROCEDURES
Bypass Graft for Obstruction of
Innominate Artery (Fig. 22-19)
A Exposure of arch of aorta and innominate artery is
shown (see Fig. 19-10A to L). An angulated vascular
clamp has grasped and excluded a portion of the
ascending aorta for the proximal anastomoses. A 10-
or 12-mm knitted Dacron graft is sutured to the aorta
using 3-0 vascular suture.
B The innominate artery is divided distal to the
occlusion. The proximal end of the divided vessel is
closed.
C The completed graft anterior to the left innomi-
nate vein from the aorta to the distal patent innominate
artery is shown. In all such bypasses, patent runoff of
the vessels must be ascertained. Multiple procedures
may be necessary, or longer bypass grafts may have to
be inserted, extending from the arch of the aorta to
the internal carotid artery, as in Takayasu's arteritis.
Kinking and angulation of the internal carotid artery
may be of clinical significance. The role of the kinked
carotid artery in the etiology of TIAs as well as the
natural history of this pathologic finding remains unclear.
Under certain circumstances, this lesion has been respon-
sible for cerebrovascular insufficiency, and its surgical
correction is recommended. The etiology of the kinking
and angulation has been described as congenital, arte-
riosclerotic, shortening or compression of the cervical
vertebrae, or secondary to fibromuscular hyperplasia.
Coils are usually congenital, may range from 90- to
300-degree angles, and usually occur in the internal
carotid artery.
Kinking is usually arteriosclerotic, may involve the
common carotid and internal carotid artery, and may
be bilateral. Another type of kinking of interest to the
vascular surgeon is the one that may result after carotid
endarterectomy. Under this circumstance if kinking is
present and reduces the flow of the internal carotid
artery, it should be corrected at the time of surgery.
Several techniques are available for the correction of
this lesion, such as shortening of the internal carotid
artery, reimplantation of the internal carotid artery, and
segmental excision of the common carotid artery with
or without ligation of the external carotid artery or its
branch. Techniques are depicted in Figures 22-20 and
22-21.
 VASCULAR PROCEDURES

In!. jugular v.

Subclavian a.

Rec.laryngeal n.

L. innominate v.
R. innominate v.

L. rec. laryngeal n.
c
 VASCULAR PROCEDURES

Resection of Kinked Obstruction in

Internal Carotid Artery (Fig. 22-20)
A TO C Kinking (A), causing partial or complete
obstruction of the internal carotid artery, should be
differentiated by arteriography from a tortuous artery
(C) without obstruction. The former is an indication
for operation. B is an operation photograph of a
kinked internal carotid artery.
D After isolation of the vesselsconcerned, small bull-
dog vascular clamps are placed proxirnally and distally
on the internal carotid artery. If feasible, an intraluminal
shunt is used (see Fig. 22-9).
F An end-to-end arteriorrhaphy is begun with a
posterior continuous 6-0 vascular suture, rotating the
clamps 180 degrees.
G The completed posterior suture is shown.
H The clamps are rotated back, and a separate
anterior continuous suture is placed. Becausethere is a
discrepancy in lumen size of the proximal and distal
ends, the resulting "dog-ear" is excised at a tangent
and closed with another suture.
The complete anastomosis is shown.

E The kinked area is resected.

 VASCULAR PROCEDURES 1273

Com. carotid a.
D

FIGURE 22-20
 VASCULAR PROCEDURES
Alternate Method to Correct Kinked
Internal Carotid Artery (Fig. 22-21)
A A portion of the common carotid artery is excised
(between the dotted lines), thus straightening the
kinked internal carotid artery. This method mayor may
not require a temporary shunt. To facilitate adequate
mobilization of the external carotid artery, the more
proximal branches are ligated and divided.
B The completed resection with end-to-end
anastomosis is shown.
Fibromuscular Dysplasia
Fibromuscular dysplasia of the internal carotid artery is
another nonatherosclerotic disease involving the
extracranial cerebral circulation. The pathologic process
FIGURE 22-21
may involve either the intima (usually in young women],
the media, which is the most common pattern with steno-
sis and dilatation (the rosary bead pattern or corkscrew
vessels], or the adventitia, usually involving the renal
arteries. Fibromuscular hyperplasia of the carotid artery
is usually bilateral and may be associated with intracra-
nial arterial aneurysm. Patients with fibromuscular
dysplasia may be asymptomatic, or they may have
symptoms referable to carotid artery insufficiency.
The diagnosis is established by arteriography. Balloon
angioplasty has been recommended in certain cases of
fibromuscular dysplasia, but this should be carried out
under control study and strict protocol by selective centers.
Surgical reconstruction may sometimes be hazardous
because of the usually high extension of the disease in
the neck. The procedure of choice has been graduated
intraluminal dilatation with postoperative anticoagula-
tion, which has produced excellent results. This proce-
dure may be complemented with localized carotid
endarterectomy in selected cases.
I
I
II~
!I
,
I
I
I

Vasculitis
This type of arterial disease is a clinicopathologic process
characterized by inflammation and necrosis of blood
vessels. The pathophysiology of this process is likely to
be due to antigens and immunologic phenomenon. Of
interest to vascular surgery of the head and neck region
is the vasculitis of the giant cell types, such as temporal
arteritis and Takayasu's arteritis (Table 22-2). Temporal
arteritis has been well recognized by its production of
fever and increased sedimentation rate. A well-recognized
complication of giant cell temporal arteritis is sudden
blindness due to involvement of the ophthalmic artery.
Surgical treatment is biopsy of the temporal artery to
establish the diagnosis. The accepted therapy is the use
of corticosteroids, which has been highly effective.
Takayasu's arteritis, or pulseless disease, is much less
common than temporal arteritis, yet the disease involves
the entire wall of the artery (panarteritis). There are
four types of arterial involvement that have been
described: Type I involves the aortic arch and its major
branches, such as the carotid and subclavian artery
and innominate artery. Type II involves the thoracic
and the abdominal aorta. Type III is a combination of
types I and II and involves the aortic arch and its
branches and the abdominal aorta. Type IV involves
the pulmonary artery. The role of surgical treatment of
this disease is very uncertain; thus surgery is not
recommended at the present time.
Radiation Arteritis
The use of radiation therapy for neoplasms of the head
and neck has dramatically increased the incidence of
radiation-induced iatrogenic carotid artery injuries
resulting in major arterial occlusion or disruption of the
arterial wall. The immediate complication of high-dose
radiation to the head and neck area is well known-
carotid artery blowout. The long-term effect is less
TABLE22-2 Clinical Picture of Giant Cell Arteritis
Variables Temporal Arteritis
Sex Women more than men
Age Elderly
Arterial involvement Temporal artery,
ophthalmic artery
Clinical picture Fever, anemia, increased
sedimentation rate,
headache
Complications Blindness
Diagnosis Temporal artery biopsy
Treatment Corticosteroids
VASCULAR PROCEDURES 1275
understood, but recent medical literature suggests that
the incidence of arteriosclerosis or occlusion is higher
among irradiated patients than in the nonirradiated
group. This pathologic lesion appears to be diffuse
scarring of the vessels, which may also stimulate the
development of atherosclerosis. Surgical therapy may
be performed in these cases with prudence. Bypass
grafting as well as endarterectomy in selected cases has
been performed successfully.
Spontaneous Carotid Artery Intimal
Dissection
Spontaneous carotid artery dissection is a pathologic
process that rarely occurs. The pathologic findings are
the characteristic double lumen, with the outer lumen
filled with thrombus. The microscopic findings in this
disease reveal that the dissection occurs in the outer
layer of the media. The smooth muscle cells are widely
separated. The etiology of the disease is obscure but
does not include atherosclerosis. This spontaneous
dissection of the carotid artery is usually not associated
with trauma or dissection of the thoracic aorta. How-
ever, a finding of fibromuscular dysplasia in the con-
tralateral carotid artery is common. The initial symp-
toms in most patients were the same as those seen with
occlusive disease of the carotid bifurcation, that is,
TIAs or strokes. The diagnosis is always made by
arteriography. On a typical arteriogram, the dissection
of the carotid artery reveals an internal tear and double
lumen of the internal carotid artery starting usually 2 to
4 em beyond the origin and extending into the intra-
cranial portion. The treatment of internal carotid artery
dissection is controversial. Surgical reconstructive proce-
dures are designed to obliterate the false lumen and to
restore patency of the carotid artery. Ligation of the
internal carotid artery also has been recommended,
especially when the stump pressure is greater than
65 mm Hg at the time of surgery.
Takayasu's Disease
Women
Young
Large and medium-sized artery, aortic arch, or branch, such as
carotid artery
Local signs related to the involved artery
Transient ischemic attack and stroke
Arteriography
Surgical correction is seldom indicated
 VASCULAR PROCEDURES
Neoplastic Disease (See Figs. 22-22
to 22-30)
Vascular surgery plays a small yet important part in the
surgical management of malignant tumors of the head
and neck and may be divided into the following
categories:
1. Vascular replacement for the common or internal
carotid artery when the tumor directly invades or is
so closely affixed to the vessel wall with or without
displacement that resection of the vessel becomes
advisable (e.g., metastatic squamous cell carcinoma,
which is usually recurrent after radical neck dissec-
tion, and large carotid body tumors, primary or recur-
rent, that preclude adequate dissection from the
vessel wall). Because we have utilized preoperative
adjuvant chemotherapy in stage 1IIand IV squamous
cell carcinoma, no patient has required carotid artery
resection. Carotid artery blowout has not occurred
with this protocol.
2. Preservation of major vessel continuity in tumors
that displace but do not invade the vessel walls.
Admittedly, these are for the most part benign in
that they do not metastasize, yet they may almost be
considered malignant because of their local exten-
sion (e.g., chemodectomas, paraganglion intravagale
tumors [arising from the ganglion nodosum] and
small carotid body tumors that were detected early).
3. Microvascular surgery for free grafts of skin with or
without bone, bowel, and omental adipose tissue.
This is not for the occasional surgeon (see Chapter
24).
4. Prevention and management of carotid artery
blowout.
Metastatic Squamous Cell Carcinoma
It is fortunate that metastatic cancer rarely invades the
walls of major vessels. When this does occur, it is more
likely to occur as recurrent disease after radical neck
dissection. If such recurrence is the only reason pre-
cluding complete excision of the tissue involved by
metastatic disease, resection of the vessels involved is
performed with interposition of a graft. Because the inci-
dence of additional recurrent disease in such patients is
higher than usual, it is believed that this interposed
graft should be relocated if feasible along the anterior
border of the trapezius muscle or at least away from
the area of disease. By such a maneuver, any recurrent
disease will probably not involve the graft and addi-
tional surgical procedures and radiation therapy will be
more easily facilitated. In instances in which recurrent
disease might involve a prosthetic graft, radiation therapy
has been shown to be feasible if directed over the graft
with the anastomotic ends beyond the field of therapy.
An advantage of using a prosthetic graft in these
problems is that in the event of breakdown or ulcera-
tion of the skin overlying a relocated graft, arterial
blowout is not likely to occur if the anastomotic ends
are not involved. In surgical procedures that involve
opening into the pharynx, larynx, or mouth, the surgeon
must be cognizant of the dangers of wound infection,
which attend the presence of any foreign material. In
these instances, breakdown of the anastomosis of the
graft to the parent vessel is always a possibility. The
danger of such a breakdown versus the advantages of
a graft must be weighed individually in each patient.
When breakdown is a danger, trial occlusion of the
carotid artery system is warranted with measurement
of the stump presspre in the distal internal carotid artery.
If the stump pressure is 60 mm Hg or higher, the vessel
is probably best permanently ligated and resected with-
out vascular reconstruction. If the stump pressure is
lower than 60 mm Hg, there are several alternative
procedures:
1. Leave the tumor attached to the carotid vessel, then
reoperate at a later date when the danger of fistula
and infection are no longer present. This is not
advised in the presence of infection but is allowed in
emergency situations.
2. Resect the vessel with the tumor and reconstruct it
using an autogenous vein graft, which has a better
chance of success than a prosthetic graft in the pres-
ence of a fistula and infection (not advised).
3. Resect the vessel with the tumor and reconstruct it
with a prosthetic graft. Again, this is not advised in
the presence of infection but is allowed in emergency
situations.
With any type of graft it should be covered with
adequate thickness of viable tissue and relocated as far
from any anticipated fistula as possible. The author
(JML) would opt for the first alternative, because the
overall risk appears to be less in the presence of the
danger of a fistula and hence infection. If the aero-
digestive tract has not been entered, primary section of
the neoplasm and the vessel with immediate recon-
struction using a prosthetic graft would be the first
choice. Normal blood pressure and normal blood volume
must be maintained throughout the procedure.
This operative procedure of relocation of the carotid
arteries using graft replacement has been performed
under both local anesthesia and general anesthesia.
The former makes possible an evaluation of cranial
oxygenation and toleration to cross clamping of the
carotid arteries. However, during a standard radical neck
dissection, the patient is under general anesthesia. In
any event, cerebral oxygenation must be guaranteed.
This procedure is performed, as previously mentioned,
according to basic principles concerning general anes-

thesia, using normocardia and maintaining normal blood
pressure or mild hypertension and normal blood volume.
Likewise, a temporary bypass is used, preferably the
interluminal type using the Javid clamps and tubing.
This technique, however, may not be feasible because
of the presence of the metastatic cancer. If none of these
is suitable, the risk may be reduced by first performing
the proximal side of vessel to end of graft anastomosis
with tangential occlusion of the common carotid artery
without cross clamping of the vessel. This technique is
quite easily performed proximally; however, distally it
is usually not possible, because the internal carotid artery
is of a much smaller caliber. Leaving the external-
internal carotid artery connection intact has been sug-
gested, but there is some question whether it is of any
help. Actually, some authors state that it is a detriment.
A distal end-to-end anastomosis is then performed and
usually entails an interval of 4 to 9 minutes while the
cranial blood flow on the operated side is temporarily
occluded.
Resection of Portion of Common and
Internal Carotid Arteries Involved by
Cancer (Fig. 22-22)
Indications
Resection of the common and internal carotid arteries
is indicated for involvement by cancer when this finding
is the only significant one precluding an adequate ablative
surgical procedure. When the gross disease is directly
continuous with these great vessels, only millimeter
clearance would be possible in preserving these vessels.
Actual invasion of the vessels is rare. The base of the
skull must not be involved, and at least 2 em of distal
internal carotid artery from the base of the skull is
necessary.
In the presence of recurrent carcinoma of the head
and neck, the decision of ligation or grafting of the
carotid artery may be extremely difficult. Carotid artery
involvement has a grave prognosis. Carotid artery
blowout is significantly increased with carotid artery
involvement by tumor. The most common complication
of ligation is cerebrovascular accident, which ranges
from death or deep coma to transient cerebral ischemia.
Ligation of the internal carotid artery gives opportunity
for wide excision of tumor. In addition, postoperative
radiation therapy with ligation can be started earlier
when a graft is interposed. The risk of anatomic disrup-
tion or graft infection with postoperative blowout is
then minimized.
The incidence of cerebrovascular complication is
much higher if the external carotid artery must be
simultaneously sacrificed or has been previously
ligated. This is because the collateral circulation via the
ophthalmic artery is now nonexistent.
VASCULAR PROCEDURES 1277
Carotid artery grafting has a high incidence of graft
failure when patients have received preoperative
radiation therapy. It also may jeopardize ideal resection
of the neoplasm. Postoperative irradiation should be
delayed 4 to 6 weeks or until such time that all wounds
are well healed and free of drainage. Preoperative
chemotherapy rather than preoperative radiation therapy
is the treatment of choice.
Preoperative evaluation ideally includes bilateral
carotid arteriograms (see Basic Principles, p. 1233). On
the homolateral side, distortion of the normal anatomy
is then detected. This is of great aid during the opera-
tion to identify and to distinguish the external carotid
artery and its branches from the internal carotid artery
(no branches in the neck), because it is not compatible
with good ablative surgery to trace the vessels from
their origin. Mistaken identity has occurred. Arterio-
graphy on the contralateral side may aid in the eval-
uation of intracranial cross blood flow; however, it
cannot be relied on for evaluation of functional intra-
cranial blood flow. Balloon occlusion is recommended
by some, but stroke (1 + %) during or after the proce-
dure can occur. Intraoperative stump pressure is an
alternative. Stump pressure of 50 to 60 mm Hg would
indicate adequate cross blood flow. This is an advan-
tage, because it is an indication of the adequacy of
cross blood flow in relation to the estimated tolerance
of temporary occlusion of the homolateral vessels during
the insertion of the graft (if no temporary bypass is
used). It is also some indication of whether the patient
could tolerate permanent ligation of these vessels if the
insertion of a graft is not feasible. Moore and associates
(1969) have reviewed 151 patients with ligation of the
common or internal carotid arteries. Of the 64 patients
who had elective ligation, 15 (23%) developed stroke
and 11 (17 %) died as a result of the ligation. In the
group of 87 patients who had nonelective ligation, 44
(50%) developed stroke and 33 (38%) died as a result
of the ligation.
Ideally, an arch angiographic study could be per-
formed to evaluate the takeoffs of the great vessels as
well as the patency of the vertebral arteries to further
ascertain the site of maximal blood supply to the brain.
Prediction of complications involving the cerebral artery
with ligation of the internal carotid artery can be obtained
with electroencephalography or by direct stump pressure
during the surgical procedure. Before ligation of the
external carotid artery for excision of head and neck
malignancies, consideration should be given to the
patency of the internal carotid artery, because coexistent
occlusion of this artery may be present. In such cases,
intracerebral circulation may have developed by means
of collateral circulation through the ophthalmic artery
from the external carotid artery and sudden interrup-
tion of this pathway may bring about an unexpected
cerebral catastrophe.
 VASCULAR PROCEDURES
Resection of Portion of Common and
Internal Carotid Arteries Involved by
Cancer (Continued) (Fig. 22-22)
When the preoperative evaluation suggests that the
preferred operative procedure is grafting, it should be
decided which graft material is best utilized. Autogenous
saphenous vein grafts have been the preferred graft
material in general vascular surgery. Saphenous vein
bypass for carotid artery surgery in patients having an
infected wound or preoperative radiation necrosis has
a higher incidence of thrombosis with associated cere-
brovascular accidents and death than in those patients
who have had no previous radiation therapy or wound
infection. As an alternative graft, prosthetic material
has a higher risk of infection in grossly contaminated
wounds. Thus, prosthetic materials should be avoided
in the presence of gross infection or when fistula and
wound infection are anticipated. In the absence of infec-
tion, and in the previously irradiated neck, a prosthetic
graft may be the preference in the cervical region rather
than the saphenous vein graft. Saphenous vein grafts
have a higher incidence of occlusion because of fibrous
tissue formation underneath the skin flap. When a vein
graft is required, muscular flap should be used to
protect the vein from early thrombosis.
Reference is made to the surgical techniques for
degenerative vascular disease and their possible appli-
cations in vascular tumor surgery (see p. 1240).
(See p. 1283 for author's [JML] experience.)
Outline of Management of Vascular Involvement
in Neoplastic Disease Relative to Evaluation of
the Intracranial Circulation
There are two different basic situations:
1. The patient has not received any previous treatment
and the cervical metastasis by its size, character-
istics, and location is suspect for being attached to
the common carotid or internal carotid artery, indi-
cating that resection and grafting are a probability.
The preoperative evaluation of this patient as far as
circulation and involvement of vessels is concerned
is with angiography (venous, and then possibly the
arterial route).
2. The patient has recurrent metastatic disease after a
previous radical neck resection that, by all proba-
bilities, will require resection of the common carotid
and internal carotid artery. Preoperative evaluation
consists of arteriography (intraoperative study would
consist of measuring the stump pressure of the
internal carotid artery). Note: Intraoperative stump
pressure is the main method of evaluating cross
intracranial circulation. The arteriogram is not reliable
for this purpose. Balloon occlusion of the internal
carotid artery can result in stroke (1 + %).
Obviously, arteriograms are not performed preopera-
tively on patients in whom involvement of these great
vessels is not suspected. This is almost always the case
in primary surgical procedures. It is up to the surgeon
then to make the decision as to whether to resect vessels
and reconstruct with a graft, preferably with a temporary
bypass, or to perform a less than satisfactory ablative
operation. If the primary lesion involves the oral cavity,
pharynx, larynx, or esophagus, it is probably better
not to attempt vessel reconstruction at the same stage
because of the danger of fistula formation and infection
(see discussion at beginning of this section on neo-
plastic disease). Yet this has been done in one patient
with success using an autogenous vein graft.
Highpoints
1. See Basic Principles, page 1233.
2. Avoid entering the respiratory or digestive tract with
the use of any graft, especially a prosthetic graft.
Wound infection dooms prosthetic graft replacement
and may be a hazard in autogenous vein graft.
3. Maintain normal blood volume and normal or prefer-
ably slightly elevated blood pressure when carotid
vessels are cross clamped. Under such circumstances,
up to 10 minutes of occlusion is usually well tolerated,
depending on the findings of preoperative angiograms,
if performed, and on intraoperative stump pressure.
4. Local anesthesia originally was used, because cerebral
oxygenation is easily evaluated. If a long operative
procedure is anticipated (more recently in all patients),
general anesthesia is used, with halothane and nor-
mocarbia and mild hypertension.
5. Adequate exposure is needed of the proximal common
carotid (3 to 4 cm) and distal internal carotid (2 cm)
arteries.
6. Clindamycin 1 % (Cleocin) or neomycin mouthwash
1% is administered four times a day for 24 to 48
hours preoperatively on all patients to aid in the
prevention of infection if (unplanned) entrance into
the upper respiratory jdigestive tract occurs.
7. For temporary bypass techniques and complications
see Figure 22-9.
8. If cross clamps are utilized, occluding blood flow, inject
heparin (10 mg in 100 mL saline; 1000 units in 1 mL)
several centimeters proximal to the proximal clamp and
distal to the distal clamp. Bypass tubing and vein graft
are also irrigated with heparin. Five thousand to 6000
units of heparin is injected intravenously at the time
of operation but not continued postoperatively because
of the danger of leak and hematoma formation.
 VASCULAR PROCEDURES 1279

RECURRENT
TUMOR

EXT. CAROTID A.

FIGURE 22-22

A1 A left carotid arteriogram depicts distortion of
the internal and external carotid arteries in a patient
with recurrent squamous cell carcinoma at the carotid
bifurcation. The original operation was a left radical
neck dissection and total laryngectomy.
A2 The right arteriogram reveals the more normal
configuration of the carotid vessels. (Adequate cross
blood flow intracranially from right to left was also
ascertained.) These arteriograms are not associated
with the patient problem depicted in A to C, as
follows, but represent involvement at the bifurcation
of the common carotid artery.
A Recurrent squamous cell carcinoma at midjugular
level is shown after a radical neck dissectionfor metastatic
carcinoma of the larynx.
B Exposure is done of the common carotid artery
below and the internal carotid artery above. Vertical
incisions are used because of the scarring from the
previous neck dissection.
Continued
 VASCULAR PROCEDURES
Resection of Portion of Common and
Internal Carotid Arteries Involved by
Cancer (Continued) (Fig. 22-22)
C A subcutaneous tunnel is made using a large
curved clamp. This extends well posteriorly from the
recurrent tumor area to the anterior border of the
trapezius muscle. A prosthetic graft (PTFE or knitted
Dacron) is pulled through the tunnel. The technique of
using an autogenous vein graft with intraluminal
bypass is shown in Figure 22-26E to G. Autogenous
vein grafts have been utilized rather than the pros-
thetic grafts; however, there is evidence that the vein
graft has a high incidence of later fibrosis and throm-
bosis. When knitted Dacron grafts are utilized, these
must be preclotted according to the manufacturer's
instructions before the systemic use of heparin. Other
types of grafts, such as woven Dacron or PTFE,do not
require preclotting.
D The proximal side-to-end anastomosis is performed
using an angulated vascular clamp that tangentially
occludes the common carotid artery while still allowing
blood to pass through the vessel. Heparin, 5000 to
6000 units, is given intravenously.
FIGURE 22-22 Continued
E A continuous 5-0 to 6-0 vascular suture completes
the proximal anastomosis. With normal blood volume
and blood pressure maintained, the internal carotid
artery distal to the tumor is cross clamped. If local anes-
thesia is used, cerebral oxygenation is easily evaluated
during a trial occlusion of 4 to 5 minutes. If general
anesthesia is used, extra precautions, as listed under
Basic Principles (p. 1233), are necessary. In any event,
a calculated risk may be necessary regardless of the
consequences. The internal carotid artery is
transected. Stay sutures hold the graft in position. The
main problem at this point maybe adequate exposure
of the distal vessel; otherwise, the operation is not
feasible. Transection of the mandible without entering
the oral cavity for additional exposure is shown in
Figure 22-23A to H.
El An end-to-end anastomosis is then performed
using 5-0 or 6-0 vascular suture. Before completion of
the anastomosis, the air is evacuated from the graft by
partially releasing the distal clamp. Also, a brief release
of the proximal clamp is done.
 VASCUIJ.R PROCEDURES

FIGURE 22-22 Continued

 VASCULAR PROCEDURES

Resection of Portion of Common and

Internal Carotid Arteries Involved by diseased area with carotid vessels and overlying skin is
Cancer (Continued) (Fig. 22-22) then resected along the dotted lines.

Fl A right anterolateral neck flap based superiorly is

F The anastomoses are completed. Ligation and then elevated and rotated to close the defect. If this
transection of the common carotid artery distal to the flap is not feasible, a pectoralis major myocutaneous
proximal anastomosis are now performed. The flap can be used.
external carotid artery is ligated and transected. The

TRAPEZIUS

PERMANENT
BYPASS GRAFT

ROTATED NECK FLAP

FIG\JRE 22-22 Continued


Results of Resection and Reconstruction
of the Internal Carotid Artery in
Metastatic Carcinoma (Lore and Boulos,
1981 )
Ten procedures were performed on nine patients. One
patient was operated on twice because of recurrent
disease fixed to a previous inserted Teflon graft.
Reconstruction
1. Autogenous saphenous vein grafts: seven patients
2. Teflon grafts: three patients
3. Graft of the common carotid to the internal carotid
artery: nine patients
4. Graft of the subclavian to the internal carotid artery:
one patient
S. Operative mortality: zero
6. Postoperative mortality: two patients. One patient
hemorrhaged from a subclavian artery graft anasto-
mosis secondary to a dead space just above the clavicle.
7. Survivals: seven of nine patients
a. There was no operative mortality. The postopera-
tive mortality rate was 20% and cerebrovascular
complications occurred in 20 % of the cases. Seven
patients survived 19 months to 4V4 years.
b. Dead of other causes: 13, 17, and 22 months
c. Lost to follow-up of 4 years, no evidence of disease.
8. Graft patency:
a. Teflon: three of three
b. Saphenous vein: two of six
c. This points out that autogenous vein grafts tend
to occlude in patients who have had radical neck
surgery. This is most likely due to the associated
scarring and lack of soft tissue to protect the graft.
The same can be said regarding the use of autoge-
nous vein grafts to reconstruct the internal jugular
vein in bilateral neck dissection. It is better to use
a prosthetic graft or try the external jugular vein
if left in its normal bed.
An alternate technique that has been used with larger
areas of disease includes extraoral transection of the
mandible combined with exposure of the facial nerve
and sacrifice of its cervicofacial division (see Fig. 17-6).
The tumor is then completely dissected except for the
great vessels using a method similar to that for resection
of a carotid body tumor (see Fig. 22-26). Additional expo-
sure techniques are shown in Figure 22-33.
Complications
• Blowout
• Thrombosis
• Hemorrhage
VASCULAR PROCEDURES 1283
Paragangliomas-Head and Neck
Guild (1941) discovered the glomus jugulare, whereas
Mulligan (1950) first proposed the term chemodectoma
to describe tumefactions arising in or related to the
chemoreceptor system. Lattes (1950) designated these
lesions involving the carotid body and aortic body as
nonchromaffin paragangliomas, based on anatomic
location and possible embryologic origin.
Pathology
Nieva B. Castillo
Paraganglia are collections of cells of neural crest origin
associated with the autonomic nervous system that are
distributed symmetrically in the para-axial regions of
the trunk and in the vicinity of the ontogenetic gill
arches. Five "families" of paraganglia were described
by Glenner and Grimley (1974), grouped on the basis
of anatomic distribution, innervation, and microscopic
structures into branchiomeric (branchial mesoderm),
intravagal, aortic sympathetic, visceral-autonomic, and
adrenal. The adrenal medulla itself is a paraganglion,
but tumor arising from it is called pheochromocytoma.
Branchiomeric paraganglia include jugulotympanic,
intracarotid, subclavian, laryngeal, coronary, aorticopul-
monary, and pulmonary paraganglia. Those in the thorax
and retroperitoneum are associated with sympathetic
nerves, and those in the head and neck are associated
primarily with parasympathetic nerves. Origin from the
sympathetic ganglion is rare, about 3 %. We have had
two patients. It is noteworthy that bilateral resection of
carotid body tumors has a relatively significant occur-
rence of the baroreflex failure syndrome. This consists
in marked lability in blood pressure secondary to the
unrestrained sympathetic drive.
Paraganglioma is the preferred term for neoplasms
of paraganglia. It is preceded by a term that identifies
the anatomic region (i.e., carotid body paraganglioma
[CBP], jugulotympanic paraganglioma [lTP] , vagal body
paraganglioma [VBP]. The term glomus tumor has also
been used and still is at times but should be abandoned
so as not to be confused with true tumors of glomera,
which are specialized arteriovenous complexes. They
are also referred to as "chemodectomas" because two
members of the group, the carotid body and aorticopul-
monary paraganglia, are known to have chemoreceptor
functions that are sensitive to fluctuations in arterial
oxygen tension and pH.
The pathology of paraganglioma is the same regard-
less of their site of origin. Most are ovoid or lobulated
with a thin, condensed fibrous capsule. The cut surface
is firm to rubbery with a mottled gray, pink-gray, or red
surface. Histologically, paragangliomas are composed
of oval to polygonal cells (chief cells) with uniform to
 VASCULAR PROCEDURES
pleomorphic, vesicular to hyperchromatic nuclei arranged
in organoid nests surrounded by vascular spaces
(Zellballen). Occasionally, spindle cell (sustentacular
cells) components may be prominent. Vascular spaces
are quite conspicuous. Some tumors may show con-
siderable nuclear pleomorphism, which does not
necessarily equate to being malignant.
There are no histologic criteria on which one can
predict malignant potential of a paraganglioma.
Unequivocal malignancy depends on demonstration of
metastasis to regional lymph nodes, bones, lung, and
liver. The reported incidence of malignancy ranges from
6 % to 23 % in paragangliomas of the head and neck
region, with the higher rates reported for vagal body
paragangliomas.
Paragangliomas are slow-growing neoplasms. Signs
and symptoms are most often due to physical impinge-
ment on normal structures and to local but invasive
growth. The most common presentation of carotid body
and vagal paragangliomas is that of a painless, slow-
growing mass. Other signs and symptoms include cranial
nerve palsies, bradycardia, syncope, and symptoms of
TIAs. Jugulotympanic paragangliomas may present as
aural polyps, tinnitus, conduction-type hearing loss, ear
fullness, otorrhea, vertigo, dizziness, and facial palsy.
Laryngeal paragangliomas present as a submucosal mass
in the supraglottic larynx, which may impinge on the
airway. Other signs and symptoms include dysphagia,
dyspnea, stridor, dysphonia, and hemoptysis. Whereas
paragangliomas of the retroperitoneum are frequently
functional, those in the head and neck are almost always
nonfunctional. Bilateral and/or multiple paragangliomas
is a well-recognized situation involving any of the para-
ganglia, but it is most common with carotid body para-
ganglion, especially in a familial setting. The incidence
of bilaterality of carotid body paraganglioma is 3 % to
8 % in sporadic cases, compared with 30 % to 33 % in a
familial setting.
Presence of dense core neurosecretory granules is
the ultrastructural hallmark of paraganglioma, but elec-
tron microscopy is very seldom done now with the use
of immunohistochemistry. On immunohistochemistry,
the tumor cells (chief cells) of paraganglioma are posi-
tive for neurospecific enolase (NSE), synaptophysin, and
chromogranin. They may also contain peptide hormones,
including neuropeptide Y, substance P, calcitonin, and
leu- and met-enkephalin. The supporting cells (susten-
tacular cells) are positive for S-100 protein and glial
acidic protein.
Head and Neck Anatomic Schematic
Classification (Figs. 22-23 and 22-24) (After
Berk, 1961; LeCompte, 1951; Palacios, 1970;
Rosenwasser, 1968)
Temporal Bone Region
The paraganglioma (glomus) (conglomerate) jugular
complex is located in the jugular fossa (bulb) and the
tympanic cavity areas. The blood supply is mainly from
the external carotid artery via the tympanic branch of
the ascending pharyngeal artery. All receive the main
nerve supply from the glossopharyngeal nerve (plus
vagus nerve ~ auricular body).
1. Jugular body (glomus) (jugulare paraganglioma).
Adventitia of the jugular bulb of internal jugular
vein arises from the superior (jugular) ganglion of
the glossopharyngeal nerve and lies in the vicinity
of the jugular (superior) ganglion of the vagus
nerve.
2. Tympanic bodies. These are located along the tym-
panic branch (Jacobson) of the glossopharyngeal
nerve (referred to as paraganglioma [glomus] tym-
panicum).
3. Auricular bodies. These are located along the tym-
panic branch ganglion of the vagus nerve associated
with the jugular (superior) ganglion of the vagus
nerve, which is located in the mucosa of the cochlear
promontory. Also, the auricular body has communi-
cations with the glossopharyngeal nerve. This type
is less common.
Clinical characteristics consist of the following:
1. Aural
a. Bluish discoloration of tympanic membrane with
or without a polypoid mass penetrating the tym-
panic membrane: do not biopsy; possibly use
fine-needle aspiration with a 2S-gauge needle.
b. Bloody discharge
c. Deafness, tinnitus (pulsatile), vertigo
d. Pain
e. Otitis media
2. Neurologic: paresis of 7th, 8th, 9th, 10th, or 11th
cranial nerve
3. Pathologic anatomic extension
a. Involvement of middle ear and tympanic mem-
brane and external auditory canal
 VASCULAR PROCEDURES 1285

AURICULAR BODY

TYMPANIC BODIES

TYMPANIC N.
Superior Ganglion GANGLION NODOSUM
Sympathetic
VAGAL BODIES

GLOSSOPHARYNGEAL N.

INT. CAROTID

CAROTID BODY
Middle Ganglion
Sympathetic GLOMUS LARYNGICUM SUP.

Common Carotid A. GLOMUS LARYNGICUM INf

body assoc.
with Vagus and I RECURRENT LARYNGEAL N.
Subclavian A. ~
GLOMUS TRACHEA
Subclavian A.
VAGUS N.

AORTIC PULMONARY
BODIES

LT. PULMONARY ARTERY

FIGURE 22-23
 VASCULAR PROCEDURES

AURICULAR N.

TYMPANIC N.

~~
(SUP) 'JUGULAR GANG.
I

, TO 7TH NERVE

to SUPERIOR
CERVICAL GANGliON
of the SYMPATHETIC

\ TO
I

I: SYM I
!i
r

....p II

11 <1,1'
SPINAL ACJ~ORY
II
!
N.
1ST AND
TO
2ND CERVICA

FIGURE22-24

b. Erosion of petrous and mastoid portions of the Cervical Region

temporal bone
c. Compression of sphenoidal sinus
d. Compression and extension into internal jugular
vein reaching the left auricle
e, Pulmonary emboli. This may account for the
apparent pulmonary metastasis reported.
Treatment consists of surgery and/or radiotherapy
and possibly stereotaxic radiosurgery with the gamma
knife (a form of small field concentration radiotherapy).
See pages 1408 to 1414 regarding temporal bone resec-
tion and also publications by Hugo Fisch.
1. Carotid body. The carotid body is located at the bifur-
cation of the common carotid artery into the internal
and external carotid arteries, The blood supply, which
is profuse, is from the external carotid artery. The
nerve connection is with the glossopharyngeal nerve
(see Fig. 22-25). Clinical characteristics include the
following:
a. Slow-growing mass in the region of bifurcation of
the common carotid artery. It may have fullness
in the lateral oral and hypopharyngeal walls.
b. Thrill and bruit may be present.

c. The tumor rarely metastasizes (2 % to 13 %) but
is locally destructive by compression.
d. When familial, it is more likely to be bilateral.
e. Widening of the bifurcation of the common carotid
artery may occur.
f. The tumor is endemic in high-altitude areas (e.g.,
Peru).
g. It may be multicentric. Surgical treatment with
preservation of carotid continuity (with prosthetic
or autogenous graft if necessary) is indicated (some
physicians believe no treatment is indicated because
of surgical complications; radiotherapy is an alter-
nate choice). Radiotherapy may halt growth, but
tumor persists.
2. Vagal bodies. These arise in relation to ganglion
nodosum (inferior ganglion of the vagus) just below
the jugular foramen and along the remaining cervi-
cal portion of the vagus nerve (paraganglia [glomus]
intravagale). Clinical characteristics include the
following:
a. Mass behind or below the angle of the mandible
with or without a mass in the lateral or retro-
oropharyngeal wall. It may mimic a tumor of the
tailor deep lobe of the parotid salivary gland in
the parapharyngeal space.
b. Transmitted pulsation is from the internal carotid
artery-possibly pulsatile from the mass itself.
c. It may be malignant and metastasize.
d. Dysfunction of 9th through 12th cranial nerves
occurs; patients exhibit hoarseness with paralysis
of vocal cord, dysphagia, and hemiatrophy of
tongue or Horner's syndrome. Ninth nerve dys-
function may be the cause of glossopharyngeal
neuralgia and be possibly related to the etiology
of the pain associated with the initial ingestion of
food (first bite syndrome).
e. Displacement of internal and external carotid arteries
medially without widening of the bifurcation occurs.
Surgical treatment with preservation of the carotid
artery continuity is indicated if at all possible.
Graft is virtually impossible when lesion extends
to and at times through the base of the skull.
Under these circumstances consider radiotherapy
(gamma knife).
3. Cervical sympathetic ganglioma
4. Laryngeal and tracheal
a. Next to the internal branch of the superior laryn-
geal nerve is the (glomus) laryngicum superior
paraganglioma.
b. Between anterior and posterior branches of the
recurrent laryngeal nerve in juxtaposition to the
cricoid and thyroid cartilage (Kleinsasser) is the
(glomus) laryngicum inferior paraganglioma.
c. Paragangliomas also occur in the trachea.
VASCULAR PROCEDURES 1287
Miscellaneous Locations in Head and Neck
1. Orbit. Tumors here may arise in the vicinity of the
ciliary ganglion, allegedly from the glomus paragan-
glioma ciliare. A functioning type has been reported
with some elevation of catecholamine content. Clinical
characteristics (Thacker and Duckworth, 1969)
include:
a. Diplopia
b. Blindness
c. Pulsating globe with exophthalmos
d. Throbbing pain
Treatment is surgical, or radiotherapy is done if
surgery is not feasible.
2. Mandible. This is rare and of some question.
3. Nasal cavity, nasopharynx, nasal sinuses
4. Cervical paravertebral
5. Subclavian
These mayor may not be primary or may have spread
from other primary tumors (Lack et al., 1977).
Other Than Head and Neck
1. Aorticosympathetic: associated with segmental ganglia
of sympathetic chain
a. Intrathoracic paravertebral and aortic pulmonary
b. Intra-abdominal
I) Superior para-aortic group that is adjacent to
adrenal in and around hilum of kidneys
2) Inferior para-aortic group below the kidney
down the aorta to iliac vessels
2. Visceroautonomic: associated with viscera such as uri-
nary bladder, gallbladder, kidney, prostate, and so on
3. Ileal mesentery
4. Femoral areas: femoral canal and thigh muscles
5. Coronary
The reader is referred to Batsakis (p. 369, 1979).
Depicted in Figure 22-24 is a diagram of the 9th, 10th,
and 11th nerves and associated ganglia, crossed inner-
vation, and branches.
Further Discussion of Anatomy (See Figs. 22-23
and 22-24)
In head and neck there are four most prevalent occur-
rences. They are benign and very rarely malignant.
1. Carotid body-at bifurcation of carotid arteries (see
Fig. 22-25)
2. Jugular (glomus)
3. Vagale: arising from the vagus nerve, superior and
inferior ganglia extending to the neck
 VASCULAR PROCEDURES
4. Sympathetic ganglia: superior and middle extending
to the neck inferiorly to just above the clavicle
5. Tympanicum: primarily within the temporal bone
The paragangliomas of the head and neck are located
and migrate along the branchiomeric distribution of the
parasympathetic nerve fibers extending from the skull
down to the aortic arch. The paragangliomas of the
cervical sympathetic ganglia are rare, although we have
had two such patients with this type of tumor.
For anatomy of the para pharyngeal space, see
Chapter 23.
Carotid Body and Carotid Sinus Complex
(Fig. 22-25)
Figure 22-25 (from Hollinshead, 1954) demonstrates
the anatomic difference of these two closely related
structures, namely, the carotid body and the carotid
sinus. The carotid body is normally a 2.5 x 5-mm to
4 x 7-mm flattened structure "on the median and deep
side of the upper end of the common carotid artery in
close relation with the point of division of the latter
vessel into the external and internal carotids. The gland
usually lies not within the bifurcation but rather on the
inner side of the common carotid so that its form and
relations are best displayed by dissection from within
outward." Its blood supply is from a small vessel,
usually from the exterior carotid artery, termed the
glomic artery or the ascending pharyngeal artery. Its
afferent nerve communication is the 9th cranial nerve
Glossopharyngeal n.
Common carotid a.
FIGURE 22-25 Anatomic difference between the carotid body and the carotid sinus.
with small communications from the 10th nerve and
by some reports from the sympathetic chain and
even the 12th nerve. The carotid body is primarily a
chemoreceptor organ, which initiates reflex changes in
cardiovascular and respiratory activity and detects
changes in partial pressure of 02' CO2, pH, and blood
flow.
Carotid Sinus
The carotid sinus is a completely different structure
than the carotid body. It is made up of complicated
nerve fibers that lie on the adventitia of the carotid
bulb (widening of the proximal portion of the internal
carotid artery), as well as extending distally along the
internal carotid artery. These nerve connections are
similar to that of the carotid body and are located 1 to
2 em from the carotid bifurcation. When grouped together
they are referred to as the carotid sinus nerve or the
nerve of Hering. This nerve is primarily from the 9th
nerve with connections with the vagus, cervical sym-
pathetic ganglion, and, at times, the 12th cranial nerve.
The carotid sinus is a pressor receptor, whereas the
carotid body is a chemoreceptor. Thus, the carotid sinus
is considered a baroreceptor. Pressure of the carotid
bulb can thus cause hypotension.
In any event, the close proximity of the carotid sinus
and the carotid body and their common nerve connec-
tions, specifically the nerve of Hering and possibly the
9th nerve, explains that with the removal of a carotid
body tumor, which is adherent to the adventitia of the
Sympathetic to
Carotid body
Carotid body
(Located posterior
to vessels)

internal carotid artery, there is interference with both
the chemoreceptor and the baroreceptor functions of
both the carotid body and the carotid sinus. There does
not appear to be any problem with unilateral resection;
however, removal of bilateral carotid body tumors can,
and usually does, result in failure of the baroreceptor
reflex (baroreflex failure syndrome) resulting in
unrestrained sympathetic drive. This can be a very
serious problem in the immediate postoperative period,
with lasting symptoms of uncontrollable hypertension,
for example, in the upright position and hypotension in
the reclining position. There also may be associated
severe tachycardia, as well as symptoms of emotional
and abnormal responses to stress. There can, likewise,
be periods of nausea and vomiting. These symptoms
can be so severe as to be life threatening. Treatment with
benzodiazepine and avoidance of stressful situations
may modify symptoms. Clonidine and low doses of
corticosteroids may, likewise, be helpful.
From the clinical point of view, baroreflex failure
syndrome should be avoided if at all possible. Hence,
bilateral removal of carotid body tumors is questionable.
It is suggested, rather, to remove the larger one and
observe and monitor the patient relative to the other
carotid body tumor. Radiotherapy may be an option.
Vagal Paragangliomas (See Figs. 22-23, 22-24,
and 22-27)
These tumors arise from:
1. Superior ganglion (the superior jugular ganglion)-
located at the skull base-at jugular foramen
a. Dumbbell shape: can extend superiorly into the
posterior fossa and into the infratemporal fossa. It
is thus intracranial extension that is the cause of
death!
b. Can extend inferiorly through the para pharyngeal
space into the superior cervical region
2. Inferior ganglion-nodosa: upper cervical region to
the level of the tip of the styloid process
a. Compresses the internal jugular vein
b. Displaces the carotid vessels anteromedially
c. Displaces the lateral oropharyngeal wall medially
d. Has minimum incidence of destruction of the
skull base
e. Can extend superiorly into the parapharyngeal
space and inferiorly into the cervical region, specifi-
cally usually located deep to the angle of the
mandible in the region of the tail of the parotid
salivary gland
3. Can arise anywhere along the course of the vagus
nerve
VASCULAR PROCEDURES
Progressive growth of vagal paragangliomas can:
1. Involve the arch of the atlas (Gulya) (see Fig. 22-121
and 11)
2. Encase and displace the internal carotid artery
3. Extend superiorly into posterior fossa with compres-
sion of the brain stem (Murphy et aI., 1970)
4. Extend laterally to the middle ear (Batsakis, 1979)
Anatomy of the Sympathetic Ganglion
Paraganglioma
1. Superior or middle sympathetic ganglion is involved.
2. There may be some evidence of gross nerve connec-
tions with the vagus nerve.
3. In the cervical lesion, the paraganglioma is posterior
to the common carotid artery.
4. Middle ganglion can have blood supply from sub-
clavian artery-thyrocervical trunk-just above the
sternoclavicular junction (see Fig. 22-29D and E).
Clinical Findings
Carotid Body Tumors
1. Prevalence is increased in high-altitude areas (e.g.,
the Peruvian Andes, Colorado, Mexico City). They
are probably secondary to chronic hypoxia and pos-
sibly genetic factors. The patient can be asymptomatic
or can have hoarseness, stridor, tongue paralysis,
vertigo, and mild dysphagia.
2. Physical examination reveals a neck mass in the
vicinity of the bifurcation of the carotid, which may
be moved from side to side but not superiorly nor infe-
riorly. There is often a bruit and transmitted pulsations.
Vagal Paragangliomas
1. Clinical picture is of a neck mass that is submandibular
but near the angle of the mandible extending down
to the neck. The tumor can also present as a para-
pharyngeal space mass intraorally. Possible nerves
involved include:
a. lath-vocal cord paresis or paralysis
b. 12th-unilateral tongue hemiatrophy, weakness,
or paralysis
c. lIth-difficulty in shrugging shoulder
d. 9th-primarily sensory to the oropharynx (there
are voluntary motor fibers to the small stylopha-
ryngeus muscle). If the sensory portion is absent
there is a lack of gag reflex. Irritation of this nerve
may result in pain in the pharynx, tongue, or ear.
This may be initiated by swallowing or chewing
 VASCULAR PROCEDURES
movements-glossopharyngeal neuralgia. With a
history of loss of gag reflex there is a loss of taste,
pain, and touch over the posterior third of the
tongue. Pain related to the 9th cranial nerve may
be paroxysmal and may be associated with the
pain that is related to other operations on para-
gangliomas (see Fig. 23-4Fl).
Sympathetic Paraganglioma (Based on
Experience of Two Patients)
One patient had combined bilateral sympathetic para-
gangliomas, with unilateral carotid body tumor and
unilateral intravagale paraganglioma. All four of these
were removed at two surgical sittings. The other patient
had a unilateral sympathetic paraganglioma, bilateral
carotid body tumors, and contralateral intravagale and
jugulare paragangliomas. Two of these were removed
surgically unilaterally, namely, one carotid body tumor
and one sympathetic paraganglioma arising from the
middle cervical ganglion (see Fig. 22-290 and E). The
blood supply to the cervical sympathetic ganglion arose
from the middle cervical ganglia from the thyrocervical
trunk, as well as an additional tributary from the sub-
clavian artery.
There is a significant crossover of signs and symp-
toms with these paragangliomas that some of the
clinical findings and signs simulate both carotid body
and intravagale paragangliomas. Symptoms and signs
include pain in ear, shooting pain, vertigo, headache,
and tenderness over the mass. Physical examination
found bilateral neck masses; in one patient the tongue
deviated to the right and the vocal cord was sluggish.
jugular Tympanicum
• Pulsatile tinnitus
• Deafness and vertigo
• Hoarseness
• Ear pain
Paragangliomas may arise in the head and neck,
mediastinum, and retroperitoneal and femoral areas.
Most have certain characteristics in common and may
have one or more of the following findings:
1. They are highly vascular.
2. There is a familial tendency (7% to 9%; in patients
younger than age 40 years; 90% in carotid bodies).
3. Tumors are multicentric or bilateral and synchronous
or metachronous.
4. There is a long, slow, progressive history.
5. The tumors are usually benign in that they do not
usually metastasize (although [glomus] jugulare
lesions have appeared in the lung and in the
skeleton and malignant carotid body tumors have
been reported).
6. They may act malignant by direct extension into
soft tissue and bone and may cause death.
7. They are more common in females (especially
[glomus] jugulare paraganglioma).
8. The tumors are intimately bound and related to
associated vascular and nerve structures.
9. Most head and neck paragangliomas are nonfunc-
tioning, although several have been reported to act
as pheochromocytoma.
10. The rate of distant metastasis is approximately
10%.
Malignant or Benign?
This is a moot question, because the criteria of whether
any tumor is malignant or benign can be based on
whether a tumor demonstrates histologic evidence of
cellular aberration, active mitosis, or capsular invasion,
or whether a tumor demonstrates actual metastasis
to lymph nodes. If the former is the case, as Batsakis
(1979) points out, then upward of 50% could be
considered malignant. On the other hand, if lymph
node metastases is the criterion, then less than 3% are
malignant. Batsakis states, "It is my opinion that there
is no correlation between the histologic appearance of
these tumors and their biologic behavior. This must be
borne in mind by surgeons, especially when they ask
for a differentiation between a benign and malignant
lesion on frozen section or later. "
In the evaluation of patients with paragangliomas, it
is important that at least plain radiographs be obtained
of all vertebrae and the sacrum. Better yet, full body CT
is advised, which would complement the head and
neck examination. This would include ribs, vertebrae,
abdomen, sacrum, and the femoral area to search for
metastatic or multicentric paragangliomas. We have a
patient with known head and neck paragangliomas
with lesions in T4, which were incidentally detected on
CT of the head and neck (see Fig. 1-59). The thoracic
vertebrae and the sacrum were evaluated, and two smaller
lesions were detected in the sacrum. The T4 lesion was
operated on, and this proved to be paraganglioma. On
careful scrutiny at the time of the operation, it revealed
that the neoplasm was seen to extend from the stalk
of the nerve root (radiograph of thoracic vertebra). The
importance of this finding is that it is certain that the
T4 lesion is a multicentric lesion arising from the thoracic
sympathetic chain. By the same token, it does not neces-
sarily rule out a malignant head and neck paraganglioma,
because this still could exist but of course is unlikely.
In another report, the literature indicates a lytic lesion

in a thoracic vertebra, which was interpreted as meta-
stasis from a malignant paraganglioma (North et aI.,
1990). Both patients were asymptomatic at the time of
discovery of the vertebral lesions.
North and colleagues strongly recommend thyroid
scan and serum calcitonin levels in the routine workup
of metastatic paragangliomas for the possibility that the
lesion is a metastatic medullary carcinoma of the thyroid.
Other clinical findings that confuse this issue are the
direct extension of some of these tumors to encircle and
encompass the internal carotid artery and associated
important nerves (e.g., 9th, 10th, 11th, and sympathetic
nerves) as well as direct extension through the foramen
at the base of the skull. Whether such findings can
result in a tumor being classified as malignant is almost
beside the point, because the ultimate result of an
untreated tumor may well be catastrophic. Nevertheless,
the surgical extirpation of such extensive lesions can
also be catastrophic unless the surgeon is well versed
in the evaluation of this extensive disease and is
prepared to reestablish the continuity of the blood supply
to the brain (see Basic Principles, p. 1233). The sacrifice
of important nerve structures must also be carefully
weighed if the tumor acts aggressively. On the other hand,
if the tumor is slow growing, leaving disease behind is
an option. Radiotherapy is then a consideration.
Radiotherapy appears to play a role in the nome-
sectable recurrent or partially resected paragangliomas,
especially those involving the skull base, jugular fora-
men, and temporal bone. In 1965, Grabb and Lampe
indicated that radiotherapy is the treatment of choice
for glomus paraganglioma. In 1990, Boyle and co-
workers concluded that "moderate dose irradiation can
safely control most temporal bone paragangliomas."
All these reports must be evaluated for long-term results
because most of the tumors exhibit a very long, slow,
progressive history. The question of whether radio-
therapy slows or halts the growth or actually destroys
the tumor is not easily answered.
The bizarre natural history of these tumors is well
exemplified when they involve the larynx (extremely
rare). Shild and Cohen added another case report of such
a tumor involving the larynx that ultimately resulted in
the death of a 44-year-old man 12 years after the
diagnosis was made. They presented and reviewed the
literature, including seven patients with malignant
paragangliomas of the larynx resulting in death. Pain
was a common early symptom. Growth was slow, with
final metastases appearing in the skin and bone and
intra-abdominally. Their conclusions strongly recom-
mended resection with wide margins of normal tissue.
The surgeon must be aware of this possibility, because
unless recognized such patients will die in the imme-
diate postoperative period. Coexistent adrenal and
cervical pheochromocytomas have been reported.
VASCULAR PROCEDURES 1291
Diagnosis and Evaluation
Initial screening of a mass in the head and neck that is
suspected of being a paraganglioma should be non-
invasive or minimally invasive (also see p. 1302).
1. Baseline blood pressure is repeated as necessary.
This may lead to identification of a rare non-adrenal-
secreting tumor presenting as cyclic changes of blood
pressure. An associated pheochromocytoma may be
the cause of labile or paroxysmal hypertension. If the
latter is suspected, an enhanced CT of the abdomen
is performed even though blood chemistries are
normal.
2. Fine-needle aspiration is not necessary if enhanced
CT or MRI is obtained and thus is seldom utilized.
With the use of a 25-gauge needle (see Chapter 3),
the possible problem of hemorrhage from the para-
ganglioma is no longer believed to be a contraindica-
tion to this methodology. The author would not use
large-bore needle aspiration or core needle biopsy.
Fine-needle aspiration, however, is freely utilized (see
p. 87) for any cervical mass in which the diagnosis
is in question. No incisional or excisional biopsy is
done unless all other diagnostic tests have been uti-
lized. When the mass is overlying the carotid vessels,
the needle is inserted in an oblique plane to avoid
entering the underlying carotid vessels. Silver stain
is helpful in the cytologic evaluation.
3. CT and MRI with contrast medium enhancement
depict paragangliomas as well as other highly vascular
lesions. However, MRI can detect paragangliomas
smaller than 5 mm whereas CT detects lesions larger
than 8 mm. CT (in very thin cuts) is the choice for
temporal bone lesions and an aid in the surgical
anatomy of the jugulare tympanicum paraganglioma
regions. MRI is superior to CT in delineation of other
features of paragangliomas (e.g., possible involvement
of vessels). MRI and CT demonstrate the splaying of
the internal and external carotid arteries, as well as
anterior displacement of the common carotid artery
by sympathetic paraganglioma. Paragangliomas
enhance homogeneously. Neurogenic tumors can
enhance but usually do so in a nonhomogeneous
pattern. The location of the vascular blush in relation
to the carotid vessels is important. If the blush lies
between the bifurcation of the carotid, there is little
doubt that the lesion is a carotid body tumor. If the
blush is posterior and displacing the carotid vessels
anteriorly, the lesion can be either a paraganglioma
or other type of neurogenic tumor. If the blush is ante-
rior to the carotid vessels, the lesion then may be
either a paraganglioma or an enhanced lymph node.
Blush posterior to the common carotid artery is the
finding seen in sympathetic paraganglioma. Fine-
 VASCULAR PROCEDURES
needle aspiration can then be performed to aid in the
differential diagnosis. Lymphadenopathy can also
enhance, and hence there is a potential differential
diagnostic problem. In addition, visualization of the
base of the skull may detect bone erosion, for example,
around the jugular foramen. This methodology aids
in the detection of multicentric and bilateral para-
gangliomas of the head and neck.
4. Angiography, although an invasive test, affords the
best information regarding the vessels associated with
the paraganglioma. It can detect the vessel abnormal-
ities consisting of: invasion, narrowing and irregu-
larity, and displacement, as well as feeding vessels
(anteroposterior, lateral and oblique views) of the
paraganglioma. The venous phase can demonstrate
thrombosis or invasion of the internal jugular vein;
this may occur with jugular paragangliomas. An
aortic arch study is done concomitantly with the head
and neck angiogram for detection of other para-
gangliomas in the aortic pulmonary region when
screening for multicentric tumors. However, this test
is not usually indicated as an initial screening test.
An example of the venous involvement of the inter-
nal jugular vein is in Figure 22-30B. Distortion and
varying degrees of obstruction of the internal jugular
vein can occur with the intravagale paraganglioma
arising from the ganglion nodosa (see Fig. 22-27C
and D).
5. As previously mentioned, calcitonin levels and thyroid
scan for medullary thyroid carcinoma can be done
when metastatic paraganglioma is suspected.
6. Levels of urinary catecholamines, dopamine, creatinine,
vanillylmandelic acid, metanephrine, epinephrine,
and norepinephrine are evaluated (see also p. 1302
for additional evaluation of extra-adrenal pheochro-
mocytomas, e.g., 1311-MIBG).Failure to recognize a
functioning paraganglioma may well result in intra-
operative and/or postoperative catastrophes. If
metastatic paraganglioma is suspected, obtain a
thyroid scan and calcitonin level to rule out
medullary carcinoma.
7. As previously mentioned, routine total body CT
can be used to evaluate multicentric disease or
metastases. Currently, however, MRI or octreotide
scans are done for this purpose.
Warnings
1. The tumor may adhere to major vessels. Carotid body
tumors may be so adherent to adventitia that surgical
removal without injury to the internal carotid artery
and the common carotid artery is not possible. This
will lead to hemorrhage, which in turn leads to inter-
ference with the blood supply to the brain. This is thus
followed by stroke and possibly death. A surgeon
must be prepared for carotid artery bypass. It is sug-
gested that Javid bypass clamps and bypass tubing
be available. When the initial dissection indicates
there is no adequate cleavage plane between the
tumor and the internal carotid artery, and if the
surgeon has not been trained or has no experience
in vascular surgery and there is no such help avail-
able, then terminate the procedure and return to
it after proper preparation. Preoperative evaluation
regarding the intracranial cross blood flow compe-
tency can be carried out by balloon occlusion of the
internal carotid artery. However, there is danger of
TIA or stroke (I + %) with this test. Thus it is not
advised. Intraoperative internal carotid artery stump
pressure should be 60 mm Hg or higher.
2. Functioning catecholamines may lead to hypertensive
CriSIS.
3. There may be intravascular extension (e.g., a
[glomus] jugulare paraganglioma extending into the
internal jugular vein [see p. 1307]).
4. Encroachment and encirclement may be possible of
any or all associated nerves (e.g., 9th, 10th, 11th,
12th, and the sympathetic chain). This explains the
rare but at times associated pain. The surgeon is
then faced with the decision regarding resection of
any of these important nerve structures and the
sequelae of their resection. Vocal cord paralysis is
certain to occur with intravagale type. Twelfth nerve
paralysis is not uncommon.
5. Avoid incisional biopsy if possible. If the diagnosis is
suspected preoperatively, the patient should be
evaluated according to the guidelines discussed
under Diagnosis and Evaluation. If the diagnosis
was not suspected and the surgical exploration indi-
cates a paraganglioma, perform fine-needle aspiration,
close the wound, and then follow with the other
diagnostic methods.
6. The decision whether to resect or not to resect is
often difficult to determine. This decision is based
on the following:
a. The age of the patient. In older patients, the sug-
gestion would be observation regarding the rate
of growth and the extension of the disease.
b. Signs and symptoms
c. Metastasis to regional lymph nodes-very rare.
Resect involved nodes. If nodes are not completely
resectable, then use radiotherapy.
d. Evaluation of the intracranial cross circulation.
When the cross circulation is inadequate, the sur-
geon must be certain that a graft is feasible (e.g.,
if the base of the skull is involved and there is not

sufficient length of the distal internal carotid artery
to place a graft, it is best not to resect the lesion).
Rush (1962) has emphasized that the optimal time
for excision of any paraganglioma is early in the stage
of disease when the lesions are small and surgical
resection is more easily accomplished. The mortality
then should approximate 1.5 %. The high mortality and
high morbidity related to attempted resection of para-
gangliomas are primarily related to the following:
1. Late stages of disease
2. Inadequate preoperative evaluation
3. Lack of preparation and skill of the surgeon regarding
vascular replacement
4. Significant invasion of vessel wall and intraluminal
involvement
5. Hypertensive and hypotensive crisis. Baroreflex failure
syndrome (DeToma et at., 2000) is most commonly
associated with resection of bilateral carotid body
tumors. We had this syndrome in one patient with
resection of other bilateral paragangliomas.
6. Possible extension of glomus jugulare tumor into the
jugular vein
7. Lack of realization that some of these tumors (e.g.,
carotid body tumors) can extend into the soft palate
as well as have the "dumbbell phenomenon" extend-
ing intracranially through the foramen at the base of
the skull (Conley, 1965). This same extension can
conceivably occur with the intravagale and the supe-
rior sympathetic ganglion paragangliomas.
One of the authors (JML) has resected bilateral
superior sympathetic paragangliomas associated
with resection of unilateral intravagale and carotid
body chemodectomas. The patient experienced ortho-
static changes in blood pressure postoperatively.
An example, which usually follows resection of
bilateral carotid body paraganglioma, is baroreflex
failure syndrome, which can also follow bilateral
resection of superiorly located cervical paragan-
gliomas. This probably is due to interruption of
carotid nerve branches from the vagal and/or sym-
pathetic ganglia.
8. Possible severe pain-jaw, face-glossopharyngeal
neuralgia
When obtaining permission for surgery of paragan-
gliomas of the head and neck, one should warn the
patient of the possible complications:
• Stroke
• Vocal cord paralysis
• Tongue paralysis
VASCULAR PROCEDURES
• Interference with speech and swallowing
• Possible lid droop with differentiation in pupils-
Horner's syndrome
• Severe pain (jaw, facial)
• Shoulder weakness and discomfort or pain
• Blood pressure abnormalities with other complaints
of dizziness, headache, and emotional problems; if
bilateral operation is performed, baroreflex failure
syndrome may occur.
Whether to operate, treat with radiation, or observe
the patient can be very difficult questions to answer.
When to Consider Not to Operate:
I. Bilateral paragangliomas, especially carotid body
tumors (baroreflex failure syndrome). Remove the
larger one. Observe and possibly consider radiotherapy
for the contralateral tumor.
2. Jugular paraganglioma and the base of the skull with
projection of tumor into foramina. There is a question
of combined trans cranial approach versus radio-
therapy; we prefer radiotherapy.
3. Older patients
4. Atherosclerotic and compromised internal carotid artery
blood flow. Correct obstruction and reevaluate.
5. Remember, tumor is usually slow growing and there
is a low incidence of malignant transformation. These
facts will help in determining the method of treat-
ment in patients who are borderline surgical risks.
When to Consider to Operate:
1. Patients with symptoms (e.g., pain, headache)
2. Patient with bilateral carotid body paraganglioma;
operate on one side only. (Baroreflex failure syn-
drome may occur.)
3. Accelerated growth
4. Accelerated symptoms
5. Intravagale paragangliomas, because these may
extend superiorly into the cranium and cause death
if simply observed
6. Younger age group
7. The smaller the paraganglioma, the better for sur-
gical resection.
8. Virtually all unilateral paragangliomas in the
younger age group
9. Consider that the jugular paragangliomas (superior
ganglion of the vagus nerve) can extend into the
internal jugular vein. See Figure 22-30.
10. All aspects of the natural history of the disease
should be explained to the patient in as much
detail as possible.
 VASCULAR PROCEDURES
Surgical Treatment
Surgery Basics
I. Depends on resectability
2. Resect only one of a bilateral carotid body tumor and
one of a bilateral sympathetic paraganglioma. This is
a suggestion. Bilateral operations may be necessary,
depending on various factors.
3. Use extreme care with resection of the superior gan-
glion of the vagus-jugulare and superior ganglion.
4. Embolization has been utilized by some surgeons as
a 1- to 2-day preoperative modality to reduce blood
loss during surgery. I (JML) do not recommend this
modality at all because of the possible complications
of cerebral ischemia, cranial nerve palsies, and stroke.
5. Be prepared for carotid artery reconstruction (see
Fig. 22-26E to G).
6. With the possible e<eception of carotid body tumors,
be aware of the technique to expose the parapharyn-
geal space and base of skull.
Surgical Complications
1. Cranial nerve injury-9th, 10th, 11th, 12th, and
sympathetic chain
2. Severe bleeding
3. Stroke
4. Baroreflex failure syndrome-associated with bilateral
resection
5. Pain associated with initial ingestion of food and up
to 30 minutes after eating. Pain is located in masseter
muscle and jaw region. This can be relieved with
topical anesthesia to the oropharynx; however, long-
term management is difficult. This is probably related
to glossopharyngeal neuralgia. It has been noted in
two patients: one patient had a resection of the sym-
pathetic ganglion paraganglioma and a carotid body
tumor, whereas the other patient had a resection of
one carotid body tumor and resection of an intrava-
gale tumor. Gabapentin (Neurontin) is suggested for
pain relief.
6. Horner's syndrome
Resection of Carotid Body Tumor
(Fig. 22-26)
The treatment of this form of paraganglioma arising
from the carotid body or the adventitia of the carotid
bulb at the carotid bifurcation is the subject of much
dispute. Some surgeons believe that because malignant
forms are very rare, as far as metastasis is concerned,
once the diagnosis is made the tumor should be left
alone. Others disagree and emphasize that by local exten-
sion the tumors involve and encroach on vital struc-
tures, especially nerve trunks. They also may become
malignant. The author (JML) agrees with the latter
thesis based on the reservations as listed under Warn-
ings (see p. 1292). The removal of a small carotid body
tumor is much easier than the removal of a large one.
As they enlarge, the extension of tumor growth not
only displaces but also involves important nerve trunks.
In addition, the extension in a superior direction presents
a problem in surgical management. In this upward
extension, the tumors become less accessible under the
angle of the mandible, and the remaining length of the
workable extra cranial internal carotid artery becomes
so short that a vascular anastomosis is most difficult.
Mobilization of the mandible by transection of stylo-
mandibular and possibly sphenomandibular ligaments
and/or dislocation of temporomandibular joint may
achieve the necessary exposure. Transection of the
mandible just posterior to the third molar region (see
Fig. 22-33) can be performed to aid the exposure. If this
exposure is necessary, it must be done without entering
the oral cavity, because such violation may lead to infec-
tion and possible oral fistula formation, which may
doom any graft replacement.
As for graft replacement (see the discussion of grafts
under Basic Principles, p. 1233), this vascular tech-
nique is relegated to those carotid body tumors that are
large and that cannot be safely removed from the vessel
wall. In any event, the proper equipment should be
present in the operating room regardless of the tech-
nique (e.g., vascular clamps, Javid clamps with bypass
tube). The common-internal carotid artery continuity
must be preserved.
The diagnosis of a carotid body tumor is suggested
by a firm, slowly growing, nontender mass in the region
of the carotid bifurcation. There may be a familial his-
tory of carotid body tumors. They may be bilateral.
Transmitted pulsations are usually quite significant.
Thrill or bruit may be present or absent. The mass is
movable from side to side but not up and down. This
finding has been challenged, but, if present, it is of
significant aid. There may be a fullness in the lateral
oropharyngeal wall. The diagnosis is verified by
enhanced CT or MRI, MRA, or digital subtraction
angiography (see Diagnosis and Evaluation, p. 1291).
The typical picture is one of widening of the carotid
bifurcation with increases in the vascularization
surrounding the tumor (see Fig. 22-26B). There is the
rare carotid body tumor that is physiologically active
with the clinical picture of the pheochromocytoma.

The angiogram may depict a branch of the ascending
pharyngeal artery supplying the tumor.
The surgical approach is through either a long oblique
horizontal incision or two shorter ones in stepladder
fashion. The proximal (3 to 4 em) and distal (2 em)
vessels are liberally exposed so that tapes and vascular
clamps may be placed around the vessels. No vessel
occlusion is done at this time. These tumors are very
vascular, and their removal is no small matter. Blood
loss up to 5000 mL has been repeated. Bipolar cautery
is used for small vessel control.
Depicted in Figure 22-26 is the technique for
resection of a carotid body tumor that cannot safely be
dissected from the carotid vessels. With smaller tumors
a careful and meticulous dissection can be performed
in a plane between the adventitia and media of the
vessel wall, first using a posterolateral approach to that
portion of the tumor involving the internal carotid
artery. The external carotid artery is sacrificed if the
patency of the internal carotid artery has been verified
by preoperative scans and angiography.
Highpoints
See Diagnosis and Evaluation, page 1291, and Warn-
ings, page 1292.
1. Exposure must be liberal and adequate so that control
of the vessel proximal and distal to the area of surgery
is possible by the placement of tapes and vascular
clamps about the vessel. An extended oblique sub-
mandibular incision may be adequate. Preserve the
ramus mandibularis and greater auricular nerves.
This incision can be extended farther in the preau-
ricular area as is done for parotid surgery (see
Fig. 17-1A to E). In addition, the main trunk of the
seventh nerve has been exposed if further retraction
or mobilization of the parotid gland becomes neces-
sary. Some surgeons utilize a long incision follow-
ing the anterior border of the sternocleidomastoid
muscle; this affords excellent exposure. Neverthe-
less, one or more horizontal incisions, in stepladder
fashion after the technique of MacFee, are preferred.
If an emergency occurs, a vertical extension may be
VASCULAR PROCEDURES
made superiorly or inferiorly. In operations on patients
who have had previous neck surgery, the incision usu-
ally follows the course of the previous scar, depending
on the exposure afforded by such a previous scar.
2. Be prepared to resect carotid vessels and reestablish
common-internal carotid continuity with vascular
graft rather than attempt to dissect a closely defiant
adherent tumor.
3. Take extreme care with open biopsy because of
vascularity. Fine-needle aspiration is preferred but
usually not necessary.
4. Preoperatively use enhanced CT and/or MRI carotid
arteriogram; intraoperative internal carotid artery
stump pressure is used as indicated.
5. Avoid injury to glossopharyngeal, vagus, hypoglos-
sal, and superior laryngeal nerves and sympathetic
chain if at all possible. Alert patient preoperatively
to these possible sequelae (see Fig. 16-15).
Complications
• Retraction of proximal common carotid artery under
the skin edge owing to poor exposure and slipping
of the bypass tubing.
• Thrombosis. Make a careful check at the close of the
operation. Use a Fogarty catheter and fine suction
and, if necessary, take down the anastomoses and
redo them. This latter maneuver requires resection
of several millimeters of vessel and graft walls for
smooth ends. There must be good expansile, not
transmitted, pulsation of all vessels. For use of heparin
see page 1235.
• Bleeding from the stump of the external carotid
artery occurred 1 week postoperatively in a patient
who had undergone resection of a carotid body tumor
with preservation of the internal carotid artery. The
arteriogram failed to show any extravasation of dye
at the stump. Ligation of the common and internal
carotid arteries was required. The patient suffered a
mild stroke but improved with 98 % return of func-
tion. Vascular graft is preferred to reestablish conti-
nuity of the common-internal carotid arteries, if
feasible.
• For a list of other complications, see page 1251.
 VASCULAR PROCEDURES
Resection of Carotid Body Tumor
(Continued) (Fig. 22-26)
A A carotid body tumor is causing widening of the
bifurcation. The dotted lines over the common carotid
and internal carotid arteries are the sites of insertion of
the intraluminal temporary bypass tubing.
B Arteriogram shows widening of bifurcation of the
carotids with increased vascularity in a soft tissue mass
at the bifurcation. The internal carotid artery is displaced
laterally and posteriorly. The tumor extends under the
angle of the mandible and infringes on the lateral
oropharyngeal wall. Other variations of distortion of
the carotid arteries are possible (Conley, 1965).
81 Cross section representation of carotid body
tumor demonstrates shape of bifurcation and intimate
attachment to the vessel walls.
C Exposure is through a long horizontal skin incision
with copious upper and lower skin flaps, taking care to
avoid injury to the mandibular branch of the facial
nerve and later the greater auricular nerve. This latter
nerve may require transection to facilitate exposure
superiorly. It is tagged, and at the close of the opera-
tion neurorrhaphy is performed. An incision is then
made along the anterior border of the sternocleido-
mastoid muscle. If it is preferred, a vertical skin incision
can be used along the anterior border of the
sternocleidomastoid muscle or additional exposure
can be obtained by the vertical limb off the horizontal
incision or a lower separate horizontal incision can be
used. The proximal (3 to 4 cm) and distal (2 cm)
vesselsare liberally exposed so that tapes and vascular
clamps may be placed around the common, external,
and internal carotid arteries. This is most important,
especially because if the proximal vessel slips away it
will retract under the skin edge. No vessel occlusion is
done at this time. The tumor is then carefully dissected
from the surrounding structures.The internal and external
branches of the superior laryngeal nerve should be
identified if possible (at times these structures cannot
be identified) and preserved as they pass deep to the
internal and external carotid arteries. The same goes for
the vagus nerve and sympathetic chain. The hypoglossal
nerve will more than likely be displaced and should be
preserved. Transection of the ansa hypoglossi may be
necessary to retract the 12th nerve. If the tumor is
large, all or some of these nerve trunks may not be in
their usual location. If exposure deep and superior to
the mandible becomes necessary, transection of the
stylomandibular ligament is done with superior and
lateral retraction. Preserve the ramus mandibularis.
o The tumor is then dissected free of all nerve
structures. This dissection may be extremely tedious
because of the multiplicity of nerves involved, which
may include the hypoglossal, external, and internal
branches of the superior laryngeal nerve, vagus,
sympathetic chain, spinal accessory, and possibly the
glossopharyngeal nerve.
Continued
 VASCULAR PROCEDURES

INTERNAL
CAROTID A.

EXTERNAL CARO

COMMON CAROTID A.

ANSA HYPOGLOSSI
"
VAGUS'N.
c 'COMMON CAROTID A.
D

INT. BR. SUP. LARYNGEAL N.

FIGURE 22-26
 VASCULAR PROCEDURES
Resection of Carotid Body Tumor
(Continued) (Fig. 22-26)
E The tumor is completely free except for its main
vascular attachments, the common carotid and
internal carotid arteries. The external carotid and its
branches have been ligated and transected, because
the patency of the internal carotid artery has been
verified preoperatively. The graft isfirst passedover the
interlurninal temporary bypass tubing. The tubing
must be smaller in diameter than the graft lumen to
facilitate the placement of the anastomotic suture;
otherwise, the suture needle may passinto the plastic.
Another reason is ease in removing the tubing at the
close of the operation. The preferred tube is the Javid
type with proximal ridge to prevent the tube from
slipping out of the common carotid artery. The use of
a tube without the ridge is extremely tricky, becauseit
can easilyslip out of the vessel.The length of the graft
closely approximates the length of the defect; if it is
too long, it may become tortuous. If an autogenous
vein graft (the author (JML) currently prefers a pros-
thetic graft) is utilized, the direction of blood flow
through the graft must be the same because of the
presence of valves in the vein. Heparin, 100 units/kg,
is given intravenously. The tubing and graft are like-
wise flushed with heparin. The distal smaller end of
the bypass tube is cut short if it is too long. This may
sacrifice the distal ridge, but this is of little concern.
The tubing covered with the graft is now ready.
Stay sutures are placed proximally and distally. The
common carotid artery proximally and the internal
carotid artery distally are cross clamped far enough
away from the area of resection as possible to insert
the intraluminal bypass tubing. Heparin solution is
injected pro*imally and distally to both clamps. The
smaller end of the bypasstube covered with the graft
is then inserted into the open end of the transected
internal carotid artery. The vascular clamp occluding
the internal carotid artery is removed, and back-
bleeding is allowed to fill the bypass tube while a
smaller Javid or Kraft clamp is applied around the
internal carotid artery and tubing. After you are sure
there is no air in the tubing, the larger end with the
ridge is inserted in the open end of the transected
common carotid artery and the larger javid clamp is
applied as depicted. The ridge prevents the migration
of the tubing. This feature is very necessary.Care must
be exercised if atheromatous plaques are present so
that no fragments find their way into the tubing. Now
that cerebral blood flow has been established, any
remaining attachments of the tumor are severed and
the tumor with the bifurcation is removed.
F The proximal and distal anastomoses are now
performed using 5-0 or 6-0 vascular sutures. If the
graft proves to be too long, it is easily trimmed over
the tubing. The bypass tube is now removed through
the partially closed proximal anastomosis or through a
proximal arteriotomy incision in the common carotid
artery. The patency of the graft is evaluated for 15 to
20 minutes. All precautions listed under Basic Prin-
ciples are closely followed (see p. 1233).
G If the graft becomes thrombosed, a No.4 Fogarty
catheter is inserted through the proximal arteriotomy
incision to remove the thrombus. A very fine suction
catheter is also utilized. If this requires any cross
clamping, heparin is again injected proximally and
distally to all clamps. The wound is closed, and a small
Penrosedrain is inserted for 24 hours. Anticoagulants
are not used postoperatively.
 VASCULAR PROCEDURES

FIGURE 22-26 Continued

 VASCULAR PROCEDURES

Resection of Intravagale Paraganglioma

With Preservation of Major Vessel
Continuity (Fig. 22-27)
With tumors that displace but do not invade vessel
walls, the continuity of major vessels in the neck can
almost always be preserved. Although many tumors,
both benign and malignant, may cause displacement,
the paragangliomas are prone to do so. As mentioned
previously, they may be classed as benign yet they are
locally destructive relative to function of the 9th, 10th,
11th and 12th cranial nerves. The management of carotid
body tumors has already been discussed (see Fig. 22-26).
A somewhat rarer type of paraganglioma, namely, the
paraganglion intravagale tumor, is closely related to the
cervical portion of the internal carotid artery and internal
jugular vein as well as being located in the parapharyn-
geal space (see Chapter 23). This tumor arises from the
ganglion nodosum of the vagus nerve (see Figs. 22-23
and 22-24). The following is a case study of a patient
with an intravagale paraganglioma (courtesy of Drs.
Berten C. Bean and Gordon J. Culver, Buffalo General
Hospital; patient of Dr. Glenn Leak).
A patient with an intravagale paraganglioma pre-
sented with a firm mass arising in the upper neck, deep
to the angle of the mandible in the region of the tail of
the parotid salivary gland. There was swelling of the
lateral pharyngeal wall. CT, MRI, and MRA were not
available at that time. Arteriograms and venograms
demonstrated the highly vascular nature of this tumor.
By careful dissection, the internal carotid artery was
preserved with removal of the internal jugular vein up
to the jugular foramen.
A A left carotid arteriogram in a patient with an
intravagale paraganglioma is shown. The tumor
receives its main supply from the branches of the
external carotid artery by way of the internal maxillary
artery with marked hypertrophy of the inferior alveolar
and mylohyoid branches of the internal maxillary
artery.
B A schematic interpretation of the arteriogram is
provided. The external carotid artery and its branches
are depicted in darker color.
C A venogram in a patient with an intravagale para-
ganglioma is obtained after a left carotid angiogram
during the venous phase. There is extensive venous
drainage to the vertebral venous plexus with visuali-
zation of large dilated internal jugular veins bilaterally.
There is narrowing of the left internal jugular vein at
the base of the skull and distention and tortuosity of
the vertebral venous plexus.
D A schematic interpretation of the venogram is
provided.
 VASCULAR PROCEDURES

LT. INTERNAL JUGULAR V.

FIGURE 22-27
 VASCULAR PROCEDURES
Intravagale Paragangliomas and Bilateral
Superior Sympathetic Ganglion
Paragangliomas and Unilateral Carotid
Body Tumors (Case Studies)
Case 1
A patient presented with a cervical mass associated with
"shooting pain" and tenderness over the right upper
cervical mass and was diagnosed as having a carotid body
tumor and a superior sympathetic ganglion chemodec-
toma on the right side (Fig. 22-28). In addition, the
patient had an intravagale and a superior sympathetic
ganglion chemodectoma on the left side. These were
resected in two stages, resulting in bilateral Horner's
syndrome and a left vocal cord paralysis. The latter
complication was due to the sacrifice of the left vagus
nerve because of the involvement of the ganglion
nod osurn, the origin of the intravagale tumor. This
patient exhibited bizarre blood pressure findings con-
sisting of lower blood pressure in the reclining position
and higher blood pressure in the erect position (ortho-
static hypertension). These findings, however, varied
from time to time and were affected by stress. This was
FIGURE 22-28 Arteriogram from patient with a superior sympathetic ganglion chemodectoma (top arrow) and a
carotid body tumor (bottom arrow) on the right side.
a typical example of the baroreflex failure syndrome,
which is reported in resection of bilateral carotid body
tumors. An undetected pheochromocytoma or another
functioning paraganglioma was suspected but was
never able to be proved despite repeated endocrine
evaluations. Unfortunately, this patient has been lost to
follow-up. An enhanced CT of the abdomen, pelvis,
and mediastinum would have been the next step in the
evaluation, with possibly 1311-MIGB.
Anecdotal as they may be, review of the findings
and surgical technique are worthwhile. The findings
and technique at the time of surgery on the left side are
outlined as follows:
I. Internal jugular vein diameter was unusually small.
2. There was an increase of small vascular
communications.
3. Exposure was achieved by retraction of the internal
carotid artery and the 12th nerve medially, while
the internal jugular vein and the vagus nerve were
retracted laterally.
4. Transection of the posterior belly of digastricus and
the stylohyoid muscle and the stylomandibular
ligament was done (see Figs. 17-3D and 23-4C).

5. Two masses were encountered that were aligned
side by side.
a. Larger one (3 x 1.5 cm) involved the sympa-
thetic chain with four large rami communicantes.
b. Smaller one (1 x 0.5 cm) involved the ganglion
nodosum.
6. Frozen section of the small portion revealed a
diagnosis of paraganglioma.
7. Dissection extended above the styloid process.
8. Transection was done inferiorly of sympathetic and
vagus nerves, and slight inferior traction was placed
on both tumor masses.
9. Silver clips, 4-0 silk ties, and cautery were used to
control bleeding. The estimated blood loss was
600 mL.
10. Transection was done superiorly at the base of skull
of both the sympathetic and vagus nerves. Intrava-
gale tumor extended up to the jugular foramen. With
the traction on the latter there was some bleeding,
which was controlled with silver clips. All major
nerve endings were secured with silver clips.
11. During the procedure the patient had no significant
change in the blood pressure. There was bradycardia
on manipulation of the internal carotid artery. This
responded to topical I % lidocaine.
Observations
1. This was an obvious complication of unilateral vocal
cord paralysis and bilateral Horner's syndrome.
2. The problem existed of intravagale tumor possibly
extending into the jugular foramen. In this patient
the distal cut section of the vagus nerve was not
involved. Yet, extension was an obvious possibility
if the surgery had been performed at a later stage of
the disease. In other reports (Batsakis, 1979), it is
the intracranial extension that causes death.
VASCULAR PROCEDURES
3. Signs and symptoms in this patient were labile blood
pressure as well as a burning pain in the oral cavity
and mandible on eating. She also had symptoms
suggestive of Frey's syndrome in the left upper
cervical region.
4. It appears that the sacrifice of both cervical sym-
pathetic chains to resect bilateral cervical superior
sympathetic ganglia paragangliomas contributed to
her orthostatic hypertension (baroreflex failure
syndrome).
5. At 7 years postoperatively the patient had a more
stabilized but persistent significant hypertension.
Facial pain on ingestion continued that was worse
10 days before menses.
Case 2
This is a case report of a 45-year-old white woman
(Fig. 22-29) first seen on 4/18/00 with a chief com-
plaint of dizziness and also a mild headache at the
back of the head and left ear pain. Physical exami-
nation revealed a mass in the left neck extending along
the anterior border of the sternocleidomastoid muscle
extending from just above the supraclavicular area,
extending superiorly underneath the angle of the
mandible. There was some suggestion that this may
have been in two parts; however, there was evidence,
also, of some continuity. Although these masses were
continuous in other areas, they seemed to be some-
what distinct. On the right side there was a mass at
level 2 (see Fig. 16-2B) extending to the angle of the
mandible. The only other positive finding in the head
and neck was a sluggish left vocal cord. Endocrine
work-up included evaluation of urinary catecholamines,
dopamine, epinephrine, norepinephrine, vanillylman-
delic acid, metanephrine, and creatinine. All results
were normal.
 VASCULAR PROCEDURES

Intravagale Paragangliomas and Bilateral

Superior Sympathetic Ganglion
Paragangliomas and Unilateral Carotid
Body Tumors (Case Studies) (Continued)
A Evaluation was with CT, MRI, MRA, and aortic arch
cranial angiogram, bilaterally, which revealed bilateral
paragangliomas. The left side revealed a carotid body
tumor and an intravagale, and/or possibly jugular,
paraganglioma. There was extension inferiorly of the
massiveganglioma arising from the middle sympathetic
ganglion, which reached the level of the inferior pole
of the left lobe of the thyroid. The angiogram revealeg
an inferior blood supply from the thyrocervical trunk
and another small vessel from the subclavian artery (D
and E).The operative findings are delineated here. The
internal carotid artery is shown along with the ninth
cranial nerve, which are dotted deep to the mandible.
The image findings on the right side indicate a carotid
body tumor and intravagale or jugulare paraganglioma.
B Lateral view of the osseous structures demon-
strates that in the horizontal plane the stylomastoid
foramen and the base of the thyroid process acting as
landmarks are virtually the same plane as the carotid
canal, which is located in the superior part of the
parapharyngeal space. Another landmark is the bony
auditory canal and its relationship to the level of the
jugular foramen. These landmarks aid in the under-
standing of the proximity of these various structures to
the base of the skull and the superior portion of the
internal carotid artery and the internal jugular vein.
C Outline of critical nerves is shown. (See also Fig.
23-4F'.)
D, E Angiograms of the blood supply to a cervical
sympathetic paraganglioma are presented. Note the
blood supply from the subclavian artery (1) primarily via
the thyrocervical trunk (2) and an additional tributary.

/,/
",--~":~~
--.....~
'"
l
\-
//
'\
/ ~
('.L
~
~J( .~
Stylomastoid

.\r~&fJI
foramen

I ..
\ --'--
9th N. 12th N.
Ant. Facial A..
Internal Carotid A.
Carotd Paraganglioma\ \~
BodyTumor l
Ext. Carotid .
Sympathetic Paragangli ma
(middle cervical ganglion)
B

Common Carotid A. Foramen magnum

FIGURE 22-29
 VASCULAR PROCEDURES 1305

STYLOHYOID L1G.

SUP. LARYNGEAL N.

ANSA HYPOGLOSSI
c

FIGURE 22-29 Continued

 VASCULAR PROCEDURES
Surgical Procedure
With the patient under general endotracheal anesthesia
an incision was made along the entire anterior edge of
the sternocleidomastoid muscle extending from the
suprasternal notch up to the mastoid process and then
carried up preauricular as a parotid gland resection.
Highpoints
1. Expose and control the common carotid artery just
above the sternoclavicular junction.
2. Expose and control the internal carotid artery up to
the level of the tip of the styloid process.
3. Expose and ligate a branch of the thyrocervical
artery, which was the blood supply of the inferior
portion of the neoplasm, and subsequently ligate
another branch from the subclavian artery to the
inferior pole.
4. Expose and preserve the seventh cranial nerve.
5. Expose the deep lobe of the parotid.
6. Expose the angle of the mandible.
7. Identify and preserve the vagus nerve just above
the suprasternal area and superiorly to the level of
the tip of the styloid process.
8. Identify and preserve the 12th and 9th cranial
nerves.
9. Expose and preserve the entire common carotid
artery and internal and external carotid arteries.
Dissection is performed just beneath the fascia of
the two neoplasms.
10. Mobilize the common carotid artery and internal
carotid artery from the area just above the sternal
notch to the tip of the styloid process.
11. Ligate a myriad number of vessels involving the
two neoplasms.
12. Remove the carotid body tumor.
13. Remove the sympathetic paraganglioma midcervical
ganglia.
14. Frozen section of two lymph nodes showed they
were benign.
15. Insert two Jackson-Pratt drains.
16. Although not used by this surgeon, some surgeons
use bipolar cautery.
Operative Report
An incision was made along the anterior border of the
sternocleidomastoid muscle extending from the supraster-
nal notch up to the mastoid process and then carried
superiorly preauricular as in a parotid gland resection.
The posterior belly of the digastric us and the stylohyoid
muscle and the stylomandibular ligament were tran-
sected, thus affording access to the parapharyngeal space.
A wide exposure at the angle of the mandible was per-
formed, as well as identification of the main trunk of
the 7th nerve. This was done if immediate mandibulotomy
became necessary. The deep lobe of the parotid gland was
mobilized. The ramus mandibularis and great auricular
nerve were initially exposed and preserved. However,
subsequently, the greater auricular nerve required tran-
section for mobilization of the parotid salivary gland.
Neurorrhaphy was done at the close of the operation.
The vagus nerve was the initial structure visualized
on the posterior lateral aspect of the neoplasm. Inferiorly,
the common carotid artery was exposed and skeletonized
just above the suprasternal notch and the vascular tape
placed around the vessel for control. A similar proce-
dure was performed around the internal carotid artery
well above the 12th nerve in the parapharyngeal space
in the region of the tip of the styloid process. Thus,
there was control of major proximal and distal blood
supply with vascular tapes as needed. This was performed
before any dissection of the neoplasm, which extended
into the parapharyngeal space. The 9th, 10th, and 12th
cranial nerves were identified and preserved. The 11th
nerve was not visualized; it did not appear to be in the
surgical field.
After proximal control of the common carotid artery
and distal control of the internal carotid artery, the dis-
section began superiorly. It became obvious that as the
internal carotid artery was further exposed, the vagus
nerve was found and was not invaded by the tumor. As
the dissection of the mass proceeded, it became clear
that the mass arose from the sympathetic chain, starting
close to the superior sympathetic ganglion. Two asso-
ciated lymph nodes were benign on frozen section.
Dissection proceeded downward, separating the tumor
from the internal carotid artery. However, bleeding was
significant, despite ligation of the two feeding vessels
inferiorly, namely, a branch from the thyrocervical trunk
and a branch directly from the subclavian artery, as
well as cross clamping the external carotid.
It was then decided to dissect the carotid body tumor
while packing was placed around the internal carotid
artery superiorly. The bifurcation was identified, and at
this point the ascending pharyngeal artery, which was
contributing to the blood supply of the tumor, was
identified and ligated and transected. This did little to
stop the bleeding. The superior thyroid artery was also
ligated. Trial occlusion of the external carotid artery was
done three times but was unsuccessful in achieving
good control of the bleeding. A bypass graft was now
considered. However, after gentle pressure, judicial wait-
ing, and patience, the bleeding significantly decreased.
The dissection varied from superior to inferior. Bleeding
again was significant along the common carotid artery.
It was controlled by clamping the edges of what appeared
to be fascia, which overlapped the carotid vessels. The
internal carotid artery and the common carotid artery
were reflected medially. Smaller vessels were encountered
virtually everywhere. During this dissection, it was certain

that the vagus nerve was not involved and that the
carotid body tumor was a separate entity. The carotid body
tumor now could be gently pressed posteriorly between
the internal and external carotid arteries and thus was
removed. The superior laryngeal nerve was not exposed.
The remainder of the dissection consisted in the
removal of the sympathetic paraganglioma, which dis-
placed the common carotid anteriorly. Anteriorly, the
tumor was thin and this afforded an entrance plane for
the dissection from the common carotid artery. It was
now without a doubt that the paraganglioma arose from
a large mass at the middle sympathetic ganglion. The
sympathetic chain was transected well beyond the gross
disease in the suprasternal region and superiorly above
the superior sympathetic cervical ganglion. Topical lido-
caine was placed on the internal carotid artery, which
was in spasm. At the close of the procedure, there were
definite pulsations of the internal carotid artery toward
the tip of the styloid process.
Total blood loss was 1000 mL. The patient received
40 mg of methylprednisolone (Solu-Medrol) to aid in
prevention of the temporary vocal cord paralysis because
there was weakness of the left vocal cord preoperatively.
At the close of the operation, when the patient was
extubated and able to phonate, flexible optical laryn-
goscopy revealed that both vocal cords were straight and
fully mobile. The left vocal cord was no longer sluggish.
Three days later the left vocal cord was immobile in mid
abduction and mid adduction. Three months postopera-
tively, both vocal cords were normal.
Postoperatively, the patient had significant pain imme-
diately on placing food in her mouth. The pain has
now localized over the masseter muscle. Interestingly,
the pain is also associated with mirror laryngoscopy,
which involves slight pressure on the oropharyngeal
wall, and relieved with topical, oral, and oropharyngeal
lidocaine. This appears to be a type of glossopharyngeal
neuralgia (see Fig. 23-4F1). Another patient who had
bilateral sympathetic paragangliomas, unilateral intrava-
gale tumor, and unilateral carotid body tumor removed
at two operations experienced similar pain. On the first
patient, described here, additional tests were done to
attempt to evaluate the type of pain. A local anesthetic
was inserted into the region of the mass of the muscle,
and a temporomandibular block was done. Neither of
these injections resulted in any pain relief. Postopera-
tively, the patient had a slight lid droop and the left
pupil is somewhat smaller than the right, which is
typical of Horner's syndrome.
At the present time we are now faced with the prob-
lem of her right carotid body tumor and intravagale or
jugular paraganglioma. Looking into the foreseeable
future management will be observation. If the second
carotid body tumor were to be removed we are reasonably
certain that the baroreflex failure syndrome will occur.
It is better to continue observation or radiotherapy. On
VASCULAR PROCEDURES 1307
the other hand, we are concerned about a tumor lying
in the jugular region for fear of this encroaching on and
into the jugular foramen and possibly extending intracra-
nially. We are considering a surgical approach for the
glomus jugulare tumor and radiotherapy for the second
carotid body tumor. The patient refuses radiotherapy.
Observation is continued with MRI and MRA.
Intravascular (Glomus) )ugulare
Paraganglioma Tumor (After Geelhoed
and Chretien) (Fig, 22-30)
It is a little appreciated fact that glomus jugulare tumors
can have intravenous extension despite the fact that
Hensen and colleagues (1953), and Gejrot and Lauren
(1964) described this very important characteristic.
Another clinical finding of equal importance is the
possibility of elevated norepinephrine simulating the
picture of a pheochromocytoma. These two possibili-
ties may well account for some of the unexplained
deaths associated with the attempted surgical removal
of glomus jugulare tumors-pulmonary emboli of tumor
and hypertensive crisis-hence the importance of
internal jugular vein phlebography and careful clinical
and laboratory evaluation of associated hypertension in
all patients with glomus jugulare tumors. The impor-
tance of arteriography in carotid body tumors is shown
in Figure 22-26 and that of venography in glomus
intravagale tumors is shown in Figure 22-27.
Depicted in Figure 22-30 is a patient of Geelhoed and
Chretien who demonstrates the vital characteristics that
may accompany any glomus jugulare tumor. In addition,
the local invasiveness of this type of tumor is evident.
Following is its description and surgical technique.
Case Study
A 19-year-old black woman was admitted to the Surgery
Branch, National Cancer Institute, for evaluation of a
possible extra-abdominal pheochromocytoma. One year
previously she developed recurrent episodes of frontal
headaches, diaphoresis, and palpitation. At another hos-
pital, she was found to have hypertension and elevated
blood levels of metanephrine and vanillylmandelic acid.
A phentolamine test was positive. With a preoperative
diagnosis of pheochromocytoma, she underwent
exploratory laparotomy. No tumor was found, however,
and her blood pressure did not rise with manipulation
of the adrenal glands.
The pertinent physical findings on admission 1
month after laparotomy were atrophy and weakness of
the right trapezius muscle, atrophy of the right side of
the tongue and deviation of the tongue to the right on
protrusion, deviation of the soft palate and uvula to the
right, and a tumor mass in the right middle ear that
encroached on the tympanic membrane.
 VASCULAR PROCEDURES
Intravascular (Glomus) Jugulare
Paraganglioma Tumor (After Geelhoed
and Chretien) (Continued) (Fig. 22-30)
Skull radiographs revealed extensive bone destruction
centering on the right jugular foramen (see Fig. 22-27A).
The area of bone destruction extended medially to near
the foramen magnum and included the lateral half of
the right occipital condyle, anteriorly to the clivus and
posterior portion of the petrous pyramid, laterally to
and including the styloid process, and posteriorly in
the area off the sigmoid sinus. A transfemoral internal
jugular venogram showed a large mass that extended
from the base of the skull through the internal jugular
vein and superior vena cava into the right atrium (see
Fig. 22-27B). The internal jugular vein was markedly
enlarged by the tumor mass. Carotid arteriograms showed
compression changes typical of a (glomus) jugulare
paraganglioma tumor. Norepinephrine assays on venous
blood samples taken via the catheter introduced through
the right femoral vein showed high levels throughout
the venous system, with the highest level in the specimen
removed from the right internal jugular vein (64 mgjL
compared with a normal level of 0.5 mgjL).
The tumor was deemed inoperable because of the
extensive destruction of the base of the skull, and radia-
tion therapy was elected. Because of the large portal
that would be required to encompass the intravenous
extension of the tumor, and the possibility of further
propagation into the heart or embolization of the
extension, this portion of the tumor was excised before
the radiation therapy.
The first step of the operation was preparation for
immediate cardiopulmonary bypass. The left femoral
vessels were exposed, and through them catheters were
introduced into the aorta and vena cava. The catheters
were then connected to a prime cardiopulmonary bypass
pump. In addition to the sterile preparation of the neck
for excision of the tumor, the anterior chest was prepared
for sternotomy. Now, in the case of rupture and emboliza-
tion of the intravenous tumor extension during the
attempted removal, it was possible to place the patient
on immediate cardiopulmonary bypass and, through a
rapid median sternotomy, extract the embolus from the
heart. After these preparations were completed, an
incision superficial to the right jugular vein was made
and the vein was exposed completely. All tributaries were
ligated and divided. The vein was immensely dilated
by the tumor that was easily palpated in the lumen.
Tapes were placed around the proximal and distal ends
of the vein and tightened sufficiently to occlude blood
flow. The vein was divided in its midportion, and the
tumor was exposed. It was free in the vein lumen, was
quite firm, and had a smooth surface. To prevent insuf-
flation of air into the vein during extraction of the tumor,
the vein was submerged in saline poured directly into
the wound. The proximal tape was then loosened, and
the tumor extension rapidly extracted from the superior
vena cava and atrium (see Fig. 22-30C). The distal end
of the vein was then ligated securely at the level of the
mastoid process with ligatures tightened sufficiently to
occlude blood flow in the tumor. The vein and the tumor
were then amputated distal to the ligatures, and the vein
end was closed over the tumor stump with a continuous
suture. The wound was closed in a routine fashion.
The specimen removed was a single tapering cylinder
of tumor 15 cm long and 3 cm in diameter at the level
of amputation. It weighed 30 g. Imprints of the tumor
fixed in formalin vapor and viewed with ultraviolet
light exhibited prominent fluorescence, indicating cate-
cholamine production, and fixation with dichromate
solution showed focal granularity. The norepinephrine
concentration of the tumor was 0.94 mLjg. No epinephrine
was detected.
Microscopic examination of the tumor showed epithe-
lioid cells characteristic of glomus jugulare tumors.
The round and polygonal cells had abundant granular
eosinophilic cytoplasm and small dark nuclei. The cells
were arranged in cords and acini-like clumps around
numerous thin-walled vascular spaces.
Postoperatively, the patient's blood norepinephrine
values rapidly declined from a preoperative level of 9.5
to 10.5 mLjday to 6.5 mLjday. One week postoperatively,
she began a course of radiotherapy to the primary
tumor. Over a 5-week course, 4500 rads was delivered
via lateral skull portals. During this period, the patient
had one hypertensive episode that was thought to be
due to acute hemorrhage of the remaining tumor and
catecholamine release. One month after completion of
the radiotherapy, her preoperative symptoms had com-
pletely subsided and her blood pressure and blood
norepinephrine levels were normal.
Highpoints
1. There was a possibility of a "functioning" (glomus)
jugulare paraganglioma tumor or of any paraganglioma
and, if so, preoperative, operative, and postoperative
management should be done accordingly (see Diag-
nosis and Evaluation, p. 1291).
2. Obtain complete radiographic studies.
3. Perform internal jugular vein phlebography and
carotid arteriography.
4. Use proper surgical approach to prevent emboliza-
tion of intravascular extension of glomus tumor.
a. Cervical approach and ligation of internal jugular
vein distal to intravascular extension
b. Cardiopulmonary bypass and preparation for
embolectomy if necessary
c. Prevention of air embolus
 VASCULAR PROCEDURES

FIGURE 22-30

A Basal view of skull shows extensive area of bone
destruction surrounding the jugular foramen (arrows
delineate the tumor).
B Internal jugular vein phlebogram shows glomus
jugulare tumor within the right internal jugular vein
extending into the right atriurn.
C The intravenous portion of the (glomus) paragan-
glioma tumor is shown after extraction from the right
atrium. The ligature securing the internal jugular vein
around the tumor is immediately inferior to the mastoid
process.
 VASCULAR PROCEDURES

Trauma to Vessels (See Figs. 22-31 to I} Complete transection

22-34) 2} Partial laceration
3} Intimal disruption (most common)
Trauma to the carotid artery deserves special attention c. Diagnosis
and understanding. This section is devoted to the basic 1) Hemispheric neurologic deficit in a conscious
principles of carotid artery injury, an understanding of patient
the potential severity of its complications, and the diffi- 2} Comatose patient-differentiation from intra-
culty in its diagnosis and management. The reader is cranial injury
also referred to Basic Principles (see p. 1233). 3} Angiogram absolutely necessary
d. Treatment
Vascular Trauma Outline I} Heparin
2} Repair of intimal dissection or repair of
1. Carotid artery trauma transection
a. Penetrating 3} Thrombectomy
b. Blunt 4. Iatrogenic carotid injury
c. Iatrogenic a. Venous-air embolism
2. Penetrating injury (for additional information, see 1) Diagnosis-Doppler ultrasound
Chapter 16) 2} Treatment-aspiration with a central venous
a. Etiology pressure line; repair or ligation of the vein
I} Missile injury b. Arterial-same as penetrating or nonpenetrating
2} Stab wound injury
b. Clinical presentation 5. Late sequelae of carotid injury
1) Bleeding . a. Arteriovenous fistula
2} Expanding hematoma b. False aneurysm
3} Neurologic deficit
4} Airway obstruction Immediate Sequelae of Vessel Injuries
c. Diagnosis (Fig. 22-31)
1) Clinical
2} Angiogram if feasible Carotid artery injury can be divided into two subgroups,
d. Preoperative management: penetrating and nonpenetrating injuries.
I} Life threatening-fluid and blood replacement
and maintain blood volume and blood pressure Penetrating Injuries (See Fig. 22-31 A)
2} Airway obstruction-endotracheal tube
3} Control of bleeding-immediate: digital com- Carotid injuries represent about 5 % of all arterial injuries
pression; temporary: packing and local com- occurring in war and approximately 8% of all civilian
pression (avoid blind clamping) arterial injuries. The majority of the injuries involve the
e. Operative management common carotid artery. Approximately 20 % of all the
1) General anesthesia if feasible carotid artery injuries involve the internal carotid artery.
2} Liberal exposure Penetrating wounds are most commonly produced by
3} Evacuation of hematoma missile injuries (60%), followed by stab wounds (30%).
4) Proximal and distal control of vessels The clinical picture of these injuries is bright red blood
5} Shunt-depends on location and extent of bleeding from the neck wound and/or a large expanding
injury hematoma. Weak or absent pulses distal to the suspected
6) Repair of injury: linear repair, patch graft or injury are fairly common. However, a normal pulse may
bypass (autogenous vein or prosthetic graft- be present, especially if the injury is an incomplete
PTFE, Dacron), ligation of vessels limited to laceration. This may be present in 20 % of the patients.
life-threatening problem Angiography is usually not feasible in most patients,
7) Associated venous injury: complication-air because a penetrating injury represents a serious emer-
embolism; treatment of air embolism-aspira- gency. If the patient has stable vital signs, and an airway
tion by central venous pressure; treatment of can be maintained possibly using an endotracheal
injury-repair or ligation (see Chapter 2) tube, an angiogram is of great help in determining the
3. Nonpenetrating injury (blunt) location of the bleeding site.
a. Etiology-stretching and hyperextension (motor A neurologic deficit may be present when the patient
vehicle accidents, sports injuries) has associated cranial injury and the etiology of the
b. Pathology deficit is difficult to evaluate. However, when the patient
 VASCULAR PROCEDURES

is fully conscious, the neurologic deficit, if still present, segment. If the area resected is not too long, end-to-end
can be attributed solely to the vascular injury. The lack arteriorrhaphy is performed.
of neurologic deficit is not a reason to exclude carotid When this is not feasible, interposition of an autoge-
artery injury, because 30% of these patients may well nous greater saphenous vein graft is performed. Auto-
have no neurologic deficit. The management of these genous material is preferred in the presence of trauma
patients requires a rapid and complete evaluation, because of the possibility of wound infection. Synthetic
because many may have other associated injuries, and grafts in the presence of wound infection may be rejected.
a priority of resuscitation should be developed, espe- However, if the wound is exceptionally clean, a syn-
cially, for example, with airway obstruction secondary thetic graft may be utilized. In very rare and extreme
to an expanding hematoma. circumstances the primary repair should be limited to
Immediate temporary control of hemorrhage from the ligation of the artery. This procedure, however,
injuries of major vessels in the head and neck some- should be reserved for only lifesaving situations.
times may be achieved by digital compression of the Injuries to the great cervical veins are usually best
common carotid artery against the carotid tubercle of handled by ligation and division of the vessels, except
the transverse process of the sixth cervical vertebra. If when both internal jugular veins are involved. It would
this emergency measure does not suffice, packing and then be advisable to repair one of these major veins.
local compression are necessary until definitive treatment Another exception to this situation might be injury to
can be instituted. Blind clamping should be avoided if the subclavian vein during the surgical procedure, in
at all possible. Airway patency must be carefully main- which case the treatment of choice is closure of the
tained, because packing or expanding hematoma may opening in the vein. In any case, immediate compres-
produce airway obstruction. Endotracheal intubation sion of the distal portion of the vessel is necessary to
should be performed freely, especially with any major prevent air embolism.
injury near the airway. Blood volume and blood pressure If there is a venous injury, immediate examination
must be maintained to prevent cerebrovascular ischemia. should be performed for a possible air embolism, because
General anesthesia is preferred. The exposure should this can be a fatal complication of venous injuries. One
be liberal. In a dire emergency an incision along the method of making the diagnosis is the use of Doppler
anterior border of the sternocleidomastoid muscle is ultrasound over the right atrium and pulmonary artery.
preferred. In the more elective exposure, other types of If an air embolism is in fact present, immediate aspira-
oblique incisions are possible. The hematoma should tion by a central venous pressure catheter is performed
be promptly evacuated. The extent of the vascular (see Chapter 2).
injury should be rapidly evaluated. Control of the After the vascular repair has been accomplished,
bleeding can then be obtained by digital tamponade exploration of the other cervical structures should be
until further dissection is performed or by the precise done and treatment done accordingly. This refers specifi-
use of vascular clamps. Blind clamping, which may cally to perforations or injuries to the hypopharynx,
injure other structures, particularly important nerves, esophagus, and larynx. Maintenance of the airway
must be avoided. Proximal and distal control must be takes precedence over other reconstructive procedures.
immediately obtained. When it becomes necessary to Debridement of devitalized tissue must accompany
obtain control of the intrathoracic portion of the sub- arterial repair. Immediate repair of vessel injuries will
clavian vein, or when the arterial lesion is below the minimize the occurrence of the late sequelae of
level of the clavicles or the suprasternal notch, or in vascular injuries. Yet, if vessel repair would jeopardize
fact where it involves the intrathoracic portion of the life, it obviously must be deferred.
left common carotid artery, a midline sternotomy
incision should be performed. Nonpenetrating Injuries (See Fig. 22-31 B)
After proximal and distal control has been accom-
plished, repair of the vessel should be carried out. An Nonpenetrating (blunt) injuries of the carotid artery are
immediate decision should be made regarding the pos- now recognized more frequently. This is usually pro-
sible use of a shunt. If the lesion requires only a con- duced by a sudden stretching and hyperextension injury
tinuous suture repair, this can be accomplished promptly of the neck or by direct trauma over the artery, as seen
and no shunt is usually necessary. However, if the injury in car accidents, contact sports, or violent trauma. These
is more extensive and requires grafting or bypass, the injuries are usually more often seen in younger people.
use of shunts is preferred to minimize the time of The pathology of the arterial injury may be of three types:
cerebral ischemia.
If the carotid vessels are severely contused and there 1. Complete transection of the artery
is evidence of intraluminal clot and spasm, the clot 2. Partial laceration
should be carefully removed. If the wall of these vessels 3. Intimal disruption (most common) with intimal dissec-
is severely damaged, it is best to resect the injured tion and thrombosis with complete occlusion
 VASCULAR PROCEDURES
Immediate Sequelae of Vessel Injuries
(Continued) (Fig. 22-31)
The injury usually involves the internal carotid artery
just proximal to the foramen of the carotid canal. This
is the fixation point of the carotid artery.
The key to confirming a suspicion of carotid artery
injury is the finding of a hemispheric neurologic deficit
in an injured patient with a good level of conscious-
ness. When possible, angiograms are a distinct aid in
the evaluation of arterial injury and should be per-
formed if there is serious doubt whether the patient
should undergo surgical exploration. It must be
recalled, however, that extravasation of the contrast
material (Lumpkin et aI., 1958) does not always occur
in arterial injury. Therefore, to depend solely on the
arteriogram in the presence of other indications is not
warranted. A frequent clinical presentation is the
delayed appearance of neurologic symptoms in these
types of injuries. Clinical signs that suggest arterial
injuries include the following (modified from Perry et
al., 1971):
1. Diminished or absent distal pulse. A distal pulse may
be present despite severe arterial injury, especially
with the subclavian artery, because of collateral path-
ways. A paradoxical distal pulse may be present due
to transmitted pulsations from the proximal pulse.
2. History of or persistent arterial bleeding
3. Large or expanding hematoma
4. Major hemorrhage with hypotension or shock
S. Bruit at or distal to suspected site of injury
6. Injury of anatomically related nerves
7. Anatomic proximity of wound to major artery
8. Embarrassed airway in neck associated with
hemorrhage or hematoma
9. Blunt trauma to neck associated with signs and
symptoms of stroke; arteriogram is necessary.
10. Wounds near the base of the skull; arteriogram is
usually advisable.
Heparin is usually not used systemically. However, if
there is evidence of significant thrombosis, especially
in the distal vessel, heparin can be used locally or
systemically during the procedure but should not be
continued postoperatively.
Debridement of devitalized tissue must accompany
arterial repair. Immediate repair of vessel injuries will
minimize the occurrence of the late sequelae of vascular
injuries. Yet, if vessel repair would jeopardize life, it
obviously must be deferred.
The reader is referred to additional basic principles
on page 1233.
Exposure of the various major vessels and the tech-
niques of arteriorrhaphy and vessel grafts are covered
under the previous sections on degeneration and
neoplastic disease.
A Depicted is a left carotid arteriogram of a 31-year-
old woman performed via a right femoral artery
catheterization about 90 minutes after a through-and-
through bullet wound at the base of the skull, just
below both external auditory meati. The left internal
carotid artery is completely occluded with slow but
definite extravasation of the contrast material at the
base of the skull, in line with the bullet fragments. The
terminal branches of the external carotid artery are
likewiseinterrupted. The findings at operation substan-
tiated the arteriographic results. An attempt to recon-
struct the internal carotid artery was not possible,
because there was insufficient length (5 to 6 mm) to
the distal vessel. Two silver clips were applied to the
distal vessel, and suture ligatures were used at the
proximal end. There were no central nervous system
sequelae. The preliminary insertion of an endotracheal
tube, followed by a tracheostomy, was lifesaving,owing
to a massive oropharyngeal and cervical hematoma.
Opacification of the left subclavian and left vertebral
arteries was also performed. The left vertebral artery
was intact, and it not only supplied the basilar artery
but, through the posterior communicating artery,
supplied the carotid siphon and the middle and ante-
rior cerebellar arteries of the left side. (Courtesy of
Ivan L. Bunnell, Angiology Department, The Buffalo
General Hospital.)
B A word of caution regarding blunt trauma:
although rare (less than 10% of arterial injuries, with
most due to penetrating wounds), one young adult
patient developed a stroke and died of an acute
thrombus of the internal carotid artery secondary to
blunt trauma of the upper neck. Only the minimum
degree of contusion was present.
 VASCULAR PROCEDURES

FIGURE 22-31

Another type of sequela of blunt trauma-traumatic Arteriovenous Fistula

intimal prolapse of the common carotid artery-has
been described by McGough and associates (1972). The arteriovenous fistula is an abnormal communica-
tion between an artery and a vein and is usually the
Summary of Possible Types of Injuries result of trauma. The etiology of this late arteriovenous
fistula is not clearly understood. It has been suggested
• Laceration that unrecognized injury to the artery and adjacent vein
• Transection at the time of surgery progresses to form this communi-
• Puncture cation. Also, a contusion of the vessel may progress to
• Contusion disruption of the wall and formation of an arteriovenous
• Spasm fistula.
• Possible foreign body within lumen reaching brain The experimental work of Schenk and colleagues
(1957) is extremely interesting. They have shown in
Possible Acute Sequelae and Complications the experimental animal with a formed fistula between
the common carotid artery and the external jugular vein
• Hemorrhage that immediately after the opening of the fistula there
• Hematoma is an enormous retrograde flow through the fistula from
• Thrombosis with or without cerebral emboli the distal artery. This, in fact, would be a steal of arterial
• Air embolism-venous (see Chapter 2) blood intended for the cranial supply to the venous
• Airway compression system. In addition, their work showed "distal vein pres-
• Wound infection sures tended to be much lower and flows much higher
• Stroke than in the femoral fistulas, suggesting the possibility
that partial competence of venous valves may be imped-
Late Sequelae of Vessel Injuries ing retrograde flow in the distal venous limb of the
femoral system but not in the (external) jugular system."
The most common late sequelae of vascular trauma to It would then seem that if the same hemodynamic were
the cervical region are arteriovenous fistula and false present in a carotid internal jugular fistula, increased
aneurysm. venous intracranial engorgement would occur, which
 VASCULAR PROCEDURES
would be a further insult to the brain. In addition, this
lends evidence to the absence of valves in the jugular
veins. It should be noted that arteriovenous commu-
nications are frequently associated with a nearby false
aneurysm.
Thrill and bruit are present shortly after the fistula
occurs, whereas the swelling may not appear until
many years later. The patient may complain of tinnitus.
Depending on the size of the fistulous tract, duration of
existence, and proximity to the heart, other signs will
be noted, such as heart failure, increased blood volume,
and tachycardia. Bacterial endarteritis of the fistula
occurs only rarely. Distal cirsoid dilatation of the vessels
of the scalp may occur rather suddenly after the delayed
appearance of the aneurysmal swelling. This does not
appear proximally, because the pressure is dissipated
upward because of the gradient in pressure in the veins.
Bradycardia occurs with digital compression over the
fistula (Nicoladoni-Branham sign).
Ligation and division of all vessels proximal and
distal to the fistula, followed by excision of the fistula,
is advocated for treatment of arteriovenous fistula
involving minor or noncritical arteries. However, when
the communication involves major vessels such as the
common and internal carotid arteries or other critical
arteries, this obliterative method is undesirable, because
major vascular catastrophe may follow. In those cases,
excision and lateral repair of the artery and vein are the
procedures of choice.
False Aneurysm
Aneurysms of the head and neck region are usually the
result of trauma; rarely do they arise from arterioscle-
rosis. The danger of a false aneurysm (organized wall
of hematoma) is the rapid expansion and possible
rupture or compression to adjacent nerves and veins.
Because of this potential complication, a false aneurysm
should be repaired as soon as possible. Infection is a
potential etiologic factor in the formation of a false
aneurysm.
The surgical technique for resection of a false aneurysm
requires proximal and distal control of the involved
vessel. The aneurysm should be dissected with care to
avoid injury to adjacent nerves and veins. Concomitant
unrecognized arteriovenous fistula may exist, and
extensive hemorrhage may ensue at the time of dissec-
tion. Air emboli may also complicate this presentation.
Venous control is advised whenever possible before the
excision of a traumatic false aneurysm. In certain
cases, the wall of the aneurysm may be left in place. If
the defect is small, a lateral closure may be possible
without compromising the lumen of the vessel. However,
if the defect is large, a saphenous vein graft may be
required.
Iatrogenic Carotid Injuries
During neck dissection, injury to any of the great
vessels may occur, and this is managed immediately by
direct pressure over the opening and then proximal and
distal occlusion of the vessel and closure of the opening
with continuous Prolene. There may also be injury to
the subclavian vein and the proximal and distal stump
of the internal jugular vein. These also are handled in
the same manner, except that one must be cognizant of
the fact that air embolism may occur with injuries to
the subclavian vein and the distal stump of the internal
jugular vein. The patient is immediately placed on his
or her left side and also in the Fowler position. Aspira-
tion of air may be necessary from the right side of the
heart using a central venous pressure catheter.
Summary of Late Sequelae of Vessel Injuries
1. Arteriovenous fistula (see Fig. 22-32)
2. False aneurysm (see Fig. 22-33)
3. Foreign body embedded in vessel wall (see Fig. 22-34)
A discussion of each of these sequelae can be found
under the respective procedure. The first two items in
this list are the most common late sequelae of vascular
trauma to the cervical region.
Resection of Arteriovenous Aneurysm of
the Face (Fig. 22-32)
Highpoints
1. Simple ligation of either proximal vessel or fistulous
communication is wholly inadequate. The commu-
nication or communications must be resected.
2. Exposure of carotid bifurcation is advisable in com-
plicated arteriovenous fistulas.
3. Distal cirsoid type of dilatation beyond the region of
fistula or fistulas usually collapses after resection of
primary disease.
4. If the aneurysm is in any way related to the region
of the facial nerve, the nerve must be exposed and
dissected exactly as in any parotid surgery.
S. CT and MRI and possibly MRA and arteriogram are
indicated.
 VASCULAR PROCEDURES

Cirsoid aneurysm

Main mass of
arterial venous aneurysm

A Ext. carotid a.

FIGURE 22-32

Discussion
Arteriovenous fistulas and abnormal direct commu-
nication between an artery and a vein are usually the
result of trauma. The etiology of this late arteriovenous
fistula is not clearly understood. It has been suggested
that unrecognized injury to an artery and adjacent vein
at the time of surgery progresses to form this commu-
nication. Also, a contusion of the vessels or a penetrating
wound may progress to disruption of the wall and for-
mation of an arteriovenous fistula. Arteriovenous com-
munications are frequently associated with a nearby
false aneurysm. (See also the discussion of arteriove-
nous fistulas, p. 1313, for additional information.)
A An 18-year-old boy accidentally fell on the blade
of an open scissors at the age of 3 years. Three to 6
months after the injury a purring sound at the side of
the child's face was noted by his parents. When the
child became older, he referred to this sound as his
"purring pussy cat." It was not until the age of 17
years that a swelling was noted. One week after the
first examination at the age of 18 years, a cirsoid type
of swelling of the veins at the scalp suddenly appeared.
The original stab wound is marked with "X." The inci-
sion is the same as that used in parotidectomy except
that a longer cervical extension is made along a natural
horizontal-oblique skin crease. This extension serves to
expose the external carotid artery, which facilitates
proximal control of the arterial supply.
B The external carotid artery is identified, and a tape
is passed around the vessel. The common facial vein
has been divided.
Continued
 VASCULAR PROCEDURES

Resection of Arteriovenous Aneurysm of

the Face (Continued) (Fig. 22-32)
C The main trunk of the facial nerve with its major
divisions, the upper or zygomaticotemporal and lower
or cervicofacial, is exposed as in a parotidectomy (see
Fig. 17-1A to E). The posterior edge of the aneurysm is
exposed as it lies deep to these divisions of the facial
nerve. The nerve is displaced laterally by the aneurysm
and is very vulnerable to injury.
D The dissection proceeds as in a parotid lateral
lobectomy. The loculations of the aneurysm are apparent
as they project between the branches of the facial
nerve. The nerve and the aneurysm are entwined.
E A large communicating vessel is doubly clamped
and divided. The exact identification of this and certain
other vessels involved is virtually impossible. Suffice it
to say that all the communicating vessels are ligated
and divided with preservation of the branches of the
facial nerve.
F The dissection proceeds with the buccinator
branch of the facial nerve gently retracted with a tape.
The origins of the external jugular vein and the pos-
terior facial vein have been ligated and divided from
their communications with the aneurysm.
G The deeper communicating vessels are best
handled with a small Mixter clamp used to ligate the
vesselsin situ. These vesselsare then divided between
the clamps. Evidently, the main fistula was between a
branch of the internal maxillary artery and certain
veins within the parotid gland, principally the origin of
the posterior facial vein.
Continued

Mastoid tjp
'0/,,'"

Parotid gland
(~up~rf.
lobelj
" ',\

FIGURE 22-32 Continued

 VASCULAR PROCEDURES

Super!. temporal a. and v.

Post.
facial v.
Com. carotid a.
Hypoglossal n. Ansa
hypoglossi
Ext. jugular v.

FIGURE 22-32 Continued

 VASCULAR PROCEDURES
Resection of Arteriovenous Aneurysm of
the Face (Continued) (Fig. 22-32)
H The facial nerve branches are moved back and
forth and up and down as the multiple communi-
cating vessels are encountered, ligated, and divided.
I The auriculotemporal nerve is exposed in the vicinity
of the superficial temporal vessels. To minimize the occur-
rence of gustatory sweating after parotid operations
(Frey's syndrome), a section of this nerve is resected.
J The superficial temporal vein and artery are now
dissected. Because both have communications with
the aneurysm, they resemble one another, the vein
taking on the characteristics of an artery and vice versa.
A small Mixter clamp is placed beneath the vein, which
is doubly ligated and divided. The artery is divided in
similar fashion. With division of these vessels-the
feeders of the cirsoid portion of the aneurysm on the
scalp-this superior extension of the arteriovenous fistula
begins to collapse. In this case, within 2 to 3 weeks it
had completely disappeared.
K With the branches of the facial nerve retracted
downward, the main source of arterial blood, the
internal maxillary artery, is now exposed. It is doubly
ligated and divided and the aneurysmal sac is
removed. The mobilized portion of the lateral lobe of
the parotid is then excised as in a parotidectomy.
L The facial nerve with all its major branches has
been preserved. Behind the nerve is the small deep
lobe of the parotid. Closure consists of approximation
of the subcutaneous tissue with 4-0 chromic catgut
and the skin with 6-0 nylon. A small dependent tissue
drain is inserted, and a pressure dressing is applied.
 VASCULAR PROCEDURES 1319

Aneurysm

Ansa hypoglossi
Vagus n.

Super!. temp. V( f

Auriculotempo[
nerve \,

Hypoglossal n.
Ext. jugular v.
Ansa hypoglossi
Vagus n.

FIGURE 22-32 Continued

 1320 VASCULAR PROCEDURES
Resection of Aneurysm of Common or
Internal Carotid Artery
Aneurysms of the head and neck are usually the result
of trauma, and they rarely occur on the basis of arte-
riosclerosis. As elsewhere, they may be true or false. A
true aneurysm has all the coats of the parent vessel,
whereas a false one simply has the organized wall of a
hematoma.
False Aneurysm (Sac Composed of a Neointima
Without Adventitia and Without Muscularis)
The danger of a false aneurysm is its rapid expansion and
possible rupture or its compression of adjacent nerves,
airway, and veins. Therefore, a false aneurysm should
be repaired as soon as possible. Infection is a potential
etiologic factor in the formation of a false aneurysm.
The surgical technique for resection of a traumatic
aneurysm of the common or internal carotid artery follows
the same approach as described for carotid body tumor
(see Fig. 22-26) and requires proximal and distal control
of the involved vessel. The aneurysm should be dissected
with care to avoid injury to adjacent nerves and veins.
Concomitant unrecognized arteriovenous fistula may
exist, and extensive hemorrhage may ensue at the time
of dissection. Air emboli may also complicate this presen-
tation. Venous control is advised whenever possible
before the excision of a traumatic false aneurysm. In
certain cases, the aneurysm wall may be left in place.
If the defect is small, a lateral closure may be possible
without compromising the lumen of the vessel. However,
if the defect is large, a saphenous vein graft may be
required, because the false aneurysm may be related to
an infectious process. The bifurcation of the common
carotid artery is usually not resected unless it is specifi-
cally involved. The skin incision is horizontal, following
a natural skin crease overlying the region of the aneurysm.
The aneurysm with a segment of the parent vessel is
resected between vascular clamps. Continuity of the
carotid blood flow is achieved by using an autogenous
saphenous vein graft.
Transection of Internal Carotid Artery/
Internal Jugular Vein Fistula With
Resection of False Aneurysm (Fig. 22-33)
Highpoints
1. Adequate exposure at the base of the skull is achieved
by transecting the mandible near the angle. Avoid
entering the oral cavity.
2. Expose and control the proximal great vessels with
tapes. Three or four centimeters is necessary. Distal
exposure sufficient for circumferential tapes may not
be possible, but exposure must be adequate for place-
ment of vascular clamps if this maneuver becomes
necessary.
3. Complete the transection of the arteriovenous fistula
with preservation of the internal carotid artery. The
internal jugular vein may be sacrificed.
4. Preserve all associated nerves (i.e., vagus, hypoglossal,
spinal accessory, sympathetic chain, glossopharyn-
geal, superior laryngeal, and facial).
This patient was shot at close range with the bullet
entering the right side of the oral cavity. He presented
with some weakness of the left upper and lower extrem-
ities and an "increasing noise" in the right upper neck.
In addition he had a right-sided congenital arteriovenous
fistula intracranially.
A1 Angiography demonstrates the arteriovenous
fistula with an associated false aneurysm of the internal
carotid artery.
A An oblique horizontal type skin incision is made
about 2 fingerbreadths below the angle of the mandible.
This is carried through the platysma muscle.
B Upper and lower skin flaps with the platysma
muscle are developed and retracted with stay sutures
or self-retaining retractor. This exposes the anterior
border of the sternocleidomastoid muscle, tail of the
parotid, salivary gland, submandibular salivary gland,
digastric and stylohyoid muscles, and carotid sheath.
The carotid sheath is opened, with dissection of its
contents, thus exposing the bifurcation of the common
carotid artery, internal jugular vein, and vagus nerve.
Three or four centimeters of common carotid artery is
exposed proximal to the bifurcation for placement of
vascular tapes. This is most important. A sizable portion
of the aneurysm lies beneath and deep to the mandible.
A sharp thrill is felt.
Continued
 VASCULAR PROCEDURES

B
FIGURE 22-33
 VASCULAR PROCEDURES
Transection of Internal Carotid Artery/
Internal Jugular Vein Fistula With
Resection of False Aneurysm (Continued)
(Fig. 22-33)
C To obtain adequate exposure, the angle of the
mandible is transected. Exposureof this area is enhanced
by transection of the stylomandibular ligament. This
ligament is a thickened or specialized band of deep
cervical fascia that, however, is usually not too well
defined. This ligament lies between the masseter and
internal pterygoid muscles and separates the parotid
and submandibular salivary glands (see Figs. 17-3D
and 23-4C). The fibers of the masseter muscle are
separated or transected to expose the bone while a
malleable retractor is carefully inserted deep to the
angle without perforating the mucous membrane of
the oral cavity. The site of transection is as high as
possible and several centimeters behind the third molar
tooth. In this manner the mucous membrane is easily
elevated from the ascending ramus and is preserved.
Transection of the mandible is performed with a
sagittal plane saw or by inserting a large curved clamp
over the malleable retractor and under the mandible
to the inner edge of the bone to grasp a Gigli saw.
In either case, extreme care must be taken that the
underlying aneurysm not be injured.
o The course and relationship of the internal jugular
vein and internal carotid artery and associated nerves
are depicted in a normal specimen. The relationship
of the spinal accessory nerve to the internal jugular
vein is variable. Soo et al. (1986) report that the nerve
passed lateral to the internal jugular vein in 18 of the
32 specimens (56%) and medial to the vein in 14
(44%). Others have reported a higher percentage
(70%) passing lateral to the internal jugular vein
(Hollinshead, 1968). The occipital and posterior
auricular arteries, which are branches of the external
carotid artery, cross in front of the internal carotid
artery, while behind the internal carotid artery lies the
superior laryngeal nerve. The glossopharyngeal, the
hypoglossal, and the vagus nerves lie essentially
between the internal jugular vein and the internal
carotid artery at the base of the skull with the former
two nerves crossing in front of the internal carotid
artery (see E). The dotted line indicates the site of
transection of the mandible.
E The cut ends of the mandible are retracted with
hooks. The upper fragment is pulled upward and
slightly forward to expose the base of the skull at the
site of the jugular foramen and the carotid canal in the
petrous portion of the temporal bone. The posterior
belly of the digastric muscle has been transected. The
occipital and posterior auricular arteries are ligated and
transected. The fistula between the internal jugular
vein and the internal carotid artery is now exposed.
Opposite the arteriovenous fistula on the medial side
of the internal carotid artery is a false aneurysm into
which the tip 'of the styloid process is projecting. To
facilitate additional exposure, the base of the styloid
process is transected along the dotted line. This releases
the stylohyoid muscle, stylohyoid ligament, and styloglos-
sus and stylopharyngeus muscles. The stylomandibular
ligament has already been cut to facilitate retraction of
the upper portion of the cut mandible. The spinal
accessory nerve crosses in front of the jugular vein just
above the arteriovenous fistula, with the vagus nerve
deep to the fistula and closely adherent to the fistula
with scar tissue. The glossopharyngeal nerve crosses
anterior to the internal carotid artery and below the
muscles attached to the styloid process. Control tapes
have been placed around the common carotid artery
and internal jugular vein.
Continued
 VASCULAR PROCEDURES

SUP.

FIGURE 22-33 Continued

 VASCULAR PROCEDURES
Transection of Internal Carotid Artery/
Internal Jugular Vein Fistula With
Resection of False Aneurysm (Continued)
(Fig. 22-33)
F The tape around the common carotid artery is
now relocated around the internal carotid artery, with
care being taken not to injure the superior laryngeal
nerve, which lies behind the artery. Only 3 to 5 mm of
artery and vein between the arteriovenous fistula and
base of the skull could be dissected. This space did not
afford adequate elective crossclamping or the placement
of tapes around these vessels to perform the usual
technique for transecting of an arteriovenous fistula. It
would, however, permit cross clamping if inadvertent
hemorrhage occurred. The arteriovenous fistula is then
skeletonized, separating it from the underlying vagus
nerve that was involved in the surrounding scar tissue.
Curved Bainbridge vascular clamps are then placed
acrossthe fistula as depicted. On the arterial side, a stay
suture is placed superiorly and inferiorly for control in
the event of arterial bleeding. The venous side is sutured
first by inserting a continuous 5-0 vascular monofila-
ment suture between the vein and the clamp. The
fistula is then transected between the clamps. The
clamp on the venous side is then removed. The arterial
side is closed with a continuous over-and-over 5-0 vas-
cular monofilament suture outside the arterial clamp.
The clamp is then removed. One bleeding site requires
a single suture. Placement of this suture is facilitated
by traction on the stay sutures.
G The false aneurysm is handled in similar fashion by
the use of an angulated Potts clamp, resection along
the dotted line, and closure using continuous 5-0 vas-
cular monofilament sutures.
H A section of the sternocleidomastoid muscle is
mobilized with a superior base and inserted and sutured
between the artery and vein at the site of the fistula to
aid in prevention of re-formation of the fistula. Blood
flow through both vein and artery appears normal. The
mandible is reapproximated using two sutures of wire
with an intramedullary Kirschner wire or Steinmann
pin (see Fig. 15-9G to K). (For further discussion refer
to Late Sequelae of Vessel Injuries, p. 1313.)
 VASCULAR PROCEDURES

FIGURE 22-33 Continued

 VASCULAR PROCEDURES
lateral Venotomy for Foreign Body
(Fig. 22-34)
Indication
• Metallic foreign body with persistent symptoms in
region of great vessels. Location is by radiograph
and Berman locator.
Although the internal jugular vein is resected with
virtual impunity in a radical neck dissection, its preser-
vation in the absence of malignant disease is indicated.
A foreign body in the wall of a vessel can extrude into
the lumen. In one instance a metal clip used in tran-
secting a patent ductus arteriosus was later found in
the lung parenchyma.
A A horizontal incision is made in a natural skin
crease slightly below the region of the foreign body.
B The platysma muscle is transected in the same plane.
C Larger upper and smaller lower skin flaps are
developed.
D The carotid sheath deep to the anterior border of
the sternocleidomastoid muscle is opened longitudinally.
E The metallic foreign body is located within the wall
of the internal jugular vein laterally. Adherence to the
vagus nerve is demonstrated with the mobilized
internal jugular vein. The ansa hypoglossi is retracted
with a suture.
F Proximal and distal tapes control the vessel. The
adhesions to the vagus nerve have been separated by
sharp dissection. A small, curved, bulldog vascular
clamp is placed vertically on the vein encompassing
that portion of the vessel wall containing the foreign
body. This area is excised with fine curved scissors.
G Details of placement of the curved clamp and the
area excised are shown. The main lumen of the vessel
is not occluded by the clamp. The tapes afford
complete control of the vessel.
H A continuous 6-0 vascular suture is placed in
simple over-and-over fashion approximating intima to
intima.
I The clamp is removed, and the suture line is
checked for bleeding. If a leak occurs, a single simple
suture, not anticoagulants, is used.
 VASCUilIR PROCEDURES 1327

Ant. border of
sternocleidomastoid

A c

Carotid sheath

Ansa hypoglossi .
Com. carotid a. /,
Foreign body
Vagus n.

D Int. jugular v. E

FIGURE 22-34
 VASCULAR PROCEDURES
Control of Hemorrhage
(See Figs. 22-35 to 22-37)
Effects of Cancer: Carotid Artery Blowout
Etiology
1. Slough of skin flaps: local or transposed flap from
whichever cause
2. Preoperative and/or postoperative radiotherapy
3. Fistula
4. Infection
Prevention
When the common carotid, internal carotid, or external
carotid artery is in jeopardy do the following:
1. Administer preoperative, intraoperative, and post-
operative antibiotics.
2. Cover arteries with viable muscle (e.g., levator
scapulae muscle flap [see Fig. 22-36] or pectoralis
major myocutaneous flap [see Chapter 8]).
3. Do not use preoperative radiotherapy.
4. Be very selective in postoperative use of radiotherapy.
5. Use extreme care when closing a defect in the
upper aerodigestive tract.
6. Allow no dead space over vessels (e.g., in the
supraclavicular area or in the submandibular area],
especially near the angle of the mandible.
7. Close (in watertight manner] all intraoral defects.
8. Do not perform vascular reconstruction in the pres-
ence of infection or highly suspected postoperative
fistula formation.
9. Use extreme care in development of cervical flaps.
Trim 0.5 to 1 cm from the anterior margin of a pos-
terior cervical skin flap in radical neck dissection if
there is any discoloration.
10. Place and secure suction catheter away from the
carotid vessels; use absorbable sutures through the
deep muscles; never place suction catheters across
the carotid vessels.
Prevention and Management of Carotid
Artery Blowout
Etiology
Carotid artery blowout occurs most frequently after a
radical neck dissection when this procedure has been
combined with preoperative radiotherapy and with a
resection of a primary lesion involving any portion of
the pharynx, larynx, oral cavity, and cervical esophagus.
It is rare otherwise but could well occur after any type
of skin slough and breakdown over the carotid artery.
The blowout can occur anywhere along the course of the
common or internal carotid arteries. Blowout has also
been seen of branches of the external carotid artery.
Since the start of a preoperative chemotherapy protocol
(see Chapter 3] in 1979 the author (JML] has encoun-
tered only one carotid blowout. This occurred in a patient
who had postoperative radiotherapy. The preoperative
chemotherapy has also facilitated easier and safer dis-
section of neoplasms abutting on the great vessels.
Although skin slough almost always to some degree
accompanies carotid artery blowout, this catastrophe
can occur under more or less intact skin. This occurs
when the skin is not in direct contact with the vessel,
and there is usually an associated dead space about the
vessel. The dead space can be related to a number of
causes, including postoperative fistula formation and
infection. These two predisposing factors can of them-
selves lead to blowout. Dead space can also be the
result of wound closure (e.g., in the supraclavicular
and submandibular areas, the latter involving dead
space associated with resection of the floor of the mouth
anteriorly to the base of the tongue posteriorly]. As far
as fistula and infection are concerned, it is a moot
question which is the primary event. Obviously, fistula
formation can be secondary to wound infection, but it
may also be related to a technique of mucosal closure
that is either incomplete under tension or fails to invert
the mucosa-to-mucosa approximation. There is another
predisposing anatomic fact-the absence of serosa in
the pharynx and esophagus-hence the importance of
meticulous mucosal closure.
The time-honored culprit, however, which sets the
stage for skin slough, fistula formation, and even infec-
tion, is preoperative radiotherapy (e.g., in salvage surgery
after organ preservation radiotherapy with chemotherapy
plus radiotherapy failure]. In brief, preoperative radio-
therapy causes devitalization of tissue by interference
of adequate blood supply to virtually all tissues-soft
tissue and blood vessel walls as well as bone. Skin inci-
sions that parallel or lie directly over the carotid vessels
in vertical fashion are invitations to exposure of the
vessels when the skin edges slough. When fistula and
infection occur with this sad group of events, blowout
is imminent. The surgeon and nursing staff must beware!
In addition, postoperative radiotherapy can also lead to
skin slough, exposure of vessels, and blowout.
Another cause of blowout, occurring either with the
preceding situations or alone, is pressure on the vessels
(e.g., from suction drainage catheters that cross or are
in contact with the vessels]. Any tube (e.g., a tracheostomy
tube] or prosthetic device that is in contact with vessels
can cause blowout from pressure necrosis alone or from
the pulsation of vessels against the foreign body tubes.
Quite apart from the carotid vessels, the innominate
artery or any anomalous great vessel in relation to the

trachea can erode from the tracheostomy tube that lies
in close contact with the vessels. A clue to impending
danger is a tracheostomy tube that is seen to move
back and forth or side to side synchronous with vessel
pulsation. The tube must be changed to a shorter tube
and repositioned. A softer and very pliable plastic tube
should replace the metal tube.
Prevention Details
An old cliche, namely, prevention is the best treatment
for any complication, is implicit in relation to carotid
artery blowout. With vessel blowout it is very pertinent
and to the point. The preventive measures are covered
in outline fashion as follows:
1. Preoperative systemic antibiotics starting the night
before or during the operation. In addition, the use
of local mouthwash with 1 % clindamycin 48 hours
preoperatively in all procedures that enter the upper
aerodigestive tract may be of some help. Neomycin
(1 %) mouthwash has been used.
2. Skin incisions should be selected so they avoid
following the underlying carotid vessels. Although
horizontal skin incisions (MacFee) have been cham-
pioned as the solution to this problem, skin slough
has occurred directly over the vessels. This may be
caused by excessive traction on the skin flap during
the operation to afford adequate exposure. Other
types of skin flaps are preferred that avoid the linear
incision over the vessels (e.g., modification of the
inverted "H" in which the vertical limb is made in
a curvilinear fashion, the Schweitzer incision, modi-
fications of the apron flap [see Fig. 8-40] and other
incisions [see Fig. 16-6]).
3. When there is any question regarding an adequate
viable cervical skin flap to cover the vessels, utilize
other viable tissue (e.g., levator scapulae muscle flap,
turned-in prevertebral fascia, various myocutaneous
flaps and free microvascular flaps [see Chapter
24]). Dermal grafts can also be used. Nevertheless,
dermis can be the source of infection. Although
dermis has probably prevented blowout, infection
has occurred and now this graft is no longer used
by the author (JML) to protect the carotid vessels
unless no other viable tissue is available. The poten-
tial problem with the dermal graft is that it does
contain hair follicles that cannot usually be sterilized
by the ordinary skin prep. Against this latter
argument, Corso and Gerold (l963) believe that the
body has natural immunity against its own dermal
organisms. To support this concept, dermal grafts
have been observed to be viable and adherent to
the protected great vessels despite the presence of
a severely infected wound.
VASCULAR PROCEDURES
4. Extreme care should be taken during the operation
to prevent slough of the cervical skin flaps:
a. Include the platysma muscle in the skin flap.
b. Resect in continuity all questionably viable skin
that may be attached to the underlying neoplasm.
c. Avoid all possible trauma to the skin flaps:
l} Avoid clamps resting and lying over the flaps
during the operative procedure.
2} During the entire procedure protect the flaps
with moist laparotomy pads.
3} Trim the edges of the posterior flap at all
times and edges and corners of other flaps
when there is evidence of questionable
viability of the edges.
5. Substitute adjuvant preoperative chemotherapy for
preoperative radiotherapy in stages III and IV
carcinoma.
6. Be highly selective for indications of postoperative
radiotherapy using the following guidelines:
a. Disease at the line of resection
b. Highest and lowest cervical nodes positive for
metastatic cancer
c. Breakthrough of capsule in the metastatic node
or nodes
d. Direct extension of the neoplasms to the deep
muscles of the neck
e. Spillage of tumor at time of resection or open
biopsy and if surgeon is doubtful regarding com-
plete resection of tumor
7. Use extreme care when closing defects in the upper
aerodigestive tract:
a. Use inverting mucosa-to-mucosa sutures (e.g.,
the continuous Connell suture).
b. Search for any openings or everted mucosa and
appropriately close these defects.
c. Use only viable tissue in the closure line.
d. Apply absolutely no tension on the suture line.
e. Avoid dead space (e.g., fill in the dead space
beneath or in the oral cavity using a levator scapu-
lae muscle flap, myocutaneous flap, or a similar
transposed viable flap). When there is a poten-
tial dead space in the supraclavicular area and
especially when a chest flap of any type is uti-
lized, resect the medial third of the clavicle so
that the flap is in direct contact with the
underlying vessel.
8. When a fistula is anticipated, a planned fistula may
be appropriate. This planned fistula is located away
from the vessels using a catheter from, for example,
the hypopharynx through the skin. In addition,
when this catheter is attached to suction it helps
decompress the hypopharynx and minimizes the
amount of fistula drainage.
9. No vascular reconstruction is performed in the
presence of infection or in a severely contaminated
 VASCULAR PROCEDURES
wound or when postoperative fistula formation is
highly suspected or anticipated.
10. Place the suction catheter away from the carotid
vessels and secure them in place with absorbable
sutures through a deep muscle. Never place a suction
catheter across any major vessel.
11. There are some experimental data that indicate that
interference with the vasa vasorum of the carotid
artery is detrimental and a contributing factor in
carotid artery blowout and possible dermal graft
failure. It is noted that dissection around the carotid
vessels is much easier after preoperative chemotherapy
(see Chapter 3) owing to clearer surgical planes.
The vasa vasorum may thus be preserved. This may
account for the much lower incidence of carotid
artery blowout after preoperative chemotherapy.
Highpoints (for Control of Any Type of Carotid
Hemorrhage)
1. Maintain blood pressure.
2. Maintain blood volume.
When the carotid artery becomes exposed and espe-
cially when infection and/or fistula is present, antici-
patory precautions must be taken. The patient is typed
and cross-matched for at least 1500 mL of blood. Carotid
artery blowout precautions are placed on the order sheet.
A suggested list of orders for when bleeding does occur
has been proposed by Ketcham and Hoye (1965). They
are excellent and include the following, which are chiefly
for nurses, who are usually the first on the scene:
1. Use a light dressing on the wound.
2. Immediately apply finger or hand pressure at the site
of hemorrhage or proximally if possible. (The
common carotid artery may be compressed against
the transverse process of the sixth cervical vertebra.)
3. Signal for help.
4. Have readily available resuscitation and monitoring
equipment.
5. Start intravenous line; type and cross-match patient's
blood, if not already done and available.
When early leakage of blood occurs, this is the time
for ligation of the carotid artery under controlled condi-
tions. These controlled conditions include replacement
of blood loss and, most important, maintenance of blood
pressure and blood volume, as well as adequate oxygena-
tion. This has been demonstrated by data published by
Moore and co-workers (1969) from the Memorial Cancer
Center (Table 22-3). They emphasized that elective
ligation is much less of a hazard than emergency liga-
tion of the common or internal carotid arteries.
Definitive Technique of Ligation
1. Ligation is best done in the operating room once
bleeding has been controlled by pressure or clamp,
with whole blood running to maintain blood pres-
sure and blood volume.
2. Expose the proximal vessel to viable vessel wall.
3. Ligate with proximal tie and distal suture ligature.
4. Use nonabsorbable plastic suture material (Prolene).
5. Resect disease and any infected portion of the vessel.
6. Ligate the distal vessel in the same fashion.
7. Debride all necrotic and/or infected soft tissue.
8. Cover ligated vessels with viable skin flaps, either
cervical or transposed flaps. The important point is
that there should be no dead space over these
ligated vessels.
9. If fistula and/or infection is present, drains must be
utilized and placed in position not to cross any
major vessels.
10. Continue vital signs and cardiac monitoring.
If necessary the medial half of the clavicle can be
removed to facilitate additional exposure of the proximal
portion of the common carotid artery. The use of graft
replacement in the patient with carotid artery blowout
in the presence of an infection or fistula is contraindi-
cated. End-to-end arteriorrhaphy is also contraindicated
for the same reasons. Bleeding from the external carotid
artery may be handled by ligation of only the external
carotid artery when the common carotid artery/internal
carotid artery continuity and patency are reasonably
certain.
 VASCULAR PROCEDURES

Protection for Carotid Artery

TABLE2.2-3 Elective Versus Emergency
Ligation of the Carotid Artery Dermal Graft (After Corso and Gerold, 1963)
-
, ,,'

-Elective Ligation -
Emergency Ligation
(Fig. 22-35A to C)

Other techniques are now preferred by the authors (see

No, of Patients 64 (100%) 87 (100%) p. 1328) and are described in the following text.

Stroke 15 (23%) 44 (50%)

Highpoints
Deaths 11 (17%) 33 (38%)

1. Use to prevent carotid artery blowout (see below for

Data from Moore as, Karlan M, Sigler L: Factors influencing the
safety of carotid ligation, Am J Surg 118:666-668,1969, other uses).
2. Cover entire carotid artery.
3. Use in patients undergoing radical neck dissections
Comment who have:
a. Preoperative radiation therapy
Since the substitution of preoperative chemotherapy b. High probability of fistula formation
for preoperative radiotherapy in advanced disease (i.e., c. Low serum protein
stages III and IV carcinoma) and the judicious and selec- 4. Do not suture to vessel wall.
tive use of postoperative radiotherapy (as previously out- 5. Be sure no remnant of the epidermis remains with
lined), carotid artery blowout has occurred only once the dermal graft.
during the past 20 years in the author's (JML) expe- 6. Be sure no hematoma is under the graft and that the
rience. This occurred in a patient who had past opera- graft is in perfect contact with vessel.
tive radiotherapy. In addition, by following this regimen 7. Buried dermis does not re-epithelialize; exposed
there has not been one single instance of significant dermis does re-epithelialize (Reed and Harrington,
cervical flap necrosis. However, the distal ends of two 1969). Hence, if a fistula occurs, the exposed dermis
transposed flaps, one a pectoralis major myocutaneous develops an epithelial layer.
flap and the other a tongue flap, have necrosed. Despite 8. The dermal graft has been seen to survive in the
these events the cervical flaps have all healed without presence of wound infection.
necrosis, and no carotid artery blowout has occurred. 9. Be sure all exposed branches of external carotid artery
This will supply information to the surgeon regarding are also covered.
whether these vessels can be electively sacrificed during
the procedure or whether, if there is impending blow-
out postoperatively, elective ligation will be reasonably
tolerated without an intracranial catastrophe. In addi-
tion, stump pressure of the distal vessel (e.g., the inter-
nal carotid artery with the common carotid artery briefly
ocduded) is likewise a good indication regarding whether
elective ligation will be tolerated. Stump pressure ideally
should be 60 mm Hg or higher.
 VASCULAR PROCEDURES
Dermal Graft (After Corso and Gerold, 1963)
(Continued) (Fig. 22-35A to C)
A An area of epidermis 0.012 to 0.014 of an inch is
first elevated with an electric dermatome. It measures
7 cm wide and 20 cm long. This flap of epidermis is
left attached at one end. Then, the dermal layer is
removed at 0.020 to 0.024 inch, being slightly
narrower and slightly shorter.
B The epidermal layer is immediately sutured back
to the donor site using continuous or interrupted
nylon sutures. Nitrofurazone gauze dressing is applied .
C The dermal graft is placed over the entire carotid
artery system. Interrupted sutures are placed at 2- to
3-cm intervals to tack the graft to the underlying soft
tissue, carefully avoiding the arteries and eliminating
all dead space under the graft.
Complications
• Infection caused by the dermal graft has been reported
by some surgeons who use dermis as the "sling" for
facial paralysis. The dermis probably cannot be
adequately prepared.
• Because exposed dermis re-epithelializes, subsequent
closure of a fistula may be tricky, since the dermal
graft is directly adherent to the carotid artery.
Other Applications of Dermal Graft
1. Reconstruction of the hypopharynx and portion of
the cervical esophagus in conjunction with tongue
flap and pectoralis major myocutaneous flap. The
dermal graft forms the posterior wall of the recon-
struction (see Figs. 21-7 and 21-8).
2. The dermal graft is an improved substitute for split
epidermal grafts for covering defects in mucous mem-
brane surfaces (e.g., oral cavity, pharyngoesophageal
reconstruction [see Fig. 21-7] and nasal septum).
The dermal graft contracts much less than the epider-
mal graft and on occasion has been seen to assume
characteristics of mucous membrane.
Other Methods of Carotid Artery Protection
• Levator scapulae muscle transfer
• Pectoralis major flap with or without skin
• Fascial transfers, especially over internal carotid
artery exposed in the lateral wall of the nasopharynx
Levator Scapulae Muscle Flap (See Fig. 22-35D)
D Depicted is mobilization of the levator scapulae
muscle. It is transected above and below and hinged
on its anterior border. Thus, the anterior border becomes
posterior, whereas the posterior border becomes ante-
rior as it covers the carotid artery. It can be sutured to
the stump of the strap muscles or the stump of the
sternocleidomastoid muscle and superiorly in the
vicinity of the digastric muscle. It is also utilized as
muscle bulk inferior to the reconstructed mandible. It
is at the superior end and, at times, inferiorly where it
is deficient. Before closure, any obvious devitalized fibers
are excised (see Fig. 22-36 for more details).
 VASCULAR PROCEDURES 1333

-'------------'--------'-'-------···--r
; I,
I
I
II
I
I
I

I
!
1
II
i
i
1

( \
I I1
\ I
I
A
,
I----,---------~
B
) J
c

FIGURE 22-35
 VASCULAR PROCEDURES
Protection for Carotid Artery and Sources
of Muscle Bulk (Fig. 22-36)
Highpoints
1. Blood supply to levator scapulae muscle is along its
anterior or medial border; preserve it.
2. Observe viability; excise any obviously devitalized
portions.
3. Do not injure the brachial plexus.
4. Use minimal mobilization superiorly when used as
in 0 to supply bulk to the superior neck.
Technique 1
A The muscle is hinged along its entire anterior or
medial border (Staley, 1961). When there is an
indication to use this type of flap, a portion of the
insertion of the sternocleidomastoid muscle is left
attached to the sternoclavicular region. This forms a
lower terminus for the transposed muscle flap. One
problem at this point is the different plane levels of the
two muscles. This may result in a dead space over the
carotid artery and must be corrected. The dead space
can contribute to carotid artery blowout! It may be more
feasible to secure this lower terminus to portions of the
strap muscles, if still present. By retraction of the anterior
border of the trapezius muscle, the posterior border of
the levator scapulae muscle is meticulously mobilized,
taking care not to injure the vascular supply along the
anterior border. No crushing instruments are placed
on the muscle. Usually, simple blunt dissection and gentle
handling will afford sufficient traction. If necessary,
stay sutures or fine double-pronged hooks can be used
to handle the muscle, thus avoiding any undue trauma
to the muscle. The lower end of the muscle is transected
as close as possible to its insertion on the vertebral border
of the scapula. The upper end (origin) is separated
from its attachment on the transverse processes of the
atlas, axis, and third and fourth cervical vertebrae.
These latter attachments may best be left partially
intact if there is any danger to the blood supply.
B The muscle is thus hinged on its anterior or medial
border and rotated 180 degrees so that its posterior
border now becomes its new anterior border. The
anterior border is sutured either to strap muscles or to
prevertebral fascia. Its superior end is sutured either to
the digastric muscle or hyoglossus muscle, while its
inferior end is sutured to the stump of the ster-
nocleidomastoid muscle or strap muscles. After a short
period of observation, any obvious devitalized portion
of the muscle is excised.
Technique 2
C The muscle is rotated as a pedicle flap with its
pedicle being the origin of the muscle from the
transverse processes of the atlas, axis, and third and
fourth cervical vertebrae. Again, every effort is made to
preserve as much of the blood supply as possible along
the anterior or medial border. Obviously, some vessels
at the lower end will require division.
The insertion along the vertebral border of the
scapula is transected and the muscle gently mobilized
up to the origin. Slips from the transverse processes of
the fourth and cervical vertebrae may require division
for adequate mobilization. In addition, there may be
variation of the muscle's attachment. These may be to
the occipital or mastoid bones, to the trapezius, scalenus,
or serratus anterior muscles, or to the first or second ribs.
D The muscle flap is rotated to cover the more
superior portion of the carotid system. The obvious
deficiency is the uncovered middle and lower portions
of the common carotid artery. Some state that it is of
little concern, because most blowouts occur at or near
the bulb, but a blowout can occur anywhere along the
course of the carotid vessels.
Moore and Papioannou (1965) describe further use
of the levator scapulae muscle as well as the strap
muscles reflected upward to buttress suture lines and
provide bulk for dead space after ablative surgery in
the region of the mandible and floor of the mouth.
This is very helpful in the vicinity of a reconstructed
mandible. It is usually not necessary to dissect and free
the superior attachments of the muscle as depicted.
The arrow shows the placement of the end of the
levator scapulae sutured to the transected end of the
mandible (periosteum).
 VASCULAR PROCEDURES 1335

A B

c o
FIGURE 22-36
 VASCULAR PROCEDURES
Ligation of More Proximal Vessel
1. External carotid artery (see Fig. 22-37)
2. Internal maxillary artery (see Fig. 6-7)
3. Ethmoidal arteries (see Fig. 6-4)
External Carotid Artery Ligation
(Fig. 22-37)
Discussion
Do not ligate the external carotid artery if there is a
possibility that a future arteriogram via the external
carotid artery may be necessary (e.g., in the evaluation
of severe epistaxis). External carotid artery ligation is
not usually used by the author to control epistaxis.
Highpoints
I. Identify common carotid artery just proximal to
bifurcation.
2. Remember that the normal relationship of external
to internal carotid artery may be altered; the termi-
nology of these vessels in no way represents their
relationship in the neck but simply refers to their
ultimate distribution.
3. Except for rare circumstances, the internal carotid
artery has no branches in the neck, whereas the
external carotid artery has three or four branches
within several centimeters of the bifurcation. It is best
to expose both internal and external carotid arteries
for at least 2.5 em and ascertain the presence or
absence of branches.
4. Avoid injury to the superior laryngeal nerve, which
passes deep to external carotid artery.
5. Before ligation of the external carotid artery, con-
sideration should be given to the patency of the
internal carotid artery, because coexistent occlusion
may be present. In such cases, intracerebral circulation
may be dependent on collateral circulation through
the ophthalmic artery, and sudden interruption of this
pathway may bring about an unexpected cerebral
catastrophe. This problem has not been the expe-
rience of the author (JML).
A A horizontal incision through skin and platysma
muscle following a natural skin fold is made at the level
between the hyoid bone and the upper border of the
thyroid cartilage. The center of the incision is located
at the anterior edge of the sternocleidomastoid muscle.
B Superior and inferior skin flaps having been
developed, an incision is made along the anterior
border of the sternocleidomastoid muscle exposing
the carotid sheath. The internal jugular vein with the
ansa hypoglossi is retracted laterally. The common
facial vein may require ligation and transection, but
usually this can be avoided by retraction downward or
upward. The bifurcation of the common carotid artery
is thus exposed, with the external carotid artery in a
more anterior plane and the internal carotid artery in
a more posterior plane. The internal carotid has no
branches in the neck-there are very rare exceptions
to this rule of thumb-whereas the external carotid
does have branches. The first branch is the ascending
pharyngeal, which is in the inner aspect of the bifur-
cation, is rather small, and is hidden by the network of
the carotid sinus. The second branch, which is the one
most readily seen and identified, is the superior thyroid
artery. This branch is on the anteromedial aspect of the
external carotid and serves as the identifying landmark.
The next branch lying in the region of the anterior
belly of the digastricus is either the lingual or external
maxillary artery (facial artery).
C The external carotid is carefully dissected from the
enveloping fascia and nerves of the carotid sinus. A
topical anesthetic (10% cocaine or 2% tetracaine) may
be applied with a dropper, or 1% lidocaine can be
injected over the sinus if there is any possibility of an
overactive sinus reflex characterized by bradycardia.
D During this maneuver the superior laryngeal nerve
must be avoided. It lies deep to the external carotid at
this point and may be injured if the plane of dissection
goes too deep. Injury to this nerve interferes with the
sensory reflexes of the larynx and the motor reflexes of
the inferior pharyngeal constrictor muscle, both of
which govern the swallowing mechanism. The cricothy-
roid muscle, the tensor of the vocal cord, which controls
the pitch of the voice, would also be paralyzed by
injury to this nerve.
E A 2-0 silk ligature is placed about the vessel distal
to the superior thyroid artery. This may prevent
formation of a thrombus too near the bifurcation of
the common carotid artery and origin of the internal
carotid artery. If such a thrombus extended proximally
into the bifurcation, it then might be the source of an
embolus. Division of the vessel, if desired, is done
between a proximal tie and distal suture ligature on
the proximal end and a tie on the distal end.
 VASCULAR PROCEDURES 1337

A B
Ext. jugular v.

c
Int. jugular v.

FIGURE 22-37
 VASCULAR PROCEDURES
Harvesting Saphenous Vein for
Graft (Fig. 22-38)
Although originally an autogenous vein graft, the greater
saphenous vein, was thought to be the ideal graft in all
major arterial replacements in the neck, there is now
evidence that this may not be the case. Our own data
and that of others indicate that a prosthetic graft (PTFE)
is the choice. (See discussion of grafts on pp. 1235 and
1236.)
A The femoral arterial pulsations are located. The
word "navel" represents the anatomic relationship of
the femoral nerve, artery, vein, empty space (femoral
canal), and lacunar ligament. A vertical incision starting
2.5 cm below the inguinal area is made through skin
and superficial fascia over the vein.
B The greater saphenous vein is identified and
traced upward to the fossa ova lis, where it empties
into the common femoral vein. This junction must not
be injured. From three to five additional tributaries may
be noted. The usual ones are the superficial circumflex
iliac, the superficial inferior epigastric, and the external
pudendal veins. A small artery may be noted crossing
the saphenofemoral junction. The greater saphenous
vein is carefully mobilized, and double clamps are
placed proximally and distally. Fine silk stay sutures are
used for holding the graft. Identification of the proximal
and distal ends of the graft must be definite, because
valves may be present and the direction of flow of
blood must be the same when the graft is placed in
the neck.
C A proximal tie and distal suture ligature are placed
at each end of the transected vessel. If possible,
depending on the length of the vein graft required,
avoid use of that portion of the graft with tributaries.
However, if additional length is required, the cephalic
end of the saphenous vein can be ligated at the level
of the fossa ovalis. This will require ligation and divi-
sion of the tributaries.
 VASCULAR PROCEDURES 1339

Saphenous v.

A B

Super!. epigastric v.

Super!. iliac circumflex v.

Super!. ext. pudendal v.

~

c
~IGURE22-38
 VASCULAR PROCEDURES
Thoracic Outlet Syndrome-
Scalenotomy (Figs. 22-39 and 22-40)
The diagnosis of the thoracic outlet syndrome continues
to be a problem. Operations for the relief of the symp-
toms are the subject of debate, and the reported results
are variable. Some clinicians doubt the existence of this
syndrome; others do not believe there are any indica-
tions for surgical treatment. Some who once advocated
first rib resection now advocate a lesser operation, such
as a scalenotomy. The controversies that exist now
regarding the thoracic outlet syndrome are as follows:
1. Selection of patients for surgical management
2. How the diagnosis is established
3. Which approach is the best for the decompression
of the nerve plexus involved as well as of the sub-
lavian artery
FIGURE 22-39 Thoracic outlet syndrome. Obstruction
of the subclavian artery is shown on an arteriogram with
the hyperabduction test. The obstruction of the
subclavian artery is by the scalenus anticus muscle.
(Courtesy of Joseph Anain.)
The symptoms referable to the nerve plexus involve-
ment in the thoracic outlet syndrome can be divided
into two major groups:
1. The upper plexus-pain in the side of the neck and
head and shoulder that is aggravated by turning the
head to the opposite side, lifting, and stretching
2. The lower plexus-pain mainly supraclavicular and
along the inner aspect of the arm, which is aggra-
vated by elevation of the arm, reaching, and lifting
The etiology of the thoracic outlet syndrome has been
relegated to a cervical rib, first thoracic rib, scalenus
anticus muscle, anomalous bands, scalenus medius mus-
cle, subclavius muscle, pectoralis minor muscle, and
clavicle. Roos (1971) has suggested that an anomalous
fibromuscular tissue directly affecting the upper nerve
of the brachial plexus is consistently encountered during
surgery. The diagnosis of thoracic outlet syndrome is
made by exclusion. Results of the Adson test, hyperab-
duction test, and military position tests are inconclusive.
Electromyographic studies, angiography, and venography
are also inconclusive and are not diagnostic. Another
consideration that must be evaluated is somewhat similar
symptoms related to spondylosis causing compression
of the cervical nerve routes. Conservative management
involves use of a cervical collar and cervical traction.
Different surgical approaches have been suggested
(e.g., the transaxillary approach, the paraspinous poste-
rior approach, and the anterior supraclavicular approach).
The supraclavicular approach utilizing scalenotomy
alone or in conjunction with the resection of a cervical
or first rib is described here.
Highpoints
1. Avoid injury to the phrenic nerve, subclavian artery
and vein, and brachial plexus.
2. If a cervical rib is present, resection of the rib is
usually necessary, including a segment of first rib.
3. Note that the scalenus anticus muscle lies between
the subclavian vein and artery.
4. Resect a rudimentary first rib if necessary.
5. An anomalous fibrous band may exist between the
scalenus anticus and the scalenus medius muscle.
Complications
• Pneumothorax
• Injury to phrenic nerve or brachial plexuses or both
• Injury to subclavian vein may cause air embolism
• Injury to the thoracic duct (left side) and the accessory
thoracic duct (right side)
 VASCULAR PROCEDURES

Sternocleidomastoid m,

Transv.cervical
vessels

D E

FIGURE 22--40

A A horizontal skin incision is made as depicted 3 cm
above the clavicle. The junction of the anterior and
middle thirds of the incision overlies the posterior
border of the sternocleidomastoid muscle.
B The incision is carried through the platysma muscle.
C With the upper and lower skin flaps retracted
using Cushing vein retractors, the underlying anatomy
is exposed. An incision is made through the fascia
along the dotted line. The external jugular vein is
doubly ligated with distal suture ligatures and
proximal ties and transected.
D With a curved Kelly clamp, the scalenus anticus fat
pad is entered, exposing the scalenus anticus fascia,
which covers the phrenic nerve.
E Finger retractors increase the exposure. The
brachial plexus is lateral; the subclavian artery is
covered by the scalenus anticus muscle. Hidden under
the clavicle is the subclavian vein. Transverse cervical
vesselscross the phrenic nerve.
Continued
 VASCULAR PROCEDURES
Thoracic Outlet Syndrome-
Scalenotomy (Continued)
(Figs. 22-39 and 22-40)
F A medium-sized curved clamp is slowly and
carefully inserted under the scalenus anticus muscle.
With the phrenic nerve and carotid sheath retracted
medially, the muscle is sectioned a few fibers at a time.
All fibers of the muscle and its tendon must be
sectioned to release pressure on the subclavian artery.
If a cervical rib or rudimentary first rib is exerting
pressure on the subclavian artery, it is resected, with
care taken not to perforate the pleura, following the
technique described by Sendzischew and Hempel
(1985) as follows:
1. The clavicular head of the sternocleidomastoid
muscle is transected.
2. The subclavian artery is mobilized for a short
distance and is retracted inferiorly.
3. The first rib is exposed medially with a periosteal
elevator.
4. The posterior and medial scalenus muscles are
divided.
5. The posterior lateral border of the first rib is further
exposed with a periosteal elevator.
FIGURE 22--40
6. With Raney rongeurs the first rib is transected from
the inner to the outer border. This results in an
inferior displacement of the medial portion of the
first rib by the intercostal muscles, thus widening
the space.
7. The lateral portion of the first rib is resected to the
level of the facet using the Raney rongeurs.
8. Blunt dissection along the inferior aspect of the first
rib is performed, freeing its intercostal attachments.
9. The medial aspect of the first rib is now further
transected from its outer to inner border with the
Raney Jongeurs, with care taken not to injure the
subclavian artery or brachial plexus.
10. The wound is filled with saline, and the anesthe-
siologist further inflates the lung to detect any
pleural leak.
11. The clavicular head of the sternocleidomastoid mus-
cle is approximated. Suction catheters are utilized,
with care taken so that the catheters are not imping-
ing on any vessels for fear of vessel erosion.
G The completed section of scalenus anticus muscle
is shown. Closure consists of approximation of the
platysma muscle and skin in separate layers. The
cervical fascia that was incised in C may be closed as a
separate layer if preferred.
Continued

BIBLIOGRAPHY
Anderson R, Scarcella JV: Carotid body tumors. Am J Surg 106:
856-859, 1963.
Arts H, Fagan P: Vagal body tumors. Otolaryngol Head Neck surg
105:78-85,1991.
Ashworth C, Williams LF, Byrne JJ: Penetrating wounds of the neck:
Re-emphasis of the need for prompt exploration. Am J surg
121:387-391,1971.
Asymptomatic Carotid Atherosclerosis Study (ACAs) Group:
Endarterectomy for asymptomatic carotid artery stenosis. JAMA
273:1421-1428,1995.
Baddeley RM, Ashton F, Slaney G: Comparison of autogenous vein
bypass grafts with patch angioplasty for short femoropopliteal
occlusions. Surg Gynecol Obstet 127:503-508, 1968.
BaKay L, Sweet WH: Cervical and intracranial intra-arterial pressures
with and without vascular occlusions. surg Gynecol Obstet 95:
67-75,1952.
Baker JD, Barker WF, Machleder HI: Evaluation of extracranial
cerebrovascular disease with ocular pneumoplethysmography,
Am J surg 306:206-208, 1978.
Barnett HJM, Taylor DW, Eliasziw M, et al: Benefits of carotid
endarterectomy in patients with symptomatic moderate or severe
stenosis. N Engl J Med 339:1415-1425,1998.
Batsakis JG: Tumors of the Head and Neck: Clinical and Pathological
Considerations, 2nd ed. Baltimore, Williams & Wilkins, 1979.
Bauer RB, Meyer Js, Fields WS, et al: Joint study of extracranial arterial
occlusion: 111.Progress report of controlled study of long-term
survival in patients with or without operation. JAMA 208:509-518,
t969.
Berger K, Sauvage LR, Rao AM, Wood sJ: Healing of arterial pros-
theses in man: Its incompleteness. Ann surg 175:118-127, 1972.
Berger RL, Sidd JJ, Ramaswamy K: Retrograde vertebral-artery flow
produced by correction of subclavian-steal syndrome. N Engl J
Med 277:64-69,1967.
Berk ME: Chemodectoma of the glomus intravagale: A case report
and review. Clin RadioI12:219-226, 1961.
Bernini FP, Elefante R, Smaltino F,Tedeschi G: Angiographic study on
the vertebral artery in cases of deformities of the occipitocervicat
joint. AJR Am J RoentgenolI07:526-529, 1969.
Bestler JM, Toomey JM: Malignant carotid body tumor. Arch
OtolaryngoI89:752-755, 1969,
Blaisdell WF, Clauss RH, Galbraith JG, et al: Joint study of extracra-
nial arlerial occlusion: IV. A review of surgical considerations.
JAMA 209:1889-1895, 1969.
Bland JE, Chapman RD, Wylie £1: Neurological complications of
carotid artery surgery. Ann Surg 171:459,464, 1970.
Bloodwell RD, Hallman GL, Keats AS, Cooley DA: Carotid endarterec-
tomy without a shunt: Results using hypercarbic general anes-
thesia to prevent cerebral ischemia. Arch Surg 96:644-652, 1968.
Bolasny BL, Killen DA: Surgical management of arterial injuries
secondary to angiography. Ann Surg 174:962-964, 1971.
Borsanyi 5J: Rupture of the carotids following radical neck surgery in
radiated patients. Eye Ear Nose Throat Monthly 41:531-533, 1962.
BOllsvaros G, Sandler IA: Tortuosity of the innominate artery: Failure
of retrograde catheterization of left side of heart by brachial
arterial route. JAMA 205:466-467, 1968.
Bradshaw JD: Radiotherapy in gtomus jugulare tumours: A review of
cases seen at the Christie Hospital, Manchester, 1943-1959. Clin
RadioI12:227-228, 1961.
Brinkman CA: Brain scanning as an aid to surgery for strokes. Am J
surg 119:452-454, 1970.
Buckberg G, Ono H: A technique for placement of an internal shunt.
surg Gynecol Obstet 126:125-126, 1968.
Burman SO: The chemoreceptor system and its tumor-the
chemodectoma. Int Abstr surg 102:330-341, 1956.
Buxton JT, Stallworth JM: Tortuous innominate arteries simulating
aneurysms. JAMA 184:1848-1849, 1963.
VASCULAR PROCEDURES 1343
Carrea R, Motins M, Murphy G: Surgical treatment of spontaneous
thrombosis of the internal carotid artery in the neck: carotid-
carotidal anastomosis: Report of a case. Acta Neurol Latinoamer
1:71-78, 1951.
Catlin D: A case of carcinoma of the larynx surviving bilateral carotid
artery ligation. Ann surg 152:809-814, 1960.
Chedid A, Jao W: Hereditary tumors of the carotid bodies and chronic
obstructive pulmonary disease. Cancer 33:1635-1641,1974.
Cheek HB, Rise EN: Carotid artery protection and a new technique.
Arch Otolaryngol 86:179-182, 1967.
Chretien PB, Engelman K, Hoye RC, Geelhoed GW: Surgical manage-
ment of intravascular glomus jugulare tumor. Presented at the
Meeting of the Society of Head and Neck Surgeons, Vancouver,
British Columbia, May 1971. Am J surg 122:740, 1971.
Cohen A, Brief D, Mathewson C Jr: Carotid artery injuries: An analysis
of eighty-five cases. Am J surg 120:210-214, 1970.
Cohen JP, Persky Ms, Reede DL: Internal jugular vein thrombosis.
Laryngoscope 95:1478-1482,1985.
Coleman CC Jr, Deterling RA Jr, Parshley Ms: Some long-term
observations on aortic homografts. Surgery 37:64-79, 1955.
Coleman CC Jr, Hoopes JE: Congenital arteriovenous anomalies of
the head and neck. Plast Reconstr surg 47:354-364, 1971.
Coller BS: GPIlb/Illa antagonists: Pathophysiologic and therapeutic
insights from studies of c7E3 Fab. Thromb Haemost 78:730-735,
1997.
Conley JJ: Carotid artery protection. Arch Otolaryngol 75:530, 1962.
Conley JJ: Carotid artery surgery in the treatment of tumors of the
neck. Arch Otolaryngol 65:437-446, 1957.
Conley JJ: The carotid body tumor: A review of 29 cases. Arch
Otolaryngol 81:187-193, 1965.
Contorni L: II circolo collaterale vertebrovertebrale nella obliterazione
dell' -arteria succlavia alia sue origine. [The vertebro-vertebral
collateral cjrculation in obliteration of the subclavian artery at its
origin.] Minerva Chir 15:268-271, 1960.
Corso PF, Gerold FP: Use of autogenous dermis for protection of the
carotid artery and pharyngeal suture lines in radical head and neck
surgery. Surg Gynecol Obstet 117:37-40, 1963.
Crawford Es, DeBakey ME, Morris GC Jr, Howell JF: Surgical treat-
ment of occlusion of the innominate, common carotid, and subcla-
vian arterjes: A 10 year experience. Surgery 65:17-31,1969.
DeBakey ME, Noon GP, Jordan GL Jr, et al: Fifteen years experience
with Dacron vascular prostheses. Exhibit and brochure produced
by Medical Illustration and Audiovisual Education, Baylor College
of Medicine.
DeBakey ME: The surgical treatment of cerebrovascular insufficiency.
Surgical Procedures, Warner-Chilcott Laboratories, April 1964.
DeBlanc HJ, Chretien P: Angiofibroma clinically indistinguishable
from carotid body tumor: A possible embryologic relationship. Am
J Surg 119:743-745, 1970.
Desai MG: Heredo-familial carotid body tumours. Clin Radiol 12:
214-218, 1961.
DeToma G, Micolanti B, Plocco M, et al: Baroreflex failure syndrome
after bilateral excision of carotid body tumors: An underestimated
problem. J Vase surg 31:806-810, 2000.
De Weese JA, Rob CG, Satran R, et al: Surgical treatment for occlu-
sive disease of the carotid artery. Ann surg 168:85-94, 1968.
Dibbell DG, Gowen GF, Shedd DP: Observations on postoperative
carotid hemorrhage. Am J surg 109:765, 1965.
Diethrich EB: Indications for carotid artery stenting: A preview of the
potential derived from early clinical experience. J Endovasc Surg
3:132-139, 1996,
Drapanas T, Hewitt RL, Weichert RF Ill, Smith AD: Civilian vascular
injuries: A critical appraisal of three decades of management. Ann
surg 172:351-360, 1970.
Duke WW, Boshell BR, soteres P, Carr JH Jr: A norepinephrine-
secreting glomus jugulare tumor presenting as a pheochromocytoma.
Ann Intern Med 60:1040-1047,1964.
 VASCULAR PROCEDURES
Egan RW,Upson JF: Carotid artery surgery for cerebrovascular insuffi~
ciency. Angiology 16:698, 1965.
Ehrenfeld WK, Chapman RD, Wylie EJ: Management of occlusive
lesions of the branches of the aortic arch. Am J 5urg 1l8:236~243,
1969.
Eldering SC, et al: Carotid artery disease following external cervical
irradiation. Ann Surg 194:609~615, 1981.
Engelman RM, Clements JM, Herrmann JB: Routine operative arte~
riography following vascular reconstruction. Surg Gynecol Obstet
128:745~752, 1969.
Ersek RA, Sako Y, Lillehei RC: Advantages of silicone rubber vessel
loop. Surg Gynecol Obstet 32:1067~1O68,1971.
Etheredge SN: A simple technic for carotid endarterectomy. Am J
Surg 120:275~278, 1970.
European Carotid Surgery Trialists' (ECST) Collaborative Group: MRC
European Carotid Surgery Trial. Interim results for asymptomatic
patients with severe (70~99%) or with mild (0-29%) carotid stenosis.
Lancet 337:1235~1241, 1991.
Ezquerro CV: Contribution to the diagnosis and treatment of tumors
of the glomus jugulare. Int Surg 50:408~414, 1968.
Farr HW: Carotid body tumors, a forty year study. CA Cancer J Clin
30:260~265, 1980.
Farr HW, Carandang CM, Huvos AG: Malignant vascular tumors of
the head and neck. Am J Surg 120:501-504, 1970.
Farrell VJ, Hawkins TD: Glomus jugulare tumours with special refer~
ence to their radiological features. Br J Surg 54:789~795, 1967.
Fields WS, Maslenikov V, Meyer JS, et al: Joint study of extracranial
arterial occlusion: V. Progress report of prognosis following surgery
or nonsurgical treatment for transient cerebral ischemic attacks and
cervical carotid artery lesions. JAMA 211:1993-2003, 1970.
Fisch D, Fagan P, Valavanis A: The infratemporal fossa approach for
the laleral skull base. Otolaryngol Clin North Am 17:513~552,
1984.
Fitchett VH, Pomerantz M, Butsch DW, et al: Penetrating wounds of
the neck. Arch Surg 99:307, 1969.
Fogarty n, Cranley JJ: Catheter technic for arterial embolectomy.
Ann Surg 161:325~330, 1965.
Fogarty n, Krippaehne WW: Postcatheterization vascular occlusion.
Mod Med, May 23, 1966.
Foster JH, Carter JW, Graham CP Jr, Edwards WH: Arterial injuries
secondary to the use of the Fogarty catheter. Ann Surg 171:971~978,
1970.
Fries JG, Chamberlin JA: Extra~adrenal pheochromocytoma: Literature
review and report of a cervical pheochromocytoma. Surgery 63:
268~279, 1968.
Galin M, Baras I: Suction ophthalmodynamometry. Scientific exhibit,
American Medical Association Convention, Atlantic City, NJ, June
1971.
Gardner P, Dalsing M, Weisberfer E, et a1: Carotid body tumors:
Inheritance and high incidence of associated cervical paragan~
gliomas. Am J Surg 172:196~199, 1996.
Gejrot T, Lauren T: Retrograde iugularography in diagnosis of glomus
tumours in the iugular region. Acta Otolaryngol 58:190~207. 1964.
Geirot T: Surgical treatment of glomus iugulare tumours. Acta
Otolaryngol 60:150~168, 1964.
Glenner GG, Grimley PM: Thmors of the Extra~adrenal Paraganglion
System (including chemoreceptors). Atlas of Thmor Pathology,
2nd Series, Fascicle 9. Washington, DC; Armed Forces Institute of
Pathology, 1974.
Goldman N, Singleton GT, Holly EH: Aberrant internal carotid artery.
Arch Otolaryngol 94:269~273, 1971.
Goldsmith HS, Beattie EJ Jr: Carotid artery protection by pedicled
omental wrapping. Surg Gynecol Obstet 130:57~60, 1970.
Goodman ML, Laforet EG: Solitary primary chemodectomas of the
lung. Chest 61:48~50, 1972.
Gray WA, DuBroff RJ, White HJ: Clinical problem~solving: A common
clinical conundrum. N Engl J Med 336:1008~101l, 1997.
Griffin LH Jr, Wray CH, Vaughan BL, Moretz WH: Detection of vas~
cular occlusions during operation by segmental plethysmography
and skin thermometry. Ann Surg 173:389~397, 1971.
Grotta J: Elective stenting of extracranial carotid arteries (Editorial).
Circulation 95:303~ 305, 1997.
Grufferman ST. Gillman MW, Pasternak JLR, et al: Familial carotid
body tumor: Case report and epidemiologic review. Cancer 46:
2116~2122,1980.
Haimov M, Jacobson JH II: Auxiliary applications of the Fogarty
catheter. Surg Gynecol Obstet 133:1~3, 1971.
Haimovici H, Hoffert PW, Zinicola N, Steinman C: An experimental
and clinical evaluation of grafts in the venous system. Surg Gynecol
Obstet 131:1l73~1l86, 1970.
Hanford JM: Carotid body tumors: Nonchromaffin paraganglioma of
the cervical region. Am J Surg 11O:398~404,1965.
Harrington SW, Clagett OT, Dockerty MB: Thmors of the carotid body.
Ann Surg 114:820. 1941.
Harrison EG Jr, Soule EH, Judd ES: Chemodectoma of the glomus
intravagale (vagal body tumor). Cancer 10:1226. 1957.
Hass WK, Fields WS, North RR, et al: Joint study of extracranial arterial
occlusion: II. Arteriography, techniques, sites, and complications.
JAMA 203:961-968, 1968.
Hawkins TD: Glomus jugulare and carotid body tumours. Clin Radiol
12:199~213, 1961.
Henson RA, Crawford JV, Cavanagh JB: Thmours of the glomus
jugulare. J Neural Neurosurg Psychiatry 16:127~138, 1953.
Hewitt RL, Collins DJ: Acute arteriovenous fistulas in war injuries.
Ann Surg 169:447~449, 1969.
Hewitt RL, Schramel RJ, Pearce CW, Weichert RF II1:Cerebral arterial
insufficiency: Angiography and surgical lreatment. Am J Surg
120:334~340, 1970.
Hinck VC, Dotter CT: Appraisal of current techniques for cerebral
angiography. AJR Am J RoentgenoI107:626~630, 1969.
Hollinshead WH: The Head and Neck: Anatomy for Surgeons, vat. 1.
New York, Hoeber~Harper, 1954.
Hollinshead WH: Anatomy for Surgeons. New York, Harper and Row,
1968, p 565.
Hopkins LN, Lanzino G, Mericle RA, et al: Carotid intervention: A
neurosurgeon's perspective. (lAGS Proceedings). J Invas Cardiol
10:279-291,1998.
Hsai DC, Krushat M, Mmosoe LM: Epidemiology of carotid endarterec~
tomies among Medicare beneficiaries. J Vase Surg 16:201~208,
1992.
Hunt TK, Blaisdell FW, Okimoto J: Vascular injuries of the base of the
neck. Arch Surg 98:586~590, 1969.
lchinose H, Hewitt RL, Drapanas T: Minute pulmonary chemodec~
toma. Cancer 28:692-700, 1971.
James NJ, Stuteville OH, Tasche C: Elective carotid artery ligation in
the treatment of advanced cancer of the head and neck. Plast
Reconstr Surg 47:243~245, 1971.
Javid H: Surgery to prevent stroke. Based on "Can surgery prevent
stroke?" by Hushang Javid. Surgery 59:1147, 1966.
Johnson WS, Beahrs OH, Harrison HC Jr: Chemodectoma of the
glomus intravagale (vagal body tumor). Am J Surg 104:812, 1962.
Kakkar VV: The cephalic vein as a peripheral vascular graft. Surg
Gynecol Obstet 128:5S1~556, 1969.
Kaplan AD, Walker AE: Complications of cerebral angiography.
Neurology 4:643~656, 1954.
Kartchner MM, McRae LP: Auscultation for carotid bruits in cerebro-
vascular insufficiency. JAMA 21O:494~497.1969.
Kemmerer WT, Ware RW, Stegall HF, et al: Blood pressure measure~
ment by Doppler ultrasonic detection of arterial wall motion. Surg
Gynecol Obstet 131:1141~1147,1970.
Ketcham AS, Hoye RC: Spontaneous carotid artery hemorrhage after
head and neck surgery. Am J Surg 110:649~655,1965.
Kim SK, Capp MP: Jugular foramen and early roentgen diagnosis of
glomus jugulare tumor. AJR Am J Roentgenol 97:597~600, 1966.

Kindt GW, Youmans JR: The effect of stricture length on critical arte-
rial stenosis. Surg Gynecol Obstet 128:729-734, 1969.
Knox WG, Miller RE: Long-term appraisal of aortic and arterial homo-
grafts implanted in years 1954-1957. Ann Surg 172:1076-1078, 1970.
Kunkel JM, Gomez ER, Spebar MJ, et al: Wound hematomas after
carotid endarterectomy. Am J Surg 148:844-847, 1984.
Lack EE, Cubella AG, Woodruff JM: Paragangliomas of the head and
neck region: A pathologic study of tumors from 71 patients. Hum
PathollO:191-219, 1979.
Lack EE, Cubella AL, Woodruff JM, Farr HW: Paragangliomas of the
head and neck region: A clinical study of 69 patients. Cancer
39:397-409, 1977.
Langenbrunner DJ, Dajani S: Pharyngomaxillary space abscess with
carotid artery erosion. Arch Otolaryngol 94:447-457,1971.
Lanzino G, Fessler RD, Wakhloo AK, et al: Successful intracranial
thrombolysis for cerebral thromboembolic complications resulting
from cardiovascular diagnostic and interventional procedures. ] carotid artery stenting. Circulation 97:1239-1245,1998.
Invas Cardiolll:439-443, 1999.
Lattes R: Nonchromaffin paragangliomas of the ganglion nodosum
carotid body and aortic-arch bodies. Cancer 3:667, 1950.
Leape LL, Palacios E: Acute traumatic vertebral arteriovenous fistula.
Ann Surg 174:908-910, 1971.
LeCompte PM: Tumors of the Carotid Body and Related Structures.
Washington, DC, Armed Forces Institute of Pathology, 1951.
Lee RH, Kieraldo JH, Jamples RW: Surgical treatment of the sub-
clavian steal syndrome. Am J Surg 114:312, 1967.
Lee YTN: Carotid artery protection by pectoralis major muscle flap.
Am J Surg 140:464, 1980.
Leipzig B, Yau PC: Massive congenital arteriovenous malformation of
the pterygomaxillary space. Otolaryngol Head Neck Surg 90:48-52,
1982.
Levitsky S, James PM, Anderson RW, Hardaway RM 1II: Vascular
trauma in Vietnam battle casualties: An analysis of S5 consecutive
cases. Ann Surg 168:831-836, 1968.
Lewis JS, Cahan WG: Cryosurgical management of glomus jugulare
tumors. Laryngoscope 77:912-917, 1967.
Lindenauer SM, Thompson NW, Kraft RO, Fry WJ: Late complications
of traumatic arteriovenous fistulas. Surg Gynecol Obstet 129:
525-532, 1969.
Loewe 0: Ueber Haut Implantation an Stelle der freier Faszien plastik.
Mi.inchen Med Wochenschr 24:1320, 1913.
Lopes DK, Mericle RA, Lanzino G, et al: Carotid angioplasty and
stenting before coronary artery bypass grafting (Abstract). Neuro-
surgery 43:686, 1998.
Lore JM Jr: The principles of vascular surgery in operations of the
head and neck. Ann 0101 Rhinol Laryngol 67:922-931,1958.
Lore JM Jr: The principles of vascular surgery in operations on the
head and neck. Ann Otol 67:922, 1958.
Lore JM Jr: Techniques of vascular surgery in operations of the head
and neck. Arch Otolaryngol 74:646-651,1961.
Lore JM Jr: Cerebra-vascular disease, surgical techniques and treat-
ment. Trans Am Acad OphthalmoJ Otolaryngol, Mar-April 1962,
pp 181-192.
Lore JM Jr: Vascular surgery in the head and neck. EENT Dig 26:
79-91, 1964.
Lore JM Jr: Vascular surgery in head and neck tumors. Arch
Otolaryngol 83:109-113, 1966.
Lore JM Jr: Vascular techniques with head and neck cancer.
Otolaryngol Clin North Am, October 1969.
Lore JM Jr, Boulos EJ: Resection and reconstruction of the carotid
artery in metastatic squamolls cell carcinoma. Am J Surg 142:
437-442, 1981.
Lore JM Jr, Grisanti A, Kane A: Traumatic carotid jugular fistula.
Laryngoscope 82:2153-2159, 1972.
Lumpkin MB, Logan WD, Couves CM, Howard JM: Arteriography as
an aid in the diagnosis and localization of acute arterial injuries.
Ann Surg 147:353, 1958.
VASCULAR PROCEDURES
MacComb WS, Fletcher GH: Cancer of the Head and Neck. Baltimore,
Williams & Wilkins, 1967.
Macdonald RE, Fearon B: Innominate artery compression syndrome
in children. Ann Otol 80:535-540, 1971.
Maddison FE: Arteriographic evaluation of carotid artery surgery.
AJR Am J RoentgenoI109:121-126, 1970.
Maddison FE, Moore WS: Ulcerated atheroma of the carotid artery:
Arteriographic appearance. AJR Am J Roentgenol 107:530-534,
1969.
Manager W: Baroreflex failure: A diagnostic challenge. N Engl J Med
329:1494-1495,1993.
Mansberger AR Jr, Linberg EJ: First rib resection for distal exposure
of subclavian vessels. Surg Gynecol Obstet 120:578-579, 1965.
Marshall RB, Horn RC: Nonchromaffin paraganglioma: Comparative
study. Cancer 14:779-787, 1961.
Mathur A, Roubin GS, Iyer SS, et al: Predictors of stroke complicating
May M, Lee C, Sapote P, et al: Penetrating wounds of the neck: Selec-
tive exploration. A study of 100 cases. Trans Am Acad Ophthalmol
Otolaryngol 75:496-509, 1971.
McConnel CS Jr, Marlowe FI: Postoperative perforation of the carotid
artery by the hyoid bone. Arch Otolaryngol 95:282-283, 1972.
McCoy G, Barsocchini LM: Experiences in carotid artery occlusion.
Laryngoscope 78:1195-1210,1968.
McCrory DS, Goldstein LB, Samsa GP, et al: Predicting complications
of carotid endarterectomy. Stroke 24:1285-1291, 1993.
McDowell HA Jr: Surgical correction of vertebral steal followed by
contralateral retrograde vertebral flow. Ann Surg 168:154-156, 1968.
McGough EC, Helfrich LR, Hughes RK: Traumatic intimal prolapse of
the common carotid artery. Am J Surg 123:724, 1972.
Meyer FB, Piepgras DG, Fode NC: Surgical treatment of recurrent
carotid artery stenosis. J Neurosurg 80:781-787,1994.
Meyer FB, Sundt TM Jr, Piepgras DG, et al: Emergency carotid
endarterectomy for patients with acute carotid occlusion and
profound neurological deficits. Ann Surg 203: 82-89, 1986.
Monroe J, Lore JM Jr: Metastatic glomus jugulare tumors. Ear Nose
Throat J 56:50-54, 1977.
Moore CH, Wolma FJ, Brown RW, Derrick JR: Vascular trauma: A
review of 250 cases. Am J Surg 122:576-578, 1971.
Moore 0, Baker HW: Carotid artery ligation in surgery of the head
and neck. Cancer 8:712,1955.
Moore OS, Karlan M, Sigler L: Factors influencing the safety of
carotid ligation. Am J Surg 118:666-668, 1969.
Moore OS, Papioannou AN: Use of muscle flaps for reconstruction
after head and neck surgery for cancer. Am J Surg 110:514-518,
1965.
Moore WS, Hall AD: Late suture failure in the pathogenesis of
anastomotic false aneurysms. Ann Surg 172:1064-1068, 1970.
Morfit HM, Swan H, Taylor ER: Carotid body tumors. Arch Surg
67:194, 1953.
Mueller RL, Hinck VC: Thyrocervical steal. AJR Am J Roentgenol
101:128-129,1967.
Mulligan RM: Chemodectoma in dog. Am J Pathol 26:680-681, 1950.
Murphy TE, Huvos AG, Frazell EL: Chemodectomas of the glomus
intravagale: Vagal body tumors, nonchromaffin paragangliomas of
the nodose ganglion of the vagus nerve. Ann Surg 172:246-255,
1970.
Myers EN, Newman J, Kaseff L, Black FO: Glomus jugulare tumor: A
radiographic-histologic correlation. Laryngoscope 81:1838-1851,
1971.
Myers RS, Pilch YH: Temporary control of tracheal-innominate artery
fistula. Ann Surg 170:149-151, 1969.
Nagashima C, 1wama K, Sakata E, Miki Y: Effects of temporary
occlusion of a vertebral artery on the human vestibular system. J
Neurosurg 33:388-394, 1970.
Nakayama K, Tamiya T, Yamamoto K, Akimoto S: A simple new
apparatus for small vessel anastomosis. Surgery 52:918, 1962.
 VASCULAR PROCEDURES

Nelson WR: Carotid body tumors. Surgery 51:326-333, 1962. Roos DB: Experience with first rib resection for thoracic outlet syn-
Netterville J, Civantos F: Rehabilitation of cranial nerve deficits after drome. Ann Surg 173:429-442, 1971.
neurologic skull base surgery. Laryngoscope 103:45-54, 1993. Rosenwasser H: Current management glomus jugulare tumors. Ann
Netterville J, Jackson V, Miller F, et al: Vagal paraganglioma: A review 010176:603, 1967.
of 46 patients treated during a 20-year period. Arch Otolaryngol Rosenwasser H: Monograph on glomus jugulare tumors. Arch
Head Neck Surg 124:1133-1140, 1998. Otolaryngol 88:29-66, 1968.
Netterville J, Reilly K, Robertson D, et aJ: Carotid body tumors: A review Rush BF Jr: Current concepts in the treatment of carotid body tumors.
of 30 patients with 46 tumors. Laryngoscope 105:115-126, 1995. Surgery 52:679-684, 1962.
Newton TH, Wylie EJ: Collateral circulation associated with occlu- Saldana JJ, Salem LG, Travezan R: High altitude hypoxia and
sion of the proximal subclavian and innominate arteries. AJR Am chemodectomas. Hum Pathol 4:251-263, 1973.
J Roentgenol 91:394-405, 1964. Satiani B, Burns J, Vasko JS: Surgical and nonsurgical treatment of
North American Symptomatic Carotid Endarterectomy Trial (NASCET) total carotid artery occlusion. Am J Surg 149:362-367, 1985.
Collaborators: Beneficial effect of carotid endarterectomy in symp- Schenk WG Jr, Bahn RA, Cordell AR, Stephens JG: The regional
tomatic patients with high-grade stenosis. N Engl J Med 325: hemodynamics of experimental acute arteriovenous fistulas. Surg
445-453, 1991. Gynecol Obstet 105:733-740, 1957.
North CA, Zinreich ES, Christiansen WN, North RB: Multiple spinal Schenk WG Jr, Martin JW, Leslie MB, Portin BA: The regional hemo-
metastasis from paraganglioma. Cancer 66:2224-2228, 1990. dynamics of chronic experimental arteriovenous fistulas. Surg
Olson JR, Abell MR: Nonfunctional nonchromaffin paragangliomas Gynecol Obste! 110:44-50, 1960.
of the retroperitoneum. Cancer 23:1358-1367, 1969. Schwentker EP, Bahnson HT: Total circulatory arrest for treat-
Palacios E: Chemodectomas of the head and neck. AJR Am J ment of advanced arteriovenous fistula. Ann Surg 175:70-74,
Roentgenoll1O:129-139, 1970. 1972.
Perdue GD, Smith RB Ill, Rhodes L, et aJ: Carotid revascularization in Scott HW Jr, Riddell DH, Brockman SK: Surgical management of
the treatment of cerebral ischemia. Arch Surg 100:562-564, 1970. pheochromocytoma. Surg Gynecol Obstet 120:707, 1965.
Perry MO: Fibromuscular disease of the carotid artery. Surg Gynecol Seda HJ, Snow JB Jr: Adrenalogenic secretions of nonchromaffin
Obstet 134:57-60, 1972. paraganglioma. Laryngoscope 82:973-977, 1972.
Perry MO, Lee JF, Hoerton J: Maintenance of cerebral blood flow Sendzischew H, Hempel GK: Anterior approach for resection of the
during carotid reconstruction. Am J Surg 120:346-350, 1970. first rib and total scalenotomy. Surg Gynecol Obstet 160:275-276,
Perry MO, Thai E, Shires GT: Management of arterial injuries. Ann 1985.
Surg 173:403-408, 1971. Shuford WH, Sybers RG, Milledge RD, Brinsfield D: The cervical
Pierce GE, et al: Incidence of recurrent stenosis after carotid aortic arch. 116:519, 1972.
endarterectomy determined by digital subtraction angiography. Shumacker HA, Campbell RL, Heimburger RF: Operative treatment of
Am J Surg 148:848-854, 1984. vertebral arteriovenous fistulas. J Trauma 6:3,1966.
Pifarre R, Jasuja M, Neville WE: Retroesophageal right subclavian Shumacker HB Jr: Authority, research and publication: Reflections
artery in the adult. Dis Chest 56:538-539, 1969. based upon some historical aspects of vascular surgery. Ann Surg
Pitt HA, et al: Prophylactic antibiotics in vascular surgery: Topical, 168:169-182, 1968.
systemic or both? Ann Surg 192:2, 1980. Sisson GA, Markovich JJ: Intraoral resurfacing wilh dermal graft.
Plaut MR, Cook AW: Anastomosis for carotid artery lesions. Mod Arch Otolaryngol 87:89-91, 1968.
Med, April 11, 1966. Smith CJ, Kohut RI, Million RR: Chemodectomas of the nasopharynx.
Pratt LW: Cavernous sinus thrombosis. J Maine Med Assoc 50: Laryngoscope 83:330-335, 1973.
317-323,1959. Soo KC, Hamlyn PJ, Pegington J, Westbury G: Anatomy of the acces-
Pratt LW: Familial carotid body tumor. Arch Otolaryngol 97:334-339, sory nerve and its cervical contributions in the neck. Head Neck
1973. Surg November/December 9:111-115, 1986.
Qvarfordt PG, Ehrenfield WK, Stoney RJ: Supraclavicular radical Staley CJ: A muscle cover for the carotid artery after radical neck
scalenectomy and trans axillary first rib resection for the thoracic dissection. Am J Surg 102:815-817, 1961.
outlet syndrome. Am J Surg 148:111-116, 1984. Sundt TM, Houser OW, Fode NC, Whisnant JP: Correlation of post-
Reed GF: The use of dermal grafts in otolaryngology. Ann Otol operative and two year follow-up angiography with neurological
74:769-784,1965. function in 99 carotid endarterectomies in 86 consecutive patients.
Reed GF, Ghyselen MD, Goldstein JC, et al: Self-epithelization of Ann Surg 203:90-100, 1986.
dermal grafts. Arch Otolaryngol 87:518-521. 1968. Sundt TM, Ebersold MJ, Sharbrough FW, et al: The risk-benefit ratio
Reed GF, Harrington PC: Dermal grafts: Clinical experience in head of intraoperative shunting during carotid endarterectomy. Ann
and neck surgery. NY J Med 69:2563-2566, 1969. Surg 203:196-204, 1986.
Reivich M, Holling HE, Roberts B, Toole JF: Reversal of blood flow Surakiatchanukul S, Goodsitt E, Storer J: Chemodectoma of the aortic
through the vertebral artery and its effect on cerebral circulation. body. Chest 60:464-467, 1971.
N Engl J Med 265:878-885, 1961. Thacker WC, Duckworth JK: Chemodectoma of the orbit. Cancer
Ricotta JJ, et al: Use of computerized cerebral tomography in selec- 23:]233-1238, 1969.
tion of patients for elective and urgent carotid endarterectomy. Thomas ML, Andress MR: Angiography in angiomas of the face. AJR
Ann Surg 202:783-787, 1985. Am J Roentgenol 112:332-338, 1971.
Risley TS, McClerkin WW: Bullet transection of both carotid arteries: Thompson BW, Read RC: Incidence of the Leriche syndrome in
Delayed repair with recovery. Am J Surg 121:385-386, 1971. patients with subclavian steal. Am J Surg 122:666-668, 1971.
Robertson D, Hollister A, Biaggioni I, et al: The diagnosis and Thompson JE, Austin DJ, Patman RD: Endarterectomy of the totally
treatment of baroreflex failure. N Engl J Med 329:1449-1455,1993. occluded carotid artery for stroke: Results in 100 operations. Arch
Robertson JT: Carotid endarterectomy: A saga of clinical science, Surg 95:791-801,1967.
personalities, and evolving technology: The Willis lecture. Stroke Thompson JE, Austin DJ, Patman RD: Carotid endarterectomy
29:2563-2567,1997. for cerebrovascular insufficiency: Long-term results in 592 patients
Robson M, Levi], Rosenfeld JB, et al: Experience with arteriovenous followed up to thirteen years. Ann Surg 172:663-679, 1970.
fistula using a parallel flow dialyzer. Surg Gynecol Obstet Thompson N: The subcutaneous dermis graft: A clinical and histo-
129:1199-1202,1969. logic study in man. Plast Reconstr Surg 26:]-22, ]960.

THanus HW, Obertop H, Van Urk H: Saphenous vein of PTFE for
femoropopliteal bypass, a randomized trial. Ann Surg 202:780-782,
1985.
Trevio RJ: Thyrocervical steal syndrome. Arch OtolaryngoI92:177-180,
1970.
Urken ML, Biller HF, Haimov M: lntratemporal carotid artery bypass
in resection of a base of skull tumor. Laryngoscope 95:1472-1477,
1985.
Valiathan MS, Weldon CS, Bender HW Jr, et al: Resection of
aneurysms of the descending thoracic aorta using a GBH-coated
shunt bypass. J Surg Res 8:197-205, 1968.
Vigor WN, Rainer WG, Basque G: Cervical chemodectomas: Clinical
consideration in sixteen cases. Am J Surg 118:976-980, 1969.
Villarreal J, Silva J, Eliasziw M, et ai, for the North American
Symptomatic Carotid Endarterectomy Trial: Prognosis of patients
with intraluminal thrombosis in the internal carotid artery (Abstract).
Stroke 29:276,1997.
von Leden H, Wilson GH, Turnbull FM Jr: Control of bleeding during
surgery on vascular tumors of the head. JAMA 205:563-566, 1968.
Waga S, Kikuchi H, Handa J, Handa H: Cavernous sinus venography.
AJR Am J RoentgenoI109:l30-137, 1970.
VASCULAR PROCEDURES 1347
Westbrook KC, Guillamondegui OM, Medellin H, Jesse RH:
Chemodectomas of the neck. Am J Surg 124:760, 1972.
White CW Jr, Allarde RR, McDowell HA: Anesthetic management for
carotid artery surgery. JAMA 202:1023-1027,1967.
Wilson H: Carotid body tumors: Familial and bilateral. Ann Surg
171:843,1970.
Wisnicki JL: Hemangiomas and vascular malformations. Ann Plast
Surg 12:41-59, 1984.
Wolf JK: Diagnosis and acute treatment of stroke. Health News, New
York State Department of Health, March 1970.
Wylie EJ, Ehrenfeld WK: Extracranial Occlusive Cerebrovascular
Disease. Philadelphia, WB Saunders, 1970.
Yao ST, Hobbs JT, Irvine WT: Pulse examination by an ultrasonic
method. BMJ 4:555-557,1968.
Yarington CT Jr, Berman B: Rupture of an aneurysm of the internal
carotid artery at the base of the skull. From the Department of
Otorhinolaryngology and Section of Neurosurgery, University of
Nebraska, College of Medicine, Omaha, Nebraska.
Zimmerman HB, Farrell WJ: Cervical vertebral erosion caused by
vertebral artery tortuosity. AJR Am J Roentgenol 108:767-770,
1970.
 23 BASE OF THE SKUll
SURGERY
The term base of the skull surgery has become popular in
head and neck surgery. Although some of the approaches
are of recent vintage, along with the extension of the
resected area, most have been described before to a greater
or lesser extent. The trans temporal approach described
by Fisch (1982) is of more recent vintage. This approach
leads to the jugular foramen, petrous apex, clivus, and
parasellar regions. Throughout this atlas many of these
approaches are described in various chapters related to
the regional anatomic areas. The reader is referred to
various books regarding skull base surgery (see
Bibliography) .
When there is a possibility of involvement of the
internal carotid artery or proximity of the neoplasm to
this vessel, preoperative evaluation of crossover blood
flow is recommended. A suitable method is digital
subtraction angiography. Imaging is necessary for the
evaluation of the extent of disease as well as for the
location of the internal carotid artery at the base of the
skull and parapharyngeal space. Although this vessel is
usually located in the posterior lateral area, it can be
located in the posterior medial area abutting on the
superior and middle pharyngeal constrictor muscle in
the vicinity of the palatine tonsil. If tortuous, it may
extend into the retro-oropharyngeal region. It has been
located lying on the transverse process of the vertebrae.
Another aberrant location includes passing through the
tympanic canal. Therefore, both computed tomography
(eT) for base of skull bone erosion and magnetic
resonance imaging (MRI) with angiography (MRA) are
important. An MRI is important for soft tissue detail.
Angiography is recommended for further evaluation of
the internal carotid artery when there is any question
regarding its exact location and course at the various
levels in the parapharyngeal space. If the lesion is
vascular, for example, a paraganglioma, then angiography
is of great aid in the identification of the blood supply
of the neoplasm, as well as the neoplasm's location.
1348
When reviewing these images with the radiologist, be
certain to locate the vessel both on sagittal and coronal
views and also on the axial views. The axial views will
provide the best relationship of the vessel's location in
the parapharyngeal space along with the other con-
tiguous structures. Confirmation with Doppler imaging
may be of help during the surgical procedure but must
be accompanied by vessel exposure.
Selective carotid arteriograms with or without balloon
occlusion can be used to evaluate the intracranial
crossover blood supply. There is a danger of stroke
(1 + %), however, utilizing balloon occlusion. An MRA
would not help establish the tendency of cross blood
flow because the dye would be in both sides of the
brain at the initial injection. The highpoints listed on
page 1377 apply to any of the procedures described in
this chapter.
Base of skull surgery can be divided into three
general categories:
1. Surgery that approaches and reaches the skull base
without any intracranial extension. An example is
surgery of the parapharyngeal space.
2. Surgery that involves resection of a selected or of
limited portions of the skull base. Examples are ante-
rior craniofacial resection associated with frontal or
maxillary sinus malignant disease and surgery of the
pituitary gland.
3. Surgery extending into the middle cranial fossa and
areas surrounding the cavernous sinus
This chapter in no way represents all of the aspects
of surgery of the base of the skull. Many additional
volumes have been and are being dedicated to a more
complete description of the surgery. What is described
here is primarily related to category 1 and the more
common aspects of category 2. Vascular procedures at
or close to the skull base are described in Chapter 22.

Base of Skull and Parapharyngeal
Space (Fig. 23-1)
Depicted in Figure 23-1 is the osseous anatomy of the
base of the skull and its relationship to the parapharyn-
geal space. The important vessels and nerves are dia-
grammed. The various approaches to this area include
but are not limited to the following:
1. Total or partial parotidectomy with resection or
reflection of the gland combined with an oblique
superior cervical incision (see Fig. 22-33)
2. Lateral mandibulotomy (see Figs. 15-9A to F and
17-3)
3. Mandibular swing (see Fig. 15-14)
4. Transmaxillary (see Figs. 5-8 to 5-11)
5. Transcranial with or without transmaxillary approach
(Ketcham et aI., 1973; Sisson et aI., 1963)
6. Transpalatal and/or trans nasopharyngeal (see
Fig. 6-9)
7. Transseptal to the sella turcica (see Fig. 23-11)-
endoscopic technique (see Fig. 23-12)
8. Transtemporal (see Fig. 23-13A to H)
9. Median labiomandibular glossotomy (see Fig. 15-4)
10. Infratemporal to the jugular foramen, petro us apex,
clivus, and parasellar regions (Hugo Fisch)
11. Ascending ramus mandibulotomy (Lore, 1973)
GLENOID
FOSSA
STYLOID
PROCESS
FIGURE 23-1 The osseous anatomy of the base of the skull and its relationship to the parapharyngeal space.
BASE OF THE SKUll SURGERY
12. Temporal bone resection (Lewis, 1975)
13. Transmaxillary approach to the skull base for
resection of chordoma (E. Cocke)
14. A combination of two or more of the above
Obviously, there are numerous important relation-
ships in the para pharyngeal space. One that should be
emphasized is the distance between the internal carotid
artery and the posterior edge of the lateral pterygoid
plate. This distance is approximately 1.5 em and must
be kept in mind when resecting the lateral pterygoid
plate. The styloid process overlies the internal carotid
artery. Additional emphasis is placed on the danger of
possible injury to the internal carotid artery, whether it
be iatrogenic or from trauma. The foramen lacerum is
located at the base of the medial pterygoid plate. The
inferior aspect of the foramen lacerum is filled with a
fibrocartilaginous plate, above which passes the internal
carotid artery after it passes through the orifice of the
carotid canal. This orifice is posterior to the foramen
lacerum.
A point of interest is the contribution from the cer-
vical plexus branches 1 and 2 to the descending ramus
of the hypoglossal nerve, which more distally forms a
loop (not pictured in Fig. 23-1), the ansa hypoglossi.
The ansa hypoglossi receives additional contributions
from C2 and C3.
 BASE OF THE SKULL SURGERY
Parapharyngeal Space (See Figs. 23-2 to
23-6)
Because knowledge of the anatomy of the parapharyn-
geal space as well as its various approaches depends
on a number of disease entities, reference is made to
other chapters and figures in this atlas as follows:
Chapter 17 relative to the deep lobe parotid tumors (see
Figs. 17-2 and 17-3)
Chapter 22 on vascular surgery (see Fig. 22-33).
Specific reference is made to temporal bone
resection in this chapter (see Fig. 23-13).
Anatomy of the Parapharyngeal Space
(See also Chapter 1)
To formulate a surgical approach to this area the diverse
anatomy in both the horizontal and vertical planes must
be understood. There is no area in human anatomy
with so many different interpretations of spaces with
different terminology. In addition, there is a difference
between the radiologist's point of view versus the sur-
geon's point of view relative to these various descrip-
tions and subdivisions. The terminology varies and the
spaces vary and include the following: pharyngomaxillary
space, pararnaxillary space, parapharyngeal space, lateral
pharyngeal space, as well as the masticator space and
carotid space, just to name a few. To the anatomist
these are important and also of concern to the radiologist.
From the surgical point of view, a simpler and more
functional view can be taken. First are the boundaries
that at various levels vary from inferior to superior as
well ·as from lateral to medial. In general terms, the
medial border is formed primarily by the wall of the
nasopharynx and oropharynx made up primarily of the
superior pharyngeal constrictor along with the pterygo-
mandibular raphe, which marks the line of connection
along with the buccinator muscle. In addition, this
medial border is formed by the bones of the pterygoid
plates and process. The lateral wall is formed princi-
pally by the temporal bone and the parotid salivary
gland. Within the lateral wall of the parapharyngeal space
is the carotid sheath, including the internal carotid artery,
the internal jugular vein, and the vagus nerve. This
structure is of paramount importance to the surgeon.
The superior boundary is primarily the base of the skull
juxtaposed to the middle cranial fossa. The infratemporal
fossa extends deep to and medial to the zygomatic arch
and can almost be considered an area juxtaposed to the
superior portion of the para pharyngeal space.
The anterior boundary is primarily the mandible and
the parotid salivary gland. The posterior boundary is
made of the confluence of soft tissue and the vertebrae.
The inferior boundary is probably the most varied as
far as the extent is concerned. This can vary to the
body of the mandible, to the superior portion of the neck,
or as low as to the hyoid bone. There are other relation-
ships that are important, one of which is the styloid
process. This could be divided into the prestyloid,
retrostyloid, and then the retropharyngeal space. The
important point is that the styloid process is a good
surgical landmark to locate the stylomastoid foramen
through which passes the main trunk of the facial
nerve. The carotid sheath can be considered to be in
the retrostyloid and posterior region.
There are numerous fascia planes and extensions.
One of the important fascia planes is the one deep to
the deep lobe of the parotid. If on CT these fibrofatty
tissue planes are intact, revealing no to little invasion
or spread of the lesion of the deep lobe of the parotid,
the lesion is probably benign. If the planes are not distinct,
the lesion is probably or suspicious of being malignant
or an extensive chronic inflammatory process.
Of all the various terms, the parapharyngeal space is
most appropriate because the space does, in fact, lie
lateral to the nasopharynx and oropharynx. In a schematic
view the parapharyngeal space thus becomes a triangle
and broadens inferiorly and narrows superiorly. This is
very important for the surgeon because the carotid artery
becomes more vulnerable as the surgical exposure or
resection proceeds superiorly. The internal carotid artery
at the apex-the superior portion-of the parapha-
ryngeal space may have only 1 cm or less clearance
from the other boundaries of the space, especially the
posterior mandible area.
In the inferior portion of the parapharyngeal space
above the cervical area, the position of the internal carotid
artery is in a lateral location that may, in fact, give a
false sense of security to the surgeon as he or she removes
metastatic disease in this area, which is posterior and
lateral to the oropharynx and nasopharynx. Hence,
extreme care must be taken in resections in this area.
The transverse processes of C1 and C2 extend quite
laterally and thus, with removal of retropharyngeal nodes
and then the lateral pharyngeal nodes, the dissection
proceeds farther lateral and the internal carotid artery,
lying on the longus capitis, is encountered. These lateral
pharyngeal nodes can be adherent to the internal carotid
artery and, as a result, there can be serious injury to
this vessel. During this dissection, which may involve
removal of the longus capitis muscle, the transverse
processes of C1 and C2 can then be encountered. This
also theoretically could place the vertebral artery in
possible jeopardy. Hence, when operating in this area,
proximal identification and control of the internal carotid
artery should be done. The artery is thus followed
superiorly to the region of the disease, and it is hoped
this can then be removed without injury to the internal

carotid artery. The internal carotid artery may even curve
medially and be even closer to the superior pharyngeal
constrictor muscle. Again, this is an indication to
identify the internal carotid artery before it reaches this
particular portion of the parapharyngeal space. An
intraoperative Doppler study may be of some help, but
the vessel itself must be identified.
Axial CT (see Fig. 23-6F and fl) demonstrates the
styloid process, internal carotid artery, and the abutting
neoplasm, which extends from the nasopharynx and
oropharynx into the parapharyngeal space. This again
emphasizes the importance of locating the internal
carotid artery proximal to the area of disease.
Related to the medial aspect of the parapharyngeal
space at the level of the oropharynx, the internal carotid
artery may be so close to the "bed" of the palatine tonsil
that injury to this vessel could occur during a tonsillec-
tomy. Two patients have been reported in whom hemor-
rhage has occurred from the internal carotid artery
during the postoperative period after a tonsillectomy.
The tonsillectomies were performed using an electric
cautery and by laser excision of the tonsil.
A tortuous internal carotid artery has been seen in
the posterolateral portion of the oropharynx area just
medial to the posterior tonsillar pillar. This is a tortuous
manifestation of the abnormality that can occur with
the internal carotid artery. The admonition is to take
extreme care regardless of the type of operation per-
formed in the parapharyngeal space and oropharynx.
Other anomalies of the internal carotid artery include
its absence, referred to as agenesis or aplasia. Absence
of the carotid canal points to agenesis of the vessel.
CT versus MRI (Fig. 23-2)
Over the past 2 to 3 years there has been an obser-
vation (by JML) that CT is not as reliable as originally
thought regarding the evaluation of the oropharynx.
This is related to the actual existence of a neoplastic
process as well as to the extent of such lesion if it is
identified. This limitation of CT was brought into per-
spective when MRI of the extracranial head and neck
recorded a 2-cm thyroglossal cyst intralingual at the
base of the tongue. It was not seen even in a retrospec-
tive review of the CT scan. Although this example is
anecdotal, nevertheless the surgeon must be wary. The
suggestion is to use MRI. With suspected bone involve-
ment, however, CT may be an important adjunct.
BASE OF THE SKULL SURGERY
Surgical Anatomy of Parapharyngeal Space
1. Skin and fascia over portion of the platysma and
risorius muscles. This latter muscle is within the
subcutaneous tissue overlying the parotid salivary
gland.
2. Lateral lobe, parotid salivary gland
3. Facial nerve
4. Deep lobe parotid salivary gland (may extend deep
to the pterygoid muscles)
5. Masseter muscle overlying and attached to the
mandible
6. Pterygoid venous plexus, posterior facial vein
7. Inferior alveolar nerve, lingual nerve
8. Internal maxillary artery and branches
9. Internal (medial) and external (lateral) pterygoid
muscles
10. Internal carotid artery within the carotid sheath also
containing the vagus nerve and internal jugular vein
11. Meningeal vessels in the foramen spinosum
12. Superior pharyngeal constrictor muscle
13. Temporalis muscle attached to the coronoid process
14. Superior portion of parapharyngeal space contiguous
with infratemporal fossa
Diseases of the Parapharyngeal Space
1. Neoplasia
a. Neurilemoma (schwannoma-peripheral [see fol-
lowing paragraph] sympathetic or cranial nerves)
b. Deep lobe of parotid-benign or malignant
FIGURE 23-2 MRI of thyroglossal duct cyst not evident
on CT.
 BASE OF THE SKULL SURGERY

c. Paragangliomas-benign, rarely malignant (see parapharyngeal abscess and then reached the para-
Chapter 22) pharyngeal space. There the infection spread along the
1) Carotid body carotid sheath: "Lincoln Highway of the neck" as
2) Jugular (glomus)-infratemporal fossa delineated by Mosher, Barnhill, and Lore, Sr. Along this
3) Vagale-arising from superior and inferior route the disease reached the neck and even at times
ganglia elsewhere in the vagus nerve; may into the mediastinum.
extend into cervical area Many of these diseases can cause distortion of the
4) Sympathetic ganglia-superior, middle extend- oropharyngeal wall displacing the tonsil medially and
ing to neck inferiorly to just above the clavicle likewise causing a mass effect in the soft palate. The
d. Sarcoma-malignant (see Chapter 3) problem with congenital anomalies (e.g., a branchial
e. Other mesenchymal neoplasms cleft remnant) is that they may be superimposed with
f. Lipoma an infectious process, which can make identification of
2. Metastatic disease important structures difficult as well as make the original
a. Direct extension from a mucosal squamous cell diagnosis obscure.
carcinoma or adenocarcinoma from nasopharynx,
oropharynx, or hypopharynx Approaches to the Parapharyngeal Space
b. Lymphadenopathy from malignant primary tumors
in vicinity of the para pharyngeal space The location of the disease entity as well as whether
3. Lymphadenopathy-benign the lesion is benign or malignant will indicate the type
4. Congenital anomalies (e.g., branchial cleft) of approach or combination of approaches necessary.
5. Inflammatory-acute, chronic
I. Parotid lobectomy (see Fig. 17-2)
Tumors of the Peripheral Nerves 2. Mobilization of mandible upward and medially by
transection of the stylomandibular ligament and/or
Benign anterior dislocation of the temporomandibular joint,
possibly with transection of the sphenomandibular
I. Neurofibroma ligament.
a. Solitary (neurofibroma) 3. Mandibulotomy
b. Multiple (neurofibromatosis, von Recklinghausen's a. At or just proximal to the angle of the mandible
syndrome) (see Figs. 17-3 and 22-33A to D)
I) Plexiform neurofibroma b. Midline mandibulotomy (see Fig. 15-14B)
2) Elephantiasis neuromatosa c. Lateral mandibulotomy through the socket of
3) Molluscum fibrosum the premolar tooth
c. Storiform neurofibroma 4. Resection of the ascending ramus of the mandible
d. Pacinian neurofibroma with or without the condyle and/or coronoid
2. Schwannoma (neurinoma, neurilemoma, perineural processes. This facilitates the most complete
fibroblastoma) exposure.
3. Granular cell "myoblastoma" 5. Transverse or oblique superior cervical-submandibular
4. Neurogenous nevi incision
5. Neuroma (amputation neuroma, traumatic neuroma) 6. Combination with a composite resection that
would involve resection of the oropharynx and/or
Malignant palate and/or alveolar ridge (see Fig. 15-14)
7. Removal and the replacement of the zygomatic
1. Neurogenous sarcoma arch (see Fig. 23-4H)
2. Neuroepithelioma 8. Combination of any of above (e.g., No.4 would
3. Malignant granular cell tumor usually be combined with total parotidectomy and
sacrifice of the seventh nerve)
In the age before antibiotics, fortunately rarely at 9. Cheek flaps
this time, there was infectious disease that began as a 10. Two separate incisions (see Fig. 23-5)
 BASE OF THE SKULL SURGERY

Figure 23-3 depicts a cross section of the parapha-
ryngeal space 12 mm below the inferior rim of the orbit.
This illustration is from Barnhill and represents in basic
fashion the parapharyngeal space with its boundaries
at the level of the external auditory canal. This demon-
strates the location of the carotid sheath. Relative anatomy
varies from inferior to superior. Surgical resection of
the oropharynx extends up into the nasopharynx just
inferior to the internal auditory meatus, which can
place the internal carotid artery in jeopardy.
To further understand this complex anatomy, the
various parts of Figure 23-4 approach the para pharyngeal
space from lateral to medial. The anatomy will be
divided into four areas. Admittedly these areas are not
compartments and vary in different levels from inferior
to superior. This is an attempt to aid the surgeon to real-
ize the structures encountered in these various areas
that would be related to specific surgical procedures.
Most of the following illustrations are self explana-
tory, with the appropriate labels. The temporalis
muscle is omitted in most of the steps. When the
surgeon is familiar with anatomy, the techniques of
various approaches, the extent of disease, and whether
it is benign or malignant, then the operation can be
"tailored" to fit the problem and thus the best proce-
dure performed.

Infraorbital nerve & vessels

Superior pharyngeal
constrictor m.
Lateral pterygoid m.
Parapharyngeal
space Medial pterygoid m.

Carotid sheath; Ext. auditory canal

vagus n.
Int. jugular v.
Int. carotid a.

FIGURE 23-3 Cross section representation of the para pharyngeal space, 12 mm below the inferior rim of the orbit.
This represents the para pharyngeal space with its boundaries at the level of the external auditory canal. (From Barnhill.)
 BASE OF THE SKUll SURGERY

Parotid Gland (cut)

Transverse Facial A.
Superior PterygoidVenousPlexus
Temporal A.
Post.
Auricular A.

Facial N.

Maxillary A.

Occipital A.
Post. Belly
of Digastric M.

Ant. Facial V.
Post. Facial V.
Common Facial V.

A
FIGURE 23-4

Area I-Lateral to the Mandible and Masseter

Muscles
A The overlying skin of the cheek and a portion of
the lateral lobe of the parotid salivary gland have been
removed. The continuity of the jugular vein has been
omitted for clarity purposes to demonstrate the
structures deep to this vein. The vein is within the
carotid sheath with the internal carotid artery and
vagus nerve deep to the sternohyoid muscle and the
posterior belly of the digastric muscle. When this vein
reaches the superior portion of the parapharyngeal
space, it is no longer anterior to the carotid artery but
somewhat posterolateral.
The ascending ramus of the mandible is dotted. The
angle of the mandible and coronoid process is deep to
the masseter muscle. The first three extracranial
branches of the facial nerve are depicted: these go to
the posterior auricular muscle, to the posterior belly of
the digastric muscle, and to the stylohyoid muscle.
The close proximity of the posterior auricular artery is
depicted juxtaposed to the main trunk of the facial
nerve. The two divisions of the nerve have been omitted
also for clarity purposes. The postauricular artery at
times can be troublesome, being the cause of sig-
nificant bleeding during the dissection/exposure of
the main trunk of the facial nerve. Further inferior is
the occipital artery, which at times is exposed in
superiorly extended radical neck dissections (see
Fig. 17-6F). An important venous anastomosis is a vein
from the pterygoid plexus veins draining into the
posterior facial vein.
Continued

Area I-Lateral to the Mandible and Masseter
Muscles (Continued)
The occipital artery arises from the external carotid
artery. "At its origin it is covered by (or at a deeper
plane than) the posterior belly of the digastric and
stylohyoid muscles which the hypoglossal nerve winds
around it from behind forward; higher up it crosses the
internal carotid artery, internal jugular vein and the
vagus and accessory nerves" (from Gray's Anatomy,
24th ed, 1942, p. SS8). It then passes in a groove deep
to the mastoid process and deep to the sternocleido-
mastoid, splenius capitis, longissimus capitis, and the
posterior belly of the digastric muscles. Ligation of this
vessel in its proximity to the hypoglossal nerve could
Condylar process
deep to capsule
FIGURE 23-4 Continued
BASE OF THE SKULL SURGERY
place the nerve in jeopardy. Blind clamping of the
vessel, if injured, could likewise injure the hypoglossal
nerve. The vertebral artery, although usually not exposed
in this area, could be injured in an extended, deep
dissection. Its surgical anatomy is discussed in Chapter
22 (see Fig. 22-121).
A1 The insertion of the temporalis muscle to the
coronoid process of the mandible is shown with removal
of a portion of the zygomatic arch. This approach, via
the bed of the zygomatic arch, affords a clear approach
with (dotted line) or without resection of the coronoid
process to the infratemporal fossa. The resected bone
is then reinserted.
Coronoid process
of mandible
 BASE OF THE SKULL SURGERY
Area II-Deep to Ascending Ramus of Mandible
and Masseter Muscle and Anterior to Pterygoid
Muscles With Overlying Pterygoid Venous Plexus
B This area represents the anatomy deep to the
ascending ramus of the mandible. It depicts the ptery-
goid plexus of veins, which are resting on the pterygoid
muscles and which can in fact extend between the
two pterygoid muscles. This can be a significant source
of bleeding in dissections of this area. In surgical
procedures in this area identification and isolation of
the posterior facial vein (retromandibular vein) is recom-
mended because this is the main drainage system of
the pterygoid plexus. There are other drainage veins in
the plexus, including anterior facial vein, veins from
the sphenopalatine, and middle meningeal, deep tem-
poral, pterygoid, masseter, buccinator, alveolar, and
palatine veins. In its communication with the anterior
facial vein the pterygoid plexus thus communicates
with the cavernous sinus.
C
\
II,
)
/ Pterygoid
/
Venous Plexus
Int. Pterygoid M.
\ Ext. Carotid A.
Common Carotid A. B
Int. Pterygoid M.
FIGURE 23-4 Continued
C A portion of the ascending mandible ramus and
also the coronoid process and zygornatic arch have
been removed. The pterygoid venous plexus is omitted.
Depicted is the relationship of the internal maxillary
artery to the two pterygoid muscles. This artery arises
from the external carotid artery and is vulnerable in
dissections of the extended deep lobe of the parotid.
The margin of the mandible is primarily removed for
clarity; however, it is conceivable that a margin of the
mandible could be removed with adherent neoplasm
if malignant. Removal of the coronoid process with a
portion of the temporalis muscle, as well as the zygo-
matic arch, is a valid approach to the infratemporal
and superior parapharyngeal space. To expose the
temporalis muscle, an incision is made, preferably above
the hairline, through the superior auricular muscle and
then through the deep temporal fascia, which is
attached to the zygomatic arch. This exposes the
temporalis muscle.
Continued
Ext. Pterygoid M.
 BASE OF THE SKUll SURGERY

Area II-Deep to Ascending Ramus of Mandible

and Masseter Muscle and Anterior to Pterygoid
Muscles With Overlying Pterygoid Venous Plexus
(Continued)
The stylomandibular ligament (see Fig. 17-3D) is a
band of the cervical fossa that extends from the region
of the apex of the styloid process to the angle and the
posterior border of the ramus of the mandible between
the masseter and internal pterygoid muscles. This liga-
ment and at times the sphenomandibular ligament (see
Fig. 17-3D) are transected to facilitate retraction of the
mandible for exposure of the parapharyngeal space.
This maneuver can at times avoid a mandibulotomy
near the angle.
D Further exposure of this area is shown with the
ascending ramus of the mandible removed. It is impor-
tant to note the lingual and inferior alveolar nerves
over the inferior pterygoid muscle. The relationship of
the upper and lower heads of the external pterygoid
muscle to the internal pterygoid muscle is depicted.
The internal jugular vein lies posterolateral in relation
to the internal carotid artery as the exposure proceeds
superiorly.
Continued

Superior Pharyngeal
Ext. Pterygoid M. Constrictor M.
Upper Head
,

Ext. Pterygoid M.
Lower Head
Glenoid Fossa
Ext. Auditory Canal

Jugular Vein ... Masseter M.

Inf. Alveolar 7
Int. Carotid A. L'Ingua IN .

D
FIGURE 23-4 Continued
 BASE OF THE SKULL SURGERY

Area III-Deep to the Pterygoid Muscles

E The external pterygoid muscle is removed, and the
internal pterygoid muscle is transected. Transection of
the internal pterygoid muscle is necessary during a
resection of the ascending ramus of the mandible. The
external pterygoid muscle is inserted on the neck of
the condyle and temporomandibular capsule of the
joint. The number 1 indicates the tensor veli palatini; 2
indicates the levator veli palatini; and 3 indicates the
superior portion of the superior pharyngeal constrictor
muscle (pars pterygopharyngea).
The internal jugular vein is noted to be posterolateral
to the internal carotid artery.Associatednervesare labeled.
This is the area when the surgical procedure reaches
the retropterygoid region. The pterygomandibular raphe
(see F) is the tendinous band of the buccopharyngeal
Ext. Auditory Canal
fascia being attached superiorly to the hamulus of the
medial pterygoid plate and inferiorly to the mylohyoid
line of the mandible. This is likewise the attachment of
the superior pharyngeal constrictor muscle. Medially is
the border of the buccinator muscle, and laterally is the
superior pharyngeal constrictor muscle. The hamulus
forms the turning point of the tensor veli palatini muscle.
F Depicted is more detail relative to branches of the
external carotid artery and the relationship of the infe-
rior alveolar and lingual nerves. The ninth nerve is omit-
ted. Step F1 details the anatomy of the ninth nerve.
The relationship of all these structures to the superior
pharyngeal constrictor muscle is shown. The occipital
artery rather than being covered by the stylohyoid
muscle and the posterior belly of the digastric muscle
may be inferior to them, as depicted. The internal carotid
artery is shown in its usual location-posterolateral.
Nevertheless, it has been encountered in a postero-
medial location. In one instance a "coil" of the artery
was encountered (see Fig. 22-1 7C).
Continued

Facial N.

Ext. Carotid A.
Int. Carotid A
E

Post.
Auricular A.
Superior
Pharyngeal Int. Pterygoid M.
Constrictor M. Raphe
Maxillary', . I pterygomandibular
)

Buccinator M.
Asc.PharyngealA.
Int. Carotid A.
Sternomastoid A. Inf. Alveolar N.

FIGURE 23-4 Continued


Area III-Deep to the Pterygoid Muscles
(Continued) (see also Fig. 5-9L)
F1 This demonstrates the course of the glossopha-
ryngeal nerve. This nerve mayor may not be visualized
in a radical neck dissection. However, it is more likely
to be exposed in the dissections of the parapharyngeal
space, especially with neurogenic tumors (e.g., vagal
sympathetic and jugular paraganglion) (see Figs. 22-23
and 22-24).
This nerve is primary sensory to the oropharynx,
tongue (sense of taste in the posterior tongue), and
possibly the middle of the ear. It is the motor supply to
the stylopharyngeus. Quoting from Hollinshead's
Anatomy for Surgeons, volume 1 (1954), "As it emerges
from the jugular foramen the glossopharyngeal nerve
Stylohyoid m.
Glossopharyngeal
n.
In!. jugular v.
Pharyngeal br. (9th n.)
Carotid branch
FIGURE 23--4 Continued
BASE OF THE SKUll SURGERY
lies anterolateral to the vagus and spinal accessory
nerves, medial to the internal carotid artery and antero-
medial to the jugular bulb. Almost immediately upon
its exit it passeslaterally between the jugular vein and
the internal carotid artery and then forward between
the external and internal carotids to lie deep to the
styloid process and the muscles attached to it. It is
most easily located here by looking along the medial
surface of the lower border of the stylopharyngeus
muscle. It supplies this muscle and curves around its
lateral border to lie on the lateral surface of this and
subsequently on the middle constrictor of the pharynx
as it runs forward toward the tongue; as it passesdeep
to the hyoglossus muscle and gives off its tonsillar and
lingual branches." In this illustration the stylohyoid
muscle is not shown but the ligament is shown.
Branch to
stylopharyngeus
Styloglossus m.
Hyoglossus m.
Pharyngeal constrictor m.
 BASE OF THE SKULL SURGERY

Glenoid Fossa
pterygo-
man~'3ular [ossa

12th N.
GlossopharyngealN.
Jugular Vein In!. Carotid A.
G

Internal Auditory Canal

Pharyngeal N. Branches
Hypoglossal N. In!. Carotid A.
Accessory N. Sup. Cervical
Sympathetic Ganglion H
from C2
FIGURE 23-4 Continued

Area IV-Deep to Superior Pharyngeal

Constrictor Muscle
G Shown is the bony relationship with the base of
the skull in the area of the superior portion of the
pharyngeal space. Note the proximity of the pterygoid
plate to the foramen lacerum. In removing pterygoid
plates, care must be taken not to fracture the ptery-
goid bone, which conceivably could injure the internal
carotid artery deep to the foramen lacerum. This
relationship is further depicted in L.
H Soft tissue relationship of the structures high in
the parapharyngeal space and the infratemporal area
at the base of the skull is shown. The zygomatic arch
has been removed and can be replaced after the
dissection is completed. The jugular vein at this level is
posterolateral to the internal carotid artery, which is
very vulnerable. Extreme care must be taken during
any surgical procedure. Note the relationship of the
auditory canal to the veli palatini muscles.
Continued

Area IV-Deep to Superior Pharyngeal
Constrictor Muscle (Continued)
Malignant neoplasms of the nasopharynx and
oropharynx can reach this area of the parapharyngeal
space by involvement of the thin superior pharyngeal
constrictor muscles. They can thus extend through the
plane of this muscle, lying on the longus colli and the
longus capitis muscles. From there the neoplasm can
reach the base of the skull superiorly and the retro-
mandibular region and superior cervical region inferiorly.
Evaluation of whether there is encasement of the internal
carotid artery is very important relative to resectability,
hence the importance not only of aCT, MRI, and pos-
sibly MRA but also of an internal carotid angiogram.
Evaluation of the internal carotid artery at the carotid
canal orifice as well as its horizontal course through
the canal is important.
BASE OF THE SKULL SURGERY 1361
Glossopharyngeal Neuralgia
Glossopharyngeal neuralgia can be initiated by swal-
lowing and chewing and has the same character as a
major trigeminal neuralgia. This neuralgia sometimes
is extremely severe and lasting. Because this may be
associated with surgical removal of paragangliomas it
can be postulated as a major form of glossopharyngeal
neuralgia. Exactly how this occurs is problematic because
it is not noted as a postoperative complication of a
radical neck dissection, even if the neck dissection
is extended superiorly into the parapharyngeal space.
The author (JML) has never noticed an absence or
diminished gag reflex with this type of neuralgia despite
the fact that it is reported when the ninth nerve is
transected. The vagus nerve may play a part in this
type of neuralgia.
 1362 BASE OF THE SKUll SURGERY

Foramen ovale

Foramen ovale

Auditory canal
Foramenspinosum
Pterygoid process
Pterygoid plates
Styloid process
Foramen lacerum

Stylomastoid K
foramen (

Carotid canal

Jugular fossa / Pterygoid plate

Foramen
spinosum Foramen
lacerum
External orifice
of carotid canal
Jugular fossa
\
J

FIGURE 23-4 Continued

Glossopharyngeal Neuralgia (Continued)

I Baseof skull is seen from below. This is the apex of
the superior portion of the parapharyngeal space. The
bony landmarks demonstrate the vital structures in this
constricted area. Surgeon beware!
Close up of I shows the course of the carotid canal.
K This depicts another route of spread to the para-
pharyngeal space. The dotted line indicates the possible
osseous area of a resection of a malignant neoplasm of
the upper alveolar ridge and hard and soft palates. The
pterygoid plates are included in the resection depend-
ing on the extension of the disease. Again it is empha-
sized that care must be taken in a resection of the
pterygoid plates because of the proximity of the ptery-
goid process to the foramen lacerum and the internal
carotid artery.
Continued

Glossopharyngeal Neuralgia (Continued)
L Portions of the zygomatic arch are removed for
clarity. Depicted are the relationship of the internal
auditory canal to the juxtaposed baseof the skull region,
levator veli palatini muscle, and superior portion of the
parapharyngeal space. In addition, the tonsil is seen
through separation of the superior pharyngeal con-
strictor muscle. The internal auditory canal is deep to
the medial pterygoid plate. The ascending palatine
vesselscan be a source of troublesome bleeding in this
area. They arise from the facial artery (external
maxillary artery) and anastomose with branches of the
ascending pharyngeal artery.
It is this area that is reached with resection of the
lateral nasopharyngeal wall that often is included in
the resection of the superior lateral and posterior wall of
the oropharynx in advanced squamous cell carcinoma.
It is easy to understand the spread of neoplasms of the
nasopharynx,oropharynx, and palate and superior alveolar
ridge into the parapharyngeal space. This area requires
In!. Jugular Vein
Tympanic membrane
Int. aud. canal
Facial N.
Styloglossus m.
(cut)
Middle Pharyngeal
Constrictor m.
Inferior Pharyngeal
Constrictor m.
FIGURE 23-4 Continued
BASE OF THE SKULL SURGERY 1363
careful evaluation and resection as indicated. If not
included in the initial surgical procedure, it then becomes
the source of recurrence as well as further metastatic
disease. If there is the slightest question regarding the
adequacy of the surgical resection, then treatment
with early postoperative radiotherapy is indicated.
Number 1 indicates where the nasopharyngeal tumor
can extend through the superior pharyngeal con-
strictor muscle. Number 2 is a tonsil site where tumor
can break through the superior pharyngeal constrictor
muscle. Number 3 is a schematic representation of the
transverse process of a cervical vertebra: the internal
carotid artery may be only a few millimeters anterior to
the transverse process. The stylomastoid artery is a
branch of the posterior auricular artery and enters the
stylomastoid foramen with the facial nerve. It supplies
the tympanic cavity and antrum, the mastoid cells,
and the semicircular canals. Clamping the vessel indis-
criminately could injure the main trunk of the facial
nerve.
Continued
Levator veli palatini m.
In!. auditory cartilage
In!.pte~goid plate
Int. aud. membrane
Ext.pterygoidplate
Buccinator m.
Thyroid cartilage
L
 BASE OF THE SKULL SURGERY

Glossopharyngeal Neuralgia (Continued)

M This depicts the relationship of the internal
auditory canal with the veli palatini and the orifice of
the internal auditory canal and the nasopharynx. This
step is a close-up view of the related area in L specifi-
cally in the region of the auditory membrane. The
eustachian tube orifice in the nasopharynx is an
excellent landmark in resection of the lateral wall of
the nasopharynx relative to the carotid canal and
inferior to the foramen lacerum.
Continued

/
f\ \ "
Attic

,
,
I
i
I
I
!

\\
!
i

I'-.... I
\} /Tympanic \
.../ membrane

\0 Mastoid process Levator veli palatini m.

M
FIGURE23-4 Continued

Infratemporal Approach to the Skull Base
Emesto A. Diaz-Ordaz
N A postauricular skin incision is made at the hairline
and extended into the neck. The neck vessels are
isolated with vessel ligatures. The facial nerve is iden-
tified at the styloid foramen, and the nerve is exposed
from the styloid foramen to the upper and lower
division of the facial nerve. The external auditory canal
is transected at the bony cartilaginous junction. The
cartilaginous ear canal skin is everted and sutured
closed. The bony canal skin is elevated, and the tym-
panic membrane fibrous rnembranous is elevated out
of the bony annulus. The incudal stapedial junction is
released. And the tensor tympani muscle is sectioned.
The tympanic membrane, malleus, and incus are
removed en bloc. The stapes suprastructure is ampu-
tated. A canal wall-down mastoidectomy is performed
with a large cutting bur. The bone over the middle
cranial fossa, sigmoid, and presigmoid posterior fossa
dura is thinned. The sinodural angle is developed. The
digastric ridge is identified, and the mastoid tip is
removed. The fallopian canal is decompressed from
the geniculate ganglion and the styloid mastoid
foramen. The facial nerve is dissected out of the
fallopian canal and relocated anteriorly. The tympanic
ring is removed and the jugular bulb, internal carotid
artery, and internal jugular vein are exposed (Jackson,
1991).
Sigmoid Sinus
Jugular Bulb
Int. Jugular V.
FIGURE 23--4 Continued
BASE OF THE SKULL SURGERY 1365
Surgery of the Parapharyngeal Space
To understand the various aspects of surgery of the
parapharyngeal space, several examples of different
areas involved and relative to preoperative planning
and intraoperative findings and some of the pitfalls are
discussed and represented in illustrations of the sur-
gical anatomy. Changes in extension of surgical proce-
dures are almost routine. The use of intraoperative
Doppler imaging is useful to locate the internal carotid
artery. Clear-cut preoperative planning is imperative.
Other examples of parapharyngeal space are depicted
in the section on deep lobe of the parotid surgery (see
Figs. 17-2 and 17-3); for paraganglioma surgery see
pages 1283 to 1309; and for aneurysm secondary to
trauma see Figure 22-33. When the surgical anatomy
and the extent of the primary disease is understood,
then the best approach to the exposure and the resec-
tion is attainable. For a discussion of the margin of
mandible resection see Figs. 14-11 and 16-9.
Facial lymph nodes may be involved. Metastasis can
occur with involvement of the cheek because in these
invasive malignant lesions the spread can be to the
facial lymph nodes.
Facial lymph nodes include the following:
• Infraorbital (maxillary)
• Buccinator: on the buccinator muscle opposite the
angle of the mandible
• Supra- or overlying mandible: outer surface of the
mandible, anterior to the masseter muscle; contact
with facial artery and vein
Int. Carotid A.
7
N
 BASE OF THE SKUll SURGERY

The four areas of exposure are limited, moderate,

advanced, and radical advanced.

Limited Exposure

An example is a large lipoma superior to the cervical

region, with extension into the parapharyngeal space
and floor of the mouth.

1. Use superior cervical incision.

2. Preserve greater auricular nerve, ramus mandibularis,
and, if possible, cervical branch of the facial nerve.

\
3. Resect external jugular vein.
4. Remove submandibular salivary gland if it is involved.
5. Tail of the parotid is not involved.
6. Remove pseudopods of lipoma into adjacent muscle
and any extension into the floor of the mouth.
7. Identify and preserve lingual nerve.
8. Ligate external maxillary artery and associated veins.
9. Remove extension of lipoma into the parapharyngeal
space by blunt dissection. Approach the retromandibular
)
area without mobilization of the mandible; retract
the mandible superiorly. FIGURE23-5 Moderate exposure is achieved with two
separate incisions. A dumbbell-shaped branchial cleft cyst
For some "moderate" and for virtually all "advanced" (type 1) and an attached lipoma involving the
and "radical advanced" operative procedures involving infratemporal region and parapharyngeal space occurred
the parapharyngeal space, it is advised that the internal deep to the zygomatic arch and then into the upper
carotid artery, vagus nerve, and internal jugular vein be cervical area. Dashed lines represent two incisions for
exposed in the superior cervical area and then followed exposure. Shaded area indicates a lipoma and cyst.
superiorly into the parapharyngeal space. Vascular
tapes are placed around the two vessels for control.

Moderate Exposure breadths below the body of the mandible, to avoid a

The first example is a deep parotid neoplasm or neuroma
in the parapharyngeal space that is benign and has
extended deep to the pterygoid muscles. The mandible
is mobilized superiorly and anteriorly through a sub-
mandibular incision combined with the incisional
approach as with a lateral parotid lobectomy (see
Fig. 17-1). The stylomandibular ligament (a portion of
the deep cervical fascia) is sectioned to mobilize the
mandible (see Fig. 23-4C). Additional mobilization may
be achieved by anterior dislocation of the temporal
mandibular joint. However, this may not be necessary
and thus is avoided. In these circumstances it is not
necessary to perform a mandibulotomy as described in
Figure 17-3.
The second example (Fig. 23-5) shows moderate
exposure with two separate incisions. A dumbbell-shaped
branchial cleft cyst (type 1) (see Fig. 16-15A) and an
attached lipoma involving the infratemporal region and
parapharyngeal space are seen deep to the zygomatic
arch and then into the upper cervical area. The initial
incision is made just above the hairline in the temple
region, while the second incision is made two finger-
possible low-lying main trunk of the facial nerve,
which is often seen in infants. The patient was 1 year
old. See Figure 17-11. For details of this surgery see
pages 836 to 838. Mandibulotomy was not necessary.
Advanced Exposure
An example is a very large deep lobe parotid tumor that
was benign or low-grade malignant and a neurogenic
tumor that was benign but presented as fullness of the
oropharyngeal wall. The patient presented with a sig-
nificant bulge of the oropharyngeal wall plus a mass
under the angle of mandible. Evaluation included CT
(pressure erosion of lateral walls of maxillary sinus,
displacement of the ascending ramus of the mandible,
no bone invasion); MRI (complex soft tissue mass para-
pharyngeal space, no evidence of invasion of skull base);
MRA (internal carotid artery displaced laterally and
posteriorly); fine-needle aspiration of the mass via the
oropharynx (nondiagnostic); and fine-needle aspiration
of the parotid mass via the cheek (13 mL amber and
serosanguineous fluid, no neoplastic cells on smear or
cell block).

1. Incision included a parotid lobectomy with an extend-
ed oblique/horizontal superior cervical incision.
2. Sternocleidomastoid muscle, mastoid process, and
external auditory canal were exposed.
3. Temporoparotid fascia was transected (see Fig. 17-lA
to E).
4. Exposure included the main trunk of the seventh
nerve (located 1 em inferiorly more than usual) and
exposure of the cervicofacial and the zygomatic
temporal divisions. All were preserved during the
entire operation.
5. Cystic mass was encountered adherent to the deep
lobe of the parotid with margins indistinct.
6. Intraoperative fine-needle aspiration was non-
diagnostic.
7. Surgery was to be extended into the parapharyn-
geal space, hence:
a. Proximal control of internal carotid artery with
vascular tapes
b. Distal control of internal jugular vein with
vascular tapes
c. Identification and preservation of 10th, 11th,
and 12th cranial nerves; the 7th cranial nerve is
already identified and preserved.
8. External carotid artery was displaced anterior lying
between the mass and the deep lobe of the parotid.
9. Further dissection of the mass necessitated a mid-
line mandibulotomy with a lateral retraction with
connection of lip incision with the original extended
cervical incision.
10. Transection of the internal pterygoid muscle was
done to improve exposure.
11. Mass adhered to base of skull and posterolateral
region of the internal carotid artery.
12. Frozen section of mass indicated that the impres-
sion was oncocytic adenoma, probably benign.
13. Additional dissection was done, keeping clear of
the region of the internal carotid artery. Surrounding
scar tissue is extending to the base of the skull and
could not be safely dissected with this exposure. It
would require resection of the superior portion of the
ascending ramus at least with the coronoid process.
14. Zygomatic and temporal divisions of the seventh
nerve were preserved during this mobilization.
15. Internal jugular vein was 50% smaller than usual
with a markedly dilated superior temporal vein
indicating compression of the internal jugular vein.
16. Marked adhesions of the mass to the base of the
skull in the vicinity of the internal carotid artery
and the jugular vein defied safe dissection. The
decision was to partially remove the mass because
it was likely benign.
17. Despite careful dissection, bleeding from the ptery-
goid plexus of veins was due to adhesion of the
mass. Initial surgical clips helped but failed to control
the bleeding completely. Control was obtained with
BASE OF THE SKULL SURGERY 1367
a bolus of Avitene wrapped with Surgicel. Temporary
pressure was achieved with cottonoid sponges,
which were later removed, and permanent pressure
was obtained using the portion of the remaining
capsule of the mass as well as reflected stylohyoid
muscle and posterior belly of the digastric muscle.
18. Closure of reconstruction was done by approxi-
mating the transected muscles where feasible (e.g.,
the mylohyoid and hyoglossus muscles). Mandibu-
lotomy was secured with a Steinmann pin and tie
wires of NO.5 malleable stainless steel.
19. Tracheostomy was done.
The final pathology report showed a well-differen-
tiated acinic cell carcinoma (papillocystic variant). This
tumor had a rather innocuous histology but was believed
to be malignant. Two other pathologists reviewed the
slides and concurred with this diagnosis.
Suggested follow-up treatment included several
options:
1. Middle cranial fossa surgery with evaluation of
intracranial blood flow
2. Radiotherapy
3. Observation
The patient preferred observation. Careful postopera-
tive evaluation was continued, including MRI and clinical
evaluation, and there was no evidence of disease at
5 years.
Another example of one of the approaches to an
advanced exposure of the parapharyngeal space com-
bined with a resection of primary carcinoma of the
oropharynx is the mandibular swing procedure that is
demonstrated in Figure 23-7B, which shows the
osseous structures at the base of the skull (dotted line)
to be resected.
Advanced Radical Exposure
An example is a high-grade mucoepidermoid carcinoma
of the right parotid salivary gland. The patient had
surgery in 1989 elsewhere; the diagnosis was chronic
sialadenitis, and treatment was a lateral parotid lobec-
tomy. Slides were reviewed in 1995, and the diagnosis
was a high-grade mucoepidermoid carcinoma. The patient
had concomitant squamous cell carcinoma of the left
vocal cord and right pyriform sinus treated with radia-
tion. Radiotherapy (done elsewhere) was to the right
parotid salivary gland because of suspicious metastatic
squamous cell carcinoma. However, this mass in the
parotid was the high-grade mucoepidermoid carcinoma.
The patient presented in 1995 with a total right
peripheral facial paralysis, an indurated mass in the
preauricular region with deep and superficial extension,
and severe unrelenting pain. CT showed a soft tissue
 BASE OF THE SKULL SURGERY
mass at the skull base involving the pterygoid muscu-
lature with a soft tissue mass abutting the mandible
and the temporalis muscle. There was no indication of
bone destruction involving the temporal bone or the
skull base and no cervical lymphadenopathy.
1. Tracheostomy was performed.
2. Direct laryngoscopy showed no gross evidence of
laryngeal or hypo pharyngeal neoplasm. Biopsies
were negative.
3. Skin incision completely surrounded the entire parotid
region and included a superior cervical extension.
4. Identification and tagging of the internal carotid
artery, internal jugular vein, and external carotid
artery was done. The external carotid artery was
subsequently ligated and removed with the internal
maxillary artery. The vagus nerve was preserved.
There was no lymphadenopathy but there was
marked scarring secondary to previous operation
and radiotherapy.
5. The seventh nerve was identified proximally and
distally. Nerve stimulation was done distally, and
anesthesia was "lightened" without response.
Nevertheless, a tag was placed for possible seventh
nerve reconstruction.
6. Exploration was done of the mandible, and gross
tumor of the parotid involving the ascending ramus
was found. A frozen section region of the condyle
is positive for neoplasm.
7. Disarticulation and transection distal to the angle
of the mandible was done with a Gigli saw without
entering the oral cavity (see Fig. 22-33A to OJ.
8. Transection of the pterygoid muscles was well away
from the tumor, and a portion of the muscle was
resected with the neoplasm and entire parotid
salivary gland.
9. The distal portion of the mandible was free, and
the proximal portion was adherent.
10. Tumor adhered to the periosteum of the external
auditory canal, so the periosteum was removed.
Partial temporal bone resection was considered.
Frozen section of soft tissue overlying the carotid
canal proved positive.
11. Tumor was resected in the vicinity of internal carotid
artery canal. The vessel was free of tumor.
12. The extra cranial base of the skull was exposed, and
tumor was found extending into the foramen spin-
osum, which is the site of the middle meningeal
vessels and a recurrent branch from the mandibular
nerve. Extreme care was taken not to avulse these
vessels, which were then occluded with metallic
clips, which then also served as identification for any
postoperative radiotherapy (possibly gamma knife).
13. Resection was now concentrated on the region of the
main trunk of the seventh nerve. The medial por-
tion of the mastoid process was excised with a sagit-
tal plane saw, including the stylohyoid, posterior belly
of the digastric muscle, and sternocleidomastoid.
14. The seventh nerve was transected 1 cm distal to
the stylomastoid foramen. Frozen section of the
proximal portion of the nerve showed it to be free
of disease; it was tagged for possible reconstruc-
tion. Exploration of the styloid process led to the
stylomastoid foramen and exposure of proximal
portion of the seventh cranial nerve trunk and
internal carotid artery.
15. Examination was done of indicated tumor mass
fixed to the deep posterior aspect of the mandible.
The mandible was resected with the neoplasm of
the parotid. Total parotidectomy with overlying
skin plus seventh nerve was performed.
16. Decision was made against facial nerve grafting,
owing to a primary lack of any distal stimulation
response.
17. Reconstruction of the defect was done using a free
rectus abdominis flap.
18. Tarsorrhaphy was performed.
19. Radiotherapy was planned for the region of the
foramen spinosum and carotid canal.
The patient's severe pain was initially relieved but
later returned. There was evidence of bone erosion
surrounding the foramen spinosum that also extended
toward the cavernous sinus. The patient died 4 years
after the ablative surgery.
In summary, in this type of exposure, resection of
the angle and ascending ramus of the mandible affords
the best overall exposure of the parapharyngeal space.
It entails total parotidectomy with removal of seventh
nerve. All slides from all previous operative and biopsy
procedures should be reviewed.
Advanced Radical Exposure (Fig. 23-6)
The example presented here is of metastasis to the
parapharyngeal space from a primary carcinoma of the
oropharynx, portion of the nasopharynx, base of tongue,
superior portion of the hypopharynx, soft palate, and
upper alveolar bridge with attached segment of the
mandible. A radical neck dissection was done. The cheek
flap was mobilized with the entire parotid salivary gland,
combined with resection of the segmented portion of
the body of the mandible and ascending ramus, with or
without the condyle and coronoid process.
Highpoints
1. The parapharyngeal space is evaluated with CT, MRI,
MRA, and, when indicated, angiograms of the carotid
and vertebral arteries (see Fig. 22-181 and 11).
2. Incision of the lower lip was combined with superior
cervical and preauricular incisions.

Advanced Radical Exposure (Continued)
(Fig. 23-6)
3. Preservation of the main trunk of the facial nerve
depends on additional mobility of the flap.
4. An intraoral incision was made in the inferior buccal
gingival sulcus. Preserve at least 1.5 cm of the
mucosa of the gingiva for closure of the edge of the
mucosa of the cheek flap (see C).
5. Mobilization of the cheek flap, which includes the
entire parotid salivary gland with the seventh nerve,
was done; the deep cleavage plane is on the masseter
muscle and the ascending ramus of the mandible
deep to the posterior fascia of the deep lobe of the
parotid salivary gland.
6. Further mobilization of the cheek flap was done with
incision in the superior gingival buccal sulcus to the
region of the first molar/canine tooth area. Preserve
at least 1.5 cm of the mucosa of the gingiva for closure.
7. Osseous resection options include:
a. Proximal segmental portion of the body of the
mandible, angle, and ascending ramus to within 2 cm
of the condyle with portion of entire coronoid process
b. Proximal segmental portion of the body of the
mandible including the angle and 1 to 2 cm of the
ascending ramus
c. Other modifications (e.g., margin of the mandible
depending on the extent of disease)
8. Use extreme care when searching for the internal
carotid artery. It may be in its posterior lateral posi-
tion or in the posteromedial position just overlying
the transverse processes of the vertebrae. This last
location can place it in jeopardy when removing any
posterior lateral pharyngeal lymph nodes.
9. Obtain proximal control of the internal carotid artery
and then dissect it superiorly to the disease area;
otherwise the artery may be injured. If a coil (see
Fig. 22-17C) is visualized in a preoperative angiogram,
it is best clearly identified; otherwise, if there is an
overlap in the coil, this could be misinterpreted as a
second or even third vessel and possibly injured. If
so, immediate reconstruction is done.
FIGURE23-6
BASE OF THE SKULL SURGERY 1369
A The cheek flap includes the entire parotid salivary
gland and the seventh nerve, which is preserved,
including the ramus mandibularis. The cervical facial
division of the seventh nerve is embedded and
undisturbed in the cheek flap. With elevation of this
flap, it is folded posterolaterally and retracted with stay
sutures. The inferior portion of the ascending ramus of
the mandible can either include resection with the
angle and body of the mandible or be left in place and
retracted laterally.The coronoid process can be resected
(see Fig. 23-4A1) for additional exposure of the para-
pharyngeal space with or without resection of the
zygomatic arch. The area of the para pharyngeal space
is exposed (see Fig. 23-46) and consists primarily of
the para pharyngeal plexus of veins, the internal maxil-
lary artery, the internal and external pterygoid muscles,
and a portion of the pterygoid plates. The disease in
this area of the para pharyngeal space can now be
resected in continuity with the primary tumor and
with retropharyngeal posterolateral lymph nodes. This
dissection extends over the transverse processes of C1
and C2 and the internal carotid artery to which these
nodes may be adherent (see E and E1). Therefore,
proximal control of the artery is important along with
its exposure up to the area of the disease.
B Resection of the mandible can be varied according
to the extent of disease (various dashed lines). If
neither the mandible nor the periosteum is involved,
the mobilized portion can be replaced after the com-
pletion of the resection of the disease in the parapha-
ryngeal space. This mobilization is somewhat similar to
the procedure as shown in Figure 22-33. If no
mandible is removed, the approximation and fixation
can be done with a single, short section of Steinmann
pin or Kirschner wire with tie wires or a mandibular
plate (see Chapter 13).
Continued
 BASE OF THE SKULL SURGERY
\
)
FIGURE 23-6
C The full cheek flap including the parotid salivary
gland and intact seventh nerve is now elevated as
described earlier. In this operation the angle of the
mandible is resected as marked by "x". The dotted line
indicates the incision in the superior gingival buccal
sulcus leaving a strip (1.5 cm wide) attached to the
superior alveolar ridge for closure of the flap. A and A1
delineate the same mucosal flap in the inferior gingival
buccal sulcus for closure. The hatched area of the palate
including the entire lateral wall of the nasopharynx up
to the level of the eustachian tube, the superior,
lateral, and posterolateral portions of the oropharynx,
and juxtaposed mandible to which the neoplasm is
adherent is resected. When the site of the proximal
transection of the mandible is reached, the cheek flap
can be left attached to the mandible at this point.
Note the mucous membrane attached to the remaining
portion of the mandible for closure of the cheek flap
back to the remaining mandible.
D The cheek flap is reflected superiorly and laterally,
showing a portion of the mandible resected (x).
D1 Further dissection extends into the juxtaposed
pharyngeal space and includes the portion of the
mandible to be removed (x) with the primary tumor
along with the contiguous metastatic disease in the
space. The dashed line in the mandible represents the
distal line of transection, and the dotted line depicts
the proximal line of resection of the mandible. The
resection of the metastatic disease, depending on its
extent, would be removal of the pterygoid plate, ptery-
goid muscles, and portion of the superior pharyngeal
constrictor muscle with the lateral and posterolateral
retropharyngeal lymph nodes. Care is taken during
this deep dissection especially related to the internal
carotid artery, which is located over the transverse
processes of the vertebrae: C1 and C2. This occurs as
the dissection proceeds laterally and posteriorly. The
internal carotid artery at this area had a coil (see
Fig. 22-17C) with metastatic disease adherent to the
lateral and retropharyngeal nodes. This demonstrates
the importance of the proximal identification and of
control and exposure of the internal carotid artery
throughout the procedure.
Continued
 BASE OF THE SKULL SURGERY

Advanced Radical Exposure (Continued)

(Fig. 23-6)
One modification of this procedure is just the distal
mandibulotomy, retraction of the angle of the mandible,
and dissection of the parapharyngeal space if the
metastatic disease is not adherent to the mandible.
Closure of the mandibulotomy in this situation is simply
done with a Steinmann pin and tie wires or a plate.
E, El The internal carotid artery relationship to the
styloid process is shown, being posterior and medial.
Adherent to the internal carotid artery are the lateral
parapharyngeal nodes, which are contiguous with the
retropharyngeal nodes as well as the oropharyngeal
neoplasm. The disease has invaded and extended
through the superior pharyngeal constrictor muscle,
thus invading the parapharyngeal space. With this
type of extension of the neoplasm and involved nodes,
resting on the transverse processes of C1 and C2, abut-
ment of the bodies of the vertebrae, and the internal
carotid artery, it is obvious that obtaining any type of
"safe margins" is impossible. Therefore, postoperative
radiotherapy is indicated. (Note: Although CT appears
adequate, an MRI would afford more detail relative to
the soft tissues.)
The CT (E) axial cut reveals the location of the
internal carotid artery in relationship to the transverse
process of the vertebrae and the styloid process. The
tumor is abutting the artery. In a situation such as this,
before the exploration of the para pharyngeal space,
the internal carotid artery must be exposed more
proximally and a tape put around it; it can then be
followed superiorly up to the critical area where the
tumor is abutting the vessel.
Continued

ropharynx

Styloid process

Internal carotid a.
Jugular v.
Transverse process

FIGURE 23-6 Continued

 BASE OF THE SKULL SURGERY
Advanced Radical Exposure (Continued)
(Fig. 23-6)
F, F1 Axial cut through cadaver specimen (F)
demonstrates the relationship of the internal carotid
artery, transverse process of the vertebra, and styloid
process similar to that seen on CT.
In the case of a coil in the internal carotid artery,
special care must be taken if this, in fact, is the area
that is juxtaposed to the tumor. See Figures 22-31 and
22-33A to D for other details regarding the internal
carotid artery. Reconstruction of the mandible can be
performed using a bent and curved Steinmann pin if
sufficient bone is available at the condylar neck for
fixation of the Steinmann pin (see Fig. 14-5C). The
ends of the Steinmann pin must always be angular and
secured with preferably two tie wires. If this is not
done, a "free" Steinmann pin can migrate through the
glenoid fossa into the cranial cavity. If the condyle has
been removed, then the "condylar head plate" can be
utilized for reconstruction.
Soft tissue reconstruction can be achieved with
either a pectoralis major flap (see Fig. 16-18) or a free
vascularized flap (e.g., from the abdominal wall). This
type of cheek flap with the mandibular resection is not
the same as the "mandibular swing" (see Fig. 23-7) in
that a midline mandibulotomy is not performed and
the cheek flap in this procedure is able to be elevated
farther superiorly. With the mandibular swing the flap
is attached to the entire body of the mandible.
Limitations of This Approach
If there is not sufficient exposure to the superior por-
tion of the parapharyngeal space, an added incision,
similar to that of Weber-Dieffenbach (see Fig. 5-9),
could be used through the upper lip and lateral to the
nose. Care must be taken to ensure viability of the flap.
There is no preauricular incision and limited posterior
extent of the submandibular incision. It may be
worthwhile to do a delayed submandibular incision if
the patient is receiving preoperative chemotherapy.
Another possibility would be to preserve the anterior
facial vessels (external maxillary). Additional data
relative to mobilization of a cheek flap are provided in
Chapter IS. It must be emphasized, however, that this
reference is just to a skin flap and not a cheek flap
including the parotid salivary gland.
 BASE OF THE SKULL SURGERY

ropharynx

Transverse process

FIGURE 23-6 Continued

 BASE OF THE SKULL SURGERY
Mandibular Swing (Fig. 23-7)
This very versatile technique, which is a modification of
the midline mandibulotomy (see Figs. 14-11A to E, IS-4A
to C, and IS-11A to E), is an excellent approach to the
middle and posterior portion and base of the tongue, to
extensive tumors of the palate with or without exten-
sion into the maxilla, to the tonsillar region and pharyn-
go maxillary space, and to the base of skull. The more
anterior lesions do not require section of the glossopala-
tine fold. In short, this approach is the most widely used
for exposure and resection of these lesions. 1t affords
excellent exposure and is readily combined with a radical
neck dissection as indicated. Obviously, if a segment of
the mandible requires resection, and although the mid-
line mandibulotomy may be utilized for the mandibular
resection, then the closure of the surgical defect as
described is not applicable (see Fig. 14-lOA to C). Under
such circumstances, a resection of the angle, ascending
ramus, and a portion of the mandible is then necessary,
and the mandibulotomy may have to be performed not
in the midline but rather through the body of the
mandible.
1f there is deep extension in the tonsillar region and
evidence of fixation to the mandible, then a midline
mandibulotomy is not done. A resection of the involved
mandible is performed, thus affording access to the
lesion and the parapharyngeal space. 1f the neoplasm is
adherent only to the upper margin of the mandible,
then it is satisfactory to perform a marginal resection of
the mandible (see Fig. 16-9). However, do not preserve
a portion of the mandible if there is any evidence either
by fixation clinically or intraoperatively or by MRI
regarding adherence to the periosteum. MRI can aid in
demonstrating adherence or extension to within several
millimeters of the periosteum. True, the periosteum can
be stripped off the bone, but the resulting margin is
either zero or just a few millimeters. Do not depend on
postoperative radiation to eradicate this potential source
of recurrence. (Refer to the bone section in Chapter 3).
A The mandible is transected in the midline, as
described in Figure 15-4. Depicted here is an extensive
neoplasm involving the palate, tonsillar region, and
posterior third of the tongue. This lesion is free of the
mandible, and, hence, the mandible can be spared. An
incision is made along the floor of the mouth, leaving,
if possible, a narrow rim of mucosa along the inner
table of the mandible to facilitate placement of sutures
for the reconstruction utilizing a pectoralis major
myocutaneous flap. The lingual nerve and 12th nerve
are included in the resected specimen, which likewise
includes the posterior half and base of the tongue, the
lateral oropharyngeal wall, including the tonsil, the
involved soft palate and hard palate, and the inferior
portion of the maxilla with the lateral wall and floor of
the nasal cavity and septum, as required. The resection
is carried superiorly to include the lateral wall of the
nasopharynx and the eustachian tube orifice, if need
be. The pterygoid plates and a major portion of the
pterygoid muscles are included in the surgical
specimen, thus approaching the base of the skull.
B The dashed line indicates the osseous resection,
including the pterygoid plates. The eustachian tube is
transected within the pterygomaxillary fossa. Extreme
care is taken not to injure the internal carotid artery
and related nerves; the artery is approximately 1.5 cm
from the posterior edge of the lateral pterygoid plate.
If the vessel is exposed it should be protected with a
transposed muscle flap or a turned-in flap of prever-
tebral fascia, which is then covered with a dermal
graft.
Continued
 BASE OF THE SKUll SURGERY

GLENOID
FOSSA

STYLOID
PROCESS

B
FIGURE 23-7
 BASE OF THE SKULL SURGERY
Mandibular Swing (Continued)
(Fig. 23-7)
C The defect is reconstructed with a split pectoralis
major myocutaneous flap. The technique of this split
pectoralis flap is described in Figure 8-30 in the section
regarding pectoralis major myocutaneous flaps. A
prosthesis is used to close the palatal defect. Closure of
the mandibulotomy is described in Figure 15-4G.
When the lesion is less extensive, the resection is
easily modified to include only those structures neces-
sary for removal of the neoplasm, which emphasizes
the versatility of this approach. The reconstruction is
then modified depending on the defect. The 12th nerve
may be spared if a minimal portion of the tongue is
resected. The reader is referred to the work of Biller
and colleagues (1981) for further details.
FIGURE23-7 Continued
Comment
The surgery shown for patients requmng advanced
radical exposure has been presented in very detailed
fashion because these patients are usually treated with
preoperative chemotherapy and uncompromised surgery.
This requires careful detailed preoperative evaluation
of the extent of disease to include all areas involved
before the chemotherapy. This involves CT, MRI, MRA,
and arteriograms, as indicated. Postoperative radio-
therapy is not used routinely but is based on selectivity
as referred to in the text. On the other hand, malignant
lesions (primary and especially metastatic) of the para-
pharyngeal space may be very difficult to remove with
free margins. Thus, if there is the slightest question
regarding the adequacy of margins, definitely use
postoperative radiotherapy.
 BASE OF THE SKULL SURGERY

Craniofacial Resection (Fig. 23-8) plus angiography. Most important is a careful physical
(After Ketcham et aL, 1963; Shah and examination, including the use of optical and nasal
Galicich, 1977; Sisson et aL, 1976; Terz examination and nasopharyngoscopy.
et aL, 1980) 2. The resected area varies depending on the type and
the extent of disease.
Indications Based on Types of Tumors 3. Use preoperative antibiotics that cross the blood-
brain barrier as well as preoperative nose and throat
Malignant cultures with appropriate antibiotics-dexamethasone
(Decadron), 4 mg every 6 hours.
• Squamous cell carcinoma 4. A two- to three-team approach is required: head and
• Malignant tumors of the minor salivary glands (e.g., neck surgeon and neurosurgeon and reconstructive/
adenoid cystic carcinoma) vascular surgeon for free flaps when indicated.
• High-grade mucoepidermoid carcinoma arising from S. Remove intended diseased area as a block, not
the mucosa of the paranasal sinuses, nasal cavity, or piecemeal.
lacrimal apparatus 6. Ensure adequate resection with contiguous struc-
• Melanoma ture that may not be grossly involved by tumor
• Esthesioneuroblastoma (e.g., dura and juxtaposed bone).
• Chondrosarcoma 7. Maintain meticulous control of all cerebrospinal
• Invasive basal squamous cell carcinoma of the skin fluid leaks and all bleeding sites.
involving the facial bones at the skull base 8. Remove all mucosa of the frontal sinus if this area
• Histiocytoma is even partially included, or at least establish
adequate drainage.
Benign (Tumors That May Extend Through or 9. Recognize complications and treat them immediately.
Approach the Floor of the Anterior and/or Middle 10. If preoperative chemotherapy is used, the area to
Cranial Fossa) be resected must be outlined before chemotherapy;
resection must include all of this area-allow no
• Olfactory meningioma compromise in the surgical resection.
• Fibrous dysplasia 11. Establish central venous pressure line and bladder
• Recurrent and invasive inverted papilloma (e.g., catheter.
those that extend into the cribriform plate) 12. Obtain a postoperative MRI (2 to 6 days before) for
• Congenital deformities (e.g., orbital hypertelorism) any evidence of pneumoencephalocele.
• Fibromatosis 13. When the circum orbital area is being resected,
sufficient bone must be removed so that there is
Structures Involved That Can Be Resected in Whole adequate soft tissue coverage over the remaining
or in Part bone. The problem is that the soft tissue retracts
during the healing process and exposes the bone.
• Cribriform plate and/or floor of the anterior cranial This is true of the ascending ramus of the zygoma
fossa as well as the nasal bones.
• Frontal sinus 14. When a partial resection of the antrum is done,
• Ethmoid and antrum provision has to be made for dependent drainage.
• Anterior wall of the sphenoidal sinus (not the entire In other words, the medial wall of the antrum should
sphenoidal sinus) be taken down so that this drains into the nasal
• Orbit and its contents cavity freely.
• Nasal cavity (e.g., extensive malignant tumors
extending to the cribriform plate) Decompression of the Dura at the Onset of the
• Meninges involving the anterior and possibly the Procedure
base of the middle cranial fossa
1. Do not use anesthetic agents that may increase the
Highpoints intracranial pressure.
2. Rapidly infuse mannitol.
1. A careful pretreatment evaluation is done of the 3. Perform a lumbar subarachnoid tap with an 18-
extent of the disease with coronal and axial CT gauge spinal needle and remove 20 to 100 mL of
(primarily for bone involvement), MRI, MRA (pri- cerebrospinal fluid (optional).
marily for soft tissue detail), and digital subtraction 4. Ensure slight hyperventilation to reduce the Pcol.
 BASE OF THE SKULL SURGERY
Craniofacial Resection (Continued)
(Fig. 23-8) (After Ketcham et aL, 1963;
Shah and Galicich, 1977; Sisson et aL,
1976; Terz et aL, 1980)
Surgical Technique
A Depicted are the various types of skin incisions
used in craniofacial resections.
1. The coronal flap is placed approximately 2 cm pos-
terior to the hairline. The supraorbital, supratrochlear,
and superficial temporal vessels are preserved in the
base of the flap. This is the preferred incision,
because it facilitates a complete frontal craniotomy
and affords excellent exposure. The periosteum is
left attached to the frontal bone flap if it is to be
elevated and replaced.
2. This small incision is preferred by Ketcham (1963).
It is used to perform a bur hole craniotomy,
through which the floor of the anterior cranial fossa
in the vicinity of the cribriform plate is transected.
However, it affords much less exposure of the floor
of the anterior cranial fossa.
3. This is the Weber-Dieffenbach (Fergusson) cheek
incision with an ellipse to include in the resection
the margins of the upper and lower eyelid (which
are sutured together) when the orbital contents of
the orbit are to be removed. Removal of the lids is
recommended when insertion of an orbital pros-
thesis is planned. If the globe is to be preserved, the
upper horizontal incision is not performed and the
edges of the lids are not resected.
4. This incision is at times utilized for additional expo-
sure of the contralateral ethmoidal sinus when a
bilateral total resection of the ethmoidal labyrinth is
done. The incision is optional, depending on the
extent of the disease and the exposure that may be
necessary.
The procedure described here uses the first and third
incisions for a squamous cell carcinoma that involves
primarily the right antrum with extension into the right
orbit, right ethmoidal sinus, and right lateral wall of the
nose and also to the nasal septum, frontal sinus, and
cribriform plate.
B A schematic of the osseous incisions and areas to
be resected is provided. A template of the frontal sinus
has been obtained from a radiograph taken in the
Caldwell position to outline the anterior wall of the
frontal sinus (see Fig. 5-8F to H). Bur holes are depicted,
which are optional, because the anterior wall of the
frontal sinus can be transected and elevated, as per-
formed in the osteoplastic approach to the frontal sinus.
Bur holes have a potential advantage of facilitating an
evaluation of the resectability of any intracranial exten-
sion of the neoplasm (e.g., into the frontal lobe). If the
latter is the case, the surgery can then be terminated
if the lesion is determined to be nonresectable.
The dashed lines indicate the osteotomies. The
zigzag line depicts the base of the bone flap, which
consists of the nasal bones and the frontal process of
the maxilla. The arrow depicts the reflection of this
bone flap leaving the periosteum intact. This affords
excellent exposure of the nasal cavity and the anterior
portion of the ethmoidal labyrinth. This bone flap will
be returned to its normal position at the reconstructive
phase of the operation. Care must be taken that there
are adequate margins. This bone flap may require removal
in advanced and infiltrative basal cell carcinoma as well
as squamous cell carcinoma, especially when the neo-
plasm arises in the medial canthal area.
The short dotted line indicates the osteotomy across
the floor of the contralateral anterior portion of the
nasal cavity, which then facilitates the retention of the
caudal end of the nasal septum and columella to lend
support to the nasal tip. The more proximal portion of
the nasal septum is removed along with the structures
that are encompassed by the solid lines. The dorsum
of the septum, if not involved with tumor, is also
preserved to support the bridge of the nose. Thus, the
following areas are resected:
1. Entire right maxilla
2. Contents of the right orbit with floor and medial
wall of the orbit
3. Right ethmoidal sinus and a portion of the left
ethmoidal sinus
4. Entire right lateral wall of the nose
5. Major portion of the nasal septum
6. Cribriform plate
7. Posterior portion of frontal sinus with all mucosa
8. Anterior wall of sphenoidal sinus
9. Left superior and middle turbinates
 BASE OF THE SKULL SURGERY 1379

FIGURE 23-8

Cross-hatching area on the medial wall of the left
orbit indicates the extent of resection when bilateral
removal of the ethmoidal labyrinth is indicated.
The anterior wall of the frontal sinus is replaced or
removed if involved. A left antrostomy can be per-
formed for drainage. The resection of the medial wall
of the orbit is above the frontoethmoidal suture line
(see Fig. 6-4B), because this line marks the level of
the cribriform plate, which is resected. The superior
level of the ethmoidal sinus may be superior to the
level of the cribriform plate. The ostia of the anterior
and posterior ethmoidal arteries are along this suture
line.
Continued
 BASE OF THE SKUll SURGERY
Craniofacial Resection (Continued)
(Fig. 23-8) (After Ketcham et aL, 1963;
Shah and Galicich, 1977; Sisson et aL,
1976; Terz et aL, 1980)
Depending on the extent of disease (frequent and mul-
tiple frozen sections are obtained), bilateral ethmoidal
sinus resection can be performed, with care taken to
preserve the contralateral globe. Ligation of the anterior
and posterior ethmoidal arteries is carefully performed.
Precise control of the bleeding is mandatory. Once the
decision to proceed with the resection is made, both teams
can operate simultaneously. The following description
and steps are thus interposed between the extracranial
and intracranial portions of the surgical procedure.
C The cheek flap has been reflected along the lines
of the Weber-Dieffenbach (Fergusson) incision (see
Fig. 5-9). The lateral osteotomy through the nasal
(frontal) process of the maxilla has been completed,
thus reflecting the right ala nasi medially. The lip inci·
sion has been extended across the base of the columella
and caudal end of the septum. An incision is then
made 1.5 em proximal and parallel to the columella,
thus preserving the columella and caudal end of the
septum (1) as support for the nasal tip. This incision is
then extended cephalad, preserving a 1.O-cm portion
of the septum (2) to support the dorsum of the nose.
The instrument depicted is placed through this inci-
sion into the left nasal cavity. The number 3 indicates
the nasal process of the maxilla, which will be removed.
The remaining portion of the septum and the nasal
process of the maxilla will be removed (4) with the
resected maxilla, the lateral wall of the nasal cavity, the
ipsilateral ethmoidal labyrinth, and the cribriform plate.
By removing the major portion of the septum, which is
left attached to the cribriform plate, excellent exposure
of the contralateral ethmoidal sinus is achieved.
Additional exposure is accomplished by extending
an osteotomy across the region of the glabella (dashed
line). The entire nasal framework can then be reflected
farther medially to the contralateral side. The zigzag
line in B is the "hinge" that is the final maneuver to
facilitate the reflection of the nasal framework and still
preserve support for the nose when it is returned to its
original position at the end of the operation.
Depending on the extent of disease, resection of the
contralateral ethmoidal sinus can be performed, taking
care not to injure the contralateral globe. This is
combined with the cranial approach of the resection.
The incision (4) is depicted in A, which may be utilized
for additional exposure of the medial wall of the orbit.
The eyelids are sutured together, with the edges of the
lids to be included in the orbital enucleation. The lids
should be resected if a prosthesis is to be inserted.
Frozen sections are obtained of any suspicious area of
the skin flap, because the disease may extend into the
skin. The skin is thus resected as necessary.
D This lateral view depicts the area to be resected, as
outlined by the dashed lines, which includes the lateral
wall of the nasal cavity, the cribriform plate, the
anterior wall of the sphenoidal sinus, the ipsilateral
hard palate, a portion of the contralateral hard palate,
and the posterior portion of the frontal sinus. The
numbered structures are as follows;
1. Scalp flap. This must be "reversed" if skin at the
brow or above the eye is involved.
2. Galeal flap. This is eventually used to form the new
anterior cranial fossa floor and is to be reflected in
the direction of the arrow, leaving the periosteum
on the free frontal bone flap (point 3).
3. Anterior wall of the frontal sinus that is removed for
access to the cribriform plate and floor of the
anterior cranial fossa. This free-bone flap with its
periosteum will later be replaced. "X" refers to a
portion of the anterior wall of the frontal sinus, which
is removed to provide space for the reflected galeal
flap. The posterior wall of the frontal sinus and all
mucosa of the frontal sinus are removed as per-
formed in a frontal sinus obliteration. Removal of all
frontal sinus mucosa is most important and is best
achieved with the use of a power-driven bur, which
eliminates all small ridges and crevices.
Continued
 BASE OF THE SKUll SURGERY

FIGURE 23-8 Continued

 BASE OF THE SKULL SURGERY
Craniofacial Resection (Continued)
(Fig. 23-8) (After Ketcham et aI., 1963;
Shah and Galicich, 1977; Sisson et aI.,
1976; Terz et aI., 1980)
E In this step the dura has been freed from the crib-
riform plate, with care taken to minimize tears in the
dura. Dura leaks are unavoidable at this stage and must
be recognized and closed meticulously. The crista galli
is removed with forceps. The olfactory nerves are tran-
sected where they perforate the cribriform plate. The
tiny dura leaks are closed with sutures, preferably braided
nylon or silk. Monofilament nylon should be avoided,
because it can cause rents in the dura. Careful hemo-
stasis is necessary. Olfactory bulbs are carefully pre-
served and covered with cottonoids. Undue retraction
of and pressure on the frontal lobe is to be avoided,
because this may cause edema. The exposure extends
along the planum sphenoidale posterior to the ante-
rior clinoid process; care must be taken to avoid injury
to the optic chiasm and internal carotid arteries along the
lateral walls of the sphenoidal sinus as well as their
branches.
A curved chisel is directed into the sphenoidal sinus
to include the anterior wall of the sinus in the resec-
tion. The dura is removed if the inner table of the floor
of the calvarium is invaded by tumor. Any dural defects
are patched with temporalis fascia or fascia lata. The
base and posterior wall of the frontal sinus are resected.
The numbered structures are the following:
1. Scalp
2. Galeal flap to be reflected inferiorly and posteriorly
to form the new floor of the anterior cranial fossa
F Anterior cranial fossa view is shown. The solid line
depicts the floor of the anterior cranial fossa resected
with the right orbital contents. The cribriform plate
along with the roof of the right orbit is resected. The
dashed lines indicate a smaller area of resection, and
the globe is preserved as with a benign lesion (e.g., an
olfactory meningioma). In these situations the contents
of the orbit are preserved. The optic chiasm and the
deeper and more medial internal carotid artery are
shown, although these structures may not be visualized
during the resection, depending on the amount of
exposure necessary. The left optic nerve and the chiasm
are carefully preserved, as is, of course, the internal carotid
artery and its branches. Ketcham and colleagues (1973)
point out that "great care must be taken in mobilizing
the posteromedial (lateral wall of the ethmoidal sinus)
confines of the orbital wall so that resection will not
extend dangerously into the middle cranial fossa."
The inner table of the frontal sinus is included in the
resection depending on the extent of disease. If gross
disease extends through the cribriform plate, then the
juxtaposed dura is best resected. If the primary tumor
is in the ethmoidal sinus or if there is significant
involvement of the ethmoidal sinus up to the midline,
then a total bilateral ethmoidectomy is performed.
G A galeal flap is mobilized along the dotted line,
with its base along the anterior edge of the frontal
bone, which was previously removed. The arrow depicts
the turn in course of the galeal flap, which then forms
the support for the frontal lobe and a new floor of the
anterior cranial fossa.
Continued
 BASE OF THE SKULL SURGERY 1383

INTERNAL
CAROTID A.

FIGURE 23-8 Continued

 BASE OF THE SKULL SURGERY
Craniofacial Resection (Continued)
(Fig. 23-8) (After Ketcham et aL, 1963;
Shah and Galicich, 1977; Sisson et aL,
1976; Terz et aL, 1980)
H The galeal flap is turned in to form the floor of the
anterior cranial fossa. This galeal flap is necessary for
the prevention of osteomyelitis, because the free
frontal bone flap would otherwise be exposed to the
nasal cavity. If a craniotomy is placed just above the
eyebrow (e.g., to be able to resect the frontal sinuses
with the glabella and frontal process that forms the
suture line with the lamina papyracea), then the galea I
flap can be based at the anterior (inferior) edge of the
scalp flap. The galeal flap is then turned inferiorly to
cover the dura where the cribriform plate is resected.
Complications
Intraoperative
• Cerebral edema that may be due to over-retraction of
the brain
• Severe hemorrhage
Postoperative
• Cerebrospinal fluid leak: may require daily spinal
taps
• Meningitis: treat with appropriate antibiotics, namely,
gentamicin or vancomycin.
• Abscess formation
• Osteomyelitis of the frontal bone: this may be mini-
mized by adequate frontal sinus drainage and the
removal of all frontal sinus mucosa.
• Mental aberration: secondary to frontal lobe edema
• Anosmia: permanent
• Transient pituitary insufficiency
• Facial swelling: usually temporary
• Pneumoencephalocele
• Cerebral edema
• Cerebrospinal fluid leak
Delayed Postoperative
• Middle ear complaints and deafness: tubes can be
inserted in the eustachian tubes, or a tube tympa-
notomy can be performed.
It is advisable to keep the patient relatively flat in
bed for the first 4 postoperative days.
Causes of Local Recurrence (After Ketcham, 1963)
• Inadequate exposure
• Failure to remove all contiguous structures that are
involved in or juxtaposed to disease (e.g., the con-
tralateral turbinates, cartilage and bone, skin, and
lateral wall of nasal cavity). The facial paranasal bony
margins should be carefully evaluated at the time of
resection.
• Failure to use a liberal number of frozen sections on
any suspicious tissue and margins
I A semidiagrammatic cutaway view shows the galeal
flap hinged from the scalp that forms the floor of the
anterior cranial fossa. The frontal bone is depicted wired
in position. A portion of the frontal bone inferiorly has
been removed with the resection of the frontal sinus.
This affords space for the turned-in galeal flap, thus
preventing impingement or pressure on the flap.
Although the dura is shown to be intact, a portion may
have required resection and patching with fascia.
J The frontal bone flap is replaced and secured with
tie wires placed through drill holes. Wire sutures are
avoided if postoperative radiotherapy is anticipated,
because "local electron scatter and osteoradionecrosis
do not subsequently develop."
K The final closure: 1, scalp flap; 2, galeal flap cover-
ing the base of the frontal lobe; and 3, replaced por-
tion of the frontal bone. Note the gap at the inferior
portion of the frontal bone to facilitate turning in of
the galeal flap. A split-thickness skin graft is placed to
cover the inner bare area of the cheek flap as well as
other large bare areas. However, a skin graft should
not be buried. It is better that the other bare areas be
covered by regrowth of mucosa to facilitate a moist
surface. The dashed line represents the location of
either gauze impregnated with nitrofurazone or a
temporary prosthesis along the resected palate. The
septal columella and dorsum of the septum have been
preserved for support of the nasal tip, alar nasi, and
nasal bridge. The remaining portion of the septum has
been resected.
If there is any significant bone defect of the cranium
over the frontal lobe, a free-septal cartilage graft or
bone graft can be placed between the dura and the
cranium. A nasal septal flap can also be placed over the
cranial bone defect. A tracheostomy is preferred.
 BASE OF THE SKULL SURGERY

GALEAL
FLAP

FIGURE 23-8 Continued

 BASE OF THE SKULL SURGERY

Bilateral Total Maxillectomy for 17. Be aware that the danger area is at the pterygoid
Chondrosarcoma (Fig. 23-9) process-internal carotid artery (see Fig. 23-4A).
18. The major source of bleeding is the internal maxil-
Cranial facial resection is used for extensive low-grade lary artery, which ideally may be occluded earlier
chondrosarcoma of the paranasal sinuses involving the in the operation via transection of the zygoma (see
cribriform plate. Bilateral resection of the maxillae, Fig. 5-9F). The palatine vessels, as well as the
bilateral ethmoidal labyrinth, nasal osseous frame, vessels within the pterygoid canal (see Fig. 23-4J),
associated soft tissue, and content of the nasal cavity are also sources of bleeding.
with preservation of both globes is combined with the
transcranial resection of the cribriform plate (see Figs. Technique
5-9 and 23-8). The resection is outlined as follows:
Extracranial Portion
1. Total bilateral maxillae
2. Total bilateral ethmoidal labyrinth with lamina
A The solid line represents the extension of the
papyracea, hard palate, anterior wall of the sphe-
tumor. A single Weber-Dieffenbach (Fergusson) inci-
noidal sinus, and a portion of the frontal sinus
sion is shown by the dotted line, left side, with an
3. Nasal osseous frame, including the floor and contents
extension superiorly over the medial canthal area to
of the nasal cavity
the brow (see Fig. 5-9). A short 1.0- to 1.5-cm trans-
4. Resection of a portion of the cribriform plate
verse incision (X) is made over the right medial canthal
ligament for exposure and transection. The flap is
Highpoints
elevated. A single problem with the left cheek flap
was the slough of a portion (Y) owing to lack of any
1. Use extreme care and evaluate the extent of disease
support for the skin flap. It was corrected with an
with CT and MRI:
advanced lateral temporal skin flap.
a. Osseous
b. Orbital
B Complete degloving of the nasal osseous frame is
c. Intracranial
done, preserving 1 em of the anterior nasal septum,
d. Soft tissue of the nasal cavity and sinuses
columella, and ala nasi in the flap. This flap was then
2. Perform an ophthalmologic and neurosurgical
reflected laterally to afford almost the same exposure
evaluation.
of the flap on the left side. No infraorbital incision was
3. Perform a tracheostomy.
necessary. The superior and medial portion of the flap
4. Use a unilateral Weber-Dieffenbach (Fergusson) skin
was elevated to expose the entire glabella and juxta-
incision with extension over the medial canthus.
posed frontal bone. Exposure on the right side with
5. Deglove the nasal osseous frame and preserve the
the degloving procedure was not quite as extensive as
columella and 1 cm of the anterior nasal septum.
on the left side; however, it did not hamper the
6. Preserve the right anterior facial vessels and bilateral
resection.
superficial temporal vessels; supratrochlear vessels
are sacrificed on the left and preserved on the right.
C Outline of osseous resection is shown on the left
7. Outline the sagittal plane saw osseous area to be
side. The right side was the same, except the line of
resected.
resection on the medial wall of the orbit did not reach
8. Transect and reconstruct both medial canthal
the foramina of the ethmoidal vessels. Both medial
ligaments.
canthal ligaments were transected and the lateral ends
9. Evaluate both orbits regarding the feasibility of
tagged with silk for future reconstruction.
preserving one or both globes.
10. Take care not to break the capsule or pseudo capsule.
11. Identify the ethmoidal vessels and occlude them The extraocular muscles on the medial and inferior
with metallic clips at the foramina. aspects of the globes were resected in continuity with
12. Sacrifice the extraocular muscles on the medial and the entire infraorbital and medial rim of the orbits. This
inferior aspects of the globes. included the lamina papyracea bilaterally with the entire
13. Resect the infraorbital rim bilaterally with the lamina ethmoidal labyrinth posteriorly to include the anterior
papyracea as part of one block with the maxillae. wall of the sphenoidal sinus and a major portion of the
14. Transect both zygomas with the sagittal plane saw cribriform plate with the crista galli, juxtaposed frontal
at the infraorbital fissure. bone, and portion of the frontal sinus. In the area of the
15. Include the hard palate and preserve the soft palate. posterior ethmoidal labyrinth and the sphenoidal sinus,
16. Remove a portion of the pterygoid plate with a proximity of the internal carotid arteries just lateral to
portion of the pterygoid muscle. the sphenoidal sinus must be realized and precautions

\
C I
FIGURE 23-9
taken not to injure these vessels (see Figs. 23-3, 23-4A
to K, and 23-12C). The danger is the removal of the
pterygoid plate and a portion of the pterygoid process.
Thus, do not attempt to remove the process because of
its proximity to the foramen lacerum and the carotid
canal. The next step was to transect each zygoma using
the infraorbital fissure as a guideline which joins the
pterygomastoid fissure (see Fig. 5-9L). The soft palate
was preserved, transecting it from the hard palate,
which was resected with the upper alveolar process
and teeth.
D The cranial portion, which was performed simulta-
neously, now had reached exposure of the cribriform
plate (see Fig. 23-8D and E) in which there was a
dehiscence through the plate that was more extensive
BASE OF THE SKULL SURGERY
~~
I D
on the left side. Cuts were made through the cribriform
plate posterior and right/left lateral (see Fig. 23-8F to
H). Anteriorly, the plate was left attached to the frontal
bone and sinus with the glabella. The frontal bone was
cut above the glabella, thus entering the lower portion
of the frontal sinus. The frontal sinus mucous membrane
and the mucosa of the sphenoidal sinus were negative
for tumor on frozen section and permanent section.
The inner table of the frontal sinus was now transected
from below with a malleable retractor protecting the
frontal lobe. This cut joined the intracranial section,
which included the anterior portion of the cribriform
plate and crista galli (see Fig. 23-8D and E). This close-
up view shows more detail relative to the cribriform
plate (x), crista galli (y), and frontal sinus (z).
Continued
 BASE OF THE SKULL SURGERY
Bilateral Total Maxillectomy for
Chondrosarcoma (Continued)
(Fig. 23-9)
The only portion holding the entire specimen in place
was in the region of the pterygoid plates, pterygoid
process, and pterygoid muscles. This required very
careful separation with an osteotome and rongeur. This
is one of the critical areas because of the proximity of
injury to the internal carotid arteries (see Fig. 1-2). The
pterygoid plates were transected from their process and
the pterygoid muscle, likewise, was transected. The
specimen was now free and removed intact. The speci-
men included the entire nasal osseous frame with its
contents, both maxillae, both ethmoidal labyrinths, the
anterior portion of the cribriform plate, the glabella, a
portion of the frontal sinus and anterior wall of the
sphenoidal sinus, the floor of the nose, and the upper
alveolar process with all upper teeth and hard palate.
Cranial Portion
I. Transcranial frontal lobotomy is done.
2. The portion of the left frontal lobe is resected
because of dehiscence in the cribriform plate.
3. The cribriform plate is resected with cuts bilaterally
and posteriorly and left attached anteriorly to the
frontal bone and the entire specimen. This is achieved
with a cut above the glabella, which anchored the
lower portion of the frontal sinus.
4. The inner table of the frontal sinus is transected from
below, protecting the frontal lobe with a malleable
retractor.
5. Closure is with a galeal flap (see Fig. 23-81 to K).
Cover the area of resected cribriform plate so that
closure is complete and secure and there is no
cerebrospinal fluid leak.
FIGURE 23-9 Continued
E A temporal is muscle sling for both globes was
abandoned because of the lack of length of the
temporal muscle to reach the remaining portion of the
frontal sinus. Thus, support of the globes was made by
securing the medial canthal ligament, the lateral
portion of which is contiguous with the inferior and
superior tarsus of the lids, with double-O wire through
the periosteum of the frontal bone. This was better
than simply passing wire through drill holes in the
frontal sinus. This not only brought the ligaments to
the more medial position but also raised them slightly,
thus preventing droop of the globes.
A double Kirschner wire was secured to the remain-
ing portions of each zygoma and crossed the surgical
defect. This was done with the purpose of supporting
the prosthesis and successfully held the postsurgical
packing in place during the postoperative period.
However, removal of the wire Was required to facilitate
insertion of the permanent prosthesis. The final prosthesis
was achieved by a two-part device. The lower portion
was held in place with magnets in the upper portion
(see Fig. 23-4C and D). A through-and-through nylon
suture was placed between the nasal skin flap about
one third of the distance from the glabella region to
pinch the nose and aid in keeping some of the
postsurgical packing in place. This helps prevent
displacing the nasal portion of the degloved flap.
Continued
A prosthetic device is constructed in two parts (see
Fig. 23-4C and D). These two parts facilitate the inser-
tion of the device and are held together with magnets
(see section on dental and prosthetic considerations in
Chapter 3).
E
 BASE OF THE SKULL SURGERY

Bilateral Total Maxllledomy for

Chondrosarcoma (Continued)
(Fig. 23-9)

F Postoperative photograph shows anterior view. G Postoperative photograph shows right lateral
view.
Continued

FIGURE 23-9 Continued

 1390 BASE OF THE SKULL SURGERY

Bilateral Total Maxillectomy for Result

Chondrosarcoma (Continued)
(Fig. 23-9) At follow-up the patient's vision was excellent. He was
able to eat anything in small portions; however, because
of difficulty in chewing, this prosthesis has a tendency
H Two-part prosthesis is shown. (Courtesy of David to drop while chewing. His voice is very good. There is
M. Casey, DDS.) no evidence of disease at 14 years and 10 months. A
review of slides confirmed the original diagnosis of a
I Prosthesis sections are shown separately. (Courtesy low-grade chondrosarcoma. Final histology showed all
of David M. Casey, DDS.) margins free of tumor.

Complication

• Slough of the medial triangle of skin of the Weber-

Dieffenbach flap. Closure was done with a medially
advanced skin flap from the temporal region.

FIGURE 23-9 Continued


Supraorbital Approach to the
Orbit and Paranasal Sinuses
(Fig. 23-10)
Cranial Portion
Gregory J. Castiglia and Daniel P Schaefer
The approach to lesions involving the paranasal sinuses
and orbit with infiltration into the anterior cranial fossa
can be technically challenging. The indications for
surgical intervention and approach are determined by
clinical findings as well as radiographic investigations.
Typically, the decision to proceed by surgical means is
based on the extent of the lesion, the pathologic process,
its location in proximity to the brain and surrounding
structures, the rate of progression of the lesion, and the
known behavior of the lesion. An extirpative approach
to the mass lesion may be limited by the extent of func-
tional deficit that may be resultant. Transcranial orbitec-
tomy with subsequent reconstruction has become an
extremely important technique in the surgical manage-
ment of orbital and periorbital tumors for both exposure
and postoperative cosmesis. A combined transcranial
orbitectomy approach greatly facilitates the visualization
FIGURE 23-10
BASE OF THE SKULL SURGERY 1391
and greatly facilitates their removal. As in all transcranial
orbitectomies, the preferred approach is the coronal flap.
The unilateral coronal flap with the vertical midline
incision is not advised.
The procedure described is based on a recurrent infil-
trative basal cell carcinoma that involved the periorbital
skin, soft tissue, bone, paranasal sinuses, and juxtaposed
dura as well as perineural invasion. The primary site
was in the region of the medial canthus of the eyelids.
Approach
A A coronal skin flap (dotted line) is made, preserv-
ing intact pericranium for later reconstruction (solid
line is area of skin and soft tissue removed).
B Frontotemporal craniotomy is carried out. (Cross
hatched area is where bone was removed.) Subfrontal
dura is mobilized from the adjacent anterior cranial
fossa floor and retracted posteriorly.The anterior clinoid,
cribriform plate, crista galli, and superior orbital fissure
and its contents ar~ exposed.
Continued
 1392 BASE OF THE SKULL SURGERY

Supraorbital Approach to the a split-thickness graft harvested from the craniotomy

Orbit and Paranasal Sinuses bone flap.

(Continued) (Fig. 23-10)

C, C1 A sagittal saw ;s used to remove the superior
orbital rim, anterior orbital roof, floor of anterior
cranial fossa, and portion of the frontal sinus as an en
bloc resection (solid line). Exenteration of the contents
of the frontal, ethmoidal, and maxillary sinuses and
the orbital contents can then be completed.
Reconstruction
A free fat graft is harvested to use to obliterate the frontal
sinus. The superior orbital rim can be reattached with
D The portion of bone removed (cross hatched area)
includes the supraorbital rim and the roof of the orbit.
D1 This is a schematic representation of the recon-
struction of resected bones as depicted in D. The
orbital roof is reconfigured using a 3-mm Medpor sheet
implant. Preserved, and still attached, the vascularized
pericranial flap is positioned in two layers to protect
the dura and cranial cavity from an open orbital
defect. The Medpor implant and fat graft are wrapped
in this pericranial flap. Additional fat graft is placed
between the Medpor implant and dura. The scalp flap
is closed in layers.

-- .~

\
I
I

pericranium

fat pad

o Medpor

FIGURE 23-10

Complication
• Infection involving Medpor sheet implant and
surrounding soft tissue and bone exposure
Procedure
En bloc trans cranial orbitectomy may be necessary in a
vast array of pathologic processes, ranging from orbital
tumors to lacrimal gland tumors, meningiomas, central
nervous system tumors, and malignancies of the paranasal
sinuses. A multidisciplinary approach has been used to
allow adequate exposure along with cosmetically accept-
able reconstruction. The supraorbital approach provides
exceptional visualization and ensures protection of the
brain structures in a direct fashion. The limiting factor
in the resection of these extensive tumors is involve-
ment of the brain stem and internal carotid artery.
Bypass of the internal carotid artery may be possible.
The procedure is begun by making a bicoronal flap,
preserving the pericranium for later use in reconstruc-
tion (see A, earlier). A periorbital skin incision can be
added later to allow the complete excision of the tumor
as well as the perineural infiltration. A frontotemporal
craniotomy can then be undertaken, exposing frontal
dura and the sylvian fissure vessels. The dura adjacent
to the posterior wall of the frontal sinus and along the
superior orbital roof is mobilized. With gentle retraction,
the lesser wing of the sphenoid bone, the anterior clinoid,
and the tuberculum sellae may be exposed. More medial
retraction allows visualization of the crista galli and
cribriform plate in the midline. If necessary, the ante-
rior sagittal sinus may be ligated to aid retraction. The
temporal dura may be mobilized as well, exposing the
superior orbital fissure and its contents. Excellent expo-
sure is thus obtained, and the area of wide excision is
outlined.
The bone may be incised along the superior orbital
rim using a sagittal plane saw. At this point, the dura is
readily visible and protected, preventing any untoward
occurrences. The periosteum is incised around the supe-
rior, lateral, and interior circumference of the orbit.
Periosteal elevators then elevate the periorbita to the
apex of the orbit. The oscillating saw is used to incise the
superior orbital roof. This may be carried out medially
as far as the cribriform plate, if needed. The inferome-
dial orbital contents and periorbita are separated from
the inferior orbital wall, and bone can be resected later-
ally as far as the zygomatic arch. Tumors extending
from the maxillary sinus superiorly into the region of
the cribriform plate may be approached in this fashion.
BASE OF THE SKULL SURGERY 1393
The posterior roof of the orbit may be incised anterior
to the clinoid and anterior to the superior orbital fissure.
This maneuver protects the internal carotid artery from
damage. After transecting the optic nerve, ophthalmic
artery, and vein complex, the orbit and its contents can
be safely removed en bloc with the mobilized section
of bone.
Cosmetic reconstruction of this defect must include
adequate protection of the brain from contaminating
structures such as the frontal and paranasal sinuses.
Multiple layers of protection are used to provide a func-
tionally separate compartment for the brain from the
surrounding regions of the face and sinuses. Packing
the frontal sinus with free fat graft can obliterate any
defect in the frontal sinus. The floor of the anterior cra-
nial fossa has been reconstructed using a Medpor sheet
implant, which is later secured in place with titanium
plates. Liberal use of fat graft and the previously har-
vested pericranial graft ensures adequate isolation of
the dura from the paranasal sinuses.
Use of the porous high-density polyethylene Medpor
implants with an average pore size greater than 100 mm
and pore volume in the 50% range permits a rapid
fibrovascular ingrowth and integration with the host
tissue and has a low incidence of infection. The implants
can be easily cut and contoured to the defect, especially
after soaking in a hot saline solution, and fixated with
suture, titanium fixation screws, and/or plates. Only non-
magnetic metallic fixation devices are used, to avoid
interference with postoperative MRI.
Tumor invasion into the periorbital bone can be
resected and reconstructed using split -thickness auto-
graft. This is readily achieved by transecting the cra-
niotomy bone flap along the diploic space. With the
use of this technique, the superior orbital rim has been
reconstructed, as well as the other bony defects (see D
and Dl). The bone is secured in place by using titanium
microplates (e.g., Codman Bioplates,Synthes Maxillofacial).
The orbitectomy cavity is covered with a split-thickness
skin graft, which when applied directly to the bone
usually results in an excellent take of the graft. This is
favored over a vascularized muscle graft because of the
ease of visualizing of early recurrences as well as the
improved air/tissue interface needed for adjuvant
radiotherapy. The main cosmetic reconstruction will be
provided by an external prosthesis.
The temporalis muscle is reapproximated with suture.
A subgaleal Hemovac drain is placed. The galea is then
closed in an interrupted fashion, and the skin is reap-
proximated using standard techniques.
 BASE OF THE SKUll SURGERY
Facial Portion
John M. Lore and Daniel P Schaefer
The craniotomy was performed with removal of the
supraorbital rim. Then orbital exenteration (see Figs. 5-9
and 23-8B and C), sinuses, and intranasal resection
was performed. This resection included the removal of
the periorbital soft tissue and the medial walls of the
orbit, ethmoidectomy, partial resection of the antrum at
the floor of the orbit, and resection of the interior, middle,
and superior turbinate along with the nasal lacrimal
and nasal frontal ducts. Resection of the lateral wall of
the orbit was performed preserving the ascending ramus
of the zygoma (subsequently, the edge of this bone
became exposed and it would have been better to include
it in the resection). A complete left ethmoidectomy with
the entire medial wall of the orbit was resected (See
Figs. 5-4 and 6-4A and B) with the lamina papyracea.
When the posterior and anterior ethmoidal vessels were
identified at the foramina, these vessels were occluded
with nonmagnetic clips. Further resection included the
lacrimal bone, floor of the orbit with the orbital plate
and frontal process of the maxillary bone, a portion of
the nasal bones, and the glabella. The frontal sinuses
were resected partially via the cranial approach and
partially with the approach outlined earlier. The entire
lateral wall of the nose with all turbinates, nasal lacrimal
ducts, and nasal frontal ducts was resected. Intranasal
and sinus bare areas were covered with dermal grafts.
Radical Resection of Maxilla With Orbital and
Partial Ethmoidal Exenteration (See Fig. 5-9)
Malignant tumors of the ethmoidal and maxillary sinuses
(antrum of Highmore), orbital tumors with extension
into the paranasal sinuses, and central nervous system
tumors involving the paranasal sinuses and the orbit
are amenable to surgical treatment and, unless very
early and limited, are better handled by a more radical
operation than by a limited one because of the intimate
and complex relationship of the antrum to the ethmoidal
and sphenoidal sinuses as well as the orbital contents.
If, after adequate investigation, there is potential or
actual intracranial involvement, a transcranial resection
should be planned. In these selected circumstances,
wide extirpation of tissue is anticipated to prolong life
or significantly reduce pain, suffering, or deformity. If
a less aggressive approach is performed, completeness
of resection may be compromised. The radical resection
with orbital and ethmoidal exenteration is described.
Permission for orbital exenteration should be obtained
in virtually all operations for malignant tumors of the
antrum. Orbitectomy with subsequent reconstruction
has become an extremely important technique in the
surgical management of orbital and periorbital tumors
for both exposure and postoperative cosmesis. The reader
is referred to en bloc resections of the ethmoidal sinus
with craniofacial resection (see Fig. 23-8).
Different techniques of exenteration may be utilized
depending on the extent of orbital involvement. The
basic principle in exenteration is to remove all diseased
tissue with wide borders, while preserving as much
normal tissue as possible. Exenteration with preserva-
tion of the eyelid skin is not applicable in this patient
because the primary basal cell carcinoma arose at the
medial canthus. The eyelids are not preserved as such
because they interfere with a prosthesis (Casey): the
edges of the eyelid are sacrificed. The uninvolved skin
of the eyelids is preserved, and the periorbital skin is
undermined to obtain as much skin as possible to line
the exenterated orbit. This may only be the skin of the
upper eyelid, the lateral aspect of the upper and lower
eyelid, or various combinations as determined by tumor
involvement. An orbit lined with normal skin tolerates
postoperative radiation and permits identification of tumor
recurrence. Exenteration with spontaneous granulation
may be advantageous in some cases. The granulation
process may take 3 months and may be associated with
delayed or incomplete healing. Exenteration with split-
thickness skin graft results in faster healing (see
Fig. 5-9).
Reconstruction
The advancements in reconstructive options make wider
resection reasonable and acceptable for many patients.
The selection and planning of reconstructive techniques
should be tailored to the surgical defect and to the needs
of the patient. Reconstruction of both the bone and soft
tissue defects must be addressed. The goal is to recon-
struct the anatomic boundaries of the orbit, sinuses,
and cranial cavity when involved. Local, regional, and
distant sources can be used. The simplest option is spon-
taneous granulation. A split-thickness skin graft allows
a faster healing time with less local wound care. Regional
flaps based on the superficial temporal artery, temporalis
muscle, the temporoparietal fascia, scalp flaps, cranial
bone, or combinations of the above can be used. The
superficial temporal vessels or facial vessels may be
used for anastomoses for free flaps. These techniques
are useful to establish anatomic barriers to the intracra-
nial and sinus spaces, but the use of these thicker flaps
will impede the observation of the socket and sinuses
for the detection of recurrent disease.

Transseptal Transsphenoidal
Hypophysectomy-Cryosurgical
and Surgical (Fig. 23-11)
Basically, there are two surgical approaches for
hypophysectomy:
1. Transcranial (usually frontal)
2. Transsphenoida1. The transsphenoidal approach has
a number of modifications or intermediate varia-
tions in the manner in which the sphenoidal sinus is
reached:
a. Transantral ethmoidal-through a Caldwell-Luc
operation and then an ethmoidectomy (Hamberger,
1961; Tollefsen et a!., 1966)
b. Transethmoidal-through an external ethmoidec-
tomy
c. Transnasal-through an osteoplastic approach
near the glabella (Macbeth, 1962)
d. Transpalatal
e. Transseptal-through an extended submucous
resection of the nasal septum (Hirsch, 1910). This
can be performed via the incision in the mucoperi-
chondrium of the nasal septum or via a sub labial
incision.
In addition, various methods aside from the surgical
techniques have been and are used for ablation of the
pituitary:
1. Insertion of radioactive material into the pituitary
(e.g., yttrium] using stereotactic method
2. Cryosurgery, using either stereotactic or direct vision
method (rarely used now)
3. Ultrasound
4. Hormonal
Figure 23-11 outlines the transseptal approach to the
sphenoidal sinus and the pituitary gland for surgical
hypophysectomy and cryosurgical hypophysectomy.
Steps A through 0 describe the septal and sphenoidal
portion of the operation. Steps E through 0 describe
the exposure of the pituitary gland. Steps P and Q
depict the direct vision cryoprobe technique, whereas
steps R through X depict the surgical removal of the
pituitary gland.
Indications for Hypophysectomy
• Tumors of the pituitary: adenomas (functioning and
nonfunctioning)
• Metastatic carcinoma of the breast and prostate-
primarily for bone pain
• Diabetic retinopathy (some difference of opinion)
• Sphenoidal sinus lesions
BASE OF THE SKULL SURGERY
• Cerebrospinal fluid rhinorrhea via sphenoidal sinus
secondary to trauma or empty sella syndrome (diag-
nosis with metrizamide cisternography)
• Sellar and parasellar lesions (e.g., craniopharyngioma,
chordoma of the clivus)
Anesthesia
Topical and general endotracheal anesthesia are both
suitable. Cocaine 10% or lidocaine 4 % with a vasocon-
strictor is combined with general anesthesia to minimize
bleeding. General anesthesia is to be avoided in the debili-
tated patient with poor cough reflex and pulmonary
metastases. When cryosurgery is utilized, topical anes-
thesia should be used to evaluate vision and to avoid
permanent damage to the optic nerves.
Highpoints
1. Carefully perform the preoperative evaluation:
a. Consult an ophthalmologist or endocrinologist
depending on purpose of operation.
b. Use radiographs, MRI and CT with contrast medium
enhancement, polytomograms (anteroposterior
and lateral), and bilateral carotid arteriograms of
sphenoidal sinus and sella turcica for their rela-
tionship (e.g., to the internal carotid artery) (see
Fig. 23-12C) and whether the sphenoidal sinus is
small or nonpneumatized. This last finding is a
contraindication to this approach.
c. Be sure there is no active nasal or sinus infection.
Nose and throat cultures should be negative.
d. Endocrinologic evaluation depends on the diagnosis.
2. Remove the posterior nasal septum to obtain access
to the sphenoidal sinus.
3. There should be complete elevation of nasal septal
mucosa posteriorly and mucosa on anterior and
inferior walls of sphenoidal sinuses.
4. Preserve this elevated mucosa intact because most
of the blood vessels lie within it and bleeding will be
much less if mucosa is not torn.
S. Incise the midline vertical plane of the sella turcica
to avoid cavernous sinuses, internal carotid arteries,
and optic nerves laterally. This incidentally is an
advantage of the transseptal approach.
6. Note that there is a high rate (20% to 30%) of
dehiscence of the carotid canal as it passes along the
posterolateral wall of the sphenoidal sinus.
7. Incise both layers of dura of the sella turcica.
8. Ensure radiographic facilities (video fluoroscopy) in
operating room for lateral films to ascertain the
proper angle of approach and depth of sella turcica.
9. Administer corticosteroids preoperatively, operatively,
and postoperatively.
 BASE OF THE SKULL SURGERY

Transseptal Transsphenoidal
Hypophysectomy-Cryosurgical A, A 1 If an anterior deviation of the nasal septum is
and Surgical (Continued) (Fig. 23-11) present, the routine submucous resection of the nasal
septum is performed (see Fig. 6-12); otherwise, the
Complications mucoperichondrial incision may be made farther pos-
teriorly. The approach may be from either the left or
• Cerebrospinal fluid rhinorrhea right as desired. In any event the posterior bony nasal
• Meningitis septum is removed up to its attachment on the anterior
• Hemorrhage wall of the sphenoidal sinus. After the posterior bony
• Intracranial damage if diaphragma sella is penetrated nasal septum has been removed, further elevation of
• Aspiration with respiratory embarrassment mucosa is necessary over the anterior and inferior walls
of both sphenoidal sinuses, as depicted.
G. H. Bateman has described a technique of hypophy-
sectomy using a dual simultaneous approach through B, B1 The crest and rostrum (triangular spine on
the septum and right ethmoidal sinus. After the sphe- inferior surface) of the sphenoid bone are thus well
noidal sinus is entered (see Band Bl), the wound is exposed. The crest is the anterior ridge on the sphenoid
packed, and an external right ethmoidectomy is per- bone that articulates with the perpendicular plate of the
formed. The incision is similar to that described in ethmoid forming the most posterior superior portion
Figure 6-34B; however, the nasal cavity is not entered. of the nasal septum. The crest is continuous inferiorly with
The lateral wall of the nose is fractured medially. The the rostrum of the sphenoid to which the vomer bone
anterior ethmoidal vessels are coagulated, and packing is articulated. Sometimes by removing the sphenoidal
is inserted to hold the orbital contents laterally. The crest and rostrum with forward grasping forceps Uansen-
ethmoidal wound is utilized for suction and visuali- Middleton or vomer), one or both sphenoidal sinuses
zation using a Zeiss operating microscope, whereas the can be entered. Otherwise, an anterior wall puncture is
septal wound is used for instrumentation. The midline made close to the midline (see Fig. 5-5C and D). If there
is carefully checked through the septal exposure. An is any question regarding location, a lateral radiograph
opening is then made in the anterior wall of the is taken or videofluoroscopy is performed. Remember
pituitary fossa (see F and G). the internal carotid location lateral to the sphenoidal
sinus in the carotid groove (see Fig. 23-12C).
 BASE OF THE SKULL SURGERY

FIGURE 23-11
 BASE OF THE SKULL SURGERY
Transseptal Transsphenoidal
Hypophysectomy-Cryosurgical
and Surgical (Continued) (Fig. 23-")
C With Hajek or Kerrison forceps, the opening in the
anterior and inferior wall of the sphenoidal sinus is
enlarged to 2 cm in diameter.
D The anterior portion of the intersinus septum is
removed with forward-biting forceps. If this intersinus
septum is far from the midline, and the sella turcica is
well visualized, the septum need not be removed.
Intersinus septum
FIGURE 23-11 Continued
E The removal of the intersinus septum is completed.
F The bulge of sella turcica on the posterior wall of
the sphenoidal sinus is exposed. The position is
checked by a lateral radiograph or videofluoroscopy
with a probe against the sella turcica. If feasible, the
mucous membrane overlying the sella turcica is incised
to form inferiorly based flaps, as outlined along the
dotted lines.
One of two techniques can now be utilized to expose
the dura.
Base of intersinus septum
Mucous membrane of
post. wall of sinus

Transseptal Transsphenoidal
Hypophysectomy-Cryosurgical
and Surgical (Continued) (Fig. 23-11)
G Depicted is a small dental-type bur with a long
shank used to expose the dura. This is especially useful
if the presenting bone of the sella turcica is
exceptionally thick ..
H A lateral view of the bur technique is diagrammed.
I The opening made with the bur is enlarged with
Hajek or fine Kerrison forceps.
J The other technique for exposure of the dura when
the bone is thin is the use of a specially designed right-
angle osteotome. This method affords better visuali-
zation than with the bur. The presenting bulge of the
sella turcica is gently fractured in cruciate fashion.
FIGURE 23-11 Continued
BASE OF THE SKULL SURGERY 1399
K This shows the lateral view of osteotome against
the sella tu rcica.
L A blunt angulated hook is then placed under the
fractured fragments of the sella turcica, pulling the
fragments outward and exposing the outer layer of
dura. Depicted are the two layers of dura surrounding
the pituitary gland. At this stage, the operation micro-
scope with 6x to lOx magnification and a 300-mm
lens is utilized. The microscope is not as necessary
when the cryosurgical probe is to be used as when
surgical ablation of the gland is planned.
M The opening in the sella turcica is enlarged with
fine Kerrison forceps.
Continued
Wabni1Z..
 BASE OF THE SKULL SURGERY

Transseptal Transsphenoidal The cryotherapy consists of lowering the temperature

Hypophysectomy-Cryosurgical from -160°C to -180°C for 15 to 20 minutes. This neces-
and Surgical (Continued) (Fig. 23-11) sitates topical rather than general anesthesia, because
the visual fields should be checked every few minutes
Cryosurgical Hypophysectomy during the period of refrigeration. If visual disturbance
occurs, refrigeration is terminated. Any impairment is
This procedure is seldofIl utilized and of historical interest usually reversible because the venous sinuses act as
only. excellent buffers. The probe is removed after a defrosting
The size of this opening in the sella turcica depends period of 7 to 8 minutes. If a special heating attachment
on the procedure contemplated. When cryosurgical is available, the defrosting time is markedly shortened.
hypophysectomy is the choice, a 5- to 7-mm opening Another technique of cryotherapy is the freezing,
suffices for exposure of the dura. Cryosurgical technique defrosting and refreezing, and defrosting method. The
is preferred in extremely poor risk patients, when exces- temperature need not be lowered as much as before
sive hemorrhage accompanies an attempted surgical (e.g., from -40°C to -80°C). This technique is based on
hypophysectomy, or in secondary procedures. Before the theory that freezing and defrosting several times is
incision of the dura a needle aspiration of the sella is the actual process that destroys living tissue. In any
performed to evaluate whether a cystic lesion, empty event, this direct vision method of cryotherapy has dis-
sella, or aneurysm is present. This may be performed tinct advantages over the stereotactic method, which is
under radiologic visualization. cumbersome and time consuming.

Surgical Ablative Hypophysectomy

N TO 01 With an angulated myringotome, the two
layers of dura are incised in cruciate fashion (01). It is The opening in the sella turcica has been enlarged with
most important to incise both layers of dura because a fine Kerrison forceps to a diameter of 15 to 18 mm as
venous sinus exists between the two layers of dura. described by Heck and co-workers (1957). The cruciate
The yellow-colored pituitary gland is now exposed. incision (01) in the two layers of dura has also been
enlarged. This must be performed with extreme care to
P A 4.9-mm cryosurgical probe (Rand-Linde) is avoid nicking the anterior transverse communicating
inserted several millimeters through the dural opening smus.
and the position checked by radiograph. The probe is
then advanced to within several millimeters of the Complications
posterior clinoid process.
• Postoperative leakage of cerebrospinal fluid is rare;
Q Lateral radiograph shows the cryoprobe within if it persists to any extent, reinsertion of a larger muscle
the pituitary gland. The probe is low, and refreezing at graft into the pituitary fossa and sphenoidal sinus
a higher level is indicated. may be required.
Continued • Meningitis
• Hypothalamic injury
• Carotid-cavernous sinus fistula
• Carotid occlusion
• Transient cranial nerve paralysis
• Visual disturbance
 BASE OF THE SKULL SURGERY

FIGURE 23-11 Continued

 BASE OF THE SKULL SURGERY

Transseptal Transsphenoidal
Hypophysectomy-Cryosurgical T, U The inner layer of dura is further separated from
the gland using Angell-James modified Olivecrona
and Surgical (Continued) (Fig. 23-11) pituitary dissectors. At this stage, troublesome bleeding
may occur and can be controlled by temporary packing.
Selective Surgical Hypophysectomy
If severe bleeding continues, it is best to stage the
procedure or to use cryotherapy.
Microadenomas can be excised with preservation of the
Continued
remaining normal pituitary. A massive adenoma was
totally removed by suction.

R, S With a Tumarkin double-headed mastoid dis-

sector, the inner layer of dura is separated from the
pituitary gland. Inner and upper dissection is performed
cautiously, keeping in mind the cavernous sinuses
laterally and the communicating sinuses superiorly
and inferiorly.

u
FIGURE 23-11 Continued

Transseptal Transsphenoidal
Hypophysectomy-Cryosurgical
and Surgical (Continued) (Fig. 23-11)
V A small ring curet can also be used to separate the
gland from the dura. For improved visualization, espe-
ciallythrough the microscope, the handles on allthese
dissectors are angulated to suit the surgeon.
W The stalk of the pituitary gland is transected with
fine forceps; ideally,the entire gland is removed intact.
Ifthe gland fragments, this is no worry; the forceps and
curet are utilized to complete the removal. Zenker's
solution can be applied to the empty fossa to destroy
any remaining cells of the gland. On one occasion
after an adenoma was exposed, suction removed the
adenoma.
X A section measuring 2.5 x 1.5 cm of the vastus
intermedius muscle is inserted into the sella turcica and
the sphenoidal sinus. Both cavitiesshould be obliterated
to prevent cerebrospinal fluid leak. The muscle plug is
dipped in bacitracin solution before insertion.
The septal incision anteriorly is closed with two
sutures of 4-0 nylon. Half-inch plain strip gauze soaked
in the same bacitracin solution is inserted in each naris
FIGURE23-11 Continued
BASE OF THE SKULL SURGERY
and left in place for 3 to 7 days. The bacitracin solution
is applied to this packing every 4 hours. Prophylactic
antibiotics are used during this time, the choice depend-
ing on results of preoperative nose and throat cultures.
Corticosteroids are administered before, during, and
after the operation as follows: One day before the
operation, 25 mg of cortisone acetate is administered
orally four times that day; the morning of the opera-
tion, 100 mg of hydrocortisone sodium succinate (Solu-
Cortef) is given intramuscularly; during the operation,
100 to 200 mg of Solu-Cortef is given intravenously.
Postoperatively, 100 to 200 mg of Solu-Cortef is adminis-
tered daily intramuscularly or intravenously in divided
doses until the patient is able to tolerate 25 mg of corti-
sone acetate by mouth four times a day. This dose is
gradually reduced over a period of 1 week to a perma-
nent maintenance dose of 12.5 mg of cortisone acetate
three times a day.
The only other maintenance medication necessary is
Synthroid, 150 to 300 ~g, or generic levothyroxine, or 2
to 3 g of desiccated thyroid extract (Armour). Polyuria
and polydipsia are always present postoperatively and
continue for some time. They gradually decrease and
cause little concern. However, if they are troublesome,
3 to 5 units intramuscularly of vasopressin (Pitressin)
tannate in oil every 2 to 5 days, or posterior pituitary
powder insufflated in the nose three to four times a
day, may be administered.
X
 BASE OF THE SKUll SURGERY

Endoscopic Endonasal 2. Eyes should be protected with generous lubrication

Transsphenoidal Approach to the and gauze taped over them.
Pituitary Gland (Fig. 23-12) 3. The patient is kept "dry" by anesthesia. This avoids
Douglas B. Moreland a false-positive high urine output, which may be
misinterpreted as diabetes insipidus.
The two standard approaches to the sellar region are:
Patient Preparation
1. Craniotomy-subfrontal, pterional, bifrontal, and
supraorbital endoscopic key hole 1. A lumbar drain should be placed before positioning
2. Transsphenoidal. Although there are modifications for larger lesions (> 1.5 cm). Intraoperatively the
in this approach taken to reach the sellar region, the anesthesiologist may need to inject 10 to 20 mL of
direct approach remains the safest. This can be air or saline to facilitate tumor delivery into the opera-
accomplished with one of three methods: tive field. The drain can be left in postoperatively if
a. Endonasal cerebrospinal fluid leak occurs or is suspected.
b. Sublabial 2. The mouth should be packed with gauze to raise the
c. Transseptal palate. This prevents blood draining into the stomach.
A clamp should be placed on the gauze for easy
Indications for Surgery retrieval at the completion of surgery.
3. Both nares should be packed back to the sphenoid
• Tumors ostium with cottonoids soaked in oxymetazoline
• Cysts (Afrin) or cocaine. These can remain in place while
• Cerebrospinal fluid rhinorrhea scrubbing (10 to 15 minutes).
• Chordomas 4. Proper patient positioning can make this procedure
• Miscellaneous lesions technically safer, easier, and less stressful on the
surgeon's spine. See A and AI for details.
Preoperative Evaluation 5. The abdomen should be prepped at the navel for a
possible fat graft.
1. Full pituitary profile/endocrinologist evaluation 6. The bracket for the scope holder should be placed
2. Full visual field study on the table (opposite side of surgeon).
3. MRI with and without contrast medium enhancement 7. The table is placed in slight reverse Trendelenburg
4. CT with bone window (may be helpful in preoperative and flexed at the patient's hip and knees.
planning) 8. The head is placed in three-point fixation and rotated
S. AngiogramjMRA if vascular lesion is suspected IS degrees, flexed laterally to the left IS degrees.
9. The C-arm is positioned in a true lateral position
Anesthesia before draping.

1. General anesthesia with endotracheal intubation is

almost always preferred.

Surgical Technique
1. With the position shown in B for a right-handed
surgeon, the left naris is preferred unless the septum
deviates too much to the ipsilateral side. The
Afrin/cocaine-soaked cottonoids are removed and
replaced with povidone-iodine (Betadine)-soaked
cottonoids, which are left in for 5 minutes (while
setting up the scope and surgical equipment).
2. A 22-gauge spinal needle is used to inject the middle
turbinate and mucoperichondrium back to the
sphenoid ostium. The endoscope or Ioupes can be
used for this.
3. The middle turbinate is outfractured. The posterior
nasal septum is scored and fractured to the opposite
side so both sphenoid ostia are exposed.
4. A small osteotome, Jensen-Middleton rongeur, or
1- to 2-mm angled Kerrison rongeur can then be
used to remove a portion of the sphenoid bone and
intersinus septum. This should be at least 10 mm but
preferably 15 mm wide. The sellar floor and carotid
grooves should be identified (C).
5. The endoscope holder can be used to fix the scope
and free a hand.
6. A nasal speculum can then be used for retraction
and exposure. The advantage is less trauma to the
mucous membranes with the constant and repeti-
tive introduction of various instruments through
the nasal passage. The disadvantage is that it limits
maneuverability with instruments more so when
using the endoscope.
7. A good set of bayonetted microinstruments is essen-
tial at this point. The sellar floor can be chipped
away with a microcuret, drill, or Kerrison rongeur
depending on its thickness (CI). Before this, always
confirm your position with the C-arm. This exposes
the dura (CI). A cruciate incision is made in the
dura (D).
8. For microadenomas the tumor may be encased in
normal tissue and a linear incision in the normal
gland is required. The sagittal view of the sella
region seen in E demonstrates the advantage of the
3D-degree endoscope. The linear incision may be
placed laterally depending on the location of the
BASE OF THE SKULL SURCERY
lesion on preoperative imaging. The consistency of
these tumors can vary from cystic fluid, a thick
liquid (curdled milk), or firm with calcifications
and attachments to normal structures such as the
dura, optic apparatus, carotid arteries, cavernous
sinus, and pituitary stalk. The firmer and larger the
tumors are, the more difficult they are to remove.
9. For tumor removal, variously sized and angled ring
curets are the most helpful (F). A major portion of
these resections is by feel. 1Wo fingers on the curet
with a gentle rubbing motion is the safest technique.
Pituitary forceps can be used, but never pull or tear
tissue you cannot see.
10. The straight and 3D-degree angled endoscopes aid
in visualization of the tumor cavity, optic chiasm,
and cavernous structure. The author finds this supe-
rior to the microscope because it in effect allows
you to "look around corners."
11. Once tumor removal is completed, hemostasis is
checked and secured with single tip bipolar cautery,
Gelfoam, and/or Surgicel. With small tumors and
no cerebrospinal fluid leak or bleeding (check with
a Valsalva maneuver) no packing of the sella is
necessary. This can result in misleading or distorted
postoperative imaging studies.
12. If the sellar floor requires reconstitution, then
abdominal fat, Surgicel, Gelfoam, or a combination
of these is usually all that is required. Other more
aggressive options include a bone strut wedged
underneath the lips of the sellar floor. Allograft or
resected sphenoid bone or septum can be used.
Titanium craniotomy plates can also be used.
Postoperative Care
1. Care in the intensive care unit or neurologic obser-
vation unit is recommended for 24 hours.
2. Urine output is monitored closely for diabetes
insipidus.
3. Cortisol and/or thyroid replacement therapy may be
necessary.
4. Discharge is usually in 1 to 3 days after surgery in
uncomplicated cases.
5. Follow-up should be arranged with an endocrinologist.
 BASE OF THE SKULL SURGERY
Endoscopic Endonasal
Transsphenoidal Approach to the
Pituitary Gland (Continued) (Fig. 23-12)
Complications
The following is a list of the more recognized compli-
cations of this procedure, but the list is by no means
exhaustive. It is prudent to inform the patient of these
complications.
• Cerebrospinal fluid leak
• Diabetes insipidus (permanent or temporary)
• Pituitary insufficiency (permanent or temporary)
• Infection (meningitis), abscess
• Hemorrhage or stroke (brain attack)
• Loss of vision
• Loss of smell and/or taste
• Vascular injury
• Cavernous sinus syndrome
• Brain damage and death
The endonasal approach is the least invasive and most
direct. It avoids the unnecessary dissection of the upper
gum and nasal septum. The sellar exposure is not
sacrificed. This technique has come into favor in recent
years with the advent of the endoscope. The endonasal
approach can be utilized for almost all lesions involv-
ing the sella, with or without suprasellar or cavernous
extension. With larger invasive lesions the surgeon should
prepare the patient for a possible staged transcranial
approach as well as possible adjuvant therapy.
 BASE OF THE SKULL SURGERY

C-arm monitor

endoscope
monitor
anesthesia
equipment
B
Surgeon's position

septum of
c sphenoid bone D

Sphenoid
sinus

FIGURE 23-12
 BASE OF THE SKULL SURGERY
Temporal Bone Resection
(Fig. 23-13)
John S. Lewis
Indications
• Carcinoma involving the bony auditory canal, the
middle ear, or mastoid and for extensive glomus
jugulare tumors
• The author believes a partial temporal bone resection
should be utilized in carcinoma of the parotid salivary
gland when the tumor has spread along the facial
nerve into the temporal bone.
Highpoints
I. Insert a malleable spinal puncture needle in the
lumbar spinal canal for withdrawal of 30 to 40 mL
of cerebrospinal fluid late in the procedure, allowing
for exposure of the petrous pyramid.
2. Attain hypotensive anesthesia.
3. Through temporal craniotomy, avoid trauma to the
temporal lobe and sigmoid and cavernous sinuses.
4. Cauterize the superior and inferior petrosal sinuses
and mastoid emissary vein and middle meningeal
vessels, if necessary.
S. At the skull base, avoid injury to the jugular vein,
internal carotid artery, and hypoglossal and vagus
nerves. The facial nerve is sacrificed. Exposure of the
internal carotid artery via resection of the condyle of
the mandible is vital.
6. Manage lateral or sigmoid sinus tears by proximal
finger pressure and closure with atraumatic surgical
silk or a temporal muscle plug. A large sinus tear at
the jugular foramen level may be controlled with
vaginal packing.
Carcinoma of the Temporal Bone
1. Total parotidectomy may be necessary if there are
intraparotid metastatic lymph nodes.
2. A seventh to peripheral seventh nerve anastomosis
can be performed after transection of the seventh
nerve (see Chapter 7).
3. A radical neck dissection can be performed simul-
taneously or can be staged for cervical metastasis. If
feasible, when the neck dissection is staged it should
be performed after the temporal bone resection to
avoid ligation of the internal jugular vein before the
temporal bone resection. This can thus eliminate
backpressure in the internal jugular vein. If suffi-
cient cerebrospinal fluid is withdrawn, this can
obviate backpressure in the ligated internal jugular
vein if the neck dissection is performed as a first
stage.
4. To further evaluate the involvement of the mastoid
air cells and possibly dura, preoperative CT,MRI, and
bone scan can be very helpful. This is especially indi-
cated when the primary site of the tumor is clinically
believed to originate in the bony external auditory
canal, when in fact the external auditory canal tumor
is the "tip of the iceberg."
S. A primary origin of the neoplasm in the mastoid air
cells is rare (3 of 130 patients). In several patients
the neoplasm was secondary to radium dial paint as
well as secondary to radiation of the nasopharynx.
A Skin incision is shown with flap including pinna
based superiorly with modification for neck dissection.
A1 Skin incision is based inferiorly with auditory
meatus circumscribed.
A2 This skin incision is made if it is necessary to
sacrifice a diseased pinna with a bony specimen. If the
external ear is sacrificed, or a large segment of dura is
removed, a posteriorly based scalp flap should be rotated
to cover the defect or a pectoralis major myocutaneous
flap should be utilized.
B The extent of bony resection is outlined.
C This diagram indicates the extent of bony resection
of the squamosa and petrous pyramid.
D The incision is carried through the auricularis and
temporal muscles to expose the squamosa and mas-
toid with muscular attachments. It is made through
the parotid gland, sacrificing the facial nerve, to the
base of the zygoma and the ascending ramus of the
mandible. The posterior facial and external jugular
veins and superficial temporal artery are ligated and
divided. The auditory canal is cored widely to be
included with the specimen.
Continued
 BASE OF THE SKULL SURGERY

.;~_ .. '-_._'.'~."..",

"",
A B

---' , \'
\ I
'/\\'V,,-

FIGURE 23-13
 BASE OF THE SKULL SURGERY
Temporal Bone Resection
(Continued) (Fig. 23-13)
E The zygoma is transected, and the ascending
ramus of the mandible is sectioned near the joint. The
sternocleidomastoid muscle and posterior belly of the
digastric muscle are sectioned, exposing the internal
jugular vein in the carotid sheath. The styloid process
is transected with the stylohyoid muscle. A temporal
craniotomy is performed, mobilizing underlying dura
of the temporal lobe of the brain. The lateral sinus and
its sigmoid portion are carefully exposed.
F Cerebrospinal fluid is withdrawn, and the temporal
lobe and sigmoid sinus are retracted from the petrous
pyramid. A Stryker air drill saw with an orbital blade
sections the anterior portion of the middle cranial fossa
into the temporomandibular joint. The orbital blade
makes the initial incisions on the three surfaces of the
petrous pyramid near the junction of its medial and
middle thirds. Chisels are directed transversely to com-
plete the transections. When dura is involved, it is freed
from the petrous pyramid with the electrocautery
knife, the bony resection is completed, and then the
dura is removed and is replaced with temporal fascia.
It may be necessary to ligate the lateral sinus. This is
accomplished by making an incision on either side of
the sinus through the dura and then clamping and
cutting through the sinus wall in stages. The opening
is then closed with continuous 3-0 or 4-0 vascular silk.
G Soft tissue attachments are transected, and the
bony specimen is removed at the level of the jugular
foramen. The operative defect, including brain and
dura, petrous remnant, carotid and jugular vessels,
and hypoglossal and vagus nerves, is shown.
H The incision is closed in layers. The auditory
meatal defect is lined in purse fashion with a split-
thickness skin graft.
Continued
 BASE OF THE SKULL SURGERY

Transected portion
middle cranial fossa

Transected ascending
E ramus mandible

In!. carotid a. Petrous

remnant

FIGURE 23-13 Continued

 BASE OF THE SKUll SURGERY

Temporal Bone Resection Complications

(Continued) (Fig. 23-13)
Approach to the Internal Carotid Artery and the
Internal Jugular Vein
I Resection of the condyle of the mandible was done
to expose the internal carotid artery and internal jugular
vein. The glenoid fossa is thus visualized.
Continued
• Hemorrhage. This is usually from the lateral sinus or
petrosal vessels. Median blood loss is 2500 mL.
• Infection. This complication is usually in postirradiated
cases and often is caused by Pseudomonas aemginosa.
The use of systemic colistimethate (Coly-Mycin) and
local acetic acid and acriflavine dressings is most
effective.
• Cerebrospinal otorrhea. This occurs from dural tears
and can be prevented by the use of temporal muscle
flaps to cover exposed dura and by rotation of the
scalp flap to cover the defect. If a postoperative leak
lasts for more than 5 days, the wound should be
reopened and the dura repaired and splinted with
muscle tamponade.
 BASE OF THE SKULL SURGERY

VAGINAL PROCESS OF TYMPANIC

PORTION OF TEMPORAL BONE

FIGURE23-13 Continued
Temporal Bone Resection Results
(Continued) (Fig. 23-13)
Results of temporal bone resection are summarized in
Table 23-1.
J With an air drill, a portion of the bony wall of the
glenoid fossa is removed, thus exposing and facili-
TABLE23-1 End Results of Treatment (Total
tating the mobilization of the infratemporal internal
Experience: 32 Cases)
carotid artery. This is a vital step to protect the vessel
during temporal bone resection.
Five-year cure rate 37/131 (28%)
Radical surgery only 28 cases (28%)
• Complete loss of facial nerve function. A facelift Preoperative radiotherapy 73 cases, 18/73 (25%)
type of procedure can easily be performed at the and surgery (includes
initial procedure if the operator so desires. A lateral sandwich radiotherapy)
tarsorrhaphy will help prevent corneal ulceration. Surgery and postoperative 31 cases, 11/31 (35.5%)
• Vertigo. This complication lasts from 5 to 15 days, radiotherapy
and there may be a period of unsteadiness for several Pathology
Squamous cell carcinoma 108
months.
Basal cell carcinoma 7
• Hearing loss-complete.
Adenocarcinoma 5
• Carotid artery thrombosis. This has occurred in two
Embryonal 4
cases from trauma and is perhaps the most serious rhabdomyosarcoma
complication. Malignant melanoma 4
• Air embolism. This occurs from repeated use of cen- Spindle cell sarcoma 2
tral venous pressure line to aspirate air. Operative Angiosarcoma 1
mortality equals 10%. Malignant xanthoma 1

INT. JUGULAR V.

FIGURE 23-13 Continued


BIBLIOGRAPHY
Adams GL, Paparella MM, EI Fiky FM: Primary and metastatic
tumors of the temporal bone. Laryngoscope 81:1273-1285,1971.
Arigan S, Sasaki CT, Spencer D: Radical en bloc resection of the
temporal bone. Am J Surg 142:443-447, 1981.
Bateman GH: Trans-sphenoidal hypophysectomy. Otolaryngol Clin
North Am 4:205-215, 1971.
Bateman GH: Experiences with cerebrospinal fluid rhinorrhoea
arising from the pituitary fossa. Proc R Soc Med 59:169-174,1966.
Biller HF, Shugar JMA, Krespi YP: A new technique for wide-field expo-
sure of the base of the skull. Arch OtolaryngolI07:698-702, 1981.
Briant TD: Trans-sphenoidal hypophysectomy. Am Acad Ophthalmol,
October, 1967.
Bridger GP: Radical surgery for ethmoid cancer. Arch Otolaryngol
106:630-634, 1980.
Brodkey JS: Hypophysectomies in breast cancer. Surg Rounds, 1979,
pp 16-19.
Burjau K: Transsphenoidal operation for tumors of the pituitary
gland. Arch Otolaryngol 86:449-452, 1967.
Calcaterra TC: Current adjuncts for surgery of the sphenoid sinus and
pituitary gland. Trans Pac Coast Oloophthalmol Soc 56:105-113,
1975.
Cocke EW Jr, Robertson JH, Robertson JT, Crook JP Jr: The extended
maxillotomy and subtotal maxillectomy for excision of skull base
tumors. Arch Otolaryngol Head Neck Surg 116: 92-104, 1990.
Coleman CC Jr: Removal of the temporal bone for cancer. Am J Surg
112:583, 1966.
Conley JJ, Novack AJ: The surgical management of malignant tumors
of the ear and temporal bone. Arch Otolaryngol 71:635-642, 1960.
Cummings BJ, et al: The treatment of glomus tumors in the temporal
bone by megavoltage radiation. Cancer 53:2635-2640, 1984.
Daniels DD, et al: Differential diagnosis of intrasellar tumors by
computed tomography. Neuroradiology 141:693-701, 1981.
DeGroot L (ed): Endocrinology. New York, Grune & Stratton, 1979,
pp 244-246.
Dehner LP, Askin FB: Tumors of fibrous tissue origin in childhood.
Cancer 38:888-900, 1976.
Dehner LP, Chen JTK: Primary tumors of the external and middle ear.
Arch OtolaryngolI06:13-19, 1980.
Fisch U: Infratemporal fossa approach for lesions in the temporal
bone and base of the skull. Adv Otorhinolaryngol 34:254-266,
1984.
Fisch UJ: Infratemporal fossa approach for glomus tumors of the
temporal bone. Ann Otol Rhinol Laryngol 91:474-479, 1982.
Goodwin WJ, Jesse RH: Malignant neoplasms of the external auditory
canal and temporal bone. Arch OtolaryngolI06:675-679, 1980.
Graham MD, et al: Total en bloc resection of the temporal bone and
carotid artery for malignant tumors of the ear and temporal bone.
Laryngoscope 94:528-533, 1984.
Hamberger CA: Transantrosphenoidal hypophysectomy. Arch 010-
laryngol 74:2-8, 1961.
Heck W, McNaught RC, Greenspan FS, Kaplan HS: Trans-septal~
sphenoid pituitary surgery. Laryngoscope 67:906-943, 1957.
Hirsch 0: Eine neue Methode der endonasalen Operation von Hypophy-
sentumoren. Wien Med Wochenschr 636,1939.
Hirsch 0: Ober Methoden der operativen Behandlung von Hypophy-
sentumoren auf endonasalen Wege. Arch Laryngol Rhinol (Berl)
24:129, 1910.
Jackson CG: Surgery of Skull Base Tumors. New York, Churchill
Livingstone, 1991.
James JA: Transethmosphenoidal hypophysectomy. Arch Otolaryngol
86:32-40, 1967.
Janecka IP, Correll JW: Extended temporal bone resection. Ann Plast
Surg 10:143-146, 1983.
Kaplan IN, Duckert LG: Lesions metastatic to the infratemporal fossa:
Report of a case and review of the literature. Otolaryngol Head
Neck Surg 92:241-246, 1984.
BASE OF THE SKULL SURGERY
Kenan PD, Hudson WR: Chromophobe adenoma: Evaluation and
management. Trans Am Acad Ophthalmol Otolaryngol 73:52-59,
1969.
Kern EB, Laws ER, Randall RV, Westwood WB: A transseptal
trans sphenoidal approach to the pituitary: An old approach-a
new technique in the management of pituitary tumors and related
disorders. Trans Am Acad Ophthalmol Ololaryngol 84:997-1110,
1977.
Ketcham AS, Hoye RC, Van Buren JM, et al: Complications of
intracranial facial resection for tumors of the paranasal sinuses.
Am J Surg 112:591-596, 1966.
Ketcham AS, Wilkins RH, Van Buren JM, Smith R: A combined
intracranial facial approach to the paranasal sinuses. Am J Surg
106:698, 1963.
Ketcham AS, Chretien PB, VanBuren JM, et al: The ethmoid sinuses:
A re-evaluation of surgical resection. Am J Surg 126:469-476,
1973.
Khangure MS, ApSimon HT: Some pitfalls in the diagnosis of pituitary
tumors: The importance of carotid angiography. Surg Neurol
16:300-308,1981.
Kinney SE, Wood BG: Surgical treatment of skull-base malignancy.
Otolaryngol Head Neck Surg 92:94-99, 1984.
Koegel L Jr, Levine HI, Waldman SR: Paraganglioma of the sphenoid
sinus appearing as labile hypertension. Otolaryngol Head Neck
Surg 90:704-707, 1982.
Krespi YP, Sisson GA: Skull base surgery in composite resection. Arch
OtolaryngolI08:681-684, 1982.
Lee DA, Davis RK, Komanicky P, et al: Role of endocrine function
tests in the evaluation of transsphenoidal hypophysectomy for
advanced breast cancer. Am J Surg 143:481-485, 1982.
Lee JH, Oh CW, Lee SH, Han DH: Aplasia of the internal carotid
artery. Acta Neurochir 145:117-125; discussion 125, 2003.
Lee KJ, Goodrich I: The differential diagnosis of sellar and parasellar
diseases: Clinical and radiographic features. Otolaryngol Clin
North Am 14:355-378, 1981.
Lewis JS: Temporal bone resection: Review of 100 cases. Arch
Otolaryngol 101:23-25, 1975.
Lewis JS: Tumors of the external ear and temporal bone. Otolaryn-
gology 2:(Chapter 26), 1971.
Lewis JS, Page R: Radical surgery for malignant tumors of the ear.
Arch OtolaryngoI83:114, 1966.
Lewis JS, Parsons H: Surgery for advanced ear cancer. Ann Otol
67:364, 1958.
Longo MF, Clagett OT, Fairbairn JF II: Surgical treatment of thoracic
outlet compression syndrome. Ann Surg 171:538-542, 1970.
Lore JM Jr: Cryosurgical aspects of hypophysectomy. J Cryosurg
1:216-219,1968.
Lore JM Jr: Transseptal transsphenoidal hypophysectomy. Am J Surg
112:577-S88, 1966.
Macbeth R: Hypophysectomy as a clinicological procedure. Arch
Otolaryngol 75:440-450, 1962.
Meder JF, Blustajn J, Trystram D, et al: Radiologic anatomy of
segmental agenesis of the internal carotid artery. Surg Radiol Anat
19:385-394,1997.
Miglets AW, Saunders WH: Dural replacement with split thickness
skin: Long term experiments and clinical results. Laryngoscope
81:8-17,1971.
Montgomery W: Transethmoidosphenoidal hypophysectomy with
septal mucosal flap. Arch Otolaryngol 78:68-77, 1963.
Myers EN, Stool S, Weltschew A: Rhabdomyosarcoma of the middle
ear. Ann Otol 77:949-958, 1968.
Neely JG, Forrester M: Anatomic considerations of the medial cuts in
the subtotal temporal bone resection. Otolaryngol Head Neck Surg
90:641-645, 1982.
Nelson WR, Kell JF Jr, Kay S: Temporal bone resection and radical
neck dissection for basal cell carcinoma with metastases. Surg
Gynecol Obstet 115:585-592, 1962.
 BASE OF THE SKULL SURGERY
Newsome JF, Timmons RL, Van Wyk J, Dugger CS: Pituitary stalk
section for metastatic carcinoma of the breast. Ann Surg 174:769-773,
1971.
Netzer RH, McCoy EC: Transseptal transsphenoidal hypophysectomy.
Arch Otolaryngol 86:252-255, 1967.
Norrell H, Alves AM, Winternitz WW, Maddy J: A clinicopathologic
analysis of cryohypophysectomy in patients with advanced
cancer. Cancer 25: 1050-1060, 1970.
Osguthorpe JD, Adkins WY, Rawe SE: Combined extracranial-
intracranial resection of a maxillary desmoid tumor. Otolaryngol
Head Neck Surg 89:392-397, 1981.
Parsons H, Lewis JS: Subtotal resection of the temporal bone for
cancer of the ear. Cancer 7:995, 1954.
Persin KH, Cullane P, Conley J: Adenoid cystic carcinoma involving
the external auditory canal. Cancer 50:2873-2883, 1982.
Rand RW: Cryohypophysectomy and transfrontosphenoidal craniotomy
in pituitary tumors. Arch Otolaryngol 86:41-43,1969.
Reed PI, Pizey NCD: Transsphenoidal hypophysectomy in the treat-
ment of advanced breast cancer. Br J Surg 54:369-374,1967.
Rhoton AL Jr, Harris FS, Renn WH: Microsurgical anatomy of the
sellar region in cavernous sinus. Clio Neurosurg 24:54-85,1977.
Rumboldt Z, Castillo M, Solander S: Bilateral congenital absence of
the internal carotid artery. Eur Radial 13(suppl 4):Ll30-Ll32,
2003.
Schramm VL Jr, Myers EN, Maroon JC: Anterior skull base surgery
for benign and malignant disease. Laryngoscope 89:1077-1091.
1979.
Shah JP, Calicich JH: Esthesioneuroblastoma: Treatment by combined
craniofacial resection. NY State J Med 79:84-86, 1979.
Shah JP, Calicich JH: Craniofacial resection for malignant tumors of
ethmoid and anterior skull base. Arch Otolaryngol 103:514-517,
1977.
Sisson CA, Bytell DE, Becker SP, Ruge D: Carcinoma of the paranasal
sinuses and craniofacial resection. J Laryngol Otol 90:59-68, 1976.
Sisson CA, Johnson NE, Amiri CS: Cancer of the maxillary sinus:
Clinical classification and management. Ann Otol Rhinal Laryngol
72:lOS0, 1963.
Sliwka U, Schmidt P, Reul J, Noth J: Agenesis of the internal carotid
artery: Color Doppler, CT, and MR angiography findings. J Clin
Ultrasound 26:213-216, 1998.
Sam P, Biller HF, Lawson W: Tumors of the parapharyngeal space:
Preoperative evaluation, diagnosis and surgical approaches. Ann
Otol Rhinal Laryngol 90(Suppl 80):3-15, 1981.
Spector CJ, Sobol S: Surgery for glomus tumors at the skull base.
Otolaryngol Head Neck Surg 88:S24-530, 1980.
Terz JJ, Alksne JF, Lawrence W Jr: Craniofacial resection for tumors
invading the pterygoid fossa. Am J Surg 118:732-740, 1969.
Terz JJ, Young HF, Lawrence W: Combined craniofacial resection for
locally advanced carcinoma of the head and neck. Am J Surg
140:618-622, 1980.
Tiwari R: Reconstruction after temporal bone resection. J Laryngol
Otol 99:143-146, 1985.
Tollefsen HR, Miller TR, CeroId FP: Transantral sphenoidal hypophy-
sectomy. Am J Surg 112:569-576, 1966.
Trokoudes KM, et al: Sellar enlargement with hyperprolactinemia
and a Rathke's pouch. JAMA 240:471-473, 1978.
Urken ML, Biller HF, Haimov M: Intratemporal carotid artery bypass
in resection of a base of skull tumor. Laryngoscope 9S:1472-1477,
1985.
VaLenta LJ, Sostrin RD, Eisenberg H, et al. Diagnosis of pituitary
tumors by hormone assays and computed tomography. Am J Med
72:86-87, 1982.
Ward CE, Lock WW, Lawrence W Jr: Radical operation for carcinoma
of the external auditory canal and middle ear. Am J Surg 82:169,
1951.
Wiet RJ, Kazan R, Sacy C: Skull base mapping. Laryngoscope 92:515-523,
1982.
Willson JT: Anatomical considerations in transsphenoidal hypophy-
sectomy. Arch Otolaryngol 86:24S-251, 1967.
Wurster CF, et al: Osteoradionecrosis of the temporal bone. Otolaryngol
Head Neck Surg 90:126-129,1982.
Yonas H, Cur D, Cood BC, et al: Stable xenon CT blood flow mapping
for evaluation of patients with extracranial-intracranial bypass
surgery. J Neurosurg 62:333, 1985.
Youmans J (ed): Neurological Surgery. Philadelphia, WB Saunders,
1982, pp 3117-3137.
Young WF, Ospina LF, Wesolowski D, Touma A: The primary empty
sella syndrome. JAMA 246:2611-2612, 1981.
 24 MICROVASCULAR
SURGERY
ROBERT W. DOLAN
Microvascular Free Flaps
Highpoints
1. Microvascular flaps can be placed without com-
promise in fields grossly contaminated with saliva,
fight infection, and lead to improvements in wound
vascularity.
2. Microvascular reconstruction of complex wounds
requires fewer procedures and a shorter hospital stay.
3. Microvascular bone has revolutionized head and neck
reconstruction.
4. A microvascular tissue transplant is the flap of choice
for anterior mandibular, circumferential cervical,
esophageal, total and subtotal scalp, extensive cranial
base, and large orofacial defects.
5. The combination of a composite microvascular flap,
prosthetic device(s), and local flap(s) often produce
the best aesthetic and functional outcome.
6. Effective postoperative monitoring of flap viability is
essential.
7. Overall success rates, in terms of flap viability, of over
95% are expected.
8. Donor site morbidity is an important consideration
in flap selection.
9. A two-team approach, with separate teams for har-
vesting the flap and removing the tumor, minimizes
operative time.
Historical Perspective and Introduction
Microvascular free tissue transfer is the latest major
advance in reconstructive surgery and the main con-
tributing factor in improving the quality of life in patients
with extensive head and neck cancer. The vast variety
of free flaps available today is a result of anatomic vas-
cular studies early in the 20th century and a resurgence
of interest in skin vascularity ignited by the introduc-
tion of Bakamjian's deltopectoral flap in the late 1960s
(Bakamjian, 1965). The modern reconstructive surgeon
is able to deliver vast quantities of well-vascularized
tissue to allow closure of even the most complex and
vast head and neck postablative wounds.
Before the deltopectoral flap was introduced, closure
of complex head and neck wounds was accomplished
by skin from the anterior chest mobilized through a
series of "delay" procedures. Particularly problematic
were pharyngeal wounds that required multiple delay
procedures and skin grafts that often resulted in a
prolonged open and draining wound and several months
in hospital. The first reported microsurgical flap transfer
was for a cervical esophageal defect reconstructed with
a jejunal segment in 1957 (Seidenberg, 1959). However,
microvascular reconstruction was not practiced with
any regularity until the early 1970s. During this period,
there was more interest in regional tissue transfer and
basic flap vascular physiology. In the late 1960s, despite
requiring at least two stages, the deltopectoral flap
debuted and was immediately embraced as a significant
advance in pharyngeal reconstruction. During the 1970s,
several axial soft tissue and composite flaps were
discovered. The most important regional axial flap
discovery, with regard to head and neck reconstruction,
was the pectoralis flap (Ariyan, 1979). Several potential
microvascular free tissue flaps were also discovered,
but this method of reconstruction remained unpopular,
owing to technical demands and problems with flap
viability. The variety of microvascular flaps and flap
viability continued to improve throughout the 1980s.
Improvements in mandibular plating systems and
reconstructive plates occurred during this same period,
and many patients received these plates in lieu of the
much more involved technique of microvascular bone
transfer. Although regional composite flaps were avail-
able (e.g., pectoralis-rib), the bone often resorbed and
was inadequate. The reconstructive plate restored form
and, because patients rarely sought dental rehabilita-
tion even when reconstructed with vascularized bone,
this method was arguably adequate and less costly and
demanding. Over the years, these plates were covered
with a variety of flaps, including free and regional (most
often the pectoralis flap). This method became quite
popular but suffered a major setback as clinicians began
noticing with increasing frequency plate breakage and
exposure leading to complete loss of the reconstruc-
tion. This was particularly evident when a plate was
used to bridge an anterior segmental mandibular defect,
with plate exposure or breakage often occurring within
months. However, it was reported that vascularized
bone placed behind the plate resulted in a hardy and
permanent reconstruction. Because only microvascular
free tissue provided durable bone of adequate stock,
this method became the only reasonable choice for
anterior mandibular defects. An increasing awareness
1417
 MICROVASCULAR SURGERY
of the versatility and viability of free tissue flaps has
propelled free tissue transplantation to the forefront of
head and neck reconstruction.
The success rate of free flap transfer approaches
100% today, owing to improvements in flap selection,
development of precise techniques and instrumenta-
tion, and careful postoperative monitoring. In addition,
microvascular reconstruction reduces the number and
length of hospitalizations and operations, lowering
health care costs and returning the patient to a more
normal routine sooner.
Certain donor sites have become preferred for the
head and neck based on their ease of harvest, quality
of donor vessels, donor site morbidity, and the specific
needs at the recipient site. The majority of head and
neck defects can be reconstructed with one of four
flaps, including the radial forearm, osteocutaneous
fibula, rectus musculocutaneous, and jejunal. The iliac
osteocutaneous flap, the scapular system of flaps, and
the lateral arm flap are also useful in many selected
situations.
Flap Classification
Manchot (1889) extensively studied cutaneous blood
supply and introduced the concept that cutaneous
arteries consistently supply defined areas of skin (i.e.,
vascular territories). This seminal work was largely
ignored until the 1960s when studies of the arterial
supply to skin reemerged spurred by clinical work in
successful transposition of regional skin flaps. The
concept of an "axial flap" with its blood supply defined
as a single pedicle was introduced in 1973 (McGregor
and Morgan, 1973) based on an analysis of the blood
supply to the deltopectoral and groin flaps. The con-
cept of vascular territories and angiosomes (Taylor,
1982) provided a sound basis to explore potential new
flaps, including free flaps.
Axial musculocutaneous flaps are categorized as
types I to V (Mathes and Nahai, 1981):
I - Single dominant pedicle as sole blood supply to
the flap (e.g., tensor fasciae latae)
II - One dominant pedicle and multiple minor pedi~
cles that cannot support the flap if the dominant
pedicle is severed (e.g., trapezius)
II1- Dual dominant pedicles (e.g., rectus)
IV - Multiple segmental pedicles (e.g., sartorius)
V - One dominant pedicle and several segmental
pedicles, either of which is capable of supporting
the tissue (e.g., pectoralis major, latissimus)
Ponten (1981) described a fasciocutaneous flap with
a unique axial blood supply coursing within the deep
fascia completely independent of underlying muscle.
This deep fascia! plexus was a newly recognized com-
ponent of the blood supply to the skin. The deep fascial
vascular plexus tends to be well developed in the
extremities and shoulders (areas where the skin is tightly
adherent to the underlying deep fascia). Therefore,
fasciocutaneous flaps are found only in these areas
(e.g., the parascapular flap). The source arteries reach
the deep fascial plexus via septocutaneous segmental
arteries, and an axial vascular network is then formed
at the deep fascial level. There are two components to
the deep fascial plexus, including the sub fascia! plexus
and the prefascial plexus. The axial vascular network is
mainly concentrated in the prefascial plexus. Cormack
and Lamberty (1984) classified fasciocutaneous flaps
according to their pattern of blood supply:
A - Multiple perforators at base (e.g., medial thigh flap)
B - Single vascular perforator (e.g., parascapular flap)
C - Segmental arterial vascular supply (e.g., radial
forearm)
D - Type C with bone (e.g., osteoseptocutaneous radial
forearm or fibula)
Typical Donor Flaps
Only a few microvascular flaps are routinely used in
the head and neck, including the radial forearm, fibula,
rectus, scapula, latissimus, jejunum, iliac crest, and
gracilis. The radial forearm or "Chinese" flap is a type
C fasciocutaneous flap first described by Yang and
colleagues (1981). It provides thin pliable fasciocuta-
neous tissue from the ventral wrist and forearm based
on the radial artery, cephalic vein, and medial and
lateral antebrachial cutaneous nerves. The proximal
fibrofatty tissue in the forearm can be additionally har-
vested for augmentation or coverage in selected cases.
The radial forearm flap can also be harvested with a
portion of the underlying radial bone. However, patho-
logic fracture at the site of bone harvest is a significant
risk despite prolonged cast immobilization. Consider-
ing the variety of alternate donor sites for vascularized
bone, radial bone harvest is rarely warranted.
The fibula, scapula, and iliac crest are used nearly
exclusively for bony defects in the head and neck. The
fibular osteocutaneous free flap is a type D flap that
was originally described for use in mandibular recon-
struction by Hidalgo (1989). The fibula is tubular and
primarily cortical in composition and is the longest
microvascular bone available for mandibular reconstruc-
tion (26 em). Because the bone is a perfectly straight
tube, several osteotomies are usually required especially
if it is being used to replace the anterior mandibular
arch. The blood supply to the bone is based on the
peroneal artery and venae comitantes. The vascular
pedicle runs on the medial surface of the fibula along
its lower two thirds, sending terminal branches to the
periosteum and a medullary branch to the mid fibula.

Septocutaneous vascular twigs from the peroneal
artery course posterior to the fibular bone and enter the
posterior crural intermuscular septum to nourish the
skin of the lateral leg. A skin paddle can be harvested
with the fibular bone up to 6 cm wide along the entire
length of harvested bone. Wider skin paddles leave a
donor site that must be reconstructed with a skin graft.
The septum is firmly attached to the overlying skin so
the skin paddle remains firmly attached to the
underlying bone causing design limitations at the
recipient site. Sensory reinnervation is possible if the
lateral sural cutaneous nerve is harvested with the skin
paddle (Dolan et aI., 2000). Donor site morbidity is
minimal and full-unassisted ambulation is expected
within 2 to 3 weeks postoperatively.
The scapular osteocutaneous flap is a type B flap
that was originally described by Swartz and associates
(1986) for mandibular reconstruction. The lateral border
of the scapula provides approximately 16 cm of straight
elliptical bone based on the circumflex scapular artery
and venae comitantes. After sending a branch along
the lateral edge of the bone, the circumflex scapular
artery proceeds to exit the triangular space, dividing
into transverse and descending branches to supply the
skin overlying the scapular bone. Large independent
skin paddles can be harvested (transverse and para-
scapular fasciocutaneous flaps) with or without the
underlying bone. The angular artery, a branch of the
artery to the serratus muscle, additionally nourishes
the distal third of the scapular bone. This artery should
be preserved if a distal osteotomy is planned. Although
the osteocutaneous scapular flap and the latissimus-
serratus flaps can be harvested together based on the
subscapular artery, this mega flap is rarely needed. The
donor site for scapular flap harvest is inconspicuous
and of low morbidity.
Taylor (1982) described the type C iliac crest osteo-
cutaneous flap for mandibular reconstruction. The iliac
crest provides vascularized bone up to 16 cm in length
that is naturally curved, minimizing the need for
osteotomies. The bone and overlying skin are based on
the deep circumflex iliac artery. The overlying skin
receives nourishment from septocutaneous twigs
similar to the osteocutaneous fibular flap. The bone
height and cortical:cancellous ratio closely match that
of the native mandible. The skin component of the iliac
crest flap is excessively thick when it is used to cover
the free edge of the bone intraorally, similar to the
problems encountered with the skin components of the
scapular and fibular flaps. The thick tissue over the
neoalveolus impedes the placement of osseointegrated
implants and implant-borne dentures. It is possible to
harvest a portion of the thin internal oblique muscle
with the iliac crest bone and skin based on the ascend-
ing branch of the deep circumflex iliac artery. The
muscle can be draped over the neoalveolus and allowed
MICROVASCULAR SURGERY
to re-epithelialize, providing improved contour to the
neoalveolus that more closely matches the natural
alveolus. Although the iliac crest flap is an excellent
substitute for native mandible there is significant donor
site morbidity. Chronic pain and difficulty walking are
common, at least for the first several months postoper-
atively. There is also a risk of hernia and bowel injury.
The significant morbidity associated with flap harvest
has considerably dampened the initial enthusiasm for
this flap.
Tansini first described the type V latissimus muscu-
locutaneous flap as a pedicled flap for breast recon-
struction in 1896; Maxwell and colleagues (1978)
described it as a free flap. It is based on the thoracodor-
sal artery and venae comitantes and the thoracodorsal
motor nerve. The full expanse of the muscle and over-
lying skin is more often indicated for extensive trau-
matic or oncologic truncal or extremity wounds. The
thoracodorsal nerve is harvested with a portion of the
muscle to maintain bulk and achieve movement. Donor
site morbidity is usually minimal; however, the site is
prone to delayed healing and seroma formation.
The type III rectus abdominis musculocutaneous free
flap was first described in 1980 for an infraclavicular
defect (Pennington and Pelly, 1980) and in 1984 for use
in the head and neck (Taylor et aI., 1984). It is based on
the deep inferior epigastric artery and venae comitantes.
The cutaneous component can be quite bulky with a
substantial amount of subcutaneous fat that varies at
the recipient site with the patient's adiposity. The skin
and fat can be sustained by a single periumbilical vas-
cular perforator. Therefore, this "perforator flap" can be
transferred with virtually no underlying muscle except
a muscular cuff around the lone vascular perforator.
The motor supply is segmental with short nerve twigs
entering the lateral aspect of each rectus muscle. The
multiple tendinous inscriptions limit muscle excursion.
Donor site morbidity is minimal. Hernia can occur,
especially if the anterior rectus sheath is not preserved
below the arcuate line.
The jejunal flap was first used clinically to reconstruct
a cervical esophageal defect in 1959 (Seidenberg, 1959).
The flap fared well, but the patient died of a stroke on
the fifth postoperative day. The jejunal flap consists of
a segment of jejunum 3 feet beyond the ligament of
Treitz. The vascular supply is based on the mesenteric
arterial arcade from the superior mesenteric artery and
vein. The jejunal flap may be left intact and used as a
conduit or split along the antimesenteric border and
used as a patch. The revascularized jejunum actively
secretes mucus, and this attribute has been touted as
useful for irradiated recipient sites. A jejunostomy tube
is placed immediately after flap harvest and removed
once the patient is tolerating oral feeding.
The type II gracilis free flap was introduced in 1976
for the surgical treatment of facial paralysis (Harii et
 MICROVASCULAR SURGERY
aI., 1976). It provides a cylindrical muscle innervated
by multiple neural fascicles from the anterior division
of the obturator nerve. The blood supply is from the
medial femoral circumflex artery (a branch of the pro-
funda femoris artery). The gracilis muscle, as is the
case with all microvascular flaps for facial paralysis, is
reserved for patients with absent or nonviable facial
musculature. The obturator nerve is anastomosed to a
motor nerve in the recipient site, most commonly the
hypoglossal nerve, or to a previously placed cross-facial
nerve graft. Cross-facial nerve grafting must precede
microvascular flap transfer by several months to allow
time for the regenerating axons to reach the recipient
site. The sural nerve is usually used as the cross-facial
graft. Although donor site morbidity is negligible regard-
ing the gracilis muscle, sural nerve harvest leaves the
patient with permanent numbness and paresthesia over
the lateral foot. The diameters of the artery (1 to 2 mm)
and the vein (1 to 1.5 mm) to the gracilis muscle are
relatively small, making the microvascular anastomosis
more difficult. A potential but rare complication of flap
harvest is paralysis of the adductor muscles of the
extremity if the obturator nerve is taken too proximally.
The latissimus muscle/thoracodorsal nerve flap may
obviate the need for two stages by providing a suffi-
cient length of nerve to reach the opposite donor facial
nerve without the need for an intervening avascular
nerve graft. Early experience with this technique
appears promising with good return of function within
8 months.
Recipient Defects and Microvascular
Flap Selection
The principal indication for microvascular free tissue
transfer is immediate reconstruction of complex onco-
logic surgical defects. Typical surgical defects or condi-
tions that compel free tissue transfer include composite
mandibulectomy, pharyngoesophagectomy, partial and
total glossectomy, selected cases of facial paralysis,
extensive cranial base resections, extensive scalp loss,
and total composite maxillectomy.
Microvascular techniques are well established for
reconstruction of segmental mandibular defects affect-
ing the anterior arch (the portion of the mandible
between the mental foramina). Failure to reconstruct
this segment results in the highly objectionable Andy
Gump deformity, oral incompetence, and retrodisplace-
ment of the tongue. In addition, the hyomandibular
muscle complex takes origin from the anterior arch
and functions to elevate the larynx during deglutition.
Modern reconstructive materials for the anterior arch
include mandibular reconstruction plates, avascular bone
grafts, pedicled vascular bone grafts, and microvascular
bone grafts. Avascular bone grafts placed primarily are
most often resorbed secondary to avascular necrosis
and infection. Pedicled vascular bone grafts (e.g.,
pectoralis-rib) meet a similar fate owing to their depend-
ence on a precarious periosteal blood supply. Experience
with steel and titanium plates has revealed an unac-
ceptably high rate (35 %) of hardware failure mainly
from intraoral plate exposure due to the pulling forces
of the hyomandibular muscles attached to the soft
tissue around the plate (Boyd et aI., 1995). However,
microvascular bone placed behind a plate creates a
durable reconstruction that resists hardware breakage
and exposure. The bone provides stability to maintain
good bite force and acts as an adequate substrate for
osseointegrated dental appliances. Any of the favored
microvascular osseous donor sites will suffice for the
borte; however, more discernment in flap selection is
needed with regard to the associated soft tissue deficits.
The scapula provides the maximum quantity of soft
tissue and is useful for high-volume composite defects
involving the anterior arch and oral, cervical, and facial
skin. In some cases, the soft tissue component of the
osseous flap may be too bulky and inflexible for intra-
oral placement. This is one of the few indications for a
dual microvascular transplant consisting of a fibula and
a radial forearm free flap. The radial forearm can be
incorporated into a flow-through design by anastomos-
ing the distal peroneal vessels to the radial artery and
cephalic vein (or vena comitans).
Isolated segmental defects involving the lateral
mandible (posterior to the mental foramen) tend to be
less morbid compared with the anterior arch. Without
reconstruction, the size and anterior position of the
defect is proportional to the morbidity in terms of
mandibular drift, malocclusion, and contour deficiency.
Speech and swallowing are related more to the asso-
ciated soft tissue deficits and radiation therapy. A
reconstruction plate is useful to prevent mandibular
drift and malocclusion and in some cases will not
prevent the use of dentures. However, the risk of hard-
ware failure (breakage or exposure) increases substan-
tially after approximately the third postoperative year.
Microvascular bone placed under a plate demonstrates
long-term stability and avoids contour deficiencies and
hardware failure.
Total laryngopharyngectomy is the typical surgical
defect that calls for a microvascular flap to reestablish
the connection between the oropharynx and esophagus
in a single stage. Before the advent of free tissue, suc-
cessful expedient single-staged surgery was not possible.
Although a jejunal free flap was transferred for this pur-
pose in 1959, only after the introduction of Bakamjian's
deltopectoral flap was this defect routinely reconstruct-
ed in fewer than three or four stages. Even the avail-
ability of multiple regional flaps (e.g., pectoralis flap)
proved unsatisfactory because they were too bulky and
were prone to breakdown and stricture formation. The
gastric pull-up method can successfully replace the

pharyngoesophagus, but it is associated with significant
morbidity owing to the abdominal and thoracic dissec-
tions. Nevertheless, this method is preferred when the
distal esophageal defect is inaccessible below the sternal
notch. The "workhorse" for replacement of the pharyn-
goesophagus was the jejunum. However, experience
with thin fasciocutaneous flaps has flourished (e.g.,
radial forearm or lateral thigh), and these flaps should
be considered first line. Abdominal surgery is avoided
by using a fasciocutaneous flap, which tolerates second-
ary ischemia much better, improving flap salvage rates
in case of postoperative vascular compromise. Esophageal
voicing is also improved using a fasciocutaneous flap
versus the jejunum and other intestinal flaps.
Tongue reconstruction remains a challenge despite
the availability of microvascular techniques. To achieve
the best outcome, the mobility of the remaining tongue
is preserved and sensation is restored to the recon-
structed parts. The tongue is closed primarily if possible,
flap tissue placed over the remaining tongue is mini-
mized, and sensation is restored to flap tissues. Primary
closure is usually possible for limited glossectomy
defects involving less than 30% of the oral tongue and
tongue base. Larger defects may be amenable to skin
grafting if there is no communication with the neck
that must be addressed (i.e., through-and-through
defect). Through-and-through defects involving over
half of the mobile tongue are best reconstructed with
thin pliable sensate tissue. The radial forearm flap is
designed in the form of an "M" and inset with one lobe
covering the floor of mouth and the other lobe
resurfacing the raw surface of the tongue (Urken and
Biller, 1994). An antebrachial cutaneous sensory nerve
from the flap is anastomosed to the ipsilateral lingual
nerve to restore sensation. A deficiency in tongue base
volume may be compensated for through an enhanced
constriction of the pharyngeal muscles, including the
superior constrictor. However, loss of more than 50%
of the tongue base (posterior to the circumvallate papil-
lae) will result in loss of swallowing efficiency, with
pooling of secretions and food in the valleculae and
piriform sinuses. Aspiration is likely if adequate bulk is
not added to the tongue base to restore the oropha-
ryngeal seal and pumping action necessary to propel
secretions and food through the piriform sinuses.
Mobility in the tongue base is key in maintaining this
pump action. However, restoring sensation to flap tissue
at the tongue base has not been proved to be of benefit.
Therefore, replacing partial tissue loss at the tongue
base to restore adequate volume can be accomplished
with insensate tissue and microvascular transfer is not
necessarily used. Regional flap transfer including the
pectoralis flap is sufficient. Severe swallowing and
aspiration difficulties are expected after total glossec-
tomy or denervation of the remaining tongue base
(McConnel et aI., 1987).
MICROVASCULAR SURGERY
Microvascular flaps offer two advantages over regional
flaps for total tongue reconstruction: (1) improved posi-
tion and bulk of the neotongue and (2) potential for
coordinated gross movement of the tongue base. Regional
flaps tend to undergo atrophy and fall away from the
hard palate because a large part of their initial bulk is
muscle that undergoes denervation atrophy over time.
Microvascular flaps tend to maintain their bulkiness
and resist sagging because the muscular component
can be reinnervated or minimized (in favor of a greater
content of fat) and the flap can be more effectively
sutured into place unimpeded by a large pedicle. The
most promising feature of microvascular flap transfer is
the ability to achieve movement at the tongue base to
partially restore the pumping function and improve
swallowing efficiency. The rectus musculocutaneous
and latissimus flaps are transferred with underlying
muscle that is reinnervated by anastomosing the motor
nerve to the hypoglossal nerve stump. Clinical experi-
ence with this method is limited, and improvements are
needed to maximize the mobility of the tongue base.
Nevertheless, microvascular reconstruction offers the
patient the best opportunity to develop a successful
swallow in the presence of an intact larynx.
Microvascular flap transfer is useful in selected cases
of facial paralysis, and it is indicated for patients with
unworkable mimetic musculature (e.g., Mobius' syn-
drome or long-standing facial denervation). Although
eye and forehead movement is attainable, microvas-
cular flaps are most often used to restore support and
movement to the oral commissure. The objectives are
to improve oral competence, symmetry, and facial
expression. The donor muscle is secured to the malar
eminence and oral commissure, and the donor nerve is
usually anastomosed to a previously placed cross-facial
nerve graft. The free gracilis muscle offers excellent bulk
and contractile characteristics, and it is easily harvested
with no donor site morbidity.
The vast majority of cranial base resections are
reconstructed with locally available tissues, including
the temporalis muscle and galea frontalis flaps. When
these flaps are insufficient or if there is a large surface
defect extending to the cranial cavity then microvas-
cular tissue is warranted. Most often, a communication
between the anterior skull base and nasal cavity must
be obliterated. A buried microvascular flap such as a
muscle-only rectus flap or a fascia-only radial forearm
flap is useful. The radial forearm flap provides a longer
vascular pedicle and is useful when recipient vessels in
the neck must be used (i.e., the superficial temporal
vessels are insufficient). Substantial through-and-
through surface defects require a large musculocuta-
neous flap such as the rectus flap or latissimus flaps.
There are numerous methods available to reconstruct
the scalp, including a host of local transposition flaps,
scalp expansion, and skin grafting. Local transposition
 MICROVASCULAR SURGERY
flaps or scalp expansion are preferable because they
bring hair-bearing skin into the reconstructed area.
Skin grafting is often a temporary measure while the
adjacent scalp is undergoing expansion. The skin graft
is discarded, and the expanded scalp is transposed into
the defect. Microvascular reconstruction of scalp defects
is reserved for extensive total or subtotal full-thickness
scalp loss, especially if there is also full-thickness bone
loss. A microvascular flap at its best only achieves
coverage with non-hair-bearing skin. If the traditional
methods of scalp reconstruction are unusable or insuf-
ficient, then microvascular reconstruction should be
considered. The goal is to provide coverage and protec-
tion of the cranial contents. If there is a full-thickness
bony scalp defect, split calvarial bone grafting or hydrox-
yapatite cement should be used and covered with vas-
cularized tissue. Vascularized bone is used if the recip-
ient bed is irradiated or avascular. Musculocutaneous
flaps are generally too bulky, adversely affecting the
aesthetic result. The ideal microvascular flap should
provide expansive thin vascularized tissue that is suit-
able for skin grafting. If vascularized bone is needed,
the latissimus/serratus/rib microvascular flap is useful.
The ribs span the bony defect while the latissimus
muscle is stretched over the scalp defect, providing a
vascularized bed for skin grafting. However, the
latissimus muscle will cover only about two thirds of
the scalp. Total scalp replacement is possible with free
omentum, the first free tissue transfer described for
scalp coverage.
The goals of maxillary reconstruction include support
for the orbital floor, restoring cheek contour, separation
of the oral cavity from the nasomaxillary cavity, and
support for maxillary dentures or osseointegrated
implants. After routine hemimaxillectomy, with or with-
out resection of the orbital floor, a dental prosthesis
supported by the remaining palate is usually adequate
to obturate the nasomaxillary cavity. The cavity is skin
grafted, and the orbit is adequately supported by
Lockwood's ligament despite an absent orbital floor.
The cavity must be cleaned daily, but it is generally
well tolerated. Although microvascular reconstruction
will obliterate the cavity and permanently close the
fistula, this type of reconstruction has not been popular.
The arguments against using microvascular flaps after
routine total maxillectomy include the relative expedi-
ency of a skin graft and an obturator and the value of
an open sinus cavity for cancer surveillance. The issue
of cancer surveillance is controversial because most
cancers that recur in this area are posterior and are
unlikely to be amenable to further surgical therapy.
There is considerably less controversy concerning the
use of microvascular flaps for reconstruction of com-
plex total maxillectomy defects involving orbital exen-
teration or cheek composite resection. Orbital exenter-
ation considerably increases the volume of the surgical
resection and results in a huge surgical cavity prone to
hygiene and contour problems. Microvascular oblitera-
tion of the space alleviates these problems and has the
added benefit of permanently closing the palatal defect.
Three surfaces must be covered with skin, including
the orbit, nasal cavity, and palate. A large microvas-
cular musculocutaneous flap is needed, such as the
rectus flap or latissimus flap. Total maxillectomy with
a significant through-and-through resection of cheek
skin (composite maxillectomy] creates a complex sur-
gical defect that requires microvascular tissue. The flap
should include bone if the malar eminence is missing
because this structure is responsible for maintaining
cheek contour after maxillectomy. In addition, bony
reconstruction of the hard palate should be considered
if the remaining hard palate is insufficient to support a
denture. This occurs if there is inadequate teeth or
insufficient remaining alveolus anteriorly. In cases of
routine hemimaxillectomy with overlying cheek skin,
a skin-only flap is sufficient. Three surfaces require
coverage, including the cheek, lateral nasal wall, and
palate. An augmented radial forearm flap folds easily;
and by including the proximal subcutaneous tissue in
the forearm, the maxillary cavity can be filled out and
obliterated. If the remaining palate or malar eminence
needs a bone graft, a microvascular osteocutaneous
flap is preferred. Avascular bone grafts should probably
be avoided if postoperative radiation therapy is planned.
The scapular osteocutaneous flap provides sufficient
bone and soft tissue to meet the requirements of even
the largest composite maxillectomy defect. When a
composite maxillectomy is combined with orbital exen-
teration a massive defect is created that requires a very
large musculocutaneous flap, such as the rectus flap or
latissimus flap. The addition of vascularized bone to
this type of reconstruction is impractical because the
size and weight of the flap tends to overwhelm the
refinement offered by well-placed bone.
Microsurgery
Microsurgery is defined as surgical procedures per-
formed under the magnification of a surgical micro-
scope. Although the vast majority of vessel anasto-
moses involving free tissue transfer are performed with
the aid of a microscope (6x to 25x], surgical loupe
magnification (2.5x to 3.5x] may be adequate for larger
vessels with diameters over 2.0 mm. The microscope
should be configured with dual heads with stereovision
to allow an assistant to be seated across the operating
table. The most important factor in achieving success is
rigorous attention to detail and meticulous atraumatic
technique. Appropriate microvascular instrumentation
is essential and should include straight jewelers forceps,
a straight or curved microneedle holder, straight and
curved microscissors, a vessel dilator, a clamp appli-

cator, and a micro bipolar. An ,assortment of microvas-
cular clamps should be available with closing pressures
less than 30 g/mm2, The clinical instruments should be
duplicated in a small animal laboratory to facilitate
realistic training sessions, The novice microvascular
surgeon should first practice microsurgical techniques
using synthetic vascular material with diameters between
LO and 2,5 mm, After the basic skills are established
the surgeon should advance to the deep inferior epigas-
tric artery and vein in the rat Consistent performance
resulting in serial patent anastomoses indicates suffi-
cient expertise to proceed into the operating room, The
needed number of laboratory training sessions varies
but approximates 40,
It makes little difference whether the artery or vein
is anastomosed first unless an impediment is created
that will present problems with access to the subsequent
anastomosis, End-to-end anastomoses are always done
on the arterial side, but end-to-side anastomoses are
often performed on the venous side between the donor
vein and the internal jugular vein, It makes no difference
at what angle the donor vein connects to the recipient
vein unless the vein is kinked or compressed, The novice
microvascular surgeon should be familiar with the end-
to-end microvascular anastomotic technique,
FIGURE 24-1
MICROVASCULAR SURGERY
End-to-end anastomoses begin by meticulous vessel
preparation, The vessels are handled using jewelers
forceps by grasping only the adventitia, The closing
forces generated by arterial clamps correlate with the
extent of intimal injury and thrombogenic potentiaL
Therefore, vascular occlusion clamps are applied with
only enough pressure to occlude blood flow, The donor
and recipient vessels can be clamped independently, or
a framed clamp (clamps joined by two parallel bars)
may be used to keep the vessel ends in alignment The
adventitia is strongly thrombogenic so it is removed
from around the area of the proposed anastomoses
using the curved microvascular scissors, Heparinized
saline irrigation (100 U/mL) is applied to each lumen
to keep them clear of clots and debris, Papaverine
(30 to 40 mg/mL) or 2 % lidocaine can be applied to
minimize vessel spasm, The vessel ends are gently
dilated with a spatulated dilator forceps, Depending on
the diameter of the vessel, an atraumatic nylon suture
is chosen between 8-0 and 10-0, Carrell's triangulation
method of suture placement is popular. Three stay
sutures are placed to initially approximate the vessel
ends 120 degrees apart As the stay sutures (two at a
time) are pulled taut, the back wall tends to fall away,
facilitating accurate placement (Fig, 24-1), Sutures are
 MICROVASCULAR SURGERY
placed by continually halving the distance between the
apposing sutures to achieve a watertight seal. The
needle must pass through the media and intima at a
right angle approximately two vessel thicknesses away
from the edge. The posterior edge is accessed for suture
placement by flipping the vascular clamps 180 degrees.
Problems that may lead to thrombosis include inadver-
tent suture placement through the back wall of the
vessel, rough handling, failure to include a slightly
separated intima with the stitch, and inclusion of a
significant amount of adventitia within the vessel lumen.
The venous anastomosis is slightly more difficult than
the arterial anastomosis because the walls of the veins
are thinner and collapsible; however, fewer sutures are
required. The venous clamps are released first. Arterial
leakage is common but will usually subside. Brisk
bleeding will require the placement of additional sutures.
Re-endothelialization along the suture line begins by
day 3 and is complete by day 7 in the veins and arteries.
Size mismatch is better tolerated on the venous side
where mismatches up to 2:1 are acceptable. Cutting the
smaller vein at an angle (spatulation) allows end-to-
end approximation, but greater mismatches are best
handled by an end-to-side anastomosis. The usual prob-
lem on the arterial side is that the donor artery is much
smaller than most of the branches of the external carotid
artery. End-to-side anastomoses are generally not per-
formed on the arterial side, and connecting to the com-
mon or internal carotid system is contraindicated.
A continuous suture technique is feasible for both
the artery and vein. It should be reserved for larger
vessels with a diameter of at least 2 mm because the
continuous suture narrows the lumen. A continuous
suture technique is most applicable to large veins where
slight luminal narrowing is insignificant and tight
approximation is not critical. Interpositional vein grafts
can be used to bridge arterial and venous gaps with
success comparable to single anastomoses. Vein grafts
must be reversed so the valves do not obstruct flow.
A useful alternative to suture for the venous anas-
tomosis is a stapling device (e.g., 3M Coupler). The
end of each vein is pulled through a plastic ring and
spread over protruding prongs that penetrate and secure
the veins. The opposing plastic rings are approximated
and secured by penetration of the prongs into the
opposite ring. These devices are indicated only for the
venous anastomosis. Anastomotic time is significantly
reduced, and animal studies show that patency rates
are equivalent to those of hand-sewn anastomoses.
Neurorrhaphy
A nerve trunk is a collection ofaxons (nerve fibers)
ensheathed in endoneurium, perineurium, and
epineurium. Endoneurium surrounds the individual
axons; perineurium encases groups ofaxons; and
epineurium surrounds the perineurium and ensheaths
the entire nerve trunk. A nerve fascicle is a group of
axons and its perineurium. It is the smallest compo-
nent of a nerve trunk that can be used for micro neural
anastomosis. A monofascicular nerve (e.g., facial nerve
trunk) consists of a single large fascicle ensheathed by
epifascicular epineurium. A polyfascicular nerve (e.g.,
inferior alveolar nerve and lingual nerve) consists of
many small fascicles of varying size with intervening
interfascicular epineurium all ensheathed by epifas-
cicuIar epineurium. In cases of microvascular transplan-
tation of muscle for facial paralysis, fascicular (perineural)
repairs are done to precisely match the unique donor
motor fascicles to the appropriate division of the facial
nerve. For example, the obturator nerve trunk consists
of nerve fascicles that innervate discrete areas of the
gracilis muscle. The epifascicular epineurium is opened
and the individual fascicles are electrically stimulated
to define two independent areas of muscular movement
and innervation. The fascicle supplying the part of the
muscle used for the oral commissure is anastomosed to
the lower division of the facial nerve. The fascicle
supplying the upper part of the muscle that is used for
the eyelids is anastomosed to the upper division of the
facial nerve (or cross-facial nerve graft from the upper
division of the opposite facial nerve).
Microneural anastomosis at the level of the epifas-
cicular epineurium is sufficient in the majority of cases
involving microvascular surgery. Unlike peripheral nerve
coaptation after traumatic neurolysis, the topographic
precision of a perineural repair is not needed when
coapting purely sensory or purely motor nerves.
Cutaneous sensory reinnervation is possible using the
radial forearm flap and the fibular as tea cutaneous flap.
The greatest benefit of sensory reinnervation is found
in the perioral area. Recovery of sensation around the
lips and anterior oral cavity improves articulation, oral
competence, and food bolus manipulation. Sensory
reinnervation using the lingual nerve or inferior alveolar
nerve results in the return of all aspects of normal sen-
sation, including touch, pressure, temperature, and pain.
Sensory discrimination may be improved at the recip-
ient site because of the greater cortical representation
of the cranial nerves. Motor reinnervation is possible
using the rectus, latissimus, and gracilis muscles. Rein-
nervation is useful to maintain muscle bulk in cases of
tongue reconstruction and to achieve movement in
cases of facial paralysis and tongue base reconstruc-
tion. The ipsilateral facial nerve or a cross-facial nerve
graft is used for cases of microvascular muscle transfer
to correct facial paralysis. An epineural repair is suffi-
cient unless the muscle is separated to reanimate the
upper face in addition to the oral commissure.
Microneurorrhaphy is a precise method of nerve
anastomosis ideally resulting in the accurate alignment
of nerve sheaths composed of viable Schwann cells to

allow unfettered axonal growth across the site of coap-
tation. Precise end-to-end alignment of the nerve fasci-
cles must be achieved. A tensionless epineural repair is
important because the epineurium will stretch imper-
ceptibly, separating the underlying nerve fascicles. An
epineural repair that results in prolapsing fascicles may
be too tight and should be loosened to allow the fasci-
cles to lie end to end. Excess fascicular content extrud-
ing through the suture line should be trimmed so that
regenerating nerve fibers are not directed through the
anastomosis. If the individual fascicles are sufficiently
large, one or two 10-0 approximating perineural sutures
can be used before suture coaptation of the epineurium.
Microneurorrhaphy (epineurium) begins by trimming
excess adventitia from the end of the donor and
recipient nerve trunks under the microscope. Two stay
sutures (10-0 or 9-0 nylon) are placed 180 degrees apart
through the epineurium of each nerve trunk being
careful not to penetrate the underlying nerve fascicles.
The spaces between the stay sutures should be halved
with interrupted sutures until the nerve trunks are
completely coapted. Small nerves may only require
four sutures, whereas larger nerve trunks may require
up to eight sutures. Factors associated with successful
neural anastomosis include optimal nerve coaptation,
minimal surgical trauma, and survival of the nerve
graft. Survival of the nerve graft is important because
viable Schwann cells are needed for axonal propaga-
tion along the nerve graft. This is usually not an issue
with microvascular transfer because the nerves are
revascularized with the rest of the transplant. Schwann
cells in nonvascularized nerve grafts depend on a
healthy vascularized bed for survival. A nonvascular-
ized nerve graft undergoes inosculation and ingrowth
of blood vessels in a process that is similar to revascu-
larization of a skin graft. Nonvascularized nerve grafts
may not perform well if they are placed on an avascular
(e.g., previously irradiated) bed. In these cases, a vas-
cularized nerve graft should be considered to maximize
neural regeneration (Schultes et aI., 1999).
Operating Room Set-up
Preparing a microsurgical case that will involve an
extirpative surgery team and a reconstructive surgery
requires careful planning. The operative fields should
remain separate and use two unique sets of surgical
instruments and nursing teams. The patient is placed
on the operating room table with the head and neck
positioned over an area under the table that is free of
obstruction. This usually requires that the patient's
head be placed at the foot-end of the table. If the posi-
tion of the patient must be changed during the course
of the procedure to allow harvest of the free flap, this
should be anticipated by placing the patient on an
appropriately conforming mattress. The harvest site
MICROVASCULAR SURGERY
should be prepped and draped separately from the head
and neck. Until the flap is needed, it is allowed to remain
pedicled by its source artery and vein at the donor site
and the pedicle is divided when the recipient site is
ready to accept the flap. The appropriate donor vessels
should be dissected at this time. The free flap is trans-
ferred to the head and neck and inset before the
microvascular anastomosis. Once the flap is inset, the
donor vessels are allowed to drape across the neck in a
position that will now be relatively stable. Recipient
vessels should be chosen that closely match the size
and geometric orientation of the donor vessels, unless
an end-to-side anastomosis is planned. The microscope
is sterilely draped and brought to the head of the table.
The microscope ocular configuration should consist of
ocular pieces that are separated by 180 degrees and are
independently maneuverable. It makes no difference
whether the artery or vein is anastomosed first. An
appropriate donor artery or vein is chosen, often the
facial or superior thyroid vessels, and the microvascular
anastomoses proceed. The microsurgical instruments
should be laid out on a separate table with the microvas-
cular clamps, irrigation solutions, and extra suture. The
irrigating solutions consist of heparin, 100 units/mL,
and papaverine, 30 to 40 mg/mL, and are dispensed
through 22-gauge intravenous catheters connected to
lO-mL syringes. Ischemia time or the elapsed time
between removing the flap from the donor site and
reestablishment of blood flow is a consideration during
this process. The ischemia time during initial flap trans-
fer is the "primary" ischemia time, whereas ischemia
time during secondary postoperative ischemic events is
"secondary" ischemia time. Composite microvascular
flaps can endure over 8 hours of ischemia time with-
out any loss of viability. Intestinal flaps including the
jejunum may only tolerate as little as 4 hours of primary
ischemia time before loss of viability. If a prolonged
primary ischemia time is anticipated, the flap should be
kept cool between 45° and 55°F. Once the anastomoses
are completed, the head is gently turned from left to
right and the vessels are observed for any kinking or
positional problems.
Recipient Site Vessel Selection in the
Difficult Neck
Although microvascular techniques have advanced, the
lack of a suitable recipient vessel may still preclude or
jeopardize successful free tissue transfer. Common
problems include inadequate pedicle length, a lack of
suitable veins, arterial mismatch, or a total lack of a
suitable artery or vein. Inadequate pedicle length can
be remedied through the use of reversed vein grafts.
Vein grafts are most commonly obtained by harvesting
them from the specimen or from the leg. The graft is
reversed so that the valves are nonfunctional. The use
 MICROVASCULAR SURGERY
of vein grafts is not associated with an increased inci-
dence of flap loss or thrombosis. If a vein is not avail-
able for anastomosis within the head and neck, the
transposed cephalic vein is useful. It is divided distally
near the biceps brachii muscle and turned into the
head and neck based on the axillary vein. The cephalic
vein is large caliber and is not typically within prior
surgical or radiation fields.
Arterial mismatch is a common problem when the
donor artery is small (1.0 to 1.S mm). The majority of
the named vessels from the external carotid artery and
thyrocervical trunk are much larger, with a single
exception-the ascending pharyngeal artery. The
ascending pharyngeal artery is often neglected because
of its posterior location. It originates posteriorly just
beyond the carotid bulb and is not easily seen. The
great advantage of this artery is that its diameter is
much smaller than the other primary branches of the
external carotid, yet its flow is very brisk. It is an ideal
recipient artery for flaps with smaller donor arteries.
Occasionally there are no vessels in the neck that are
useable; and if a flap is to be transferred, an artery and
vein must be brought into the field. Thoracodorsal
vessel transposition provides a practical solution to this
problem (Dolan et aI., 1996). The thoracodorsal vascular
pedicle provides both arterial and venous components
of large caliber (3- to 4-mm artery and vein) without
manipulation of the carotid system that may be encased
in scar. It is readily accessible, is of sufficient length to
easily reach the lower neck, and eliminates the neces-
sity for additional anastomoses, reducing operating time
and lowering the risk of anastomotic complications.
Use of virgin recipient vessels outside existing radiation
fields may also contribute to improved flap survival.
Thoracodorsal pedicle harvest is possible while the
patient is supine or in' a lateral decubitus position,
allowing simultaneous dissection with the free flap
harvest.
Secondary Ischemia
Secondary ischemia is more harmful to tissues than the
primary ischemic event. Tissue tolerance to secondary
ischemia is proportional to the elapsed time between
the primary and secondary ischemic events and inversely
proportional to the length of primary ischemia. In addi-
tion, outflow (venous) obstruction is more harmful than
inflow (arterial) obstruction. The physiologic basis for
this phenomenon is unknown. Clinically, a secondary
ischemic event usually results from venous outflow
obstruction, and secondary ischemia occurring within
48 hours of the primary ischemic event produces accel-
erated cell death and tissue loss. The etiology of venous
obstruction is variable. A thrombus may form at the
site of the anastomoses owing to technical errors
involving suture placement or vessel handling. Given
today's level of microsurgical expertise, technical errors
involving the anastomoses leading to thrombosis are
rare. The most common causes of outflow are compres-
sion or kinking of the vein from hematoma or problems
with vessel orientation and geometry. Once a perfusion
problem is recognized, the donor and recipient vessels
must be surgically explored as soon as possible. With-
out pharmacotherapeutic intervention, the critical
secondary ischemia time for skin flaps with venous
obstruction is approximately 4 hours. Therefore, a suc-
cessful salvage effort requires that the anastomosis is
revised and blood flow reestablished within 4 hours.
Reperfusion injury and the no-reflow phenomenon
are important events in the pathophysiology of tissue
injury found in temporarily ischemic tissue. An
ischemic flap can sustain a paradoxic increase in tissue
injury within 60 seconds after the reestablishment of
nutrient blood flow by a phenomenon known as
reperfusion injury. During ischemia endothelial cells
liberate cytokines that accumulate within the vessel
lumens. After blood flow is reestablished, endothelial
surface proteins and cytokines attract inflammatory
cells (primarily neutrophils) that pass through the
endothelium into the ischemic tissue. The neutrophils
release oxygen free radicals that cause cell injury and
death and further release of cytokines. The no-reflow
phenomenon is intimately related to the reperfusion
injury process. After significant ischemia and reperfu-
sion, blood flow will return to parts of a flap incre-
mentally over 20 to 30 minutes. The areas of the flap
that initially had no blood flow experience the no-
reflow phenomenon. Although the cause has not been
documented histologically, it is most likely due to
intraluminal neutrophil accumulation and plugging.
Reducing reperfusion injury prolongs the critical
ischemia time in microvascular flaps, and several
experimental and clinical studies show that oxygen free
radical scavengers, antineutrophil antibodies, and anti-
inflammatory drugs are effective. Anti-inflammatory
drugs are most conveniently administered in the clinical
setting. Corticosteroids are particularly effective and
work to reduce the accumulation of neutrophils by
inhibiting the release of inflammatory mediators (e.g.,
leukotrienes) (Dolan et aI., 1995a). Intravenous dexa-
methasone can be administered in the perioperative
period to ameliorate the effects of primary and secondary
ischemic events (Dolan et aI., 1995b). This is particu-
larly relevant if a perfusion abnormality is discovered
postoperatively because the critical ischemia time is
lengthened, improving the likelihood of a successful
salvage attempt. Dexamethasone should be administered
intravenously at a dose of 1.5 mg/kg intraoperatively. If
a secondary ischemic event is noted, the dose should be
repeated before anastomotic revision and reperfusion.

Postoperative Care and Monitoring
Hemodynamics and blood volume must be closely
monitored postoperatively. The hematocrit should be
maintained between 27% and 30 %. Blood pressure
should be maintained appropriately. Postoperative anti-
platelet polypharmacy is common, including the use of
dextran 40, aspirin, and full heparinization. Dextran 40
and aspirin have not been shown to be of benefit in
preventing postoperative thrombosis. Although low dose
and subcutaneous heparin may have a marginal benefit
in preventing postoperative thrombosis, full hepariniza-
tion is not justified because of the risk of hematoma
(Kroll et al., 1996). Only two factors are associated
with a greater risk of flap loss: a previously irradiated
recipient site and skin-grafted muscle (Khouri et aI.,
1995). The elapsed time between flap transfer and irra-
diation of the recipient site positively correlates with
the risk of vessel thrombosis and flap loss. Skin-grafted
muscle interferes with postoperative monitoring and
early detection of perfusion abnormalities. Tobacco use,
diabetes, patient age, and type of anastomosis (end-to-
side versus end-to-end or running suture versus
interrupted sutures) are not associated with flap loss.
There is an approximately 10% incidence of a
significant perfusion abnormality in the immediate
postoperative period. Timely intervention is critical to
salvage the flap. In clinical practice, 70% of these flaps
are salvaged by various means, including anastomotic
revision or evacuation of hematoma. The vast majority
of anastomotic problems occur within 3 days post-
operatively; therefore, a monitoring protocol must be
designed to detect flap perfusion abnormalities within
this period. An effective system of monitoring and the
immediate availability of an operating room and staff
to explore and revise the anastomosis are vital. Contin-
uous monitoring is ideal, but intermittent monitoring
is sufficient. A typical timing protocol for interval
monitoring is hourly during the first 24 hours, every
2 hours during the subsequent 24 hours, and every
3 hours during the next 2 to 3 days.
The most accurate method of monitoring skin circu-
lation is by arterial injection of radioactive microspheres;
of course, this method is limited to laboratory use.
There are several clinically useful tools to monitor flap
perfusion, including thermocouple probes, Doppler
ultrasonography, pulse oximetry, fluorescein dye, and
laser Doppler flowmetry. All but the thermocouple and
Doppler ultrasound methods require an external skin
surface for probe placement. Small thermocouple and
Doppler probes can be placed directly on the donor and
recipient blood vessels. The thermocouple works by
detecting changes in the rate of electron transport
between two different metals caused by a change in
temperature. A reference probe is placed proximal,
MICROVASCULAR SURGERY
and a registration probe is placed distal to the anasto-
mosis. Theoretically, clot or static blood flow cools the
distal probe and the temperature difference between
the probes indicates the problem. Doppler ultrasound
converts sound waves reflected by flowing blood into
an audible signal or waveform. A tiny Doppler probe
can be placed directly over the donor or recipient vessels
or over the anastomosis itself. Both the thermo-
couple and internal Doppler ultrasound probe methods
suffer from invasiveness and lack of sensitivity. The
Doppler probe is prone to displacement and low predic-
tive value.
Pulse oximetry, fluorescein dye, and laser Doppler
flowmetry require an external skin surface for probe
placement and monitoring. Pulse oximetry has few
applications in the head and neck but has been used
successfully for digit replants by monitoring differences
between the replant and adjacent normal digit.
Fluorescein dye must be administered intravenously
and is detectable within a few seconds in flap skin with
the aid of a Wood's lamp. The fluorescein is deposited
in the extracellular space and is detectable for several
hours. This method may be useful to initially monitor
flap perfusion but cannot be used for repeated measure-
ments within a several-hour time span. Laser Doppler
flowmetry measures the frequency shift of light rather
than sound waves. The probe is mounted to skin and
detects the movement of red blood cells in the cuta-
neous circulation. The laser Doppler device is the most
accurate clinical method of monitoring, and it can be
used in a continuous mode (Sloan and Sasaki, 19S5).
The accuracy can be improved if the flowmeter is linked
to a computerized acquisition system. The drawbacks
to this method are the cost, need for an external skin
segment, inability to differentiate between venous and
arterial flow abnormalities, and occasional inaccurate
readings despite the presence of a significant perfusion
abnormality.
An international review of practices in microvascular
surgery in 1991 reported that postoperative monitoring
of tissue viability was performed, at least in part, by
clinical observation in 75% of respondents (Salemark,
1991). Clinical observation seeks to detect perfusion
abnormalities through the subjective assessment of
capillary refill, color, texture, and bleeding. These qual-
ities are best assessed in an external skin paddle in
white patients. Extremely pale skin with no capillary
refill indicates an arterial inflow perfusion problem. A
blue hue with very rapid capillary refill indicates a
problem with venous outflow. The skin may also be
pricked with an IS-gauge needle to assess for bleeding.
Bright red blood appearing after a 1- to 5-second delay
indicates a healthy flap. Immediate dark blood indi-
cates a venous outflow problem, whereas no evidence
of bleeding indicates an arterial problem. This method
 MICROVASCULAR SURGERY
is dependent on providing an exteriorized monitoring
segment for flaps that are buried (e.g., pharyngeal
replacement flap). Skin flaps can be created with an
island of skin and an intervening de-epithelialized area
connecting the island to the main flap. The skin island
can be permanently sewn into the neck incision for
monitoring purposes. Clinical observation is very effec-
tive but requires personnel familiar with the appear-
ance of compromised tissue.
Advantages and Disadvantages
of Specific Flaps
Radial Forearm
Advantages
• A two-team approach is possible.
• Thin, pliable tissue is available.
• The flap is easily harvested.
• The flap is sensate.
• Cephalic vein and radial artery are large-caliber
vessels.
Disadvantages
• Osteocutaneous harvest risks radial bone fracture.
• Skin is not a good color match to the face.
• Donor site requires skin grafting.
• Numbness over the anatomical snuffbox is common.
Fibular Osteocutaneous Flap
Advantages
• A two-team approach is possible.
• It is the only microvascular flap that can replace the
entire mandible.
• The flap is sensate.
• Donor vessels are large caliber.
• Donor site morbidity is minimal.
Disadvantages
• Skin paddle is thick and closely adherent to bone.
• Skin is not a good color match to the face.
• Harvest is more difficult.
• The bone often requires multiple osteotomies.
• If a septocutaneous vessel is not included, the skin
paddle is subject to necrosis.
• Preoperative vascular studies of the leg are
required.
• A skin graft placed over the donor site often under-
goes partial necrosis.
Rectus Flap
Advantages
• A two-team approach is possible.
• Muscle is thin and flat and ideal for skull base
reconstruction.
• The flap is easily harvested.
• Motor reinnervation is possible.
• Donor vessels are large caliber.
• Donor site morbidity is minimal.
Disadvantages
• Skin paddle can be extremely bulky.
• Skin is not a good color match to the face.
• Muscular excursion after reinnervation is limited by
the tendinous inscriptions.
• Sacrifice of the anterior rectus sheath, especially
below the arcuate line, risks hernia.
• The flap is insensate.
Scapular Flap
Advantages
• Extensive amount of tissue is transferable, including
bone, muscle, and skin.
• Scapular skin paddles are thin or medium thickness.
• Bone and skin paddles can be manipulated inde-
pendently based on their vascular branches.
• Vascular pedicle is lengthy and large caliber.
• Donor site morbidity is minimal.
Disadvantages
• A two-team approach is usually not possible.
• Bone is the thinnest of all the commonly used
microvascular bone flaps.
• Bone length is limited and the distal tip is subject to
necrosis unless the angular artery is included.
• The flap is insensate.
• Skin is not a good color match to the face.
Latissimus Flap
Advantages
• Large flat muscle is ideal for coverage.
• The flap can be harvested with the serratus and
ribs.
• Motor reinnervation is possible.
• Vascular pedicle is very large and lengthy.
• Functional donor site morbidity is well tolerated.

Disadvantages
• A two-team approach is difficult.
• Skin is not a good color match to the face.
• There is no dedicated sensory nerve.
• Donor site is prone to seroma formation, requiring
prolonged drainage.
Jejunal Flap
Advantages
• A two-team approach is possible.
• Mucus secretion is provided.
• Vessels are large caliber.
Disadvantages
• Tracheoesophageal voice is of poor quality.
• The flap requires intra-abdominal dissection.
• The flap is intolerant of ischemia.
• The flap is difficult to monitor postoperatively.
• Dysphagia occurs in up to 30 % of cases, owing
to distal strictures, redundancy, and dyskinetic peri-
stalsis.
Iliac Crest Osteocutaneous Flap
Advantages
• A two-team approach is possible.
• Contour of the bone more closely matches the native
mandible, reducing needed osteotomies.
• Height and cortical bone:cancellous bone ratio is
nearly an identical match to native mandible.
• Donor site is easily hidden.
Disadvantages
• Skin paddle is thick and closely adherent to bone.
• Skin is not a good color match to the face.
• Flap harvest is technically more difficult.
• The flap is insensate.
• Donor artery can be relatively small.
• There is prolonged donor site pain.
• Numbness occurs over the lateral thigh if the lateral
femoral cutaneous nerve is injured.
Gracilis Flap
Advantages
• A two-team approach is possible.
• Size of the muscle is ideal for facial reanimation.
MICROVASCULAR SURGERY
• Individual nerve fascicles innervate unique functional
muscular units.
• Muscle possesses excellent excursion.
• The flap is easily harvested.
• Vascular pedicle length is good.
• Donor site is completely inconsequential.
Disadvantages
• Donor vessels are small diameter.
• If the obturator nerve is taken too proximally,
paralysis of the thigh adductor muscles may occur.
Radial Forearm (Fig. 24-2)
Neurovascular Anatomy
1. Sensory reinnervation is possible using the medial
or lateral antebrachial cutaneous nerve of the volar
forearm.
2. The nerves run parallel courses along the ulnar and
radial aspects of the forearm within the subcuta-
neous tissue.
3. The lateral antebrachial nerve travels in close asso-
ciation with the cephalic vein.
4. The radial artery sends vascular twigs to the under-
lying radial bone and septocutaneous perforators
to the overlying skin.
5. The radial artery branches from the brachial artery
near the antecubital fossa and courses deep between
the flexor carpi radialis and brachioradialis muscles
in the proximal forearm. The artery emerges from
this muscular trough approximately 7 cm cephalic
to the wrist crease to enter the subcutaneous
tissue.
6. Venous drainage is through either the venae comi-
tantes that accompany the radial artery or the much
larger superficial venous drainage system via the
cephalic vein.
7. The cephalic vein courses subcutaneously on the
radial side of the wrist near the superficial radial
nerve. The vein travels cephalically superomedially
toward the antecubital fossa.
8. Several branches of the superficial radial nerve are
found cephalad to the anatomical snuffbox in
intimate relation to the cephalic vein. Preservation
of this nerve is important to maintain sensation
over the radial aspect of the thumb and index
finger.
9. Blood flow to the hand is jeopardized when the
radial artery is taken with the flap. It is essential to
assess the circulation to the hand provided by the
ulnar artery before the flap is harvested.
 MICROVASCULAR SURGERY
10. The superficial palmar arch is the major vascular
supply to the hand, and it is formed predominantly
by a branch from the ulnar artery. In 4 % to 5 % of
cases the ulnar artery will be inadequate.
11. The Allen test is noninvasive and reliably detects
circulation problems by assessing arterial inflow in
the presence of one functioning artery. Edgar V.
Allen originally described the test in 1929 as a non-
invasive assessment of hand circulation in patients
with thromboangiitis obliterans (Fuhrman et a!.,
1992). The test was subsequently modified in the
1950s to assess the ulnar artery before cannulation
of the radial artery. A similar method is used today
to assess the ulnar artery before harvesting the
radial forearm flap.
12. The test consists of the following steps: (1) raise
the hand above the head; (2) digitally occlude the
radial and ulnar arteries; (3) lower the hand to the
level of the heart; (4) open and close the hand
several times (exsanguinate); (5) release the ulnar
artery; and (6) record the time to the blush over the
radial side of the hand.
13. A positive test (normal) documents the appearance
of the blush within 6 seconds.
14. The ulnar artery should be reassessed intraopera-
tively by temporarily occluding the radial artery
with a vascular clamp before surgical division.
15. The radial artery can be reconstructed with a
saphenous vein graft, but the flap should probably
be abandoned if the Allen test is negative.
Highpoints
1. The design and position of the skin island in the
volar forearm depends on several factors, including
the desire to include the superficial venous drainage
system and specific functional and cosmetic require-
ments at the recipient site.
2. To include the superficial drainage system, the skin
island should favor the radial side of the wrist to
encompass the cephalic vein.
3. A specific shape is often desired to accommodate
the functional requirements at the recipient site
(e.g., a bilobed design for tongue and floor of
mouth).
4. Although rarely necessary, the skin island can be
placed over the proximal forearm in an area devoid
of hair based on the distal radial vessels. The
venous system is reversed but functions adequately
owing to abundant venous cross-flow allowing the
venous effluent to bypass the valves.
5. A tourniquet can be used but is not necessary.
6. The skin island is outlined over the distal forearm,
encompassing the radial artery and cephalic vein,
and the flap edges are incised.
7. The incisions are deepened to include the deep
fascia, except along the proximal edge, where the
superficial veins and nerves lie in the immediate
subcutaneous tissue plane.
8. The radial artery is exposed and temporarily
occluded to assess the adequacy of circulation to
the hand via the ulnar artery.
9. The radial artery and venae comitantes and the
distal cephalic vein are divided.
10. The flap is raised from the ulnar and radial sides,
taking care to include the deep fascia but preserv-
ing the fine peritenon.
11. Several branches of the superficial radial nerve are
intermingled with the cephalic vein. These branches
must be carefully dissected and preserved.
12. If desired, the palmaris tendon can be included
with the flap by dividing the tendon along the distal
incision.
13. Fragile septocutaneous perforators from the radial
artery supply the skin island. Once the radial artery
is encountered it must be carefully dissected out of
the trough between the flexor carpi radialis and
brachioradialis muscle and tendons.
14. A midline curvilinear incision is extended toward
the antecubital fossa to allow dissection of the
vessels and nerves in the proximal forearm.
15. A cuff of 1 to 2 cm of fat should be preserved
around the cephalic vein as it is released in the
proximal forearm. The fat helps prevent deforma-
tion of the vein at the recipient site and preserves
the lateral antebrachial sensory nerve that courses
in the fat adjacent to the cephalic vein.
16. After the fat/nerve/vein pedicle is divided at the
antecubital fossa it is allowed to fall to the side to
allow dissection of the underlying radial artery and
venae comitantes.
17. If the skin island is to be used in a buried location
at the recipient site (e.g., cervical esophagus), an
additional proximal island of skin at least 2 cm in
diameter should be used for monitoring purposes.
The skin island monitor is based on an intervening
segment of fat-fascia from the proximal edge of the
main flap and is sutured into the neck incision at
the recipient site.
18. The radial artery and venae comitantes are liberated
from the proximal forearm and divided a few milli-
meters distal to the brachial artery (the brachial
artery must be left intact).
Donor Site Closure
The donor site is closed by approximating the proximal
forearm incision with a running suture and applying
a split-thickness skin graft to the area of distal skin
harvest. A typical bolster dressing is applied, and the

site is stabilized with a dorsal wrist splint. The bolster
and splint are removed after 5 days and replaced with
a nonadhesive dressing.
Complications
• The initial appearance of the donor site is poor,
owing to the contrast of the split-thickness graft and
the surrounding normal skin. Over the ensuing several
months the skin graft tends to undergo shrinkage
and begins to become less noticeable.
• Commonly, a portion of the skin graft does not sur-
vive over a tendon. Although the tendon may be com-
pletely exposed, simple wet-to-dry dressing changes
will result in re-epithelialization within a few weeks.
• Injury to the superficial radial nerve results in numb-
ness over the anatomical snuffbox and radial side of
MICROVASCULAR SURGERY
the thumb and index finger. This nerve must be
preserved during flap harvest and, if possible, covered
by advancing skin from the radial side of the donor
site before skin grafting .
• Radial bone fracture is a significant risk if an osteo-
cutaneous flap is harvested .
• A devastating complication is vascular insufficiency
of the hand. An Allen test is a reliable and sensitive
method to detect circulation problems preoperatively
and is an essential component of the preoperative
evaluation. In addition, the adequacy of the ulnar
supply should be confirmed intraoperatively before
dividing the radial artery. If a problem is detected,
the flap should probably be abandoned; otherwise,
reconstruction of the radial artery using a saphenous
vein graft is required.
 MICROVASCULAR SURGERY
Radial Forearm (Continued)
(Fig. 24-2)
A Depicted is a basic proximally based radial fore-
arm flap that has been designed to encompass the
cephalic vein on the radial side of the wrist. Care must
be exercised when dividing the distal vein because
several branches of the superficial sensory radial nerve
intertwine with the vein near the anatomical snuffbox.
The fine peritenon covering the exposed tendons must
be preserved to provide a vascularized bed for the
split-thickness skin graft. The proximal cephalic vein
must be completely freed from the forearm before the
radial artery can be dissected out of the trough between
the flexor carpi radialis and brachioradialis muscle and
tendons. Over the ulnar side of the flap, the palmaris
tendon and medial antebrachial cutaneous nerve are
included with the subcutaneous tissues of the flap. The
lateral antebrachial nerve is usually closely associated
with the cephalic vein and is more readily included
with the flap when the vein is harvested. The palmaris
tendon is useful if the flap is to be tethered or draped
over a surface and support is required. The primary
indication for the palmaris tendon is for total lower lip
reconstruction. The tendon is secured to the oral com-
missures (modioli labii) and the flap folds over the
tendon, forming the free edge of the new lip.
81 One of the most useful indications for the radial
forearm flap is total pharyngectomy. Total circum-
ferential pharyngectomy and cervical esophagectomy
was considered a devastating surgical defect before
the advent of microvascular tissue transplantation. It
is now considered a routine surgical defect with the
expectation of successful reconstitution of an oropha-
ryngeal-esophageal conduit in all cases. However, not
all patients will regain the ability to swallow, mainly
because of associated defects in the base of tongue
and palate. Regardlessof the type of microsurgical flap
employed, rehabilitation of swallowing is expected in
approximately 85% of cases. The jejunum was the
"workhorse" flap for this defect, but recent experience
using thin microvascular fasciocutaneous flaps (e.g.,
radial forearm, lateral thigh) has proved that these
flaps are at least as successful and an abdominal
dissection is avoided. In addition, esophageal voicing
is improved using a skin flap versus an intestinal flap.
A cervical esophageal defect that extends below the
sternal notch is not amenable to this reconstructive
method because the distal (esophageal) suture line is
not accessible. A gastric pull-up procedure is usually
the method of choice in this situation.
Depicted is a typical neopharyngeal design. The
unique aspect of this design is that it incorporates an
external monitoring segment based on the proximal
fibrofatty tissue of the volar forearm. The skin island is
permanently i·ncorporated into the neck incision or
inserted into the cervical skin flap. Changes in the
appearance of the external monitor reflect changes in
the buried portion of the flap. The flap is slightly wider
superiorly to accommodate the size mismatch between
the esophagus and oropharynx. The width of the distal
flap should be no less than 6 cm. The distal incision
should incorporate a small tongue of tissue in the form
of a "V" to break up the distal flap/esophageal suture
line, lessening the effects of scar contracture and pos-
sible stricture formation.
82 The flap is inset with interrupted long-lasting
absorbable sutures. The flap edges should be buried so
that no skin is visible, creating a tract to the neck. A
small vertical incision is made in the esophageal stump
to accommodate the tongue of tissue created along
the distal edge of the flap. A single-layer closure is
sufficient, and the microvascular anastomosis can pro-
ceed after the flap is entirely inset.
Continued
 MICROVASCULAR SURGERY

;I

\ 1
\ f
/
I

FIGURE 24-2
 MICROVASCULAR SURGERY
Radial Forearm (Continued)
(Fig. 24-2)
C A mandibular reconstruction plate alone (without
vascularized bone) may be appropriate for patients
with lateral defects who do not desire the potential for
full dental restoration, have a very poor prognosis, or are
unsuitable candidates for microvascular bone transfer.
Problems with plate breakage and exposure tend to
be delayed for the lateral mandible compared with
the anterior mandible. A plate placed over a lateral
mandibular defect and covered with a microvascular
skin flap can be expected to endure 2 to 3 years before
problems with plate breakage and exposure are encoun-
tered. Reconstruction plates over the anterior mandible
are prone to exposure and breakage much earlier,
often within months, resulting in complete collapse of
the anterior jaw. A reconstruction plate alone should
never be used for an anterior mandibular defect (i.e.,
between the mental foramina).
Intraoral soft tissue coverage over a reconstruction
plate is best accomplished with sensate, thin, and
pliable tissue that can conform to the contours of the
floor of mouth and neoalveolus without encumbering
tongue mobility. A radial forearm free flap possesses
these qualities, and the design and implementation is
straightforward. The donor sensory nerve is usually the
ipsilateral lingual nerve. Depicted is a radial forearm
flap draped over a mandibular plate. At least three
bicortical screws are placed into each of the proximal
and distal bone stumps to secure the plate.
Dl, D2 There are several issues in lower lip
reconstruction using microvascular tissue that must
be considered, including defect size, aesthetic units,
support, prevention of drooling, re-creation of the ver-
milion, and associated defects of the mandible. Local
flaps, such as a Karapandzic or Bernard-Burow, should
be considered first if less than two thirds of the lower
lip is missing. Bernard-Burow, nasolabial, or platysmal
flaps may be considered for total lower lip defects if
the associated chin defect is only of moderate size, but
a full discussion of these options is beyond the scope
of this chapter.
Microsurgical flaps should be considered for exten-
sive total lower lip defects that are not amenable to
repair using local flaps. Regional flaps are too bulky or
require multiple stages (deltopectoral flap) and should
not be used. The radial forearm flap possessesmany
favorable qualities that elevate this flap above others
for lip reconstruction. It is sensate, is easily contoured,
and has a built-in sling (palmaris tendon) that supports
the free border of the new lip. The chin defect should
be tailored to conform to the topographic unit con-
cept, and the flap should be designed accordingly. An
antebrachial cutaneous nerve is harvested with the
flap and anastomosed to one of the mental nerve
stumps. The palmaris tendon is sutured to the deep
muscles of the oral commissures (modioli labii) and
tethered across the defect. The flap tissue is draped
across the tendon to provide intraoral and extraoral
(chin) coverage. The tendon moves with the commis-
sures, resulting in dynamic and mimetic movement of
the new lower lip. After the flap has healed and attained
a stable position (in 2 to 3 weeks), the vermilion is re-
created using a staged ventral tongue flap.
When an anterior segmental mandibular defect is
associated with a total lower lip defect it is tempting
to simply use the soft tissue component of the osteo-
cutaneous free flap to reconstruct the lip. However,
the skin is often too bulky and inflexible for this pur-
pose. If a local flap (e.g., Bernard-Burow) is not pos-
sible, two microvascular transfers should be
considered: the osteocutaneous flap in addition to the
radial forearm.
Depicted is a large total lip/chin defect recon-
structed with a radial forearm flap that is draped across
its palmaris tendon. The antebrachial nerve is anasto-
mosed to the mental nerve stump. The flap provides
both intraoral and extraoral coverage and conforms
to the chin aesthetic unit. The lip is reconstructed in
a single stage; however, re-creation of the vermilion
requires additional stages. Lip seal is excellent, and
drooling is prevented because sensation is reconsti-
tuted and the palmaris tendon prevents inferior migra-
tion of the flap.
 MICROVASCULAR SURGERY

/
/
, I
IJ
,
,
~
'·"~C
//
-c:::.::::./"
./

FIGURE 24-2 Continued

 MICROVASCULAR SURGERY
Fibular Osteocutaneous (Fig. 24-3)
Neurovascular Anatomy
1. The peroneal artery supplies the distal two thirds
of the fibula primarily through its periosteal
attachments.
2. The skin over the lateral leg is also nourished by
the peroneal artery via septocutaneous vessels that
course posterior to the fibula to enter the posterior
crural intermuscular septum. The vessels, more
numerous in the lower half of the leg, can be easily
seen coursing through the thin connective tissue
mesentery that joins the skin paddle with the
underlying bone.
3. The peroneal artery branches from the posterior
tibial artery just proximal to the head of the fibula.
4. The venae comitantes often merge to form a single
large vein near the posterior tibial artery. The
diameters of the artery and vein are between 2 and
4 mm and are considered large by microvascular
standards.
5. The length of the vascular pedicle depends on the
level at which the peroneal artery branches from
the posterior tibial artery and the quantity of har-
vested bone.
6. To maximize pedicle length, the distal-most bone
should be used except the terminal 10 cm that is
needed for ankle stability.
7. The simplest method to obtain the longest pos-
sible pedicle is to harvest the maximum amount of
bone possible and remove the proximal unneeded
bone. The vascular pedicle is effectively length-
ened because the soft tissue and vascular pedicle
formerly attached to the discarded bone can be
redirected toward the recipient vessels.
8. The lateral branch of the lateral sural cutaneous
(LSC) nerve provides sensation within the territory
of the skin paddle.
9. The most reliable method to identify the common
LSC nerve is to follow the common peroneal nerve
superiorly to the origin of the nerve.
10. The common LSC nerve originates from the com-
mon peroneal nerve a median of 9 cm (0 to 13 cm)
above the head of the fibula. The common LSC
nerve courses inferiorly to its lateral and medial
terminal branches.
11. The level at which the common LSC nerve branches
is inconstant, ranging from 5 cm above to 8 cm
below the head of the fibula.
12. The medial branch of the LSC is unusable because
it travels away from the skin paddle and terminally
arborizes in the mid leg.
13. The lateral branch tends to travel toward the postero-
superior aspect of the skin paddle terminally arboriz-
ing within 7 cm below the head of the fibula. 11travels
to within 3 cm from the intermuscular septum.
14. Congenital absence of the LSC nerve occurs in
approximately 10% of legs.
Highpoints
1. A pneumatic tourniquet is applied to the thigh and
the knee is partially flexed for access to the postero-
lateral leg.
2. The most important landmark during the initial steps
of the dissection is the posterior intermuscular sep-
tum. 11attaches to the posterior border of the fibula
separating the peroneal muscles in the lateral mus-
cular compartment from the soleus muscle posteriorly.
3. The skin paddle must be placed over the posterior
intermuscular septum to capture at least one septo-
cutaneous vascular perforator. The maximum width
of the skin paddle is 6 cm to allow primary closure
of the donor site.
4. Inclusion of the sensory nerve creates a dilemma
because the nerve courses well posterior to the
intermuscular septum in the upper half of the leg
while the majority of the septocutaneous perfora-
tors are located in the distal half of the leg within
the intermuscular septum.
5. To harvest a neurosensory flap, the initial skin inci-
sion should be placed approximately 2 cm anterior
to the intermuscular septum from the mid leg to
the head of the fibula.
6. The peroneal nerve is found inferior to the head of
the fibula and followed into the popliteal fossa to
the origin of the common LSC nerve. This nerve is
dissected inferiorly to the lateral branch, which is
dissected to the superior border of the proposed
skin paddle.
7. The posterior position of the lateral branch of the
LSC nerve defines the posterior border of the skin
paddle.
8. The anterior aspect of the intermuscular septum is
widely exposed through the initial skin incision
and a proximal septocutaneous perforator is sought.
The most proximal septocutaneous perforator defines
the inferior border of the skin paddle.
9. Occasionally, the first perforator is found in the
lower half of the leg and a very long skin paddle is
required to encompass both the perforator and the
sensory nerve.
10. The muscles in the lateral compartment (peroneus
longus and brevis) are separated from the fibula by
incising the muscle fibers just outside the periosteum.
11. The anterior intermuscular septum is divided and
the extensor digitorum longus and extensor hallucis
longus muscles are retracted anteriorly by sharply
dividing their muscular fibers adjacent to the fibula.

12. The deep peroneal nerve and anterior tibial artery
and vein are exposed and must be preserved. These
vessels and muscles within the anterior compart-
ment lie on the interosseous membrane that firmly
connects the fibula to the tibia.
13. Superior and inferior osteotomies are performed by
circumferentially dissecting a cuff of periosteum
from the proposed osteotomy sites.
14. The inferior osteotomy is routinely placed 10 em
proximal to the lateral malleolus to preserve ankle
stability. The superior osteotomy is most conve-
niently performed 5 em distal to the head of the
fibula to facilitate the dissection of the vascular
pedicle regardless of the length of bone required at
the recipient site. Proximal excess bone is simply
discarded after the flap is harvested.
15. The osteotomies are performed using a Gigli saw
that is carefully placed around the inner aspect of
the bone, thereby avoiding the peroneal vessels.
16. The peroneal vascular pedicle is visualized through
the inferior osteotomy and divided between clamps
and suture-ligated.
17. The bone is pulled laterally and the interosseous
membrane is sharply divided with scissors, thus
releasing the osteocutaneous unit.
18. The remaining muscular attachments (tibialis pos-
terior, flexor hallucis longus, and soleus) posterior
to the interosseous membrane are divided, taking
care to preserve the septocutaneous vascular perfo-
rators to the skin paddle.
19. The peroneal vascular pedicle is divided between
clamps distal to its origin from the posterior tibial
artery.
Donor Site Closure
The muscles of the lateral and posterior compartments
are allowed to passively fill the void left after the bone
is harvested. 1£the skin defect cannot be closed primarily,
MICROVASCULAR SURGERY
a split-thickness skin graft is applied over the exposed
muscle.
Complications
• The donor site is benign with full ambulation and
resumption of normal activities typically within
1 month.
• Many patients experience a minor disability in foot
and toe extension.
• In patients who require skin grafting, partial survival
of the skin graft is common, requiring several weeks
of wet -to-dry dressings.
• Instability of the knee or ankle can occur if the
entire fibula is harvested.
• 1£the common peroneal nerve is injured, disabling
footdrop will occur. This injury is quite rare because
the common peroneal nerve is very large and easily
avoided.
• Vascular injury during flap harvest can jeopardize
foot circulation. Preoperative angiography (e.g.,
magnetic resonance angiography) should be per-
formed preoperatively in all patients. There are
congenital vascular anomalies that may jeopardize
foot circulation when the peroneal artery is taken
despite the presence of normal pedal pulses and
no history of trauma or ischemic vasculopathy. In
large series, several vascular anomalies have been
detected, including hypoplasia of either the pos-
terior tibial or anterior tibial artery, arteria peronea
magna, and absence of the peroneal artery
(Bretzman et a!., 1994). The congenital abnormality
of most concern is arteria peronea magna with a
hyperplastic peroneal artery solely providing arte-
rial blood supply to the foot. Apparently normal
pedal pulses will be present preoperatively, and with-
out an appropriate vascular study this abnormality
will lead to a catastrophic loss of foot circulation
postoperatively.
 MICROVASCULAR SURGERY
Fibular Osteocutaneous (Continued)
(Fig. 24-3)
A The cutaneous component of the fibular osteocu-
taneous flap was once considered unreliable owing to
an inconsistent blood supply. However, further expe-
rience using the flap established the importance of
preserving the septocutaneous perforators to ensure
the viability of the skin paddle. The septocutaneous
perforators course through the posterior crural inter-
muscular septum to reach the skin over the lateral leg,
but their distribution along the septum is variable and
they tend to be more numerous in th~ lower half of
the leg. Although the perforators can be detected per-
cutaneously using Doppler ultrasonography, this
method is prone to misinterpretation. A more reliable
method is to locate adequate perforators through a
horizontal incision along the proposed anterior border
of the skin paddle (anterior to the septum). Dissection
posteriorly exposes the septum, and the perforators
can be plainly seen as they course through the septum
to the overlying skin. Although a single perforator can
sustain the skin paddle, it should be designed to
include as many perforators as possible.
The sensory nerve is found by following the common
peroneal nerve into the popliteal fossa to the origin of
the common lateral sural cutaneous nerve. This nerve
is then traced inferiorly to the lateral sural cutaneous
nerve, which supplies the skin in the territory of the
skin paddle. The superior aspect of the skin paddle must
be designed to encompass the nerve before it arborizes
in the upper posterolateral leg. It is sometimes neces-
sary to harvest a longer (and wider) skin paddle than
usual to capture both the sensory nerve in the upper
posterior leg and adequate septocutaneous perforators
concentrated in the lower half of the leg.
Depicted are septocutaneous perforators coursing
through the posterior crural intermuscular septum from
the posterior aspect of the fibula. The sensory nerve is
seen emanating from the posterosuperior leg entering
the superior aspect of the skin paddle. The skin paddle
must span both the lower aspect of the leg to capture
the perforators and the posterosuperior aspect of the
leg to capture the sensory nerve.
B The bone is cut superiorly and inferiorly, the per-
oneal artery is ligated and divided through the inferior
osteotomy, and the interosseous membrane is sharply
divided. These maneuvers free the bone segment and
attached skin. The remaining posterior muscular attach-
ments are divided and the flap is left pedicled to the
peroneal artery and venae comitantes. The pedicle is
divided when the recipient site is prepared.
Continued
 MICROVAKUlAR SURG~RY

A B

FIGURE 24-3
 MICROVASCULAR SURGERY
Fibular Osteocutaneous (Continued)
(Fig. 24-3)
(1 TO (3 The bone can be osteotomized in situ or
on a back table after the flap is harvested. Shaping
osteotomies are often required because the bone is
perfectly straight. The periosteu opposite the vascular
pedicle is stripped away, and the cut is made with an
oscillating saw. Great care must be exercised along the
FIGURE 24-3
deep portion of the osteotomy because it is adjacent
to the vascular pedicle. The vascular pedicle can be
brought into the anterior or posterior neck depending
on how the bone is manipulated around the osteotomy
sites. Depicted are typical osteotomies for lateral (C1)
and anterior (C2) segmental defects of the mandible.
A spanning reconstruction plate or multiple smaller
plates can be used to secure the osteotomies and the
graft to the native mandible.
Continued

Rectus Musculocutaneous (Fig. 24-4)
Neurovascular Anatomy
1. The arterial supply to the rectus muscle is from the
superior and inferior epigastric arteries.
2. The superior epigastric artery (internal thoracic
artery) enters the superior aspect of the rectus
muscle and anastomoses within the muscle with
the inferior epigastric artery.
3. The superior epigastric artery is relatively diminu-
tive compared with the inferior epigastric artery and
unsuitable for microvascular transfer of the rectus
muscle.
4. The deep inferior epigastric vessels course supero-
medially over the peritoneum from the external iliac
artery to the umbilicus.
5. At the arcuate line, the vascular pedicle pierces the
transversalis muscle to enter the rectus sheath at
the posterolateral aspect of the rectus muscle.
6. The vessels course superiorly on the deep surface
of the muscle sending musculocutaneous perfora-
tor vessels to the overlying skin.
7. The perforators are distributed along two rows cor-
responding to the medial and lateral aspects of the
ipsilateral rectus muscle but are most numerous
near the umbilicus.
8. A single periumbilical perforator can support very
sizeable transverse or vertical skin paddles.
9. Vertically oriented skin paddles that extend beyond
the underlying rectus muscle are designed to follow
a line that bisects the umbilicus and tip of the scapula
along which a well-developed dermal and subcuta-
neous vascular plexus resides.
10. The motor nerve supply to the rectus muscle is
segmental, originating from the T7 through T12
intercostal nerves along the muscle's lateral border.
11. The motor nerves are no more than 2 em in length,
and muscular contraction (excursion) is limited by
the tendinous inscriptions.
Highpoints
1. There are four basic types of rectus flaps: (1) muscle
only, (2) vertical rectus abdominis muscle flap, (3)
extended vertical rectus abdominis muscle flap, and
(4) transverse rectus abdominis muscle (TRAM)
flap.
2. The vertical flap consists of the ipsilateral rectus
muscle along with its overlying skin and subcutaneous
tissue.
3. The extended vertical flap consists of the rectus
muscle and an oblique skin paddle oriented along a
line from the umbilicus to the tip of the scapula.
4. The transverse flap consists of the ipsilateral rectus
muscle and a transversely oriented skin paddle. The
MICROVASCULAR SURGERY
skin paddle must encompass the umbilicus and is
typically 10 em wide by 30 em across.
5. Because a single large periumbilical perforator can
support a large skin paddle, yet another type of flap
is possible. Only a cuff of the anterior rectus sheath
and underlying muscle sufficient to conduct and
protect the perforator vessel is included with the
skin paddle. This "perforator flap" is a unique type
of flap based on this vascular configuration.
Muscle Only
1. There are many choices with regard to the type of
skin incision for a muscle-only harvest, the only
requirement being adequate exposure of the anterior
rectus sheath.
2. Pfannenstiel's incision (low transverse) is favored
for cosmetic reasons and provides ample access to
the entire rectus muscle.
3. The anterior rectus sheath is exposed and incised
vertically 1 to 2 em from its lateral border.
4. The muscle is completely mobilized from the xiphoid
process to just below the arcuate line by dividing the
intercostal nerves and vessels and sharply separat-
ing the tendinous inscriptions from the anterior and
posterior rectus sheaths.
5. Near the arcuate line the vascular pedicle is identi-
fied and dissected to the external iliac artery.
6. The· venae comitantes often merge into a single vein
near the external iliac vein.
7. The rectus muscle is divided superiorly at the desired
level, taking care to control the superior epigastric artery.
8. The muscle is divided inferiorly just beyond the
vascular pedicle, leaving a muscular layer over the
thinner abdominal fascia below the arcuate line.
9. When the recipient site is prepared. the vascular
pedicle is divided and the flap is transferred.
Musculocutaneous and Perforator Flaps
1. Musculocutaneous and perforator flaps require a
slightly different surgical approach with an emphasis
on identifying and preserving the perforator vessels
and the anterior rectus sheath.
2. Regardless of the skin design, a major portion of the
skin paddle must be placed over the ipsilateral peri-
umbilical area to capture the large vascular perfora-
tors typically found there.
3. The ipsilateral portion of the skin paddle is elevated,
and the lateral perforators are divided. Further medial
elevation near the umbilicus reveals the desired medial
row of vascular perforators.
4. The portion of the skin paddle over the contralateral
rectus sheath is elevated entirely to the midline (linea
alba), dividing the medial and lateral rows of vascu-
lar perforators.
 - - -- ---- --- - - -
f '
MICROVASCULAR SURGERY
5. Transverse skin paddles encompass the umbilicus;
however, in raising the skin paddle toward the mid-
line the umbilicus itself is cored out and preserved.
6. A single large vascular perforator can be used to
nourish the skin paddle, but often at least two or
three periumbilical perforators are included.
7. Inclusion of the lateral row of perforators or numer-
ous medial perforators requires sacrifice of a substan-
tial portion of the anterior rectus sheath. Loss of the
anterior sheath, especially below the arcuate line,
increases the risk of abdominal laxity and hernia.
8. Only a few large medial periumbilical perforators should
be used, thus limiting the loss of the anterior sheath.
9. The subsequent dissection proceeds in the manner
described for harvest of a muscle-only flap.
Donor Site Closure
Donor site closure most importantly consists of restoring
the anterior rectus sheath. Closure of the sheath is
straightforward when a muscle-only flap is harvested.
It is closed with a running or interrupted nonabsorbable
suture or a substantial absorbable suture. However, loss
of a portion of the anterior rectus sheath always occurs
after a musculocutaneous flap is harvested. The poste-
rior rectus sheath thins considerably below the arcuate
line consisting only of transversalis fascia. Loss or weak-
ness of the anterior sheath below the arcuate line risks
noticeable abdominal wall laxity or hernia. Leaving
rectus muscle below the arcuate line strengthens this
portion of the incision. The addition of abdominal mesh
is rarely necessary.
Complications
• Donor site morbidity is minimal.
• Abdominal wall laxity is rarely a problem if the ante-
rior rectus sheath is sacrificed conservatively and
selectively as described .
• Loss of one rectus muscle produces little functional
morbidity.
~I
Rectus Musculocutaneous
(Continued) (Fig. 24-4)
A The rectus muscle is harvested through either a
vertical paramedian incision (depicted) or through
Pfannenstiel's incision (low transverse). The muscle is
sharply separated from the anterior and posterior rectus
sheaths, preserving these structures. The sheaths are
densely adherent to the tendinous inscriptions, and
dissection around these structures must be meticulous
to prevent injury to the sheaths and deep inferior epi-
gastric vessels. Before the muscle can be completely
released along its lateral border the intercostal nerves
and vessels must be divided. The vascular pedicle enters
the muscle along its lateral border near the arcuate line.
B Superior mobilization of the muscle requires divi-
sion of the superior epigastric vessels and the superior-
most aspect of the muscle. Inferiorly, the vascular pedicle
is dissected to the external iliac vessels, where they are
divided. The posterior rectus sheath above the arcuate
line consists of three layers of fascia, including the
aponeuroses of the internal and external oblique muscles
and the transversalis fascia. Below the arcuate line the
posterior sheath thins, consisting only of transversalis
fascia. To prevent hernia and abdominal wall laxity the
anterior rectus sheath must be preserved below the
arcuate line. In addition, the inferior muscle cut should
be no lower than the arcuate line to provide an extra
reinforcing layer over the weakened posterior sheath.
C The deep inferior epigastric artery anastomoses
with the superior epigastric artery and multiple inter-
costal arteries along the muscle's lateral border. The
vessels tend to run along the lateral and medial borders
of the muscle, sending terminal musculocutaneous
perforators to the skin. These perforators tend to be
concentrated along the medial aspect of the muscle
near the umbilicus.
Continued
 MICROVASCULAR SURGERY

c
FIGURE 24-4
 MICROVASCULAR SURGERY
Rectus Musculocutaneous
(Continued) (Fig. 24-4)
Dl, D2 The transverse rectus abdominis flap
(TRAM) is an extensively used flap for breast recon-
struction, and it is occasionally useful in the head and
neck. It provides a tremendous amount of subcuta-
neous fat and overlying skin to fulfill practically any
requirement for tissue bulk and coverage. The fat does
not undergo atrophy because it is revascularized, but
it will fluctuate in size with the patient's body weight.
The flap is harvested through low transverse elliptical
incisions that encompass the umbilicus to capture the
large periumbilical perforators. The umbilicus itself is
preserved by coring it out of the flap. Only a small
portion of the anterior rectus sheath and underlying
muscle surrounding the periumbilical perforators need
be sacrificed,minimizing the chance of hemia or abdom-
inal wall laxity postoperatively. Rectus muscle is pre-
served below the arcuate line, and the anterior rectus
sheath is closed primarily.
El, E2 The rectus muscle is an ideal donor flap to
separate the frontal and temporal lobes from the
sinuses and skull base when local flaps are insufficient.
The muscle is highly effective in sealing the cranial
cavity and forming an ideal surface for remucosaliza-
tion over its extemalized surfaces. The vesselsare large,
and venous anastomotic problems are particularly rare
with this flap. The superficial temporal vesselsare the
usual donor vessels. If these are insufficient, vein grafts
may be necessaryto reach vesselsin the neck. Depicted
is a muscle-only rectus flap inset into a typical anterior
cranial base defect. The recipient vesselsare the super-
ficial temporal artery and vein. This flap will be com-
pletely buried, but monitoring anastomotic patency
by Doppler ultrasonography is somewhat more useful
in this area owing to the superficial location of the vas-
cular pedicle. If desired, a skin island could be pre-
served over the proximal muscle and sutured into the
incision line for monitoring purposes.
Continued
 MICROVASCULAR SURGERY

'''-,

"
\
\
\
1
1
I
\
I
i
I
/
j

FIGURE 24-4 Continued

 MICROVASCULAR SURGERY
Rectus Musculocutaneous
(Continued) (Fig. 24-4)
Fl Depicted is a radical composite maxillectomy
defect with orbital exenteration and a large anterior
cheek deficit. This is an absolute indication for free
tissue transfer primarily caused by the extensive soft
tissue cheek defect. To restore the natural contour to
the cheek, the malar eminence and lateral aspect of
the inferior orbital rim must be reconstructed. Alter-
natively, the defect can be replaced with a large soft
tissue flap that would provide bulk to the cheek to
restore and maintain cheek contour. In the process
of replacing the maxillary defect with soft tissue the
lateral wall of the nose and hard palate is reconsti-
tuted, eliminating the typical troublesome defects asso-
ciated with a radical maxillectomy: oronasal fistula and
sinonasal fistula. A bulky three-dimensional reconstruc-
tion is necessary to provide skin coverage to the lateral
nasal wall, palate, and cheek.
F2, F3 The rectus musculocutaneous flap provides
adequate bulk to completely fill the radical maxil-
FIGURE 24-4 Continued
lectomy defect and can be designed to fold three-
dimensionally to provide the needed skin coverage. A
musculocutaneous flap is designed over the ipsilateral
rectus muscle and conceptualized as three quadrangles
representing the palate, lateral nasal wall, and cheek.
The first quadrangle will provide for palate coverage
and is placed over the inferior rectus muscle at the
level of the umbilicus. The second quadrangle will
provide for lateral nasal wall coverage and is placed
immediately above the first over the mid portion of the
rectus muscle. The third quadrangle will provide for
cheek coverage and is placed lateral to the second
quadrangle (lateral to the rectus muscle). The resulting
flap is in the shape of an "L" turned 180 degrees. The
vascular pedicle exits through the palatal portion of
the flap into the neck.
Depicted is an ipsilateral musculocutaneous rectus
flap partially inset that was designed using the three-
quadrangle method. Each quadrangle is separated by
an area of de-epithelialized skin to create independent
paddles. The paddles are sutured in place and the vas-
cular pedicle is directed into the neck for micro-
vascular anastomosis.
FIGURE 24-4 Continued
 MICROVASCULAR SURGERY
Scapular Osteocutaneous (Fig. 24-5)
Neurovascular Anatomy
1. The subscapular artery, a branch of the third part
of the axillary artery, supplies the circumflex scapu-
lar flaps (scapular bone and overlying skin) and
the thoracodorsal flaps (serratus and latissimus).
2. Although they share a common vascular pedicle,
the circumflex scapular and thoracodorsal systems
are rarely transferred together.
3. When a combined "mega-flap" is required, the
subscapular vessels provide ample blood supply
based on a single arterial and venous anastomosis.
4. The subscapular artery is between 2 and 3 mm in
diameter. A single large vein (2.5 to 4 mm in
diameter) is formed near the axillary artery as the
venae comitantes merge.
5. The subscapular artery divides into the circumflex
scapular artery and thoracodorsal artery approxi-
mately 3 cm distal to the axillary artery.
6. The circumflex scapular vessels can be found within
the triangular space formed by the lateral divergence
of the teres muscles from the scapular border. The
long head of the triceps muscle defines the lateral
extent of the triangle.
7. As the circumflex scapular artery passes posteriorly
through the triangular space, it sends periosteal
branches to the upper two thirds of the lateral
border of the scapula.
8. The primary blood supply to the lower third of the
scapula is provided by the thoracodorsal system
through the angular artery, a branch of the artery
to the serratus.
9. Although the entire lateral border of the scapula
will survive based on the circumflex scapular
artery, if a distal osteotomy is performed the tip
may become devascularized. To ensure vascularity
to distal third of the scapula in the presence of a
distal osteotomy or to allow independent vascu-
larized bone segments the angular artery should be
preserved.
10. As the circumflex scapular artery emerges from the
triangular space it enters the subcutaneous tissues
and terminally divides into transverse and descend-
ing branches. Skin paddles are designed along the
long axis of these vessels.
Highpoints
1. The patient is positioned so that the hemilateral
back is exposed and the arm is sterilely prepped
and draped so that it may be extended and rotated.
2. The triangular space is the essential anatomic land-
mark for the design of the skin paddle and identi-
fication of the circumflex scapular artery. It is found
by placing the thumb along the midlateral border
of the scapula and wrapping the fingers around the
upper posterior axillary fold. As the patient's arm
is extended, the thumb falls into the triangular space
defined by the firm fibers of teres minor muscle
above and the teres major muscle below.
3. An ellipse of skin either centered over the trans-
verse branch (transverse flap) or the parascapular
branch (parascapular flap) is outlined with its lateral
extent over the triangular space.
4. The skin paddle is a true fasciocutaneous flap and
is raised from medial-to-lateral in a loose areolar
plane over the deep fascia of the shoulder region.
5. The fasciocutaneous vessels are visualized on
the deep surface of the flap while the thick white
deep fascia over the infraspinatus muscle is left
undisturbed.
6. The skin flap is circumferentially raised and pedicled
on the circumflex scapular artery while the muscles
bordering the triangular space are retracted.
7. If the lateral border of the scapula is harvested
with the flap (i.e., osteocutaneous scapular flap),
the descending periosteal branches are preserved.
8. If a skin-only flap is needed, the circumflex scapu-
lar artery is divided from the scapular bone and
followed to the subscapular artery.
9. To harvest the bone, a cautery device is used to
sharply incise the teres muscles and infraspinatus
muscle along a line approximately 2 cm from the
lateral scapular border.
10. An oscillating saw is taken through the thinner
bone along the muscle diastasis and a transverse
osteotomy is performed 1 to 2 cm inferior to the
glenoid fossa.
11. To completely mobilize the bone, the serratus muscle
is incised from the tip and the subscapularis muscle
is sharply separated from its posterior border.
12. The angular artery will be seen entering the perios-
teum near the tip of the scapula. If this artery is to
be preserved, it is followed superiorly to the serratus
branch, the thoracodorsal artery, and its common
progenitor with the circumflex scapular artery, the
subscapular artery.
13. The subscapular artery is divided, and the flap is
transferred to the recipient site.
Donor Site Closure
Donor site closure is limited to reattaching the serratus
muscle to the periosteum over the tip of the scapula in
case these structures were separated. There is no need
to reattach the teres muscles and the scapula, and
doing so may lead to problems with shoulder stiffness.
A suction drain is placed in the axilla, and the skin is
 MICROVASCULAR SURGERY

/
f
/

I
I

1
j

I
I
A
J

FIGURE 24-5

undermined over the back sufficiently to allow primary

closure. Range of movement exercises can commence
within 3 weeks. This donor site is particularly well
tolerated in terms of both function and cosmesis.
Complications
• Donor site complications are rare.
• Shoulder stiffness is the most common problem but
can be overcome with appropriate physical therapy.
• Loss of the distal tip of the scapula is a problem if
the angular artery is not preserved when a distal
osteotomy is performed.
A The triangular space is located by palpation and
the skin paddle is designed so that its lateral segment
overlaps this space. The transverse and descending
branches of the circumflex artery richly supply the skin
over the scapula and ipsilateral upper back. Virtually
any skin flap design is possible as long as it encom-
passes the triangular space and captures the circum-
flex scapular vessels as they enter the subcutaneous
tissue. Depicted are transverse and parascapular skin
paddles that parallel the transverse and descending
branches of the circumflex scapular artery. Parascapular
skin paddles are centered over the descending branch
that follows the lateral border of the scapula. Para-
scapular flaps can be much larger than transverse flaps
while still allowing primary closure of the donor site.
The thoracodorsal artery originates from the subscapu-
lar artery and courses under the teres major muscle
before entering the latissimus muscle. To harvest the
flaps based on the thoracodorsal artery with the scapular
system of flaps the teres major muscle must be divided.
Continued
 MICROVASCULAR SURGERY
Scapular Osteocutaneous
(Continued) (Fig. 24-5)
B Depicted is a transverse skin paddle raised off the
infraspinatus aponeurosis from medial to lateral toward
the triangular space. The transverse branch is clearly
seen along the undersurface of the flap. The fascias
over the surrounding muscles (teres major and teres
minor muscles) are included with the flap. It is impor-
tant to keep the thick fibrous cover of the infraspinatus
muscle down so that entrance into the triangular
space is facilitated.
C Depicted is the transverse scapular flap completely
mobilized over the triangular space. The circumflex
scapular artery must be followed deep into the trian-
gular space to the subscapular artery. Abducting the
arm and retracting the teres major and minor muscles
and the long head of the triceps away from the pedicle
facilitates the dissection. Multiple vascular tributaries
to the lateral border of the scapula and the thora-
codorsal artery must be divided to completely free the
vascular pedicle and extricate the skin flap.
Continued
 MICROVASCULAR SURGERY

B
~ ..

:I
(~

,/A,\ \
c (
FIGURE 24-5 Continued
 MICROVASCULAR SURGERY
Scapular Osteocutaneous
(Continued) (Fig. 24-5)
D1, D2 The vascular tributaries that course along
the lateral border of the scapula inferior to the
circumflex scapular artery are preserved if an osteocu-
taneous flap is needed. The teres major and minor
muscles and the subscapularis muscle are divided 1 cm
lateral to the lateral border of the scapula. An incision
through the infraspinatus muscle 2 cm medial to the
border of the scapula is done in preparation for the
osteotomies. The scapular tip is freed by cutting through
the fibers of the serratus and latissimus muscles as
required. Fingers are placed behind the scapula to pro-
tect underlying structures, and a sagittal saw is used to
perform the osteotomy 2 to 3 cm medial to the
scapular border. A transverse osteotomy between the
glenoid fossa and the circumflex scapular artery com-
pletes the bony cuts. The bone is completely mobi-
lized by dividing the subscapularis muscle. The subse-
quent dissection proceeds as in a skin-only harvest.
The angular artery may be preserved if a distal
osteotomy is planned or if the distal third of the
scapula is separated for use as an independent vascu-
larized bony segment. The angular artery is seen
branching from the artery to the serratus after the
teres major is divided. To preserve the angular artery
the thoracodorsal artery and its branch to the serratus
must be preserved.
Continued
 MICROVASCULAR SURGERY

FIGURE 24-5 Continued

 MICROVASCULAR SURGERY
Scapular Osteocutaneous
(Continued) (Fig. 24-5)
E1, E2 Up to 16 cm of bone is available for recon-
struction of limited segmental defects of the mandible.
The number of osteotomies should be limited because
the scapular tip is subject to ischemia unless the
angular artery is included. A typical flap consists of a
transverse or parascapular skin paddle and the entire
lateral border of the scapula from 1 to 2 cm below the
glenoid fossa.
E3, E4 Excessbone is removed either from the distal
tip or proximally near the vascular pedicle. If the
length of the vascular pedicle is adequate, excess bone
should be removed from the distal tip. If a longer vas-
cular pedicle is required, the periosteum and vascular
pedicle is stripped from the proximal bone and the
excess bare bone is removed. The flap is inset using
either a continuous reconstruction plate or separate
mandibular plates over the osteotomy sites and
mandibular stumps. The skin paddle is sutured over
the neoalveolus. The skin paddle is often thick and
non pliable, and secondary revision procedures to thin
the flap are often required, especially if osseointegrated
implants or denture use is planned.
Fl, F2 Restoration of facial contour is an ideal
application of free tissue because the flap tissues are
hidden and there is no requirement for movement.
Free tissue actually improves wound vascularity if the
area is ischemic secondary to irradiation or other
disease-related factors. The advantages to using a de-
epithelialized transverse or parascapular flap are (1)
the fibrofatty tissue is relatively cohesive compared
with fat in other parts of the body, (2) the fat will not
atrophy like muscle or avascular injected fat cells, and
(3) abdominal dissection is avoided and the flap is less
likely to sag compared with the omental flap. Depicted
are a typical cheek contour defect (F1) and the inset-
ting of a de-epithelialized scapular skin paddle (F2).
Several non absorbable sutures are placed into the
periosteum overlying the medial infraorbital rim and
zygoma. The sutures are in turn taken through the
superior edge of the flap, and the flap is drawn into
the wound through a facelift incision. A separate hori-
zontal neck incision is created for vascular access.
 MICROVASCULAR SURGERY

FIGURE 24-5 Continued

 MICROVASCULAR SURGERY
latissimus (Fig. 24-6)
Neurovascular Anatomy
1. The latissimus muscle is transferred based on the
thoracodorsal artery, the main vascular supply to the
muscle.
2. The thoracodorsal artery originates from the sub-
scapular artery and courses inferiorly, sending a
branch to the serratus muscle on its way to the
latissimus muscle.
3. The artery courses deep to the latissimus muscle for
several centimeters before penetrating its deep surface.
4. Once the artery enters the muscle, it divides into
medial and lateral branches.
5. The length of the vascular pedicle is excellent, meas-
uring between 8 and 10 cm.
6. The thoracodorsal motor nerve is enclosed in a com-
mon sheath with the thoracodorsal artery.
7. The nerve divides into posterior and anterior branches
before entering the deep surface of the muscle.
8. A portion of the muscle served by selected branches
of the thoracodorsal artery and nerve can be trans-
ferred for use in facial reanimation (Harii et al., 1998).
Highpoints
1. The patient is positioned so that the hemilateral back
is exposed and the arm is sterilely prepped and
draped so that it may be extended and rotated.
2. A muscle-only flap is harvested through an incision
in the posterior axillary fold from the mid scapula to
the tenth thoracic vertebra. The subcutaneous tissues
are dissected off the surface of the muscle and the
lateral edge of the muscle is identified.
3. The thoracodorsal neurovascular pedicle is identi-
fied in the axillary fat by retracting the humeral head
of the muscle, and a vessel loop is loosely applied.
4. The undersurface of the muscle is easily freed from
the underlying muscles and fascia, including the
serratus muscle.
S. The vascular pedicle is separated from the thora-
codorsal nerve and dissected superiorly to the sub-
scapular artery.
6. The branch to the serratus is divided.
7. The vascular pedicle is retracted from the humeral
head, and the latter is divided with cautery .
8. The muscle is completely mobilized by dividing its
inferomedial attachments.
9. Division of the subscapular artery and thoracodorsal
nerve completes the harvest.
Musculocutaneous Flap
1. Terminal musculocutaneous arteries generously
supply the skin overlying the nonaponeurotic portions
of the latissimus.
2. Skin outside the boundaries of the muscle is subject
to ischemia and necrosis.
3. The skin paddle should be no less than 25 cm2 to
ensure the inclusion of sufficient musculocutaneous
vessels.
4. A distal skin paddle results in greater reach of the
vascular pedicle.
5. The first step in harvesting a musculocutaneous flap
is to outline a skin paddle that borders the posterior
axillary fold (corresponding to the lateral edge of the
muscle).
6. Depending on the size and shape of the skin paddle,
superior and inferior incisions along the lateral
border of the muscle may be necessary.
7. The perimeter of the skin paddle is incised down to
the latissimus muscle. The external surface of the
muscle is exposed, and the remainder of the dissec-
tion proceeds as in a muscle-only harvest.
Donor Site Closure
Primary closure is nearly always possible, especially
if the long axis of the skin paddle parallels the lateral
edge of the muscle and the width does not exceed
10 em. The subcutaneous tissues are closed with
strong absorbable suture, and the skin is closed with
staples supplemented with horizontal mattress non-
absorbable sutures. Two large suction drains are placed
in the dependent areas of the wound and left for
at least 7 days. The sutures are allowed to remain for
2 weeks.
Complications
• The functional morbidity resulting from the loss of
the latissimus muscle is minimal.
• Weakness will be noted in arm extension and pulling
the arm downward and backward.
• The most common problems with the donor site
are its tendency to form seromas and for wound
separation.
 MICROVASCULAR SURGERY

FIGURE 24-6

A The latissimus flap is harvested through a posterior
axillary incision corresponding to the anterior border
of the latissimus muscle. The patient must be placed in
a lateral decubitus position with the arm draped over
a Mayo stand or arm holder. The skin paddle is centered
over the muscle with its anterior border in line with the
initial access incision. The inferiormost portion of the
skin paddle should not extend over the aponeurotic
portion of the latissimus muscle (below T12) because
the skin in this area is random and subject to ischemic
necrosis.
Continued
 MICROVASCULAR SURGERY
latissimus (Continued) (Fig. 24-6)
81, 82 The skin paddle is secured to the fascia over
the underlying muscle using interrupted 3-0 Vicryl
sutures (B1). The entire anterior border of the
latissimus muscle is exposed to facilitate the vascular
dissection. The vascular pedicle is identified first and
followed inferiorly to its entrance into the muscle. Both
the thoracodorsal artery and nerve divide close to the
muscle to supply separate areas of the muscle. It is
possible to harvest only a portion of the latissimus
muscle based on the anterior branch of the thora-
codorsal artery. It is also possible to split the muscle
into peninsular segments based on the anterior and
posterior branches of the thoracodorsal artery.
The anterior border of the muscle is retracted to
reveal the long thoracic nerve and the vascular supply
to the lower serratus muscle and underlying ribs
(depicted in B2). If the serratus muscle is to be
harvested with the latissimus muscle, the serratus
branch must be preserved. The thoracodorsal vascular
pedicle is dissected to the subscapular artery, and the
circumflex scapular artery is divided. To facilitate this
dissection the humeral head of the muscle is divided.
The latissimus muscle is bluntly dissected away from
the underlying rib cage and its associated muscula-
ture. It is then sharply divided proximal to its multiple
insertions along the thoracic spine and iliac crest.
Continued
 MICROVASCULAR SURGERY

FIGURE 24-6 Continued

 MICROVASCULAR SURGERY
Latissimus (Continued) (Fig. 24-6)
Cl, C2 The latissimus muscle is a broad, thin, and
highly vascular flap that is ideal for subtotal scalp
replacement. It provides a well-vascularized bed for
skin grafting and coverage for underlying bone sub-
stitutes in cases where the underlying calvarium is
missing. Subtotal full-thickness calvarial defects may
be reconstructed with vascularized serratus-rib grafts
that are harvested with the latissimus muscle. Smaller
defects «(2) are best reconstructed using split calvarial
bone grafts or hydroxyapatite cement.
FIGURE 24-6 Continued
C3 TO CS Depicted in (3 is the latissimus muscle
inset. The thoracodorsal pedicle can reach the upper
neck if necessary. However, the superficial temporal
vessels usually suffice. A meshed skin graft taken from
the lateral thigh is placed over the muscle and secured
to the muscle using fine chromic suture. A bolster is
not required, but the muscle surface should be pro-
tected from shearing forces, especially if the posterior
occiput is involved. A neurosurgical halo worn for
1 week postoperatively is an effective means to protect
the graft.
 MICROVASCULAR SURGERY

FIGURE 24-6 Continued

 MICROVASCULAR SURGERY
Jejunal (Fig. 24-7)
Neurovascular Anatomy
1. Branches of the superior mesenteric artery form vas-
cular arcades within the mesentery that distribute to
the jejunum.
2. A jejunal segment is isolated based on a vascular
arcade that is traced to a common branch of the
superior mesenteric artery and vein.
3. The vascular pattern within the mesentery is opti-
mally visualized by stretching a segment of jejunum
with its attached mesentery in front of a light source.
4. There are no useable neural elements that accom-
pany the jejunal segment.
Highpoints
1. Multiple operative teams are often employed, includ-
ing general surgery, reconstructive microsurgery,
and surgical oncology.
2. The general surgeon is responsible for harvest of the
jejunal segment and postoperative care of the abdom-
inal wound.
3. The flap is harvested through an upper midline
abdominal incision, and a segment of jejunum is
isolated approximately 3 feet distal to the ligament
of Treitz. Taking a segment too close to the ligament
makes the enteric anastomosis more difficult.
4. A segment of jejunum sufficient to span the cervical
esophageal defect and provide for an exteriorized
monitoring segment is identified based on an appro-
priate mesenteric vascular arcade.
5. The vascular pedicle is developed, and the mesen-
tery is dissected to the border of the jejunal segment.
6. A gastrointestinal stapling device is used to harvest
the jejunal segment, and the direction of natural
peristalsis is noted with a stitch.
7. The vascular pedicle is divided when the recipient
site is ready to accept the graft.
8. Enteric anastomosis proceeds, and a jejunostomy
tube is placed. The abdomen is closed in the typical
fashion.
9. Feeding through the jejunostomy can proceed in the
immediate postoperative period.
Complications
• The most common donor site complications are
wound dehiscence and gastrointestinal bleeding.
• Occasionally, a life-threatening hemorrhage or enteric
dehiscence is encountered.
A A segment of jejunum is selected with vascular
arcades that are traceable to a single artery and vein
branching off of the superior mesenteric artery and
vein. The jejunal vascular arcades are visualized by
transilluminating the mesentery. Depicted is a jejunal
segment sufficient for replacement of the cervical
esophagus and for provision of an exteriorized monitor-
ing segment. After the flap is harvested, enteric anas-
tomosis proceeds and a jejunostomy tube is placed.
B Depicted is the jejunal flap inset with the proximal
and distal enteric anastomoses completed. The distal
anastomosis is prone to stricture formation. It should
be performed using an interrupted suturing technique
with a tongue of tissue from the flap in the shape of a
"V" inserted into a small vertical cut into the esophageal
stump to lessen the constricting effects of scar contrac-
ture. There should be no redundancy that could lead
to dysphagia. The vascular anastomoses are performed
immediately after the flap is inset. The exteriorized
monitoring segment is brought through the suture
line and removed on the fifth postoperative day.
 MICROVASCULAR SURGERY

FIGURE 24-7
 MICROVASCULAR SURGERY
Iliac Crest Osteocutaneous (Fig. 24-8)
Neurovascular Anatomy
1. The deep circumflex iliac artery (DCIA) supplies
the osteomyocutaneous iliac crest flap via periosteal
branches to the iliac crest bone, septocutaneous
perforators to the overlying skin, and an ascending
branch to the internal oblique muscle.
2. The diameter of the DCIA varies considerably at
its origin from the external iliac artery, measuring
between 1.0 and 2.5 mm.
3. The venae comitantes merge near the external iliac
vein to form a single deep circumflex vein that
measures between 2 and 4 mm.
4. The DCIA courses obliquely toward the anterior-
superior iliac spine (ASIS) deep to the inguinal
ligament encased in a fibrous sheath formed by the
junction of the iliac and transversalis fascias.
5. The vessels pierce the transversalis fascia near the
ASIS and course along the inner aspect of the iliac
crest over the iliacus muscle.
6. The DCIA gives off an ascending branch opposite
the ASIS that courses superolaterally between the
internal oblique and transversalis muscles.
7. As the DCIA continues over the iliacus muscle, it
sends vessels en route to the overlying skin through
a fascial mesentery between the crest and over-
lying skin.
8. The lateral femoral cutaneous nerve is an impor-
tant structure that is subject to injury during dissec-
tion of the vascular pedicle.
9. The nerve supplies sensation to the lateral thigh
and if injured results in bothersome numbness over
the area. It originates from the second and third
lumbar nerves and crosses over the surface of the
iliacus muscle and DCIA and continues under the
lateral inguinal ligament.
10. The nerve is carefully separated from the DCIA and
venae comitantes and preserved.
Highpoints
1. Important superficial landmarks for the iliac crest
free flap include the pubic tubercle, inguinal liga-
ment, ASIS, and iliac crest.
2. The skin paddle must be centered over the iliac
crest from the ASIS up to the posterior-superior iliac
spine. An ellipse of skin up to 13 cm in width can
be harvested while still allowing primary closure of
the donor site.
3. The initial incision should extend from the pubic
tubercle to the posterior-superior iliac spine follow-
ing the inguinal ligament and the perimeter of the
skin paddle over the iliac crest.
4. If no skin paddle is needed, the incision follows the
iliac crest.
5. The inferior skin ellipse is incised down to the
tensor fasciae latae muscle and the superior ellipse
is incised down to the external oblique fascia.
6. Dissection proceeds to within 2 cm of the iliac
crest, and the external oblique fascia is incised along
the full extent of the proposed bone harvest.
7. Dissection proceeds along the medial aspect of the
ilium where the conjoined fascias of the internal
oblique and transversus abdominis muscles are
divided.
8. Near the ASIS, the vascular pedicle and lateral
femoral cutaneous nerve is identified and preserved.
9. The vascular pedicle is dissected to the external
iliac vessels.
10. The pedicle can be completely extricated from the
nerve after the pedicle is divided.
11. The iliac crest is harvested by first sharply dividing
the muscles and fascial fibers of the tensor fasciae
latae from the external lip of the crest and ilium,
preserving the underlying periosteum.
12. The inner aspect of the ilium is exposed to below
the vascular pedicle that can be seen coursing under
the iliacus muscle fascia.
13. Using cautery, the iliacus muscle is incised to bone
1 cm below the vascular pedicle to prepare a trough
for the horizontal osteotomy (parallel to the crest).
A similar trough is created along the external surface.
14. Vertical osteotomies are required posteriorly and
near the ASIS to completely free the bone segment.
15. The use of an osteotome is proscribed, and the ASIS
should be left at least 2 cm in width to prevent
pathologic fracture.
16. The bone cuts are made with an oscillating saw
from the external surface with the surgeon's hand
providing a protective barrier between the inner
cortex and the peritoneum.
17. The ascending branch of the DCIA must be pre-
served if the internal oblique muscle is harvested
with the bone. This branch is isolated as it exits the
DCIA near the ASIS.
18. The surface of the internal oblique muscle is exposed
by dissecting within the plane between this muscle
and the external oblique muscle superior to the iliac
crest. A segment of muscle approximately 6 cm
wide by 15 to 20 cm long, parallel to and within 2
to 3 cm of the iliac crest is harvested.
19. The medial and superior borders are elevated from the
underlying transversus muscle toward the iliac crest.
20. The vascular pedicle (ascending branch) is positively
identified because absence of a discrete pedicle
occurs in approximately 20% of cases. If there is
no discrete pedicle, the flap is either abandoned or
left attached to the iliac crest.

21. Once the presence of a pedicle is confirmed, the
final lateral incision is performed with the pedicle
in full view. The muscle is then freed with respect
to the bone and can be manipulated independently
based on the ascending branch.
Donor Site Closure
The donor site is closed in three layers with strong
nonabsorbable sutures. Any sharp edges along the
bone cuts should be removed. The transversalis fascia
is the first layer and is secured to the tensor fasciae
latae or to the iliac bone through drill holes. The second
layer consists of the external oblique muscle that is also
sutured to the tensor fascia. The final layer is the sub-
cutaneous tissue and skin. Two large drains are inserted
MICROVASCULAR SURGERY
into the wound before closure and brought out infe-
riorly through separate stab incisions.
Complications
• There is substantial pain at the donor site for several
weeks postoperatively.
• The patient may be burdened with a permanent limp.
Physical therapy beginning within 3 weeks after sur-
gery is helpful.
• Injury of the lateral femoral cutaneous nerve will result
in troublesome numbness over the lateral thigh.
• Hernia is possible but rarely occurs unless there is a
technical problem with wound closure or the patient
is obese.
 MICROVASCULAR SURGERY
Iliac Crest Osteocutaneous
(Continued) (Fig. 24-8)
A Depicted is the deep circumflex iliac artery origi-
nating from the external iliac artery and coursing parallel
to the inguinal ligament and inner aspect of the iliac
crest. The lateral femoral cutaneous nerve is seen ema-
nating from the depths of the wound coursing along
the surface of the iliacus muscle and exiting to the
thigh under the inguinal ligament. Near the ASIS the
nerve and vascular pedicle intermingle. The nerve
should be preserved by carefully separating it from the
artery and venae comitantes.
B Depicted is a composite iliac crest flap harvested
from the right hip. The skin paddle and internal oblique
muscle components are shown. At least 2 cm of the
ASISis preserved, and the bone cuts are made with an
oscillating saw. Osteotomes are avoided to prevent
splintering and weakening of the remaining iliac crest.
The inferior bony cuts can be fashioned to reconstruct
the ascending mandibular ramus.
A
FIGURE 24-8
(1 TO(3 There are design limitations with respect
to the bone because of the position of ~he vascular
pedicle and skin paddle and the natural curvature of
the iliac crest. The convex (outer) surface of the iliac
crest must correspond to the outer surface of the new
mandible. In addition, the upper border of the iliac
crest at the donor site must correspond to the lower
border of the mandible at the recipient site so that the
vessels and bulk of the skin paddle are placed away
from the neoalveolus. To position the vascular pedicle
posteriorly the ipsilateral iliac crest is used. Depicted is
an ipsilateral iliac crest harvest for reconstruction of a
right segmental mandibular defect. The vascular
pedicle exits posteriorly to drape into the neck in a
relatively favorable position for the subsequent micro·
vascular anastomoses. The internal oblique muscle is
used to cover the neoalveolus with no need for skin
grafting because the surface is rapidly mucosalized
(C3).
\1
,
"-) /
I
 MICROVASCULAR SURGERY

FIGURE 24-8 Continued

 MICROVASCULAR SURGERY
Gracilis (Fig. 24-9)
Neurovascular Anatomy
1. The innervated gracilis flap is based on the medial
femoral circumflex artery and the obturator nerve.
2. The medial femoral circumflex artery, a branch of
the deep femoral artery, courses between the adduc-
tor longus and adductor brevis muscles to reach the
middle third of the gracilis muscle.
3. The diameter of the artery is between 1.0 and 2.0 mm,
and the diameter of the accompanying venae comi-
tantes measures between 1.0 and 1.5 mm each.
4. Several musculocutaneous perforators supply the
skin directly over the upper third of the muscle.
5. The obturator nerve passes through the obturator
foramen surrounded by ischium and pubis and con-
tinues inferiorly into the thigh.
6. The obturator nerve splits into a posterior branch
that passes under the adductor brevis muscle and an
anterior branch that passes superficial to the muscle
on its way to the gracilis muscle.
7. Proximal to the gracilis muscle, the anterior branch of
the obturator nerve divides into several branches that
innervate distinct longitudinal segments of the muscle.
8. The individual fascicles are stimulated with a nerve
stimulator to define the functional segments.
9. Each fascicle supplying a functional segment of
muscle can be anastomosed to different divisions of
the facial nerve to achieve independent movement.
Highpoints
1. The gracilis muscle is the most superficial muscle in
the medial thigh, originating from the inferior pubis
and inserting into the medial surface of the tibia.
2. It is harvested through a linear incision over the
medial thigh on a line tangent to the pubis and medial
condyle of the tibia.
3. The incision is carried down to the muscle and the
intermuscular septum between the gracilis and the
adductor longus.
4. The vascular pedicle is seen entering the anterior aspect
of the gracilis muscle from under the adductor longus.
S. The anterior branch of the obturator nerve splits into
several fascicles before entering the muscle near the
vascular pedicle.
6. Although the muscle is often used as a single func-
tional unit, it can be split into independent functional
segments each supplied by a unique nerve fascicle.
7. If only a single functional unit is required, only the
anterior half of the muscle need be harvested because
the vascular pedicle directly enters this portion.
8. When the muscle is to be used for facial reanima-
tion, marking silk sutures are placed at 1 em incre-
ments along the muscle to denote the resting tension.
The muscle is reexpanded at the recipient site using
the sutures as a reference.
Donor Site Closure
The donor site is closed by suture-approximating the
subcutaneous tissue and skin over a suction drain.
Complications
• Donor site morbidity is minimal without functional
morbidity.
A The gracilis is harvested through an inconspicuous
medial thigh incision with the leg in an abducted posi-
tion. The vascular pedicle (medial femoral circumflex
artery and vein) is seen branching above the muscle
and entering its deep surface near the branches of the
anterior division of the obturator nerve. The anterior
and posterior longitudinal segments of the muscle are
capable of moving independently and are innervated
by separate branches of the anterior division of the
obturator nerve. The vascular pedicle is dissected by
retracting the adductor longus muscle and taken distal
to the deep femoral vessels. The nerve is dissected
proximally while preserving the muscular branches to
other muscles within the medial thigh. The marking
silk sutures are placed before flap harvest.
B Depicted is a monofascicular segment of gracilis
muscle suitable for facial reanimation. Several distal
minor vascular pedicles are seen that have been divided
during flap harvest.
C Depicted is a case of facial reanimation using a
revascularized monofascicular gracilis graft inset with a
previously placed cross-facial nerve graft. The muscle
is reexpanded, and its distal stump is sutured to the
zygomatic arch and the proximal segment is sutured
to the oral commissure (modiolus). After the muscle
is secured, the neural and vascular anastomoses
proceed.
 MICROVASCULAR SURGERY

A \
\ \

i
I
/
/
i

FIGURE 24-9
 MICROVASCULAR SURGERY
BIBLIOGRAPHY
Ariyan 5: The pectoralis major myocutaneous flap: A versatile flap
for reconstruction in the head and neck. Plast Reconstr
63:73-81, 1979.
Bakamjian VY: A two-stage method for pharyngoesophageal recon-
stmction with a primary pectoral skin flap. Plast Reconstr Surg
36:173, 1965.
Boyd JB, Mulholland RS, Davidson J, et al: The free flap and plate in
oromandibular reconstruction: Long-term review and indications.
Plast Reconstr Surg 95:1018-1028,1995.
Bretzman PA, Manaster BJ, Davis WL, Coleman DA: MR angiography
for preoperative evaluation of vascularized fibular
Interv Radiol 5:603-610, 1994.
Cormack Ge, Lamberty BG: Fasciocutaneous vessels:
bution on the trunk and limbs, and their clinical application in
tissue transfer. [Review]. Anat Clin 6: 121-131, 1984.
Dolan R, Carr RM, McAvoy D: Operative anatomy of the sensory
nerves to the fibula osteoseptocutaneous flap. Arch Facial Plast
Surg in press.
Dolan R, Gooey J, Cho YJ, Fuleihan N: Microvascular access in the
multiply operated neck: Thoracodorsal transposition [published
erratum appears in Laryngoscope 107(1):149, 1997]. Laryngoscope
106:1436-1437, 1996.
Dolan RW, Kerr D, Arena 5: Reducing ischemia-reperfusion injury in
rat island groin flaps by dexamethasone and BW755C. Laryngoscope
105:1322-1325, 1995a.
Dolan RW, Kerr D, Schneiderman T, Arena S: Reducing ischemia-
reperfusion injury in rat island groin flaps using dexamethasone.
Ann Plastic Surg 35:285-289, 1995b.
Fuhrman TM, Pippin WD, Talmage LA, Reilley TE: Evaluation of col-
lateral circulation of the hand. J Clin Monit 8:28-32, 1992.
Harii K, Asato H, Yoshimura K, et al: One-stage transfer of the latis-
simus dorsi muscle for reanimation of a paralyzed face: A new
alternative. Plast Reconstr Surg 102:941-951, 1998.
Harii K, Ohmori K, Torii 5: Free gracilis muscle transplantation, with
microneurovascular anastomoses for the treatment of facial paral-
ysis: A preliminary report. Plast Reconstr Surg 57:133-143, 1976.
Hidalgo DA: Fibula free flap: A new method of mandible reconstruc-
tion. Plast Reconstr Surg 84:71-79,1989.
Khouri RK, Cooley BC, Kunselman AR, et al: A prospective study of
microvascular free-flap surgery and outcome. Plast Reconstr Surg
102:711-721,1998.
Kroll 55, Schusterman MA, Reece GP, et al: Timing of pedicle throm-
bosis and flap loss after free-tissue transfer. Plast Reconstr Surg
Surg 98:1230-1233, 1996.
Manchot C: Die Hautarterien des Menschlichen Koerpers. Leipzig,
FCW Bogel, 1889.
Mathes 5J, Nahai F: Classification of the vascular anatomy of muscles:
Experimental and clinical correlation. Plast Reconstr Surg 67:177-187,
1981.
Maxwell GP, Stueber K, Hoopes JE: A free latissimus dorsi myocuta-
neous flap: Case report. Plast Reconstr Surg 62:462-466, ] 978.
McConnel FM, Teichgraeber JF, Adler RK: A comparison of three
grafts. ] Vase methods of oral reconstruction. Arch Otolaryngol Head Neck Surg
113:496-500, 1987.
Their distri- McGregor lA, Morgan G: Axial and random pattern flaps. Br J Plast
Surg 26:202-213, 1973.
Pennington DG, Pelly AD: The rectus abdominis myocutaneous free
flap. Br J Plast Surg 33:277-282, 1980.
Ponten B: The fasciocutaneous flap: Its use in soft tissue defects of
the lower leg. Br J Plast Surg 34:215-220, 1981.
Salemark L: International survey of current microvascular practices
in free tissue transfer and replantation surgery. Microsurgery
12:308-311,1991.
Schultes G, Gaggl A, Karcher H: Reconstruction of accessory nerve
defects with vascularized long thoracic VB. non-vascularized
thoracodorsal nerve. J Reconstr Microsurg 15:265-270, 1999.
Seidenberg B: Immediate reconstruction of the cervical esophagus by
a revascularized isolated jejunal segment. Ann Surg 142:162,1959.
Sloan GM, Sasaki GH: Noninvasive monitoring of tissue viability.
[Review]. Clin Plast Surg ]2:185-195, 1985.
Swartz WM, Banis JC, Newton ED, et al: The osteocutaneous scapular
flap for mandibular and maxillary reconstruction. Plast Reconstr
Surg 77:530-545, 1986.
Taylor GI: Reconstruction of the mandible with free composite iliac
bone grafts. Ann Plast Surg 9:361-376, 1982.
Taylor GI, Corlett RJ, Boyd JB: The versatile deep inferior epigastric
(inferior rectus abdominis) flap. Br J Plast Surg 37:330-350, 1984.
Urken ML, Biller HF: A new bilobed design for the sensate radial
forearm flap to preserve tongue mobility following significant
glossectomy. Arch Otolaryngol Head Neck Surg ]20:26-31, 1994.
Yang G, Chen B, Gao Y: Forearm free skin flap transplantations. Natl
Med J China 61:139,1981.
 INDEX

Note: Italic page numbers refer to illustrations; page numbers followed by (t) refer to tables.

Abbe-Estlander lip operation, 464-466, Ameloblastoma, mandibular; 658, 659 Angulation, of internal carotid artery,
465, 466 Ampullar nerve, posterior, CT scan of, 39 1266, 1267
modifications of, 469, 469-471, 471 Anaplastic carcinoma, of thyroid Antibiotics
Abbott Northwestern Staged Diet, 146 classification of, 917, 928 extended treatment with, 128
Abductor vocal cord paralysis, 1071, 1071 cytology of, 895 postoperative, 119
arytenoidpexy for, 1086-1089, 1087, 1089 management of, 928, 931 (I) preoperative prophylaxis with, 114
laryngofissure for, 1082-1085, 1083, 1085 substernal, 930 Anticoagulants, in vascular surgery, 1235
Abscess(es) Anastomosis, vascular, 1234-1235, 1235 Antrostomy
facial, 394, 395 Anesthesia intranasal, 214-216, 215, 216, 218,219
of floor of mouth, 854, 855 for cerebral vascular surgery, 1243 maxillary, 260, 261, 261
lateral cervical, 854, 855 for composite graft from ear to nose, 342 Antrotomy, Caldwell-Luc, 217, 217-219,
of neck, incision and drainage of, for dermabrasion, 371 218,219
854, 855 for direct rigid laryngoscopy, 182-183 Antrum of Highmore. See Maxillary sinus
of tongue, 854, 855 for endoscopic sinus surgery, 259 Aortic arch, MRI of, 48, 50, 52
Accessory nerve, spinal, 781 for esophagoscopy, 194 Apron flap, 402, 436, 437
preserving, in radical neck dissection, for external ethmoidectomy, 223 Arch bars, 602, 602
802-803, 803, 808-810,809, 810, for flexible bronchoscopy, 192 Arm flap, for nose reconstruction, 344, 345
950-954, 951, 953, 954 for fractured nose reduction, 597 Arteriovenous fistula
Adductor vocal cord paralysis, 1071, 1071 for hypopharyngoscopy, 182-183 facial, resection of, 1314-1319, 1315,
Adenocarcinoma, not otherwise specified for hypophysectomy, 1395 1316,13]7,1319
(NOS), of salivary gland, 883-884 for intranasal antrostomy, 214 thyroid surgery and, 964
Adenoidectomy, 770-772, 771, 772 for laryngoscopy, 1092-1093 vascular trauma and, 1313-1314
Adenolipoma, parathyroid, 973 and malignant hyperthermia, 65 venous malformation with, CT
Adenoma for microscopic endolaryngoscopy, 200 angiography of, 42, 43
carcinoma ex pleomorphic, 884 preoperative consultation for, 116 Arteritis
parathyroid, 966-967, 972 for rigid bronchoscopy, 188 giant cell, 1275(1)
excision of, 990-993, 994, 995 for trans sphenoidal approach to pituitary radiation, 1275
complications of, 1002 gland, 1404 Takayasu's, 1268, 1275, 1275(t)

and hypocalcemia, 1002 for unilateral cleft lip repair, 494 temporaL 127~, 127~(t)
postoperative care, 1002, 1003(t) Aneurysm Artery. See specific arteries, e.g., Carotid

mediastinal, excision of, 986, 988, atherosclerotic, 1240, 1241, 1266, 1267 artery
996-1002 of common carotid artery, 1320 Aryepiglottic fold
surgical management of, preoperative of external carotid artery, 1266 laryngoscopy of, 186
and intraoperative techniques for, false, 1266, 1320 MRI of, 28, 31, 33
976-1002 carotid artery surgery and, 1251 Arytenoid cartilage, 9
Adenomatous nodule, cytology of, 894 with internal carotid artery/internal esophagoscopy of, 195
Adipose tissue, associated. 1000, 1001 jugular vein fistula, treatment of, laryngoscopy of, 186, 187
Advanced cardiac life support, 70 1320-1325, 1321, 1323, 1325 lateralization of, for bilateral abductor
Air embolism, 65 vascular trauma and, 1314 vocal cord paralysis, 1086-1089,
Airway of internal carotid artery, 1266, 1267, 1320 1087, 1089
establishment of, emergency, 84-85, Aneurysmal bone cyst, 656 MRI of, 31, 33
1016 Angina, Ludwig's, 854, 855 Arytenoid dislocation, 906
obstruction of Angiofibroma Arytenoidectomy, for bilateral abductor vocal
cricothyroidotomy for, 82, 83 biopsy precautions with, 208 cord paralysis, 1082-1085, 1083, 1085
location of, 84 iuvenile, characteristics of, 288-289 Arytenoidpexy, for bilateral abductor vocal
thyroid surgery and, 963 Angiography cord paralysis, 1086-1089, 1087, 1089
Ala nasi in epistaxis, 270 Aspiration
excision and reconstruction of, 336, 337 of paraganglioma, 1292 management of. 1162-1164
revision of, 3S2, 353 of parathyroid glands, 979, 980, 981 surgical prevention of, 1164
Alaryngeal speech, types of, 144 in vascular surgery, 1239, 1239 Aspiration biopsy
Alcohol, preoperative cessation of, 114 Angle fractures, 616 fine-needle, 87, 88
Allografts, in vascular surgery, 1236 open repair of, 607-608, 608, 609 in lymph node evaluation, 138

1471
 1472 INDEX

Aspiration biopsy (Continued) Battered middle turbinate syndrome, 263,263 Bone grafts (Continued)
of parotid salivary gland, 861-862 Bell's patsy, fascial slings for, 388 for mandibular reconstruction,
of thyroid lesions, 893 Berci-Ward telescope, 180, 180, 205, 210, 211 678-682, 679, 681
large-needle, 87, 89, 89-90, 90 Bernard reconstruction, with lower lip trap door type, 110, 111
of neck nodes, 780-781 resection, 482, 483 Bone imaging, 142-143
of parotid salivary gland, 861-862 Biopsy Bowel prep, 116
of thyroid lesions, 893 esophageal, 196 Branchial cleft cysts, 836-842
Associated adipose tissue, 1000, 1001 exfoliative cytotogy, 91 first, 836-838, 837
Atheromatous plaques, 1240, 1241, 1242 histopathologic slides from, review of, fourth, 838
Atherosclerotic aneurysm, 1240, 1241, 124-125 resection of, 840-842, 841, 842
1266, 1267 imaging studies prior to, 125 second, 838, 839
Atlas, 3, 5 of infraclavicular internal jugular node, resection of, 840-842, 841, 842
Atresia, choanal, posterior, 295-299, 297, 299 832,833 third, 838, 839
Atypia, 91 of lymph nodes, 780-781 Branchiat fistula, excision of, 843, 843-844,
Auditory bony canal, en bloc resection of, with microscopic endolaryngoscopy, 844
588-590, 589 200-201 Breathy voice, omohyoid muscle
Auditory canal mucosal,91 laryngoplasty for, 1114-1115, 1115
external of nasopharynx, 208, 209 Bridge flap, for large upper eyelid defects,
CT scan of, 41 of neck nodes, 780-781 542-543, 543
resection of, for recurrent malignant needle Bronchoscope selection, 193(t), 1015(t)
melanoma, 590-593, 591, 592 core, 87-89 Bronchoscopy
slenosis of, Z-plasty for, 582, 583 in soft tissue sarcoma diagnosis, 153 flexible, 192
tumors of of neck nodes, 780-781 anesthesia for, 192
en bloc resection of, 589, 589-590 of parotid salivary gland, 861-862 rigid, 188-191, 189, 191
excision of, 584, 585 techniques of, 87-89 anesthesia for, 188
internal, CT scan of, 39 of thyroid lesions, 893 Bronchus
Auditory meatus for occult mass, 127-128 left
internal,S open inspection of, 190
squamous cell carcinoma of, PET scan in lymph node evaluation, 138 MRI of, 48, 50
of,60 pilfalls of, 124 right, inspection of, 190
Augmentative communication devices, 144 in soft tissue sarcoma diagnosis, 153 Buccal fat pad, 11
Auricle of oral cavity lesions, 124 Buccal mucous membrane, lesion of,
hematoma of, surgical treatment of, of parotid salivary gland, 861-862 excision of, 698-700, 699
580, 581 punch Buccal wall
malignant tumors of, excision of, 586, 587 for hypo laryngeal lesions, 1073, 1073 benign lesions of, 742-743, 743
protruding, correction of, 573-579, 574, for laryngeal lesions, 1073, 1073 carcinoma of, resection of, 747, 747-751,
575, 577 repeat, 125 749, 750, 751
total resection of, for recurrent malignant of scalene node, 832, 833 with mandibulectomy, 745-746
melanoma, 590-593, 591, 592 of thyroid lesions, 893 lesions of
Auricular bodies, neoplastic disease of, 1284 Bitemporal flap, for large upper lip defects, reconstruction of, 746

Auricular cartilage grafts, 110, 111 480,481 resection of, 742-751, 744(t)
Auricular prosthesis, 170, 170 Bleomycin premalignant and malignant lesions of,
Auriculotemporal nerve, resection of, for preoperative, 132 resection of, 744-745
gustatory sweating, 876-877, 877 with radiation therapy, 131 reconstruction and reimplantation of,
Autogenous bone grafts, for mandibular for recurrent cancer, 129 Stensen's duct in, 774
reconstruction, 675-676, 677 Blindness, 66-70 Buccal wall-cheek flap, 747, 747
Autografts, in vascular surgery, 1235-1236 bilateral, 69 Buccinator muscle, MRI of, 32
Autonomous thyroid nodule, 960 iatrogenic, 66-67 Bulla ethmoidalis, 267, 269
Axillary artery, course of, 406 in thyroid-related orbitopathy, 155 Burow's technique, for upper lip lesion
Axis, 5 unilateral, 69 excision, 476, 477
Blood transfusion, preoperative, 116 Bypass
Backbiting forceps, 260, 260 Blow-in fracture, of orbital floor, 640 ECA/ICA, CT angiogram of, 45
Barton-type bandage, 600, 601 Blowout, of carotid artery, 1237, 1328-1335 vascular, temporary, 1237
Base of skull etiology of, 1328-1329 Bypass graft
CT scan of, 40 prevention of, 1328-1335, 1333, 1335 for innominate artery obstruction,
infratemporal approach to, 1365-1392 dermal graft for, 133]-1332, 1333 1270, 127]
osseous anatomy of, 1349, 1349 tevator scapulae muscle flap for, placement of, 1262, 1263
and parapharyngeal space, 1349-1374 1332, 1333
perineural disease at, detection of, 35, 35 Blowout fracture, of orbital floor, 640, 641 C-cell hyperplasia, 922, 923, 924-925, 931(t)
surgery on, 1348-1414. See also specific Body fractures, open repair of, 607, 607, 608 Cl, lateral mass of, MRI of, 33
procedures, e.g., Hypophysectomy Bone cyst, aneurysmal, 656 C4-5 intervertebral disc, MRI of, 33
trans maxillary approach to, 294, 294 Bone density, hyperparathyroidism C4 vertebral body, MRt of, 33
Trotter approach to, 704-707, 705, 707 treatment and, 1002 Calcitonin
tumors of, craniofacial resection for, Bone grafts, 107-112 in malignant disease, 922, 924, 925
1377-1385 autogenous, for mandibular as stain for head and neck lesions, 91
Basic life support, 70-72, 7] reconstruction, 675-676, 677 Calcium preparations, 1003(t)
Basilar artery, CT angiography of, 45 iliac, 108, 109 Calcium replacements, 1003(t)

Calculus (calculi), of salivary gland,
773, 773
Caldwell-Luc antrotomy, 217,217-219,
218,219
Cancer. See under specific locations, e.g.,
Larynx
Candida albicans, 698
Canine eminence, on CT reconstruction, 19
Canthal ligament, medial
repair of, 554-557, 555, 557
surgical anatomy of, 553, 555
Canthoplasty, medial, 554-557, 555, 557
Canthorrhaphy, 562
Canthus
lateral, carcinoma of, excision of, 546, 547
medial, lesions of, excision of, 552, 553
Carbon dioxide laser, 1077-1078
complications of, 1078
for laryngeal cancer, 1097
for obstructive webs, 1164
precautions with, 1077-1078
Carboplatin
in combination chemotherapy, 130
for recurrent cancer, 129
Carcinoma. See under specific locations,
e.g., Esophagus
Carcinoma ex pleomorphic adenoma, 884
Carcinosarcoma, 884
Cardiac arrest, 70
Cardiac massage
closed, 72
open, 72, 73
Cardiopulmonary resuscitalion, 70-73
closed cardiac massage for, 72
open cardiac massage for, 72, 73
Carotid artery
common
aneurysm of, 1320
cancer involvement of, resection for,
1277-1282, 1279, 1280, 1281,
1282
CT angiography of, 43
CT scan of, 46
distal
by-pass placement for, 1262, 1263
exposure of, 1262, 1263
exposure of, 1268, 1269
MRI of, 31, 32, SO
occlusion of, surgical treatment of,
1264, 1264, 1265
contralateral, CT scan of, 47
dissection of, 1275
external,3
aneurysms of, 1266
CT angiography of, 43
CT scan of, 46
distal, CT angiography of, 43
ligation of, 1330, 1336, 1337
MRI of, 30
hemorrhage of, control of, 1328-1337
internal, 3
aneurysm of, 1266, 1267, 1320
angutation of, 1266, 1267
anomalies of, 1266, 1267
cancer involvement of, resection for,
1277-1282,1279, 1280, 1281, 1282
coil of, 1266, 1267
Carotid artery (Continued]
CT angiography of, 43
CT scan of, 46, 47
dissection of, 1275
exposure of, 1322, 1323
in parotid extension of radical neck
dissection, 798-801, 799, 801,
886
in temporal bone resection, 1412,
1413, 1414
fibromuscular dysplasia of, 1274
kinking of, 1266, 1267, 1272, 1273,
1274, 1274
metastatic carcinoma of
reconstruction of, 1283
resection results in, 1283
MRI of, 29, 30, 31, 32, 33
partial or complete absence of,
1266, 1267
tortuous, 1266, 1267
ligation of, 1330
metastatic squamous cell carcinoma of,
1276-1277
petrous, CT scan of, 40
postoperative care of, 122
protection of, 1331-1335, 1333, 1335
resection of, 136
spontaneous intimal dissection of, 1275
Carotid artery blowout, 1237, 1328-1335
etiology of, 1328-1329
prevention of, 1328-1335, 1333, 1335
dermal graft for, 1331-1332, 1333
levator scapulae muscle flap for,
1332,1333
Carotid artery bruit, asymptomatic,
1252-1254, 1253
Carotid artery disease, 1242
surgery for
anesthesia for, 1243
carotid bifurcation exposure in,
1244-1247, 1245, 1247
complications of, 1250-1252
prevention of, 1251(t)
contraindications to, 1242
controversies of, 1252-1254
danger maxims in, 1250
indications for, 1242-1243
intraoperative considerations in, 1243
neurologic deficit after, 1252, 1253
Carotid artery dissection, 1275
Carotid artery occlusion, acute, surgery for,
1252
Carotid artery stenosis, carotid artery
surgery and, 1242
Carotid artery stenting, 1254-1256
future of, 1256
indications for, 1254-1255
preprocedure patient evaluation for, 1255
technique of, 1255-1256
Carotid artery trauma, 1310-1313, 1313
arteriovenous fistula, 1313-1314
from bullet, 1312, 1313
iatrogenic, 1314
nonpenetrating, 1311-1313, 1313
clinical signs of, 1312
sequelae of, 1313
penetrating, 1310-1311, 1313
INDEX 1473
Carotid artery ulceration, asymptomatic,
management of, 1252
Carotid body, 1288, 1288
Carotid body tumor, 1286-1287, 1289
resection of, 1294-1299, 1297, 1299
unilateral, 1302, 1302-1307, 1304, 1305
Carotid canal, 3
Carotid phonangiography, 1238, 1238
Carotid sinus, 1288, 1288-1289
Carotid space. See Parapharyngeal space
Cartilage grafts, 107-112
auricular, 110, 111
Cartilage incision technique, for prominent
ear correction, 573, 574
Cauliflower ear, surgical treatment of,
580, 581
Cavum, cartilage graft from, 110, 111
Central node dissection, 926
Cerebral artery
anterior, CT angiography of, 45
middle, CT angiography of, 45
posterior, CT angiography of, 45
Cerebrospinal fluid leak, 263
Cerebrovascular disease, extra cranial,
1242-1243
Cervical abscess, lateral, 854, ass
Cervical esophagocolostomy, 1213,
1213-1215,1214, 1215
Cervical esophagoscopy, 181, 194, 196,
197, 212, 1190
Cervical esophagus
carcinoma of
management of, 1187-1188
resection of, 1199-1212, 1201, 1203,
1205, 1207, 1209, 1211, 1212
lumen of, 9
reconstruction of
deltopectoral flap for, 425-433, 427,
429, 431, 433
pectoralis major flap for, 412, 413
using PMF with dermal graft,
1190-1191,1191
resection of adenocarcinoma from,
1176-1178
Cervical lymph nodes, 780-787
biopsy of, 780-781
metastatic guide to, 781-787,783, 785,
787(t)
Cervical lymphadenopathy, evaluation of,
797
Cervical mediastinotomy, 1024-1025, 1025
Cervical skin flap, for esophageal
reconstruction of, 1192-1195, 1193,
1195
Cheek
defects of, bitemporal flap for, 480, 481
reconstruction of, forehead flap for,
446-451, 447, 449, 451
tumors of, excision of, 379, 379
Z-plasty for, 100, 100, 101
Cheek-buccal wall flap, 747, 747
Cheek flap, 378, 378, 379,379
lateral, for lower eyelid reconstruction,
532,533
mobilization of, 746
upper lip reconstruction with, 472, 473
 INDEX

Chemodectoma, 1283. See also Cleft palate, 506-519 Computed tomography (Continued)
Paraganglioma complete, repair of, 506-510, 507, 509, 511 in thyroid cancer, 922
fine-needle aspiration biopsy of, 88 incomplete, repair of, 512, 513 of thyroid gland, 896
Chemotherapy, 128-131 repair of, 506-519, 507, 509, 511, 5]3, for tumor location, 37-38
adjuvant, 130 515,516,5] 7,519 in vascular surgery, 1240
for soft tissue sarcoma, 154 objectives of, 506 venography, 44
for anaplastic carcinoma of thyroid, 928 optimal age for, 506 Condylar fractures, 600, 601
combination, 130 pharyngeal flap in, 516, 516, 517 open repair of, 609, 609
combined modality, 130 speech rehabilitation with, 147 Congenital ventricular cyst, endoscopic
compromised resection and, 126 standards of care for, 147 removal of, 1076, 1076
induction, 130 unilateral, complete, repair of, 514, 515 Congo red, 91
for laryngeal cancer, 1097-1098 vela pharyngeal insufficiency in, 517-518, Conjunctiva, wounds of, 524, 525
and organ preservation, 131 5]9 Constrictor muscle of pharynx, inferior,
postoperative, 130 Clinoid process, anterior, 3, 5 cricopharyngeus portion of, 9
preoperative, 130, 132-141 Clivus Consultation(s}
and radiation therapy, 131 on CT reconstruction, 23 for dental and prosthetic needs, 162, 163
for recurrent and metastatic cancer, MRI of, 32 multidisciplinary, 125
129-130 Clotting, postoperative, 120 preoperative, with speech pathologist,
salvage, for laryngeal cancer, 1100(tJ Cocaine, in anesthesia, 182, 183 143-144
single-agent, 129 Cochlea, CT scan of, 39 Cordectomy
for squamous cell carcinoma of thyroid, Cochlear implants, 148 for carcinoma of true vocal cord, 1105,
929 Colon interposition, for esophageal 1105
Chest, sealed drainage of, 80, 81 reconstruction, 1199, 1216-1224, 1217, laryngofissure for, 1082-1085, 1083,
Chest flap, 438, 439 1219, 1221, 1223 1085, 1101, 1101
Choanal atresia, posterior, 295-299, 297, 299 Columella Core needle biopsy, 87-89
Chondrosarcoma excision and reconstruction of, 336, 337 in soft tissue sarcoma diagnosis, 153
bilateral total maxillectomy for, skin lengthening of, 330, 331 Cornea, protection of, tarsorrhaphy for,
1386-1390, 1387-1390 skin shortening of, 330, 331 562, 563
en-bloc resection of, 246 slanted, straightening, 330, 33] Coronary artery disease, carotid artery
Chordoma, MRI of, 27(t) Columellar grafts, for collapsed nasal tip, surgery and, 1252
Cigarette smoking, preoperative cessation 328, 329 Coronoid fracture, open repair of, 609
of, 114 Columnar cell variant, of papillary Corticosteroids, for thyroid-related
Cisplatin carcinoma, 915-916 orbitopathy, 156, 160-161
in combination chemotherapy, 130 Commissure Costochondral graft, 108, 109
preoperative, 132 anterior CPR. See Cardiopulmonary resuscitation
with radiation therapy, 131 device for holding endotracheal tube Craniofacial resection, 1377-1385
for recurrent cancer, 129 at, 187, 187 for chondrosarcoma, 1386-1390,
Cisterna magna, MRl of, 32 MRI of, 28, 31 1387-1390

Clavicle posterior, MRI of, 28 complications of, 1384

medial third of, resection of, 1040-1045, Common carotid artery. See Carotid artery, indications, 1377
1042[t), 1043, 1044, 1045 common surgical technique of, 1378-1385, 1379,
MRI of, 52 Communication, methods of, 144 1383, ]385, 1386
Claviculectomy, 1S3 Compression plating, for mandibular tumor recurrence after, 1384
Cleft lip, 493-505 fractures, 610-619, 611, 613, 615, 617, Cribriform plate of, 7, 9, 13, 15, 17
bilateral 619 Cricoid cartilage,S
basic deformities in, 500, 501 Computed tomography, 16-25, 34-48, 53 fracture of, 1155, 1155
repair of, 500-505, 501, 503, 50S angiography, 42, 43, 45 laryngoscopy of, 186
optimal age for, 500 avoiding dental artifacts in, 36 MRI of, 29, 33
rotation advancement for, 504, 505 for cervical lymphadenopathy evaluation, posterior aspect of. 9
straight-line closure for, 502, 503 797 Cricoid-tracheal stenosis, treatment of,
maxillary deformity in, 494, 495, 500, 501 compared to other imaging modalities, 1160, 1161
nasal deformity in, 494, 495, 500, 501 56(t) Cricopharyngeal myotomy, 1122, Jl23,
normal anatomy and, 493, 493 contrast medium-enhanced, 35, 40, 40, 1178, 1179
repair of, 494-505, 495, 497, 498, 499, 41,46,47 Cricothyroidotomy, 82, 83
501, 503, 505 en do luminal and cut~away view, 47 Crista galli, on CT reconstruction, 25
speech rehabilitation with, 147 vs. MRI, 1351, 1351 Cross-face nerve grafts, 381-382, 383
standards of care for, 147 of orbit, 157, 159 Cryosurgical hypophysectomy, 1400, 140]
types of, 493 of paraganglioma, 53, 1291-1292 CT. See Computed tomography
unilateral of parathyroid glands, 977, 978, 979, 981 Cupid's bow, 460, 461
basic deformities in, 494, 495 single-plane, 16-18 Cyst
repair of, 494-499, 497, 498, 499 three-dimensional bone, aneurysmal, 656
anesthesia for, 494 angiography, 43, 45 of branchial cleft. See Branchial cleft cysts
objectives of, 494 of inner ear, 39, 39 dentigerous, 250, 251
optimal age for, 494 reconstructed, 18-25 excision of, 656, 657
rotation advancement for, 498, of vascular tumor relationship, 46 developmental, 250, 251
498-499, 499 venography, 44 follicular, 250, 251
triangular flap for, 496, 497 globulomaxillary, 250, 251
 INDEX 1475

Cyst (Continued) Direct optical laryngoscopy, 180, 180-181 Endarterectomy, carotid (Continued)
of mandible, excision of, 653-657 in laryngeal carcinoma, 1092 straight vinyl tubing shunt in, 1250, 1250
maxillary, 250, 251 Direct optical nasopharyngoscopy, 180, stroke prevention in, 1252
nasoalveolar, 250, 251 180-181,205,206,207,210,211 Endemic goiter, 960
excision of, 252, 253 Direct optical rhinoscopy, 210, 211 Endobronchial surgery, carbon dioxide
nasopalatine, 250, 251 Direct rigid laryngoscopy, 181-187, 185, laser in, 1077-1078
excision of, 254, 255 186, 187 Endocrine surgery, 892-1003, See also
odontogenic, 250, 251 anesthesia for, 182-183 specific glands, e,g" Thyroid gland
parathyroid, 967, 972-973 in laryngeal carcinoma, 1092 Endolaryngeal stent, 1155, 1155
radicular, 250, 251 Direct rigid nasopharyngoscopy, 181, 205, Endolaryngeal surgery, telescopic, 204, 204
excision of, 653-654, 655 206,207, 210, 211 Endolaryngoscopy, microscopic, 200-203,
retention, of floor of mouth, excision of, Direct rigid rhinoscopy, 210, 211 203
766, 767 Diverticulum anesthesia for, 200-203, 203
sebaceous, facial, excision of, 369, Killian, 1171 complications of, 201
369-370,370 pharyngoesophageal, repair of, instruments of, 200
of submental space, excision of, 848, 849 1171-1175,1173, 1175 Endoscopes, holding, 259-260
thyroglossal Zenker, repair of, 1171-1175, 1173, 1175 Endoscopy
excision of, 824-827, 825, 827 Docetaxel, 129 diagnostic, 179-212
MRI of, 1351, 1351, 1353 Dog-ears, excision of, 106, 106 for sinusitis, 222
ventricular, congenital, endoscopic Doppler imaging, in vascular surgery, 1239 peroral, 179-212
removal of, 1076, 1076 Dorsum sellae, on CT reconstruction, 23 in sinus surgery, 258, 258-264, 259(t),
Cystadenoma, parathyroid, 972-973 Dressings 260, 261, 262, 263
excision of, 996-1002 postoperative care of, 120, 120-122, 121 anesthesia for, 259
with median sternotomy, 999-1002, pressure, 120 indications for, 258
1001 for rhinoplasty, 322, 323 pitfalls of, 263-264
Cystic hygroma, excision of, 845, 845-847, Droperidol, 200 Endotracheal tube, device for holding,
847 Dynamic bendable defect-bridging plates at anterior commissure, 187, 187
Cytokeratin, 91 (DBDB), 616-617, 617, 618-619, 619 Enucleation
Dyskeratosis, 91 of salivary gland tumors, 128
Dacron graft, in vascular surgery, 1236 Dysplasia, 91 of thyroid gland tumors, 128
Dacryocystorhinostomy, 558, 559 fibromuscular, 1274 Epiglottis, 5, 7, 9
De-epithelialization, of vocal cords, cancer of, supraglottic laryngectomy for,
1074-1075, 1075 Ear 1118-1124, 1119, 1121, 1123, 1124
Definitive obturator, 166, 167 cauliflower, surgical treatment of, CT scan of, 47
Deltopectoral flap, 425-433, 427, 428, 429, 580, 581 engagement of, 186, 186
431, 433 facial hemangioma involvement of, esophagoscopyof, 195
advantages of, 425 586, 587 laryngeal surface tumor of, supraglottic
applications of, 434-437, 435, 437 inner, three-dimensional CT of, 39, 39 laryngectomy for, 1119, 1119
complications of, 430 middle, surgery on, 148-149 laryngoscopy of, 186
disadvantages of, 425 nose graft from, 342, 343 lingual surface tumor of, supraglottic
limitations of, 401 prominent, correction of, 573-580, 574, laryngectomy for, 1120, 1121
Dental and prosthetic needs, 161-165, 162, 576, 578, 580 MRI of, 29, 30, 31, 32, 33
163, 165, 166, 166, 167, 168,168, 169 tumors of, excision of, 586, 587 traumatic displacement of, 1157, 1157
Dental artifacts, avoiding in CT scans, 36 Eccentric dynamic compression plates Epinephrine, in anesthesia, 183
Dentigerous cyst, 250, 251 (EDCP), for mandibular fractures, Epistaxis
excision of, 656, 657 616,617 anatomy of, 270-271, 271
Depression, postoperative, 143, 149 Ectropion, of eyelids, correction of, 560, 561 ethmoidal artery ligation for, 276-278,
Dermabrasion, facial, 371, 371-372, 372 Edema, carbon dioxide laser surgery and, 277, 278
Dermal graft 1079 external ethmoidectomy approach to,
for carotid artery blowout prevention, Elective node dissection, 150 279,279
1331-1332, 1333 Elliptical excision, of benign lip lesions, maxillary artery ligation for, 282-285,
for hypopharyngeal and esopharyngea1 460,461 283,285
reconstruction, 1190-1191, 1191 Embolism, air, 65 packing for, 272-275, 273, 275
Dermoplasty, septal, 280, 281 Emergency procedures, 65-85 septal dermoplasty for, 280, 281
Developmental cysts, 250, 251 Empyema, drainage of, open thoracotomy Epithelium, squamous, 91
Diagnosis, preoperative studies for, 114 for, 78, 79 Ernst ligatures, 611, 611
Dieffenbach, lip reconstruction cases of, Encapsulated papillary carcinoma, 915 Erythema, dermabrasion and, 372
484-487 Endarterectomy, carotid, 1244~1247, Erythroplakia, excision of, 698-700, 699
Diet, in swallowing rehabilitation, 145-146 1245, 1247 Esophageal lumen
Diffuse sclerosing variant, of papillary cerebral protection during, 1252 esophagoscopyof, 195
carcinoma, 916 coronary artery disease and, 1252 laryngoscopy of, 186
Digastric muscle, MRI of, 31 external, 1252 Esophageal speech, 144
Digital subtraction angiography, in vascular high risk candidates for, 1254 Esophagectomy
surgery, 1239, 1239 intraluminal shunts in, 1248-1250, extrathoracic, gastric pull-up with,
Diplopia 1249, 1250 1200-1205, 1201, 1203, 1205
after decompression surgery, 161 with patch graft, 1248, 1248 total, reconstruction of, 1192-1198, 1193,
in thyroid-related orbitopathy, 155, 159 results of, 1254 1195, 1197, 1198
 INDEX

Esophagocolostomy, cervical, 1213, Ethmoidectomy (Continued) Eyelids (Continued)

1213-1215,1214, 1215
Esophagoscopy, 194-199, 195, 197, 199
anesthesia for, 194
cervical, 181, 194, 196, 197, 212,1190
flexible, 194, 197
rigid, 196-199, 197, 199
Esophagus
biopsy of, 196
cervical
carcinoma of
management of, 1187-1188
resection of, 1199-1212, 1201, 1203,
1205, 1207, 1209, 1211, 1212
lumen of, 9
reconstruction of
deltopectoral flap for, 425-433, 427,
429, 431, 433
pectoralis major flap for, 412, 413
using PMF with dermal graft,
1190-1191, 1191
resection of adenocarcinoma from,
1176-1178
iatrogenic injury to, repair of, 1176, 1177
lesions of, biopsy of, 196
MRI of, 29, 31, 32, 49
perforation of, in esophagoscopy, 196
reconstruction of, 1186, 1186-1189,
1I87[t)
after esophagectomy, 1192-1198, 1193,
1195, 1197, 1198
colon interposition for, 1199,
1216-1224,12]7, 12]9, ]221, 1223
gastric interposition for, 1199-1200
gastric pull-up for, 1199
greater curvature gastric tube for,
1199-1200
resection of, for thyroid cancer, 919
thoracic, exposure of superior portion of,
1176-1178,1177
indications for, 223 principles of, 524
for nasal glioma resection, 358-361, scar contracture of, correction of,
359, 361 560, 561
Exfoliative cytology biopsy, 91
Exophthalmos Face
in Graves' disease, 566-568, 934 abscesses of, 394, 395
measurement of, 566 arteriovenous fistula of, resection of,
orbital decompression for, 566-568, 1314-1319,1315,1316,1317,1319
567, 568 dermabrasion of, 371,371-372,372
External beam radiotherapy, for thyroid fractures of. See Fractures, facial
cancer, 921 lymph nodes of, malignant lesions of, 745
External branch of superior laryngeal muscles of, anatomy of, 367, 367-368, 368
nerve, 899, 943, 945 sebaceous cysts of, excision of, 369,
paralysis of, 905 369-370, 370
External carotid artery. See Carotid artery, Facial artery, CT angiography of, 43
external Facial nerve
Eye. See also Orbit CT scan of, 39
anatomy of, 523, 523 identification of, 862
iatrogenic blindness in, 66-67 in infants, 866, 867
Eyebrow, reconstruction of, 550 mandibular branch of, injury to, 390
Eyelash, reconstruction of, 550, 551 paralysis of, 380-391
Eyelid retraction, in thyroid-related facial reanimation for, 381-382, 383
orbitopathy, 156, 158 fascial slings for, 388-391, 389,391
Eyelids free nerve grafts for, 876, 877
basal cell carcinoma of, resection of, hypoglossal-facial nerve anastomosis
544, 545 for, 384, 385
lacerations of, repair of, 524, 525 management of, 381
lower masseter muscle transposition for,
basal cell carcinoma of, reconstruction 386, 386-387, 387
for, 532, 533 upper lid gold weights for, 382, 383
horizontal defect of, reconstruction of, Facial reanimation, 381-382, 383
548, 549 Facial recess, CT scan of, 40
lateral canlhus of, carcinoma of, Facial vein
excision of, 546, 547 CT venography of, 44
reconstruction of, 526-533, 527, 529, MRI of, 28,30
53], 533 False aneurysm, 1266, 1320
with 25% defect, 526, 527, 528, 529 carotid artery surgery and, 1251
with 30% defect, 528, 529 with internal carotid artery/internal
with 30% to 50% defect, 530, 53] jugular vein fistula treatment of,

thoracic inlet carcinoma of, resection of, with 50% to 75% defect, 530, 531 1320-1325,1321, 1323, 1325
1206-1212,1207,1209,1211,1212 with 100% defect, 530, 531 vascular trauma and, 1314
Esthesioneuro blastoma Fricke lid flap for, 548, 549 Fan flap, upper lip reconstruction wilh,
nonresectable, 238 principles of, 524 474, 475
resectable, 237 scar contracture of, correction of, Fascial slings, for facial paralysis, 388-391,
Ethmoid 560,56] 389, 391
cribriform plate of, 7, 9, 13, 15, 17 vertical defect of, reconstruction of, Fat flip flap, 454, 454
intranasal surgery of, 220-222, 221 526-533,527,529,531,533 Faucial pillar, anterior, frontal coronal
partial exenteration of, with radical margins of, "near-far, far-near" suture of, section of, 15, 18
maxillectomy, 239, 239-245,240, 524, 525 Faucial tonsil, MRI of, 30
241, 242, 243, 245 medial canthus of, lesions of, excision Feedings, postoperative
perpendicular plate of, 9, 11, 13, 16 of, 552, 553 and swallowing problems, 146
on CT reconstruction, 22 reconstruction of, 523-551 tube placement for, 122-123, 123
uncinate process of, 7 alternative and additional concepts of, Fentanyl, 200
Ethmoidal arteries, ligation of, 276-278, 526 Fiberoptic laryngoscopy, flexible, in
277, 278 basic principles of, 524 laryngeal carcinoma, 1092
Ethmoidal cells upper Fibromuscular dysplasia, 1274
posterior, 15, 18 benign lesion of, excision of, 548, 549 Fibular osteocutaneous flap, 1436-1440,
uncapping of, 220, 221 reconstruction of, 534-543, 535, 537, 1439, 1440
Ethmoidal sinus,S, 7, 9, 13, 17 539, 541, 543 advantages and disadvantages of, 1428
anterior, 11, 16 with 25 % defect, 534, 535 complications of, 1437
endoscopic examination of, 259(t) with 30% to 50% defect, 536, 537 donor site closure in, 1437
MRt of, 32 with 50% to 60% defect, 538, 539 neurovascular anatomy in, 1436
Ethmoidectomy, 220, 221, 261, 261-262 with 60% to 75% defect, 538, 539 Fine-needle aspiration biopsy, 87, 88
external, 223-225, 225, 595 with 75 % to 100% defect, 540, 541 in lymph node evaluation, 138
anesthesia for, 223 bridge flap repair in, 542-543, 543 of parotid salivary gland, 861-862
for epistaxis, 279, 279 Fricke lid flap for, 526 of thyroid lesions, 893

Fistula
arteriovenous
facial, resection of, 1314-1319, 1315,
1316, 1317, 1319
thyroid surgery and, 964
vascular trauma and, 1313-1314
venous malformation with,
CT angiography of, 42, 43
branchial, excision of, 843, 843-844, 844
internal carotid artery/internal
vein, 1320-1325, 1321, 1323, 1325
oroantral, closure of, 256, 257
of trachea, closure of, 1034, 1034-1035,
1035
tracheoesophageal, closure of, 1036
Flap(s)
apron, 402, 436, 437
arm, for nose reconstruction, 344, 345
bitemporal, for large upper lip defects,
480,481
blood supply to, 402-403, 403
bridge, for large upper eyelid defects,
542-543, 543
cheek, 378, 378, 379,379
lateral, for lower eyelid reconstruction,
532, 533
mobilization of, 746
upper lip reconstruction with, 472, 473
cheek-buccal wall, 747, 747
chest, 438, 439
defects requiring, 399-400
deltopectoral, 425-433, 427, 428, 429,
431, 433
advantages of, 425
applications of, 434-437, 435, 437
complications of, 430
disadvantages of, 425
limitations of, 401
design of, 399-402, 399(t). 400 (t)
donor site for, 400
fan, upper lip reconstruction with,
474,475
fat flip, 454, 454
forehead, 401, 444-445, 445
for cheek reconstruction, 446-451,
447, 449, 451
complications of, 445
hemiglossectomy with, 724, 725
limitations of, 401
for mandibular reconstruction,
682-687, 683, 685, 687
midline, 452, 453
for nose reconstruction, 346, 347, 348,
349
free, limitations of, 402
Fricke lid
for lower eyelids, 548, 549
for upper eyelids, 526
general purpose, 399-454
latissimus dorsi, 400
levator scapulae muscle, 1332, 1333
limitations of, 401-402
microvascular, 1417-1469.See also
specific types, e.g., Gracilis flap
advantages and disadvantages of,
1427-1428
classification of, 1418
INDEX
Flap(s) (Continued) 5-Fluorouracil
donor sites for, 1418-1420 in combination chemotherapy, 130
historical perspective of, 1417-1418 preoperative, 132
selection of, 1420-1422 with radiation therapy, 131
myocutaneous, classification of, 400-401 for recurrent cancer, 129
nape of neck Follicular carcinoma, of thyroid
limitations of, 401 classification of, 916
Mutter, 440, 441 cytology of, 894
nasofacial, 332, 333 incidence of, 916
jugular nasolabial, 332, 333, 336, 337 subtypes of, 916
for upper lip lesion excision, 460, 461 Follicular cyst, 250, 251
palatal, 290, 291 Follicular variant, of papillary carcinoma,
pectoralis major, 400, 404-419, 405, 407, 915
409, 411, 413, 415, 416, 417, 419 Foramen lacerum, carotid canal to, 5
applications of, 420, 420-424, 421, Foramen magnum, 7
422, 423, 424 Foramen ovale
complications of, 418 CT scan of, 40
hemiglossectomy with, 724, 725 MRI of, 33
limitations of, 402 Foramen spinosum, 3
pharyngeal CT scan of, 40, 41
for cleft palate repair, 516, 516, 517 Forehead
for velopharyngeal insufficiency, pedicle of, transection of, 352, 353
517-518,519 tumors of, excision of, 373, 373-374, 374
pitfalls of, 401-402 Forehead flap, 401, 444-445, 445
of posterior scapula, 442, 443 for cheek reconstruction, 446-451, 447,
rhombic, 104, 105 449, 451
rotation, 377, 377-378,378 complications of, 445
scalp, for nose reconstruction, 348, 349 hemiglossectomy with, 724, 725
scalping limitations of, 401
limitations of, 402 for mandibular reconstruction, 682-687,
for nose reconstruction, 348, 349 683, 685, 687
selection of, 399-402, 399(t). 400 (t) midline, 452, 453
septal, 334, 335 for nose reconstruction, 346, 347, 348, 349
sickle, for nose reconstruction, 348, 349 Foreign body, lateral venotomy for,
simplest choice for, 400 1326, 1327
skin Fossa, of Rosenmiiller, MRI of, 29
lateral, for esophageal reconstruction Fractures, facial, 595-650
of, 1192-1195, 1193, 1195 basic principles of, 595-596
thoracic, for esophageal in edentulous mandible, 618
reconstruction, 1196-1198, 1197, external traction for, 646, 647
1198 of frontal sinus, 638-639
sternocleidomastoid,400-401 of hard palate, internal fixation of,
temporal, 444-445, 445 638, 639
temporal scalp, 377, 377 intraosseous wiring for, 626, 627, 630, 631
tongue, for hypopharyngeal of mandible, 599-619
reconstruction, 1142, 1142, angle, 607-608, 608, 609, 616
1188-1190, 1189 body, 607, 607, 608
trapezius, 400 complications of, 600
limitations of, 402 compression plating for, 610-619, 611,
triangular, for unilateral cleft lip repair, 613.615.617,619
496, 497 condylar, 600, 601. 609, 609
turn-in, for nasal cavity, 350. 351 coronoid, 609
visor, for large upper lip defects, 480, 481 dynamic bendable defect-bridging
Flexible bronchoscopy, 192 plates for, 616-617, 617. 618-619,
anesthesia for, 192 619
Flexible esophagoscopy, 194, 197 eccentric dynamic compression plates
Flexible fiberoptic laryngoscopy, for, 616, 617
in laryngeal carcinoma, 1092 maxillomandibular fixation for,
Flexible naso1aryngoscopy, 196, 197 602, 602, 605
Flexible rhinoscopy, 210 open reduction and internal fixation
Floor of mouth. See Mouth, floor of for, 602-605, 603, 604, 605
Fluid accumulation, postoperative posterior to row of teeth, 614, 615
prevention of, 120 rigid internal fixation for, 612, 613
Fluorodeoxyglucose-Positron emission in row of teeth, 614, 615
tomography, 57-63, 58(t) symphyseal and parasymphyseal,
of parathyroid glands, 978, 978 60S, 605-606, 606, 607
types of, 605
 INDEX
Fractures, facial (Continued)
of maxilla
early reduction of, 624, 625
Le Fort I, 630, 631, 636,636, 637
Le Fort II, 632, 633, 636-637, 637
Le Fort llI, 634, 635, 637, 637
miniplate fixation for, 636, 636-637, 637
with zygomatic fracture, 622-623, 623
miniplate fixation for, 596, 596, 608, 636,
636-637, 637
of nose, 596-598, 597, 599
of orbital floor, 640-645, 641, 643, 645
tent peg reduction and fixation for,
628,629
of zygoma
management of, 648-650
with maxillary fracture, 622-623, 623
with zygomatic arch fracture, 620, 621
of zygomatic arch, open reduction of,
620, 621, 622-623, 623
Free flap, limitations of, 402
Free nonvascularized autogenous bone
grafts, for mandibular reconstruction,
675-676, 677
Frey's syndrome, 876-877, 877
Fricke lid flap
for lower eyelids, 548, 549
for upper eyelids, 526
Frontal bone, orbital plate of, 5, 15, 18
Frontal sinus, 3, 5, 7, 9, 11, 13
drainage of, 268, 269
endoscopic examination of, 259(t)
fracture of, 638-639
MRI of, 32
osteoplastic approach to, 234-238,
235, 236
trephination for, 230, 231
Frontal sinus duct, 268, 269
Frontal sinusotomy, 230, 231, 262,
262-263,263
Frontoethmoidectomy, external, 232-233,
233
Frontonasal duct, anatomy of, 234-235, 235
Frozen section examination, of parathyroid
glands, 967-968
Full-thickness graft, to nose, 340, 341
Ganglioneuroma, of neck, resection of,
850-852, 851, 853
Gastric interposition, for esophageal
reconstruction, 1199-1200
Gastric pull-up
complications of, 1204
for esophageal reconstruction, 1199,
1200-1205,1201, 1203, 1205
with extrathoracic esophagectomy,
1200-1205, 1201, 1203, 1205
Gastroesophageal reflux disease, 145
Gastrostomy
Janeway, 1224-1226, 1225, 1226
percutaneous endoscopic, 1227-1229,
1229
Stamm, 1222-1224, 1223
Gelfoam paste, endoscopic intracordal
injection of, 1079, 1079
Gelfoam smears, bronchoscopic, 190, 191
Gemcitabine, 129
Genioglossus muscle, 5, 7, 9
Geniohyoid muscle, 5, 7, 9
Giant cell arteritis, 1275(t)
Gillies' technique, for upper lip lesion
excision, 476, 477
Gingiva, carcinoma of, 726
Glabella, fracture of, 634, 635
Glioma, nasal, resection of, external ethmoid
approach to, 358-361, 359, 361
Globe, preservation of, in maxillectomy,
246, 247
Globulomaxillary cyst, 250, 251
Glomic artery, 1288
Glomus tumor, 1283, 1307-1309, 1309
Glossectomy
for carcinoma of floor of mouth,
688-695, 689, 690, 691, 693, 695
partial, for carcinoma of tongue and floor
of mouth, 726-731, 727, 729, 731
speech rehabilitation after, 146
total, 738-741, 739, 741
Glossoepiglottic fold, median, MRI of,
30,31
Glossopharyngeal nerve, 838, 839
Glossopharyngeal neuralgia, 842, 842,
1361-1364,1362, 1363, 1364
Glossotomy, labiomandibular, median,
704-707, 705, 707
Goiter. See also Graves' disease
adenomatous, MRI of, 49, 51
cervical, MRI of, 48, 50
endemic, 960
from hyoid bone to aortic arch, 50
multinodular
MRI of, 52
toxic, 934-935, 960
nodular
cytology of, 894
toxic, 960
substernal, 929-932
Gold weights, upper lid, 382, 383
Gracilis flap, 1468, 1469
advantages and disadvantages of, 1429
complications of, 1468
donor site closure in, 1468
neurovascular anatomy in, 1468
Graft(s)
bone, 107-112
autogenous, for mandibular
reconstruction, 675-676, 677
iliac, 108, 109
for mandibular reconstruction,
678-682, 679, 681
trap door type, 110, 111
bypass
for innominate artery obstruction,
1270, 1271
placement of, 1262, 1263
cartilage, 107-112
auricular, liD, 111
columellar, for collapsed nasal tip,
328, 329
composite, from ear to nose, 342, 343
costochondral, 108, 109
cross-face nerve, 381-382, 383
Dacron, in vascular surgery, 1236
Graft(s) (Continued)
dermal
for carotid artery blowout prevention,
1331-1332, 1333
for hypo pharyngeal and esopharyngeal
reconstruction, 1190-1191, 1191
ear to nose, 342, 343
full-thickness, to nose, 340, 341
iliac bone, 108, 109
for mandibular reconstruction,
678-682, 679, 681
trap door type, 110, 111
for infraorbital rim defect, 564, 565
inlay, for carcinoma of floor of mouth,
710-713, 711, 713
nerve, 112, 113
for facial nerve paralysis, 876, 877
patch, with carotid endarterectomy,
1248, 1248
for resected carotid artery, 1277, 1278
rib, 108, 109
saphenous vein, for arterial
replacements, 1338, 1339
skin, over tantalum gauze, for
esophageal reconstruction,
1196, 1197
synthetic, in vascular surgery, 1236
Teflon, in vascular surgery, 1236
vascular, in vascular surgery, 1236
in vascular surgery, 1235-1236
Granuloma, laryngeal, intracordal Teflon
paste injection and, 1079
Graves' disease, 932-935
evaluation of, 932
exophthalmos in, 566-568, 934
hungry bone syndrome in, 910
management of
options in, 932-933
postoperative medication in, 934
preoperative, 933
surgery in, 933-934
indications for, 932
thyroid storm in, 934
and vocal cord paralysis, 906
thyroid storm in, 934, 964
Graves' ophthalmopathy. See Thyroid-
related orbitopathy
Guerin fracture, 630, 631
Gunning-type splints, in mandibular
reconstruction, 678, 679, 679, 680, 681
Gustatory sweating, auriculotemporal nerve
resection for, 876-877, 877
Hamartoma, parathyroid, 973
Hamulus of pterygoid process, 5, 13, 15
Hard palate, 5
fracture of, internal fixation of, 638, 639
lesions of, excision of, 752-759, 753,
755, 756, 757, 759
MRI of, 30
Hashimoto's thyroiditis, 960, 962
Head, postoperative positioning of, 116
Head and Neck Oncology Service, 141-142
Hearing, rehabilitation of, 148-149
Heineke-Mikulicz pyloroplasty, 1222, 1223
Hemangioma
facial, ear involvement with, 586, 587
 INDEX 1479

Hemangioma (Continued) Hyperparathyroidism (Continued) Hypopharynx (Continued)

MRI of, 27(t)
of tongue, resection of, 768, 769
Hematoma
of auricle, surgical treatment of, 580, 581
postoperative, carotid artery surgery and,
1251
Hemiglossectomy
for carcinoma of tongue and floor of
mouth, 726-731, 727, 729, 731
for hemimandible and oropharyngeal
wall resection, 724, 725
tongue reconstruction after, 414, 415
Hemilaryngectomy, 1101
Hemimandible, resection of, 724, 725
Hemimandibulectomy, for carcinoma of
floor of mouth and tongue, 726-731,
727, 729, 731
Hemorrhage, carotid, control of, 1328-1337
Hertel exophthalmometry, 157
Hiatus semilunaris, 267, 269
Histiocytoma, malignant fibrous, 152
HMB-45,91
Hoarseness, 1070
laryngeal nerve paralysis and, 906
Holinger hourglass anterior commissure
speculum, 181, 204
Holinger tracheotomy tube, 193(t)
Hopkins rod optical telescope, 205, 210, 211
Hungry bone syndrome, 910, 1002
Hurthle cell thyroid carcinoma
classification of, 916
cytology of, 894
management of, 912, 913, 927, 931(t)
PET scan of, 62
Hygroma, cystic, excision of, 845, 845-847,
847
Hyoepiglottic ligament, MRI of, 31
Hyoglossus muscle, 7
Hyoid bone, 3, 5, 7, 9
CT angiography of, 43
MRI of, 50
Hypercalcemia
acute, 990
causes of, 974
diagnostic considerations of, 984-985
emergency treatment of, 990
familial hypocalciuric, 984
laboratory tests for, 975
psychosis in, 990
thyroidectomy and, 910
tumoral, 984
Hypercellularity, 968
Hyperkeratosis, 91
Hyperparathyroid crisis, 990
Hyperparathyroidism, 972-976
chemical diagnosis of, 984-985
evaluation of, laboratory tests in, 975
history in, 975
us. hypoparathyroidism, 922
in multiple endocrine neoplasia,
975-976
primary, 966, 973-974
secondary, 966, 967, 973
signs and symptoms of, 975
surgical management of
indications for, 984
preoperative and intraoperative
techniques for, 976-1002
tertiary, 966, 974
Hyperpigmentation, dermabrasion and, 372
Hyperplasia
C-cell, 922, 923, 924-925, 931(t)
parathyroid, 967, 972
surgical management of, preoperative
and intraoperative techniques for,
976-1002
Hypertension, postoperative, carotid artery
surgery and, 1251
Hyperthermia, malignant, 65-66
Hyperthyroidism
eyelid retraction in, 158
and thyroid-related orbitopathy, 154
treatment of, and course of thyroid-
related orbitopathy, 155-156
Hypertrophic scars, dermabrasion and, 372
Hypocalcemia. 5ee also Hungry bone
syndrome
clinical findings in, 909
management of, 1003(t]
parathyroid adenoma excision and, 1002
postoperative, 909-910
thyroid surgery and, 964
Hypogenesis vocalis, 1079
Hypoglossal canal,S
Hypoglossal-facial nerve anastomosis,
384, 385
Hypoparathyroidism
after thyroid surgery, 908-909
us. hyperparathyroidism, 922
signs of, 909
thyroid surgery and, 964, 965
Hypopharyngectomy, total, 135
hypopharyngeal reconstruction after,
1188-1190, 1189
Hypopharyngoscopy, 182-187, 185,186,
187
anesthesia for, 182-183
before bronchoscopy, 188
Hypopharynx
cancer of
distant metastasis in, 135(t)
radiotherapy for, 137(t)
recurrent, 135(t)
treatment of, 133(t), 135, 1187-1188
indirect mirror examination of, 1070
lesions of, punch biopsy of, 1073, 1073
malignant tumors of, resection of,
714-719,715,717
MRI of, 28, 33
posterior wall carcinoma of, resection
1181-1185,1183. 1185
reconstruction of
after esophagectomy, 1192-1198, 1193,
1195, 1197, 1198
cross section after, 412, 413
923, deltopectoral flap for, 425-433, 427,
429, 431, 433
myomucosal tongue flap for,
Il88-1190, 1189
pectoralis maior flap for, 412, 413
tongue flap for, 1142, 1142
using PMF with dermal graft,
1190-1191, 1191
resection of, for thyroid cancer, 919
Hypophysectomy
anesthesia for, 1395
complications of, 1396
frontoethmoidectomy approach for,
232-233,233
indications for, ] 395
transseptal transsphenoidal, 1395-1403,
1398,1399,1400,1402,1404
ablative, 1400-1403, 1404
cryosurgical, 1400, 1402
Hypopigmentation, dermabrasion and, 372
Hypotension, postoperative, carotid artery
surgery and, 1251
Iliac bone graft, 108, 109
for mandibular reconstruction, 678-682,
679, 681
trap door type, 110, 111
Iliac crest osteocutaneous flap, 1464-1467,
1466, 1467
advantages and disadvantages of, 1429
complications of, 1465
donor site closure in, 1465
neurovascular anatomy in, 1464
Implants, bone, 107
Incision(s)
general considerations, 112
preoperative preparation of, 116
for radical neck dissection, 804-807,
805, 807
Incus, CT scan of, 39
Indirect mirror laryngoscopy, 179
in laryngeal carcinoma, 1092
Indirect mirror nasopharyngoscopy, 179,
205, 206, 207
Infraclavicular internal jugular node,
biopsy of, 832, 833
Infraorbital foramen, 11
CT angiography of, 45
on CT reconstruction, 19, 21, 22
'Infraorbital groove, on CT reconstruction, 25
Infraorbital rim, defect of, graft for, 564, 565
Infundibulum ethmoidalis, 267-268
Inlay graft, for carcinoma of floor of
mouth, 710-713,711, 713
Innominate artery
CT scan of, 46
exposure of, 1268, 1269
MRI of, 50, 52
obstruction of, bypass graft for,
of, 1270, 1271
Innominate artery steal, 1240, 1241
Innovar, 200
Insular carcinoma, cytology of, 895
Intercostal catheter
insertion of, 74-76, 75, 76, 77
suction drainage with, underwater seals
and, 80, 81
Interdental wire, 600, 601
in mandibular reconstruction, 678
Internal carotid artery. See Carotid artery,
internal
Intracranial blood flow, evaluation of. 1240
 INDEX

Intracranial circulation, evaluation of, Keel, larynx, 1162, 1163
neoplastic disease and, 1278-1282, Keratosis, 91
1279, 1280, 1281, 1282 Killian diverticulum, 1171
Intraluminal shunts, in carotid Kinking
endarterectomy, 1248-1250, 1249, 1250 of internal carotid artery, 1266, 1267,
Intranasal antrostomy, 214-216, 215, 216, 1272, 1273, 1274, 1274
218,219 of major vessels, 1240, 1241
Intranasal ethmoidal surgery, for benign Kirschner wire, 600, 601
disease, 220-222, 221 for mandibular reconstruction, 665, 667
Intraoperative examination, of parathyroid with Steinmann pin, 672-674, 673,
glands, 967-968 674, 674(t)
Intraoperative lymphatic mapping, 150-152 us. Steinmann pin, 665
Intraorbital mass
diagnosis of, 569 Labiomandibular glossotomy, median,
resection of, 569 704-707, 705, 707
Intraosseous wiring. for facial fractures, Lacrimal gland
626, 627, 630, 631 adenoid cystic carcinoma of, resection of,
Intravagale paraganglioma, 1302, 570, 570
1302-1307, 1304, 1305 benign tumor of, resection of, 569,
resection of, 1300, 1301 569-570, 570
Intravascular (glomus) jugulare Lag screws, for oblique mandibular
paraganglioma, 1307-1309, 1309 fractures, 605, 605, 606, 607, 618, 619
Iodine Large-needle aspiration biopsy, 87, 89,
for hyperthyroidism, 156 89-90, 90
radioactive Laryngeal instruments, 204, 204
for thyroid cancer, 919-922, 931(t) Laryngeal nerve
for thyroid-related orbitopathy, 156 MRI of, 51
Iodine-131 scan nonrecurrent, 898
precautions with, 922 recurrent
in thyroid cancer, 919-922 extralaryngeal branching of, 897-898
Ischemia injury to, thyroid surgery and, 963,
secondary, in microvascular surgery, 1426 964(t)
transient, 1242 paralysis of, 90S, 906
Ischemic optic neuropathy, 69 thyroid surgery and, 964-965
Iverson dermabrader, 371, 371, 372,372 postoperative function of, 905-906
thyroid surgery and, 897-898, 898
Janeway gastrostomy, 1224-1226, 1225, superior
1226 anatomy of, 1069, 1069-1072, 1071, 1072
Jejunal flap, 1462, 1463 external branch of, 899, 943, 945
advantages and disadvantages of, 1429 paralysis of, 905
complications of, 1462 injury to, thyroid surgery and, 963,
neurovascular anatomy in, 1462 964(t)
Jesberg esophagoscope, 194, 195 Laryngeal stent, 1154, 1155
Jesberg short adult esophagoscope, 181 Laryngeal suspension, 1125, 1125
Jugular body, neoplastic disease of, 1284 Laryngeal vestibule, MRI of, 31
Jugular bulb,S Laryngeal web, correction of, 1162-1164
Jugular foramen, 3 Laryngectomy
Jugular tympanicum, 1290 frontolateral, 1102, 1106-1113, 1107, 1109,
Jugular vein 1111,1113
external horizontal, 1101, 1118-1124, 1119, 1121,
CT angiography of, 43 1123, 1124
CT venography of, 44 partial
MRI of, 31 basic type 1, 1102, 1103
internal basic type 2, 1102, 1103
exposure of basic type 3, 1102, 1103
in parotid extension of radical neck keel, 1162, 1162
dissection, 798-801, 799, 801, for laryngeal cancer, 1095-1096,
886 1100-1104, 1101, 1103, 1104
in temporal bone resection, 1412, modifications in, 1104, 1104
1413, 1414 preoperative, thyroid surgery and, 905-906
MRI of, 28, 29, 30, 31, 32, 33, 50, 52 stomata of, postoperative care of, 118-119
preserving, in radical neck dissection, supra cricoid, 1101
808-810, 809, 810 supraglottic, 1101, 1118-1124, 1119, 1121,
MRI of, 30, 32 1123, 1124
Juvenile angiofibroma, characteristics of, total, 135, 1126-1133, 1127, 1129, 1131,
288-289 1133
cervical esophagoscopy after, 194
Laryngectomy (Continued)
complications of, 1132
hypopharyngeal reconstruction after,
1142,1142, 1188-1190, 1189
for laryngeal cancer, 1095-1096
with radical neck dissection,
1136-1141,1137, 1139, 1141. 1148,
1149
rehabilitation after, 143-144
skin incision for, 112
vertical, 1101, 1102, 1106-1113, 1107, 1109,
1111,1113
voice prostheses after, 1143, 1143-1151,
1145, 1147, 1149, 1151
Laryngectomy tube, obstruction of, 1134
Laryngocele
external, resection of, 1152, 1153
internal
endoscopic removal of, 1076, 1076
resection of, 1152
Laryngofissure, 1082-1085, 1083, 1085,
1101, 1101
Laryngopharyngectomy, orodigestive tract
reconstruction after, 1182
Laryngoplasty
with omohyoid muscle, 1114-1115, 1115
with strap muscles, 1116, 1117
Laryngoscopy. See also Endolaryngoscopy
before bronchoscopy, 188
direct optical, 180, 180-181
in laryngeal carcinoma, 1092
direct rigid, 181-187, 185, 186, 187
anesthesia for, 182-183
in laryngeal carcinoma, 1092
flexible fiberoptic, in laryngeal
carcinoma, 1092
indirect mirror, 179
in laryngeal carcinoma, 1092
mirror, 1069, 1069-1072, 1071, 1072
Laryngotomy, 1082-1085, 1083, 1085
Larynx, 1069-1164. See also Vocal cordts)
artificial, 144
cancer of, 1089-1100
anesthesia for, 1092-1093
basic concepts in, 1094-1095
conservation surgery for, swallowing
after, 144-146
cordectomy for, 1101, 1101
diagnostic methods for, 1091-1092
distant metastasis in, 135(t)
etiology of, 1089-1090
extracapsular spread in, 1098
incidence of, 1088(t), 1089
natural history of, 1090-1091
pathology of, 1090
recurrent, 135(t)
staging of, 1093-1094, 1093(t), 1094(t)
stomal recurrence of, 1100
survival rates for, 1I00(t)
symptoms of, 1090(t)
TNM classification of, 1093(t)
tracheal stoma recurrence of, 1136
treatment of, 133(t), 135, 1094-1100
carbon dioxide laser surgery in, 1097
chemotherapy in, 131, 1097-1098
combined modalities in, 1098-1099
cordectomy in, 1105, 1105

Larynx (Continued]
failure of, 1099-1100
laryngeal web, 1162-1164
partial laryngectomy in, 1095,
1100-1104, 1101, 1103, 1104
radiation therapy in, 137(t),
1096-1097
radical neck dissection in, 1096,
1120-1124,1121, 1123, 1124,
1136-1141, 1137, 1139, 1141
salvage chemotherapy in, 1100
salvage radiotherapy in, 1100
salvage surgery in, 1099-1100
supraglottic laryngectomy in,
1118-1124, 1119, 1121, 1123,
1124
surgery in, 1095
total laryngectomy in, 1095-1096,
1126-1133, II27, 1129, 1131,
1133,1136-1141,1137, II 39,
1141
vertical laryngectomy in, 1106-1113,
1107, 1109, 1111,1113
carbon dioxide laser surgery of,
1077-1078
dilator muscle group of, 1071-1072
epiglottis of, cancer of, 1090, 1091
glottis of, cancer of, 1090, 1091
granuloma of, intracordal Teflon paste
injection and, 1079
indirect mirror examination of, 1069,
1069-1072, 1071, 1072
lesions of, punch biopsy of, 1073, 1073
MRI of, 29
preservation of, 131, 140
reconstruction of, after esophagectomy,
1192-1198, 1193, 1195, 1197, 1198
resection of, for thyroid cancer, 919
sphincteric muscle group of, 1071
subglottis of, cancer of, 1090, 1091
supraglottis of, cancer of, 1090-1091, 1118
trauma to, 1154-1161, 1155, 1157, 1158,
1159, 1161
acute, 1154, 1155
chronic, 1lS6-1161, 1157, 1158, 1159,
1161
glottic, 1156, 1159, 1159
laryngeal stents, 1154, 1155
subglottic, 1156-1157, 1160, 1161
supraglottic, 1156, 1157, 1157-1158,
1158
Latissimus dorsi flap, 400
Latissimus flap, 1456-1461, 1457, 1459,
1460, 1461
advantages and disadvantages of,
1428-1429
complications of, 1456
donor site closure in, 1456
neurovascular anatomy in, 1456
LeA,91
Le Fort I fracture, 630, 631, 636,636, 637
Le Fort II fracture, 632, 633, 636-637, 637
Le Fort III fracture, 634, 635, 637,637
Leucovorin, 129
Leukoplakia, 91
of tongue, excision of, 698-700, 699
Levator aponeurosis, 158
Levator scapulae muscle, MRI of, 28, 32
Levator scapulae muscle flap, 1332, 1333
Lichen planus, 698
Lidocaine, in anesthesia, 182, 183
Life support, ABCs of, 70-72, 71
Lifestyle changes, thyroid surgery and,
965(t)
Ligatures, Ernst, 611, 611
Lingual artery, 5, 7
CT angiography of, 43
Lingual septum, MRI of, 30
Lingual thyroid, 962-963, 963
Lingual tonsil, MRI of, 29
Lip(s)
Abbe-Estlander operation of, 464-466,
465, 466
modifications of, 469, 469-471, 471
anatomy of, 493, 493
benign lesions of
elliptical excision of, 460, 461
excision of, with nasolabial flap,
460,461
cancer of, reconstruction after,
Dieffenbach's cases of, 484-487
cleft. See Cleft lip
excision of, 458-461, 459, 461
large defects of, repair of, 462, 463
lower
abscess of, 394, 395
cenler defect of, reconstruction of,
469, 469
large defects of, repair of, 462, 463
paralysis of, 390
orbicularis oris muscle plication for,
468, 468
reconstruction of, 484-491, 489, 491
resection of, with Bernard
reconstruction, 482, 483
shield excision of, 458, 459
planning, 458
reconstruction of, 458-461, 459, 461
rounded commissure of, correction of,
467, 467, 470, 471
upper
abscess of, 394, 395
benign lesions of, excision of, with
nasolabial flap, 460, 461
Cupid's bow reconstruction for,
460,461
defects of, reconstruction of, 470, 471
large defects of
bitemporal flap for, 480, 481
cheek flap reconstruction for,
472,473
fan nap reconstruction for, 474, 475
indications for repair of, 478, 479
reconstruction of, 462, 463, 472-481,
473, 475, 477, 479, 481
large lesions of, excision of, 476-481,
477, 479. 481
paralysis of, masseter muscle
transposition for, 386, 386-387,
387
Lipoadenoma, 967
Liposarcoma, 152
MRI of, 27(t)
INDEX 1481
Lobectomy
deep, of parotid salivary gland, 868-871,
871
mandibulotomy and, 868-871, 871
thyroid
parathyroid locations and, 900
posterior suspensory ligament in,
897, 898, 941, 943, 945
subtotal, 946-949, 947, 949
for thyroid cancer, 907-908
total, 935-945, 939, 941, 943, 945
basic technique of, 903-904
total, of parotid salivary gland, 862-866,
863, 865
Longus capitis muscle, 5, 7
MRI of, 30, 33
Lore head light, for mirror laryngoscopy,
1072, 1072
Lore rigid optical instrument, 180, 180
Lore-Storz laryngeal telescopic forceps,
204, 204, 210, 211
Lore telescopic biopsy forceps, 180, 180
Lower esophageal sphincter, 145
Ludwig's angina, 854, 855
Lymph hemangioma, 846-847
Lymph nodes
cervical, 780-787
biopsy of, 780-781
metastatic guide to, 781-787, 783, 785,
787(t)
dissection of
for medullary carcinoma of thyroid,
926-927
for papillary carcinoma of thyroid, 927
facial, malignant lesions of, 745
management of, in melanoma treatment,
150-152
of neck
bronchogenic carcinoma of, 128
evaluation of, 138-139
pharyngeal, 780
Lymphadenectomy, 150-152
Lymphadenopathy, cervical, evaluation of,
797
Lymphangioma, excision of, 845, 845-847,
847
Lymphoma
MRI of, 27(t)
of thyroid gland, 928
Macrofollicular variant, of papillary
carcinoma, 915
Magnetic resonance imaging, 26-33
angiography, 54
in vascular surgery, 1239
in bone imaging, 142-143
for cervical lymphadenopathy
evaluation, 797
compared to other imaging modalities, 56(t)
us. CT, 1351, 1351
of mediastinum, 48-52
of orbit, 159
of paraganglioma, 27(t), 1291-1292
of parapharyngeal space tumors, 27(tJ
of parathyroid glands, 977, 978, 979, 981
in thyroid cancer, 922
of thyroid gland, 896
 INDEX
Malar bone
body of, 13, 17
fracture of. management of, 648-650
Malignant fibrous histiocytoma, 152
Malignant hyperthermia, 65-66
Malignant melanoma. See Melanoma,
malignant
Malleus, CT scan of, 39
Malnutrition, preoperative treatment of,
115-116
Mandible, 11, 16, 1354, 1354-1355
ameloblastoma of. 658, 659
ascending ramus of, 13, 1356-1357,
1356, 1357
atrophic, open repair of, 609-610, 610
benign tumors of, resection of, 660-663,
661, 663
body of, MRI of, 31, 32
coronoid process of. 13
on CT reconstruction, 21, 22
on CT reconstruction, 21. 25
cysts of. excision of, 653-657
edentulous, fracture in, 618
fractures of. 599-619
angle, 607-608, 608, 609, 616
body, 607, 607, 608
complications of, 600
compression plating for, 610-619, 611,
613, 615, 617, 619
condylar, 600, 601, 609, 609
coronoid, 609
dynamic bend able defect-bridging
plates for, 616-617, 617, 618-619,
619
eccentric dynamic compression plates
for, 616, 617
maxillomandibular fixation for, 602,
602, 605
open reduction and internal fixation
for, 602-605, 603, 604, 605
posterior to row of teeth, 614, 615
rigid internal fixation for, 612, 613
in row of teeth, 614, 615
symphyseal and parasymphyseal, 605,
605-606, 606, 607
types of, 60S
margin resection of. with radical neck
dissection, 814-817, 815, 817
MRI of, 28, 29, 30, 32, 33, 142-143, 143
reconstruction of. 424, 664-687
autogenous bone grafts for, 675-676,
677
donor sites for, 664-665
forehead flap for, 682-687, 683, 685,
687
iliac bone graft for, 678-682, 679, 681
Kirschner wire for, 665, 667
Steinmann pin for, 665-671, 669, 671.
682-687, 683, 685, 687
Steinmann pin/Kirschner wire for,
672-674, 673, 674, 674(t)
tie wires for, 665-671, 669, 671,
682-687, 683, 685, 687
resection of, 142,682-687,683,685,687
for carcinoma of floor of mouth,
688-695, 689, 690, 691, 693, 695
iliac bone graft for, 678-682, 679, 681
Mandible (Continued]
for malignant tumors, 714-719, 715, 717
segmental, 660
segmental resection of, 658, 659
transection of, parotid salivary gland
lobectomy and, 868-871, 871
Mandibular canal, 15
Mandibular foramen, on CT reconstruction,
20
Mandibular reconstruction, with implants,
168, 168, 171
Mandibular swing, 736, 737, 1374-1376,
1375, 1376
tongue base resection with, 734, 735
Mandibulectomy, buccal wall radical
resection with, 745-746
Mandibulotomy
and deep lobectomy of parotid salivary
gland, 868-871, 871
midline, 736, 737
mandibular swing modification of,
1374-1376, 1375, 1376
tongue base resection with, 734, 735
for resection of carcinoma of tonsil, soft
palate, and base of tongue, 720-723,
721, 723
Manubrium
MRI of, 52
resection of, 1041
Masseter muscle, 11, 13, IS, 18, 1354,
1354-1357, 1356, 1357
MRI of, 28, 29, 30, 33
resection of, for buccal wall lesions, 745
transposition of, for upper lid paralysis,
386, 386-387, 387
Masticator space. See Parapharyngeal space
Mastoid air cells, MRI of, 29
Mastoid process, CT scan of. 41
Mattress suture technique, for prominent
ear correction, 576, 577
Maxilla
carcinoma of, resection of, 236
chondrosarcoma of, en-bloc resection of,
246
cysts of. 250, 251
deformity of, in cleft lip, 494, 495, SOD,
501
fracture of
early reduction of, 624, 625
Le Fort I, 630, 631, 636, 636, 637
Le Fort II, 632, 633, 636-637, 637
Le Fort III, 634, 635, 637, 637
miniplate fixation for, 636, 636-637,637
with zygomatic fracture, 622-623, 623
MRI of, 30
resection of
limited, 248, 249
with orbit exenteration, globe
preservation in, 246, 247
partial, 236-238
removal of soft palate after, 238
radical, 236-238
with orbital and partial ethmoidal
exenteration, 239, 239-245,
240, 241, 242, 243, 245
upper dental arch of. fracture of, 630, 631
Maxillary antrostomy, 260, 261, 261
Maxillary artery
CT angiography of, 45
CT scan of, 41
external, 13
internal, 15
branches of, 282, 283
ligation of. 282-285, 283, 285
Maxillary sinus, 3, 5, 11, 13, 16, 17
endoscopic examination of, 259(t)
midportion of, sagittal section of, 3
MRI of, 29, 32
tumors of, maxillary resection for, 239,
239-245,240,241,242,243,245
Maxillectomy. See also Maxilla, resection of
bilateral total, for chondrosarcoma,
1386-1390, 1387-1390
radical, facial drooping after, 388
Maxillofacial prostheses, 166, 166-170,
167,168,169,170,171
Maxillomandibular fixation (MMF), for
mandibular fractures, 602, 602, 605
Meckel's cave, intracranial tumor extension
into, CT scan of, 35
Medialization of vocal cord, 1080, 1081
Median sternotomy. See Sternotomy,
median
Mediastinal nodes, dissection of, 904-905
Mediastinoscopy, 997, 1038-1040, 1039
Mediastinotomy, cervical, 1024-1025, 1025
Mediastinum
access to, 1036-1037
anatomy of, 998,1036-1037, 1037
dissection of, 1040-1041
clavicular resection for, 1040-1045,
1042(t), 1043, 1044, 1045
median sternotomy for, 1041, 1042(t)
substernal approach to, 1040
for thyroid cancer, 931(t)
for tracheostoma recurrence,
1056-1061, 1057, 1059, 1061
exploration of, in parathyroid surgery,
988-989
ganglioneuroma of, resection of,
850-852,851, 853
MRI of, 48-52
parathyroid adenoma of, excision of,
986, 988, 996-1000
superior
access to, thyroid surgery and.
900-901
anatomy of, 998
Medulla oblongata, MRt of, 29
Medullary carcinoma of thyroid, 922-927
classification of, 918, 923
cytology of, 895
diagnosis of, 923-924
familial type, 918, 923, 924
family screening for, 925
management of, 931(t)
radiation therapy in, 927
surgery in, 926-927
origins and characteristics of, 922-923
postoperative follow-up in, 924-925
prognosis of, 927
recurrence of, management of, 926
sporadic type, 918, 923

Melanoma, malignant, 149-152
cause of, 149
incidence of, 149
micro staging, 149
PET scan of, /52
postauricular area involved in, total
resection of auricle for, 590-593,
591, 592
recurrence of, 150
staging, 150
treatment of, 150
lymph node management in, 150-152
Meningeal artery, middle, CT scan of, 41
Meperidine, 200
Metaplasia, 91
Metastasizing mixed tumor, 884
Metastatic vascular tumor, MRI of, 27(t)
Methimazole, for thyroid-related
orbitopathy, 156
Methotrexate
compared to combination chemotherapy,
130
with radiation therapy, 131
for recurrent cancer, 129
Microlaryngoscopy
by carbon dioxide laser, 1077-1078
in laryngeal carcinoma, 1092
Microneurorrhaphy, 1424-1425
Microscopic endolaryngoscopy, 200-203, 203
anesthesia for, 200
complications of, 201
instruments of, 200
Microsurgery, 1422-1428, 1423
Microvascular flaps, 1417-1469. See also
specific types, e.g., Gracilis flap
advanlages and disadvantages of,
1427-1428
classification of, 1418
donor sites for, 1418-1420
historical perspective of, 1417-1418
selection of, 1420-1422
Microvascular surgery, 1417-1469
operating room set -up for, 1425
postoperative care and monitoring in,
1427
recipient site vessel selection in,
1425-1426
secondary ischemia in, 1426
Middle ear surgery, 148-149
Milia, dermabrasion and, 372
Miniplate fixation, for facial fractures, 596,
596, 608, 636, 636-637, 637
Mirror laryngoscopy, 1069, 1069-1072,
1071, 1072
indirect, 179
in laryngeal carcinoma, 1092
Mirror nasopharyngoscopy, indirect, 179
Mitomycin, 131
Mixed medullary-follicular carcinoma, of
thyroid, 918-919
Mixed medullary-papillary carcinoma, of
thyroid,918-919
Mixed tumors, of salivary gland, 884-885
Molar teeth
second, frontal coronal section of, 11, 16
third, frontal coronal section of, 13, 17
Motility abnormality, in thyroid-related
orbitopathy, 159
Mouth
cancer of
distant metastasis in, 135(tJ
glossectomy for, 146
recurrent, 135(t)
treatment of, 133(t)
distortion of, Z-plasty for, 460, 461
floor of
abscess of, 854, 855
carcinoma of
inlay graft for, 710-713, 711, 713
mandibular resection for, 688-695,
689, 690, 691, 693, 695
resection of, 726-731, 727, 729, 731
ranula of, excision of, 766, 767
stage Tl carcinoma of, resection of,
708, 709
lesions of
excisional biopsy of, pitfalls of, 124
incisional biopsy of, 124
leukoplakia of, excision of, 698-700, 699
malignant tumors of, resection of,
714-719,715,717
postoperative care of, 119, 120
MRI. See Magnetic resonance imaging
Mucin, 91
Mucocele, 232
Mucosa, condemned, 127
Mucosal biopsy, 91
Mucosal repair, sutures for, 112
Muller's muscle, 158
Multiple endocrine neoplasia, 923
hyperparathyroidism in, 923, 975-976
Multiple primary syndrome, 127
Mutter nape of neck flap, 440, 441
Myasthenia gravis, thymectomy in,
1062-1063
Myasthenia laryngis, 1079
Mylohyoid muscle, 11
Myocutaneous flaps, classification of,
400-401
Myotomy, cricopharyngeal, 1122, 1123,
1178, 1179
Nape of neck flap
limitations of, 401
Mutter, 440, 441
Narcotics, postoperative, 119
Naris (nares)
enlargement of, with Z-plasty, 352, 353
flared, narrowing, 330, 331
pinched, correction of, 330, 331
Nasal concha, inferior, MRI of, 32
Nasal prosthesis, 168, 169
Nasal spine deformity, correction of, 306,
307
Nasal tip
broad, correction of, 325, 325
bulbous, correction of, 330, 331
collapsed, columellar graft for, 328, 329
correction of, 325, 325, 326, 327
flattened, correction of, 330, 331
tumor of, resection of, 338, 338, 339
Nasoalveolar cyst, 250, 251
excision of, 252, 253
INDEX 1483
Nasoesophageal feeding tube, 123, 123
Nasofacial flaps, 332, 333
Nasofrontal duct, anatomy of, 234-235, 235
Nasogastric feeding tube, 146
Nasolabial flaps, 332, 333, 336, 337
for upper lip lesion excision, 460, 461
Nasolabial fold, revision of, 352, 353
Nasolacrimal sac, obstruction of,
dacryocystorhinostomy for, 558, 559
Nasolaryngoscopy, flexible, 196, 197
Nasopalatine cyst, 250, 251
excision of, 254, 255
Nasopharyngoscopy, 205-209, 207, 209
complications of, 208
direct optical, 180, 180-181,205,206,
207, 210, 211
direct rigid, 181, 205, 206, 207, 210,211
indirect mirror, 179,205,206,207
nasal route of, 205, 210, 211
oral route of, 205, 210, 211
soft palate retraction in, 206, 207
Nasopharynx
anatomic regions of, 208
biopsy of, 208, 209
juvenile angiofibroma of, 288-289
malignant tumors of, resection of,
714-719, 715, 717
MRI of, 29, 32, 33
polyps of, removal of, 286, 287
reconstruction of
myomucosal tongue flap for,
1188-1190, 1189
pectoralis major flap for, 412, 413
trans maxillary approach to, 294, 294
trans palatine exposure of, 288-293, 291,
292, 293
"Near-far, far-near" suture, for eyelid
margin approximation, 524, 525
Neck
abscesses of, incision and drainage of,
854,855
anterior portion of, anatomy of, 781
cervical lymph nodes of, metastatic
guide to, 781-787, 783, 785, 787(t)
ganglioneuroma of, resection of,
850-852, 851, 853
incisions for, 804-807, 80S, 807
lump in, open biopsy of, pitfalls of, 124
lymph nodes of
biopsy of, 780-781
bronchogenic carcinoma of, 128
evaluation of, 138-139
nape of, flap of
limitations of, 401
Mutter, 440, 441
penetration wounds of, 856, 1310
Neck dissection
central
definition of, 905
for squamous cell carcinoma of
thyroid, 929
for thyroid cancer, 919
central compartment, 811
extended, 814
functional, 138
lateral, 811
for thyroid cancer, 931(t)
Neck dissection (Continued)
posterior, 818-823, 819, 821, 823
posterolateral, 811
radical, 138, 788-797, 789, 791, 793, 795
after chemotherapy, 132
for buccal wall lesions, 744
for carcinoma of floor of mouth,
688-695, 689, 690, 691, 693, 695,
726-731,727, 729, 731
for carcinoma of tongue, 726-731, 727,
729, 731
and carotid artery blowout, 1328
classic
definition of, 904
for squamous cell carcinoma of
thyroid, 929
complications of, 796
for hypopharyngeal carcinoma,
1181-1185, 1183, 1185
incisional modifications for, 804-807.
805, 807
for laryngeal cancer, 1096, 1120-1124,
1121, 1123, 1124
mandible margin resection with,
814-817,815,817
modified, 797-813, 799, 801, 803, 805,
807, 810, 813
definition of, 904
for laryngeal cancer, 1096
for thyroid cancer, 919, 950-954,
951, 953, 954
for oropharyngeal carcinoma,
1181-1185,1183,1185
parotid extension of, 798-801, 799,
801, 886-888, 887, 889
preserving internal jugular vein in,
808-810, 809, 810
preserving spinal accessory gland in,
802-803,803, 808-810, 809, 810,
950-954, 951, 953, 954
preserving sternocleidomastoid muscle
in, 808-810, 809, 810, 950-954,
951, 953, 954
radiotherapy after, 796-797
for recurrent malignant melanoma,
590-593, 591, 592
skin incision for, 112
with supraglottic laryngectomy,
1120-1124, 1121, 1123, 1124
with total laryngectomy, 1136-1141,
1137, 1139, 1141, 1148, 1149
with total thyroidectomy, 955-961,
955-958, 961, 1046-1055, 1047,
1049, 1051, 1053, 1055
and recurrence in neck, 796-797, 796ft)
selective, 811, 811-813, 813
suprahyoid, 138
supraomohyoid, 138, 811
Needle biopsy
core, 87-89
in soft tissue sarcoma diagnosis, 153
of neck nodes, 780-781
of parotid salivary gland, 861-862
techniques of, 87-89
of thyroid lesions, 893
Neoplastic disease. See under specific
locations, e.g., Larynx
Nerve. See specific nerves, e.g., Laryngeal
neroe
Nerve grafts, 112, 113
for facial nerve paralysis, 876, 877
Neuralgia, glossopharyngeal, 842, 842,
1361-1364,1362, 1363, 1364
Neuroendocrine carcinoma, nonresectable,
238
Neurofibroma, of tongue, resection of,
768, 769
Neurogenic tumor, MRI of, 27(t)
Neuroleptanalgesia, 200
Neuroma, excision of, 852, 853
Neurorrhaphy, 1424-1425
Nose
anatomy of, 267-269, 269
basal cell carcinoma of, resection of,
544, 545
bleeding from. See Epistaxis
bulla ethmoidalis of, 267, 269
carcinoma of, resection of, 356, 357
composite ear graft to, 342, 343
deformity of, in cleft lip, 494, 495, 500,
501
dorsum of, augmentation of, 326
external defect of, septal flap for, 334, 335
floor of,S
sagittal section of, 7
fractures of, 596-598, 597, 599
full-thickness graft to, 340, 341
glioma of, resection of, 358-361, 359, 361
hard palate of,S
infundibulum ethmoidalis of, 267-268
lateral wall of
anatomy of, 267-269, 269
sagittal section of, 5
polyps of, removal of, 286, 287
reconstruction of
ala nasi revision in, 352, 353
with arm flap, 344, 345
forehead and scalp pedicle transection
for, 352, 353
with lateral forehead flap, 346, 347
nasolabial fold revision in, 352, 353
with scalp and forehead flap, 348, 349
with scalping flap, 348, 349
limitations of, 402
with sickle flap, 348, 349
resection of, for carcinoma, 356, 357
right cavity of, lateral wall of, anatomy
of, 267-269, 269
saddleback, correction of, 326
septum of
abscess of, 394, 395
cartilage, correction of, 306, 307
deformity of, correction of, 304-315,
305, 307, 309, 311, 313, 315
reconstructed, lateral view of, 308, 309
resection of, for carcinoma, 354, 355
septoplasty type I of, 304-309, 305,
307, 309
septoplasty type II of, 310-315, 311,
313, 315
submucous resection of, 300~303,
301, 303
superior dorsum of, tumor of, resection
of, 340
Nose (Continued)
Teflon splints for, 302, 305, 305, 306, 307
tip of
broad, correction of, 325, 325
bulbous, correction of, 330, 331
collapsed, columellar graft for, 328, 329
correction of, 325, 325, 326,327
flattened, correction of, 330, 331
tumor of, resection of, 338, 338, 339
turn-in flaps for, 350, 351
uncinate process of, 267, 269
Not otherwise specified (NOS) tumors, of
salivary gland, 883-884
Nylon sutures, 112
Oblique muscle, superior, MRI of, 32
Occipital artery
CT angiography of, 43
CT scan of, 41
Oculoplethysmography, 1237-1238, 1238
Odontogenic cysts, 250, 251
Odontoid process, MRI of, 29, 30, 33
Odynophagia, 145
Omohyoid muscle, laryngoplasty with,
1114-1115,1115
Oncocytic carcinoma. See Hurthle cell
thyroid carcinoma
Oncology service, 141-142
Open reduction and internal fixation
(ORIFJ, for mandibular fractures,
602-605, 603, 604, 605
Ophthalmic complications, of head and
neck surgery, 66-70
Optic chiasm, MRI of, 32, 33
Optic nerve, 3
injury to, 67, 595
MRI of, 32
Optic neuropathy
ischemic, 69
in thryoid-related orbitopathy, 159-160
Optical laryngoscopy, direct, 180, 180-181
in laryngeal carcinoma, 1092
Optical nasopharyngoscopy, direct, 180,
180-181,210,211
Optical rhinosc9PY, direct, 210, 211
Oral cavity. See Mouth
Orbicularis oris muscle, plication of, for
lower lip paralysis, 468, 468
Orbit, 11
CT scan of, 157, 159
decompression of, for exophthalmos, 566
exenteration of
globe preservation with, 246, 247
with radical maxillectomy, 239,
239-245, 240, 241, 242, 243, 245
floor of
on CT reconstruction, 20
fractures of, 640-645, 641, 643, 645
fracture of, 634, 635
medial wall of, 13, 17
on CT reconstruction, 20
MRI of, 159
neoplastic disease of, 1287
rim of, on CT reconstruction, 19, 21, 25
roof of, on CT reconstruction, 20, 21, 25
sagittal section of, 3
 INDEX

Orbit (Continued) Palate (Continued) Para maxillary space. See Parapharyngeal

supraorbitat approach to, 1391-1394, lesions of, excision of, 752-759, 753, space
1391, 1392, 1393 755, 756, 757, 759 Paranasal sinus
walts of, damage to, 67-68 MRI of, 28, 30, 32 chondrosarcoma of, bilateral total
Orbital decompression surgery removal of, 162, 163, 164 maxillectomy for, 1386-1390,
complications of, 161 after partial maxillectomy, 238 1387-1390
indications for, 161 retraction of, in nasopharyngoscopy, supraorbital approach to, 1391-1394,
for optic neuropathy, 159-160 206, 207 1391, 1392, 1393
for thyroid-related orbitopathy, 160 salivary gland tumors of, resection of, Parapharyngeal space
Orbital fat, 264 760-763, 761, 763 anatomy of, 1350-1351
Orbital fissure Palatine tonsil, MRI of, 30 approaches to, 1352-1361
inferior, on CT reconstruction, 25 Panje voice bulton prosthesis, 1146, 1147 cross section of, 1354
superior, on CT reconstruction, 19, 23 Papillary carcinoma, of thyroid diseases of, 1351-1352
Orbitat hematoma, 68-69, 69(tJ classification of, 914-915 dissection of, 868-871, 871
Orbitat injections, 69-70 cytology of, 894-895 osseous anatomy of skult base and,
Orbitat prosthesis, 168, 169 incidence of, 914 1349,1349
Orbital swelting, 264 management of, 927, 931(t) and skult base, 1349-1374
Orbital ultrasound, 157 radiation-induced,914 surgery of, 1365-1373
Orbitopathy, thyroid-related. See Thyroid- recurrence of, 911 advanced exposure, 1366-1367
related orbitopathy variants of, 915-916 advanced radical exposure, 1367-1373,
Oroantrat fistula, closure of, 256, 257 Papiltary microcarcinoma, 915 1369-1373
Oropharynx Paraganglioma, 1283-1294 limited exposure, 1366
cancer of angiography of, 1292 moderate exposure, 1366, 1366
distant metastasis in, 135(t) classification of, 1284-1288 surgical anatomy of, 1351
glossectomy for, 146 CT scan of, 53, 1291-1292 tumors of
radiotherapy for, 137(IJ definition of, 1283 MRI of, 27(t)
recurrent, 135(t) diagnosis and evaluation of, 1291-] 292 resection of, 714-719, 715, 717
resection of, 1181-1185, 1183, 1185 intravagale, 1302, 1302-1307, 1304, 1305 Parapharyngeal space fat, MRI of, 30
treatment of, 133(t) resection of, 1300, 1301 Parasymphyseal fractures, open repair of,
evaluation of, 1351 intravascular (glomus) jugulare, 605, 605-606, 606, 607
matignant tumors of, resection of, 1307-1309, 1309 Parathyroid glands, 966-1003
714-719, 715, 717 malignancy of, 1284, 1290-]291 adenolipoma of, 973
MRI of, 28, 29, 33 MRI of, 27(t), 1291-1292 adenoma of, 966-967, 972
reconstruction of pathology of, 1283-1284 excision of, 990-996, 993, 994, 995
deltopectoral flap for, 425-433, 427, radiation therapy for, 1291 complications of, 1002
429, 431, 433 signs and symptoms of, 1284 and hypocalcemia, 1002
myomucosal tongue flap for, surgery for, 1293-1294 postoperative care, 1002, 1003(t)
1188-1190, 1189 sympathetic, 1289, 1290, 1302, mediastinal, excision of, 986, 988,
pectoralis major flap for, 412, 413 1302-1307, 1304, 1305 996-1002
walt of, resection of, 724, 725 vagal, 1285, 1286, 1289-1290, 1301 surgical management of, preoperative
"Orphan Annie nuclei," 915 warnings with, 1292-1293 and intraoperative techniques for,
Osseo integrated implants, 171 Parakeratosis, 91 976-1002
Osteoma, of frontal sinus, treatment of, 234 Paralysis anatomy of, 966, 968-971, 969,
Osteomeatal complex, 218, 219 abductor vocal cord, 1071, 1071 974-975
Osteoporosis, hyperparathyroidism arytenoidpexy for, 1086-1089, 1087, blood supply to, 900, 968-971, 971
treatment and, 1002 1089 carcinoma of, 967, 972
Ostial meatus complex, 268 laryngofissure for, 1082-1085, 1083, 1085 cyst of, 967, 972-973
Otoplasty, 573-579, 573-575, 577, 579 adductor vocal cord, 1071, 1071 cystadenoma of, 972-973
facial nerve, 380-391 excision of, 996-1000
Paclitaxel facial reanimation for, 381-382, 383 with median sternotomy, 999-1002,
preoperative, 132 fascial slings for, 388-391, 389, 391 1001
for recurrent cancer, 129 free nerve grafts for, 876, 877 diseases of, 966-967, 972-973. See also
Palatal ablation, 147 hypoglossal-facial nerve anastomosis specific diseases, e.g ..
Palatal flap, 290, 291 for, 384, 385 Hyperparathyroidism
Palatal surgery, speech rehabilitation after, management of, 381 embryology of, 966, 974-975
147 masseter muscle transposition for, frozen section examination of, 967-968
Palate 386, 386-387, 387 hamartoma of, 973
anatomy of, 290, 291, 510,511 upper lid gold weights for, 382, 383 hypercellularity of, 968
cleft. See Cleft palate lower lip, 390 hyperplasia of, 967, 972
hard,5 orbicularis oris muscle plication for, surgical management of, preoperative
fracture of, internal fixation at 638, 639 468, 468 and intraoperative techniques for,
lesions of, excision of, 752-759, 753, recurrent laryngeal nerve, 905, 906 976-1002
755, 756, 757, 759 thyroid surgery and, 964-965 identification of, 935-936
MRI of, 30 superior laryngeal nerve, 90S imaging of, 976-984
soft, 9, 15 vocal cord, 1070 inferior
carcinoma of, resection of, 720-723, Graves' disease surgery and, 906 blood supply to, 968-971, 969, 971
721, 723, 764, 765 temporary, steroid use and, 905 location of, 899-900
 INDEX
Parathyroid glands (Continued)
intraoperative examination of, 967-968
locations of, 899-900, 935, 936, 968,
969, 971, 993, 995
pathology of, 966-968
reimplantation of, 936
superior
blood supply to, 968-971, 969, 971
location of, 900
surgery of, 968-971, 969, 971. See also
Thymectomy
principles of, 985-990
thyroid surgery and, 899-900, 935-936,
969, 971, 972, 993, 995
Parathyromatosis, 967
Parotid salivary gland, 15, 861-889
deep lobectomy of, 868-871, 871
mandibulotomy and, 868-871, 871
malignant tumors of, 882-883
MRI of, 30, 33
recurrent benign tumor of, excision of,
878-879, 879
resection of, with radical neck dissection,
798-801, 799, 801, 886-888, 887, 889
total lobectomy of, 862-866, 863, 865
Parotidectomy, for recurrent malignant
melanoma, 590-593, 591, 592
Parotitis, 888
Patch graft, with carotid endarterectomy,
1248, 1248
Pectoral artery, 408, 409
Pectoralis major flap, 400, 404-419, 405,
407,409,411,4]3,4]5,416,417,4]9.
See also Microvascular surgery
applications of, 420, 420-424, 42], 422,
423,424
complications of, 418
hemiglossectomy with, 724, 725
limitations of, 402
Pectoralis major muscle
anatomy of, 405, 405
blood supply to, 406, 407
nerve supply to, 405
Percutaneous endoscopic gastrostomy,
1227-1229, 1229
Perineural disease, at skull base, detection
of, 35, 35
Perpendicular plate, 9, 11, 13, ]6
on CT reconstruction, 22
PET scan. See Positron emission
tomography
Petrous bone, on CT reconstruction, 23, 24
Pharyngeal artery, ascending, 1288
Pharyngeal constrictor muscle, 1360,
1360-1361
superior, 9 treatment of, 160
Pharyngeal flap
for cleft palate repair, 516, 516, 5] 7
for velopharyngeal insufficiency,
517-518,5]9
Pharyngeal lymph nodes, 780
Pharyngoesophageal diverticulum, repair
of, 1171-1175, 1173, 1175
Pharyngoesophagograms, 194
Pharyngomaxillary space. See Parapharyngeal
space
Pharyngotomy
anterior, 1180, 1181
lateral, 1181-1185, 1183, 1185
suprahyoid, 1180
transhyoid, 1180, 118]
Pharynx
constrictor muscle of, inferior,
cricopharyngeus portion of, 9
CT scan of, avoiding dental artifacts in, 36
reconstruction of, 1186, 1186-1189, 1187(t)
Trotter approach to, 704-707, 705, 707
Pheochromocytoma
adrenal, 1283
diagnosis of, 923-924
in multiple endocrine neoplasia, 923
Phon angiography, carotid, 1238, ]238
Phrenic nerve crush, 832, 833
Physical examination
completeness of, 127
diagnostic primacy of, 125
Pierre Robin syndrome, 774-776, 775, 776
Pinhole collimator, iodine-131 scan with, 922
Pituitary gland, 7, 9
endoscopic endonasal trans sphenoidal
approach to, 1404-1407, 1407
MR1of, 32
Plaque, atheromatous, 1240, ]24], ]242
Platysma muscle, injury to, 390
Pneumoperitoneum, tension, 1023, 1023
Pneumothorax, thoracentesis for, 74, 75
Polyps
nasal, removal of, 286, 287
nasopharyngeal, removal of, 286, 287
Pons, MRI of, 32
Positron emission tomography, 56-63
compared to other imaging modalities,
56(t)
in oncology, 57-63
of parathyroid glands, 978, 978, 979
in thyroid cancer, 922
of thyroid gland, 896
Posterior commissure scar, 1159, 1159
Postoperative care, 116-123, 117, 120, ]2],
]23
Prednisone, for thyroid-related orbitopathy,
156
Preoperative care, 114-116
Prepharyngoesophageal air retention
evaluation, for voice prostheses, 1144
Pressure dressings, 120
Prevertebral space, 7, 9
Promethazine, 200
Proptosis
in thyroid-related orbitopathy, 154, 155,
156,158-159
Prosthodontic rehabilitation, 166
Proteus infection, postoperative, 122
Pseudo proptosis, 156
Psychosis, hypercalcemia and, 990
Psychosocial support, 149
Pterygoid canal,S
Pterygoid muscle, 1356-1357, 1356, 1357,
1359, 1359
external, 13
heads of, 3, 15
Proptosis (Continued)
internal, 13, ] 5
heads of, 3
lateral, MRI of, 29, 32, 33
medial, MRI of, 28, 30, 32, 33
Pterygoid plates
on CT reconstruction, 20, 24
CT scan of, 4]
Pterygoid process
hamulus of,S, 13, ] 5
of sphenoid bone, 7, 13
Pterygoid venous plexus, 1356-1357,
1356, 1357
Pterygomaxillary fissure, 3
Pterygopalatine fossa,S
CT scan of, 4]
tumor in, CT scan of, 35
Pulmonary apex, MRI of, 32
Punch biopsy
for hypolaryngeallesions, 1073, 1073
for laryngeal lesions, 1073, 1073
Pyloroplasty, Heineke-Mikulicz, 1222, ]223
Pyramidal eminence, CT scan of, 40
Pyramidal fracture, maxillary, 632, 633
Pyramidal lobe
dissection of
for Graves' disease, 933-934
for medullary carcinoma, 926-927
for thyroid cancer, 919
location of, thyroglossal duct tract and,
901
Pyriform fossa, laryngoscopy of, 186
Pyriform recess, MRI of, 3]
Pyriform sinus
CT scan of, 47
MRI of, 28
Radial forearm flap, 1429-1435, 1433, 1435
advantages and disadvantages of, 1428
complications of, 1431
donor site closure in, 1430-1431
neurovascular anatomy in, 1429-1430
Radiation arteritis, 1275
Radiation therapy
after radical neck dissection, 796-797
for anaplastic carcinoma of thyroid, 928
assessment of, 126-127
and carotid artery blowout, 1328
and chemotherapy, 131
compromised resection and, 126
external beam, for thyroid cancer, 921
for laryngeal cancer, 133(t), 1096-1097
for medullary carcinoma of thyroid, 927
for paraganglioma, 1291
pectoralis major flap after, 416, 416
salvage, for laryngeal cancer, 1100(t)
selective, 132-141
early, 136, 137(t)
late, 136, 137(t)
for soft tissue sarcoma, 153
for squamous cell carcinoma of thyroid,
929
for thyroid cancer, 919-922, 931(t)
for thyroid-related orbitopathy, 160-161
Radical neck dissection. See Neck dissection,
radical

Radicular cyst, 250, 251
excision of, 653-654, 655
Radioactive iodine
for thyroid cancer, 919-922, 931(t)
for thyroid-related orbitopathy, 156
Ranula, excision of, 766, 767
Reconstruction ptates, 606, 607
Rectus flap, 1441-1447, 1443, 1445, 1446,
1447
advantages and disadvantages of, 1428
complications of, 1442
donor site closure in, 1442
neurovascular anatomy in, 1441
Rectus muscle
inferior, MRI of, 32
lateral, MRI of, 32
medial, MRI of, 32
superior, MRI of, 32
Recurrent laryngeal nerve
extralaryngeal branching of, 897-898
iniury to, thyroid surgery and, 963, 964(t)
paralysis of, 905, 906
thyroid surgery and, 964-965
postoperative function of, 905-906
thyroid surgery and, 897-898, 898
Rendu-Osler-Weber disease, epistaxis in,
270, 280
Resectability, iudgment of, 125-126
Respiratory arrest, 70
Respiratory emergencies, management of,
84-85, 1016
Resuscitation, cardiopulmonary, 70-73
closed cardiac massage for, 72
open cardiac massage for, 72, 73
Retention cyst, of floor of mouth, excision
of, 766, 767
Retromolar trigone, carcinoma of
mandibutectomy for, 745-746
resection of, 726-731, 727, 729, 731, 747,
747-751,749, 750, 751
Retropharyngeat mass, CT scan of, 47
Retropharyngeal space, MRI of, 29
Rhinophyma, excision of, 362, 362
Rhinoplasty, 316-324, 317, 319, 321, 323, 324
alternate techniques of, 324, 324
basic surgical technique of, 316-322, 317,
3]9,321, 323
dressing for, 322, 323
Rhinoscopy, 214-216, 215, 216
direct optical, 210, 211
direct rigid, 210, 211
Rhinotomy, lateral, 280, 281, 354, 355
Rhombic flap, 104, 105
Rib graft, 108, 109
Rigid bronchoscopy, 188-191, ]89, 19]
anesthesia for, 188
Rigid esophagoscopy, 196-199, 197, 199
Rigid internal fixation, for mandibular
fractures, 612, 613
Rigid laryngoscopy, direct, 181-187, 185,
186, 187
anesthesia for, 182-183
in laryngeal carcinoma, 1092
Rigid nasopharyngoscopy, direct, 181, 210,
211
Rigid rhinoscopy, direct, 210, 211
Rosenmiiller's fossa, MRI of, 29
Rotation advancement
for bilateral cleft lip repair, 504, 505
for unilateral cleft lip repair, 498,
498-499, 499
Rotation flaps, 377, 377-378, 378
S-100, 91
S-plasty, 100, 101
Saddleback nose, correction of, 326
Sagittal sinus, on CT reconstruction,
Salivary gland
adenocarcinoma not otherwise specified
(NOS] of, 883-884
calculi of, 773, 773
mucoepidermoid carcinoma of,
histopathologic grading of, 124-125
neoplasm of, 745
parotid. See Parotid salivary gland
retention cyst of, excision of, 766, 767
sublingual, 11, 662, 663
submandibular, 11, 13, 15
benign disease aC resection of,
828-831, 829, 831
MRI of, 28, 30, 31, 32, 33
tumors of
enucleation of, 128
histologic classification of, 884(t]
malignant mixed tumors, 884-885
management of, 880-881
resection of, 760-763, 761, 763
staging criteria for, 885(t)
Salivary gland tumor, MRI of, 27(t]
Salvage surgery, 1099-1100
Saphenous vein graft, for arterial
replacements, 1338, 1339
Scalene muscle
medial, MRI of, 32
posterior, MRI of, 32
Scalene node, biopsy of, 832, 833
Scatenotomy, for thoracic outlet syndrome,
1340, 1340-1342, 1341, 1342
Scalp
muscles of, anatomy of, 367, 367-368, 368
pedicle of, transection of, 352, 353
Scalp flap, for nose reconstruction, 348, 349
Scalping flap
limitations of, 402
for nose reconstruction, 348, 349
Scapula, posterior, flap of, 442, 443
Scapular flap, 1448-1455, 1449, 1451,
1453, 1455
advantages and disadvantages of, 1428
complications of, 1449
donor site closure in, 1448-1449
neurovascular anatomy in, 1448
Scintigraphy, of parathyroid glands, 980, 983
Sebaceous cysts, facial, excision of, 369,
369-370, 370
Sedation, postoperative, 119
Sella turcica, on CT reconstruction,
Semicircular canal
lateral, CT scan of, 39
posterior, CT scan of, 39
superior, CT scan of, 39
Semispinalis cervicis muscle, MRI of, 30
Sentinel node biopsy, 150-152
Septal dermoplasty, 280, 281
INDEX 1487
Septal flap, 334, 335
Septoplasty type I, 304-309, 305, 307, 309
Septoplasty type 11,310-315, 311, 313, 315
Septum, nasal
abscess of, 394, 395
cartilage, correction of, 306, 307
deformity of, correction of, 304-315, 305,
307, 309, 311, 313, 315
reconstructed, lateral view of, 308, 309
24 resection of, for carcinoma, 354, 355
septoplasty type I of, 304-309, 305,
307, 309
septoplasty type 11of, 310-315, 311,
313, 315
submucous resection of, 300-303,
301, 303
Shield excision, of lips, 458, 459
Sickle flap, 348, 349
Singer-Blom prosthesis, for
postlaryngectomy speech, 1144-1146
Single-photon emission computed
tomography, 56
compared to other imaging modalities,
56(t]
Sinus. See specific sinuses, e.g., Frontal
sinus
Sinus surgery, endoscopic, 258, 258-264,
259(t), 260, 261, 262, 263
anesthesia for, 259
indications for, 258
pitfalls of, 263-264
Sinus tract, excision of, 843, 843-844, 844
Sinusitis
endoscopic diagnosis of, 222
transnasal endoscopic surgery for, 222
Sinusotomy
frontal, 230, 231
sphenoidal, 226-229, 227, 229
Sisson procedure, for tracheostoma
recurrence, 1056-1061, 1057, 1059, 1061
Skin flap
lateral, for esophageal reconstruction of,
1192-119S, 1193, 1195
thoracic, for esophageal reconstruction,
1196-1198, 1197, 1198
Skin graft, over tantalum gauze, for
esophageal reconstruction, 1196, 1197
Skin incision(s)
general considerations, 112
preoperative preparation of, 116
for radical neck dissection, 804-807,
805,807
Skull, middle of, sagittal section of, 9
Skull base
CT scan of, 40
infratemporal approach to, 1365-1392
osseous anatomy of, 1349, 1349
and parapharyngeal space, 1349-1374
perineural disease at, detection of, 35, 35
23 surgery on, 1348-1414. See also specific
procedures, e.g., Hypophysectomy
trans maxillary approach to, 294, 294
Trotter approach to, 704-707, 705, 707
tumors of, craniofacial resection for,
1377-1385
Slings, fascial, for facial paralysis, 388-391,
389, 391
, 1488 INDEX
Soft palate, 9, IS
carcinoma of, resection of, 720-723, 721,
723, 764, 765
lesions of, excision of, 752-759, 753,
755, 756, 757, 759
MRI of, 28, 30, 32
removal of, 162, 163, 164
after partial maxillectomy, 238
retraction of, in nasopharyngoscopy,
206,207
salivary gland tumors of, resection of,
760-763, 761, 763
Soft tissue damage, 67-68
Soft tissue sarcoma, 152-154
FDG-PET scan of, 60
histologic types of, 152
MRI of, 27(t)
presentation and diagnosis of, 153
recurrence of, 153, 154
results and prognostic parameters of,
153-154
treatment of, 153
Sonogram, of thyroid gland, 895-896, 896
SPECT, of parathyroid glands, 977, 977,
978,979, 980, 980-981, 982, 983
Speech
alaryngeal, types of, 144
esophageal, 144
postoperative rehabilitation of, 143-147
prostheses for
complications of, 1150
Panje voice button prosthesis in,
1146, 1147
preoperative consideration of, 114-115
Singer-BJorn prosthesis in, 1144-1146
tracheal esophageal puncture in, 1143,
1143-1151,1145,1147,1149,1151
Sphenoid bone
lateral pterygoid plate of, 3
medial pterygoid plate of, 5
pterygoid process of, 7, 13
lateral, 15
medial, 15
rostrum of, 15
Sphenoid rostrum, on CT reconstruction, 24
Sphenoidal ostium, enlargement of, 226, 229
Sphenoidal sinus,S, 7, 9
anterior wall of, puncture of, 226, 229
on CT reconstruction, 24
drainage of, sphenoidal ostium
enlargement for, 226, 229
endoscopic examination of, 259(t)
irrigation of, 226, 227
MRI of, 32, 33
transpalatine exposure of, 288-293, 291,
292, 293
transseptal approach to, 1395-1403,
1398, 1399, 1400, 1402, 1404
Sphenoidal sinusotomy, 226-229, 227, 229
Sphenoidotomy, 262, 262
Spinal accessory nerve, 781
preserving. in radical neck dissection,
802-803, 803, 808-810, 809, 810,
950-954,951, 953, 954
Spinal cord, 7
MRI of, 28, 29, 32
Splenius capitis muscle, MRI of, 30
Splints Strap muscles (Continued)
Gunning-type, in mandibular resection of
reconstruction, 678, 679, 679, 680, for squamous cell carcinoma of
681 thyroid, 929
Teflon, for nasal septum resection, for thyroid cancer, 919
302, 305, 305, 306, 307 thyroid s~rgery and, 901
Squamous cell carcinoma, of thyroid, Stripping, vocal cords, 200, 201, 204,
928-929 1074-1075,1075
management of, 929, 931(t) Struma lymphoma tosa, 960-962
substernal, 930 Styloid process, CT scan of, 41
Stabilization plates, 60S, 605-606, 607 Stylomastoid foramen, CT scan of, 41
Stains, for head and neck lesions, 91 Subarachnoid space, MRI of, 29, 32
Stamm gastrostomy, 1222-1224, 1223 Subclavian artery
Stapes, CT scan of, 39 cervical portion of, exposure of,
Staphylococcus aureus, dermabrasion and, 1256-1258,1257, 1259
372 CT scan of, 46
Steinmann pin divisions of, 406, 407
us. Kirschner wire, 665 obstruction of, scalenotomy for, 1340,
for mandibular reconstruction, 665-671, 1340-1342,1341, 1342
669,671,682-687,683,685,687 occlusion of, surgical treatment of, 1264,
with Kirschner wire, 672-674, 673, 1264, 1265
674, 674(t) right, proximal portion of, exposure of,
Stenosis 1268, 1269
of carotid artery, carotid artery surgery Subclavian artery steal, 1240, 1241, 1264,
and, 1242 1264, 1265
cricoid-tracheal, treatment of, 1160, 1161 Subclavian artery steal syndrome, 1241,
of external auditory canal, Z-plasty for, 1262, 1265
582,583 Subglottic web, treatment of, 1160, 1161
of Stensen's duct, 774 Sublingual salivary gland, 11, 662, 663
of trachea, 1026-1027 Submandibular salivary gland, 11, 13, 15
carbon dioxide laser surgery in, benign disease of, resection of, 828-831,
1077-1078 829,831
of tracheal stoma, correction of, 1135, MRI of, 28, 30, 31, 32, 33
1135-1136 Submental space, benign lesions of,
Stensen's duct excision of, 848, 849
laceration of, repair of, 773, 773 Substernal goiter, 929-932
reconstruction and reimplantation of, 774 Succinylcholine, 200
stenosis of, 774 Superior laryngeal nerve
Stent anatomy of, 1069, 1069-1072, 1071, 1072
endolaryngeal, 1155, 1155 external branch of, 899, 943, 945
laryngeal, 1154, 1155 paralysis of, 905
Stenting, carotid artery. See Carotid artery injury to, thyroid surgery and, 963,
stenting 964(t)
Sternocleidomastoid flap, 400-401 Suprahyoid pharyngotomy, 1180
Sternocleidomastoid muscle Supraorbital notch, on CT reconstruction,
MRI of, 28, 31, 32, 33 19,22
preserving, in radical neck dissection, Sural nerve grafts, 112, 113
808-810, 809, 810, 950-954, 951, Surgical obturator, 166, 166
953,954 Suspension wires, 630, 631
Sternotomy Suspensory ligament, posterior, thyroid
median surgery and, 897, 898, 941, 943, 945
complete, 1052 Swallowing
for mediastinal dissection, 1041, after glossectomy, 146
1042(t) diet and, 145-146
for parathyroid cystadenoma excision, difficulties in, after conservation surgery,
999-1002, 1001 144-145
with total thyroidectomy, 1046-1055, instrumental assessment of, 145
1047, 1049, 1051, 1053, 1055 manofluorographic analysis of, 145
partial, for substernal thyroid surgery, medications and, 145
900 Sweating, gustatory, auriculotemporal
Stoma. See Tracheal stoma nerve resection for, 876-877, 877
Strabismus, treatment of, 159 Swinging flashlight test, 157
Straight -line closure, for bilateral cleft lip Sympathetic paragangliomas, 1289, 1290,
repair, 502, 503 1302, 1302-1307, 1304, 1305
Straight sinus, 9 Symphyseal fractures, open repair of, 605,
Strap muscles 605-606, 606, 607
laryngoplasty with, 1116, 1117
 INDEX

Takayasu's arteritis, 1268, 1275, 1275(t) Thyrogen, for thyroid cancer, 921-922, 921(t) Thyroid gland (Continued)
Tall cell variant, of papillary carcinoma, Thyroglobulin, 91 magnetic resonance imaging in, 896
915, 927 levels of, thyroid carcinoma and, 919-920 physical examination in, 893
Tantalum gauze, free skin graft over, for Thyroglossal cyst positron emission tomography in, 896
esophageal reconstruction, 1196, 1197 excision of, 824-827, 825, 827 sonography in, 895-896
Tarsorrhaphy, 158, 562, 563 MRI of, 1351, 1351, 1353 thyroid scans in, 895
Taxa!. See Paclitaxel Thyroglossal duct tract ectopic, normal, 901-903
Technetium flow studies, in vascular carcinoma of, 901 lingual, 962-963, 963
surgery, 1240 pyramidal lobe location and, 901 lobectomy of. See Thyroid lobectomy
Teflon graft, in vascular surgery, 1236 Thyrohyoid muscle, MRI of, 28 lymphoma of, 928
Teflon paste, endoscopic intracordal Thyroid artery, inferior metastatic papillary carcinoma of, CT
injection of, 1078- 1079, 1079 MRI of, 51 scan of, 53
Teflon splints, for nasal septum resection, thyroid surgery and, 898-899, 969, 971 MRI of, 31, 32, 52
302, 305, 305, 306, 307 Thyroid cancer. See also specific types, e.g., postoperative scan of, 901-903, 902
Telangiectasia. familial, epistaxis in, Medullary carcinoma of thyroid replacement compounds for, 910, 911(t)
270, 280 FDG-PET scan of, 59, 62 postoperative, 921, 921(t)
Telescopic endolaryngeal surgery, 204, 204 management of, 907-929, 931(t) substernal, 929-932
Temple, carcinoma of, excisions for, 375, central neck dissection in, 919 surgery of. See also Thyroid lobectomy;
375-376,376 esophageal resection in, 919 Thyroidectomy
Temporal arteritis, 1275, 1275(t) hormonal therapy in, 920-921 complications of, 963-965, 964(t) ,
Temporal artery, superficial hypopharyngeal resection in, 919 965(t)
CT angiography of, 45 imaging in, 922 indications for, 892
CT scan of, 41 inadequate, consequences of, 912(t) parathyroid glands and, 899-900, 969,
CT venography of, 44 laryngeal resection in, 919 971, 972, 993, 995
Temporal bone lateral neck dissection in, 931(t) posterior suspensory ligament and,
carcinoma of, resection of, 1408-1414, lobectomy in, 907-908 897, 898, 941, 943, 945
]409, 1411, 1413, 1414 mediastinal dissection in, 931(t) postoperative orders after, 966
CT scan of, 40 modified neck dissection in, 919, recurrent laryngeal nerve and,
neoplastic disease of, 1284-1286 950-954, 951, 953, 954 897-898, 898
petro us portion of, 3 postoperative iodine-131 scan in, scope of, 892
Temporal flap, 444-445, 445 919-920 ' strap muscle transection and, 901
Temporal mandibular joint, CT scan of, 40 pyramidal lobe dissection in, 919 superior laryngeal nerve and, 899,
Temporal scalp flap, 377, 377 radioiodine in, 919-922, 931(tl 943, 945
Temporalis muscle, 13, 15, 18, 1355, ]355 strap muscle resection in, 919 superior medastinum access and,
Tennison-Randall technique, for triangular thyrogen in, 921-922, 921(t) 900-901
flap cleft lip repair, 496, 497 thyroidectomy in, 907-908, 919 teamwork for, 892
Tension band plates, 606, 606, 608, 609 tracheal resection in, 919 thyroid artery and, 898-899, 969,
Tension band splints, 605, 605-606, 607 poorly differentiated, classification of, 971, 972
Tension pneumoperitoneum, 1023, 1023 917-918,918(t) tumors of, enucleation of, 128
Tension pneumothorax undifferentiated Thyroid isthmus, 9
intercostal catheter insertion for, 74-76, classification of, 917, 918(t), 928 Thyroid lobectomy
75, 76, 77 management of, 928 parathyroid locations and, 900
thoracentesis for, 74, 75 well-differentiated posterior suspensory ligament in, 897,
Tent peg reduction and fixation, for facial classification of, 914-919, 918(t) 898, 941, 943, 945
fractures, 628, 629 danger of underestimating malignancy subtotal, 946-949, 947, 949
Tetracaine, in anesthesia, 182, 183 of,919 for thyroid cancer, 907-908
Therapeutic node dissection, 152 management of, 919-922 total, 935-945, 939, 941, 943, 945
Thoracentesis, 74, 75 Thyroid cartilage, 3, 5, 7, 9 basic technique of, 903-904
Thoracic artery, to pectoralis major muscle, incision of, 1082-1085, 1083, 1085, 1101, Thyroid nodule, autonomous, 960
406 1101 Thyroid-related orbitopathy, 154-161
Thoracic esophagus, exposure of superior lamina of, sagittal section of,S clinical course of, 155-156
portion of, 1176-1178, 1177 MRI of, 33 differential diagnosis of, 156-160
Thoracic inlet, carcinoma of, resection of, portion of, 3 epidemiology of, 155
1206-1212,1207, 1209, 1211, ]212 Thyroid gland, 3, 892-966. See also Goiter pathogenesis of, 154-155
Thoracic outlet syndrome, 1340, anatomic considerations of, 896-903, 898 treatment of, 160-161
1340-1342,1341, 1342 C-cell hyperplasia of, 922, 923, 924-925, Thyroid scans, 895
Thoracic skin flap, for esophageal 931(t) Thyroid storm, management of, 934, 964
reconstruction, 1196-1198, 1197, 1198 calcification of, in medullary carcinoma Thyroidal artery, superior, CT angiography
Thoracoacromial artery, pectoral branch of, of thyroid, 924 of, 43
course of, 406, 407 cancer of. See Thyroid cancer Thyroidectomy
Thoracotomy. open, for empyema drainage, capsule of, 905 direct optical laryngoscopy after, 181
78,79 CT scan of, 46 for Graves' disease, 932, 933-934
Thymectomy diagnostic evaluation of, 892-896 hormonal replacement after, 910
postoperative phases of, 1063 computed tomography in, 896 for Hurthle cell carcinoma, 912
trans cervical total, 1062-1065, 1065 cytologic findings in, 893-895 hypercalcemia after, 910
Thymoma, resection of, 1062-1065, 1065 fine-needle aspiration in, 893 hypocalcemia after, 909-910
Thyroarytenoideus muscle, MRI of, 28 history in, 892 hypoparathyroidism after, 908-909
 INDEX

Thyroidectomy (Continued) Tongue (Continued) Transoral telescope, 210, 211

laryngeal nerve function after, 905-906 reconstruction of, 414, 415 Transseptal transsphenoidal
nerve paralysis after, 908, 964-965 small limited carcinoma of, excision of, hypophysectomy, 1395-1403, 1398,
subtotal 700, 701 1399, 1400, 1402, ]404
for thyroid cancer, 907-908 Tongue Oap, for hypopharyngeal Trapezius flap, 400
us. total thyroidectomy, 907-908, reconstruction, 1142, 1142, 1188-1190, limitations of, 402
910-911 ll89 Trapezius muscle, MRI of, 28
for thyroid-related orbitopathy, 156 Tonsil Triangular flap, for unilateral cleft lip
total carcinoma of, resection of, 720-723, repair, 496, 497
definition of, 904 721, 723 Trigeminal cistern, MRI of, 33
hypoparathyroidism afler, 965 frontal coronal section of, 15, 18 Trigeminal nerve, MRI of, 33
with median sternotomy, 1046-1055, squamous cell carcinoma of, FOG-PET Trigeminal neuralgia, 392-393, 393
1047, 1049, 105], 1053, 1055 scan of, 59 True malignant mixed tumor, 884
for medullary carcinoma, 926-927 Tonsillectomy, 770-772, 771, 772 TTF-1, 91
objectives of, 907 Torticollis, muscle lengthening for, 834, 835 Tumor. See also under specific locations,
for papillary carcinoma of thyroid, 927 Tortuous internal carotid artery, 1266, 1267 e.g., Larynx
in pyramidal lobe carcinoma, 901 Torus tubarius, MRI of, 29, 33 mapping vascular relationship of, 46
with radical neck dissection, 955-961, Total parenteral nutrition, preoperative, 116 multi planar techniques for locating, 37-38
955-958, 961, 1046-1055, 1047, Toxic shock syndrome, epistaxis packing Turbinate bone
1049, 1051, 1053, 1055 and, 274 inferior, 5, 7, 11, 13, 16, 17
recurrent laryngeal nerve paralysis Trachea, 7, 9 MRI of, 29, 32
after, 964-965 CT scan of, 46, 47 middle, 7, 11, 13, ]6, ] 7
for squamous cell carcinoma of fistula of, closure of, 1034, 1034-1035, in endoscopic sinus surgery, 263, 263
thyroid, 929 1035 MRI of, 32
us. subtotal thyroidectomy, 907-908, lengths of, 192, 193(t) superior, 13
910-911 in infants, 193 Turn-in flaps, for nasal cavity, 350, 351
for thyroid cancer, 907-908, 919 MRI of, 28, 31, 32, 33, 48, 49, 50, 52 Tympanic bodies, neoplastic disease of,
voice disorders after, 147-148 resection of, 1026-1033, 1028, 1031, 1033 1284
Thyroiditides, cytology of, 894 for thyroid cancer, 919 Tympanicum, jugular, 1290
Thyroiditis, Hashimoto's, 960, 962 stenosis of, 1026-1027
Thyroplasty, 1080, 1081 carbon dioxide laser surgery in, Ultrasound, 54, 55
Thyrotomy, 1082-1085, 1083, 1085 1077-1078 orbital, 157
Tic Douloureux, 392-393, 393 trauma to, 1027 of parathyroid glands, 977, 978, 980,
Tie wires, for mandibular reconstruction, Tracheal esophageal puncture, ll43, 982, 983
665-671,669, 671, 682-687, 683, 685, 1143-1151, ll45, ll47, ll49, ll51 in vascular surgery, 1238, 1238-1239
687 Tracheal stoma Uncinate process, 267, 269
TNM classification for tumor staging, 1093(t) carcinoma recurrence at, 1136 Uncinectomy, 260, 260
Toluidine blue staining technique, 91, construction of, 1134, 1134 Uncompromised surgery, 132-141
200-201 obstruction of, 1134 Upper lid gold weights, 382, 383
Tongue, ll, 13, 15, 16, 17, 18 oval, 1133, 1134 Uvula, 9
abscess of, 854, 855 pectoralis major flap for, 416, 417 MRI of, 30, 33
anatomy of, 732 split, 1134, 1134
anterior third of, cancer of, excision of, stenosis of, correction of, 1135, Vagal bodies, neoplastic disease of, 1287
702, 703 1135-1136 Vagal paragangliomas, 1285, 1286,
base of, 732-735 Tracheoesophageal fistula, closure of, 1036 1289-1290, ] 301
carcinoma of, resection of, 720-723, Tracheoesophageal puncture, 144 Vallecula, 9
721, 723 Tracheomediastinotomy, 1024-1025, 1025 CT scan of, 47
laryngoscopy of, 186 Tracheoscopy, 204, 1015 laryngoscopy of, 186
MRt of, 29 Tracheostoma. recurrence of, mediastinal MRf of, 29, 30, 32
reconstruction of, 422, 422 dissection for, 1056-1061, 1057, 1059, Vascular disease, degenerative, 1240-1275.
resection of, 732-733, 738-741, 739, 741 1061 See also specific diseases and vessels
approaches to, 733 Tracheostomy, 1015-1024, 1017, 1019, 1021 Vascular surgery
with midline mandibulotomy, complications of, 1024 allografts in, 1236
734, 735 pediatric, 1022-1023 angiography in, 1239, 1239
squamous cell carcinoma of, PET scan postoperative care for, 116-118, 117, 1022 anticoagulants in, 1235
of,61 stenosis prevention with, 1026-1027 autografts in, 1235-1236
Trotter approach to, 704-707, 705, 707 swallowing problems with, 146 basic principles of, 1233-1240, 1235,
body of, sagittal section of, 7 Tracheostomy tubes 1238, 1239
cancer of selection of, 1015-1016, 1015(t) carotid phonangiography in, 1238, 1238
glossectomy for, 146 types of, 1018-1022 computed tomography in, 1240
resection of, 726-731, 727, 729, 73] Tracheotomy tubes, selection of, 193(t) diagnostic laboratory tests for, 1237
hemangioma of, resection of, 768, 769 Transcervical total thymectomy, 1062-1065, Doppler imaging in, 1239
indirect mirror examination of, 1070 1065 exposure for, 1233
lateral border of, sagittal section of, 5 Transhyoid pharyngotomy, 1180, 118] grafts in, 1235-1236
leukoplakia of, excision of, 698-700, 699 Transient ischemic attacks, 1242 instrumentation for, 1233-1234
MRI of, 28, 29, 30, 32, 33 Transnasal endoscopic surgery, for intracranial blood flow crossover
neurofibroma of, resection of, 768, 769 sinusitis, 222 evaluation in, 1240
 INDEX

Vascular surgery (Continued) Vital signs, postoperative monitoring of, 116 Voice prostheses (Continued)
magnetic resonance angiography in, 1239 Vitallium mesh, for mandibular tracheal esophageal puncture in, 1143,
for neoplastic disease, 1276-1309 reconstruction, 686, 687 1143-1151, 1145, 1147, 1149, 1151
nerve preservation in, 1235 Vitamin D analogues, 1003(t) Vomer bone, 9, 11, 13, 16, 17
oculoplethysmography in, 1237-1238, Vocal cord(s). See also Larynx
1238 abductor, bilateral paralysis of, 1071, 1071 W-plasty, 102, 103
physical examination for, 1237 arytenoidpexy for, 1086-1089, 1087, Watch-and-wait attitude, t27
selective venography in, 1239-1240 1089 Web
synthetic grafts in, 1236 laryngofissure for, 1082-1085, 1083, of anterior commissure, treatment of,
technetium flow studies in, 1240 1085 1t62-1164, 1163
techniques of, 1235 adductor, bilateral paratysis of, 1071, 1071 subglottic, treatment of, 1160, 1161
temporary vascular bypass in, 1237 anterior commissure of, webbing of, Wermer's syndrome, 923
ultrasound in, 1238, 1238-1239 1162-1164, 1163 White patches. See Leukoplakia
vascular anastomosis in, 1234-1235, 1235 bowing of, 1074
vascular grafts in, 1236 demonstrating, 1070-1071, 1071 Xerostomia, 145
vessel preservation in, 1237 bronchoscope introduction between, 188
vessel wall care in, 1233-1234 carcinoma of, partial laryngectomy for, Z-plasty, 91-102
Vasculitis, 1275 1100-1104, 1101, 1103, 1104 basic, technique of, 92-98, 93, 95, 96,
Vein. See specific veins, e.g., Jugular vein de-epithelialization of, 1074-1075, 1075 97, 99, 100, 101
Velopharyngeal function, 147 evaluating function of, after complications of, 102
Velopharynx, insufficiency of, pharyngeal thyroidectomy, 905-906 continuous, 98, 99
flap for, 517-518, 519 evaluating motion of, 181 definition of, 91
Venography, selective, in vascular surgery, impaired mobility of, arytenoid double, for tracheal stoma stenosis,
1239-1240 dislocation of, 906 1135, 1135
Venotomy, lateral, for foreign body, 1326, intracordal Teflon paste injection of, for external auditory canal stenosis,
1327 1078-1079, 1079 582, 583
Venous malformation laryngqscopy of, 187 half, 98, 99
with arteriovenous fistula, CT medialization of, 1080, 1081 interrupted, 98, 99
angiography of, 42, 43 MRI of, 28 for lower eyelid scar contracture, 560, 561
facial, CT venography of, 44 paralysis of, 1070 mouth correction with, 460, 461
Ventricle, 9 Graves' disease surgery and, 906 multiple, 98, 99
Ventricular band, 9 temporary, steroid use and, 905 for nares enlargement, 352, 353
laryngoscopy of, 187 posterior commissure of, scar of, 1159, single, 97, 98
Vermilion defects, repair of, 462, 463 1/59 for tracheal stoma stenosis, 1133, 1135
Vertebra, cervical stripping, 200, 201, 204, 1074-1075, 1075 tissue expansion, 100-102
first, 3, 5 true, 9 types and modifications of, 98-100
second,S carcinoma of, cordectomy for, 1105, 1105 for upper eyelid scar contracture, 560, 561
Vertebral artery,S MRI of, 31 Zenker diverticulum, repair of, 1171-1175,
CT angiography of, 43, 45 vertical laryngectomy for, 1106-1113, 1173, 1175
left, MRI of, 29 1107, 1109, 1111,1113 Zygoma
MRI of, 28, 30, 31 Vocal therapy and management, 148 CT venography of, 44
occlusion of, surgical treatment of, Voice changes, thyroid surgery and, 965(t) fracture of
1258-1261, 1259, 1261 Voice disorders, 147-148 management of, 648-650
proximal portion of, exposure of, evaluation of, 147-148 with maxillary fracture, 622-623, 623
1256-1258, 1257, 1259 treatment of, 148 tent peg reduction and fixation for,
reconstruction of, 1258 Voice prostheses 628,629
Video nasopharyngoscopy, 147 complications of, 1150 with zygomatic arch fracture, 620, 621
Videofluoroscopic examination, of Panje voice button prosthesis in, 1146, Zygomatic arch, 15, 18
velopharyngeal function, 147 1147 on CT reconstruction, 21, 22, 24, 25
Videofluoroscopic swallow study, 145 post-total laryngectomy, 1143, 1143-1151, fracture of, open reduction of, 620, 621,
Vision, iatrogenic injury to, 66-67 1145, 1147, 1149, 1151 622-623, 623, 634, 635
Visor flap, for large upper lip defects, preoperative consideration of, 114-115 Zygomatic bone, on CT reconstruction,
480, 481 Singer-BJorn prosthesis in, 1144-1146 19,21,22,25
 ‫‪1‬‬

‫ﻣﺮﻛﺰ ﺧﺪﻣﺎﺕ ﻓﺮﻫﻨﮕﻲ ﺳﺎﻟﻜﺎﻥ‬

‫ﺍﺭﺍﺋﻪﻛﻨﻨﺪﻩ ﻛﺘﺎﺏ ﻭ ﻧﺮﻡﺍﻓﺰﺍﺭﻫﺎﻱ ﺗﺨﺼﺼﻲ ﭘﺰﺷﻜﺎﻥ‬
‫ﻫﻤﮕﺎﻡ ﺑﺎ ﺗﻮﺳﻌﻪ ﻋﻠﻤﻲ ﻭ ﻓﺮﻫﻨﮕﻲ ﺟﻬﺎﻥ ﻣﻌﺎﺻﺮ ﻭ ﺍﺳﺘﻔﺎﺩﻩ ﺭﻭﺯﺍﻓﺰﻭﻥ ﻛﺎﻣﭙﻴﻮﺗﺮ ﺩﺭ ﺑﻴﻦ ﺟﻮﺍﻣﻊ ﺑﺸﺮﻱ ﺧﺼﻮﺻ ًﹰﺎ ﺭﺷﺘﻪﻫﺎﻱ ﻣﺨﺘﻠﻒ ﻋﻠﻮﻡ ﻭ ﺍﺳﺘﻔﺎﺩﻩ ﺑﻬﻴﻨﻪ ﺍﺯ ﺁﺧﺮﻳﻦ ﻳﺎﻓﺘﻪﻫﺎﻱ ﭘﺰﺷﻜﻲ ﺩﻧﻴﺎ ﻭ ﺍﺭﺍﺋﻪ ﺍﻳﻦ ﻳﺎﻓﺘﻪﻫـﺎ ﺩﺭ ﻗﺎﻟـﺐ ﻧـﺮﻡﺍﻓﺰﺍﺭﻫـﺎﻱ‬
‫ﭘﺰﺷﻜﻲ )‪ VHS ، DVD ، VCD ، ebook‬ﻭ ‪ (...‬ﻣﺎ ﺭﺍ ﺑﺮ ﺁﻥ ﺩﺍﺷﺖ ﻛﻪ ﺑﺎ ﮔﺮﺩﺁﻭﺭﻱ ﻭ ﺍﺭﺍﺋﺔ ﺍﻳﻦ ﻳﺎﻓﺘﻪﻫﺎ ﮔﺎﻣﻲ ﻛﻮﭼﻚ ﺩﺭ ﺭﺍﻩ ﺍﺭﺗﻘﺎﺀ ﺳﻄﺢ ﻋﻠﻤﻲ ﻣﺘﺨﺼﺼﻴﻦ ﻛﻠﻴﻪ ﺭﺷﺘﻪﻫﺎﻱ ﭘﺰﺷﻜﻲ ﻛﺸﻮﺭ ﺑﻪ ﺻﻮﺭﺕ ﺳﻤﻌﻲ ﻭ ﺑﺼﺮﻱ ﺑﺮﺩﺍﺭﻳﻢ‪ .‬ﺍﻣﻴﺪ ﺍﺳﺖ ﻣﺸﻮﻕ ﻣﺎ‬
‫ﺩﺭ ﺍﻳﻦ ﺭﺍﻩ ﺑﺎﺷﻴﺪ‪.‬‬
‫ﻟﺬﺍ ﻋﻼﻗﻤﻨﺪﺍﻥ ﻣﻲﺗﻮﺍﻧﻨﺪ ﺑﺮﺍﻱ ﺩﺭﻳﺎﻓﺖ ﻫﺮ ﻳﻚ ﺍﺯ ﻣﺤﺼﻮﻻﺕ ﺍﺭﺍﺋﻪﺷﺪﻩ ﺑﻪ ﺍﺯﺍﺀ ﻫﺮ ‪ CD‬ﻣﺒﻠﻎ ‪ ٥٠٠٠‬ﺗﻮﻣﺎﻥ ﺑﻪ ﺣﺴﺎﺏ ﺟﺎﺭﻱ ‪ ١٣٢٤٣٦‬ﺑﺎﻧﻚ ﺭﻓﺎﻩ ﻛﺎﺭﮔﺮﺍﻥ ﺷﻌﺒﻪ ﻣﻴﺪﺍﻥ ﺍﻧﻘﻼﺏ ﻛﺪ ﺷﻌﺒﻪ ‪ ١١٢‬ﺑﻪ ﻧﺎﻡ ﻣﺮﻛﺰ ﺧﺪﻣﺎﺕ ﻓﺮﻫﻨﮕﻲ ﺳﺎﻟﻜﺎﻥ ﻭﺍﺭﻳﺰ ﻭ ﭘـﺲ‬
‫ﺍﺯ ﻓﺎﻛﺲ ﻓﻴﺶ ﻓﻮﻕ ﺑﻪ ﻫﻤﺮﺍﻩ ﻧﺸﺎﻧﻲ ﺩﻗﻴﻖ ﻧﺴﺒﺖ ﺑﻪ ﺧﺮﻳﺪ ﺍﻗﻼﻡ ﻭ ﺩﺭﻳﺎﻓﺖ ﻛﺎﻻﻱ ﻣﻮﺭﺩ ﻧﻈﺮ ﺧﻮﺩ ﺍﻗﺪﺍﻡ ﻧﻤﺎﻳﻨﺪ‪ .‬ﻻﺯﻡ ﺑﻪ ﺫﻛﺮ ﺍﺳﺖ ﻓﻘﻂ ﺑﻪ ﺳﻔﺎﺭﺷﺎﺗﻲ ﻛﻪ ﻭﺟﻪ ﻣﻮﺭﺩ ﺳﻔﺎﺭﺵ ﺑﻪ ﺣﺴﺎﺏ ﻓﻮﻕ ﺫﻛﺮ ﻭﺍﺭﻳﺰ ﺷﺪﻩ ﺗﺮﺗﻴﺐ ﺍﺛﺮ ﺩﺍﺩﻩ ﺧﻮﺍﻫﺪ ﺷﺪ‪ ،‬ﻟـﺬﺍ‬
‫ﺧﻮﺍﻫﺸﻤﻨﺪ ﺍﺳﺖ ﺍﺯ ﻭﺍﺭﻳﺰ ﻭﺟﻪ ﺑﻪ ﻫﺮ ﮔﻮﻧﻪ ﺣﺴﺎﺏ ﺩﻳﮕﺮﻱ ﺍﻛﻴﺪﺍ ﺧﻮﺩﺩﺍﺭﻱ ﻓﺮﻣﺎﺋﻴﺪ‪.‬‬
‫ﻻﺯﻡ ﺑﻪ ﺫﻛﺮ ﺍﺳﺖ ﺩﺭ ﺻﻮﺭﺕ ﻧﻴﺎﺯ ﺑﻪ ﻫﺮﮔﻮﻧﻪ ﺍﻃﻼﻋﺎﺕ ﺗﻜﻤﻴﻠﻲ ﻣﻲﺗﻮﺍﻧﻴﺪ ﺑﻪ ﻧﺸﺎﻧﻲ ﻣﺮﻛﺰ ﻣﺮﺍﺟﻌﻪ ﻭ ﻳﺎ ﺑﺎ ﺗﻠﻔﻦ ‪ ٦٦٩٣٦٦٩٦‬ﺗﻤﺎﺱ ﺣﺎﺻﻞ ﻧﻤﺎﻳﻴﺪ‪.‬‬

‫‪ -١‬ﺭﺍﺩﻳﻮﻟﻮﮊﻱ‬

‫ﻋﻨﻮﺍﻥ ‪CD‬‬ ‫ﺳﺎﻝ ﺍﻧﺘﺸﺎﺭ‬

‫‪1.1‬‬ ‫)‪3D Conformal Radiation Therapy A multimedia introduction to methods and techniques (Springer‬‬ ‫ــــــ‬
‫)‪2.1 Abdominal and pelvic Ultrasound with CT and MR correlation (R. Brooke Jeffrey, Jr., M.D.‬‬ ‫ــــــ‬
‫ﺍﻳﻦ ﻳﻚ ﻧﺮﻡﺍﻓﺰﺍﺭ ﺁﻣﻮﺯﺷﻲ ﻗﻮﻱ ﺑﻤﻨﻈﻮﺭ ‪ Self teaching‬ﻭ ‪ Self evaluation‬ﺗﺸﺨﻴﺺﻫﺎﻱ ﺳﻮﻧﻮﮔﺮﺍﻓﻲ ﺷﻜﻢ ﻭ ﻟﮕﻦ ﻣﻲﺑﺎﺷﺪ ﻛﻪ ﺩﺭ ﻛﻨﺎﺭ ﺗﺼﺎﻭﻳﺮ ﺳﻮﻧﻮﮔﺮﺍﻓﻴﻚ ﻣﺮﺑﻮﻁ ﺑﻪ ﻫﺮ ﺑﻴﻤﺎﺭﻱ‪ ،‬ﺍﺯ ﺗﺼﺎﻭﻳﺮ ﻫﻤﺰﻣﺎﻥ ‪ CT Scan‬ﻭ ‪ MRI‬ﺑﺮﺍﻱ ﻓﻬﻢ ﻭ ﺩﺭﻙ ﺑﻬﺘـﺮ ﻣﻄﺎﻟـﺐ ﺍﺳـﺘﻔﺎﺩﻩ‬
‫ﺷﺪﻩ ﺍﺳﺖ‪ .‬ﺩﺭ ﺍﻳﻦ ‪ ، CD‬ﻣﺒﺎﺣﺚ ﻣﺨﺘﻠﻒ ﺑﻪ ﺻﻮﺭﺕ ‪ Case‬ﻣﻄﺮﺡ ﮔﺮﺩﻳﺪﻩ ﻭ ﺿﻤﻦ ﺑﻴﺎﻥ ﺷﺮﺡ ﺣﺎﻝ ﺑﻴﻤﺎﺭ‪ ،‬ﺗﺼﺎﻭﻳﺮ ﺳﻮﻧﻮﮔﺮﺍﻓﻲ )ﻭ ﺩﺭ ﺻﻮﺭﺕ ﻟﺰﻭﻡ ‪ MRI‬ﻭ ‪ (CT Scan‬ﺑﻪ ﻧﻤﺎﻳﺶ ﮔﺬﺍﺷﺘﻪ ﺷﺪﻩ ﻭ ﺑﺎ ‪ Click‬ﺁﺭﺍﻳﺔ ‪ ،Text‬ﻣﻄﺎﻟﺐ ﺗﺌﻮﺭﻱ ﻣﺮﺑﻮﻁ ﺑﻪ ﻫﺮ ‪ Case‬ﺑﺎ ﺑﻴﺎﻧﻲ ﺳـﺎﺩﻩ ﻭ‬
‫ﺩﺭ ﻋﻴﻦ ﺣﺎﻝ ﻛﺎﻣﻞ‪ ،‬ﺩﺭ ﺍﺧﺘﻴﺎﺭ ﻛﺎﺭﺑﺮ ﻗﺮﺍﺭ ﻣﻲﮔﻴﺮﺩ‪.‬‬
‫ﺗﻌﺪﺍﺩ ‪Case‬ﻫﺎﻱ ﻣﻮﺟﻮﺩ ﺩﺭ ﺍﻳﻦ ‪ CD‬ﺑﺮ ﺣﺴﺐ ﻣﻮﺿﻮﻉ ﺑﻪ ﻗﺮﺍﺭ ﺟﺪﻭﻝ ﺫﻳﻞ ﻣﻲﺑﺎﺷﺪ‪:‬‬
‫ﻣﻮﺿﻮﻉ‬ ‫ﺗﻌﺪﺍﺩ ‪Case‬‬ ‫ﻣﻮﺿﻮﻉ‬ ‫ﺗﻌﺪﺍﺩ ‪Case‬‬ ‫ﻣﻮﺿﻮﻉ‬ ‫ﺗﻌﺪﺍﺩ ‪Case‬‬ ‫ﻣﻮﺿﻮﻉ‬ ‫ﺗﻌﺪﺍﺩ ‪Case‬‬ ‫ﻣﻮﺿﻮﻉ‬ ‫ﺗﻌﺪﺍﺩ ‪Case‬‬ ‫ﻣﻮﺿﻮﻉ‬ ‫ﺗﻌﺪﺍﺩ ‪Case‬‬
‫ﻛﺒﺪ‬ ‫‪٦٧‬‬ ‫ﻛﻴﺴﺔ ﺻﻔﺮﺍ ﻭﻣﺠﺎﺭﻱ ﺻﻔﺮﺍﻭﻱ‬ ‫‪٤٠‬‬ ‫ﻃﺤﺎﻝ‬ ‫‪١٢‬‬ ‫ﭘﺎﻧﻜﺮﺍﺱ‬ ‫‪٣٧‬‬ ‫ﻛﻠﻴﻪ ﻭ ﻏﺪﻩ ﺁﺩﺭﻧﺎﻝ‬ ‫‪٣٥‬‬ ‫ﺳﻴﺴﺘﻢ ﮔﻮﺍﺭﺷﻲ‬ ‫‪٧٨‬‬
‫ﺣﺎﻣﻠﮕﻲ‬ ‫‪١٠‬‬ ‫ﻟﮕﻦ‬ ‫‪٤٦‬‬ ‫ﺭﺗﺮﻭﭘﺮﻳﺘﻮﺋﻦ‬ ‫‪٧‬‬

‫‪3.1‬‬ ‫)‪ACR - Chest (Learning file) (American college of Radiology‬‬ ‫‪2001‬‬

‫ﺍﻳﻦ ‪ CD‬ﺷﺎﻣﻞ ﻋﻨﺎﻭﻳﻦ ﺯﻳﺮ ﻣﻲﺑﺎﺷﺪ‪:‬‬
‫‪1- chest Trauma‬‬ ‫‪2- Cardiac Disease‬‬ ‫‪3- Vascular Disease‬‬ ‫‪4- Airway Disease‬‬
‫‪5- Mediastinal Masses‬‬ ‫‪6- Pleural Disease‬‬ ‫‪7- Chest Wall and Diaphragm‬‬ ‫‪8-Pediatric Chest‬‬
‫‪9- Normal Disease‬‬ ‫‪10- Neoplasma and Tumors‬‬ ‫‪11- Pulmonary Infection‬‬ ‫‪12- Immunocompromised Host‬‬
‫‪13- Diffuse Disease‬‬

‫ﺗﻠﻔﻦ‪٠٩١٢١٣٧٢٣٦١-٦٦٩٣٦٦٩٦ :‬‬ ‫ﻧﺸﺎﻧﻲ‪ :‬ﺗﻬﺮﺍﻥ‪ ،‬ﻡ ﺍﻧﻘﻼﺏ‪ ،‬ﺥ ﻛﺎﺭﮔﺮ ﺟﻨﻮﺑﻲ‪ ،‬ﺥ ﻟﺒﺎﻓﻲﻧﮋﺍﺩ‪ ،‬ﺑﻴﻦ ﻛﺎﺭﮔﺮ ﻭ ﺟﻤﺎﻟﺰﺍﺩﻩ‪ ،‬ﺑﻦﺑﺴﺖ ﺳﻴﻤﻴﻦ‪ ،‬ﭘﻼﻙ ‪٢٣٩‬‬ ‫ﻣﺮﻛﺰ ﺧﺪﻣﺎﺕ ﻓﺮﻫﻨﮕﻲ ﺳﺎﻟﻜﺎﻥ ‪ :‬ﺍﺭﺍﺋﻪ ﻛﻨﻨﺪﺓ ﻛﺘﺎﺏ ﻭ ﺳﻲﺩﻱﻫﺎﻱ ﺗﺨﺼﺼﻲ ﭘﺰﺷﻜﻲ‬
 2
4.1 ACR - Gastrointestinal (Learning file) (American college of Radiology) (Igor Laufer, M.D., James M. Messmer, M.D.) 1998
5.1 ACR - Genitourinary (Learning file) (American college of Radiology) 1998
‫( ﺑﻮﺩﻩ ﻭ ﺩﺭﺻﻮﺭﺕ‬... ‫ ﺳﻮﻧﻮﮔﺮﺍﻓﻲ ﻭ‬، CT Scan ،‫ ﻣﻄﺎﻟﻌﺎﺕ ﺑﺎ ﻣﻮﺍﺩ ﺣﺎﺟﺐ‬،‫ ﺗﺼﺎﻭﻳﺮ ﺭﺍﺩﻳﻮﮔﺮﺍﻓﻴﻚ )ﻋﻜﺲﻫﺎﻱ ﺳﺎﺩﻩ‬،‫ ﺩﺍﺭﺍﻱ ﺗﺎﺭﻳﺨﭽﻪ ﺑﺎﻟﻴﻨﻲ‬Case ‫ ﻫﺮ‬.‫ ﻣﻄﺮﺡ ﮔﺮﺩﻳﺪﻩﺍﻧﺪ‬Case ‫ ﺗﻌﺪﺍﺩﻱ‬،‫ ﺷﺎﻣﻞ ﻓﺼﻮﻝ ﻣﺘﻌﺪﺩﻱ ﺩﺭ ﺧﺼﻮﺹ ﺍﻭﺭﻭﺭﺍﺩﻳﻮﻟﻮﮊﻱ ﻣﻲﺑﺎﺷﺪ ﻭ ﺩﺭ ﻫﺮﻓﺼﻞ‬CD ‫ﺍﻳﻦ‬
.‫ ﺗﺸﺨﻴﺺ ﻧﻬﺎﻳﻲ ﻭ ﻫﻤﭽﻨﻴﻦ ﺗﻮﺿﻴﺤﺎﺕ ﻋﻠﻤﻲ ﺍﺿﺎﻓﻪ ﻣﺮﺗﺒﻂ ﺑﺎ ﺗﺸﺨﻴﺺ ﺑﺎ ﺍﻃﻼﻉ ﺷﺪ‬، ‫ ﺑﺎ ﺍﺳﺘﻔﺎﺩﻩ ﺍﺯ ﺁﺭﺍﻳﻪﻫﺎﻱ ﻣﺮﺑﻮﻃﻪ ﻣﻲﺗﻮﺍﻥ ﺍﺯ ﺗﺸﺨﻴﺺﻫﺎﻱ ﺍﻓﺘﺮﺍﻗﻲ‬،‫ ﺩﺭﻧﻬﺎﻳﺖ‬.‫ ﻣﻄﻠﻊ ﮔﺮﺩﺩ‬Finding ‫ ﻧﻤﻮﺩﻥ ﺑﺮﺭﻭﻱ ﺁﻳﻜﻮﻥ‬Click ‫ ﺑﺎ‬Imaging ‫ ﻓﺮﺩ ﻣﻲﺗﻮﺍﻧﺪ ﺍﺯ ﻳﺎﻓﺘﻪﻫﺎﻱ‬،‫ﻧﻴﺎﺯ‬
:‫ ﻫﺎﻱ ﻣﻄﺮﺡ ﺷﺪﻩ ﺑﺮ ﺣﺴﺐ ﻫﺮ ﻓﺼﻞ ﺑﻪ ﻗﺮﺍﺭ ﺯﻳﺮ ﻣﻲﺑﺎﺷﺪ‬Case ‫ﺗﻌﺪﺍﺩ‬

‫ﻣﻮﺿﻮﻉ‬ ‫ﺗﻌﺪﺍﺩ‬ ‫ﻣﻮﺿﻮﻉ‬ ‫ﺗﻌﺪﺍﺩ‬ ‫ﻣﻮﺿﻮﻉ‬ ‫ﺗﻌﺪﺍﺩ‬ ‫ﻣﻮﺿﻮﻉ‬ ‫ﺗﻌﺪﺍﺩ‬ ‫ﻣﻮﺿﻮﻉ‬ ‫ﺗﻌﺪﺍﺩ‬ ‫ﻣﻮﺿﻮﻉ‬ ‫ﺗﻌﺪﺍﺩ‬ ‫ﻣﻮﺿﻮﻉ‬ ‫ﺗﻌﺪﺍﺩ‬ ‫ﻣﻮﺿﻮﻉ‬ ‫ﺗﻌﺪﺍﺩ‬ ‫ﻣﻮﺿﻮﻉ‬ ‫ﺗﻌﺪﺍﺩ‬ ‫ﻣﻮﺿﻮﻉ‬ ‫ﺗﻌﺪﺍﺩ‬
Case Case Case Case Case Case Case Case Case Case
‫ﺳﻴﺴﺘﻢ‬ ‫ﺩﺳﺘﮕﺎﻩ‬
‫ﺑﻴﻤﺎﺭﻳﻬﺎﻱ‬ ‫ﺑﻴﻤﺎﺭﻳﻬﺎﻱ‬ ‫ﺑﻴﻤﺎﺭﻳﻬﺎﻱ‬ ‫ﺑﻴﻤﺎﺭﻳﻬﺎﻱ‬ ‫ﻏﺪﺩ‬ ‫ﺍﺩﺭﺍﺭﻱ‬ ‫ﺑﻴﻤﺎﺭﻳﻬﺎﻱ‬ ‫ﺑﻴﻤﺎﺭﻳﻬﺎﻱ‬
١١٨ ٢٦ ١٧ ١٥ ١١ ١٨ ‫ﺭﺗﺮﻭﭘﺮﻳﺘﻮﺋﻦ‬ ١٠ ١٧ ١٠ ‫ﺗﻨﺎﺳﻠﻲ‬ ١٦
‫ﻛﻠﻴﻪ ﺑﺎﻟﻐﻴﻦ‬ ‫ﻛﻠﻴﻪ ﺍﻃﻔﺎﻝ‬ ‫ﺣﺎﻟﺐ‬ ‫ﮊﻧﻴﻜﻮﻟﻮﮊﻳﻚ‬ ‫ﺁﺩﺭﻧﺎﻝ‬ ‫ﺗﺤﺘﺎﻧﻲ‬ ‫ﻣﺜﺎﻧﻪ‬ ‫ﭘﺮﻭﺳﺘﺎﺕ‬ ‫ﺧﺎﺭﺟﻲ ﻣﺬﻛﺮ‬
‫ﺍﻃﻔﺎﻝ‬
6.1 ACR - Head & Neck (Learning file) (American college of Radiology) 1998
7.1 ACR - Neuroradiology (Learning file) (American college of Radiology) 1998
8.1 ACR - Nuclear medicine (Learning file) (American college of Radiology) (Paul Shreve, M.D. and James Corbett, M.D.) ‫ــــــ‬
9.1 ACR - Pediatric (Learning file) (American college of Radiology) (Beverly P. Wood, M.D., David C. Kushner, M.D.) 1998
:‫ ﻣﺮﺗﺒﻂ ﺑﺎ ﺭﺍﺩﻳﻮﻟﻮﮊﻱ ﺍﻃﻔﺎﻝ ﺑﻮﺩﻩ ﻭ ﺩﺍﺭﺍﻱ ﻣﺒﺎﺣﺚ ﺯﻳﺮ ﻣﻲﺑﺎﺷﺪ‬Teaching File ‫ ﻓﻮﻕ ﻳﻚ‬CD
‫ﻋﻨﻮﺍﻥ‬ Case ‫ﺗﻌﺪﺍﺩ‬ ‫ﻋﻨﻮﺍﻥ‬ Case ‫ﺗﻌﺪﺍﺩ‬ ‫ﻋﻨﻮﺍﻥ‬ Case ‫ﺗﻌﺪﺍﺩ‬ ‫ﻋﻨﻮﺍﻥ‬ Case ‫ﺗﻌﺪﺍﺩ‬ ‫ﻋﻨﻮﺍﻥ‬ Case ‫ﺗﻌﺪﺍﺩ‬
Chest ٢٠٢ ‫ﻗﻠﺐ‬ ٧٨ ‫ﮔﻮﺍﺭﺵ‬ ١٦٣ ‫ ﭘﺎﻧﻜﺮﺍﺱ‬،‫ ﻃﺤﺎﻝ‬،‫ﻛﺒﺪ‬ ٧١ Genitourimary ١٠٩
‫ﺳﺮ ﻭ ﮔﺮﺩﻥ‬ ٣١ ‫ﻧﻮﺭﻭﺭﺍﺩﻳﻮﻟﻮﮊﻱ‬ ٩٠ Skeletal ٩٧
10.1 ACR - Skeletal (B.J Manaster, M.D., Ph.D.) (Learning file) ‫ــــــ‬
1. Tumolrs 2. Arthritis 3. Trauma 4. Metabolic Congeaital
11.1 ACR - Ultrasound (Learning file) (American college of Radiology) 1998
12.1 Anatomy and MRI of the JOINTS (A Multiplanar Atlas) (William D. Middleton, Thomas L. Lawson)
(Department of Radiology Medical College of Wisconsin Milwaukee, Wisconsin)
The Tmporomandibular The Shoulder The Wrist The Finger The Vertebral Column The Hip The Knee The Ankle
TM
9.9 Brainiac! Medical Multimedia Systems Presents (Version 1.52) (An interactive digital atlas designed to assist in learning human neuroanatomy) (Serial # 316.34427) 2000
13.1 Breast Implant Imaging (SALEKAN E-BOOK) (MICHAEL S. MIDDLETON, PH,D., M.D, MICHAEL P.MCNAMARA JR., M.D.) 2003
: ‫ﺍﻳﻦ ﻛﺘﺎﺏ ﻛﻪ ﺩﺭ ﻣﺮﻛﺰ ﺧﺪﻣﺎﺕ ﻓﺮﻫﻨﮕﻲ ﺳﺎﻟﻜﺎﻥ ﺗﺒﺪﻳﻞ ﺑﻪ ﻛﺘﺎﺏ ﺍﻟﻜﺘﺮﻭﻧﻴﻜﻲ ﮔﺮﺩﻳﺪﻩ ﺍﺳﺖ ﺷﺎﻣﻞ ﻋﻨﺎﻭﻳﻦ ﺯﻳﺮ ﻣﻲ ﺑﺎﺷﺪ‬
A History and Overview of Breast Augmentation and Implant Imaging Clinical Presentation Methods of Imaging
Basic Principles of Breast Implant Imaging Principles of Imaging Breast Implant Rupture and Soft-Tissue Silicone Artifacts of MR and Ultrasound Imaging of Breast Implants and Soft-Tissue Silicone
Classification of Breast Implants Practical Consideration in the Evaluaion of Implant Integrity Evaluation of Soft-Tissue Silicone from Ruptured Implants
Evaluation of Silicone Fluid Injecitons Breast Cancer Imaging Surgical and Other Considerations
14.1 Carotid Duplex Ultrasonography Extracranial and Intracranial (Michael Jaff DO, Serge Kownator MD, Alain Voorons Audlovlsuel) ‫ــــــ‬
‫ ﺣﻠﻘﺔ ﻭﻳﻠﻴﺲ ﺗﻨﻪ ﺑﺮﺍﻛﻴﻮﺳﻔﺎﻟﻴﻚ ﻭ ﻗﻮﺱ ﺁﺋﻮﺭﺕ ﻣﻮﺭﺩ ﺑﺤﺚ ﻭ ﺑﺮﺭﺳﻲ ﻗﺮﺍﺭ ﮔﺮﻓﺘﻪ ﺍﺳﺖ ﻭ ﺍﺯ ﺗﺼﺎﻭﻳﺮ ﺛﺎﺑﺖ ﻭ ﻣﺘﺤﺮﻙ ﮔﻮﻳـﺎ )ﺑـﻪ ﺯﺑـﺎﻥ ﺍﻧﮕﻠﻴﺴـﻲ( ﺟﻬـﺖ ﻧﻤـﺎﻳﺶ ﺗﻜﻨﻴـﻚﻫـﺎﻱ‬،‫ ﻭﺭﺗﺒﺮﺍﻝ‬،‫ ﺳﺎﺏ ﻛﻼﻭﻳﻦ‬،‫ ﻛﻠﻴﺎﺕ ﺍﻧﺠﺎﻡ ﺳﻮﻧﻮﮔﺮﺍﻓﻲ ﺩﺍﭘﻠﺮ ﺷﺮﻳﺎﻥﻫﺎﻱ ﻛﺎﺭﻭﺗﻴﺪ‬، CD ‫ﺩﺭ ﺍﻳﻦ‬
:‫ ﺭﺋﻮﺱ ﻣﻄﺎﻟﺐ ﻣﻮﺭﺩ ﺑﺤﺚ ﺩﺭ ﺍﻳﻦ ﻧﺮﻡﺍﻓﺰﺍﺭ ﺑﺪﻳﻦ ﻗﺮﺍﺭ ﺍﺳﺖ‬.‫ ﺍﺳﺘﻔﺎﺩﻩ ﺷﺪﻩ ﺍﺳﺖ‬،‫ﺳﻮﻧﻮﮔﺮﺍﻓﻲﻫﺎﻱ ﻓﻮﻕ ﻭ ﻫﻤﭽﻨﻴﻦ ﭼﮕﻮﻧﮕﻲ ﺗﻔﺴﻴﺮ ﻧﺘﺎﻳﺞ ﺣﺎﺻﻞ ﺍﺯ ﺳﻮﻧﻮﮔﺮﺍﻓﻲ ﺩﺍﭘﻠﺮ ﺷﺮﻳﺎﻥﻫﺎﻱ ﻓﻮﻕ ﻭ ﻫﻤﭽﻨﻴﻦ ﭼﮕﻮﻧﮕﻲ ﺗﻔﺴﻴﺮ ﻧﺘﺎﻳﺞ ﺣﺎﺻﻞ ﺍﺯ ﺳﻮﻧﻮﮔﺮﺍﻓﻲ ﺩﺍﭘﻠﺮ ﺷﺮﻳﺎﻥﻫﺎﻱ ﻓﻮﻕﺍﻟﺬﻛﺮ‬
‫ﺁﺷﻨﺎﻳﻲ ﺑﺎ ﺩﺳﺘﮕﺎﻩ ﺳﻮﻧﻮﮔﺮﺍﻓﻲ ﺩﺍﭘﻠﺮ‬ ‫ ﺩﺳﺘﮕﺎﻩ‬Setting ‫ﭼﮕﻮﻧﮕﻲ ﺍﺳﻜﻦﻛﺮﺩﻥ ﻋﺮﻭﻕ ﻓﻮﻕﺍﻟﺬﻛﺮ ﻭ ﻧﺤﻮﺓ‬ ‫ﺷﺮﻳﺎﻥﻫﺎﻱ ﻛﺎﺭﻭﺗﻴﺪ ﺍﻛﺴﺘﺮﺍﻛﺮﺍﻧﻴﺎﻝ‬
‫ﺷﺮﻳﺎﻥﻫﺎﻱ ﺳﺎﺏ ﻛﻼﻭﻳﻦ‬ ‫ﺷﺮﻳﺎﻥﻫﺎﻱ ﻭﺭﺗﺒﺮﺍﻝ‬ ‫ﻗﻮﺱ ﺁﺋﻮﺭﺕ ﻭ ﺗﻨﺔ ﺑﺮﺍﻛﻴﻮ ﺳﻔﺎﻟﻴﻚ‬
‫ﺷﺮﻳﺎﻥﻫﺎﻱ ﺍﻳﻨﺘﺮﺍﻛﺮﺍﻧﻴﺎﻝ ﺳﻮﺑﺮﺍﻝ ﻭ ﺣﻠﻘﺔ ﻭﻳﻠﻴﺲ‬ ‫ﺿﺎﻳﻌﺎﺕ ﻣﺠﺎﻭﺭ‬ Revaseularization ‫ﺳﻮﻧﻮﮔﺮﺍﻓﻲ ﺩﺍﭘﻠﺮ ﭘﺲ ﺍﺯ‬

.‫ ﻣﻲﺑﺎﺷﺪ‬Post-Test ‫ ﻭ‬Pre-Test ‫ ﺟﻬﺖ ﺍﺭﺯﻳﺎﺑﻲ ﻓﺮﺩ ﺍﺯ ﺧﻮﺩ ﺩﺍﺭﺍﻱ‬CD ‫ﺿﻤﻨﹰﺎ ﺍﻳﻦ‬

٠٩١٢١٣٧٢٣٦١-٦٦٩٣٦٦٩٦ :‫ﺗﻠﻔﻦ‬ ٢٣٩ ‫ ﭘﻼﻙ‬،‫ ﺑﻦﺑﺴﺖ ﺳﻴﻤﻴﻦ‬،‫ ﺑﻴﻦ ﻛﺎﺭﮔﺮ ﻭ ﺟﻤﺎﻟﺰﺍﺩﻩ‬،‫ ﺥ ﻟﺒﺎﻓﻲﻧﮋﺍﺩ‬،‫ ﺥ ﻛﺎﺭﮔﺮ ﺟﻨﻮﺑﻲ‬،‫ ﻡ ﺍﻧﻘﻼﺏ‬،‫ ﺗﻬﺮﺍﻥ‬:‫ﻧﺸﺎﻧﻲ‬ ‫ ﺍﺭﺍﺋﻪ ﻛﻨﻨﺪﺓ ﻛﺘﺎﺏ ﻭ ﺳﻲﺩﻱﻫﺎﻱ ﺗﺨﺼﺼﻲ ﭘﺰﺷﻜﻲ‬: ‫ﻣﺮﻛﺰ ﺧﺪﻣﺎﺕ ﻓﺮﻫﻨﮕﻲ ﺳﺎﻟﻜﺎﻥ‬
 ‫‪3‬‬
‫‪15.1 CASE REVIEW Obstetric and Gynecologic Ultrasound‬‬ ‫‪WITH CROSS-REFERENCES TO THE REQUISITES SERIES‬‬ ‫)‪(Pamela T. Johnson, Alfred B. Kurtz‬‬ ‫ــــــ‬
‫ﺍﻳﻦ ‪ CD‬ﻣﺤﺘﻮﻱ ‪ Case ١٢٧‬ﺳﻮﻧﻮﮔﺮﺍﻓﻲ ﺯﻧﺎﻥ ﻭ ﺯﺍﻳﻤﺎﻥ )ﺑﺼﻮﺭﺕ ﭘﺮﺳﺶ ﻭ ﭘﺎﺳﺦ( ﻣﻲﺑﺎﺷﺪ ﻛﻪ ﺑﻪ ﻫﻤﺮﺍﻩ ﺗﻮﺿﻴﺤﺎﺕ ﻭ ﺗﺼﺎﻭﻳﺮ ﻣﺮﺑﻮﻃﻪ ﺑﻮﺩﻩ ﻭ ﺩﺭ ﻓﻬﻢ ﺗﺸﺨﻴﺺﻫﺎﻱ ﺳﻮﻧﻮﮔﺮﺍﻓﻴﻚ ‪ Gynecology‬ﻭ ‪ Obstetric‬ﺑﺴﻴﺎﺭ ﻣﻔﻴﺪ ﺧﻮﺍﻫﺪ ﺑﻮﺩ‪.‬‬
‫)‪16.1 CD Roentgen (Michael McDermott, M.D., Thorsten Krebs, M.D.) (Williams & Wilkins‬‬ ‫ــــــ‬
‫‪17.1 Cerebral and Spinal Computerized Tomography‬‬ ‫‪2000‬‬
‫)‪18.1 Cerebral MR Perfusion Imaging CD-ROM to complement the book (A. Gregory Sorensen, Peter Reimer) (Thieme‬‬ ‫ــــــ‬
‫ﺍﻳﻦ ‪ CD‬ﺩﺭ ﺯﻣﻴﻨﺔ ﺗﺼﻮﻳﺮﺑﺮﺩﺍﺭﻱ ﭘﺮﻓﻮﺯﻳﻮﻥ ﻣﻐﺰﻱ ﺑﻮﺳﻴﻠﺔ ‪ MRI‬ﺑﻪ ﺷﺮﺡ ﺗﻜﻨﻴﻚﻫﺎﻱ ﻣﺮﺑﻮﻃﻪ ﻭ ﻫﻤﭽﻨﻴﻦ ﻛﺎﺭﺑﺮﺩﻫﺎﻱ ﺑﺎﻟﻴﻨﻲ ﺁﻧﻬﺎ ﭘﺮﺩﺍﺧﺘﻪ ﻭ ﺑﺎ ﺍﺳﺘﻔﺎﺩﻩ ﺍﺯ ﺗﺼﺎﻭﻳﺮ ﺛﺎﺑﺖ ﻭ ﻣﺘﺤﺮﺕ ﺑﻪ ﺷﺮﺡ ﻣﻔﺎﻫﻴﻢ ﻣﺮﺗﺒﻂ ﺑﺎ ﺍﻳﻦ ﺭﻭﺵ ﺗﺸﺨﻴﺼﻲ ﻣﻲﭘﺮﺩﺍﺯﺩ‪.‬‬
‫‪19.1 CHEST X-RAY INTERPRETATION‬‬ ‫‪2002‬‬
‫‪ CD‬ﺣﺎﺿﺮ ﻳﻜﻲ ﺍﺯ ﺑﻬﺘﺮﻳﻦ ﺑﺮﻧﺎﻣﻪﻫﺎ )ﭼﻪ ﻛﺘﺎﺏ ﻭ ﭼﻪ ‪ (CD‬ﺩﺭ ﻣﻮﺭﺩ ﭼﮕﻮﻧﮕﻲ ﺗﻔﺴﻴﺮ ‪ CXR‬ﻣﻲﺑﺎﺷﺪ‪ .‬ﺍﻳﻦ ‪ CD‬ﺷﺎﻣﻞ ‪ ٣‬ﺑﺨﺶ ‪ Clinic -٣ seminar -٢ Library -١‬ﻣﻲﺑﺎﺷﺪ‪ .‬ﺩﺭ ﻫﺮ ﺑﺨﺶ ﻋﻜﺲ ﺳﺎﻟﻢ ﺭﻳﻪ ﻫﻤـﺮﺍﻩ ﺑـﺎ ﺗﻮﺿـﻴﺤﺎﺕ ﻭ‬
‫ﺗﺸﺨﻴﺺ ﺍﻓﺘﺮﺍﻗﻲ ﻭﺟﻮﺩ ﺩﺍﺭﺩ ﻭ ﺑﺮﺍﻱ ﻓﻬﻢ ﻣﻄﻠﺐ ﻓﻴﻠﻢﻫﺎﻱ ‪ ٣‬ﺑﻌﺪﻱ ‪ animatory‬ﻧﺸﺎﻥ ﺩﺍﺩﻩ ﺷﺪﻩ ﺍﺳﺖ‪.‬‬
‫ﺩﺭ ﺑﺨﺶ ﺍﻭﻝ‪ Library :‬ﻳﺎ ﻛﺘﺎﺑﺨﺎﻧﻪ ‪:‬‬
‫ﺍﻟﻒ( ﺑﻴﻤﺎﺭﻱﻫﺎ ﺑﻪ ﺗﺮﺗﻴﺐ ﺣﺮﻭﻑ ﺍﻟﻔﺒﺎ ﺁﻭﺭﺩﻩ ﺷﺪﻩ ﻭ ﺳﭙﺲ ‪ CXR‬ﻭ ﻣﺘﻦ ﻣﺮﺑﻮﻁ ﺑﻪ ﺁﻥ ﺑﻴﻤﺎﺭﻱ ﻭ ﺗﻔﺴﻴﺮ ﺭﺍﺩﻳﻮﻟﻮﮊﻱ ﺁﻭﺭﺩﻩ ﺷﺪﻩ ﺍﺳﺖ‪.‬‬
‫ﺏ‪ :‬ﺍﺑﺘﺪﺍ ﻳﻚ ﻋﻜﺲ ﺭﻳﻪ ﻧﺸﺎﻥ ﺩﺍﺩﻩ ﺷﺪﻩ ﺍﺳﺖ ﻭ ﺳﭙﺲ ﺗﺸﺨﻴﺺ ﺍﻓﺘﺮﺍﻗﻲ ﺁﻥ ﺷﺮﺡ ﺩﺍﺩﻩ ﺷﺪﻩ ﺍﺳﺖ‬
‫ﺝ‪ : Sings, clue :‬ﻋﻼﺋﻢ ﺭﺍﺩﻳﻮﻟﻮﮊﻳﻚ ﺗﻌﺮﻳﻒ ﻭ ﺩﺭ ‪ CXR‬ﻧﺸﺎﻥ ﺩﺍﺩﻩ ﺷﺪﻩ ﻣﺎﻧﻨﺪ‪(…,westermark Sing, Sign) :‬‬
‫ﺩ‪ : Anatomy World :‬ﺁﻧﺎﺗﻮﻣﻲ ﻗﻔﺴﻪ ﺳﻴﻨﻪ ﺑﺎ ﻣﻘﺎﻃﻊ ﻃﻮﻟﻲ ﻭ ﻋﺮﺿﻲ ﻭ ﻫﻮﺭﻳﺰﻧﺘﺎﻝ ﺑﻪ ﺻﻮﺭﺕ ‪ 3D‬ﻧﺸﺎﻥ ﺩﺍﺩﻩ ﺷﺪﻩ ﺍﺳﺖ‪.‬‬
‫ﻫ‪ :‬ﺩﻳﻜﺸﻨﺮﻱ‪ :‬ﺗﻌﺎﺭﻳﻒ ﻋﻼﺋﻢ ﻭ ﻧﺸﺎﻧﻪﻫﺎﻱ ﻧﻤﺎﻳﺶ ﺩﺍﺩﻩ ﺷﺪﻩ ﺍﺳﺖ‪.‬‬
‫ﻭ‪ :CME Quiz :‬ﻋﻜﺲ ﺭﺍﺩﻳﻮﮔﺮﺍﻓﻲ ﻭ ﺷﺮﺡ ﺣﺎﻝ ﺑﻴﻤﺎﺭ ﻧﺸﺎﻥ ﺩﺍﺩﻩ ﺷﺪ‪ .‬ﺳﭙﺲ ﻛﺎﺭﺑﺮ ﺑﺎﻳﺪ ﻳﺎﻓﺘﻪﻫﺎﻱ ﺭﺍﺩﻳﻮﻟﻮﮊﻱ ﺭﺍ ﻣﺸﺨﺺ ﻧﻤﺎﻳﺪ‪.‬‬
‫ﺑﺨﺶ ﺩﻭﻡ ﻳﺎ ‪ :Seminar‬ﺑﻪ ‪ ٥‬ﺑﺨﺶ‪:‬‬
‫‪ -٢ Soft tissue -١‬ﺍﺳﺘﺨﻮﺍﻧﻬﺎ ‪ -٣‬ﭘﻠﻮﺭﻭﺩﻳﺎﻓﺮﺍﮔﻢ ‪ -٤‬ﺭﻳﻪ ﻭ ‪ -٥‬ﻣﺪﻳﺸﺎﻥ ﺗﻘﺴﻴﻢ ﺷﺪﻩ‪.‬‬
‫ﺩﺭ ﻫﺮ ﻗﺴﻤﺖ ﺍﺑﺘﺪﺍ ﻋﻜﺴﻲ ﺍﺯ ﺭﻳﻪ ﻧﺸﺎﻥ ﺩﺍﺩﻩ ﺷﺪﻩ ﻭ ﺷﺨﺺ ﺑﺎﻳﺪ ﻣﺤﻞ ﺿﺎﻳﻌﻪ ﻭ ﺗﺸﺨﻴﺺ ﺑﻴﻤﺎﺭﻱ ﺭﺍ ﻣﺸﺨﺺ ﺳﺎﺯﺩ‪ .‬ﺩﺭ ﻣﻮﺭﺩ ﻗﺴﻤﺖ ﺭﻳﻪ ﺧﻮﺩ ﺑﻪ ‪ ٤‬ﺑﺨﺶ ‪ Search‬ﻭ ‪ Localize‬ﻭ ‪ describe‬ﻭ ﺗﺸﺨﻴﺺ ﺍﻓﺘﺮﺍﻗﻲ ﺗﻘﺴﻴﻢ ﺷﺪﻩ ﺍﺳﺖ‪.‬‬
‫‪ : Search‬ﻋﻜﺲ ﺭﻳﻪ ﻧﺸﺎﻥ ﺩﺍﺩﻩ ﺷﺪﻩ ﻭ ﻛﺎﺭﺑﺮ ﺑﺎﻳﺪ ﻣﺤﻞ ﺿﺎﻳﻌﻪ ﺭﺍ ﻧﺸﺎﻥ ﺩﻫﺪ ) ﺑﺎ ﺍﺳﺘﻔﺎﺩﻩ ﺍﺯ ﻣﻮﺱ(‬
‫‪ :Localize‬ﺍﺑﺘﺪﺍ ﻋﻼﻣﺖ ﻳﺎ ﻧﺸﺎﻧﻪ ﺑﻴﻤﺎﺭﻱ ﺩﺭ ‪ CXR‬ﺷﺮﺡ ﺩﺍﺩﻩ ﻣﻲﺷﻮﺩ ﻭ ﻛﺎﺭﺑﺮ ﺑﺎﻳﺪ ﻣﺤﻞ ﺁﻧﺮﺍ ﻧﺸﺎﻥ ﺩﻫﺪ‪.‬‬
‫‪ :Describe‬ﺍﺑﺘﺪﺍ ‪ CXR‬ﻧﺸﺎﻥ ﺩﺍﺩﻩ ﺷﺪﻩ ﻭ ﻛﺎﺭﺑﺮ ﺑﺎﻳﺪ ﺍﺯ ﺑﻴﻦ ‪ ٢‬ﮔﺰﻳﻨﻪ ﻳﻜﻲ ﺭﺍ ﺍﻧﺘﺨﺎﺏ ﻧﻤﺎﻳﺪ ﻣﺜ ﹰ‬
‫ﻼ ﺗﻮﺩﻩﺍﻱ ﺩﺭ ‪ CXR‬ﻧﺸﺎﻥ ﺩﺍﺩﻩ ﻣﻲﺷﻮﺩ ﻛﺎﺭﺑﺮ ﺑﺎﻳﺪ ﺑﺘﻮﺍﻧﺪ ﺗﻌﻴﻴﻦ ﻛﻨﺪ ﺧﻮﺵ ﺧﻴﻢ ﺍﺳﺖ ﻳﺎ ﺑﺪ ﺧﻴﻢ‪.‬‬
‫‪ CXR :Differential diagnosis‬ﻧﺸﺎﻥ ﺩﺍﺩﻩ ﻣﻲﺷﻮﺩ ﻭﺳﭙﺲ ﺑﻴﻤﺎﺭﻳﻬﺎ‪pattern ،‬ﻫﺎﻱ ﺑﻴﻤﺎﺭﻱ ﺑﻪ ﺻﻮﺭﺕ ﺗﺴﺖ ﭼﻨﺪ ﺟﻮﺍﺑﻲ ﺁﻭﺭﺩ ﺷﺪﻩ ﺍﺳﺖ‪.‬‬
‫ﺑﺨﺶ ﺳﻮﻡ ‪ :Clinic‬ﺍﻳﻦ ﺑﺨﺶ ﺭﺍ ﺑﺮﺍﻱ ﻛﻤﻚ ﺑﻪ ﺗﻘﺴﻴﻢ ﻗﺪﻡ ﺑﻪ ﻗﺪﻡ ﻭ ﻳﺎ ﻧﻮﺷﺘﻦ ﻳﻚ ﺗﻔﺴﻴﺮ ﺭﺍﺩﻳﻮﻟﻮﮊﻱ ﺍﺳﺖ‪.‬‬
‫ﺑﻴﻤﺎﺭ ﺑﻪ ﻫﻤﺮﺍﻩ ﺷﺮﺡ ﺣﺎﻝ‪ ،‬ﻣﻌﺎﻳﻨﻪ ﻓﻴﺰﻳﻜﻲ ﻭ ‪ CXR‬ﻭ ﺩﺭ ﺻﻮﺭﺕ ﻟﺰﻭﻡ ‪ CT/MRI‬ﺑﺮﻭﻧﻜﻮﺳﻜﻮﻳﻲ ﻭ ﺑﻴﻮﭘﺴﻲ ﻭ ﻧﻮﻛﺌﺎﺭﺩﺍﺳﻜﻦ ﺍﺭﺍﺋﻪ ﺷﺪﻩ ﺍﺳﺖ‪.‬‬
‫ﻛﺎﺭﺑﺮ ﺑﺎﻳﺪ ﺑﺮ ﺍﺳﺎﺱ ﻓﻮﺭﻳﺖ ﺗﻌﻴﻴﻦ ﺷﺪﻩ ﺍﺑﺘﺪﺍ ‪ ← Softtissue‬ﺍﺳﺘﺨﻮﺍﻥ ← ﭘﻠﻮﺭﻭﺩﻳﺎﻓﺮﺍﮔﻢ ← ﺭﻳﻪ ← ﻣﺪﻳﺴﺘﺎﻥ ← ﻧﺎﻑ ﺭﻳﻪ ﻋﻜﺲ ﺭﺍ ﻣﻄﺎﻟﻌﻪ ﻧﻤﺎﻳﺪ ﺑﺮﺍﻱ ﻛﻤﻚ ﺑﻪ ﺗﻔﺴﻴﺮ‪ ،‬ﺧﻮﺩ ﺑﺮﻧﺎﻣﻪ ﺑﺎ ﺗﻌﻴﻴﻦ ﺧﺼﻮﺻﻴﺎﺕ ﻣﻨﻄﻘﻪ ﺑﻪ ﻛـﺎﺭﺑﺮ ﺩﺭ ﺗﻔﺴـﻴﺮ‬
‫ﻛﻤﻚ ﻣﻲﻛﻨﺪ ﺑﺮﺍﻱ ﻣﺜﺎﻝ‪ :‬ﺩﺭ ﻣﻮﺭﺩ ‪ ...... Softtissue‬ﺑﺎﻓﺖ ﻧﺮﻡ ﺟﺪﺍﺭ ﻗﻔﺴﻪ ﺳﻴﻨﻪ ﺍﻓﺰﺍﻳﺶ‪ ،‬ﻛﺎﻫﺶ‪ ،‬ﻧﺮﻣﺎﻝ ﻭ ﻛﻠﻴﺴﻔﻴﻜﺎﺳﻴﻮﻥ ﻭ ﺍﺑﻨﺮﻣﺎﻝ ‪ air‬ﻭ ‪ ....‬ﻣﻲﺑﺎﺷﺪ‪.‬‬
‫‪20.1 Comprehensive Reviw of Radiography‬‬ ‫)‪(Mosby‬‬ ‫ــــــ‬
‫ﺍﻳﻦ ‪ CD‬ﺑﻤﻨﻈﻮﺭ ﺧﻮﺩﺁﺯﻣﺎﻳﻲ )‪ (Self evaluation‬ﺍﻓﺮﺍﺩ ﻣﺮﺗﺒﻂ ﺑﺎ ﺣﺮﻓﺔ ﺭﺍﺩﻳﻮﻟﻮﮊﻱ ﺗﺸﺨﻴﺼﻲ ﺩﺭ ﺯﻣﻴﻨﻪﻫﺎﻱ ﺯﻳﺮ ﺍﺭﺍﺋﻪ ﮔﺮﺩﻳﺪﻩ ﺍﺳﺖ‪:‬‬
‫ﺗﻬﻴﻪ ﻭ ﺍﺭﺯﻳﺎﺑﻲ ﮔﺮﺍﻓﻲﻫﺎﻱ ﺭﺍﺩﻳﻮﻟﻮﮊﻱ ﻛﺎﺭﻛﺮﺩ ﻭ ﻧﮕﻬﺪﺍﺭﻱ ﺍﺯ ﺩﺳﺘﮕﺎﻩﻫﺎﻱ ﺭﺍﺩﻳﻮﻟﻮﮊﻱ ﺣﻔﺎﻇﺖ ﺍﺯ ﺍﺷﻌﻪ ﻧﮕﻬﺪﺍﺭﻱ ﻭ ﻣﺪﻳﺮﻳﺖ ﺑﺮﺧﻮﺭﺩ ﺑﺎ ﺑﻴﻤﺎﺭﺍﻥ ﺭﻭﺵﻫﺎﻱ ﺭﺍﺩﻳﻮﮔﺮﺍﻓﻴﻚ‬
‫ﭘﺲ ﺍﺯ ﻧﺼﺐ ‪ CD‬ﻓﻮﻕ‪ ،‬ﺩﺭ ﺷﺮﻭﻉ‪ ،‬ﺷﺨﺺ ﺑﺎﻳﺴﺘﻲ ﻳﻜﻲ ﺍﺯ ﻣﺒﺎﺣﺚ ﭘﻨﺞﮔﺎﻧﻪ ﻓﻮﻕ ﺭﺍ ﺟﻬﺖ ﺧﻮﺩﺁﺯﻣﺎﻳﻲ ﺍﻧﺘﺨﺎﺏ ﻧﻤﺎﻳﺪ ﻭ ﺑﻪ ﺩﻧﺒﺎﻝ ﺁﻥ‪ ،‬ﺳﺆﺍﻻﺕ ﻫﺮ ﻣﺒﺤﺚ ﺑﺼﻮﺭﺕ ﭼﻨﺪﮔﺰﻳﻨﻪﺍﻱ ﻣﻮﺭﺩ ﺁﺯﻣﻮﻥ ﻗﺮﺍﺭ ﺧﻮﺍﻫﻨﺪ ﮔﺮﻓﺖ ﻭ ﺑﻪ ﺩﻧﺒﺎﻝ ﻫﺮ ﭘﺎﺳﺦ‪ ،‬ﺗﻮﺿﻴﺤﺎﺕ ﻋﻠﻤﻲ ﻣﺮﺑﻮﻁ ﺟﻬـﺖ‬
‫ﺍﺭﺗﻘﺎﺀ ﻋﻠﻤﻲ ﻓﺮﺩ‪ ،‬ﺑﻪ ﻭﻱ ﺍﺭﺍﺋﻪ ﺧﻮﺍﻫﺪ ﮔﺮﺩﻳﺪ‪.‬‬

‫ﺗﻠﻔﻦ‪٠٩١٢١٣٧٢٣٦١-٦٦٩٣٦٦٩٦ :‬‬ ‫ﻧﺸﺎﻧﻲ‪ :‬ﺗﻬﺮﺍﻥ‪ ،‬ﻡ ﺍﻧﻘﻼﺏ‪ ،‬ﺥ ﻛﺎﺭﮔﺮ ﺟﻨﻮﺑﻲ‪ ،‬ﺥ ﻟﺒﺎﻓﻲﻧﮋﺍﺩ‪ ،‬ﺑﻴﻦ ﻛﺎﺭﮔﺮ ﻭ ﺟﻤﺎﻟﺰﺍﺩﻩ‪ ،‬ﺑﻦﺑﺴﺖ ﺳﻴﻤﻴﻦ‪ ،‬ﭘﻼﻙ ‪٢٣٩‬‬ ‫ﻣﺮﻛﺰ ﺧﺪﻣﺎﺕ ﻓﺮﻫﻨﮕﻲ ﺳﺎﻟﻜﺎﻥ ‪ :‬ﺍﺭﺍﺋﻪ ﻛﻨﻨﺪﺓ ﻛﺘﺎﺏ ﻭ ﺳﻲﺩﻱﻫﺎﻱ ﺗﺨﺼﺼﻲ ﭘﺰﺷﻜﻲ‬
 ‫‪4‬‬
‫)‪21.1 Computed Body Tomography with MRI Correlation (Joseph K. T. Lee, Stuart S. Sagel, Robert J. Stanley, Jay P. Heiken) (3rd Edition) (LIPPINCOTT WILLIAMS & WILKINS‬‬ ‫ــــــ‬
‫‪22.1 CT Teaching Manual‬‬ ‫)‪(Matthias Hofer) (Thieme‬‬ ‫)‪(Salekan E-Book‬‬ ‫ــــــ‬
‫)‪23.1 Diagnostic Imaging Expert (A CD-ROM Reference & Review) (Ralph Weissleder, Jack Witterberg, Mark J. Rieumont, Genevieve Bennett‬‬ ‫‪2000‬‬

‫ﺍﻳﻦ ﻳﻚ ﻧﺮﻡﺍﻓﺰﺍﺭ ﺁﻣﻮﺯﺷﻲ ﺍﺯ ﻣﻄﺎﻟﺐ ﻣﺨﺘﻠﻒ ﺭﺍﺩﻳﻮﻟﻮﮊﻱ ﻭ ﺗﺼﻮﻳﺮﺑﺮﺩﺍﺭﻱ ﻣﺤﺴﻮﺏ ﻣﻲﺷﻮﺩ ﻭ ﺩﺭ ﺯﻣﻴﻨﻪﻫﺎﻱ ﻣﺨﺘﻠﻒ‪ ،‬ﺑﻪ ﺑﺤﺚ ﺩﺭ ﻣﻮﺭﺩ ﺑﻴﻤﺎﺭﻱﻫﺎ ﻭ ﺭﻭﺵﻫﺎﻱ ﺭﺍﺩﻳﻮﻟﻮﮊﻱ ﻭ ‪ Imaging‬ﻣﺮﺑﻮﻁ ﺑﻪ ﺁﻧﻬﺎ ﻣﻲﭘﺮﺩﺍﺯﺩ‪ .‬ﺍﻳـﻦ ‪ CD‬ﺩﺍﺭﺍﻱ ﺁﺭﺍﻳـﻪﻫـﺎﻱ ﺫﻳـﻞ‬
‫ﻣﻲﺑﺎﺷﺪ‪:‬‬
‫‪14- Vascular 13- Head and Neck‬‬ ‫‪11- Neurologic‬‬ ‫‪9- Musculoskeletal‬‬ ‫‪7- Genitourinary‬‬ ‫‪5- Gastrointestinal‬‬ ‫‪3- Cardiac‬‬ ‫‪1- Chest‬‬
‫‪12- Imaging Physics‬‬ ‫‪10- Contrast agent‬‬ ‫‪8- Nuclear Imaging‬‬ ‫‪6- Pediatric‬‬ ‫‪4- Obstetric‬‬ ‫‪2- Breast‬‬
‫)‪24.1 DIAGNOSTIC ULTRASOUND A LOGICAL APPROACH (JOHN P. McGAHAN, BARRY B. GOLDBERG‬‬ ‫ــــــ‬

‫ﺍﻳﻦ ﻛﺘﺎﺏ ﺍﻟﻜﺘﺮﻭﻧﻴﻜﻲ‪ ٣‬ﻗﺴﻤﺖ ﺍﺳﺖ‪:‬‬

‫‪ -١‬ﻛﺘﺎﺏ ‪ Diagnostic Ultrasound‬ﻋﻼﻭﻩ ﺑﺮ ﺍﻳﻦ ﻛﺘﺎﺏ ﺩﻭ ﺟﺰﺀ ﻣﻨﺤﺼﺮ ﺑﻪ ﻓﺮﺩ ﺩﻳﮕﺮ ﺷﺎﻣﻞ ﺩﻭ ﻓﻴﻠﻢ ﺳﻮﻧﻮﮔﺮﺍﻓﻲ ﻭ ﺩﺍﭘﻠﺮ ﻫﺮ ﺑﺨﺶ ﺑﻪ ﺻﻮﺭﺕ ﺯﻧﺪﻩ ﺑﺎ ﻛﻴﻔﻴﺖ ﺑﺎﻻ ﻧﺸﺎﻥ ﺩﺍﺩﻩ ﺷﺪﻩ ﺍﺳﺖ‪.‬‬
‫‪ Selp-assessment -٢‬ﺑﻪ ﺻﻮﺭﺕ ‪ CMP‬ﻭ ﺗﺴﺖﻫﺎﻱ ﭼﻨﺪﮔﺰﻳﻨﻪﺍﻱ ﻣﻲﺑﺎﺷﺪ‪.‬‬
‫ﻛﺘﺎﺏ ﺍﻟﻜﺘﺮﻭﻧﻴﻜﻲ ﺣﺎﺿﺮ ﺷﺎﻣﻞ ‪ ٤١‬ﻓﺼﻞ ﻣﻲﺑﺎﺷﺪ ﻛﻪ ﺷﺎﻣﻞ‪:‬‬
‫‪ -١‬ﻓﻴﺰﻳــــﻚ ‪ -٢ bioeffects‬ﺁﺭﺗﻔﻜــــﺖ ‪ ٣‬ﻭ ‪ -٤‬ﺭﻭﺵﻫــــﺎﻱ ﺗﻬــــﺎﺟﻤﻲ ﺑــــﺎ ﺳــــﻮﻧﻮﮔﺮﺍﻓﻲ ﺩﺭ )ﺑﻴﻮﭘﺴــــﻲ‪ ،‬ﺁﺳﭙﻴﺮﺍﺳــــﻴﻮﻥ ﻭ ﺩﺭﻧــــﺎﮊ( ﻭ ﺩﺭ ﺑﻴﻤــــﺎﺭﻱﻫــــﺎﻱ ﺯﻧــــﺎﻥ ﻭ ﺯﺍﻳﻤــــﺎﻥ ‪ -٥‬ﺭﻭﺵﻫــــﺎﻱ ﺍﻭﻟﺘﺮﺍﺳــــﻮﻧﻮﮔﺮﺍﻓﻲ ﺣــــﻴﻦ ﻋﻤــــﻞ ﺟﺮﺍﺣــــﻲ‬
‫‪ :٦-١٨‬ﺳﻮﻧﻮﮔﺮﺍﻓﻲ ﺗﺮﻳﻤﺴﺘﺮ ﺍﻭﻝ ﺣﺎﻣﻠﮕﻲ‪ ،‬ﭘﻼﺳﻨﺘﺎ ﻭ ‪ Cervix‬ﻭ ﺑﻨﺪ ﻧﺎﻑ ﻭ ﭘﺮﺩﻩ ﺁﻣﻨﻴﻮﺗﻴﻚ‪ ،‬ﺳﺮ ﻭ ﺻﻮﺭﺕ ﻭ ﮔﺮﺩﻥ ﻭ ﻗﻔﺴﻪ ﺳﻴﻨﻪ ﺷﻜﻢ ﻭ ﻟﮕﻦ ﻭ ﺿﺮﺑﺎﻥ ﻗﻠﺐ ﻭ ﺍﻧﺪﺍﺯﻩﻫﺎﻱ ﺟﻨﻴﻦ ﻭ ﺣﺎﻣﻠﮕﻲ ﺩﻭﻗﻠﻮﺋﻲ ﻭ ‪ Small-for-date , large-for-data‬ﻭ ‪....‬‬
‫ﺩﺭ ﺑﺨﺶﻫﺎﻱ ﺩﻳﮕﺮ ﻫﺮ ﺳﻴﺴﺘﻢ ﺑﺪﻥ ﺍﺯ ﻟﺤﺎﺽ ﺁﻧﺎﺗﻮﻣﻲ ﻧﺮﻣﺎﻝ‪ ،‬ﺗﺸﺨﻴﺺﻫﺎﻱ ﺍﻓﺘﺮﺍﻗﻲ ﺩﺭ ﺳﻮﻧﻮﮔﺮﺍﻓﻲ ‪ ،‬ﺗﻘﺴﻴﻢﺑﻨﺪﻱ ﻳﺎﻓﺘﻪﻫﺎ ﺑﻪ ﻧﺮﻣﺎﻝ ﻭ ﻏﻴﺮﻧﺮﻣﺎﻝ ﺩﺭ ﺳﻮﻧﻮﮔﺮﺍﻓﻲ‪ ،‬ﺗﺸﺨﻴﺺ ﻳﺎﻓﺘﻪ ﻭ ﺭﺳﻴﺪﻥ ﺑﻪ ﻳﻚ ﺗﺸﺨﻴﺺ ﺑﺎﻟﻴﻨﻲ ﺩﺭ ﺳﻮﻧﻮﮔﺮﺍﻓﻲ ‪ -١٩‬ﺩﺳﺘﮕﺎﻩ ﮔﻮﺍﺭﺵ )ﺣﻔـﺮﻩ‬
‫ﭘﺮﻳﺘﻮﺍﻥ( ‪ -٢٠‬ﺍﺭﺯﻳﺎﺑﻲ ﺳﻮﻧﻮﮔﺮﺍﻓﻲ ﺍﻋﻀﺎﺀ ﭘﻴﻮﻧﺪ ﺯﺩﻩ ﺷﺪﻩ )ﻛﺒﺪ – ﻛﻠﻴﻪ‪ -‬ﭘﺎﻧﻜﺮﺍﺱ( ‪ -٢١‬ﻛﺒﺪ ‪ -٢٢‬ﻛﻴﺴﻪ ﺻﻔﺮﺍ ﻭ ﻣﺠـﺎﺭﻱ ﺻـﻔﺮﺍﻭﻱ ‪ -٢٣‬ﺭﺗﺮﻭﭘﺮﺗﻴـﻮﺍﻥ ﻭ ﭘـﺎﻧﻜﺮﺍﺱ‪ ،‬ﻃﺤـﺎﻝ‪ ،‬ﻟﻤـﻒ ﻧـﻮﺩ ‪ -٢٤‬ﺩﺳـﺘﮕﺎﻩ ﺍﺩﺭﺍﺭﻱ ‪ -٢٥‬ﭘﺮﻭﺳـﺘﺎﺕ ‪ -٢٧ Penis -٢٦‬ﺍﺳـﻜﺮﻭﺗﻮﻡ ﻭ ‪testes‬‬
‫‪ -٣٠ Post meno Pausal Pelvis -٢٩ Female Pelvis -٢٨‬ﺳﻴﺴــﺘﻢ ﻋــﺮﻭﻕ ﻣﺤﻴﻄــﻲ ‪ -٣١‬ﻛﺎﺭﻭﺗﻴــﺪ ‪ -٣٥ Chest -٣٤ Brest -٣٣ trans cranial -٣٢‬ﺗﻴﺮﻭﺋﻴــﺪ‪ ،‬ﭘﺎﺭﺍﺗﻴﺮﻭﺋﻴــﺪ ﻭ ﻏــﺪﺩ ﺩﻳﮕــﺮ ‪ -٣٦‬ﺳﻴﺴــﺘﻢ ‪ Skeletal‬ﻭ ‪Pediactric Head -٣٧ Softtissue‬‬
‫‪ -٤١ ultrasound-Guided Percutaneous tissue Ablation -٤٠ Three dimensional ultrasound -٣٩ Ultrasoud Contrast agent -٣٨‬ﺍﻭﻟﺘﺮﺍﺳﻮﻧﺪﺍﻧﺪﻭﺳﻜﻮﭘﻴﻚ‬
‫ﻻﺯﻡ ﺑﻪ ﺫﻛﺮ ﺍﺳﺖ ﻛﻪ ﺩﺭ ﻫﻨﮕﺎﻡ ﻧﺼﺐ ﺍﻳﻦ ‪ CD‬ﺑﺎﻳﺴﺘﻲ ﺍﺯ ﻛﺪ ﻋﺒﻮﺭ ‪ RUSR 2335‬ﺍﺳﺘﻔﺎﺩﻩ ﺷﻮﺩ‪.‬‬
‫)‪25.1 Diagnostic Ultrasound of Fetal Anomalies: Principles and Techniques (CD I,II‬‬ ‫‪1999‬‬

‫ﺍﻳﻦ ﻧﺮﻡﺍﻓﺰﺍﺭ ﺁﻣﻮﺯﺷﻲ ﺩﺍﺭﺍﻱ ‪ ٢‬ﻋﺪﺩ ‪ CD‬ﻣﻲﺑﺎﺷﺪ‪ .‬ﺩﺭ ‪ CD‬ﺷﻤﺎﺭﻩ ‪ ١‬ﺑﺎ ﺑﻬﺮﻩﮔﻴﺮﻱ ﺍﺯ ﺗﺼﺎﻭﻳﺮ ﺛﺎﺑﺖ ﻭ ﻣﺘﺤﺮﻙ ﺳﻮﻧﻮﮔﺮﺍﻓﻲ ﺟﻨﻴﻦ ﻛﻪ ﺩﺍﺭﺍﻱ ﻛﻴﻔﻴﺖ ﻓﻮﻕﺍﻟﻌﺎﺩﻩ ﻋﺎﻟﻲ ﻣﻲﺑﺎﺷﻨﺪ‪ ،‬ﺁﻧﻮﻣﺎﻟﻲﻫﺎﻱ ﻣﺨﺘﻠﻒ ﻣﺎﺩﺭﺯﺍﺩﻱ ﺑﺼﻮﺭﺕ ﺗﻴﭙﻴﻚ ﺑﻪ ﻧﻤﺎﻳﺶ ﺩﺭﺁﻣﺪﻩ ﻭ ﺩﺭ ﻣﻮﺭﺩ ﻫﺮ ﻳﻚ‪ ،‬ﺗﻮﺿﻴﺤﺎﺕ‬
‫ﻛﺎﻓﻲ ﺩﺍﺩﻩ ﺷﺪﻩ ﺍﺳﺖ‪ .‬ﺩﺭ ‪ CD‬ﺷﻤﺎﺭﻩ ‪ ، ٢‬ﺍﻣﻜﺎﻥ ﺧﻮﺩﺁﺯﻣﺎﻳﻲ ﺷﺨﺺ ﺑﻪ ﺻﻮﺭﺕ ‪Case‬ﻫﺎﻱ ﻣﺨﺘﻠﻒ ﻭ ﺑﻪ ﻃﺮﻳﻘﺔ ‪ Multiple Choice question‬ﻓﺮﺍﻫﻢ ﮔﺮﺩﻳﺪﻩ ﻭ ﺩﺭ ﻣﻮﺭﺩ ﻫﺮ ‪ ، Case‬ﺗﻮﺿﻴﺤﺎﺕ ﻻﺯﻡ ﺩﺍﺩﻩ ﺷﺪﻩﺍﻧﺪ‪ .‬ﻣﺒﺎﺣﺚ ﻭ ﺗﻌﺪﺍﺩ ‪ Case‬ﻫﺎﻱ ﻣﻄﺮﺡﺷﺪﻩ ﺩﺭ ﺍﻳﻦ ‪ ٢‬ﻋﺪﺩ‬
‫‪ CD‬ﺑﻪ ﺷﺮﺡ ﺫﻳﻞ ﻣﻲﺑﺎﺷﻨﺪ‪:‬‬
‫ﻣﺒﺤﺚ‬ ‫ﺗﻌﺪﺍﺩ ‪Case‬‬ ‫ﻣﺒﺤﺚ‬ ‫ﺗﻌﺪﺍﺩ ‪Case‬‬ ‫ﻣﺒﺤﺚ‬ ‫ﺗﻌﺪﺍﺩ ‪Case‬‬ ‫ﻣﺒﺤﺚ‬ ‫ﺗﻌﺪﺍﺩ ‪Case‬‬ ‫ﻣﺒﺤﺚ‬ ‫ﺗﻌﺪﺍﺩ ‪Case‬‬
‫‪ Head‬ﺟﻨﻴﻦ‬ ‫‪٣٦‬‬ ‫‪Neural tube‬‬ ‫‪١٩‬‬ ‫‪Amniotic Fluid‬‬ ‫‪٢‬‬ ‫ﺟﻨﺴﻴﺖ‬ ‫‪٤‬‬ ‫ﺟﻨﻴﻦ‬ ‫ﺍﺳﻜﺘﺎﻝ‬ ‫ﺳﻴﺴﺘﻢ‬ ‫‪١٦‬‬
‫‪Body wall‬‬ ‫‪٢٠‬‬ ‫‪Umblical Cord‬‬ ‫‪٣‬‬ ‫ﻣﻮﺍﺭﺩ ﻣﺘﻔﺮﻗﻪ‬ ‫‪٢‬‬ ‫ﺩﺳﺘﮕﺎﻩ ﺍﺩﺭﺍﺭﻱ ﺟﻨﻴﻦ‬ ‫‪١٢‬‬
‫ﻗﻠﺐ ﺟﻨﻴﻦ‬ ‫‪١٤‬‬ ‫ﺻﻮﺭﺕ ﺟﻨﻴﻦ‬ ‫‪٦‬‬ ‫‪ Chest‬ﺟﻨﻴﻦ‬ ‫‪١٢‬‬ ‫ﺳﻴﺴﺘﻢ ﮔﻮﺍﺭﺷﻲ ﺟﻨﻴﻦ‬ ‫‪٤‬‬
‫‪26.1 Digital Human Anatomy and Endoscopic Ultrasonography‬‬ ‫)‪(MANOOP S. BHUTANI, MD, JOHN C. DEUTSCH, MD‬‬ ‫)‪(Salekan E-Book‬‬ ‫‪2005‬‬
‫)‪27.1 EBUS (Endo Bronchial Ultrasound‬‬ ‫ــــــ‬
‫‪28.1 Endoscopy and Gastrointestinal Radiology‬‬ ‫)‪(Gregory G. Ginsberg, Michael L. Kochman‬‬ ‫‪2004‬‬
‫‪Upper endoscopy‬‬ ‫‪Colonoscopy‬‬ ‫‪Endoscopiy‬‬
‫‪Contrast Radiology‬‬ ‫‪Clinical Application of Magnetic Resonance Imaging in the Abdomen‬‬ ‫‪Percutaneous Management of Biliary Obstruction‬‬
‫‪Endoscopic Retrograte Cholagiopancreatography‬‬ ‫‪Computed Tomography and Ultrasound of the Abdomen and Gastrointestinal Tract‬‬ ‫‪Endoscopic Ultrasound‬‬

‫ﺗﻠﻔﻦ‪٠٩١٢١٣٧٢٣٦١-٦٦٩٣٦٦٩٦ :‬‬ ‫ﻧﺸﺎﻧﻲ‪ :‬ﺗﻬﺮﺍﻥ‪ ،‬ﻡ ﺍﻧﻘﻼﺏ‪ ،‬ﺥ ﻛﺎﺭﮔﺮ ﺟﻨﻮﺑﻲ‪ ،‬ﺥ ﻟﺒﺎﻓﻲﻧﮋﺍﺩ‪ ،‬ﺑﻴﻦ ﻛﺎﺭﮔﺮ ﻭ ﺟﻤﺎﻟﺰﺍﺩﻩ‪ ،‬ﺑﻦﺑﺴﺖ ﺳﻴﻤﻴﻦ‪ ،‬ﭘﻼﻙ ‪٢٣٩‬‬ ‫ﻣﺮﻛﺰ ﺧﺪﻣﺎﺕ ﻓﺮﻫﻨﮕﻲ ﺳﺎﻟﻜﺎﻥ ‪ :‬ﺍﺭﺍﺋﻪ ﻛﻨﻨﺪﺓ ﻛﺘﺎﺏ ﻭ ﺳﻲﺩﻱﻫﺎﻱ ﺗﺨﺼﺼﻲ ﭘﺰﺷﻜﻲ‬
 ‫‪5‬‬
‫‪29.1 Essentials of Radiology‬‬ ‫ــــــ‬
‫ﺩﺭ ‪ CD‬ﻓﻮﻕ‪ ،‬ﺿﺮﻭﺭﻳﺎﺕ ﺭﺍﺩﻳﻮﻟﻮﮊﻱ ﺗﺸﺨﻴﺼﻲ ﺑﺼﻮﺭﺕ ‪ Case‬ﻣﻄﺮﺡ ﮔﺮﺩﻳﺪﻩﺍﻧﺪ ﻭ ﺍﺯ ﺗﺼﺎﻭﻳﺮ ﺭﺍﺩﻳﻮﮔﺮﺍﻓﻴﻚ ﺗﻴﭙﻴﻚ ﻫﻤﺮﺍﻩ ﺑﺎ ﺗﻮﺿﻴﺤﺎﺕ ﻛﺎﻓﻲ ﻭ ﺗﻮﺻﻴﻒ ﺩﻗﻴﻖ ﻧﻤﺎﻫﺎﻱ ﺭﺍﺩﻳﻮﻟﻮﮊﻳﻚ ﺍﺳﺘﻔﺎﺩﻩ ﺷﺪﻩ ﺍﺳﺖ‪ .‬ﺗﻌﺪﺍﺩ ‪Case‬ﻫﺎﻱ ﻣﻄﺮﺡﺷﺪﻩ ﺩﺭ ﺍﻳﻦ ‪ CD‬ﺑﺮ ﺣﺴﺐ ﻣﻮﺿﻮﻉ ﺑﻪ ﻗﺮﺍﺭ ﺯﻳﺮ ﻣﻲﺑﺎﺷﺪ‪:‬‬

‫ﻣﻮﺿﻮﻉ‬ ‫ﺗﻌﺪﺍﺩ ‪Case‬‬ ‫ﻣﻮﺿﻮﻉ‬ ‫ﺗﻌﺪﺍﺩ ‪Case‬‬ ‫ﻣﻮﺿﻮﻉ‬ ‫ﺗﻌﺪﺍﺩ ‪Case‬‬ ‫ﻣﻮﺿﻮﻉ‬ ‫ﺗﻌﺪﺍﺩ ‪Case‬‬
‫ﭘﻨﻮﻣﻮﻧﻲ‬ ‫‪٣٠‬‬ ‫ﺍﻧﺴﺪﺍﺩ ﻭ ﭘﺮﻓﻮﺭﺍﺳﻴﻮﻥ‬ ‫‪٨‬‬ ‫‪TB‬‬ ‫‪١٥‬‬ ‫ﻣﺮﺍﻗﺒﺖ ﺑﺤﺮﺍﻧﻲ‬ ‫‪٢٠‬‬
‫ﻛﺎﻧﺴﺮ ﺭﻳﻪ‬ ‫‪١٢‬‬ ‫ﻧﺎﺣﻴﻪ ‪ RUQ‬ﺷﻜﻢ‬ ‫‪١٢‬‬ ‫ﻧﺎﺣﻴﻪ ‪ RLQ‬ﺷﻜﻢ‬ ‫‪٧‬‬ ‫ﻛﻮﻟﻮﻥ ﻭ ﻧﺎﺣﻴﻪ ‪ LLQ‬ﺷﻜﻢ‬ ‫‪١٦‬‬
‫ﻣﺮﻱ‬ ‫‪٦‬‬ ‫ﻣﻌﺪﻩ‬ ‫‪٦‬‬ ‫ﺭﻭﺓ ﺑﺎﺭﻳﻚ‬ ‫‪٧‬‬ ‫ﻣﻄﺎﻟﻌﺎﺕ ﻓﻠﻮﺭﻭﺳﻜﻮﭘﻴﻚ ﺷﻜﻢ‬ ‫‪١‬‬
‫ﭘﻨﻮﻣﻮﻛﻮﻧﻴﻮﺯ‬ ‫‪٩‬‬ ‫‪AIDS‬‬ ‫‪١٢‬‬ ‫ﻗﻠﺐ‬ ‫‪٧‬‬ ‫ﺳﻴﺴﺘﻢ ﺍﺩﺭﺍﺭﻱ ﺗﻨﺎﺳﻠﻲ‬ ‫‪١٣‬‬
‫ﺍﻃﻔﺎﻝ‬ ‫‪١٨‬‬ ‫ﺗﺮﻭﻣﺎ‬ ‫‪١٧‬‬ ‫ﮊﻧﻴﻜﻮﻟﻮﮊﻱ‬ ‫‪٥‬‬ ‫ﺳﻴﺴﺘﻢ ﺍﺳﻜﻠﺘﺎﻝ‬ ‫‪٢٨‬‬
‫‪obstetrics‬‬ ‫‪١٦‬‬ ‫ﺑﻴﻤﺎﺭﻱﻫﺎﻱ ‪Breast‬‬ ‫‪١٨‬‬ ‫ﻧﻮﺭﻭﺭﺍﺩﻳﻮﻟﻮﮊﻱ ﺳﺘﻮﻥ ﻓﻘﺮﺍﺕ‬ ‫‪٣‬‬ ‫ﻧﻮﺭﻭﺭﺍﺩﻳﻮﻟﻮﮊﻱ ﻣﻐﺰ‬ ‫‪١٢‬‬
‫ﭘﺰﺷﻜﻲ ﻫﺴﺘﻪﺍﻱ‬ ‫‪١٣‬‬
‫)‪30.1 Exam Preparation for Diagnostic Ultrasound Abdomen and OB/GYN (RogerC. Sanders, Jann D. Dolk, Nancy Smith Miner‬‬ ‫ــــــ‬
‫‪31.1 Fundamentals of Body CT‬‬ ‫)‪(Second Edition) (W. Richard Webb, M.D. , William E. Brant, M.D. , Clyde A. Helms, M.D.) (Salekan E-Book‬‬ ‫ــــــ‬
‫)‪32.1 Image Data Bank RADIOGRAPHIC ANATOMY & POSITIONING (APPLETON & LANGE‬‬ ‫ــــــ‬
‫‪33.1 Imaging Atlas of Human Anatomy‬‬ ‫)‪(version 2.0‬‬ ‫)‪(Mosby‬‬ ‫‪1998‬‬
‫ﺑﺎ ﻛﻤﻚ ﺍﻳﻦ ﻧﺮﻡﺍﻓﺰﺍﺭ ﻗﺎﺩﺭ ﺧﻮﺍﻫﻴﺪ ﺑﻮﺩ ﻛﻪ ﺩﺭ ﻣﺪﺕ ﺑﺴﻴﺎﺭ ﻛﻮﺗﺎﻫﻲ ﺑﺎ ﺁﻧﺎﺗﻮﻣﻲ ﺑﺪﻥ ﺩﺭ ﺗﺼﺎﻭﻳﺮ ﻣﺨﺘﻠﻒ ﺭﺍﺩﻳﻮﻟﻮﮊﻱ )ﻓﻴﻠﻢﻫﺎﻱ ﺳﺎﺩﻩ‪ ،‬ﺗﺼﺎﻭﻳﺮ ﺑﺎ ﻛﻨﺘﺮﺍﺳـﺖ ﺭﺍﺩﻳﻮﮔﺮﺍﻓﻴـﻚ‪ MRI ، CT Scan ،‬ﻭ ﺳـﻮﻧﻮﮔﺮﺍﻓﻲ( ﺁﺷـﻨﺎ ﺷـﻮﻳﺪ‪ .‬ﺭﻭﺵ ﻳـﺎﺩﮔﻴﺮﻱ ﺁﻧـﺎﺗﻨﻮﻣﻲ‬
‫ﺭﺍﺩﻳﻮﻟﻮﮊﻳﻚ ﺑﺎ ﺍﺳﺘﻔﺎﺩﻩ ﺍﺯ ﺍﻳﻦ ‪ CD‬ﺑﺴﻴﺎﺭ ﺁﺳﺎﻥ ﺑﻮﺩﻩ ﻭ ﺍﻣﻜﺎﻧﺎﺕ ﻣﺨﺘﻠﻔﻲ ﺍﺯ ﻗﺒﻴﻞ ﺑﺰﺭﮒﻧﻤﺎﻳﻲ ﺗﺼﻮﻳﺮ‪ negative ،‬ﻛﺮﺩﻥ ﺗﺼﻮﻳﺮ‪ ،‬ﺧﻮﺩﺁﺯﻣﺎﻳﻲ ﻭ ‪ ...‬ﺟﻬﺖ ﺍﻳﺠﺎﺩ ﻋﻼﻗﻤﻨﺪﺍﻥ ﺑﻴﺸﺘﺮ ﺩﺭ ﺍﻣﺮ ﻳﺎﺩﮔﻴﺮﻱ ﺩﺭ ﻧﻈﺮ ﮔﺮﻓﺘﻪ ﺷﺪﻩ ﺍﺳﺖ‪ .‬ﺿﻤﻨﹰﺎ ﺑﺎ ﺍﺳـﺘﻔﺎﺩﻩ ﺍﺯ ﺁﺭﺍﻳـﺔ‬
‫‪ ، note‬ﻣﻲﺗﻮﺍﻥ ﺑﻪ ﺍﻃﻼﻋﺎﺕ ﻋﻠﻤﻲ ﺍﺿﺎﻓﻲ ﻣﺮﺗﺒﻂ ﺑﺎ ﺗﺼﻮﻳﺮ ﻣﻮﺭﺩ ﻣﻄﺎﻟﻌﻪ ﺩﺳﺘﻴﺎﺑﻲ ﭘﻴﺪﺍ ﻧﻤﻮﺩ‪.‬‬
‫)‪34.1 Imaging of Diffuse Lung Disease (David A. Lynch, MB, John D. Newell Jr, MD, FCCP, Jin Seong Lee, MD‬‬ ‫‪1998‬‬
‫‪ CD‬ﺣﺎﺿﺮ ﺷﺎﻣﻞ ‪ ١١‬ﻓﺼﻞ ﺍﺯ ﺑﻴﻤﺎﺭﻱﻫﺎﻱ ﻣﻨﺘﺸﺮ ﺭﻳﻪ )‪ (DLN‬ﻣﻲﺑﺎﺷﺪ‪ .‬ﻛﻪ ﺑﻪ ﮔﻔﺘﻪ ﻣﺆﻟﻔﻴﻦ ﺷﺎﻣﻞ ﺗﻠﻔﻴﻘﻲ ﺍﺯ ﻣﻌﺎﻳﻨﻪ‪ ،‬ﺷﺮﺡ ﺣﺎﻝ ‪ ،‬ﭘﺎﺗﻮﻓﻴﺰﻳﻮﻟﻮﮊﻱ ﻭ ﺗﻔﺴﻴﺮ ﻋﻜﺲﺑﺮﺩﺍﺭﻱ )‪ MRI,CT-Xray‬ﻭ ‪ (....‬ﺩﺭ ﺍﻃﻔﺎﻝ ﻭ ﺑﺎﻟﻐﻴﻦ ﺩﺭ ﻣﻮﺭﺩ ﺑﻴﻤﺎﺭﻱﻫـﺎﻱ ﻣﻨﺘﺸـﺮ‬
‫ﺭﻳﻪ ﻣﻲﺑﺎﺷﺪ‪.‬‬
‫ﺑﻌﻀﻲ ﻓﺼﻮﻝ ﻛﺘﺎﺏ ﺷﺎﻣﻞ ‪:‬‬
‫ﺍﺭﺯﻳﺎﺑﻲ ﭘﺎﺗﻮﻟﻮﮊﻱ ﺑﻴﻤﺎﺭﻫﺎﻱ ﺭﻳﻪ‬ ‫ﺑﻴﻤﺎﺭﻱﻫﺎﻱ ﺷﻐﻠﻲ ﻭ ﻣﺤﻴﻄﻲ ﻭ‪DLD‬‬ ‫ﭘﻴﻮﻧﺪ ﺭﻳﻪ‬ ‫ﺗﺼﻮﻳﺮﺑﺮﺩﺍﺭﻱ ‪ DLD‬ﻛﻮﺩﻛﺎﻥ ﺗﺼﻮﻳﺮ ﺑﺮﺩﺍﺭﻱ ﻋﺮﻭﻕ ﺭﻳﻮﻱ‬
‫ﺗﺸﺨﻴﺺ ﺍﻓﺘﺮﺍﻗﻲ ﺭﺍﺩﻳﻮﻟﻮﮊﻱ ‪ DLD‬ﻭ ﻣﻘﺎﻳﺴﻪ ‪ X-Ray,CT‬ﺁﻧﻬﺎ ﺑﻪ ﻃﻮﺭ ﻣﺠﺰﺍ ﻣﻲﺑﺎﺷﺪ‬ ‫ﺗﺼﻮﻳﺮﺑﺮﺩﺍﺭﻱ ﺭﺍﻫﻬﺎﻱ ﻫﻮﺍﺋﻲ‬ ‫ﺗﺼﻮﻳﺮﺑﺮﺩﺍﺭﻱ ﺁﻣﻔﻴﺰﻡ‬ ‫ﺗﺼﻮﻳﺮﺑﺮﺩﺍﺭﻱ ﺑﻴﻤﺎﺭﻱﻫﺎﻱ ﺍﻧﻔﻴﻠﺘﺮﺍﺗﻴﻮ ﺭﻳﻪ‬

‫ﺍﻳﻦ ﻛﺘﺎﺏ ﺩﺭ ﺑﺮﻧﺎﻣﻪ ‪ Acrobat Reader‬ﺑﻮﺩﻩ ﻭ ﺑﻪ ﮔﻔﺘﻪ ﻣﺆﻟﻔﻴﻦ ﻧﮕﺎﻫﻲ ﺟﺪﻳﺪ ﺑﻪ ﻣﺘﺨﺼﺼﻴﻦ ﻭ ﺭﺯﻳﺪﻧﺖﻫﺎﻱ ﺩﺍﺧﻠﻲ‪ ،‬ﺭﻳﻪ ‪ ،‬ﻗﻠﺐ ﻭ ﺭﺍﺩﻳﻮﻟﻮﮊﻱ ﻣﻲﺩﻫﺪ‪.‬‬
‫)‪35.1 Imaging of Spinal Trauma in Children (Lawrence R. Kuhns, M.D.) (University of Michigan Medical Center‬‬ ‫___‬
‫ﻋﻨﺎﻭﻳﻦ ﺍﻳﻦ ‪ CD‬ﺷﺎﻣﻞ‪:‬‬
‫‪Principles AND TECHNIQUES‬‬ ‫‪ATLAS OF SPINAL INJURIES IN CHILDREN‬‬
‫‪Epidemiology‬‬ ‫‪Normal Spine Variants and Anatomy‬‬ ‫‪Special Views and Techniques‬‬ ‫‪Cervcal Spine‬‬ ‫‪Lumbar Spine‬‬
‫‪Measurements‬‬ ‫‪Mechanisms and Patterns of Injury‬‬ ‫‪Experimental and Necropsy Data‬‬ ‫‪Thoracic Spine‬‬ ‫‪Sacrococcygeal Spine‬‬
‫‪Occipitocervical Injuries‬‬ ‫‪Thoracic Spine Injuries‬‬ ‫‪Sacral Injuries‬‬ ‫‪Lumbar‬‬
‫)‪36.1 MAGNETIC RESONANCE IMAGING (Third Edition) (Dauld Stark, William Bradley‬‬ ‫ــــــ‬
‫ﺳﻪ ﺟﻠﺪ ﻛﺘﺎﺏ ‪ David Stark‬ﺩﺭ ﺍﻳﻦ ‪ CD‬ﻣﻮﺟﻮﺩ ﻣﻴﺒﺎﺷﺪ‪.‬‬
‫‪1. Generation and Manipulation of Magnetic Resonance Images‬‬ ‫‪2. Magnetic Resonance: Bioeffects and Safety‬‬
‫‪3. Three-Dimensional Magnetic Resonance Rendering Technique‬‬ ‫‪4. Principles of Echo Planar Imaging: Implications for Musculoskeletal System‬‬
‫‪5. MR Imaging of Articular Cartilage and of Cartilage Degneration‬‬ ‫‪6. The Hip‬‬ ‫‪7. The Knee‬‬ ‫‪8. The Ankle and Foot‬‬

‫ﺗﻠﻔﻦ‪٠٩١٢١٣٧٢٣٦١-٦٦٩٣٦٦٩٦ :‬‬ ‫ﻧﺸﺎﻧﻲ‪ :‬ﺗﻬﺮﺍﻥ‪ ،‬ﻡ ﺍﻧﻘﻼﺏ‪ ،‬ﺥ ﻛﺎﺭﮔﺮ ﺟﻨﻮﺑﻲ‪ ،‬ﺥ ﻟﺒﺎﻓﻲﻧﮋﺍﺩ‪ ،‬ﺑﻴﻦ ﻛﺎﺭﮔﺮ ﻭ ﺟﻤﺎﻟﺰﺍﺩﻩ‪ ،‬ﺑﻦﺑﺴﺖ ﺳﻴﻤﻴﻦ‪ ،‬ﭘﻼﻙ ‪٢٣٩‬‬ ‫ﻣﺮﻛﺰ ﺧﺪﻣﺎﺕ ﻓﺮﻫﻨﮕﻲ ﺳﺎﻟﻜﺎﻥ ‪ :‬ﺍﺭﺍﺋﻪ ﻛﻨﻨﺪﺓ ﻛﺘﺎﺏ ﻭ ﺳﻲﺩﻱﻫﺎﻱ ﺗﺨﺼﺼﻲ ﭘﺰﺷﻜﻲ‬
 ‫‪6‬‬
‫‪9. The Shoulder‬‬ ‫‪10. The Elbow‬‬ ‫‪11. The Wrist and hand‬‬ ‫‪12. The Temporomandibular Joint‬‬ ‫‪13. Kinematic Magnetic Resonance Imaging 14. The Spine‬‬
‫‪15. Marrow Imaging 16. Bone and Soft-Tissue Tumors 17. Magnetic Resonance Imaging of Muscle Injuries‬‬
‫‪37.1‬‬ ‫)‪Magnetic Resonance Imaging computed Tomography of the Head and Spine (C. Barrie Grossman‬‬
‫)‪38.1 Magnetic Resonance Imaging in Orthopedics and Sport Medicine (David W. Stoller‬‬ ‫ــــــ‬
‫ﺍﻳﻦ ﻧﺮﻡﺍﻓﺰﺍﺭ ﺩﺭ ﺍﺭﺗﺒﺎﻁ ﺑﺎ ﻛﺎﺭﺑﺮﺩ ‪ MRI‬ﺩﺭ ﺍﺭﺗﻮﭘﺪﻱ ﻭ ﻃﺐ ﻭﺭﺯﺵ ﻣﻲﺑﺎﺷﺪ ﻭ ﺷﺎﻣﻞ ﻣﺒﺎﺣﺚ ﺯﻳﺮ ﺍﺳﺖ‪:‬‬
‫‪ -١‬ﺗﻬﻴﺔ ﺗﺼﺎﻭﻳﺮ ‪MRI‬‬ ‫‪ -٦‬ﺍﺛﺮﺍﺕ ﺑﻴﻮﻟﻮﮊﻳﻚ ﻭ ﺍﻳﻤﻨﻲ ﺩﺭ ‪MRI‬‬ ‫‪ -١١‬ﺗﻜﻨﻴﻚ ﺑﺎﺯﺳﺎﺯﻱ ﺟﻬﺖ ‪ MRI‬ﺳﻪﺑﻌﺪﻱ‬ ‫‪ -١٦‬ﺗﻮﻣﻮﺭﻫﺎﻱ ﺍﺳﺘﺨﻮﺍﻥ ﻭ ﺑﺎﻓﺖ ﻧﺮﻡ‬
‫‪ -٢‬ﺍﺻﻮﻝ ﺗﺼﻮﻳﺮﺳﺎﺯﻱ ‪ Echo-Planar‬ﺟﻬﺖ ﺳﻴﺴﺘﻢ ﻣﻮﺳﻜﻮﻟﻮﺍﺳﻜﻠﺘﺎﻝ‬ ‫‪ MRI -٧‬ﻋﻀﺮﻭﻑ ﻣﻔﺼﻠﻲ ﻭ ﺩﮊﻧﺮﺍﺳﻴﻮﻥ ﻋﻀﺮﻭﻓﻲ‬ ‫‪ -١٢‬ﻣﻔﺼﻞ ﺭﺍﻥ )‪(Hip‬‬ ‫‪ MRI -١٧‬ﺁﺳﻴﺒﻬﺎﻱ ﻋﻀﻼﻧﻲ‬
‫‪ -٣‬ﺯﺍﻧﻮ‬ ‫‪ -٨‬ﻣﭻ ﭘﺎ ﻭ ﭘﺎ‬ ‫‪ -١٣‬ﺷﺎﻧﻪ‬
‫‪ -٤‬ﺁﺭﻧﺞ‬ ‫‪ -٩‬ﻣﭻ ﺩﺳﺖ ﻭ ﺩﺳﺖ‬ ‫‪ -١٤‬ﻣﻔﺼﻞ ﻛﻤﭙﻮﺭﻭﻣﺎﻧﺪﻳﺒﻮﻻﺭ )‪(TMJ‬‬
‫‪Kinematic MRI -٥‬‬ ‫‪ -١٠‬ﺳﺘﻮﻥ ﻓﻘﺮﺍﺕ‬ ‫‪ -١٥‬ﺗﺼﻮﻳﺮﺑﺮﺩﺍﺭﻱ ‪ MRI‬ﺍﺯ ﻣﻐﺰ ﺍﺳﺘﺨﻮﺍﻥ‬
‫‪39.1 Mammography Diagnosis and Intervention‬‬ ‫)‪(Ralphl. Smathers, M.D.‬‬ ‫‪2000‬‬
‫ﺩﺭ ﺍﻳﻦ ‪ CD‬ﻣﻄﺎﻟﺒﻲ ﺩﺭ ﺭﺍﺑﻄﻪ ﺑﺎ ﻣﺎﻣﻮﮔﺮﺍﻓﻲ ﺑﺎ ﻋﻨﺎﻭﻳﻦ ﺫﻳﻞ ﻣﻄﺮﺡ ﺷﺪﻩ ﺍﺳﺖ‪:‬‬
‫‪ -‬ﺗﻮﺩﻩﻫﺎﻳﻲ ﺑﺎ ﺣﺪﻭﺩ ﻧﺎﻣﺸﺨﺺ ﻭ ﺗﻮﻣﻮﺭﻫﺎﻱ ﺑﺪﺧﻴﻢ ﻭ ‪Aggressive‬‬ ‫‪ -‬ﺗﻐﻴﻴﺮﺍﺕ ﻓﻴﺒﺮﻭﻛﻴﺴﺘﻴﻚ ﻭ ﺗﻮﺩﻩﻫﺎﻳﻲ ﺑﺎ ﺣﺪﻭﺩ ﻣﺸﺨﺺ ﻭ ﺧﻮﺵﺧﻴﻢ‬ ‫‪ -‬ﺗﻐﻴﻴﺮﺍﺕ ﺯﻣﺎﻥ ﻭ ﺁﺭﺗﻔﻜﺖﻫﺎ‬ ‫‪ -‬ﺁﻧﺎﺗﻮﻣﻲ ﻧﺮﻣﺎﻝ ﭘﺴﺘﺎﻥ‬
‫‪ -‬ﺑﺮﺭﺳﻲ ﺑﻴﻤﺎﺭﻱﻫﺎﻱ ﭘﻴﺸﺮﻓﺘﻪ ﻭ ﻣﺘﺎﺳﺘﺎﺯ ﻭ ﻫﻤﭽﻨﻴﻦ ﺩﺭ ﻣﻮﺭﺩ ﺭﺍﺩﻳﻮﺗﺮﺍﭘﻲ‬ ‫‪ -‬ﺭﻭﺵﻫﺎﻱ ﺍﻧﺠﺎﻡ ﻣﺎﻣﻮﮔﺮﺍﻓﻲ )ﺑﻪ ﺻﻮﺭﺕ ﻟﻮﻛﺎﻟﻴﺰﻩ ﺑﺎ ‪ Needle‬ﻭ ﻳﺎ ﺳﻮﻧﻮﮔﺮﺍﻓﻲ(‬
‫)‪40.1 MR Angiography Thoracic Vessels (O. Ratib & D. Didier‬‬ ‫‪2001‬‬
‫‪Methods & Techniques‬‬ ‫‪Aortic Aneurysms‬‬ ‫‪Aortic Arch Anomalies‬‬ ‫‪Aortic Arch Anomalies‬‬ ‫‪Aortic Coarcation‬‬
‫‪Aortitis‬‬ ‫‪Pulmonary astesies diseases‬‬ ‫‪Aequised venous diseases‬‬ ‫‪Congenital venous anomalies‬‬ ‫‪Miscellaneous‬‬
‫)‪41.1 MR Imagin Expert (Geir Torhim, Peter A. Rinck‬‬ ‫‪4th Edition‬‬ ‫‪2001‬‬
‫"‪This version is a special adaptation for "Magnetic Resonance in Medicine The Basic Textbook of the European Magnetic Redonance Forum‬‬
‫‪42.1 MRI der Extremitaten‬‬ ‫ــــــ‬
‫)‪43.1 MRI of the BRAIN & SPINE (SCOT W. ATLAS) (LIPPINCOTT-ROVEN‬‬ ‫ــــــ‬

‫ﺍﻳﻦ ‪ CD‬ﻳﻚ ﻧﺮﻡﺍﻓﺰﺍﺭ ﺁﻣﻮﺯﺷﻲ ﭼﻨﺪﻣﻨﻈﻮﺭﻩ ﺑﻪ ﺣﺴﺎﺏ ﻣﻲﺁﻳﺪ ﺯﻳﺮﺍ ﺩﺭ ﺁﻥ‪ ،‬ﻋﻼﻭﻩ ﺑﺮ ﺗﻮﺿﻴﺤﺎﺕ ﻻﺯﻡ ﻭ ﺩﺭ ﻋﻴﻦ ﺣﺎﻝ ﻣﺨﺘﺼﺮ ﺩﺭ ﻣﻮﺭﺩ ﻓﻴﺰﻳﻚ ﻭ ﺍﺻﻮﻝ ‪ MRI‬ﻭ ﻫﻤﭽﻨﻴﻦ ﺗﻜﻨﻴﻜﻬﺎﻱ ﻣﺮﺑﻮﻃﻪ‪ ،‬ﺩﺭ ﻣﻮﺭﺩ ﻫﺮ ﻣﺒﺤﺚ ﺑﺎﻟﻴﻨﻲ ﻧﻴﺰ ﺩﺭ ﻃﻲ ‪ ٣٢‬ﻓﺼﻞ ﺑﻪ ﺑﺤﺚ ﻭ ﺑﺮﺭﺳﻲ ﻳﺎﻓﺘﻪﻫﺎﻱ ‪ Imaging‬ﭘﺮﺩﺍﺧﺘﻪ‬
‫ﺷﺪﻩ ﻭ ﺑﻴﺶ ﺍﺯ ‪ ٤٠٠٠‬ﺗﺼﻮﻳﺮ ‪ MRI‬ﺑﺎ ﻛﻴﻔﻴﺖ ﺑﺎﻻ ﺑﺮﺣﺴﺐ ﻣﻮﺭﺩ ﺑﻪ ﻧﻤﺎﻳﺶ ﺩﺭﺁﻣﺪﻩ ﺍﺳﺖ‪ .‬ﺿﻤﻨﹰﺎ ﺑﺮﺍﻱ ﻓﻬﻢ ﺑﻬﺘﺮ ﻣﻄﺎﻟﺐ‪ ،‬ﺩﺭ ﺍﺭﺗﺒﺎﻁ ﺑﺎ ﻫﺮ ﻣﻮﺿﻮﻉ ﺑﺎﻟﻴﻨﻲ ﻭ ﻳﺎ ﺗﺼﻮﻳﺮﺑﺮﺩﺍﺭﻱ ﺍﺯ ﺟﺪﺍﻭﻝ ﻣﻔﻴﺪ ﺍﺳﺘﻔﺎﺩﻩ ﺷﺪﻩ ﺍﺳﺖ‪ .‬ﺩﺭ ﻗﺴﻤﺖ ﺁﻧﺎﺗﻮﻣﻲ ﻧﻴﺰ‪ ،‬ﻧﻮﺭﻭﺁﻧﺎﺗﻮﻣﻲ ﺑﻪ ﺻﻮﺭﺕ ‪ Sectional‬ﻭ ﺑﺎ ﺍﺳﺘﻔﺎﺩﻩ ﺍﺯ ﺳﻪ‬
‫ﺭﻭﺵ )ﺗﺼﺎﻭﻳﺮ ﺷﻤﺎﺗﻴﻚ ‪ +‬ﺗﺼﺎﻭﻳﺮ ﻃﺒﻴﻌﻲ‪ +‬ﺗﺼﺎﻭﻳﺮ ‪ (MRI‬ﺁﻣﻮﺯﺵ ﺩﺍﺩﻩ ﺷﺪﻩ ﺍﺳﺖ‪ .‬ﻧﻜﺘﺔ ﺑﺴﻴﺎﺭ ﺟﺎﻟﺐ ﺩﺭ ﺍﻳﻦ ﻧﺮﻡﺍﻓﺰﺍﺭ‪ ،‬ﺧﻮﺩﺁﺯﻣﺎﻳﻲ ﻣﻄﺎﻟﺐ ﻣﻄﺎﻟﻌﻪ ﺷﺪﻩ ﺑﻮﺳﻴﻠﻪ ‪ Case‬ﻫﺎﻱ ﻣﺘﻌﺪﺩ ﺍﺳﺖ ﻛﻪ ﺑﺮﺣﺴﺐ ﻣﻮﺿﻮﻉ ‪ ،‬ﺗﻌﺪﺍﺩ ‪ Case‬ﻫﺎﻱ ﻣﻄﺮﺡ ﺷﺪﻩ ﺑﻪ ﻗﺮﺍﺭ ﺯﻳﺮ ﻣﻲﺑﺎﺷﺪ‪:‬‬
‫ﻣﻮﺿﻮﻉ‬ ‫ﺗﻌﺪﺍﺩ ‪ Case‬ﻫﺎﻱ ﻣﻄﺮﺡ ﺷﺪﻩ‬ ‫ﻣﻮﺿﻮﻉ‬ ‫ﺗﻌﺪﺍﺩ ‪ Case‬ﻫﺎﻱ ﻣﻄﺮﺡ ﺷﺪﻩ‬
‫ﺍﺧﺘﻼﻻﺕ ﺗﻜﺎﻣﻠﻲ ﻣﻐﺰ‬ ‫‪٧‬‬ ‫ﺧﻮﻧﺮﻳﺰﻱ ﺍﻳﻨﺘﺮﺍﻛﺮﻳﻨﺎﻝ‬ ‫‪٥‬‬
‫ﺗﻮﻣﻮﺭﻫﺎﻱ ﺍﻳﻨﺘﺮﺍﺁﮔﺰﻳﺎﻝ ﻣﻐﺰ‬ ‫‪٦‬‬ ‫ﺗﻮﻣﻮﺭﻫﺎﻱ ﺍﻛﺴﺘﺮﺍﺁﮔﺰﻳﺎﻝ ﻣﻐﺰ‬ ‫‪٦‬‬
‫ﻣﺎﻟﻔﻮﺭﻣﺎﺳﻴﻮﻧﻬﺎﻱ ﻋﺮﻭﻗﻲ ﻭ ﺁﻧﻮﺭﻳﺴﻢﻫﺎﻱ ﺍﻳﻨﺘﺮﺍﻛﺮﺍﻳﻨﺎﻝ‬ ‫‪٦‬‬ ‫ﺍﻳﺴﻜﻤﻲ ﻭ ﺁﻧﻔﺎﺭﻛﺘﻮﺱ ﻣﻐﺰﻱ‬ ‫‪٦‬‬
‫ﺗﺮﻭﻣﺎﻱ ﺳﺮ‬ ‫‪٥‬‬ ‫ﺑﻴﻤﺎﺭﻳﻬﺎﻱ ﻣﺎﺩﺓ ﺳﻔﻴﺪ‬ ‫‪٦‬‬
‫ﻋﻔﻮﻧﺖﻫﺎﻱ ﺍﻳﻨﺘﺮﺍﻛﺮﺍﻳﻨﺎﻝ‬ ‫‪٥‬‬ ‫ﺗﻈﺎﻫﺮﺍﺕ ﺳﻴﺴﺘﻢ ﺍﻋﺼﺎﺏ ﻣﺮﻛﺰﻱ ﺩﺭ ﺍﺭﺗﺒﺎﻁ ﺑﺎ ﻓﺎﻛﻮﻣﺎﺗﻮﺭﻫﺎ‬ ‫‪٦‬‬
‫‪ Aging‬ﻣﻐﺰ ﻭ ﺑﻴﻤﺎﺭﻳﻬﺎﻱ ﻧﻮﺭﻭﺩﮊﻧﺮﺍﻳﺘﻮ‬ ‫‪٤‬‬ ‫ﺳﻼﺗﻮﺭﺳﻴﻜﺎ ﻭ ﻧﺎﺣﻴﻪ ﭘﺎﺭﺍﺳﻼﺭ‬ ‫‪٥‬‬
‫ﻗﺎﻋﺪﺓ ﺟﻤﺠﻤﻪ‬ ‫‪٥‬‬ ‫ﺁﻧﺎﺗﻮﻣﻲ ﻭ ﺑﻴﻤﺎﺭﻱﻫﺎﻱ ﺍﺳﺘﺨﻮﺍﻥ ﻛﻤﭙﻮﺭﺍﻝ‬ ‫‪٣‬‬
‫ﺍﻭﺭﺑﻴﺖ ﻭ ﺳﻴﺴﺘﻢ ﺑﻴﻨﺎﻳﻲ‬ ‫‪٦‬‬ ‫ﺑﻴﻤﺎﺭﻳﻬﺎﻱ ﺍﮊﻧﺮﺍﻳﺘﻮ ﺳﺘﻮﻥ ﻓﻘﺮﺍﺕ‬ ‫‪٥‬‬
‫ﺗﺮﻭﻣﺎﻱ ﺳﺘﻮﻥ ﻓﻘﺮﺍﺕ‬ ‫‪٣‬‬ ‫ﺑﻴﻤﺎﺭﻳﻬﺎﻱ ﻋﻔﻮﻧﻲ ﻭ ﺍﻟﺘﻬﺎﺑﻲ ﺳﺘﻮﻥ ﻓﻘﺮﺍﺕ‬ ‫‪٤‬‬
‫ﺁﻧﺎﻣﺎﻟﻴﻬﺎﻱ ﻣﺎﺩﺭﺯﺍﺩﻱ ﺳﺘﻮﻥ ﻓﻘﺮﺍﺕ ﻭ ﻧﺨﺎﻉ‬ ‫‪٣‬‬ ‫ﺑﻴﻤﺎﺭﻳﻬﺎﻱ ﻧﺌﻮﭘﻼﺳﺘﻴﻚ ﺳﺘﻮﻥ ﻓﻘﺮﺍﺕ ﻭ ﻧﺨﺎﻉ‬ ‫‪٥‬‬
‫ﺍﺧﺘﻼﻻﺕ ﻋﺮﻭﻕ ﻧﺨﺎﻋﻲ‬ ‫‪٢‬‬
‫)‪44.1 Normal Findings in CT and MRI (Torsten B Moeller, Emil Reif) (Thieme‬‬ ‫‪2000‬‬

‫ﺗﻠﻔﻦ‪٠٩١٢١٣٧٢٣٦١-٦٦٩٣٦٦٩٦ :‬‬ ‫ﻧﺸﺎﻧﻲ‪ :‬ﺗﻬﺮﺍﻥ‪ ،‬ﻡ ﺍﻧﻘﻼﺏ‪ ،‬ﺥ ﻛﺎﺭﮔﺮ ﺟﻨﻮﺑﻲ‪ ،‬ﺥ ﻟﺒﺎﻓﻲﻧﮋﺍﺩ‪ ،‬ﺑﻴﻦ ﻛﺎﺭﮔﺮ ﻭ ﺟﻤﺎﻟﺰﺍﺩﻩ‪ ،‬ﺑﻦﺑﺴﺖ ﺳﻴﻤﻴﻦ‪ ،‬ﭘﻼﻙ ‪٢٣٩‬‬ ‫ﻣﺮﻛﺰ ﺧﺪﻣﺎﺕ ﻓﺮﻫﻨﮕﻲ ﺳﺎﻟﻜﺎﻥ ‪ :‬ﺍﺭﺍﺋﻪ ﻛﻨﻨﺪﺓ ﻛﺘﺎﺏ ﻭ ﺳﻲﺩﻱﻫﺎﻱ ﺗﺨﺼﺼﻲ ﭘﺰﺷﻜﻲ‬
 ‫‪7‬‬
‫‪20.3 Obstetric Ultrasound Principles and Techniques‬‬ ‫ــــــ‬
‫ﺩﺭ ﺍﻳﻦ ‪ CD‬ﻣﻄﺎﻟﺐ ﺟﺎﻣﻊ ﻭ ﺍﺭﺯﻧﺪﻩﺍﻱ ﺩﺭ ﺭﺍﺑﻄﻪ ﺑﺎ ﻣﻬﺎﺭﺕﻫﺎﻱ ﻻﺯﻣﻪ ﺩﺭ ﺳﻮﻧﻮﮔﺮﺍﻓﻲ ﻣﺎﻣﺎﺋﻲ ﺍﺭﺍﺋﻪ ﻣﻲﺷﻮﺩ ﻛﻪ ﻋﻨﺎﻭﻳﻦ ﺁﻥ ﺑﻪ ﺷﺮﺡ ﺯﻳﺮ ﻣﻲﺑﺎﺷﺪ‪:‬‬
‫‪ -‬ﺑﺮﺭﺳﻲ ﺁﻧﺎﺗﻮﻣﻲ ﺟﻨﻴﻦ ﻭ ﺁﻧﻮﻣﺎﻟﻲﻫﺎﻱ ‪ CNS‬ﻭ ‪Body‬‬ ‫‪ -‬ﺗﻌﻴﻴﻦ ﺳﻦ ﺣﺎﻣﻠﮕﻲ ﺑﺮ ﺍﺳﺎﺱ ﻣﻌﻴﺎﺭﻫﺎﻱ ‪ FL . BPD‬ﻭ ‪ AC‬ﻭ ‪ HC‬ﻭ ﺟﺪﺍﻭﻝ ﺁﻧﻬﺎ‬
‫‪ -‬ﺁﻧﺎﺗﻮﻣﻲ ﺭﺣﻢ ﻭ ﺁﺩﻧﻜﺲﻫﺎ ﻭ ﺍﻣﺒﺮﻳﻮ ﻭ ﻛﻴﺴﻪ ﺯﺭﺩﻩ ﺩﺭ ﺗﺮﻳﻤﺴﺘﺮ ﺍﻭﻝ‬ ‫‪ -‬ﺗﻌﻴﻴﻦ ﺳﻦ ﺑﺎﺭﺩﺍﺭﻱ ﺩﺭ ﺗﺮﻳﻤﺴﺘﺮ ﺍﻭﻝ ﺑﺮ ﺍﺳﺎﺱ ‪ Gs‬ﻭ ‪ CRL‬ﻭ ﻧﺤﻮﺓ ﺍﻧﺪﺍﺯﻩﮔﻴﺮﻱ ﺁﻧﻬﺎ‬
‫‪ -‬ﺗﻌﻴﻴﻦ ﺳﻦ ﺑﺎﺭﺩﺍﺭﻱ ﺩﺭ ﺗﺮﻳﻤﺴﺘﺮ ﺩﻭﻡ ﻭ ﺳﻮﻡ ﺑﺮ ﺍﺳﺎﺱ ‪ FL‬ﻭ ‪ AC‬ﻭ ﻧﺤﻮﻩ ﺍﻧﺪﺍﺯﻩﮔﻴﺮﻱ ﺁﻧﻬﺎ‬ ‫‪ -‬ﺗﻌﻴﻴﻦ ﺳﻦ ﺑﺎﺭﺩﺍﺭﻱ ﺩﺭ ﺗﺮﻳﻤﺴﺘﺮ ﺩﻭﻡ ﻭ ﺳﻮﻡ ﺑﺮ ﺍﺳﺎﺱ ﺩﻭﺭ ﺳﺮ ﻭ ﻧﺤﻮﻩ ﺍﻧﺪﺍﺯﻩﮔﻴﺮﻱ ﺁﻥ‬
‫‪ -‬ﺗﻌﻴﻴﻦ ﻣﺤﻞ ﺟﻔﺖ ﻭ ﺣﺠﻢ ﻣﺎﻳﻊ ﺁﻣﻨﻴﻮﺗﻴﻚ‬ ‫‪ -‬ﻣﻄﺎﻟﺐ ﺟﺎﻟﺒﻲ ﺩﺭ ﺭﺍﺑﻄﻪ ﺑﺎ ﺁﻧﺎﺗﻮﻣﻲ ﺟﻨﻴﻦ ﺩﺭ ﺗﺮﻳﻤﺴﺘﺮ ﺩﻭﻡ ﻭ ﺳﻮﻡ )ﻣﻌﺪﻩ‪ -‬ﻛﻠﻴﻪ ‪(........‬‬
‫‪ -‬ﺍﻧﻔﺎﺭﻛﺘﻮﺱ ﻭ ﻭﺍﺭﻳﺎﺳﻴﻮﻥ ﻣﺤﻞ ﺧﺮﻭﺝ ﺑﻨﺪ ﻧﺎﻑ )‪(Cord Insertion‬‬ ‫‪ -‬ﺗﻌﻴﻴﻦ ﻣﺤﻞ ﻻﻧﻪﮔﺰﻳﻨﻲ ﺟﻔﺖ ﻭ ﺑﺮﺭﺳﻲ ﺭﻛﻮﻟﻤﺎﻥ ﻭ ﭘﻼﻧﺘﺎﭘﺮﻭﻳﺎ‬
‫‪ -‬ﺑﺮﺭﺳﻲ ﻟﻜﻴﻨﻴﻜﺎﻝ ﻭ ﺳﻮﻧﻮﮔﺮﺍﻓﻲ ‪ Case Study‬ﻭ ﻣﻄﺮﺡﻛﺮﺩﻥ ﺳﺆﺍﻻﺕ ﺩﺭ ﺭﺍﺑﻄﻪ ﺑﺎ ﺁﻧﻬﺎ ﻭ ﭘﺎﺳﺦ ﻣﺮﺑﻮﻃﻪ‬ ‫‪ -‬ﺗﻮﺿﻴﺤﺎﺗﻲ ﺩﺭ ﺭﺍﺑﻄﻪ ﺑﺎ ‪) BPP‬ﺑﻴﻮﻓﻴﺰﻳﻜﺎﻝ ﭘﺮﻭﻓﺎﻳﻞ(‬
‫‪45.1 PEDIATRIC GASTROINTESTINAL IMAGING AND INTERVENTION‬‬ ‫)‪(Second Edition‬‬ ‫)‪(DAVID A. STRINGER, PAUL S. BABYN, MDCM‬‬ ‫ــــــ‬
‫)‪46.1 Peripheral Musculoskeletal Ultrasound Interactive Atlas A CD-ROM (J. E. Cabay, B. Daenen) (R. F. Dondelinger‬‬ ‫ــــــ‬
‫ﺁﻣﻮﺯﺵ ﺳﻮﻧﻮﮔﺮﺍﻓﻲ ‪ MusculoSkeletal‬ﻣﺤﺴﻮﺏ ﻧﻤﻮﺩ ﭼﺮﺍ ﻛﻪ ﺑﺎ ﻛﻤﻚ ﺗﺼﺎﻭﻳﺮ ﺛﺎﺑﺖ ﻭ ﻣﺘﺤﺮﻙ ﻣﺘﻌﺪﺩ ﻭ ﺗﻴﭙﻴﻚ‪ ،‬ﺷﻤﺎ ﺭﺍ ﺑﻪ ﺧﻮﺑﻲ ﺑﺎ ﺗﻜﻨﻴﻚﻫﺎﻱ ﻻﺯﻡ ﺟﻬﺖ ﺳﻮﻧﻮﮔﺮﺍﻓﻲ ﻧﺴﻮﺝ ﻧﺮﻡ ﺳﻄﺤﻲ ﻭ ﺗﺼﺎﻭﻳﺮ ﻧﺮﻣﺎﻝ ﻭ ﭘﺎﺗﻮﻟﻮﮊﻱﻫﺎﻱ ﺍﻳﻦ ﺳﻴﺴﺘﻢ ﺁﺷﻨﺎ ﻣﻲﺳﺎﺯﺩ ﻭ ﺿـﻤﻨﹰﺎ ﺍﻣﻜـﺎﻥ‬
‫ﺧﻮﺩﺁﺯﻣﺎﻳﻲ )‪ (Quiz‬ﺩﺭ ﺍﻳﻦ ﻧﺮﻡﺍﻓﺰﺍﺭ ﻓﺮﺍﻫﻢ ﺍﺳﺖ‪ .‬ﺩﺭ ﻣﻨﻮﻱ ﺍﻳﻦ ‪ CD‬ﺷﻤﺎ ﺑﺮﺍﻱ ﺑﺮﺭﺳﻲ ﺗﺼﺎﻭﻳﺮ ﺳﻮﻧﻮﮔﺮﺍﻓﻴﻚ ﻧﺮﻣﺎﻝ ﻭ ﻳﺎ ﭘﺎﺗﻮﻟﻮﮊﻳﻚ ﺩﺭ ﺳﻴﺴﺘﻢ ﻣﻮﺳﻜﻮﻟﻮ ﺍﺳﻜﻠﺘﺎﻝ ﺍﺯ ﺩﻭ ﺷﻴﻮﺓ ﻣﺨﺘﻠﻒ ﻣﻲﺗﻮﺍﻧﻴﺪ ﺑﻬﺮﻩﻣﻨﺪ ﺷﻮﻳﺪ‪:‬‬
‫ﺍﻟﻒ‪ -‬ﺑﺎ ﺍﺳﺘﻔﺎﺩﻩ ﺍﺯ ﻣﻨﻮﻱ ‪ :General‬ﻛﻪ ﺩﺭ ﺍﻳﻦ ﺻﻮﺭﺕ ﺷﻤﺎ ﻳﻜﻲ ﺍﺯ ‪item‬ﻫﺎﻱ ﺯﻳﺮ ﺭﺍ ﻣﻲﺗﻮﺍﻧﻴﺪ ﺍﻧﺘﺨﺎﺏ ﻧﻤﺎﺋﻴﺪ‪:‬‬
‫‪ -١‬ﻋﻀﻠﻪ‬ ‫‪ -٢‬ﺗﺎﻧﺪﻭﻥ‬ ‫‪ -٣‬ﻟﻴﮕﺎﻣﺎﻥ‬ ‫‪ -٤‬ﺍﺳﺘﺨﻮﺍﻥ ﻭ ﭘﺮﻳﻮﺳﺖ‬ ‫‪ -٥‬ﻛﭙﺴﻮﻝ ﻣﻔﺼﻠﻲ ﻭ ﺑﻮﺭﺱ‬ ‫‪ -٦‬ﻏﻀﺮﻭﻑ ﻫﻴﺎﻟﻴﻦ‬ ‫‪ -٧‬ﻏﻀﺮﻭﻑ ﻓﻴﺒﺮﻭ‬ ‫‪ -٨‬ﻋﺮﻭﻕ‬ ‫‪ -٩‬ﻋﺼﺐ‬ ‫‪ -١٠‬ﭘﻮﺳﺖ‬
‫ﺏ‪ -‬ﺑﺎ ﺍﺳﺘﻔﺎﺩﻩ ﺍﺯ ﻣﻨﻮﻱ ‪ :Region‬ﻛﻪ ﺩﺭ ﺍﻳﻦ ﺻﻮﺭﺕ ﺷﻤﺎ ﻣﻲﺗﻮﺍﻧﻴﺪ ﻳﻜﻲ ﺍﺯ ‪item‬ﻫﺎﻱ ﺯﻳﺮ ﺭﺍ ﺍﻧﺘﺨﺎﺏ ﻧﻤﺎﺋﻴﺪ‪:‬‬
‫‪8- Wrist‬‬ ‫‪7- Shoulder‬‬ ‫‪6- Knee‬‬ ‫‪5- Hip‬‬ ‫‪4- Hand‬‬ ‫‪3- Foot‬‬ ‫‪2- Elbow‬‬ ‫‪1- Ankle‬‬
‫‪47.1 Principles of MRI‬‬ ‫ــــــ‬
‫‪48.1 Quality Management in the Imaging sciences‬‬ ‫)‪(Jeery Papp) (Mosby‬‬ ‫‪2002‬‬
‫‪49.1 RADIOLOGIC ANATOMY‬‬ ‫‪Interactive Tutorial on Normal Radiology‬‬ ‫)‪(UNIVERSITY OF FLORIDA COLLEGE OF MEDICINE DEPARTMENT OF RADIOLOGY‬‬ ‫ــــــ‬

‫ﻼ ﺍﮔﺮ ﻣﻲﺧﻮﺍﻫﻴﻢ ﺩﺭ ﻣﻮﺭﺩ ‪ (Lower Extremity‬ﺍﻃﻼﻋﺎﺕ ﺁﻧﺎﺗﻮﻣﻴﻚ ﺭﺍﺩﻳﻮﻟﻮﮊﻱ ﺑﺪﺳﺖ ﺁﻭﺭﻳﻢ ﺑﺮ ﺭﻭﻱ ﺍﻧـﺪﺍﻡ ﺗﺤﺘـﺎﻧﻲ ﺷـﻜﻞ ﻣـﺬﻛﻮﺭ‬ ‫ﺑﺮﺍﻱ ﺍﺳﺘﻔﺎﺩﻩ ﺍﺯ ﺍﻳﻦ ‪ ، CD‬ﺍﺑﺘﺪﺍ ﺑﺎﻳﺪ ﺑﺮ ﺭﻭﻱ ﻗﺴﻤﺖ ﻣﻮﺭﺩ ﻧﻈﺮ ﺑﺮ ﺭﻭﻱ ﺷﻜﻞ ﺍﻧﺴﺎﻥ )ﺩﺭ ﻛﺎﺩﺭ ﺳﻤﺖ ﺭﺍﺳﺖ( ‪ Click‬ﺷﻮﺩ )ﻣﺜ ﹰ‬
‫‪ Click‬ﻣﻲﻛﻨﻴﻢ(‪ ،‬ﺳﭙﺲ ﺩﺭ ﻛﺎﺩﺭ ﺳﻤﺖ ﭼﭗ ﻟﻴﺴﺖ ﻗﺴﻤﺖﻫﺎﻱ ﻛﻠﻲ ﻣﺮﺑﻮﻁ ﺑﻪ ﻧﺎﺣﻴﻪ ﺁﻧﺎﺗﻮﻣﻴﻚ ﻣﻮﺭﺩ ﻣﻄﺎﻟﻌﻪ ﻇﺎﻫﺮ ﻣﻲﺷﻮﺩ ﻭ ﻣﺎ ﻣﻲﺗﻮﺍﻧﻴﻢ ﺑﺎ ﺍﻧﺘﺨﺎﺏ ﻫﺮ ﻛﺪﺍﻡ ﺍﺯ ﺍﻳﻦ ﻗﺴﻤﺖﻫﺎﻱ ﻛﻠﻲ‪ ،‬ﻭﺍﺭﺩ ﺟﺰﺋﻴﺎﺕ ﺑﻴﺸﺘﺮ ﺁﻥ ﺷﻮﻳﻢ‪ .‬ﺿﻤﻨﹰﺎ ﺩﺭ ﻗﺴﻤﺖ ﭘﺎﻳﻴﻦ ﻛﺎﺩﺭﻫـﺎﻱ ﻓـﻮﻕ‪ ،‬ﺳـﻪ ﻋـﺪﺩ‬
‫‪ Icon‬ﻛﺎﺭﺑﺮﺩﻱ ﺩﺭ ﻗﺴﻤﺖ ﻭﺳﻂ ﻭﺟﻮﺩ ﺩﺍﺭﺩ ﻛﻪ ﺑﺎ ﻛﻤﻚ ﺁﻧﻬﺎ ﻣﻲﺗﻮﺍﻥ ﺑﺘﺮﺗﻴﺐ ﺍﺯ ﺗﻜﻨﻴﻚ ﺗﺼﻮﻳﺮﺑﺮﺩﺍﺭﻱ ﻣﺮﺑﻮﻁ ﺑﻪ ﻗﺴﻤﺖ ﻣﻮﺭﺩ ﻧﻈﺮ‪ ،‬ﺁﻧﺎﺗﻮﻣﻲ ﻃﺒﻴﻌﻲ ﻗﺴﻤﺖ ﻣﺬﻛﻮﺭ ﻭ ﻫﻤﭽﻨﻴﻦ ﻣﺴﺎﺋﻞ ﻛﻠﻴﻨﻴﻜﻲ ﻭ ﭘﺎﺗﻮﻟﻮﮊﻳﻚ ﻋﻀـﻮ ﻣـﻮﺭﺩ ﻣﻄﺎﻟﻌـﻪ ﺁﮔـﺎﻫﻲ ﻛﺎﻣـﻞ ﻳﺎﻓـﺖ‪ .‬ﺿـﻤﻨﹰﺎ ﺍﻣﻜـﺎﻥ‬
‫ﺧﻮﺩﺁﺯﻣﺎﻳﻲ )‪ (Self evaluation‬ﺑﺮ ﺍﺳﺎﺱ ﻣﺒﺎﺣﺚ ﻣﻮﺭﺩ ﻧﻈﺮ ﻭﺟﻮﺩ ﺩﺍﺭﺩ‪ .‬ﻧﻜﺘﺔ ﻗﺎﺑﻞ ﺗﻮﺟﻪ ﺩﺭ ﺍﻳﻦ ‪ ، CD‬ﺍﺳﺘﻔﺎﺩﻩ ﺍﺯ ﻛﻠﻴﺔ ﺭﻭﺵﻫﺎﻱ ‪) Imaging‬ﺍﺯ ﻗﺒﻴﻞ ‪ ، Plain Film‬ﻣﻄﺎﻟﻌﺎﺕ ﺑﺎ ﻣﻮﺍﺩ ﺣﺎﺟﺐ ﺭﺍﺩﻳﻮﮔﺮﺍﻓﻴـﻚ‪ MRI ، CTScan ،‬ﻭ ‪ (...‬ﺑـﺮﺍﻱ ﻧﺸـﺎﻥﺩﺍﺩﻥ ﺗﻜﻨﻴـﻚﻫـﺎﻱ‬
‫ﻣﺨﺘﻠﻒ ﻣﺮﺑﻮﻁ ﺑﻪ ‪ Imaging‬ﻫﺮ ﻋﻀﻮ ﺍﺳﺘﻔﺎﺩﻩ ﺷﺪﻩ ﺍﺳﺖ‪.‬‬
‫( ﻃﺮﻳﻘﺔ ﻧﺼﺐ ‪ : hCD‬ﺑﻌﺪ ﺍﺯ ﻗﺮﺍﺭﺩﺍﺩﻥ ‪ CD‬ﺩﺭ ‪ CD-ROM‬ﺩﺳﺘﮕﺎﻫﺘﺎﻥ ﺻﻔﺤﺔ ‪ Autoplay menu‬ﺭﺍ ﺑﺒﻨﺪﻳﺪ ﺳﭙﺲ ﺑﻪ ‪ my computer‬ﺭﻓﺘﻪ ﻭ ﺭﻭﻱ ﺩﺭﺍﻳﻮ ‪ CD-ROM‬ﺩﺳﺘﮕﺎﻩ ﺧﻮﺩ ﺭﺍﺳـﺖﻛﻠﻴـﻚ ﻛﻨﻴـﺪ ﻭ ﮔﺰﻳﻨـﺔ ‪ Open‬ﺭﺍ ﺍﻧﺨـﺎﺏ ﻛﻨﻴـﺪ‬
‫ﺳﭙﺲ ﺭﻭﻱ *‪ ، Setup‬ﺩﺍﺑﻞ ﻛﻠﻴﻚ ﻛﻨﻴﺪ ﺻﻔﺤﻪﺍﻱ ﺑﺎ ﻧﺎﻡ ‪ radiologic Anatomy installation‬ﻇﺎﻫﺮ ﻣﻲﺷﻮﺩ ﻣﺴﻴﺮ ﻧﺼﺐ ﺭﺍ ﻭﺍﺭﺩ ﻛﺮﺩﻩ ﻭ ﻳﺎ ﭘﻴﺶﻓﺮﺽ ﺭﺍ ﺑﺎ ﻛﻠﻴﻚ ﺑﺮ ﺭﻭﻱ ‪ OK‬ﺍﻧﺘﺨﺎﺏ ﻛﻨﻴﺪ‪ .‬ﺑﻌﺪ ﺍﺯ ﻧﺼﺐ ﭘﻴﻐـﺎﻣﻲ ﻣﺒﻨـﻲ ﺑـﺮ ﻧﺼـﺐ ﻛﺎﻣـﻞ ‪CD‬‬
‫ﻣﻲﺁﻳﺪ ﻛﻪ ﺁﻥ ﺭﺍ ‪ OK‬ﻛﻨﻴﺪ‪ ،‬ﺳﭙﺲ ﺍﺯ ﻣﻨﻮﻱ ‪ Start‬ﺑﻪ ‪ Program‬ﺭﻓﺘﻪ ﻭ ﺩﺭ ‪ radilogic Anatomy‬ﻋﻨﻮﺍﻥ ﻣﺮﺑﻮﻃﻪ ﺭﺍ ﺍﻧﺘﺨﺎﺏ ﻛﻨﻴﺪ‪.‬‬
‫* ‪icon‬ﻫﺎﻱ ﺩﻳﮕﺮﻱ ﺑﺎ ﻋﻨﺎﻭﻳﻦ )‪ (ssetup.apm ، setup.cfg ، ssetup ، Setup.‬ﻭﺟﻮﺩ ﺩﺍﺭﺩ ﻛﻪ ﻣﺮﺑﻮﻁ ﺑﻪ ﺍﻳﻦ ﺑﺮﻧﺎﻣﻪ ﻧﻴﺴﺖ ﻟﻄﻔﹰﺎ ﻓﻘﻂ ‪ setup.exe‬ﺭﺍ ﺍﻧﺘﺨﺎﺏ ﻛﻨﻴﺪ‪.‬‬
‫‪50.1 Radiology Image Bank: Orthopedic Radiology‬‬ ‫)‪(International Medical Multimedia‬‬ ‫ــــــ‬
‫)‪51.1 Radiology on CD-ROM Diagnosis, Imaging, Intervention (Juan M. Taveras, MD, Joseph T. Ferrucci, MD‬‬ ‫ــــــ‬
‫)ﻛﻪ ﻳﻜﻲ ﺍﺯ ﻣﻌﺘﺒﺮﺗﺮﻳﻦ ﻭ ﻛﺎﻣﻞﺗﺮﻳﻦ ﻣﺮﺍﺟﻊ ﺭﺍﺩﻳﻮﻟﻮﮊﻱ ﺩﺭ ﺟﻬﺎﻥ ﻣﻲﺑﺎﺷﺪ( ﻫﻤﺮﺍﻩ ﺑﺎ ﺁﺧﺮﻳﻦ ﺗﻐﻴﻴﺮﺍﺕ ﺩﺍﺩﻩﺷﺪﻩ ﺗﺎ ﺳﺎﻝ ‪ 2001‬ﻣﻴﻼﺩﻱ ﺑﻮﺩﻩ ﻭ ﺷﺎﻣﻞ ﻣﺒﺎﺣﺚ ﻋﻤﺪﺓ ﺯﻳﺮ ﻣﻲﺑﺎﺷﺪ‪:‬‬ ‫ﺍﻳﻦ ‪ ، CD‬ﻣﺠﻤﻮﻋﻪ ﻛﺎﻣﻠﻲ ﺍﺯ ﻛﺘﺎﺏ ﺭﺍﺩﻳﻮﻟﻮﮊﻱ ‪Tavers‬‬

‫‪ -١‬ﺭﺍﺩﻳﻮﻟﻮﮊﻱ ‪Pulmonary‬‬ ‫‪ -٢‬ﺳﻴﺎﺳﺖ ﺑﻬﺪﺍﺷﺘﻲ ﻭ ﻣﺪﻳﺮﻳﺖ ﺩﺭ ﺭﺍﺩﻳﻮﻟﻮﮊﻱ‬ ‫‪ -٣‬ﺭﺍﺩﻳﻮﻟﻮﮊﻱ ‪Vascular‬‬ ‫‪ -٤‬ﺭﺍﺩﻳﻮﻟﻮﮊﻱ ‪Gastrointestinal‬‬
‫‪ -٥‬ﺭﺍﺩﻳﻮﻟﻮﮊﻱ ‪Genitourinary‬‬ ‫‪ -٦‬ﻓﻴﺰﻳﻚ ﺭﺍﺩﻳﻮﻟﻮﮊﻱ‬ ‫‪Breast Imaging -٧‬‬ ‫‪ -٨‬ﺭﺍﺩﻳﻮﻟﻮﮊﻱ ‪Cardiac‬‬
‫‪ -٩‬ﻧﻮﺭﻭﺭﺍﺩﻳﻮﻟﻮﮊﻱ ﻭ ﺭﺍﺩﻳﻮﻟﻮﮊﻱ ﺳﺮ ﻭ ﮔﺮﺩﻥ‬ ‫‪ -١٠‬ﺭﺍﺩﻳﻮﻟﻮﮊﻱ ‪Adbomen‬‬ ‫‪ -١١‬ﺭﺍﺩﻳﻮﻟﻮﮊﻱ ‪Skeletal‬‬

‫)‪52.1 REVIEW FOR THE Radiography Examination (A & LERT) (McGrow-Hill's‬‬ ‫‪2002‬‬

‫ﺗﻠﻔﻦ‪٠٩١٢١٣٧٢٣٦١-٦٦٩٣٦٦٩٦ :‬‬ ‫ﻧﺸﺎﻧﻲ‪ :‬ﺗﻬﺮﺍﻥ‪ ،‬ﻡ ﺍﻧﻘﻼﺏ‪ ،‬ﺥ ﻛﺎﺭﮔﺮ ﺟﻨﻮﺑﻲ‪ ،‬ﺥ ﻟﺒﺎﻓﻲﻧﮋﺍﺩ‪ ،‬ﺑﻴﻦ ﻛﺎﺭﮔﺮ ﻭ ﺟﻤﺎﻟﺰﺍﺩﻩ‪ ،‬ﺑﻦﺑﺴﺖ ﺳﻴﻤﻴﻦ‪ ،‬ﭘﻼﻙ ‪٢٣٩‬‬ ‫ﻣﺮﻛﺰ ﺧﺪﻣﺎﺕ ﻓﺮﻫﻨﮕﻲ ﺳﺎﻟﻜﺎﻥ ‪ :‬ﺍﺭﺍﺋﻪ ﻛﻨﻨﺪﺓ ﻛﺘﺎﺏ ﻭ ﺳﻲﺩﻱﻫﺎﻱ ﺗﺨﺼﺼﻲ ﭘﺰﺷﻜﻲ‬
 8
53.1 Teaching Atlas of Mammography (Laszlo Tabar, Peter B. Dean) (Thieme) ‫ــــــ‬
54.1 The Basics of MRI of NMR (Joseph P. Hornak, Ph.D.) ‫ــــــ‬
55.1 The Encyclopaedia of Medical Imaging from NICER ‫ــــــ‬
56.1 THE MRI TEACHING FILE (Robert B. Lufkin, William G. Bradley, Jr., Michael Brant-Zawadzki) 2001

‫ ﺗﻌـﺪﺍﺩ‬.‫ ﺑﺎ ﺗﻮﺟﻪ ﺑﻪ ﺷﺮﺡ ﺣﺎﻝ ﻭ ﻳﺎﻓﺘﻪﻫﺎﻱ ﺭﺍﺩﻳﻮﮔﺮﺍﻓﻴﻚ ﺩﺍﺭﺍﻱ ﺗﺸﺨﻴﺺﻫﺎﻱ ﺍﻓﺘﺮﺍﻗﻲ ﻭ ﺗﺸﺨﻴﺺ ﻧﻬﺎﻳﻲ ﺑﻮﺩﻩ ﻭ ﺩﺭ ﻣﻮﺭﺩ ﻫﺮ ﺗﺸﺨﻴﺺ ﻧﻜﺎﺕ ﻣﻬﻢ ﺷﺮﺡ ﺩﺍﺩﻩ ﺷﺪﻩ ﺍﺳـﺖ‬Case ‫ ﻣﻲﺑﺎﺷﺪ ﻭ ﻫﺮ‬MRI ‫ﻫﺎﻱ ﻣﺘﻌﺪﺩ ﻣﺮﺑﻮﻁ ﺑﻪ ﻣﺒﺎﺣﺚ ﻣﺨﺘﻠﻒ ﺩﺭ ﺯﻣﻴﻨﺔ‬Case ‫ ﻓﻮﻕ ﺩﺍﺭﺍﻱ‬CD
:‫ ﺑﺼﻮﺭﺕ ﺟﺪﻭﻝ ﺫﻳﻞ ﻣﻲﺑﺎﺷﺪ‬CD ‫ﻫﺎﻱ ﻣﻄﺮﺡﺷﺪﻩ ﺑﺮ ﺣﺴﺐ ﻫﺮ ﻣﻮﺿﻮﻉ ﺩﺭ ﺍﻳﻦ‬Case
‫ﻣﻮﺿﻮﻉ‬ Case ‫ﺗﻌﺪﺍﺩ‬ ‫ﻣﻮﺿﻮﻉ‬ Case ‫ﺗﻌﺪﺍﺩ‬ ‫ﻣﻮﺿﻮﻉ‬ Case ‫ﺗﻌﺪﺍﺩ‬ ‫ﻣﻮﺿﻮﻉ‬ Case ‫ﺗﻌﺪﺍﺩ‬
‫ﺑﻴﻤﺎﺭﻱﻫﺎﻱ ﻏﻴﺮﻧﺌﻮﭘﻼﺳﺘﻴﻚ ﻣﻐﺰ‬ ٢٠١ ‫ﻧﺌﻮﭘﻼﺳﻢﻫﺎﻱ ﻣﻐﺰﻱ‬ ١٠٢ ‫ ﻣﻐﺰ‬MRA ١٠ ‫ﺳﺮ ﻭ ﮔﺮﺩﻥ‬ ١٠٠
‫ﺳﺘﻮﻥ ﻓﻘﺮﺍﺕ‬ ١٠٠ ‫ﺳﻴﺴﺘﻢ ﻋﻀﻼﻧﻲ ﺍﺳﻜﻠﺘﻲ‬ ١٠٠ ‫ﺗﻨﻪ‬ ١٠٢ ‫ﺳﻴﺴﺘﻢ ﻗﻠﺒﻲﻋﺮﻭﻗﻲ‬ ١٠٤
‫ﺍﻃﻔﺎﻝ‬ ١٠٠ ‫ﺍﺻﻮﻝ ﻭ ﺁﺭﺗﻴﻔﻜﺖﻫﺎ‬ ١٠٠
57.1 THE RADIOLOGIC CLINICS OF NORTH AMERICA High-Resolution CT of the Lung II (DAVID A. LYNCH, MD) (NUMBER 1 VOLUME 40) ‫ــــــ‬
:‫ ﺭﻳﻪ ﺍﺳﺖ‬HRCT ‫ ﻣﻲﺑﺎﺷﺪ ﻭ ﺩﺍﺭﺍﻱ ﻣﺒﺎﺣﺚ ﻋﻤﺪﺓ ﺫﻳﻞ ﺩﺭﺧﺼﻮﺹ‬The Radiologic clinics of North America ‫ ﺑﺮﮔﺮﺩﺍﻥ ﺷﻤﺎﺭﻩ ﺍﻭﻝ ﺟﻠﺪ ﭼﻬﻠﻢ ﺍﺯ ﻣﺠﻤﻮﻋﺔ ﻛﺘﺎﺑﻬﺎﻱ‬CD ‫ﺍﻳﻦ‬

‫ ﻭ ﺑﺮﻭﻧﺸﻜﺘﺎﺯﻱ‬Air Way ‫ ﻣﺮﺑﻮﻁ ﺑﻪ ﺑﻴﻤﺎﺭﻳﻬﺎﻱ‬CT Scan - Peripheral Airways ‫ ﻣﺮﺑﻮﻁ ﺑﻪ ﺑﻴﻤﺎﺭﻳﻬﺎﻱ‬HRCT - ‫ ﻣﺮﺑﻮﻁ ﺑﻪ ﺁﻣﻔﻴﺰﻡ‬CT Scan - ‫ ﺩﺭ ﺍﺭﺯﻳﺎﺑﻲ ﺑﻴﻤﺎﺭﻳﻬﺎﻱ ﺭﻳﻮﻱ ﺍﻃﻔﺎﻝ‬HRCT ‫ ﻧﻘﺶ‬-
‫ ﺩﺭ ﺍﺭﺯﻳﺎﺑﻲ ﺑﻴﻤﺎﺭﻳﻬﺎﻱ ﺷﻐﻠﻲ ﻭ ﻣﺤﻴﻄﻲ ﺭﻳﻪ‬HRCT ‫ ﻧﻘﺶ‬- Drug-Induced ‫ ﻣﺮﺑﻮﻁ ﺑﻪ ﺑﻴﻤﺎﺭﻳﻬﺎﻱ ﺭﻳﻮﻱ‬HRCT - Non-TB ‫ ﻭ‬TB ‫ ﻣﺮﺑﻮﻁ ﺑﻪ ﻋﻔﻮﻧﺘﻬﺎﻱ ﻣﺎﻳﻜﻮﺑﺎﻛﺘﺮﻳﺎﻳﻲ‬CT Scan - ‫ ﻣﺮﺑﻮﻁ ﺑﻪ ﺑﻴﻤﺎﺭﻳﻬﺎﻱ ﺗﺮﻭﻣﺒﻮﺁﻣﺒﻮﻟﻴﻚ ﺭﻳﻮﻱ‬CT Scan -
‫( ﺭﻳﻪ‬quantitative) ‫ ﻛﻤﻴﺘﻲ‬CT - ‫ ﻧﺪﻭﻝ ﻣﻨﻔﺮﺩ ﺭﻳﻮﻱ‬-
58.1 THE RADIOLOGIC CLINICS OF NORTH AMERICA Imaging of Musculoskeletal and Spinal Infections 1999
• PRINCIPLES AND TECHNIQUES
1. Epidemiology 3. Normal Spine Variants and Anatomy 5. Measurements 7. Sacral Injuries 9- Mechanisms and Patterns of Injury
2. Thoracic Spine Injuries 4. Experimental and Necropsy Data 6. Special Views and Techniwques 8. Occipitocervical Injuries
• ATLAS OF SPINE INJURIES IN CHILDREN
1. Cervcal Spine 2. Thoracic Spine 3. Lumbar Spine 4. Sacrococcygeal Spine
59.1 THE RADIOLOGIC CLINICS OF NORTH AMERICA Pediatric Musuloskeletal Pediatric Radiology (SALEKAN E-BOOK) (James S. Meyer, MD) 2001
:‫ ﻛﻪ ﺩﺭ ﻣﺮﻛﺰ ﺧﺪﻣﺎﺕ ﻓﺮﻫﻨﮕﻲ ﺳﺎﻟﻜﺎﻥ ﺗﺒﺪﻳﻞ ﺑﻪ ﻛﺘﺘﺎﺏ ﺍﻟﻜﺘﺮﻭﻧﻴﻜﻲ ﮔﺮﺩﻳﺪﻩ ﺍﺳﺖ ﺷﺎﻣﻞ ﺍﻳﻦ ﻣﺒﺎﺣﺚ ﻣﻲﺑﺎﺷﺪ‬CD ‫ﺍﻳﻦ‬
y Ultrasound in Padiatric Musculoskeletal Disease: Teachinques and Applications y Nuclear Medicnine Topics in Pediatric Musculoskeletal Disease: Teachinques and Applications
y Imaging of Musculoskeletal Infections y Malignant and Benign Bone Tumors y Magnetic Rsonance Imaging of Musculoskeletal Soft Tissue Mass y Imaging of Pediatric Hip Disorder
y Imaging of Pediatric Foot Disorder in Children y Imaging of Sports Injuries in Children and Adolescents y A Pragmatic Approach to the Radiologic Diagnosis of Pediatric Syndromes and Skeletal Dysplasias
y The Orthopedists Perspective: Bone Tumors, Scoliosis, and Trauma y Imaging of Crowth Distubance in Children y Imaging of Child Abuse
60.1 THE RADIOLOGIC CLINICS OF NORTH AMERICA Update on Nuclear Medicine ‫ــــــ‬
61.1 THE RADIOLOGIC CLINICS OF NORTH AMERICA Update on Ultrasonography (FAYE C. LAING, MD) (W.B. SAUNDERS COMPABY) ‫ــــــ‬
:‫ ﻣﻲﺑﺎﺷﺪ ﻭ ﺩﺍﺭﺍﻱ ﻣﺒﺎﺣﺚ ﻋﻤﺪﺓ ﺫﻳﻞ ﺩﺭ ﺧﺼﻮﺹ ﺳﻮﻧﻮﮔﺮﺍﻓﻲ ﺍﺳﺖ‬The Radiologic Clinics Of North America ‫ ﺍﺯ ﻣﺠﻤﻮﻋﻪ ﻛﺘﺎﺏﻫﺎﻱ‬٣٩ ‫ ﺑﺮﮔﺮﺩﺍﻥ ﺷﻤﺎﺭﻩ ﺳﻮﻡ ﺟﻠﺪ‬CD ‫ﺍﻳﻦ‬
‫ ﺗﻜﻨﻮﻟﻮﮊﻱ ﺭﻭﺯ‬-١ ‫ ﻣﻮﺍﺩ ﺣﺎﺟﺐ ﺍﻭﻟﺘﺮﺍﺳﻮﻧﺪ‬-٢ ‫( ﺗﺤﺖ ﺭﺍﻫﻨﻤﺎﻳﻲ ﺳﻮﻧﻮﮔﺮﺍﻓﻲ‬intervention) ‫ ﺍﻗﺪﺍﻣﺎﺕ ﻣﺪﺍﺧﻠﻪﺍﻱ‬-٣
‫ ﺳﻮﻧﻮﮔﺮﺍﻓﻲ ﺩﺭ ﺣﻴﻦ ﻋﻤﻞ ﺟﺮﺍﺣﻲ‬-٤ ‫ ﻭﺿﻌﻴﺖ ﻓﻌﻠﻲ ﺗﺸﺨﻴﺼﻲ ﻭ ﺩﺭﻣﺎﻧﻲ ﺳﻮﻧﻮﮔﺮﺍﻓﻲ ﺍﻧﺪﻭﺳﻜﻮﭘﻴﻚ‬-٥ ‫ ﺳﻮﻧﻮﮔﺮﺍﻓﻲ ﻣﻮﺳﻜﻮﻟﻮﺍﺳﻜﻠﺘﺎﻝ‬-٦
Breast ‫ ﺳﻮﻧﻮﮔﺮﺍﻓﻲ‬-٧ Gynecology ‫ ﻭ‬Obstetric ‫ ﺳﻮﻧﻮﮔﺮﺍﻓﻲ ﺳﻪﺑﻌﺪﻱ ﺩﺭ‬-٨ Gynecologic ‫ ﺳﻮﻧﻮﮔﺮﺍﻓﻲ‬-٩
‫ ﺍﺭﺯﻳﺎﺑﻲ ﺳﻮﻧﻮﮔﺮﺍﻓﻴﻚ ﺍﺗﺴﺎﻉ ﺑﻄﻦﻫﺎﻱ ﺩﺍﺧﻞ ﻣﻐﺰﻱ ﺑﻪ ﺩﻧﺒﺎﻝ ﺧﻮﻧﺮﻳﺰﻱ‬-١٠ ‫ ﺳﻮﻧﻮﮔﺮﺍﻓﻲ ﺷﺮﻳﺎﻥﻫﺎﻱ ﻣﺤﻴﻄﻲ‬-١١ ‫ ﺳﻮﻧﻮﮔﺮﺍﻓﻲ ﻛﺎﺭﻭﺗﻴﺪ‬-١٢
62.1 Ultrasound Atlas of Vascular Diseases (Carol A. Krebs, RT, RDMS, Vishan L. Giyanani, , Ronald L. Eisenberg) (APPLETON & LANGE Stamford, Connecticut) (SALEKAN E-Book) ‫ــــــ‬
63.1 Ultrasound Teaching Manual The basics of Performing and Interpreting Ultrasound Scans (Matthias Hofer) (With the collaboration of Tatjana Reihs) (Thieme) ‫ــــــ‬

٠٩١٢١٣٧٢٣٦١-٦٦٩٣٦٦٩٦ :‫ﺗﻠﻔﻦ‬ ٢٣٩ ‫ ﭘﻼﻙ‬،‫ ﺑﻦﺑﺴﺖ ﺳﻴﻤﻴﻦ‬،‫ ﺑﻴﻦ ﻛﺎﺭﮔﺮ ﻭ ﺟﻤﺎﻟﺰﺍﺩﻩ‬،‫ ﺥ ﻟﺒﺎﻓﻲﻧﮋﺍﺩ‬،‫ ﺥ ﻛﺎﺭﮔﺮ ﺟﻨﻮﺑﻲ‬،‫ ﻡ ﺍﻧﻘﻼﺏ‬،‫ ﺗﻬﺮﺍﻥ‬:‫ﻧﺸﺎﻧﻲ‬ ‫ ﺍﺭﺍﺋﻪ ﻛﻨﻨﺪﺓ ﻛﺘﺎﺏ ﻭ ﺳﻲﺩﻱﻫﺎﻱ ﺗﺨﺼﺼﻲ ﭘﺰﺷﻜﻲ‬: ‫ﻣﺮﻛﺰ ﺧﺪﻣﺎﺕ ﻓﺮﻫﻨﮕﻲ ﺳﺎﻟﻜﺎﻥ‬
 ‫‪9‬‬
‫‪64.1‬‬ ‫)‪Uterosalpingography in Gynecology Hysterospingography (Salekan E-Book‬‬ ‫ــــــ‬
‫)‪65.1 VOXEL-MAN 3D-Navigator Brain and Skull (Regional, Functional, and Radiological Anatomy) (IMDM university Hospital Eppendorf, Humburg‬‬ ‫ــــــ‬
‫)‪(Springer‬‬
‫ﺍﻳﻦ ﻧﺮﻡﺍﻓﺰﺍﺭ ﺩﺭ ﻗﺎﻟﺐ ﻳﻚ ﺍﻃﻠﺲ ﺳﻪﺑﻌﺪﻱ ‪ Interactive‬ﺍﺯ ﺍﻧﺪﺍﻡﻫﺎﻱ ﺩﺍﺧﻠﻲ ﺗﻨﻪ ﺩﺭ ﺳﻪ ﻋﺪﺩ ‪ CD‬ﺟﻬﺖ ﺗﺸﺨﻴﺺﻫﺎﻱ ﺭﺍﺩﻳﻮﻟﻮﮊﻳﻜﻲ‪ ،‬ﻃﺮﺍﺣﻲ ﺷﻴﻮﺓ ﻋﻤﻞ ﺟﺮﺍﺣﻲ ﻭ ﺁﻣﻮﺯﺵ ﺩﺭﻭﺱ ﺁﻧﺎﺗﻮﻣﻲ ﻭ ﺭﺍﺩﻳﻮﻟﻮﮊﻱ ﻃﺮﺍﺣﻲ ﺷﺪﻩ ﺍﺳـﺖ‪ .‬ﻓﺼـﻮﻝ ﻣﺨﺘﻠـﻒ‬
‫ﺍﻳﻦ ‪ CD‬ﺑﻪ ﺷﺮﺡ ﺫﻳﻞ ﺍﺳﺖ‪:‬‬
‫ﺑﺨﺶ ﺍﻭﻝ( ﺁﻧﺎﺗﻮﻣﻲ‪ :١-١ :‬ﺗﺸﺮﻳﺢ ﺳﻪﺑﻌﺪﻱ ﺍﻧﺪﺍﻡﻫﺎﻱ ﺩﺍﺧﻞ ﺗﻨﻪ‪ :‬ﺩﺭ ﺍﻳﻦ ﻗﺴﻤﺖ ﺁﻧﺎﺗﻮﻣﻲ ﺳﻪﺑﻌﺪﻱ ﻗﻔﺴﻪ ﺳﻴﻨﻪ ﺑﺎ ﻗﺎﺑﻠﻴﺖ ﭼﺮﺧﺶ ‪ Ventricol‬ﻭ ﭼﺮﺧﺶ ‪ horizontal‬ﻭ ﺁﻧﺎﺗﻮﻣﻲ ﺷﻜﻢ ﺑﺎ ﻗﺎﺑﻠﻴﺖ ﭼﺮﺧﺶ ﺍﻓﻘﻲ ﻭ ﻋﻤﻮﺩﻱ ﺍﺭﺍﺋﻪ ﺷﺪﻩ‬
‫‪ : ٢-١‬ﺗﺸﺮﻳﺢ ﺩﺳﺘﮕﺎﻩﻫﺎ ﻛﻪ ﺩﺭ ‪ ٩‬ﺑﺨﺶ ﺍﺭﺍﺋﻪ ﺷﺪﻩ ﺍﺳﺖ )ﺍﺳﻜﻠﺖ ﺍﺳﺘﺨﻮﺍﻧﻲ‪ ،‬ﺳﻴﺴﺘﻢ ﻗﻠﺒﻲ ﻋﺮﻭﻗﻲ‪ ،‬ﺳﻴﺴﺘﻢ ﻋﺼﺒﻲ ‪ ،‬ﻛﺒـﺪ‬ ‫ﺍﺳﺖ‪ .‬ﺩﺭ ﺍﻳﻦ ﺑﺨﺶ ﻗﺎﺑﻠﻴﺖ ﺣﺬﻑ ﻭ ﺍﺿﺎﻓﻪﻧﻤﻮﺩﻥ ﻫﺮ ﻳﻚ ﺍﺯ ﺑﺨﺶﻫﺎﻱ ﺗﺼﺎﻭﻳﺮ ﻭ ﭼﺮﺧﺶ ‪ ١٨٠o‬ﺁﻧﻬﺎ ﻭﺟﻮﺩ ﺩﺍﺭﺩ‪.‬‬
‫‪ : ٣-١‬ﺁﻧﺎﺗﻮﻣﻲ ﻣﻘﺎﻃﻊ ﻋﺮﺿﻲ‪ :‬ﺷﺎﻣﻞ ‪ ٢‬ﻗﺴﻤﺖ ﺁﻧﺎﺗﻮﻣﻲ ﻣﻘﺎﻃﻊ ﻋﺮﺿﻲ ﺳﻄﻮﺡ ‪ Coronal‬ﻭ ‪ Sagittal‬ﻣﻲﺑﺎﺷﺪ‪.‬‬ ‫ﻭ ﺍﻧﺪﺍﻡﻫﺎﻱ ﺟﺎﻧﺒﻲ‪ ،‬ﺷﺒﻴﻪﺳﺎﺯﻱ ﮔﺎﺳﺘﺮﻭﺳﻜﻮﭘﻲ ﺑﺎ ﻗﺎﺑﻠﻴﺖ ﺣﺮﻛﺖ ﺩﺭ ﻓﻀﺎﻱ ﻣﺮﻱ ﻭ ﻣﻌﺪﻩ(‬

‫‪ -‬ﺗﻮﻣﻮﮔﺮﺍﻓﻲ‬ ‫ﺑﺨﺶ ﺩﻭﻡ( ﺭﺍﺩﻳﻮﻟﻮﮊﻱ‪:‬‬

‫‪ -٢-١‬ﻣﻘﺎﻃﻊ ﻋﺮﺿﻲ ﺁﻧﺎﺗﻮﻣﻴﻜﻲ )ﺑﺎ ﻗﺎﺑﻠﻴﺖ ﺣﺮﻛﺖﺩﺍﺩﻥ ﺳﻄﺢ ﻣﻘﻄﻊ ﻭ ﻣﺸﺎﻫﺪﻩ ﺗﺼﻮﻳﺮ ﻫﺮ ﻗﺴﻤﺖ(‬ ‫‪ -١-١‬ﻣﻘﺎﻃﻊ ﻋﺮﺿﻲ ‪CT‬‬
‫‪ -٤-١‬ﺷﺒﻴﻪﺳﺎﺯﻱ ﻗﺴﻤﺖ ﺍﻭﻟﺘﺮﺍﺳﻮﻧﻴﻚ ﻛﺒﺪ‬ ‫‪ -٣-١‬ﻣﻘﺎﻳﺴﻪ ﺑﻴﻦ ﺗﺼﺎﻭﻳﺮ ‪ CT‬ﺑﺎ ﺗﺼﺎﻭﻳﺮ ﺳﻪﺑﻌﺪﻱ ﻭ ﻣﻘﺎﻃﻊ ﻋﺮﺿﻲ ﺁﻧﺎﺗﻮﻣﻴﻜﻲ‬
‫‪ -٤-٢‬ﺗﺼﺎﻭﻳﺮ ‪ X-ray‬ﺍﺯ ﻛﻠﻴﺔ ﺍﻧﺪﺍﻡﻫﺎ‬ ‫‪ -٣-٢‬ﺗﺼﺎﻭﻳﺮ ‪ X-ray‬ﺍﺯ ﺍﻧﺪﺍﻡﻫﺎﻱ ﻣﻨﻔﺮﺩ‬ ‫‪ -٢-٢‬ﺗﺼﺎﻭﻳﺮ ‪ X-ray‬ﺍﺯ ﺷﻜﻢ‬ ‫‪ -١-٢‬ﺗﺼﺎﻭﻳﺮ ‪ X-ray‬ﺍﺯ ﻗﻔﺴﺔ ﺳﻴﻨﻪ‬ ‫‪ -‬ﺗﺼﺎﻭﻳﺮ ‪X-ray‬‬
‫ﻣﺎﺭﻙﺩﺍﺭﻧﻤﻮﺩﻥ ﻫﺮ ﺑﺨﺶ ﺍﺯ ﺗﺼﺎﻭﻳﺮ ﻭ ﻣﻘﺎﻃﻊ ﺗﺸﺮﻳﺤﻲ‬ ‫ﻗﺪﺭﺕ ﺍﻓﺰﺍﻳﺶ ‪ Zoom‬ﺗﺼﺎﻭﻳﺮ‬
‫ﻼ ﻭﺍﻗﻌﻲ ﻛﻪ‬ ‫ﺍﺭﺍﺋﻪ ﺗﺼﺎﻭﻳﺮ ﺑﺎﺯﺳﺎﺯﻱﺷﺪﻩ ﻛﺎﻣ ﹰ‬
‫ﺍﺭﺍﺋﻪ ﻓﻬﺮﺳﺖ ﻛﺎﻣﻞ ﻣﻨﺪﺭﺟﺎﺕ ﺗﺼﺎﻭﻳﺮ ﺑـﻪ ﺳـﻪ ﺯﺑـﺎﻥ ﺍﻧﮕﻠﻴﺴـﻲ‪ ،‬ﺁﻟﻤـﺎﻧﻲ ﻭ ﻧﺎﻣﮕــﺬﺍﺭﻱ ﺑﺨــﺶﻫــﺎﻱ ﻣﺨﺘﻠــﻒ ﺗﺼــﺎﺋﻴﺮ ﺑﺼــﻮﺭﺕ‬
‫ﻛﺎﺭﺑﺮﺩ ﺁﻣﻮﺯﺷﻲ ﺟﺬﺍﺑﻲ ﺭﺍ ﺑﻪ ﻫﻤﺮﺍﻩ ﺩﺍﺭﺩ‪.‬‬
‫‪Intractive‬‬ ‫ﻻﺗﻴﻦ‬

‫‪66.1‬‬ ‫)‪VOXEL-MAN 3D-Navigator Inner Organs (Regional, Systemic and Radiological Anatomy) (IMDM university Hospital Eppendorf, Hamburg‬‬ ‫ــــــ‬
‫)‪67.1 Whole Body Computed Tomography (Second Edition) (Otto H. Wegener) (Blackwell Science‬‬ ‫ــــــ‬
‫ﺩﺭ ﺍﻳﻦ ‪ CD‬ﺩﺭ ﻃﻲ ‪ ٢٨‬ﻓﺼﻞ ﺑﻪ ﺷﺮﺡ ﺁﻧﺎﺗﻮﻣﻲ‪ ،‬ﺗﻜﻨﻴﻚ ﻭ ﻓﻴﺰﻳﻚ ﻣﺮﺑﻮﻁ ﺑﻪ ‪ CT Scan‬ﻫﻤﺮﺍﻩ ﺑﺎ ﺑﺮﺭﺳﻲ ﺟﺰﺀ ﺑﻪ ﺟﺰﺀ ﻣﺴﺎﺋﻞ ﭘﺎﺗﻮﻟﻮﮊﻳﻚ ﻧﻮﺍﺣﻲ ﻣﺨﺘﻠﻒ ﺑﺪﻥ ﺑﺎ ﺍﺳﺘﻔﺎﺩﻩ ﺍﺯ ﺗﺼﺎﻭﻳﺮ ﮔﻮﻳﺎﻱ ‪ CT Scan‬ﭘﺮﺩﺍﺧﺘﻪ ﺷﺪﻩ ﺍﺳﺖ‪ .‬ﻓﻬﺮﺳـﺖ ﻛﻠـﻲ ﻓﺼـﻮﻝ‬
‫ﺑﻪ ﻗﺮﺍﺭ ﺯﻳﺮ ﻣﻲﺑﺎﺷﺪ‪:‬‬
‫ﺗﻜﻨﻴﻜﻬﺎﻱ ‪CT Scan‬‬ ‫ﻣﻮﺍﺩ ﺣﺎﺟﺐ ﺗﺤﻠﻴﻞ ﺗﺼﻮﻳﺮ ﺩﺭ ‪ CT Scan‬ﺁﻧﺎﺗﻮﻣﻲ ﺩﺭ ‪CT Scan‬‬ ‫ﻛﻠﻴﻪ ﺍﺭﮔﺎﻧﻬﺎﻱ ﺗﻨﺎﺳﻠﻲ ﺯﻥ ﺗﻮﻣﻮﺭﻫﺎﻱ ﺍﺳﺘﺨﻮﺍﻧﻲ‬
‫ﻣﺪﻳﺎﺳﺘﻦ ﺭﻭﺵ ﻭ ﺍﺳﺘﺮﺍﺗﮋﻱ ﺍﺭﺯﻳﺎﺑﻲ ﺑﻴﻤﺎﺭ‬ ‫ﻗﻠﺐ‬ ‫ﺭﻳﻪﻫﺎ‬ ‫ﺳﺘﻮﻥ ﻓﻘﺮﺍﺕ‬ ‫ﺣﻔﺮﺓ ﺭﺗﺮﻭﭘﺮﻳﺘﻮﺋﻦ‬ ‫ﻏﺪﺩ ﻓﻮﻕ ﻛﻠﻴﻮﻱ‬
‫ﺟﻨﺐ )ﭘﻠﻮﺭ(‬ ‫ﺩﻳﻮﺍﺭﺓ ﻗﻔﺴﻪ ﺳﻴﻨﻪ‬ ‫ﻛﺒﺪ‬ ‫ﻟﮕﻦ ﺍﺳﺘﺨﻮﺍﻧﻲ ﺳﻴﺴﺘﻢ ﺻﻔﺮﺍﻭﻱ‬ ‫ﻋﻀﻼﺕ‬ ‫ﻣﺜﺎﻧﻪ‬
‫ﭘﺎﻧﻜﺮﺍﺱ‬ ‫ﺩﺳﺘﮕﺎﻩ ﮔﻮﺍﺭﺵ‬ ‫ﺣﻔﺮﺓ ﭘﺮﻳﺘﻮﺋﻦ‬ ‫ﻃﺤﺎﻝ‬ ‫ﺗﺮﻣﻴﻨﻮﻟﻮﮊﻱ ‪CT‬‬ ‫ﭘﺮﻭﺳﺘﺎﺕ ﻭ ﺳﻤﻴﻨﺎﻝ ﻭﺯﻳﻜﻮﻝﻫﺎ ﺗﻮﻣﻮﺭﻫﺎﻱ ﻧﺴﺞ ﻧﺮﻡ‬

‫‪ -٢‬ﮔﻮﺵ‪ ،‬ﺣﻠﻖ ﻭ ﺑﻴﻨﻲ‬

‫ﻋﻨﻮﺍﻥ ‪CD‬‬ ‫ﺳﺎﻝ ﺍﻧﺘﺸﺎﺭ‬
‫‪1.2‬‬ ‫)‪Advanced Rhinoplasty Techniques Cosmetic Rhinoplasty (Rollin K. Daniel, M.D.‬‬ ‫ــــــ‬
‫‪Analysis, Marking & Anesthesia, Closed/Open Approach, Septum Exposure, Exposure & Dorsal Reduction,‬‬ ‫& ‪Caudal Septum Resection, Ideal Profile Line, Open Approach, Tip Analysis, Septoplasty‬‬
‫‪Septal Harvest, Grafts, Spreaser Grafts, Grural Strut, Tip Suture Technique, Closure, Nostril Sill Alar Wedge, Composite Graft, Lateral Osteotomy, Final Steps, Acknowledgments‬‬
‫‪2.2‬‬ ‫‪Advanced Therapy of OTITIS MEDIA‬‬ ‫‪2004‬‬
‫‪3.2‬‬ ‫)‪Atlas D'ORL Realise avec la collaboration des (Dr Michel Boucherat, Dr Jean-Robert Blondeau‬‬ ‫ــــــ‬
‫‪-Anatomie de l’oreille normale - Images pathologiques‬‬ ‫‪- Cas cliniques‬‬ ‫‪-Anatomie naso-sinusienne normale‬‬
‫‪-Images pathologiques‬‬ ‫‪- Cas cliniques‬‬ ‫‪- Rappels des principes de la TDM et de l’IRM‬‬

‫ﺗﻠﻔﻦ‪٠٩١٢١٣٧٢٣٦١-٦٦٩٣٦٦٩٦ :‬‬ ‫ﻧﺸﺎﻧﻲ‪ :‬ﺗﻬﺮﺍﻥ‪ ،‬ﻡ ﺍﻧﻘﻼﺏ‪ ،‬ﺥ ﻛﺎﺭﮔﺮ ﺟﻨﻮﺑﻲ‪ ،‬ﺥ ﻟﺒﺎﻓﻲﻧﮋﺍﺩ‪ ،‬ﺑﻴﻦ ﻛﺎﺭﮔﺮ ﻭ ﺟﻤﺎﻟﺰﺍﺩﻩ‪ ،‬ﺑﻦﺑﺴﺖ ﺳﻴﻤﻴﻦ‪ ،‬ﭘﻼﻙ ‪٢٣٩‬‬ ‫ﻣﺮﻛﺰ ﺧﺪﻣﺎﺕ ﻓﺮﻫﻨﮕﻲ ﺳﺎﻟﻜﺎﻥ ‪ :‬ﺍﺭﺍﺋﻪ ﻛﻨﻨﺪﺓ ﻛﺘﺎﺏ ﻭ ﺳﻲﺩﻱﻫﺎﻱ ﺗﺨﺼﺼﻲ ﭘﺰﺷﻜﻲ‬
 ‫‪10‬‬
‫‪4.2‬‬ ‫)‪Atlas of Head & Neck Surgery Otolaryngology (TEXTBOOK) (Byron J. Bailey, Karen H. Calhoun, Amy R. Coffey, J. Gail Neely‬‬ ‫ــــــ‬
‫‪1- Atlas :‬‬
‫ﺩﺭ ﺍﻳﻦ ﻗﺴﻤﺖ ‪ ٢٥‬ﺭﻭﺵ ﺟﺮﺍﺣﻲ ﺍﻧﺘﺨﺎﺑﻲ ﺍﺭﺍﺋﻪ ﺷﺪﻩ ﺍﺳﺖ‪ .‬ﺍﻳﻦ ﻗﺴﻤﺖ ﺩﺍﺭﺍﻱ ‪ ٢٥‬ﻓﺼﻞ ﺩﺭ ﭼﻬﺎﺭ ﺑﺨﺶ ﺍﺻﻠﻲ ﺍﺳﺖ‪:‬‬
‫‪- Head & Neck Surgery :‬‬
‫ﺷﺎﻣﻞ ‪ ٦‬ﻋﻨﻮﺍﻥ ﺍﺻﻠﻲ ﺍﺳﺖ ﻛﻪ ﺩﺭ ﻫﺮ ﻗﺴﻤﺖ ﺍﻃﻼﻋﺎﺕ ﺍﺳﺎﺳﻲ ﺭﺍﺟﻊ ﺑﻪ ﺍﻧﺪﻳﻜﺎﺳﻴﻮﻥ ﺗﻤﻬﻴﺪﺍﺕ ﻗﺒﻞ ﺍﺯ ﻋﻤﻞ ﺟﺮﺍﺣﻲ‪ ،‬ﻭﺳﺎﻳﻞ ﻭ ﺭﻭﺵﻫﺎﻱ ﺑﻴﻬﻮﺷﻲ ﻭ ‪ ....‬ﺍﺭﺍﺋﻪ ﺷﺪﻩ ﺍﺳﺖ‪ ٦ .‬ﻋﻨﻮﺍﻥ ﺍﺻﻠﻲ ﺷﺎﻣﻞ ﻣﻮﺍﺭﺩ ﺯﻳﺮ ﺍﺳﺖ‪:‬‬
‫‪• Salivary Gland • Nose & maxilla • Oral Clarity • Ear‬‬ ‫‪• Neck & Larynx‬‬ ‫‪• Thyroid & Parathyroid‬‬
‫‪- Otologic procedures‬‬ ‫‪:‬‬
‫‪• Middle Ear and Ossicular Chain‬‬ ‫‪• Tran temporal Skull Base‬‬ ‫‪• Congenital Aural Base‬‬
‫‪- Plastic & Reconstructive Surgery :‬‬
‫‪• Larygoplasty, Rhytidectomy, Rhinoplasty‬‬ ‫‪• Mandibular Surgery, Local & Regional Flaps,‬‬ ‫‪• Excision of skin Lesions‬‬
‫‪- Pediatric and General Otolaryngology‬‬ ‫‪:‬‬
‫‪• Frontal Sinus‬‬ ‫‪• Nasal Polypectomy‬‬ ‫‪• Ton Sillectomy‬‬
‫‪2- Bilbo Med Medline :.‬‬ ‫ﺩﺭ ﺍﻳﻦ ﻗﺴﻤﺖ ﺑﺮ ﺍﺳﺎﺱ ﻣﻮﺿﻮﻉ‪ ،‬ﻛﻠﻤﺎﺕ ﻭ ﻭﺍﮊﻫﺎﻱ ﺗﺨﺼﺼﻲ‪ ،‬ﻧﺎﻡ ﻧﻮﻳﺴﻨﺪﻩ‪ ،‬ﺷﻤﺎﺭﺓ ﻣﺠﻠﻪ ﻣﻲﺗﻮﺍﻧﻴﺪ ﻣﺒﺎﺣﺚ ﻣﻮﺭﺩ ﻧﻈﺮﺗﺎﻥ ﺭﺍ ﺟﺴﺘﺠﻮ ﻭ ﻣﻄﺎﻟﻌﻪ ﻧﻤﺎﺋﻴﺪ‬
‫‪3- Head & Neck Surgery:‬‬
‫‪- Textbook‬‬ ‫‪- Drug Reference‬‬
‫‪- Textbook :‬‬
‫ﺍﻳﻦ ﺑﺨﺶ ﺑﺼﻮﺭﺕ ﻳﻚ ﻛﺘﺎﺏ ﺍﻟﻜﺘﺮﻭﻧﻴﻜﻲ ﻧﻮﺷﺘﺔ ﺩﻛﺘﺮ ‪ Bailey‬ﻫﻤﺮﺍﻩ ﺑﺎ ﺗﺼﺎﻭﻳﺮ ﺭﻧﮕﻲ ﻣﺘﻌﺪﺩ ﮔﻮﻳﺎ ﻭ ﻧﻤﻮﺩﺍﺭﻫﺎﻱ ﺁﻣﻮﺯﺷﻲ ﺍﺳﺖ ﻛﻪ ﺷﺎﻣﻞ ‪ ١٨٠‬ﻓﺼﻞ ﻣﻲﺑﺎﺷﺪ‪.‬‬
‫‪1- Basic Science / General Medicine‬‬ ‫‪ ٤‬ﺑﺨﺶ ﺍﺻﻠﻲ ﺍﻳﻦ ﻛﺘﺎﺏ ﺑﻪ ﺍﻳﻦ ﺷﺮﺡ ﺍﺳﺖ‪:‬‬

‫‪2- Head & Neck :‬‬ ‫)ﺷﺎﻣﻞ ﻣﺒﺎﺣﺚ ﮔﻮﻧﺎﮔﻮﻥ ﻭ ﺗﺨﺼﺼﻲ ﺭﺍﺟﻊ ﺑﻪ ﺁﻧﺎﺗﻮﻣﻲ ﻭ ﻓﻴﺰﻳﻮﻟﻮﮊﻱ ﮔﻮﺵ‪ ،‬ﺳﺮ‪ ،‬ﮔﺮﺩﻥ(‬
‫‪3- Otology‬‬
‫‪4- Facial Plastic Reconstructive Surgery‬‬
‫‪- Drug Reference :‬‬ ‫ﺩﺍﺭﻭﻫﺎﻱ ﺍﺻﻠﻲ ﻭ ﮊﻧﻮﺗﻴﻚ ﺑﻪ ﺷﻜﻞ ﺍﻟﻔﺒﺎﻳﻲ ﺁﻭﺭﺩﻩ ﺷﺪﻩ ﺍﺳﺖ ﻭ ﺍﻃﻼﻋﺎﺕ ﻛﺎﻣﻞ ) ﺍﻧﺪﻳﻜﺎﺳﻴﻮﻥ‪ ،‬ﺭﺩﺓ ﺩﺍﺭﻭﻳﻲ‪ ،‬ﺍﺳﺎﻣﻲ ﺷﻴﻤﻴﺎﻳﻲ ﻭ ﺗﺠﺎﺭﺗﻲ‪ ،‬ﻣﻘﺪﺍﺭ ﻣﺼﺮﻑ ﺍﺛﺮﺍﺕ ﺟﺎﻧﺒﻲ‪،‬‬
‫ﻓﺎﺭﻣﺎﻛﻮﻛﺴﻴﻚ ﺩﺍﺭﻭ ﻭ‪(.....‬‬
‫‪5.2‬‬ ‫)‪Atlas of Rhinoplasty Open and Endonasal Approaches (Gilbert Aiach, M.D‬‬ ‫ــــــ‬

‫)‪6.2 Causes of FAILURE in STAPES SURGERY (VCD I‬‬ ‫)‪(Howard P. House, TED N. Steffen‬‬ ‫ــــــ‬
‫)‪PITFALLS in STAPES SURGERY (VCD II‬‬
‫)‪STAPEDECTOMY (Prefabricated Wire-Loop and Gelfoam Technique) (VCD III‬‬
‫)‪7.2 Chirurgia Endoscopica Dei Seni Paranasali (A Cura di E. Pasquini G. Farneti‬‬ ‫ــــــ‬
‫‪1. Principi di anatomia endoscopica‬‬ ‫‪2. Tecnica chirurgica‬‬ ‫‪3. Aspetti radiologici‬‬
‫)‪8.2 Cobblation Assisted Tonsillectomy (CAT) __ Cobblation Assisted Procedures (VCD‬‬ ‫)‪(CD I , II‬‬
‫ــــــ‬

‫ﺩﺭ ‪ CD‬ﺷﻤﺎﺭﺓ ‪ ١‬ﻧﺤﻮﺓ ﺍﻧﺠﺎﻡ ﺍﻋﻤﺎﻝ ﺟﺮﺍﺣﻲ ﺭﻭﻱ ﺗﻮﻧﺴﻴﻞﻫﺎ ﺑﺎ ﻛﻤﻚ ﺩﺳﺘﮕﺎﻩ ‪ Coblation‬ﺑﻪ ﺷﻤﺎ ﻧﺸﺎﻥ ﺩﺍﺩﻩ ﻣﻲﺷﻮﺩ‪ .‬ﺍﻳﻦ ‪ VCD‬ﺷﺎﻣﻞ ﻣﻮﺍﺭﺩ ﺁﻣﻮﺯﺷﻲ ﺯﻳﺮ ﻣﻲﺑﺎﺷﺪ‪:‬‬
‫‪1- Subtotal Cololation Assisted tonsillectomy‬‬ ‫‪2- Lop – off "CAT" technique‬‬ ‫‪3- Coblation Assisted tonsilectomg‬‬
‫ﺩﺭ ‪ CD‬ﺷﻤﺎﺭﺓ ‪ ٢‬ﺷﻤﺎ ﺑﺎ ﺩﺳﺘﮕﺎﻩ ‪ Coblation‬ﻛﻪ ﺗﺤﻮﻟﻲ ﻋﻈﻴﻢ ﺩﺭ ﺣﻴﻄﻪ ﺍﻋﻤﺎﻝ ﺟﺮﺍﺣﻲ ‪ ENT‬ﺍﻳﺠﺎﺩ ﻛﺮﺩﻩ ﺍﺳﺖ ﺁﺷﻨﺎ ﻣﻲﺷﻮﻳﺪ‪ .‬ﻧﺤﻮﺓ ﻋﻤﻠﻜﺮﺩ ﺩﺳﺘﮕﺎﻩ ﺑﺮ ﺍﺳﺎﺱ ﺍﻣﻮﺍﺝ ﺭﺍﺩﻳﻮﻓﺮﻛﻮﺋﻨﺴﻲ ﺑﺎ ﻭﺍﺳﻄﻪ ﭘﻼﺳـﻤﺎ ﻣـﺎﻳﻊ ﻣـﻲﺑﺎﺷـﺪ ﻭ ﻣﺰﺍﻳـﺎﻱ ﻓﺮﺍﻭﺍﻧـﻲ ﺑـﺮ ﺩﺳـﺘﮕﺎﻫﻬﺎﻱ ﻟﻴـﺰﺭ ﻭ‬
‫ﺭﺍﺩﻳﻮﻓﺮﻛﻮﺋﻨﺴﻲ ﻗﺪﻳﻤﻲ ﺩﺍﺭﺩ‪ .‬ﻋﺪﻡ ﻧﻴﺎﺯ ﺑﻪ ﺑﻲﻫﻮﺷﻲ ﻋﻤﻮﻣﻲ ﻭ ﺍﻣﻜﺎﻥ ﺍﻧﺠﺎﻡ ﺍﻋﻤﺎﻝ ﺟﺮﺍﺣﻲ ﺑﻪ ﺻﻮﺭﺕ ﺳﺮﭘﺎﻳﻲ‪ ،‬ﺩﻭﺭﺍﻥ ‪ recovery‬ﻛﻮﺗﺎﻩ‪ ،‬ﺗﺤﻤﻞ ﺑﺎﻻﻱ ﺑﻴﻤﺎﺭﺍﻥ‪ ،‬ﻭﺟﻮﺩ ﺩﺭﺩ ﺑﺴﻴﺎﺭ ﻣﺨﺘﺼﺮ ﻳﺎ ﺣﺘﻲ ﻋﺪﻡ ﻭﺟﻮﺩ ﺩﺭﺩ ﭘﺲ ﺍﺯ ﺍﻋﻤﺎﻝ ﺟﺮﺍﺣﻲ‪ ،‬ﻇﺮﺍﻓﺖ ﻭ ﺗﻤﻴﺰﻱ ﺍﻋﻤﺎﻝ‪ ،‬ﻫﻤﻮﺳـﺘﺎﺯ‬
‫ﻋﺎﻟﻲ‪ ،‬ﺣﺼﻮﻝ ﺳﺮﻳﻊ ﻧﺘﺎﻳﺞ‪ ،‬ﺳﺮﻋﺖ ﺑﺎﻻﻱ ﺍﻧﺠﺎﻡ ﻋﻤﻞ ﻭ ﺭﺍﺣﺘﻲ ﻓﻮﻕﺍﻟﻌﺎﺩﻩ ﺟﺮﺍﺡ ﺑﺮﺧﻲ ﺍﺯ ﻣﺰﺍﻳﺎﻱ ﺍﺳﺘﻔﺎﺩﻩ ﺍﺯ ﺍﻳﻦ ﺩﺳﺘﮕﺎﻩ ﻣﻲﺑﺎﺷﺪ‪ .‬ﺍﺯ ﺍﻳﻦ ﺩﺳﺘﮕﺎﻩ ﺩﺭ ﺣﻴﻄﺔ ‪ ENT‬ﺩﺭ ﻣﻮﺍﺭﺩ ﺯﻳﺮ ﺍﺳﺘﻔﺎﺩﻩ ﻣﻲﺷﻮﺩ‪:‬‬
‫‪1- Coblation channeling of the inferior turbinate‬‬
‫ﺑﺎ ﺍﺳﺘﻔﺎﺩﻩ ﺍﺯ ﺍﻳﻦ ﺩﺳﺘﮕﺎﻩ ﻭ ﺗﺤﺖ ﺑﻲﺣﺴﻲ ﻟﻮﻛﺎﻝ‪ ،‬ﺍﻧﺴﺪﺍﺩ ﺑﻴﻨﻲ ﻧﺎﺷﻲ ﺍﺯ ﻫﻴﭙﺮﺗﺮﻭﻓﻲ ﺗﻮﺭﺑﻴﻨﻪ ﺗﺤﺘﺎﻧﻲ ﺑﻪ ﻛﻤﻚ ‪ Channeling‬ﺗﻮﺭﺑﻴﻨﻪ ﺩﺭﻣﺎﻥ ﻣﻲﺷﻮﺩ‪ .‬ﻧﺘﻴﺠﻪ ﻋﻤﻞ ﺑﻪ ﺻﻮﺭﺕ ﺭﻳﺪﺍﻛﺸﻦ ﺳﺮﻳﻊ ﺗﻮﺭﺑﻴﻨﻪ ﺑﻼﻓﺎﺻﻠﻪ ﻗﺎﺑﻞ ﻣﺸﺎﻫﺪﻩ ﺍﺳﺖ‪ :‬ﺍﻳﻦ ﻋﻤﻞ ﺗﻘﺮﻳﺒﹰﺎ ﺑﻲﺩﺭﺩ ﺧﻮﺍﻫﺪ ﺑﻮﺩ‪.‬‬
‫‪2- Coblation channeling of the Soft palate‬‬

‫ﺗﻠﻔﻦ‪٠٩١٢١٣٧٢٣٦١-٦٦٩٣٦٦٩٦ :‬‬ ‫ﻧﺸﺎﻧﻲ‪ :‬ﺗﻬﺮﺍﻥ‪ ،‬ﻡ ﺍﻧﻘﻼﺏ‪ ،‬ﺥ ﻛﺎﺭﮔﺮ ﺟﻨﻮﺑﻲ‪ ،‬ﺥ ﻟﺒﺎﻓﻲﻧﮋﺍﺩ‪ ،‬ﺑﻴﻦ ﻛﺎﺭﮔﺮ ﻭ ﺟﻤﺎﻟﺰﺍﺩﻩ‪ ،‬ﺑﻦﺑﺴﺖ ﺳﻴﻤﻴﻦ‪ ،‬ﭘﻼﻙ ‪٢٣٩‬‬ ‫ﻣﺮﻛﺰ ﺧﺪﻣﺎﺕ ﻓﺮﻫﻨﮕﻲ ﺳﺎﻟﻜﺎﻥ ‪ :‬ﺍﺭﺍﺋﻪ ﻛﻨﻨﺪﺓ ﻛﺘﺎﺏ ﻭ ﺳﻲﺩﻱﻫﺎﻱ ﺗﺨﺼﺼﻲ ﭘﺰﺷﻜﻲ‬
 11
.‫ ﻧﺘﻴﺠﺔ ﻋﻤﻞ ﻧﻴﺰ ﺑﻪ ﺳﺮﻋﺖ ﺣﺎﺩﺙ ﻣﻲﺷﻮﺩ‬.‫ ﺍﻳﻦ ﻋﻤﻞ ﺳﺮﭘﺎﻳﻲ ﻭ ﺗﺤﺖ ﺑﻲﺣﺴﻲ ﻟﻮﻛﺎﻥ ﻭ ﺗﻘﺮﻳﺒﹰﺎ ﻓﺎﻗﺪ ﺩﺭﺩ ﺍﺳﺖ‬.‫ ﻛﺎﻡ ﻧﺮﻡ ﺍﺯ ﺣﺠﻢ ﺁﻥ ﻛﺎﺳﺘﻪ ﺷﺪﻩ ﻭ ﺑﺎﻋﺚ ﺭﻓﻊ ﺧﺮﺧﺮ ﺩﺭ ﺑﻴﻤﺎﺭﺍﻥ ﻣﻲﺷﻮﺩ‬Channeling ‫ ﺑﺎ‬،‫ﺩﺭ ﺍﻳﻦ ﻋﻤﻞ‬
3- Coblation channeling of the tonsil
.‫ ﻧﺘﻴﺠﻪ ﺑﻪ ﺳﺮﻋﺖ ﺣﺎﺩﺙ ﺷﺪﻩ ﻭ ﻋﻤﻞ ﺗﻘﺮﻳﺒﹰﺎ ﻓﺎﻗﺪ ﺩﺭﺩ ﺍﺳﺖ‬.‫ ﺑﺴﺘﻪ ﺑﻪ ﺷﺮﺍﻳﻂ ﺍﻳﻦ ﻋﻤﻞ ﻣﻲﺗﻮﺍﻧﺪ ﺳﺮﭘﺎﻳﻲ ﻳﺎ ﺗﺤﺖ ﺑﻲﻫﻮﺷﻲ ﻋﻤﻮﻣﻲ ﺑﺎﺷﺪ‬.‫ ﺗﻮﻧﺴﻴﻞ ﻛﺎﺳﺘﻪ ﻣﻲﺷﻮﺩ‬bulk ‫ ﻫﻴﭙﺮﺗﺮﻭﻧﻲ ﺗﻮﻧﺴﻴﻠﺮ ﺑﺮﻃﺮﻑ ﺷﺪﻩ ﻭ ﺍﺯ‬،‫ﺑﺎ ﺍﻳﻦ ﺭﻭﺵ‬
4- Coblation Assisted Tonsillectomy(CAT)
.‫ ﻭ ﺩﻭﺭﺍﻥ ﺑﻬﺒﻮﺩﻱ ﺳﺮﻳﻊ ﻣﻲﺑﺎﺷﺪ‬.‫ﻻ ﺑﺴﻴﺎﺭ ﻣﺨﺘﺼﺮ ﺍﺳﺖ‬
‫ ﺩﺭﺩ ﭘﺲ ﺍﺯ ﻋﻤﻞ ﻣﻌﻤﻮ ﹰ‬.‫ﺩﺭ ﺻﻮﺭﺕ ﻭﺟﻮﺩ ﺗﻮﻧﺴﻴﻞﻫﺎﻱ ﺑﺰﺭﮒ ﻳﺎ ﺗﻮﻧﺴﻴﻠﻴﺖ ﻓﺮﺽ ﺍﺯ ﺍﻳﻦ ﺭﻭﺵ ﺟﻬﺖ ﺍﻧﺠﺎﻡ ﺗﻮﻧﺴﻴﻠﻜﺘﻮﻣﻲ ﺍﺳﺘﻔﺎﺩﻩ ﻣﻲﺷﻮﺩ‬
9.2 Color Atlas of Diagnostic Endoscopy in Otorhinolaryngolgy (EIJI YANAGISAWA, MD) ‫ــــــ‬
10.2 Color Atlas of Ear Disease (Salekan E-book) (Richard A. Chole, MD, PhL, James W. Forsen) 2002
11.2 DALLAS RHINOPLASTY Nasal Surgery by the Masters (Reducing Tip Projection and Nostrill Show Via the Open Approach) (CD I , II) 2002
VCD: 1 VCD: 2
1) Cadaveric Rhinoplasty Dissection Technique Reducing Tip Projection and Nostril Show Via the Open Approach
2) Role of Component Dorsal Reduction: Spreader Grafts in the Deviated Nose
:‫ ﺑﻪ ﺷﻤﺎ ﺗﻜﻨﻴﻚﻫﺎﻱ ﺟﺮﺍﺣﻲ ﺭﻳﻨﻮﭘﻼﺳﺘﻲ ﺑﺮ ﺭﻭﻱ ﻛﺎﺭﺁﻭﺭ ﺍﺯ ﺍﺑﺘﺪﺍ ﻭ ﺩﺭ ﻏﺎﻟﺐ ﻋﻨﺎﻭﻳﻦ ﺯﻳﺮ ﺑﻪ ﺗﺮﺗﻴﺐ ﺁﻣﻮﺯﺷﻲ ﺩﺍﺩﻩ ﻣﻲﺷﻮﺩ‬،‫ ﻛﻪ ﺩﺭ ﺳﭙﻮﺯﻳﻮﻡ ﺭﻳﻨﻮﭘﻼﺳﺘﻲ ﺩﺍﻻﺱ ﺗﻬﻴﻪ ﺷﺪﻩ ﺍﺳﺖ‬١ ‫ ﺷﻤﺎﺭﺓ‬VCD ‫ﺩﺭ‬
1) Exposure/Nasal incisions 2) Tip Alteration 3) Sptal reconstraction 4) Osteotmies 5) Adjuctive techniques/Closure
A. Closed endonasal approach A. Columellar Stat placement A. Septal reconstraction A. Medial Osteotomy A. Alare base resection
- Intracartilaginous (IC) - Intercarural suture stabilization - Inferior tarbinate resection B. Lateral Osteotomy - Correction of alalr flaring
incision B. Controlling dome angalation (Submacosal) C. External Osteotomy - Diminishing nostril shape
B. Cartilage delivery technique and tip defining points - Septal reconstruction B. Closare
- Infracartilaginous incision - Interdomal sutures B. Modification of the dorsum C. Splints
- Intercartilaginous incision - Transdomal Satares - Component dorsum
C. Open Rhinoplasty approach C. Correction of alar reduction
- Transcolumellar incision pinching/notching - Spreader graft placement
- lateral crural strut grafts
- Alar contour grafts
D. Tip grafts
- Infratip graft
- Onlay tip graft
‫ ﺑـﻪ‬Gunter ‫ ﺍﺯ ﻣﺼﺎﺣﺒﻪ ﺑﺎ ﺑﻴﻤﺎﺭ ﺁﻏﺎﺯ ﺷـﺪﻩ ﻭ ﺳـﭙﺲ ﺩﻛﺘـﺮ‬VCD ‫ ﺁﻣﻮﺯﺵ ﺩﺭ ﺍﻳﻦ‬.‫ ﻗﺮﺍﺭ ﻣﻲﮔﻴﺮﺩ‬Open ‫ ﺗﺤﺖ ﻋﻤﻞ ﺟﺮﺍﺣﻲ ﺭﻳﻨﻮﭘﻼﺳﺘﻲ ﺑﺎ ﺍﭘﺮﻭﭺ‬Gunter ‫ ﺯﻳﺎﺩ ﺗﻮﺳﻂ ﺁﻗﺎﻱ ﺩﻛﺘﺮ‬nostril show , Projected tip ‫ ﺧﺎﻧﻢ ﺟﻮﺍﻧﻲ ﺑﺎ ﺷﻜﻞ‬٢ ‫ ﺷﻤﺎﺭﺓ‬VCD ‫ﺩﺭ‬
.‫ ﺳﭙﺲ ﻋﻤﻞ ﺟﺮﺍﺣﻲ ﺑﺎ ﻇﺮﺍﻓﺖ ﻋﺎﻟﻲ ﺩﺭ ﻏﺎﻟﺐ ﻣﺮﺍﺣﻞ ﺯﻳﺮ ﺍﻧﺠﺎﻡ ﻣﻲﺷﻮﺩ‬.‫ﺁﻧﺎﻟﻴﺰ ﻧﺎﺯﻭﻧﺎﺷﻴﺎﻝ ﻭﻱ ﻣﻲﭘﺮﺩﺍﺯﺩ‬
4) Transaction of lat Crura 3) Underminig tip Skin 2) Infracartilaginous and trans columellar incisions 1)Complete transfixion incision
8) Reduction of dorsal septum (DS) and upper lateral cartilage (ULC) 7) reduction of bony darsum (BD) 6) Preparing submucosal tunnels 5) Resection of feet of medial crura
12) Cephalic resection of lateral Crura (LC) 11) Spreader grafts 10) Medial asteomius 9) Harvesting Septal cartilages for grafting
16) Final adjustment of dorsal height 15) Lateral asteotomy Cinternal 14) Aligning the dorsum 13) Preparation for lateral crural grafts (LCSG)
19) Closure 18) Placement of lateral crural strut grafts 17) Columellar strt placemend
!!‫ ﺗﻮﺟﻪ ﺷﻤﺎ ﺭﺍ ﺑﻪ ﺍﺳﺘﻔﺎﺩﻩ ﺍﺯ ﻭﺳﻴﻠﻪ ﺭﻳﺪﺍﻛﺸﻦ ﺩﻭﺭ ﺳﻮﻡ ﺍﺳﺘﺨﻮﺍﻧﻲ ﻧﻴﺰ ﺟﻠﺐ ﻣﻲﻛﻨﻴﻢ‬VCD ‫ ﺩﺭ ﺍﻳﻦ‬.‫ﺩﺭ ﻧﻬﺎﻳﺖ ﺷﻤﺎ ﻧﺘﺎﻳﺞ ﺑﻌﺪ ﺍﺯ ﻋﻤﻞ ﺑﻴﻤﺎﺭ ﺩﺭ ﻓﻮﺍﺻﻞ ﻣﺨﺘﻠﻒ ﻣﺸﺎﻫﺪﻩ ﻣﻲﻛﻨﻴﺪ‬
12.2 Diseases of the Sinuses Diagnosis and Management (Darid W. Kennedy, MD, FRCSI, William E. Bolger, MD, FACS, S. James Zinreich, MD) ‫ــــــ‬
.‫ ﺍﻳﻦ ﻛﺘﺎﺏ ﺗﻘﺮﻳﺒﹰﺎ ﻣﻌﺘﺒﺮﺗﺮﻳﻦ ﺭﻓﺮﺍﻧﺲ ﺳﻴﻨﻮﻧﺎﺯﻭﻟﻮﮊﻱ ﺩﺭ ﺩﻧﻴﺎ ﻣﻲﺑﺎﺷﺪ‬.‫ﮔﻨﺠﺎﻧﺪﻩ ﺷﺪﻩ ﺍﺳﺖ‬ 2001 ‫ ﺗﺸﺨﻴﺺ ﻭ ﺩﺭﻣﺎﻥ ﺑﻴﻤﺎﺭﻳﻬﺎﻱ ﺳﻴﻨﻮﺱ ﺑﻪ ﺗﺎﻟﻴﻒ ﺁﻗﺎﻱ ﺩﻛﺘﺮ ﺩﻳﻮﻳﺪﻛﻨﺪﻱ ﻣﺤﺼﻮﻝ ﺳﺎﻝ‬text book ، CD ‫ﺩﺭ ﺍﻳﻦ‬

13.2 EENT Welch Allyn Institute of Interactive Learning ‫ــــــ‬

14.2 ENDONASAL SINUSECTOMY WITH CORRECTION OF THE NASAL CAVITY (Rikio Ashikawe, Takashi Ohmae, Toshio Ohnisshi, Yutaka Uchida) ‫ــــــ‬
The Endonasal sinusectomy with correction of the nasal cavity (Takahash's methodn) is carried out in seven steps.
15.2 Endoscopic Assisted Procedures used in Astatic Facial Plastic Surgery (VCD) (CD I , II) ‫ــــــ‬

‫ ﺁﻣﻮﺯﺷﻲ ﺑﻪ ﺻـﻮﺭﺕ ﻗـﺪﻡ‬.‫ ﺳﭙﺲ ﺑﻪ ﺷﻤﺎ ﺗﻜﻨﻴﻚ ﺟﺮﺍﺣﻲ ﺍﻧﺪﻭﺳﻜﻮﭘﻴﻚ ﻣﺎﻻﺭﻭﻓﺮﻭﻧﺘﺎﻝ ﻛﻪ ﺗﻮﺳﻂ ﺩﻛﺘﺮ ﻫﻨﺮﻱ ﺩﻟﻤﺎﺭ ﺍﺭﺍﺋﻪ ﻣﻲﺷﻮﺩ ﺁﻣﻮﺯﺵ ﺩﺍﺩﻩ ﻣﻲﺷﻮﺩ‬.‫ ﺷﺮﻛﺖ ﻛﺎﺭﻝ ﺍﺷﺘﻮﺭﺗﺰ ﭘﻴﺸﺮﻭ ﺩﺭ ﺍﺭﺍﺋﻪ ﺗﺠﻬﻴﺰﺍﺕ ﺍﻧﺪﻭﺳﻜﻮﭘﻲ ﻭ ﻣﺤﺼﻮﻻﺕ ﺁﻥ ﺁﺷﻨﺎ ﻣﻲﺷﻮﻳﺪ‬،‫ ﺍﻭﻝ ﺷﻤﺎ ﺩﺭ ﺍﺑﺘﺪﺍ‬VCD ‫ﺩﺭ ﺍﻳﻦ‬

٠٩١٢١٣٧٢٣٦١-٦٦٩٣٦٦٩٦ :‫ﺗﻠﻔﻦ‬ ٢٣٩ ‫ ﭘﻼﻙ‬،‫ ﺑﻦﺑﺴﺖ ﺳﻴﻤﻴﻦ‬،‫ ﺑﻴﻦ ﻛﺎﺭﮔﺮ ﻭ ﺟﻤﺎﻟﺰﺍﺩﻩ‬،‫ ﺥ ﻟﺒﺎﻓﻲﻧﮋﺍﺩ‬،‫ ﺥ ﻛﺎﺭﮔﺮ ﺟﻨﻮﺑﻲ‬،‫ ﻡ ﺍﻧﻘﻼﺏ‬،‫ ﺗﻬﺮﺍﻥ‬:‫ﻧﺸﺎﻧﻲ‬ ‫ ﺍﺭﺍﺋﻪ ﻛﻨﻨﺪﺓ ﻛﺘﺎﺏ ﻭ ﺳﻲﺩﻱﻫﺎﻱ ﺗﺨﺼﺼﻲ ﭘﺰﺷﻜﻲ‬: ‫ﻣﺮﻛﺰ ﺧﺪﻣﺎﺕ ﻓﺮﻫﻨﮕﻲ ﺳﺎﻟﻜﺎﻥ‬
 12
.‫ﺭﺍ ﺑﻪ ﻧﻤﺎﻳﺶ ﻣﻲﮔﺬﺍﺭﺩ‬ Endoscopic forehead rhytidectomy and brow elevation ‫ ﺗﻜﻨﻴﻚ ﺟﺮﺍﺣﻲ‬Grlecory S. Keller ‫ ﺩﺭ ﻣﺮﺣﻠﺔ ﺑﻌﺪ ﺩﻛﺘﺮ‬.‫( ﺍﺩﺍﻣﻪ ﻣﻲﻳﺎﺑﺪ‬closure) ‫ﺑﻪ ﻗﺪﻡ ﺍﺯ ﻧﺸﺎﻧﻪﮔﺬﺍﺭﻱ ﺭﻭﻱ ﭘﺮﺕ ﻭ ﺗﺰﺭﻳﻖ ﻭ ﺑﺮﺵﻫﺎ ﺷﺮﻭﻉ ﺷﺪﻩ ﻭ ﺗﺎ ﭘﺎﻳﺎﻥ ﻋﻤﻞ‬

Extended Composite face Lift Endoscopic midface Lift Endoscopic forehead Lift :‫ ﺷﻤﺎ ﺑﺎ ﺍﻳﻦ ﻣﻮﺍﺭﺩ‬Endoscopic assisted forehead and face lifting ‫ ﺩﻭﻡ ﺗﺤﺖ ﻋﻨﻮﺍﻥ‬VCD ‫ﺩﺭ‬
‫ ﺍﺑﺰﺍﺭﺁﻻﺕ ﻻﺯﻡ ﺩﺭ ﻋﻤﻞ‬،‫ ﺩﺭ ﭘﺎﻳﺎﻥ ﻧﺤﻮﺓ ﺛﺒﺖ ﺳﻪﺑﻌﺪﻱ ﺗﻐﻴﻴﺮﺍﺕ‬.‫ ﻣﺎﻩ ﺑﻌﺪ( ﻫﻢ ﺑﻪ ﺷﻤﺎ ﻧﺸﺎﻥ ﺩﺍﺩﻩ ﻣﻲﺷﻮﺩ‬٢) ‫ ﺩﺭ ﻫﺮ ﻣﻮﺭﺩ ﺑﺮﺍﻱ ﺷﻤﺎ ﻳﻚ ﺑﻴﻤﺎﺭ ﻣﻮﺭﺩ ﻋﻤﻞ ﺟﺮﺍﺣﻲ ﺗﻮﺳﻂ ﺁﻥ ﺗﻜﻨﻴﻚ ﻗﺮﺍﺭ ﮔﺮﻓﺘﻪ ﻭ ﻧﺘﺎﻳﺞ ﺑﻌﺪ ﺍﺯ ﻋﻤﻞ‬.‫ﺍﻧﺪﻳﻜﺎﺳﻴﻮﻥﻫﺎ ﻭ ﻓﻮﺍﻳﺪ ﻫﺮ ﺭﻭﺵ ﺁﺷﻨﺎ ﻣﻲﺷﻮﻳﺪ‬
.‫ﺟﺮﺍﺣﻲ ﻫﻢ ﺑﻪ ﺷﻤﺎ ﻣﻌﺮﻓﻲ ﻣﻲﺷﻮﺩ‬

16.2 Endoscopic Sinus Surgery (SALEKAN-eBook) ‫ــــــ‬

‫ ﺁﺷﻨﺎﻳﻲ ﺷﻤﺎ ﺷﺎﻣﻞ ﺍﺑﺘﺪﺍﻳﻲﺗﺮﻳﻦ ﻣﺴﺎﺋﻞ ﻣﻦﺟﻤﻠﻪ ﺍﺑﺰﺍﺭﺁﻻﺕ ﺑﻜﺎﺭ ﺭﻓﺘﻪ ﺩﺭ ﺟﺮﺍﺣﻲﻫﺎﻱ ﺁﻧﺪﻭﺳﻜﻮﭘﻴﻚ ﺳﻴﻨﻮﺱ ﻭ ﺣﺘﻲ ﻧﺤﻮﺓ ﺍﻳﺴﺘﺎﺩﻥ ﻳﺎ‬.‫ ﻛﻪ ﺑﻪ ﺻﻮﺭﺕ ﻃﺒﻘﻪﺑﻨﺪﻱ ﺍﺭﺍﺋﻪ ﻣﻲﺷﻮﺩ ﺷﻤﺎ ﺑﺎ ﻓﻴﻠﺪ ﺗﺸﺨﻴﺺ ﻭ ﺩﺭﻣﺎﻥ ﺁﻧﺪﻭﺳﻜﻮﭘﻴﻚ ﺑﻴﻤﺎﺭﻳﻬﺎﻱ ﺳﻴﻨﻮﺳﻲ ﺁﺷﻨﺎ ﻣﻲﺷﻮﻳﺪ‬CD ‫ﺩﺭ ﺍﻳﻦ‬
‫( ﺑـﻪ‬Atlas and textbook) ‫ ﻣﺮﺍﺣﻞ ﻣﺨﺘﻠﻒ ﺟﺮﺍﺣﻲ ﺁﻧﺪﻭﺳﻜﻮﭘﻴﻚ ﺳﻴﻨﻮﺱﻫﺎﻱ ﭘﺎﺭﺍﻧﺎﺯﺍﻝ ﻭ ﺑﻴﻤﺎﺭﻳﻬﺎﻱ ﻣﺮﺗﺒﻂ ﺑﺎ ﺍﻧﻬﺎ ﺑﻪ ﺻﻮﺭﺕ ﻣﺘﻦ ﻭ ﮔـﺮﺍﻑ‬.‫ ﻣﺒﺎﻧﻲ ﺁﻧﺎﺗﻮﻣﻴﻚ ﻭ ﺩﺍﻳﺴﻜﺸﻦ ﺑﺮﺍﻱ ﺷﻤﺎ ﺗﺸﺮﻳﺢ ﻣﻲﺷﻮﺩ‬.‫ﻧﺸﺴﺘﻦ ﻫﻨﮕﺎﻡ ﻋﻤﻞ ﻭ ﮔﺮﻓﺘﻦ ﺍﺑﺰﺍﺭ ﺩﺭ ﺩﺳﺖ ﻫﻢ ﻣﻲﺷﻮﺩ‬
:‫ ﺷﺎﻣﻞ ﻣﺒﺎﺣﺚ ﺯﻳﺮ ﺍﺳﺖ‬CD ‫ ﻓﺼﻮﻝ ﺍﻳﻦ‬.‫ﺷﻤﺎ ﻧﺸﺎﻥ ﺩﺍﺩﻩ ﻣﻲﺷﻮﺩ‬
1- Consistent and Relible Anatomical Landmarks in Endoscopic Sinus Surgery 2- Surgical Instrumentation 3- Setup and patient positioning 4- Basic Dissection 5- Advanced Dissection
17.2 Endoscopic Sinus Surgery NEW HORIZONS (Nikhil J. Bhatt, M.D.) ‫ــــــ‬
18.2 EVIDENCE-BASED OTITIS MEDIA (Richard M. Rosenfeld, MD, MPH, Charles D. Bluestone, MD) ‫ــــــ‬
‫ ﺩﺭﻣـﺎﻥﻫـﺎﻱ ﺩﺍﺭﻭﻳـﻲ ﻭ ﺟﺮﺍﺣـﻲ ﺁﻥ‬،‫ ﺗﺸﺨﻴﺺ‬،‫ ﻋﻼﺋﻢ ﻭ ﻣﺴﻴﺮ ﺑﺎﻟﻴﻨﻲ‬،‫ ﺁﺷﻨﺎﻳﻲ ﺍﺯ ﻣﺴﺎﺋﻞ ﺍﭘﻴﺪﻣﻴﻮﻟﻮﮊﻳﻚ ﻭ ﺗﺤﻘﻴﻘﺎﺕ ﺍﻧﺠﺎﻡ ﺷﺪﻩ ﺁﻏﺎﺯ ﺷﺪﻩ ﻭ ﺩﺭ ﺍﺩﺍﻣﻪ ﺑﻪ ﻣﻮﺷﻜﺎﻓﻲ ﺩﺭ ﻣﻮﺭﺩ ﺍﻧﻮﺍﻉ ﺍﺗﻴﻮﻟﻮﮊﻱ‬.‫ ﺷﻤﺎ ﺑﺎ ﺑﻴﻤﺎﺭﻱﻫﺎﻱ ﺍﻭﺗﻴﺖ ﻣﺪﻳﺎ ﺑﻪ ﺻﻮﺭﺗﻲ ﺍﺻﻮﻟﻲ ﺁﺷﻨﺎ ﻣﻲﺷﻮﻳﺪ‬CD ‫ﺩﺭ ﺍﻳﻦ‬
:‫ ﺷﺎﻣﻞ ﻣﺒﺎﺣﺚ ﺯﻳﺮ ﺍﺳﺖ‬CD ‫ ﻓﺼﻮﻝ ﺍﻳﻦ‬.‫ ﺩﺭ ﺿﻤﻦ ﺍﺛﺮﺍﺕ ﺍﻳﻦ ﺑﻴﻤﺎﺭﻱ ﺭﻭﻱ ﺗﻜﺎﻣﻞ ﻛﻮﺩﻙ ﻭ ﻛﻴﻔﻴﺖ ﺯﻧﺪﮔﻲ ﺍﻭ ﻧﻴﺰ ﺗﺸﺮﻳﺢ ﻣﻲﮔﺮﺩﺩ‬.‫ ﺩﺭ ﺍﻧﺘﻬﺎ ﻧﺘﺎﻳﺞ ﺩﺭﻣﺎﻥ ﺑﺮﺭﺳﻲ ﻣﻲﺷﻮﺩ‬.‫ﻣﻲﭘﺮﺩﺍﺯﺩ‬

1- Methodology 2- Clinical Management 3- Consequences and Sequelae

19.2 Facial Nerve Surgery (Jack L. Pulec, M.D.) Otologic Medical Group, Inc. Los Angeies ‫ــــــ‬
20.2 Facial Plastic & Reconstructive Surgery (Terence M. Davidson, MD) (VCD I , II) ‫ــــــ‬
21.2 Head and Neck Surgery (Jatin P Shah, MD, MS (Surg), FACS) (Mosby) ‫ــــــ‬
22.2 Introduction to Ear Acupuncture (Martin Franke) 2001
‫ ﺁﻣﻮﺯﺵ ﺍﺯ ﺁﻧﺎﺗﻮﻣﻲ ﻭ ﻧﻮﺍﺣﻲ ﻣﺨﺘﻠﻒ ﻣﻮﺭﺩﻧﻈﺮ ﺩﺭ ﻃﺐ ﺳﻮﺯﻧﻲ ﮔﻮﺵ ﺁﻏﺎﺯ ﺷﺪﻩ ﻭ ﺳﭙﺲ ﺑﺎ ﻧﺤﻮﺓ ﺍﻧﺠﺎﻡ ﻃـﺐ‬.‫ ﺍﺭﺍﺋﻪ ﺷﺪﻩ ﺍﺳﺖ ﺷﻤﺎ ﺑﺎ ﺍﺻﻮﻝ ﻛﻠﻲ ﻃﺐ ﺳﻮﺯﻧﻲ ﮔﻮﺵ ﺁﺷﻨﺎ ﻣﻲﺷﻮﻳﺪ‬Thieme ‫ ﺁﻣﻮﺯﺷﻲ ﻛﻪ ﺗﻮﺳﻂ ﻣﺎﺭﺗﻴﻦ ﻓﺮﺍﻧﻚ ﺗﻬﻴﻪ ﻭ ﺗﻮﺳﻂ ﺍﻧﺘﺸﺎﺭﺍﺕ ﻣﻌﺘﺒﺮ‬CD ‫ﺩﺭ ﺍﻳﻦ‬
.‫ ﺍﺩﺍﻣﻪ ﻣﻲﻳﺎﺑﺪ ﺳﭙﺲ ﺷﻤﺎ ﻣﻲﺗﻮﺍﻧﻴﺪ ﻧﮕﺎﻫﻲ ﺑﻪ ﻧﺘﺎﻳﺞ ﺍﻳﻦ ﺍﻋﻤﺎﻝ ﻫﻢ ﺩﺍﺷﺘﻪ ﺑﺎﺷﻴﺪ ﻭ ﺁﻧﻬﺎ ﺭﺍ ﺍﺭﺯﻳﺎﺑﻲ ﻧﻤﺎﺋﻴﺪ‬... ‫ ﺍﻋﺘﻴﺎﺩ ﺑﻪ ﺳﻴﮕﺎﺭ ﻭ‬،‫ ﺳﺮﮔﻴﺠﻪ‬،‫ ﺑﻴﻤﺎﺭﻳﻬﺎﻱ ﺧﻮﺍﺏ‬،‫ﺳﻮﺯﻧﻲ ﺩﺭ ﺑﻴﻤﺎﺭﻳﻬﺎﻱ ﻣﺨﺘﻠﻒ ﻫﻤﭽﻮﻥ ﻣﻴﮕﺮﻥ‬
1- Localization Assignment 2- Localization Determination 3- Treatment 4- Evaluation

23.2 La Rhinoplastica Ragionata (Valerio Micheli-Pellegrini, Roberto Polselli) ‫ــــــ‬

24.2 Local Flaps in Head and Neck Reconstruction (Lan T. Jackson, M,D.) (SALEKAN E-BOOK) 2002
25.2 Nasal Aesthetics and Anatomy: A Cadaver Study (Rollin K. Daniel, M.D.) ‫ــــــ‬
26.2 OPEN RHINOPLASTY Cadaver Dissection Program (Dean M. Toriumi, MD.) (Vol I , II) (College of Medicine at Chicago) ‫ــــــ‬
1- Access to nasal Septum 3- Open Rhinoplasty approach 5- Management of Middle Nasal Vault 7- Management of Lower third of the nose
- Hemitrans Fixatu incision - Incisions - Division of apper Lateral Cartilages from septum - Cephalic trimming of lateral Crura
- Havvestiong Septal Cartilage - Flap Elevation - Application of Spreader grafts - Satured – in – place Collamellar Strut
- Transdomal Sutur
- Sutured – in – place tip
2- Havvestiog of Conchal Cartilage 4- Stractural grafts used in Secondary 6- Major septal reconstruction 8- Chin augmentation
- Anterior approach for harvestiog Cartilage - loteral Crural grafts - Reconstraction of L-Shaped Septal Strat - Preparation of the implant
- Flap elevention - Alar Batten grafts - Incision and dissection
- Cartilage excision - placement of Implant
- Closure and dressing
27.2 Open Structure Rhinoplasty (A Case Oriented Approach) 2005

٠٩١٢١٣٧٢٣٦١-٦٦٩٣٦٦٩٦ :‫ﺗﻠﻔﻦ‬ ٢٣٩ ‫ ﭘﻼﻙ‬،‫ ﺑﻦﺑﺴﺖ ﺳﻴﻤﻴﻦ‬،‫ ﺑﻴﻦ ﻛﺎﺭﮔﺮ ﻭ ﺟﻤﺎﻟﺰﺍﺩﻩ‬،‫ ﺥ ﻟﺒﺎﻓﻲﻧﮋﺍﺩ‬،‫ ﺥ ﻛﺎﺭﮔﺮ ﺟﻨﻮﺑﻲ‬،‫ ﻡ ﺍﻧﻘﻼﺏ‬،‫ ﺗﻬﺮﺍﻥ‬:‫ﻧﺸﺎﻧﻲ‬ ‫ ﺍﺭﺍﺋﻪ ﻛﻨﻨﺪﺓ ﻛﺘﺎﺏ ﻭ ﺳﻲﺩﻱﻫﺎﻱ ﺗﺨﺼﺼﻲ ﭘﺰﺷﻜﻲ‬: ‫ﻣﺮﻛﺰ ﺧﺪﻣﺎﺕ ﻓﺮﻫﻨﮕﻲ ﺳﺎﻟﻜﺎﻥ‬
 ‫‪13‬‬
‫)‪28.2 Open Tip Graft in Twin Patient (Rollin K. Daniel, M.D.‬‬ ‫ــــــ‬
‫‪Analysis, Operative Planning, Twins Pre and Post, Anesthesia, Transfixion Incision, Septal Harvest, Open Approach, Exposure, Tip Anatomy, Tim Strips, Graft Preparation, Radix Graft, Crural Strut,‬‬
‫‪Domal Excision, Graft, Shaping, Graft, Insertion, Closure, Post Op Result, Credits‬‬
‫‪29.2 Otorhinolaryngology Head and Neck Surgery‬‬ ‫)‪(SIXTEENTH EDITION) (James B, Snow Jr, MD, John Jacob Ballenger, MD,‬‬ ‫‪2003‬‬
‫‪Otology and Neurotology‬‬ ‫‪Facial Plastic and Reconstructive Surgery‬‬ ‫‪Pediatric Otolaryngology‬‬ ‫‪Rhinology‬‬ ‫‪Bronchoesphagology‬‬ ‫‪Laryngology‬‬ ‫‪Head and Neck Surgery‬‬
‫)‪30.2 Plastic Surgery (Fifth Edition) (Grabb and Smith's) (Salekan E-Book‬‬ ‫ــــــ‬
‫ﺍﻳﻦ ﻛﺘﺎﺏ ﺍﻟﻜﺘﺮﻭﻧﻴﻜﻲ ﻣﺸﺘﻤﻞ ﺑﺮ ‪ ٩٢‬ﻓﺼﻞ ﺩﺭ ‪ ٧‬ﻗﺴﻤﺖ‪ ،‬ﻛﺘﺎﺑﻲ ﻛﺎﻣﻞ ﻭ ﻛﺎﺭﺑﺮﺩﻱ ﺩﺭ ﺗﻤﺎﻡ ﻣﺒﺎﺣﺚ ﺟﺮﺍﺣﻲ ﭘﻼﺳﺘﻴﻚ ﻣﻲﺑﺎﺷﺪ‪ .‬ﺍﻳﻦ ﻛﺘﺎﺏ ﺑﻪ ﻣﻨﻈﻮﺭ ﻋﻼﻗﻤﻨﺪﻱ ﺑﻪ ﺟﺮﺍﺣﻲ ﭘﻼﺳﺘﻴﻚ ﺩﺭ ﺗﻤﺎﻡ ﺳﻄﻮﺡ ﺁﻣﻮﺯﺵ ﻭ ﺩﺭﻣﺎﻥ ﭘﺰﺷﻜﻲ ﻣﻲﺑﺎﺷﺪ ﻭ ﻣﻮﺭﺩ ﺍﺳﺘﻔﺎﺩﻩ ﺩﺳﺘﻴﺎﺭﺍﻥ‬
‫ﻭ ﻣﺘﺨﺼﺼﻴﻦ ﺟﺮﺍﺣﻲ ﭘﻼﺳﺘﻴﻚ ﻣﻲﺑﺎﺷﺪ‪ .‬ﺑﻪ ﮔﻔﺘﺔ ﻣﺆﻟﻔﻴﻦ ﺍﻳﻦ ﻛﺘﺎﺏ ﻫﻤﭽﻨﻴﻦ ﺑﺮﺍﻱ ﺍﻣﺘﺤﺎﻧﺎﺕ ﻭ ﺁﻣﻮﺯﺵ ﻣﺪﺍﻭﻡ ﺑﻮﺭﺩ ﺟﺮﺍﺣﻲ ﭘﻼﺳﺘﻴﻚ ﺁﻣﺮﻳﻜﺎ ﺳﻮﺩﻣﻨﺪ ﺍﺳﺖ‪.‬‬
‫ﺑﺨﺶ ﺍﻭﻝ‪ General Reconstruction :‬ﺑﻮﺩﻩ ﻭ ﺩﺭ ﻣﻮﺭﺩ ﺗﺮﻣﻴﻢ ﺯﺧﻢ‪ ،‬ﺗﻜﻨﻴﻚﻫﺎﻱ ﺍﻭﻟﻴﺔ ﺟﺮﺍﺣﻲ ﭘﻼﺳﺘﻴﻚ ﺁﻧﺸﺮﻱ‪ ، implants ،‬ﺗﻜﻨﻴﻚﻫﺎﻱ ﺍﺳﺘﻔﺎﺩﻩ ﺍﺯ ‪ flap‬ﻭ ‪ graft‬ﻭ ‪ ...‬ﻣﻲﺑﺎﺷﺪ‪.‬‬
‫ﺑﺨﺶ ﺩﻭﻡ‪ :‬ﺑﻪ ﺟﺮﺍﺣﻲ ﭘﻼﺳﺘﻴﻚ ﺩﺭ ﭘﻮﺳﺖ ﻣﻲﭘﺮﺩﺍﺯﺩ ﻛﻪ ﺷﺎﻣﻞ ﭼﮕﻮﻧﮕﻲ ﺟﺮﺍﺣﻲﻫﺎﻱ ﺗﻮﻣﻮﺭﻫﺎﻱ ﭘﻮﺳﺖ‪ ،‬ﺧﺎﻝﻫﺎﻱ ﻣﺎﺩﺭﺯﺍﺩﻱ‪ ،‬ﺟﺮﺍﺣﻲ ﺑﺎ ‪ Moths‬ﻭ ﺍﺳﺘﻔﺎﺩﻩ ﺍﺯ ﻟﻴﺰﺭ ﺩﺭ ﭘﻮﺳﺖ ﻣﻲﺑﺎﺷﺪ‪.‬‬
‫ﺑﺨﺶ ﺳﻮﻡ‪ :‬ﺑﻪ ﺩﺭﻣﺎﻥ ﺿﺎﻳﻌﺎﺕ ﺳﺮ ﻭ ﮔﺮﺩﻥ ﻣﻲﭘﺮﺩﺍﺯﺩ ﻣﺎﻧﻨﺪ )ﺍﺻﻼﺡ ﺩﻓﺮﻳﺘﻤﻲﻫﺎﻱ ﺳﺮ ﻭ ﺻﻮﺭﺕ‪ ،‬ﺍﺗﻮﭘﻼﺳﻤﻲ ‪ Reconstruction ،‬ﺑﻴﻨﻲ‪ ،‬ﮔﻮﺵ ﻭ ﮔﻮﻧﻪ ﻭ ﻟﺐ ﻭ ‪ (...‬ﻣﻲﺑﺎﺷﺪ‪.‬‬
‫ﺑﺨﺶ ﭼﻬﺎﺭﻡ‪ :‬ﺟﺮﺍﺣﻲﻫﺎﻱ ﺯﻳﺒﺎﻳﻲ ﻣﻲﺑﺎﺷﺪ ﺷﺎﻣﻞ‪ ، dermabrasion, peeling) :‬ﺗﺰﺭﻳﻖ ﻛﻼﮊﻥ ﺑﻠﻔﺎﺭﻭﭘﻼﺳﺘﻲ‪ ،‬ﻟﻴﭙﻮﺳﺎﻛﺸﻦ‪ (...endoscopic plastic surgery ،‬ﻣﻲﺑﺎﺷﺪ‪.‬‬
‫ﺑﺨﺶ ﭘﻨﺠﻢ‪ :‬ﺟﺮﺍﺣﻲﻫﺎﻱ ﺯﻳﺒﺎﻳﻲ ﻭ ﺗﺮﻣﻴﻤﻲ ‪ breast‬ﺷﺮﺡ ﺩﺍﺩﻩ ﺷﺪﻩ ﻛﻪ ﺷﺎﻣﻞ‪ :‬ﻣﺎﻣﻮﭘﻼﺳﺘﻲ‪ ،‬ﻛﻤﭙﻠﻴﻜﺎﺳﻴﻮﻥ‪ ،‬ﺗﺼﻴﺤﻴﺤﻲ ﮊﻳﻨﻜﻮﻣﺎﺳﺘﻲ ﻭ ‪ ...‬ﭘﺮﺩﺍﺧﺘﻪ ﺍﺳﺖ‪.‬‬
‫ﺑﺨﺶ ﺷﺸﻢ‪ :‬ﺍﻳﻦ ﻗﺴﻤﺖ ﺑﻪ ﺟﺮﺍﺣﻲ ﺗﺮﻣﻴﻤﻲ ﺩﺳﺖ ﺍﺧﺘﺼﺎﺹ ﺩﺍﺭﺩ‪.‬‬
‫ﺑﺨﺶ ﻫﻔﺘﻢ‪ :‬ﻣﺮﺑﻮﻁ ﺑﻪ ﻧﺎﺣﻴﺔ ﺍﻧﺪﺍﻡ ﺗﺤﺘﺎﻧﻨﻲ ﻭ ﺗﻨﻪ ﻣﻲﺑﺎﺷﺪ ﺷﺎﻣﻞ‪ :‬ﺩﺭﻣﺎﻥ ﺯﺧﻢ ﺑﺴﺘﺮ‪ Reconstruction ،‬ﺩﻳﻮﺍﺭﺓ ﺷﻜﻢ ﻭ ‪.....‬‬
‫ﺑﺨﺶ ﻫﺸﺘﻢ‪ :‬ﺑﺤﺚ ﻧﺎﺣﻴﺔ ﮊﻧﻴﺘﺎﻟﻴﺎ ﻣﻲﺑﺎﺷﺪ ﺷﺎﻣﻞ‪ :‬ﺩﺭﻣﺎﻥ ﻫﻴﭙﻮﺳﭙﺎﺩﻳﺎﺱ ﻭ ‪ Reconstruction of peni‬ﻭ‪....‬‬
‫ﻣﺆﻟﻔﻴﻦ ﻛﺘﺎﺏ ﺍﺯ ﺑﺮﺟﺴﺘﻪ ﺗﺮﻳﻦ ﭘﻴﺸﮕﺎﻣﺎﻥ ﺍﺳﺘﻔﺎﺩﻩ ﺍﺯ ﻟﻴﺰﺭ ﺩﺭ ﺩﺭﻣﺎﻥ ﺿﺎﻳﻌﺎﺕ ﭘﻮﺳﺘﻲ ﻣﻲﺑﺎﺷﻨﺪ ‪ Fitzpatrick‬ﻭ ‪ Goldman‬ﻫﻤﺮﺍﻩ ﺑﺎ ‪ Alster‬ﺳﻪ ﺗﻦ ﺍﺯ ﻣﻄﺮﺡﺗﺮﻳﻦ ﺍﺷﺨﺎﺹ ﺩﺭ ﻣﺒﺎﺣﺚ ﻟﻴﺰﺭﻱ ﻣﻲﺑﺎﺷﻨﺪ‪ .‬ﺑﻪ ﮔﻔﺘﺔ ﻣﺆﻟﻔﻴﻦ‪ :‬ﻣﺎ ﺳﻌﻲ ﻛﺮﺩﻩ ﺍﻳﻢ ﻳﻜﺒﺎﺭ ﺩﻳﮕﺮ ﺍﻛﺜﺮ ﺗﺤﻘﻴﻘـﺎﺕ ﻭ‬
‫ﺩﺍﻧﺶ ﻛﺎﺭﺑﺮﺩ ﻟﻴﺰﺭ ﺩﺭ ﭘﻮﺳﺖ ﺭﺍ ﺩ ﺍﺧﻞ ﻳﻚ ﻛﺘﺎﺏ ﮔﺮﺩﺁﻭﺭﻱ ﻛﻨﻴﻢ‪ .‬ﻣﺒﺎﺣﺚ ﺍﻳﻦ ﻛﺘﺎﺏ ﺑﻪ ﻃﻮﺭ ﺗﺨﺼﺼﻲ ﻣﻮﺭﺩ ﺍﺳﺘﻔﺎﺩﺓ ﺩﺭﻣﺎﺗﻮﻟﻮﮊﻳﺴﺖ ﻫﺎ ﻭ ﺟﺮﺍﺣﺎﻧﻲ ﻛﻪ ﺩﺭ ﺯﻣﻴﻨﺔ ‪ rejuvenation‬ﭘﻮﺳﺖ ﺻﻮﺭﺕ ﻓﻌﺎﻟﻴﺖ ﺩﺍﺭﻧﺪ ﻣﻮﺭﺩ ﺍﺳﺘﻔﺎﺩﻩ ﺍﺳﺖ‪.‬‬
‫‪31.2‬‬ ‫‪Primary‬‬ ‫‪Rhinoplasty‬‬ ‫‪(Bahman‬‬ ‫)‪Guyuron, MD, FACS, Cleveland, Ohio) (VCD‬‬ ‫ــــــ‬
‫ﺩﺭ ﺍﻳﻦ ‪ VCD‬ﺁﻣﻮﺯﺷﻲ ﻛﻪ ﺗﻮﺳﻂ ﻳﻜﻲ ﺍﺯ ﺑﺰﺭﮔﺘﺮﻳﻦ ﺟﺮﺍﺣﺎﻥ ﺻﺎﺣﺐ ﻧﺎﻡ ﺩﻧﻴﺎ‪ ،‬ﺍﺯ ﻛﺸﻮﺭ ﻋﺰﻳﺰﻣﺎﻥ ﺍﻳﺮﺍﻥ ‪ ،‬ﺑﻪ ﻧﺎﻡ ﺁﻗﺎﻱ ﺩﻛﺘﺮ ﺑﻬﻤﻦ ﻏﻴﻮﺭﺍﻥ ﺍﺯ ﺩﺍﻧﺸﮕﺎﻩ ‪ Ohio‬ﺗﻬﻴﻪ ﺷﺪﻩ ﺍﺳﺖ‪ ،‬ﻣﺮﺍﺣﻞ ﻣﺨﺘﻠﻒ ﻳﻚ ﻋﻤﻞ ﺭﻳﻨﻮﭘﻼﺳﺘﻲ ﺍﻭﻟﻴﻪ ﺑﺎ ﺍﭘﺮﻭﺝ ‪ Open‬ﺁﻣﻮﺯﺵ ﺩﺍﺩﻩ ﻣﻲﺷﻮﺩ‪ .‬ﻣﻮﺭﺩ ﻋﻤﻞ‬
‫ﺩﺧﺘﺮ ﺟﻮﺍﻧﻲ ﻣﻲﺑﺎﺷﺪ ﻛﻪ ‪ Case‬ﻓﻮﻕﺍﻟﻌﺎﺩﻩ ﻣﺸﻜﻠﻲ ﺩﺭ ﺯﻣﻴﻨﻪ ﺭﻳﻨﻮﭘﻼﺳﺘﻲ ﻣﺤﺴﻮﺏ ﺷﺪﻩ ﻭ ﺁﻗﺎﻱ ﺩﻛﺘﺮ ﻏﻴﻮﺭﺍﻥ ﭘﺲ ﺍﺯ ﺁﻧﺎﻟﻴﺰ ﻛﺎﻣﻞ ﻧﺎﺯﻭﻓﺎﺷﻴﺎﻝ ﺟﺮﺍﺣﻲ ﺭﺍ ﺑﺎ ﻇﺮﺍﻓﺖ ﻫﺮ ﭼﻪ ﺗﻤﺎﻣﺘﺮ ﺍﺯ ﺍﺑﺘﺪﺍﻱ ﺍﻣﺮ )ﺗﺰﺭﻳﻖ ﻭ ﺑﻲﺣﺴﻲ ﺗﻮﭘﻴﻜﺎﻝ( ﺗﺎ ﺍﻧﺘﻬﺎ )ﭘﺎﻧﺴﻤﺎﻥ( ﺍﺟﺮﺍ ﻣـﻲﻛﻨﻨـﺪ‪ .‬ﺩﻳـﺪﻥ ﺍﻳـﻦ‬
‫‪ VCD‬ﺭﺍ ﺍﻛﻴﺪﹰﺍ ﺑﻪ ﻛﻠﻴﻪ ﻣﺘﺨﺼﺼﻴﻦ ﺗﻮﺻﻴﻪ ﻣﻲﻛﻨﻴﻢ‪.‬‬
‫‪32.2 RHINOPLASTY‬‬ ‫‪GOLDMAN TECHNIQUE‬‬ ‫)‪(ROBERT L. SIMONS, MD., NORTH MIAMI BEACH, FLORIDA) (VCD) (CD I , II‬‬ ‫ــــــ‬
‫ﺩﺭ ﺍﻳﻦ ‪ VCD‬ﺁﻣﻮﺯﺷﻲ ﻣﺮﺍﺣﻞ ﻣﺨﺘﻠﻒ ﻋﻤﻞ ﺭﻳﻨﻮﭘﻼﺳﺘﻲ ﺗﻮﺳﻂ ﺩﻛﺘﺮ ﺳﻴﻤﻮﻥ ﺍﺯ ﺩﺍﻧﺸﮕﺎﻩ ﻣﻴﺎﻣﻲ ﺗﺸﺮﻳﺢ ﻣﻲﺷﻮﺩ‪ .‬ﻋﻤﺪﻩ ﻫﺪﻑ ﺍﻳﻦ ﺑﺮﻧﺎﻣﻪ ﺗﺼﺤﻴﺢ ‪ tip‬ﺑﻴﻤﺎﺭ )‪ (tip plasty‬ﺑﺎ ﻛﻤﻚ ﺗﻜﻨﻴﻚ ﮔﻠﺪﻣﻦ ﻣﻲﺑﺎﺷﺪ‪ .‬ﺩﺭ ﻧﺮﻡﺍﻓﺰﺍﺭ ﻓﻮﻕ ﺑﺮﺍﻱ ﺗﺸﺮﻳﺢ ﺗﻜﻨﻴﻚ ﻳـﻚ‬
‫‪ Case‬ﻛﻪ ﺧﺎﻧﻢ ‪ ٢٧‬ﺳﺎﻟﻪﺍﻱ ﻣﻲﺑﺎﺷﺪ ﺗﺤﺖ ﻋﻤﻞ ﺑﺎ ﺑﻲﻫﻮﺷﻲ ‪ Stand by‬ﺍﻧﺠﺎﻡ ﻣﻲﺷﻮﺩ‪ .‬ﺑﻴﻨﻲ ﺑﻴﻤﺎﺭ ﺍﺯ ﻧﻮﻉ ‪ projected tip‬ﻣﻲﺑﺎﺷﺪ‪ .‬ﺩﺭ ﺍﺑﺘﺪﺍ ﻳﻚ ﺁﻧﺎﻟﻴﺰ ﻛﺎﻣﻞ ﺍﺳﺘﺎﺗﻴﻚ ﻧﺎﺯﻭﻓﺎﺷﻴﺎﻝ ﺍﺯ ﺑﻴﻤﺎﺭ ﺑﻪ ﻋﻤﻞ ﻣﻲﺁﻳﺪ‪.‬‬
‫‪33.2 RHINOPLASTY‬‬ ‫)‪A Practical Guide to functional and asthetic surgery of the nose (G. J. Nolst‬‬ ‫ــــــ‬
‫ﺍﻳﻦ ﺑﺮﻧﺎﻣﻪ ﺁﻣﻮﺯﺷﻲ ﻛﻪ ﺗﻮﺳﻂ ﺩﻛﺘﺮ ﻧﻮﻟﺴﺖ ﺍﺭﺍﺋﻪ ﻣﻲﺷﻮﺩ‪ .‬ﺭﺍﻫﻨﻤﺎﻳﻲ ﻋﻤﻠﻲ ﺟﻬﺖ ﺟﺮﺍﺣﻲ ﻓﺎﻧﻜﺸﻨﺎﻝ ﻭ ﺍﺳﺘﺎﺗﻴﻚ ﺑﻴﻨﻲ ﻣﻲﺑﺎﺷﺪ‪ .‬ﺩﺭ ﺍﻳﻦ ﻓﻴﻠﻢ ﺍﺻﻮﻝ ﭘﺎﻳﻪ ﺯﻳﺒﺎﻳﻲﺷﻨﺎﺳﻲ ﻭ ﺗﻜﻨﻴﻚﻫﺎﻱ ﺟﺮﺍﺣﻲ‪ ،‬ﺍﺯ ﻣﺮﺍﺣﻞ ﭘﺎﻳﻪ )ﺍﺯ ﺗﻜﻨﻴﻚ ﺗﺎ ﺍﻋﻤﺎﻝ ﺟﺮﺍﺣﻲ( )ﺗﺤﺖ ﺑﻲﻫﻮﺷﻲ ﻋﻤﻮﻣﻲ( ﺁﻣﻮﺯﺵ ﺩﺍﺩﻩ ﻣﻲﺷﻮﺩ‪.‬‬
‫ﺩﺭ ﺍﻳﻦ ﻓﻴﻠﻢ ﺗﻮﺟﻪ ﺷﻤﺎ ﺭﺍ ﺑﻪ ﻧﺤﻮﺓ ﺍﻧﺠﺎﻡ ﺍﺳﺘﺌﻮﺗﻮﻣﻲ ﺍﺯ ﺭﺍﻩ ﭘﻮﺳﺖ ﻭ ﻧﻴﺰ ﺣﻔﻆ ﺳﺎﭘﻮﺭﺕ ‪ tip‬ﺟﻠﺐ ﻣﻲﻛﻨﻴﻢ‪ .‬ﺩﺭ ﺍﻧﺘﻬﺎ ﺍﺯ ﻏﻀﺮﻭﻑ ﻛﻮﻧﻜﺎﻱ ﮔﻮﺵ ﺑﻴﻤﺎﺭ‪ ،‬ﮔﺮﺍﻓﺖ )ﺷﻴﻠﺪ ﻳﺎ ﺍﺳﺘﺮﺍﺕ ﻛﻠﻮﻣﻼ( ﺗﻬﻴﻪ ﻣﻲﺷﻮﺩ ﻭ ﺑﺮﺍﻱ ﻗﺮﺍﺭﺩﺍﺩﻥ ﺁﻥ ﺍﺯ ﺍﭘﺮﻭﭺ ‪ open‬ﻛﻤﻚ ﮔﺮﻓﺘﻪ ﻣﻲﺷﻮﺩ‪.‬‬
‫ﺩﺭ ﻫﺮ ﻓﺼﻞ ﺍﺑﺘﺪﺍ ﺑﻪ ﺻﻮﺭﺕ ‪ text‬ﺗﻮﺿﻴﺤﺎﺗﻲ ﺩﺍﺩﻩ ﺷﺪﻩ ﻭ ﺳﭙﺲ ﺗﺼﺎﻭﻳﺮ ﺭﻧﮕﻲ ﻭ ﻓﻴﻠﻢ ﻣﺮﺑﻮﻁ ﺑﻪ ﺟﺮﺍﺣﻲﻫﺎﻱ ﺁﻥ ﺑﺨﺶ ﻧﺸﺎﻥ ﺩﺍﺩﻩ ﺷﺪﻩ ﺍﺳﺖ‪ .‬ﻓﺼﻮﻝ ﺍﻳﻦ ‪ CD‬ﺷﺎﻣﻞ‪:‬‬
‫‪ : Basic Knowledge -‬ﺷﺎﻣﻞ ﺁﻧﺎﺗﻮﻣﻲ‪ ،‬ﺯﻳﺒﺎﺋﻲﺷﻨﺎﺧﺘﻲ ‪ Pre-op‬ﻭ ‪ Post-op‬ﻭ ﻛﻤﭙﻠﻴﻜﺎﺳﻴﻮﻥﻫﺎ ﻭ ﻧﺤﻮﺓ ﺑﻲﺣﺴﻲ ﺑﻪ ﺻﻮﺭﺕ ﻓﻴﻠﻢ ﭘﺮﺩﺍﺧﺘﻪ ﺍﺳﺖ‪.‬‬
‫‪ : Operative techniques -‬ﺑـﻪ ﺷـﻴﻮﻩﻫـﺎﻱ ﻋﻤـﻞ ﺳـﭙﺘﻮﭘﻼﺳـﺘﻲ ﻭ ‪ turbinate surgery‬ﮔﺮﺍﻓـﺖﻫـﺎ‪ ،Spreadergrafs modified zplasty-Nasalvalve surgery ،‬ﺟﺮﺍﺣـﻲ ‪ osseocartileginous‬ﺭﻳﻨﻮﭘﻼﺳـﺘﻲ ‪، external rhinoplasty ، Open‬‬
‫‪ Wedgeresection in alar base surgery‬ﭘﺮﺩﺍﺧﺘﻪ ﺍﺳﺖ‪.‬‬
‫‪ : Capita selecta -‬ﻓﺼﻞ ﺁﺧﺮ ﺑﻪ ﺩﺭﻣﺎﻥ ﺑﻴﻤﺎﺭﻱﻫﺎﻱ ﺳﺎﺧﺘﻤﺎﻧﻲ ﭘﺮﺩﺍﺧﺘﻪ ﺍﺳﺖ ﻣﺎﻧﻨﺪ ﺗﺼﺤﻴﺢ ﺷﻜﺎﻑ ﻟﺐ ﻭ ﺑﻴﻨﻲ‪ rhinosurgery ، augmentation rhinoplasty ،‬ﺩﺭ ﻛﻮﺩﻛﺎﻥ‪ Revision surgery ،‬ﺗﺼﺤﻴﺢ ‪ Pverprojected nasel tip. Saddle nose‬ﭘﺮﺩﺍﺧﺘﻪ ﺍﺳﺖ‪.‬‬
‫ﺍﺳﺘﻔﺎﺩﻩ ﺍﺯ ﺍﻳﻦ ‪ CD‬ﺁﺳﺎﻥ ﺑﻮﺩﻩ ﻭ ﺩﺍﺭﺍﻱ ‪ Video gallery‬ﺷﺎﻣﻞ‪ :‬ﻧﺸﺎﻥ ﺩﺍﺩﻥ ﺗﻜﻨﻴﻚﻫﺎﻱ ﺭﻳﻨﻮﭘﻼﺳﺘﻲ ﻛﻮﺩﻛﺎﻥ ﻭ ﺍﭘﺮﻭﭺﻫﺎﻱ ﻣﺨﺘﻠﻒ ﺑﺮﺍﻱ ﺭﻳﻨﻮﭘﻼﺳﺘﻲ )ﺍﻛﺴﺘﺮﻧﺎﻝ ﻭ ‪ ( ...‬ﻣﻴﻜﺮﻭﺍﺳﺘﺌﻮﺗﻮﻣﻲ ﻭ ‪ Conchal Cartilage harvesting‬ﻣﻲﺑﺎﺷﺪ‪.‬‬

‫)‪34.2 Rhinoplasty The American Academy of Facial Plastic and Reconstructive Surgery (CD I, II) (E. Gaylon McCollough, M.D.) (the St. Louis Aging Face Symposium‬‬ ‫ــــــ‬
‫ﺩﺭ ﺍﻳﻦ ﺑﺮﻧﺎﻣﺔ ﺁﻣﻮﺯﺷﻲ ﻛﻪ ﺗﻮﺳﻂ ﺩﻛﺘﺮ )‪ (E. Gaglon McCollough M.D.‬ﺩﺭ ﺳﻤﭙﻮﺯﻳﻮﻡ ‪ Aging Face‬ﺍﺭﺍﺋﻪ ﻣﻲﺷﻮﺩ‪ ،‬ﻣﺮﺍﺣﻞ ﻣﺨﺘﻠﻒ ﻳﻚ ﻋﻤﻞ ﺭﻳﻨﻮﭘﻼﺳﺘﻲ ﺑﺮ ﺭﻭﻱ ﺑﻴﻤﺎﺭ ﻣﻴﺎﻧﺴﺎﻝ ﺗﺤﺖ ﺑﻲﻫﻮﺷﻲ ‪ Stand by‬ﺑﻪ ﺗﻔﻜﻴﻚ ﺑﻴﺎﻥ ﻭ ﺍﺟﺮﺍ ﻣﻲﺷـﻮﺩ‪ .‬ﺩﺭ ﺍﻳـﻦ ﻋﻤـﻞ ﺍﺯ‬
‫ﺍﭘﺮﻭﭺ ‪ Closed‬ﺍﺳﺘﻔﺎﺩﻩ ﻣﻲﺷﻮﺩ ﻭ ﺑﻴﺸﺘﺮﻳﻦ ﺗﻮﺟﻪ ﺭﻭﻱ ‪ tip plasty‬ﻣﻲﺑﺎﺷﺪ‪ .‬ﺑﺮ ﺭﻭﻱ ‪ tip‬ﺑﻴﻨﻲ ﺍﻳﻦ ﺑﻴﻤﺎﺭ‪ ،‬ﺍﻓﺰﺍﻳﺶ ‪ rotation‬ﺩﺍﺩﻩ ﻣﻲﺷﻮﺩ‪ .‬ﺍﺯ ﺭﻭﺵ ‪ delivery‬ﺟﻬﺖ ﺗﺮﻣﻴﻢﻛﺮﺩﻥ ﻗﺴﻤﺖ ﺳﻔﺎﻟﻴﻚ ﻏﻀﺮﻭﻑﻫﺎﻱ ‪ LLC‬ﺍﺳﺘﻔﺎﺩﻩ ﻣﻲﺷﻮﺩ‪.‬‬

‫ﺗﻠﻔﻦ‪٠٩١٢١٣٧٢٣٦١-٦٦٩٣٦٦٩٦ :‬‬ ‫ﻧﺸﺎﻧﻲ‪ :‬ﺗﻬﺮﺍﻥ‪ ،‬ﻡ ﺍﻧﻘﻼﺏ‪ ،‬ﺥ ﻛﺎﺭﮔﺮ ﺟﻨﻮﺑﻲ‪ ،‬ﺥ ﻟﺒﺎﻓﻲﻧﮋﺍﺩ‪ ،‬ﺑﻴﻦ ﻛﺎﺭﮔﺮ ﻭ ﺟﻤﺎﻟﺰﺍﺩﻩ‪ ،‬ﺑﻦﺑﺴﺖ ﺳﻴﻤﻴﻦ‪ ،‬ﭘﻼﻙ ‪٢٣٩‬‬ ‫ﻣﺮﻛﺰ ﺧﺪﻣﺎﺕ ﻓﺮﻫﻨﮕﻲ ﺳﺎﻟﻜﺎﻥ ‪ :‬ﺍﺭﺍﺋﻪ ﻛﻨﻨﺪﺓ ﻛﺘﺎﺏ ﻭ ﺳﻲﺩﻱﻫﺎﻱ ﺗﺨﺼﺼﻲ ﭘﺰﺷﻜﻲ‬
 14
.‫ ﺍﻧﺠﺎﻡ ﺷﺪﻩ ﻭ ﭘﺎﻧﺴﻤﺎﻥ ﻣﺨﺼﻮﺹ ﻭ ﺟﺎﻟﺐ ﻣﻮﻟﻒ ﺑﺮ ﺭﻭﻱ ﺻﻮﺭﺕ ﺑﻴﻤﺎﺭ ﻗﺮﺍﺭ ﺩﺍﺩﻩ ﻣﻲﺷﻮﺩ‬Alar base resection ‫ﺩﺭ ﻧﻬﺎﻳﺖ ﺑﺮﺍﻱ ﺑﻴﻤﺎﺭ‬

35.2 RHINOPLASTY DOUBLE DOME UNIT (CD I , II) (E. Gaylon McCollough MD, Birmingham, Albama) ‫ــــــ‬
‫ ﺍﻳﻦ ﺑﺮﻧﺎﻣﻪ ﻧﮕﺮﺷﻲ‬.‫ ﺑﻮﺩﻩ ﻭ ﻫﺪﻑ ﻋﻤﺪﻩ ﺟﻤﻊ ﻛﺮﺩﻥ ﺁﻥ ﺍﺳﺖ‬tip ‫ ﻣﺮﺍﺣﻞ ﻣﺨﺘﻠﻒ ﻋﻤﻞ ﺭﻳﻨﻮﭘﻼﺳﺘﻲ ﺑﺮ ﺭﻭﻱ ﺧﺎﻧﻤﻲ ﺍﻧﺠﺎﻡ ﻣﻲﺷﻮﺩ ﻛﻪ ﻣﺸﻜﻞ ﺁﻥ ﻋﻤﺪﺗﹰﺎ ﺩﺭ ﻧﺎﺣﻴﻪ‬.‫ ﺍﺯ ﺩﺍﻧﺸﮕﺎﻩ ﺑﻴﺮﻣﻨﮕﺎﻡ ﺍﺭﺍﺋﻪ ﻣﻲﺷﻮﺩ‬E. Gaglon MC Collouch ‫ﺩﺭ ﺍﻳﻦ ﺑﺮﻧﺎﻣﺔ ﺁﻣﻮﺯﺷﻲ ﻛﻪ ﺗﻮﺳﻂ ﺩﻛﺘﺮ‬
.‫ ﺁﻥ ﺍﺳﺖ‬management ‫ ﻭ ﻧﺤﻮﺓ‬Double Dome Unit ‫ﺑﻪ‬
36.2 Rhinoplasty The Overly Projected Nasal Tip (Trent W. Smith, M.D.F.A.C.S.) ‫ــــــ‬
،‫ ﺑﻴﻨـﻲ‬tip ‫ ﺑﺎ ﺗﻮﺟﻪ ﺑﻪ ﺑﻠﻨﺪﺑﻮﺩﻥ ﻃﻮﻝ ﻣﻮﻳﺎﻝ ﻛﺮﻭﺭﺍﻫﺎ ﺑﻪ ﻋﻨﻮﺍﻥ ﻋﻠﺖ ﺑﺮﭼﺴﺘﻪ ﺑـﻮﺩﻥ‬.‫ ﺑﺮﺟﺴﺘﻪ ﻣﻮﺭﺩ ﺑﺮﺭﺳﻲ ﻗﺮﺍﺭ ﮔﺮﻓﺘﻪ ﻭ ﻣﺮﺍﺣﻞ ﻣﺨﺘﻠﻒ ﻋﻤﻞ ﺑﺮ ﺭﻭﻱ ﻳﻚ ﺑﻴﻤﺎﺭ ﺍﻧﺠﺎﻡ ﻣﻲﺷﻮﺩ‬tip ‫ﺩﺭ ﺍﻳﻦ ﺑﺮﻧﺎﻣﺔ ﺁﻣﻮﺯﺷﻲ ﻣﺘﺮﻭﻟﻮﮊﻱ ﻭ ﻧﺘﺎﻳﺞ ﻛﻠﻴﻨﻴﻜﻲ ﺭﻳﻨﻮﭘﻼﺳﺘﻲ ﺩﺭ ﺑﻴﻨﻲﻫﺎﻱ ﺑﺎ‬
.‫ ﺍﻳﻦ ﺑﺮﻧﺎﻣﻪ ﺗﻮﺳﻂ ﺁﻗﺎﻱ ﺩﻛﺘﺮ ﺍﺳﻤﻴﺖ ﺍﺳﺘﺎﺩ ﻭ ﻣﺪﻳﺮ ﮔﺮﻭﻩ ﺑﺨﺶ ﮔﻮﺵ ﻭ ﺣﻠﻖ ﻭ ﺑﻴﻨﻲ ﻭ ﺟﺮﺍﺣﻲ ﭘﻼﺳﺘﻴﻚ ﺩﺍﻧﺸﮕﺎﻩ ﺍﻭﻫﺎﻳﻮ ﺍﺭﺍﺋﻪ ﺷﻮﺩ‬.‫ﺗﻼﺵ ﺩﺭ ﺟﻬﺖ ﻛﻮﺗﺎﻩ ﺑﻮﺩﻥ ﻃﻮﻝ ﺁﻧﻬﺎ ﺩﺭ ﺟﻬﺖ ﺍﺻﻼﺡ ﺍﻳﻦ ﺑﺮﺟﺴﺘﮕﻲ ﺍﻧﺠﺎﻡ ﻣﻲﺷﻮﺩ‬
37.2 San Diego Classics in Soft Tissue & Cosmetic Surgery Rhinoplasty (Part 1-6) (Richard C. Webster, MD, Terence M. Davidson, Alan M. Nahum) ‫ــــــ‬
38.2 SURGERY of the EAR (Fifth Edition) (Glasscock-Shambaugh) (Michael E. Glasscock III, MD, FACS, Aina Julianna Gulya, MD) 2003
:‫ ﻋﺒﺎﺭﺗﻨﺪ ﺍﺯ‬CD ‫ ﻋﻨﺎﻭﻳﻦ ﺍﻳﻦ‬.‫ ﻛﺘﺎﺏ ﺷﺎﻣﭙﻮ ﻳﻜﻲ ﺍﺯ ﻣﻌﺘﺒﺮﺗﺮﻳﻦ ﺭﻓﺮﺍﻧﺲﻫﺎﻱ ﺟﺮﺍﺣﻲ ﮔﻮﺵ ﺩﺭ ﺩﻧﻴﺎ ﻣﻲﺑﺎﺷﺪ‬.‫( ﺑﻪ ﺷﻤﺎ ﺍﺭﺍﺋﻪ ﻣﻲﺷﻮﺩ‬2003) ‫ ﺍﻭﻳﺸﻦ ﭘﻨﺠﻢ‬،‫ ﺟﺮﺍﺣﻲ ﮔﻮﺵ ﺷﺎﻣﭙﻮـ ﮔﻼﺳﻜﻮ‬textbook . CD ‫ﺩﺭ ﺍﻳﻦ‬
1- Scientific Foundations 3- Clinical Evaluation 5- Fundametals of Otologic/Neurotologic Surgery 7- Surgery of the External Ear
2- Surgery of the Tympanomastoid Compartment 4- Surgery of the Inner Ear 6- Surgery of the IAC/CPA/Petrous Apex 8- Surgery of the Skull Base
39.2 The MEDPOR Lower Eyelid Spacer (James Patrinely, M.D.F.A.C.S., and Charles N.S. Soparkar, M.D., Ph.D.) (VCD) ‫ــــــ‬

.‫ ﺍﻳﻦ ﺁﺷﻨﺎﻳﻲ ﺩﺭ ﻏﺎﻟﺐ ﻣﻮﺍﺭﺩ ﺯﻳﺮ ﺍﺭﺍﺋﻪ ﻣﻲﺷﻮﺩ‬.‫ ﺷﻤﺎ ﺑﺎ ﭘﺮﻭﺗﺰﻫﺎﻱ ﻣﺪﭘﻮﺭ ﭘﻠﻚ ﺗﺤﺘﺎﻧﻲ ﺁﺷﻨﺎ ﻣﻲﺷﻮﻳﺪ‬،‫ ﺁﻣﻮﺯﺷﻲ ﻛﻪ ﺗﻮﺳﻂ ﺩﻛﺘﺮ ﭘﺎﺗﺮﻳﻨﻠﻲ ﻭ ﺩﻛﺘﺮ ﺳﻮﭘﺎﺭﻛﺎﺭ ﺍﺭﺍﺋﻪ ﻣﻲﺷﻮﺩ‬VCD ‫ﺩﺭ ﺍﻳﻦ‬
3) Medpore biomaterial 2) Addressing and management potential Complications 1) Introduction and Surgical technique
- managing winging are edge flare - Cartilage grafts
- managing ridging - Non-rigid spacer grafts (hard Patale/Sclera,dermis)
- managing under correction - Medpore Lower Lid Advantages
- managing overcorrection
- managing implant exposure
- managing entropion
- managing entropion
- Implant exchange
40.2 The MEDPOR Nasal Shell Implant (Paul O'Keefe, M.B, B.S., (SYD), F.R.C.S., F.R.A.C.S.) (VCD) ‫ــــــ‬
41.2 VCD Journal of ENT APPROACH VESTIBULAR NEURECTOMY-TRANSTEMPORAL SUPRALABYRINTHINE APPROACH ‫ــــــ‬
MICROSURGERY OF THE SKULL BASE TRANSOTIC APPROACH ACOUSTIC NEUROMA (Prof. U. Fisch Zurich) (VCD#2)
42.2 VCD Journal of ENT INFRATEMPORAL FOSSA APPROACH TYPE C (Prof. U. Fisch Zurich) (VCD#4) ‫ــــــ‬
43.2 VCD Journal of ENT INFRATFMPORAL FOSSA APPROACH GLOMUS TEMPORALE TUMOR (Prof. U. Fisch Zurich) (VCD#1) ‫ــــــ‬
44.2 VCD Journal of ENT MICROSURGERY OF THE SKULL BASE TRANSOTIC APPROACH ACOUSTIC NEUROMA-INFRATEMPORAL FOSSA APRROACH TYPE C (Prof. U. Fisch Zurich) (VCD#3) ‫ــــــ‬
45.2 VJGS Invited Presentation: Thyroidectomy (Jon A. van Heerden, ND) ‫ــــــ‬

‫ ﺯﻧﺎﻥ ﻭ ﻣﺎﻣﺎﺋﻲ‬-٣

CD ‫ﻋﻨﻮﺍﻥ‬ ‫ﺳﺎﻝ ﺍﻧﺘﺸﺎﺭ‬

1.3 Abdominal Colposacropexy and Vaginal Sacropinus Suspension (Harold P. Drutz MD FRCS (C) (VCD) ‫ــــــ‬
2.3 Adapted form Physical Examination and Health Assessment, 2/e (Carolyn Jarvis, RN, C, MSN, FNP) (W.B. Saunders Company) (VCD) ‫ــــــ‬
3.3 Advanced Colposcopy: Understanding Vessel Patterns (Dorothy M. Babo, MD) (VCD) ‫ــــــ‬

٠٩١٢١٣٧٢٣٦١-٦٦٩٣٦٦٩٦ :‫ﺗﻠﻔﻦ‬ ٢٣٩ ‫ ﭘﻼﻙ‬،‫ ﺑﻦﺑﺴﺖ ﺳﻴﻤﻴﻦ‬،‫ ﺑﻴﻦ ﻛﺎﺭﮔﺮ ﻭ ﺟﻤﺎﻟﺰﺍﺩﻩ‬،‫ ﺥ ﻟﺒﺎﻓﻲﻧﮋﺍﺩ‬،‫ ﺥ ﻛﺎﺭﮔﺮ ﺟﻨﻮﺑﻲ‬،‫ ﻡ ﺍﻧﻘﻼﺏ‬،‫ ﺗﻬﺮﺍﻥ‬:‫ﻧﺸﺎﻧﻲ‬ ‫ ﺍﺭﺍﺋﻪ ﻛﻨﻨﺪﺓ ﻛﺘﺎﺏ ﻭ ﺳﻲﺩﻱﻫﺎﻱ ﺗﺨﺼﺼﻲ ﭘﺰﺷﻜﻲ‬: ‫ﻣﺮﻛﺰ ﺧﺪﻣﺎﺕ ﻓﺮﻫﻨﮕﻲ ﺳﺎﻟﻜﺎﻥ‬
 15
:‫ ﺗﻐﻴﻴﺮ ﻛﻮﻟﭙﻮﺳﻜﻮﭘﻲ ﺑﻪ ﺩﻭ ﻓﺎﻛﺘﻮﺭ ﻣﻬﻢ ﻧﻴﺎﺯ ﺩﺍﺭﺩ‬:‫ ﺩﺭ ﻣﻮﺭﺩ‬VJOG ‫ ﺍﺯ ﺳﺮﻱ‬CD ‫ﺍﻳﻦ ﻭﻳﺪﺋﻮ‬
.‫ ﺩﺍﻧﺶ ﺍﻟﮕﻮﻫﺎﻱ ﻧﺮﻣﺎﻝ ﻳﺎ ﺍﺑﻨﺮﻣﺎﻝ ﺳﺮﻭﻳﻜﺲ‬-٢ ‫ ﻧﮕﺮﺵ ﺩﻗﻴﻖ‬-١
‫( ﻭ ﺍﻓﺘﺮﺍﻕ ﺁﻧﻬﺎ ﺍﺯ ﻳﻜﺪﻳﮕﺮ ﻭ ﭘﺎﺗﻮﻟﻮﮊﻱ ﺿﺎﻳﻌﺎﺕ ﻫﻤﺮﺍﻩ ﺑﺎ ﻋﻜﺲﻫﺎﻱ ﺭﻧﮕﻲ ﻭ ﺍﺳﻼﻳﺪ ﻧﺸﺎﻥ ﺩﺍﺩﻩ ﺷـﺪﻩ ﺍﺳـﺖ ﺩﺭ ﻗﺴـﻤﺖ ﺁﺧـﺮ‬.....‫ ﻛﺮﺍﺗﻴﻦ ﻭ‬،‫ﺍﺑﺘﺪﺍ ﺩﺭ ﻣﻮﺭﺩ ﻓﻴﺰﻳﻚ ﺩﺳﺘﮕﺎﻩ ﻭ ﺳﭙﺲ ﻋﻮﺍﻣﻠﻲ ﻛﻪ ﺩﺭ ﻣﺸﺎﻫﺪﻩ ﺿﺎﻳﻌﺎﺕ ﻣﻮﺛﺮ ﺍﺳﺖ )ﻣﺎﻧﻨﺪ ﺑﺎﺯﺗﺎﺏ ﻧﻮﺭ ﺗﻮﺳﻂ ﻣﻮﻛﻮﺱ‬
.‫ﺭﻭﺵ ﻛﺎﺭﻛﺮﺩﻥ ﺻﺤﻴﺢ ﺑﺎ ﻛﻮﻟﭙﻮﺳﻜﻮﭖ ﻧﺸﺎﻥ ﺩﺍﺩﻩ ﺷﺪﻩ ﺍﺳﺖ‬
4.3 Advanced Therapy of BRAST DISEASE (S. Eva Singletry, MD, Geoffrey L. Robb, MD) 2000
5.3 Active Management of Labour (Kieran O'Driscoll, Declan Meagher) (SALEKAN E-BOOK) 2004
6.3 American Cancer Society Atlas of Clinical Oncology (Cancer of the Female Lowe Genital Tract) (Patricia J. Eifel, M.D. Charles Levenback, M.D.) (SALEKAN E-BOOK) 2001

Cervix ‫ ﺁﺧﺮﻳﻦ ﺗﻐﻴﻴﺮﺍﺕ ﺩﺭ ﺩﺭﻣﺎﻥﻫﺎﻱ ﭘﺬﻳﺮﻓﺘﻪﺷﺪﻩ ﺑﺮﺍﻱ ﻛﺎﻧﺴﺮ ﻣﻬﺎﺟﻢ‬.‫ ﺍﺭﺯﻳﺎﺑﻲ ﻭ ﺩﺭﻣﺎﻥ ﻛﺎﻧﺴﺮﻫﺎ ﺩﺳﺘﮕﺎﻩ ﺗﻨﺎﺳﻠﻲ ﺗﺤﺘﺎﻧﻲ ﺯﻧﺎﻥ ﻣﻲﺑﺎﺷﺪ‬،‫ ﺗﺸﺨﻴﺺ‬،‫ﺍﻳﻦ ﻛﺘﺎﺏ ﺍﻟﻜﺘﺮﻭﻧﻴﻜﻲ ﺑﻪ ﮔﻔﺘﺔ ﻣﺆﻟﻔﻴﻦ ﺑﻪ ﻣﻨﻈﻮﺭ ﻓﺮﺍﻫﻢﻛﺮﺩﻥ ﻣﺮﻭﺭ ﻭ ﺁﻧﺎﻟﻴﺰ ﺑﻴﻮﻟﻮﮊﻱ‬
.‫ﻭ ﻳﻚ ﺑﺎﺯﻧﮕﺮﻱ ﻛﻠﻲ ﺩﺭ ﻫﻤﻪ ﻣﺒﺎﺣﺚ ﺁﻭﺭﺩﻩ ﺷﺪﻩ ﺷﺪﻩ ﺍﺳﺖ‬
Chemotherapy in Curative Surgical Treatment of Invasive Cervical
Surgery for Vulvar Cancer Diagnostic Imaging Epidemiology
Management Cancer
Radiation Therapy for Invasive Cervical
Post-treatment Surveillance Radiation Therapy for Vulvar Cancer Screening for Neoplasms Pathology
Cancer
Radical Management of Recurrent Cervical Treatment of Squamous Intraepithelial Molecular Biology
Palliative Care Acute Effects of Radiation Therapy
Cancer Lesions
Late Complications of Pelvic Radiation Anatomy and Natural
Management of Vaginal Cancer Invasive Carcinoma of the Cervix
Therapy History
7.3 Atlas of Clinical oncology Breast Cancer (American Cancer Society ) (David J Winchester, MD, David P Winchester, MD) 2000
:‫ ﺷﺎﻣﻞ ﻣﺒﺎﺣﺚ ﺯﻳﺮ ﻣﻲﺑﺎﺷﺪ‬CD ‫ﻋﻨﺎﻭﻳﻦ ﺍﻳﻦ‬
yGenetics, Natural History, and DNA-Based Genetic Counseling in Hereditary Brast Cancer y Breast Cancer Risk and Management: Chemoprevention, Surgery, and Surveillance
y Screening and Diagnostic Imaging yImaging-Directed y Breast Biopsy yHistophathology of Malignant Breast Disease yUnusual Breast Pathology y Prognostic and Predictive Markers in Breast Cancer
y Surgical Management of Ductal Carcinoma In Situ yEvaluation and Surgical Management of Stage I and II Breast Cancer y Locally Advanced Breast Cancer y Breast Reconstruction
8.3 ATLAS OF ENDOSCOPIC TECHNIQUES IN GYNECOLOGY (First Edition) (Jeffrey M. Goldberg, MD, Tommaso Falcone, MD) (©W.B. Saunders, Philadelphia) 2001
:‫ﺍﻳﻦ ﻛﺘﺎﺏ ﺍﻟﻜﺘﺮﻭﻧﻴﻜﻲ ﺷﺎﻣﻞ ﻋﻨﺎﻭﻳﻦ ﺫﻳﻞ ﻣﻲﺑﺎﺷﺪ‬
1- Instrumentation and Pelvic Anatomy 5- Patient Preparation 8- Tubal Surgery
2- Surgery for Pelvic Support 6- Surgery for Endometriosis and Pelvic Pain 9- New Procedures
3- Ovarian Surgery 7- Complications 10- Uterine Surgery
4- Hysteroscopic Surgery
9.3 Atlas of Gynecologic Surgery (3rd edition) (H.A. Hirsch, M.D., O. Käser, M.D., F.A. Iklé, M.D.) (Thieme) (SALEKAN E-BOOK) ‫ــــــ‬
10.3 Atlas of Transvaginal Surgery (Second Edition) (©W.B. Saunders, Philadelphia) (VCD) 2001
- Prolene sling in the treatment of stress incontinence - Fibro-fatty labial flap (Martius Flat) for vaginal reconstruction - Transvaginal hysterectomy for severe prolapse
- Transvaginal repair of enterocele and vault prolapse - Transvaginal repair of vesico-vaginal fistula using a peritoneal flap - Transvaginal repair of grade IV cystocele
- Excision of urethral diverticula - Transvaginal repair of posterior vaginal wall prolapse
11.3 COLPOSCOPY an Interactive CD-ROM (Thomas V. Sedlacek, MD, Charles J. Dunton, MD) ‫ــــــ‬
12.3 Core Curriculum in Primary Care Patient Evaluation for Non-Cardiac Surgery and Gynecology and Urology (Michael K. Rees, MD, MPH) ‫ــــــ‬
‫ ﻫﺮ ﻛﺪﺍﻡ ﺍﺯ ﺍﻳـﻦ‬.‫ ﺯﻧﺎﻥ ﻭ ﺍﻭﺭﻭﮊﻱ ﺭﺍ ﮔﺮﺩﺁﻭﺭﻱ ﻛﺮﺩﻩ ﺍﺳﺖ‬،‫ ﺣﺎﺿﺮ ﺩﺭ ﻣﻮﺭﺩ ﺟﺮﺍﺣﻲ‬CD .‫ ﺑﻨﺎ ﻧﻬﺎﺩﻩ ﺷﺪﻩ ﺍﺳﺖ‬Harvard ‫ﻫﺎﻳﻲ ﻣﻲﺑﺎﺷﺪ ﻛﻪ ﺑﺮﺍﻱ ﺁﻣﻮﺯﺵ ﻣﺪﺍﻭﻡ ﺩﺳﺘﻴﺎﺭﺍﻧﮓ ﻭ ﻣﺘﺨﺼﺼﻴﻦ ﻫﺮ ﺭﺷﺘﻪ ﺗﻮﺳﻂ ﺍﻋﻀﺎﺀ ﻫﻴﺌﺖ ﻋﻠﻤﻲ ﺩﺍﻧﺸﮕﺎﻩ ﭘﺰﺷﻜﻲ‬CD ‫ ﻣﺠﻤﻮﻋﻪﺍﻱ ﺍﺯ‬CCC
‫ ﺳﭙﺲ ﺧﻼﺻﻪ ﻫﺮ ﺳﺨﻨﺮﺍﻧﻲ ﺑﻪ ﺻـﻮﺭﺕ ﻳـﻚ ﻣﻘﺎﻟـﻪ ﭼـﺎﭘﻲ ﺩﺭ‬.‫ ﺳﺆﺍﻻﺕ ﻣﺮﺑﻮﻃﻪ ﺑﻪ ﺻﻮﺭﺕ ﭼﻬﺎﺭﮔﺰﻳﻨﻪﺍﻱ ﺑﺮﺍﻱ ﺍﺭﺯﻳﺎﺑﻲ ﻛﺎﺭﺑﺮ ﺁﻭﺭﺩﻩ ﺷﺪﻩ ﺍﺳﺖ‬،‫ ﺩﺭ ﺁﺧﺮ ﻫﺮ ﺳﺨﻨﺮﺍﻧﻲ ﻭ ﻣﺒﺤﺜﻲ‬.‫ﺳﺨﻨﺮﺍﻧﻲﻫﺎ ﻋﻼﻭﻩ ﺑﺮ ﺍﺳﻼﻳﺪﻫﺎﻱ ﺁﻣﻮﺯﺷﻲ ﻣﺘﻦ ﺳﺨﻨﺮﺍﻧﻲ ﻧﻴﺰ ﺩﺭ ﺩﺳﺘﺮﺱ ﻛﺎﺭﺑﺮ ﻣﻲﺑﺎﺷﺪ‬
:‫ ﺷﺎﻣﻞ ﻣﺒﺎﺣﺚ ﺯﻳﺮ ﻣﻲﺑﺎﺷﺪ‬.‫ﻣﺠﻼﺕ ﻋﻠﻤﻲ ﻭ ﺭﻭﺯﻧﺎﻣﻪﻫﺎ ﺁﻭﺭﺩﻩ ﺷﺪﻩ ﺍﺳﺖ‬
Male impotence ‫ ﻋﻘﻴﻤﻲ ﻣﺮﺩﺍﻥ‬-٣ .(AUB) ‫ ﺍﺭﺯﻳﺎﺑﻲ ﺧﻮﻧﺮﻳﺰﻱﻫﺎﻱ ﺍﺑﻨﺮﻣﺎﻝ ﺭﺣﻢ‬-٢ ‫ ﭼﮕﻮﻧﻪ ﻳﻚ ﺑﻴﻤﺎﺭ ﺭﺍ ﺑﺮﺍﻱ ﺍﻋﻤﺎﻝ ﺟﺮﺍﺣﻲ )ﺑﺠﺰ ﺟﺮﺍﺣﻲ ﻗﻠﺐ( ﺍﺭﺯﻳﺎﺑﻲ ﻭ ﺁﻣﺎﺩﻩ ﻛﻨﻴﻢ؟‬-١
13.3 Core Curriculum in Primary Care Gynecology (Michael, Isaac Schiff, Keith, Thomas, Annekathryn) ‫ــــــ‬

٠٩١٢١٣٧٢٣٦١-٦٦٩٣٦٦٩٦ :‫ﺗﻠﻔﻦ‬ ٢٣٩ ‫ ﭘﻼﻙ‬،‫ ﺑﻦﺑﺴﺖ ﺳﻴﻤﻴﻦ‬،‫ ﺑﻴﻦ ﻛﺎﺭﮔﺮ ﻭ ﺟﻤﺎﻟﺰﺍﺩﻩ‬،‫ ﺥ ﻟﺒﺎﻓﻲﻧﮋﺍﺩ‬،‫ ﺥ ﻛﺎﺭﮔﺮ ﺟﻨﻮﺑﻲ‬،‫ ﻡ ﺍﻧﻘﻼﺏ‬،‫ ﺗﻬﺮﺍﻥ‬:‫ﻧﺸﺎﻧﻲ‬ ‫ ﺍﺭﺍﺋﻪ ﻛﻨﻨﺪﺓ ﻛﺘﺎﺏ ﻭ ﺳﻲﺩﻱﻫﺎﻱ ﺗﺨﺼﺼﻲ ﭘﺰﺷﻜﻲ‬: ‫ﻣﺮﻛﺰ ﺧﺪﻣﺎﺕ ﻓﺮﻫﻨﮕﻲ ﺳﺎﻟﻜﺎﻥ‬
 ‫‪16‬‬
‫‪14.3 Danforth's Obstetrics and Gynecology‬‬ ‫)‪(James R. Scott) (9 Edition) (SALEKAN E-BOOK‬‬ ‫‪2003‬‬
‫)‪15.3 Diagnosis of Benign Breast Disease (Dorothy M. Barbo, MD) (VCD) Submitted Subject The Limits of Laparoscopy: Diapharbmatic Endometriosis (David B. Redwine, MD‬‬ ‫ــــــ‬
‫ﺍﻳﻦ ﻭﻳﺪﺋﻮ ‪ CD‬ﺍﺯ ﺳﺮﻱ ‪ (Video Journal ob/Gyn) VJOG‬ﻣﻲﺑﺎﺷﺪ‪.‬‬
‫‪ .١‬ﺍﻳﻦ ﻭﻳﺪﺋﻮ ‪ CD‬ﺍﺑﺘﺪﺍ ﺁﻧﺎﺗﻮﻣﻲ ﻭ ﺳﭙﺲ ﻃﺮﺯ ﻣﻌﺎﻳﻨﻪ ﻭ ﺍﻓﺘﺮﺍﻕ ﺿﺎﻳﻌﺎﺕ ﺧﻮﺵﺧﻴﻢ ﺍﺯ ﺑﺪﺧﻴﻢ ﺍﺯ ﻃﺮﻳﻖ ﺷﺮﺡ ﺣﺎﻝ ﺑﺎﻟﻴﻨﻲ ﻭ ﻣﺎﻣﻮﮔﺮﺍﻓﻲ ﺁﻭﺭﺩﻩ ﺷﺪﻩ ﺍﺳﺖ ﻭ ﺳﭙﺲ ﺷﻜﺎﻳﺎﺕ ﺷﺎﻳﻊ ﺑﻴﻤﺎﺭﺍﻥ ﺑﻴﺎﻥ ﺷﺪﻩ ﻭ ﺳﭙﺲ ﺑﺼﻮﺭﺕ ﺍﻟﮕﻮﺭﻳﺘﻢ ﻃﺮﺯ ﺑﺮﺧﻮﺭﺩ ﻭ ﺍﻧﺠﺎﻡ ﺁﺯﻣﺎﻳﺸﺎﺕ ﻣﺮﺑﻮﻃﻪ ﺩﺭ ﻣﻮﺭﺩ‬
‫‪ nipple discharge ، Mastodynia‬ﻭ ‪ Cyst‬ﻭ ﻳﻚ ﺗﻮﺩﻩ ‪ Solid‬ﺁﻭﺭﺩﻩ ﺷﺪﻩ ﺍﺳﺖ‪ .٢ .‬ﺩﺭ ﺍﻳﻦ ﻭﻳﺪﺋﻮ ‪ CD‬ﺩﺭ ﻣﻮﺭﺩ ﻣﺤﺪﻭﺩﻳﺖﻫﺎﻱ ﻻﭘﺎﺭﺍﺳﻜﻮﭘﻲ ﺑﺤﺚ ﺷﺪﻩ ﺍﺳﺖ‪ .‬ﻭ ﺩﺭ ﻣﻮﺭﺩ ﺗﺸﺨﻴﺺ ﻭ ﺩﺭﻣﺎﻥ ‪ ٢‬ﺑﻴﻤﺎﺭ ﺑﺎ ﺍﻧﺪﻭﻣﺘﺮﻳﻮﺯ ﻧﺎﺣﻴﻪ ﺩﻳﺎﻓﺮﺍﮔﻢ ﺑﺤﺚ ﮔﺮﺩﻳﺪﻩ ﺍﺳﺖ‪.‬‬
‫‪16.3 Endoscopic Surgery for Gynecologists‬‬ ‫)‪(Suttond & diamond) (second Edition‬‬ ‫ــــــ‬
‫)‪17.3 Handbook of disease of the breast (Second Edition‬‬ ‫)‪(Michael Dixon, Richarc Sainsbury) (Salekan E-book‬‬ ‫ــــــ‬
‫)‪18.3 INTERACTIVE COLOR GUIDES Obstetrics Gynecology Neonatology (David James, Mary Pillai, Janice Rymer, Andrew N. J. Fish, Warren Hye‬‬ ‫ــــــ‬

‫ﺑﻪ ﺷﺮﺡ ﺯﻳﺮ ﺍﺳﺖ‪:‬‬ ‫ﺍﻳﻦ ‪CD‬‬ ‫ﻋﻨﺎﻭﻳﻦ ﻣﻮﺟﻮﺩ ﺩﺭ‬

‫‪1. Normal Infant‬‬ ‫‪3. Birth Trauma‬‬ ‫‪5. Deformations‬‬ ‫‪7. Iatrogenic Lesions‬‬ ‫‪9. Skin Disorders‬‬
‫‪2. Congennital Abnormalities‬‬ ‫‪4. Syndromes‬‬ ‫‪6. Infection‬‬ ‫‪8. Surgical Problems‬‬ ‫‪10. Low-Birth-Weight Infants‬‬

‫?‪19.3 LAVM: Our First one Hundred Cases; What have We Learned‬‬ ‫)‪(Dr G. F. Stohs, MD & Dr. L. P. Johonson, MD‬‬ ‫ــــــ‬
‫ﺍﻣﺮﻭﺯﻩ ﻫﻴﺴﺘﺮﻛﺘﻮﻣﻲ ﺑﻪ ﻃﺮﻳﻘﻪ ﻻﭘﺎﺭﺍﺳﻜﻮﭘﻲ ﻓﺮﺍﮔﻴﺮ ﺷﺪﻩ ﺍﺳﺖ‪ .‬ﺩﺭ ﺍﻳﻦ ﻭﻳﺪﺋﻮ ‪ CD‬ﻣﻮﺭﺑﻴﺪﻳﺘﻲ ﻭ ﻣﻮﺭﺗﺎﻟﻴﺘﻲ ﻭ ﻋﻮﺍﺭﺽ ﺍﻳﺠﺎﺩ ﺷﺪﻩ ﺑﺎ ﺍﻳﻦ ﺭﻭﺵ ﺣﻴﻦ ﻋﻤﻞ ﺩﺭ ‪ ١٠٠‬ﺑﻴﻤﺎﺭ ﻧﺸﺎﻥ ﺩﺍﺩﻩ ﺷﺪﻩ ﺍﺳﺖ‪.‬‬
‫)‪Nine Month Miracle (A.D.A.M. Software, Inc.‬‬ ‫ــــــ‬
‫‪20.3‬‬
‫‪1. Anatomy‬‬ ‫‪2. The Family Album‬‬ ‫‪3. A Child's View of Pregnancy‬‬
‫‪21.3 Obstetric Ultrasound Principles and Techniques‬‬ ‫ــــــ‬
‫ﺩﺭ ﺍﻳﻦ ‪ CD‬ﻣﻄﺎﻟﺐ ﺟﺎﻣﻊ ﻭ ﺍﺭﺯﻧﺪﻩﺍﻱ ﺩﺭ ﺭﺍﺑﻄﻪ ﺑﺎ ﻣﻬﺎﺭﺕﻫﺎﻱ ﻻﺯﻣﻪ ﺩﺭ ﺳﻮﻧﻮﮔﺮﺍﻓﻲ ﻣﺎﻣﺎﺋﻲ ﺍﺭﺍﺋﻪ ﻣﻲﺷﻮﺩ ﻛﻪ ﻋﻨﺎﻭﻳﻦ ﺁﻥ ﺑﻪ ﺷﺮﺡ ﺯﻳﺮ ﻣﻲﺑﺎﺷﺪ‪:‬‬
‫‪ -‬ﺑﺮﺭﺳﻲ ﺁﻧﺎﺗﻮﻣﻲ ﺟﻨﻴﻦ ﻭ ﺁﻧﻮﻣﺎﻟﻲﻫﺎﻱ ‪ CNS‬ﻭ ‪Body‬‬ ‫‪ -‬ﺗﻌﻴﻴﻦ ﺳﻦ ﺣﺎﻣﻠﮕﻲ ﺑﺮ ﺍﺳﺎﺱ ﻣﻌﻴﺎﺭﻫﺎﻱ ‪ FL . BPD‬ﻭ ‪ AC‬ﻭ ‪ HC‬ﻭ ﺟﺪﺍﻭﻝ ﺁﻧﻬﺎ‬
‫‪ -‬ﺁﻧﺎﺗﻮﻣﻲ ﺭﺣﻢ ﻭ ﺁﺩﻧﻜﺲﻫﺎ ﻭ ﺍﻣﺒﺮﻳﻮ ﻭ ﻛﻴﺴﻪ ﺯﺭﺩﻩ ﺩﺭ ﺗﺮﻳﻤﺴﺘﺮ ﺍﻭﻝ‬ ‫‪ -‬ﺗﻌﻴﻴﻦ ﺳﻦ ﺑﺎﺭﺩﺍﺭﻱ ﺩﺭ ﺗﺮﻳﻤﺴﺘﺮ ﺍﻭﻝ ﺑﺮ ﺍﺳﺎﺱ ‪ Gs‬ﻭ ‪ CRL‬ﻭ ﻧﺤﻮﺓ ﺍﻧﺪﺍﺯﻩﮔﻴﺮﻱ ﺁﻧﻬﺎ‬
‫‪ -‬ﺗﻌﻴﻴﻦ ﺳﻦ ﺑﺎﺭﺩﺍﺭﻱ ﺩﺭ ﺗﺮﻳﻤﺴﺘﺮ ﺩﻭﻡ ﻭ ﺳﻮﻡ ﺑﺮ ﺍﺳﺎﺱ ‪ FL‬ﻭ ‪ AC‬ﻭ ﻧﺤﻮﻩ ﺍﻧﺪﺍﺯﻩﮔﻴﺮﻱ ﺁﻧﻬﺎ‬ ‫‪ -‬ﺗﻌﻴﻴﻦ ﺳﻦ ﺑﺎﺭﺩﺍﺭﻱ ﺩﺭ ﺗﺮﻳﻤﺴﺘﺮ ﺩﻭﻡ ﻭ ﺳﻮﻡ ﺑﺮ ﺍﺳﺎﺱ ﺩﻭﺭ ﺳﺮ ﻭ ﻧﺤﻮﻩ ﺍﻧﺪﺍﺯﻩﮔﻴﺮﻱ ﺁﻥ‬
‫‪ -‬ﺗﻌﻴﻴﻦ ﻣﺤﻞ ﺟﻔﺖ ﻭ ﺣﺠﻢ ﻣﺎﻳﻊ ﺁﻣﻨﻴﻮﺗﻴﻚ‬ ‫‪ -‬ﻣﻄﺎﻟﺐ ﺟﺎﻟﺒﻲ ﺩﺭ ﺭﺍﺑﻄﻪ ﺑﺎ ﺁﻧﺎﺗﻮﻣﻲ ﺟﻨﻴﻦ ﺩﺭ ﺗﺮﻳﻤﺴﺘﺮ ﺩﻭﻡ ﻭ ﺳﻮﻡ )ﻣﻌﺪﻩ‪ -‬ﻛﻠﻴﻪ ‪(........‬‬
‫‪ -‬ﺍﻧﻔﺎﺭﻛﺘﻮﺱ ﻭ ﻭﺍﺭﻳﺎﺳﻴﻮﻥ ﻣﺤﻞ ﺧﺮﻭﺝ ﺑﻨﺪ ﻧﺎﻑ )‪(Cord Insertion‬‬ ‫‪ -‬ﺗﻌﻴﻴﻦ ﻣﺤﻞ ﻻﻧﻪﮔﺰﻳﻨﻲ ﺟﻔﺖ ﻭ ﺑﺮﺭﺳﻲ ﺭﻛﻮﻟﻤﺎﻥ ﻭ ﭘﻼﻧﺘﺎﭘﺮﻭﻳﺎ‬
‫‪ -‬ﺑﺮﺭﺳﻲ ﻟﻜﻴﻨﻴﻜﺎﻝ ﻭ ﺳﻮﻧﻮﮔﺮﺍﻓﻲ ‪ Case Study‬ﻭ ﻣﻄﺮﺡﻛﺮﺩﻥ ﺳﺆﺍﻻﺕ ﺩﺭ ﺭﺍﺑﻄﻪ ﺑﺎ ﺁﻧﻬﺎ ﻭ ﭘﺎﺳﺦ ﻣﺮﺑﻮﻃﻪ‬ ‫‪ -‬ﺗﻮﺿﻴﺤﺎﺗﻲ ﺩﺭ ﺭﺍﺑﻄﻪ ﺑﺎ ‪) BPP‬ﺑﻴﻮﻓﻴﺰﻳﻜﺎﻝ ﭘﺮﻭﻓﺎﻳﻞ(‬
‫‪22.3 Operative Obstetrics‬‬ ‫)‪(Larry C. Gilstrap III) (2nd Edition) (SALEKAN E-BOOK‬‬ ‫ــــــ‬
‫)‪23.3 Safety principles for surgical techniques in minimally invasive gynecologic surgery (Dr. Samir Sawalhe) (CD I , II‬‬ ‫ــــــ‬
‫)‪(Equipment, preparation, positioning, approach alternatives, safe entry, nots on application‬‬
‫‪1. Instruments/equipment‬‬ ‫‪2. Positioning‬‬ ‫‪3. Disinfection/preparation 4. Approach alternatives‬‬ ‫‪5. Electrical morcellation‬‬
‫)‪24.3 Single Puncture Laparoscopic Technique (Marco Pelosi, MD) (VCD‬‬ ‫ــــــ‬
‫ﺩﺭ ﺍﻳﻦ ﻭﻳﺪﺋﻮ ‪ CD‬ﺭﻭﺵ ﻻﭘﺎﺭﺍﺳﻜﻮﭘﻲ ﺑﻪ ﺻﻮﺭﺕ ‪ Single puncture‬ﺗﻮﺻﻴﻒ ﮔﺮﺩﻳﺪﻩ ﻭ ﺷﺮﺍﻳﻂ ﺍﻃﺎﻕ ﻋﻤﻞ‪ ،‬ﻃﺮﻳﻘﻪ ﻭ ﻭﺳﺎﺋﻞ ﻋﻤﻞ ﺗﻮﺿﻴﺢ ﺩﺍﺩﻩ ﻣﻲﺷﻮﺩ‪ .‬ﻭ ﺳﭙﺲ ﻣﺰﺍﻳﺎ ﺍﻳﻦ ﺭﻭﺵ ﺑﻪ ﻧﻮﻉ ‪ multiple puncture‬ﺑﻴﺎﻥ ﻣﻲﮔﺮﺩﺩ‪.‬‬
‫‪25.3 Submitted Subject: Transvaginal Sonographic Assessment of Pelvic Pathology: Preoperative Evaluation‬‬ ‫)‪(Frances R. Batzer, MD‬‬ ‫ــــــ‬

‫ﺍﻳﻦ ﻭﻳﺪﺋﻮ ‪ CD‬ﺍﺯ ‪ ٣‬ﺑﺨﺶ ﺯﻳﺮ ﺗﺸﻜﻴﻞ ﺷﺪﻩ ﺍﺳﺖ‪:‬‬

‫)ﻓﻴﻠﻢ ﺍﻭﻝ(‪ :‬ﺩﺭ ﺍﻳﻦ ﻗﺴﻤﺖ ﺍﺑﺘﺪﺍ ﺩﺭ ﻣﻮﺭﺩ ﻛﺎﺭﺑﺮﺩﻫﺎﻱ ﺳﻮﻧﻮﮔﺮﺍﻓﻲ ﺗﺮﺍﻧﺲ ﻭﺍﮊﻳﻨﺎﻝ ﺑﺤﺚ ﺷﺪﻩ ﻭ ﺳﭙﺲ ﺷﺮﺡ ﺣﺎﻝ ‪ ٦‬ﺑﻴﻤﺎﺭ ﺑﻴﺎﻥ ﺷﺪﻩ ﻭ ﺑﺎ ﺳﻮﻧﻮﮔﺮﺍﻓﻲ ﺗﺮﺍﻧﺲ ﻭﺍﮊﻳﻨﺎﻝ ﺗﺸﺨﻴﺺ ﻭ ﻣﺤﻞ ﺩﻗﻴﻖ ﺿﺎﻳﻌﺎﺕ ﻟﮕﻦ ﺩﺍﺩﻩ ﻣﻲﺷﻮﺩ ﻭ ﺳﭙﺲ ﺑﺎ ﻫﻴﺴﺘﺮﺳﻜﻮﭘﻲ ﻭ ﻻﭘﺎﺭﺍﺳﻜﻮﭘﻲ ﺿﺎﻳﻌﺎﺕ‬
‫ﺟﺮﺍﺣﻲ ﻣﻲﮔﺮﺩﺩ‪ Case .‬ﻫﺎﻱ ﺳﻄﺮ ﺑﻪ ﺷﺮﺡ ﺯﻳﺮ ﺍﺳﺖ‪:‬‬
‫ﻫﻴﺴﺘﺮﻭﺳﻜﻮﭘﻴﻚ ‪resection‬‬ ‫←‬ ‫ﺩﺭﻣﺎﻥ‬ ‫ﺧﺎﻧﻢ ‪ ٤٢‬ﺳﺎﻟﻪﺍﻱ ﺑﻪ ﻣﻨﻮﻣﺘﺮﻭﺭﺍﮊﻱ ﺑﻪ ﻣﺪﺕ ‪ ٢‬ﺳﺎﻝ ← ﺗﺸﺨﻴﺺ ﺗﺮﺍﻧﺲ ﻭﺍﮊﻳﻨﺎﻝ ﺳﻮﻧﻮﮔﺮﺍﻓﻲ ← ﺳﺎﺏ ﻣﻮﻛﻮﺱ ﻓﻴﺒﺮﻭﻥ ←‬
‫ﺩﺭﻣﺎﻥ‪Hysteroscopic Resection :‬‬ ‫←‬ ‫‪Septate uterus‬‬ ‫‪ -١‬ﺧﺎﻧﻢ ‪ ٢٤‬ﺳﺎﻟﻪﺍﻱ ﺑﺎ ﺗﺎﺭﻳﺨﭽﻪ ﺧﺘﻢ ﺣﺎﻣﻠﮕﻲ ﻣﻜﺮﺭ ﺩﺭ ﺗﺮﻳﻤﺴﺘﺮ ﺩﻭﻡ ← ﺗﺸﺨﻴﺺ ﺗﺮﺍﻧﺲ ﻭﺍﮊﻳﻨﺎﻝ ﺳﻮﻧﻮﮔﺮﺍﻓﻲ ←‬
‫‪ -٢‬ﺧﺎﻧﻢ ‪ ٣٦‬ﺳﺎﻟﻪ ﺑﺎ ﺗﺎﺭﻳﺨﭽﻪ ﺍﻧﺪﻭﻣﺘﺮﻳﻮﺯ ﻭ ﺩﺭﺩ ﻧﺎﮔﻬﺎﻧﻲ ﻭ ﺵ‬

‫ﺗﻠﻔﻦ‪٠٩١٢١٣٧٢٣٦١-٦٦٩٣٦٦٩٦ :‬‬ ‫ﻧﺸﺎﻧﻲ‪ :‬ﺗﻬﺮﺍﻥ‪ ،‬ﻡ ﺍﻧﻘﻼﺏ‪ ،‬ﺥ ﻛﺎﺭﮔﺮ ﺟﻨﻮﺑﻲ‪ ،‬ﺥ ﻟﺒﺎﻓﻲﻧﮋﺍﺩ‪ ،‬ﺑﻴﻦ ﻛﺎﺭﮔﺮ ﻭ ﺟﻤﺎﻟﺰﺍﺩﻩ‪ ،‬ﺑﻦﺑﺴﺖ ﺳﻴﻤﻴﻦ‪ ،‬ﭘﻼﻙ ‪٢٣٩‬‬ ‫ﻣﺮﻛﺰ ﺧﺪﻣﺎﺕ ﻓﺮﻫﻨﮕﻲ ﺳﺎﻟﻜﺎﻥ ‪ :‬ﺍﺭﺍﺋﻪ ﻛﻨﻨﺪﺓ ﻛﺘﺎﺏ ﻭ ﺳﻲﺩﻱﻫﺎﻱ ﺗﺨﺼﺼﻲ ﭘﺰﺷﻜﻲ‬
 17
YA ‫ ﺑﺮﺩﺍﺷﺘﻦ ﻛﻴﺴﺖ ﺑﺎ ﻻﭘﺎﺭﺍﺳﻜﻮﭖ ﺑﺎ ﻟﻴﺰﺭﻱ‬:‫ﺩﺭﻣﺎﻥ‬ ← ‫ ﺩﻳﺪ ﻧﺎﺣﻴﻪ ﻟﮕﻦ ← ﺗﺸﺨﻴﺺ ﺗﺮﺍﻧﺲ ﻭﺍﮊﻳﻨﺎﻝ ﺳﻮﻧﻮﮔﺮﺍﻓﻲ ← ﺍﻧﺪﻭﻣﺘﺮﻳﻮﻣﺎ‬-٣
‫ ﺑﺮﺩﺍﺷﺘﻦ ﺩﺭﻣﻮﺋﻴﺪ ﻛﻴﺴﺖ ﺑﺎ ﻻﭘﺎﺭﺍﺳﻜﻮﭘﻲ‬:‫ ← ﺩﺭﻣﺎﻥ‬Cyst ‫ ﺳﺎﻟﻪ ﺑﺎ ﺩﺭﺩ ﻧﺎﺣﻴﻪ ﻟﮕﻦ ← ﺗﺸﺨﻴﺺ ﺗﺮﺍﻧﺲ ﻭﺍﮊﻳﻨﺎﻝ ﺳﻮﻧﻮﮔﺮﺍﻓﻲ ← ﺩﺭﻣﻮﺋﻴﺪ‬٤١ ‫ ﺧﺎﻧﻢ‬-٤
‫ ﺑﺮﺩﺍﺷﺘﻦ ﺿﺎﻳﻌﻪ ﺑﺎ ﻻﭘﺎﺭﺍﺳﻜﻮﭖ‬:‫ ← ﺩﺭﻣﺎﻥ‬Cyst ‫ ﺳﺎﻟﻪ ﺑﻄﻮﺭ ﺍﺗﻔﺎﻗﻲ ﻣﺘﻮﺟﻪ ﺑﺰﺭﮔﻲ ﺗﺨﻤﺪﺍﻥ ﻳﻜﻄﺮﻑ ﻣﻲﺷﻮﺩ ← ﺗﺸﺨﻴﺺ ﺗﺮﺍﻧﺲ ﻭﺍﮊﻳﻨﺎﻝ ﺳﻮﻧﻮﮔﺮﺍﻓﻲ ← ﻓﻮﻟﻴﻜﻮﻝ ﺩﺭ‬٤٣ ‫ ﺧﺎﻧﻢ‬-٥
Left Salpingectomy :‫← ﺩﺭﻣﺎﻥ‬ ectopicpregnancy ‫ﺗﺸﺨﻴﺺ ﺗﺮﺍﻧﺲ ﻭﺍﮊﻳﻨﺎﻝ ﺳﻮﻧﻮﮔﺮﺍﻓﻲ‬ ← ‫ ﻫﻔﺘﻪ ﻗﺒﻞ ﺗﺸﺨﻴﺺ‬٣ LMP ‫ ﺳﺎﻟﻪﺍﻱ ﺑﺎ ﺧﻮﻧﺮﻳﺰﻱ ﻣﺪﺍﻭﻡ ﻭ‬٢١ ‫ﺧﺎﻧﻢ‬ -٦

:(‫)ﻓﻴﻠﻢ ﺩﻭﻡ‬
Limiting Physician Exposure to Hepatitis B and HIV : Ob / Gyns (R.Viscarello.MD)
.‫ ﺩﺭ ﺗﻤﺎﺱ ﻣﻲﺑﺎﺷﺪ ﮔﻔﺘﻪ ﺷﺪﻩ ﺍﺳﺖ ﻭ ﺭﺍﻫﻬﺎﻱ ﺻﺤﻴﺢ ﺍﺳﺘﻔﺎﺩﻩ ﺍﺯ ﺳﻮﻧﻮﮔﺮﺍﻓﻲ ﻭ ﻻﭘﺎﺭﺍﺳﻜﻮﭘﻲ ﻭ ﺭﻭﺵﻫﺎﻱ ﭘﻴﺸﮕﻴﺮﻱ ﺩﺭ ﻣﻄﺐ ﻣﺘﺨﺼﺼﻴﻦ ﺯﻧﺎﻥ ﻭ ﺯﺍﻳﻤﺎﻥ ﺑﻴﺎﻥ ﺷﺪﻩ ﺍﺳﺖ‬HIV ‫ ﻳﺎ‬HBV ‫ ﺭﺍﻩﻫﺎﻱ ﭘﻴﺸﮕﻴﺮﻱ ﻭ ﺩﺭﻣﺎﻥ ﻓﺮﺩﻱ ﻛﻪ ﺑﺎ‬CD ‫ﺩﺭ ﺍﻳﻦ ﻭﻳﺪﺋﻮ‬
:(‫)ﻓﻴﻠﻢ ﺳﻮﻡ‬
Laparoscopic Retropubic Colposuspension For Stress urinary incontinence (Gordon. D. Davis, MD. & R.W.Lobel,MD
.‫ ﺑﻄﺮﻳﻘﻪ ﻻﭘﺎﺭﺍﺳﻜﻮﭘﻲ ﺑﻴﺎﻥ ﺷﺪﻩ ﺍﺳﺖ‬Stress incontinence ‫ ﻃﺮﻳﻘﻪ ﺍﺻﻼﺡ‬CD ‫ﺩﺭ ﺍﻳﻦ ﻭﻳﺪﺋﻮ‬
:(‫)ﻓﻴﻠﻢ ﭼﻬﺎﺭﻡ‬
Bi-polar Desiccation of Vascular Tissue: Laparoscopic Hysterectomy (Paul, D. Indman,MD)
.‫ ﻧﺸﺎﻥ ﺩﺍﺩﻩ ﺷﺪﻩ ﺍﺳﺖ‬bi-polar desiccation ‫ﺩﺭ ﺍﻳﻦ ﻓﻴﻠﻢ ﻃﺮﻳﻘﻪ ﺑﺮﺩﺍﺷﺘﻦ ﭘﺎﻳﻪﻫﺎﻱ ﻋﺮﻭﻗﻲ ﻛﻮﭼﻚ ﻭ ﻣﺘﻮﺳﻂ ﺩﺭ ﺍﻋﻤﺎﻝ ﺟﺮﺍﺣﻲ ﺗﻮﺳﻂ‬
26.3 TEXT AND ATLAS OF Female in Fertility Surgery (ROBERT B. HUNT) (Third Edition) (Mosby) (SALEKAN E-BOOK) 1999
:‫ﺍﻳﻦ ﻛﺘﺎﺏ ﺍﻟﻜﺘﺮﻭﻧﻴﻜﻲ ﺷﺎﻣﻞ ﻋﻨﺎﻭﻳﻦ ﺫﻳﻞ ﻣﻲﺑﺎﺷﺪ‬
BASIC SCIENCE ENERGY SOURCES RADIOLOGIC PROCEDURES HYSTEROSCOPY LAPAROSCOPY LAPAROTOMY ENDOMETRIOSIS ADDITIONAL CONSIDERATIONS
27.3 Triplet Pregnancies and their Consequences (Louis G. Keith, MD, Isaac Blickstein, MD) (SALEKAN E-BOOK) 2002

Epidemiology and biology Antepartum considerations Delivery/birth considerations The Matria database Short-term outcomes Sources of information on multiple births
Prenatal diagnosis Long-term outcomes Preventive measures Miscellaneous Future dicections
28.3 TVT Tension-free Vaginal – Tape ‫ــــــ‬
:‫ ﺍﺯ ﺑﺨﺶ ﺯﻳﺮ ﺗﺸﻜﻴﻞ ﺷﺪﻩ ﺍﺳﺖ‬CD ‫ﺍﻳﻦ‬
Stress Incontinence Anatomy&Terminology Tension-free Vaginal Tape Indication&Patient Selection TVT Procedure Clinical Information Sales Support
29.3 Urogynecology: Evaluation and Treatment of Urinary Incontinence (Bruce Rosenzweig, MD, Jeffrey S. Levy, MD, Donald R. Ostergard, MD) ‫ــــــ‬
.‫ ﻭﺟﻮﺩ ﺩﺍﺭﺩ‬CD ‫ﻼ ﺭﻧﮕﻲ ﺑﻮﺩﻩ ﻭ ﺗﻮﺿﻴﺤﺎﺕ ﺑﻪ ﺻﻮﺭﺕ ﻧﻮﺷﺘﺎﺭﻱ ﻭ ﻓﺎﻳﻞ ﺻﻮﺗﻲ ﻛﻪ ﺑﺮ ﺭﻭﻱ ﻫﺮ ﻗﺴﻤﺖ ﺍﺯ ﺍﻳﻦ‬
‫ ﻛﻪ ﺑﻪ ﺻﻮﺭﺕ ﺗﺼﺎﻭﻳﺮ ﻛﺎﻣ ﹰ‬CD ‫ﺍﻳﻦ‬
:‫ ﻗﺴﻤﺖ ﻣﺠﺰﺍ ﺩﺍﺭﺩ ﺷﺎﻣﻞ‬٤ Urogynechology
Consideration for the OB/GYN Generalist - won surgical & surgical Management - Evaluation - Introduction Definigg Incontinence -
:‫ ﺍﻳﻦ ﻗﺴﻤﺖ ﺧﻮﺩ ﺷﺎﻣﻞ ﻣﺒﺎﺣﺚ‬:Introduction & Defining Incontince (١
Types of incontinernce y incontinence awareness y Patient misconceptions y affected women y incontince ‫ ﺗﺸﺨﻴﺺ‬y

:incontinency ‫( ﺍﺭﺯﻳﺎﺑﻲ ﺑﻴﻤﺎﺭﺍﻥ ﺑﺎ‬٢

Cystoscopy y uroflowmetry y Postvoid residual y Cystometrogram y Pad test y ‫ ﻣﻌﺎﻳﻨﺎﺕ ﺑﺎﻟﻴﻨﻲ‬y ‫ ﺗﺎﺭﻳﺨﭽﻪ‬y Voiding diary y un , u/s y
Pessary test y Multi-Channel urodynamics y

: Stress urinary incontinence ‫( ﺗﺪﺍﺑﻴﺮ ﺩﺭﻣﺎﻧﻲ ﺟﺮﺍﺣﻲ ﻭ ﻏﻴﺮ ﺟﺮﺍﺣﻲ ﺩﺭ‬٣

.‫( ﺑﺤﺚ ﺷﺪﻩ ﺍﺳﺖ‬.... ‫ ﻭ‬funetional electrieal Stimalation ‫ ﻭ ﺩﺭﻣﺎﻥﻫﺎﻱ ﺩﺍﺭﻭﺋﻲ‬biofeedback, Beharioral modification)) ‫ﺍﻳﻦ ﻗﺴﻤﺖ ﺷﺎﻣﻞ ﺍﻟﮕﻮﺭﻳﺘﻢ ﺗﺼﻤﻴﻢﮔﻴﺮﻱ ﺩﺭ ﻣﻮﺭﺩ ﺭﻭﺵ ﺩﺭﻣﺎﻧﻲ ﻣﻲﺑﺎﺷﺪ ﻭ ﺳﭙﺲ ﺭﻭﺵ ﺩﺭﻣﺎﻧﻲ ﻏﻴﺮﺟﺮﺍﺣﻲ‬

٠٩١٢١٣٧٢٣٦١-٦٦٩٣٦٦٩٦ :‫ﺗﻠﻔﻦ‬ ٢٣٩ ‫ ﭘﻼﻙ‬،‫ ﺑﻦﺑﺴﺖ ﺳﻴﻤﻴﻦ‬،‫ ﺑﻴﻦ ﻛﺎﺭﮔﺮ ﻭ ﺟﻤﺎﻟﺰﺍﺩﻩ‬،‫ ﺥ ﻟﺒﺎﻓﻲﻧﮋﺍﺩ‬،‫ ﺥ ﻛﺎﺭﮔﺮ ﺟﻨﻮﺑﻲ‬،‫ ﻡ ﺍﻧﻘﻼﺏ‬،‫ ﺗﻬﺮﺍﻥ‬:‫ﻧﺸﺎﻧﻲ‬ ‫ ﺍﺭﺍﺋﻪ ﻛﻨﻨﺪﺓ ﻛﺘﺎﺏ ﻭ ﺳﻲﺩﻱﻫﺎﻱ ﺗﺨﺼﺼﻲ ﭘﺰﺷﻜﻲ‬: ‫ﻣﺮﻛﺰ ﺧﺪﻣﺎﺕ ﻓﺮﻫﻨﮕﻲ ﺳﺎﻟﻜﺎﻥ‬
 ‫‪18‬‬
‫ﺭﻭﺵﻫﺎﻱ ﺟﺮﺍﺣﻲ‪ :‬ﺍﺑﺘﺪﺍ ﺩﺭ ﻣﻮﺭﺩ ﺭﻭﺵﻫﺎﻱ ﺍﻧﺠﺎﻡ ﺟﺮﺍﺣﻲ ﺑﺤﺚ ﺷﺪﻩ ﻭ ﺳﭙﺲ ‪ Procedure‬ﺍﻋﻤﺎﻝ ﺟﺮﺍﺣﻲ ﺷﺮﺡ ﺩﺍﺩﻩ ﺷﺪﻩ ﺍﺳﺖ‪ .‬ﺩﺭ ﻗﺴﻤﺖﻫﺎﻱ ﺑﻌﺪﻱ ﻣﻘﺎﻳﺴﻪ ﺩﺭﺻﺪ ﻣﻮﻓﻘﻴﺖ ﺭﻭﺵﻫﺎ ﺫﻛﺮ ﺷﺪﻩ ﻭ ﺩﺭ ﺁﺧﺮ ‪ Complication‬ﺍﻳﻦ ﺭﻭﺵﻫﺎ ﺗﻮﺿﻴﺢ ﺩﺍﺩﻩ ﺷﺪﻩ ﺍﺳﺖ‪.‬‬

‫‪: Consideration for the OB/Gyn Generalist (٤‬‬

‫‪incontinrence management to private patients y‬‬ ‫‪Non surgical therapy y‬‬ ‫‪urogynechology as a subdiscipline y‬‬ ‫ﺩﺭ ﺍﻳﻦ ﻓﺼﻞ‪:‬‬
‫ﻣﻮﺭﺩ ﺑﺤﺚ ﻗﺮﺍﺭ ﮔﺮﻓﺘﻪ ﺍﺳﺖ‪.‬‬ ‫‪Allied Staff y‬‬ ‫‪equipment cost y‬‬ ‫‪Set-up requirement y‬‬ ‫‪Urodynamics y‬‬ ‫‪professional consideration y‬‬ ‫‪eystometry y‬‬

‫)‪30.3 Video Journal of Gynecology (Vaginal Hysterectomy Wedge morcellization Technique for the Large Uterus) (The Infertile Couple) (David Olive, MD, George W. Morley MD,‬‬ ‫ــــــ‬
‫)‪31.3 WOMEN'S HEALTH (MOSBY'S PRIMARY CARE‬‬ ‫ــــــ‬
‫ﺍﻳﻦ ‪ CD‬ﺷﺎﻣﻞ ‪ Procedure‬ﻫﺎﻱ ﺳﺮﭘﺎﺋﻲ ﻣﺮﺑﻮﻁ ﺑﻪ ﺑﻴﻤﺎﺭﻳﻬﺎﻱ ﺯﻧﺎﻥ ﻭ ﺩﺳﺘﮕﺎﻩ ﮊﻧﻴﺘﺎﻟﻬﺎﻱ ﺯﻧﺎﻥ )‪ (Female Genitalia‬ﻭ ﻣﻌﺎﻳﻨﺎﺕ ﺑﺎﻟﻴﻨﻲ ‪ Female Genitiourinary Tract‬ﻣﻲﺑﺎﺷﺪ‪.‬‬
‫ﺩﺭ ﻫﺮ ﻓﺼﻞ ﻋﻼﻭﻩ ﺑﺮ ﺭﻭﺵ ‪ ، L‬ﺁﻧﺎﺗﻮﻣﻲ ‪ ،‬ﺍﻧﺪﻳﻜﺎﺳﻴﻮﻥ ﻭ ﻛﻨﺘﺮﺍﺍﻧﺪﻳﻜﺎﺳﻴﻮﻥ ‪ L‬ﻭ ﭼﮕﻮﻧﮕﻲ ﺍﻧﺠﺎﻡ ﻋﻤﻞ ﻭ ﻋﻮﺍﺭﺽ ﻭ ﺗﺴﺖﻫﺎﻱ ﺗﺸﺨﻴﺼﻲ ﻭ ﻏﻴﺮﻩ ﺑﺤﺚ ﺷﺪﻩ ﺍﺳﺖ‪.‬‬
‫ﺧﺼﻮﺻﻴﺖ ﻣﻨﺤﺼﺮ ﺑﻪ ﻓﺮﺩ ﺍﻳﻦ ‪ CD‬ﺷﺎﻣﻞ ‪ :‬ﻧﺸﺎﻥ ﺩﺍﺩﻥ ﺗﻤﺎﻡ ﺭﻭﺵﻫﺎ ﺑﻪ ﺻﻮﺭﺕ ﻓﻴﻠﻢﻫﺎﻱ ﻭﻳﺪﺋﻮﺋﻲ ﺩﺭ ‪ CD‬ﻭ ﺩﻳﮕﺮ ‪ CNG‬ﻳﺎ ﺗﺴﺖﻫﺎﻱ ﭼﻨﺪ ﮔﺰﻳﻨﻪﺍﻱ ﺍﺳﺖ ﻛﻪ ﺩﺭ ﺁﺧﺮ ﻫﺮ ﺑﺨﺶ ﺁﻭﺭﺩﻩ ﺷﺪﻩ ﺍﺳﺖ‪:‬‬
‫ﻋﻨﺎﻭﻳﻦ ﺍﻳﻦ ‪ CD‬ﺷﺎﻣﻞ ‪:‬‬
‫‪ Breast examination -١‬ﺷﺎﻣﻞ‪ :‬ﺁﻧﺎﺗﻮﻣﻲ ‪ ،‬ﭘﺎﺗﻮﻓﻴﺰﻳﻮﻟﻮﮊﻱ ‪ ،‬ﺍﻧﺪﻳﻜﺎﺳﻴﻮﻥ ﻭ ﻛﻨﺘﺮﺍﺍﻧﺪﻳﻜﺎﺳﻴﻮﻥ ‪ ،‬ﺗﺠﻬﻴﺰﺍﺕ ‪ ،‬ﺁﻣﻮﺯﺵ ﺑﻪ ﺑﻴﻤﺎﺭ‪ ،‬ﻓﺮﻡ ﺭﺿﺎﻳﺖ ﻧﺎﻣﻪ‪ Pojition ،‬ﺑﻴﻤﺎﺭ ﺗﻜﻨﻴﻚ ﻭ ﺛﺒﺖ ﻳﺎﻓﺘﻪﻫﺎ ﻭ ﭘﺮﻭﻧﺪﻩ ﻭ ﺍﺷﻜﺎﻻﺕ ﺗﻜﻨﻴﻜﻲ ‪ ،‬ﺗﺸـﺨﻴﺺ ﺍﻓﺘﺮﺍﻗـﻲ ﻭ ‪ quiz‬ﺍﻧﺘﻬـﺎﻱ ﺑﺨـﺶ‬
‫ﻣﻲﺑﺎﺷﺪ ﺗﻤﺎﻡ ﻣﺮﺍﺣﻞ ﺑﺎﻳﺪ ﺑﻪ ﺻﻮﺭﺕ ﺗﻤﺎﺱﻫﺎﻱ ﺭﻧﮕﻲ ﻭ ﻓﺎﻳﻞﻫﺎﻱ ﻭﻳﺪﻳﻮﺋﻲ ﺑﻪ ﻧﻤﺎﻳﺶ ﺩﺭﺁﻣﺪﻩ ﺍﺳﺖ‬
‫‪ : Colposcopy -٢‬ﺍﺑﺘﺪﺍ ﺁﻧﺎﺗﻮﻣﻲ ‪ cervix‬ﺑﺎ ﺷﻜﻠﻬﺎﻱ ﺗﻤﺎﻡ ﺭﻧﮕﻲ ﻧﻤﺎﻳﺶ ﺩﺍﺩﻩ ﺷﺪﻩ ﺍﺳﺖ ﻭ ﺗﻮﺿﻴﺤﺎﺕ ﻻﺯﻡ ﺩﺭ ﻣﺘﻦ ﺁﻭﺭﺩﻩ ﺷﺪﻩ ﺍﺳﺖ‪.‬‬
‫ﺳﭙﺲ ﺩﺭ ﻣﻮﺭﺩ ﭘﺎﺗﻮﻟﻮﮊﻱ ﻭ ﻓﻴﺰﻳﻮﻟﻮﮊﻱ ﻧﺎﺣﻴﻪ ﺳﺮﻭﻛﻴﻞ ﺷﺮﺡ ﺩﺍﺩﻩ ﺷﺪﻩ ﺍﺳﺖ‪ .‬ﺍﻧﺪﻳﻜﺎﺳﻴﻮﻥ ﻭ ﻛﻨﺘﺮﺍﺍﻧﺪﻳﻜﺎﺳﻴﻮﻥ ﺑﺎ ﺁﻣﻮﺯﺵ ﺑﻪ ﺑﻴﻤﺎﺭ ﺗﺠﻬﻴﺰﺍﺕ ﻻﺯﻡ ‪ ، Positioning ،‬ﺁﻣﺎﺩﻩ ﻛﺮﺩﻥ ﻣﺤﻞ‪ ،‬ﺁﻧﺴﺘﺰﻱ‪ ،‬ﺗﻜﻨﻴﻚ ﺍﻧﺠﺎﻡ ‪ Procedne‬ﻭ ﻛﻤﭙﻴﻜﺎﺳﻴﻮﻥ ‪ ،‬ﺗﺸﺨﻴﺺﻫﺎﻱ ﺍﻓﺘﺮﺍﻗﻲ‬
‫ﻭ ﺗﻐﻴﻴﺮ ﻧﺘﺎﻳﺞ ﺷﺮﺡ ﺩﺍﺩﻩ ﺷﺪﻩ ﺩﺭ ﺁﺧﺮ ﻓﺼﻞ ‪ Quiz‬ﻭﺟﻮﺩ ﺩﺍﺭﺩ‪ ٧ .‬ﻓﻴﻠﻢ ﺩﺭ ﻣﻮﺭﺩ ﭼﮕﻮﻧﮕﻲ ﺍﻧﺠﺎﻡ ﺭﻭﺵ ﻛﻮﭘﻴﻮﺳﻜﻮﭘﻲ ﺩﺭ ﺍﻳﻦ ﻓﺼﻞ ﻭﺟﻮﺩ ﺩﺍﺭﺩ‪.‬‬
‫‪ -٣‬ﺍﻧﺪﻭﻣﺘﺮﻳﺎﻝ ﺑﻴﻮﭘﺴﻲ‪ :‬ﺍﺑﺘﺪﺍ ﻭ ﻣﻘﺪﻣﻪ ﺗﺎﺭﻳﺨﭽﻪﺍﻱ ﺍﺯ ‪ D&C‬ﻭ ﺑﻴﻮﭘﺴﻲ ﺁﻧﺪﻭﻣﺘﺮﻳﺎﻝ ﻫﻤﺮﺍﻩ ﺑﺎ ﺗﺼﺎﻭﻳﺮ ﻗﺪﻳﻤﻲ ﺁﻭﺭﺩﻩ ﺷﺪﻩ ﺍﺳﺖ ﺳﭙﺲ ﺁﻧﺎﺗﻮﻣﻲ ﭘﺎﺗﻮﻓﻴﺰﻳﻮﻟﻮﮊﻱ ﺁﻥ ﺑـﻪ ﺗﺼـﺎﻭﻳﺮ ﺭﻧﮕـﻲ ﺷـﺮﺡ ﺩﺍﺩﻩ ﺷـﺪﻩ ﺍﺳـﺖ‪.‬ﺳـﭙﺲ ﻣﺎﻧﻨـﺪ ﺩﻳﮕـﺮ ‪ Procedure‬ﻫـﺎ ﺍﻧﺪﻳﻜﺎﺳـﻴﻮﻥ ﻭ‬
‫ﻛﻨﺘﺮﺍﺍﻧﺪﻳﻜﺎﺳﻴﻮﻥ ﻭ ﺗﻜﻨﻴﻚ ‪ ،‬ﺁﻣﺎﺩﮔﻲ ﺑﻴﻤﺎﺭ‪ Position ،‬ﺑﻴﻤﺎﺭ‪ ،‬ﺁﻧﺴﺘﺰﻱ ﻭ ‪ ....‬ﺁﻭﺭﺩﻩ ﺷﺪﻩ ﺍﺳﺖ‪ .‬ﺩﺭ ﺁﺧﺮ ﻓﺼﻞ ﻓﻴﻠﻢﻫﺎﻱ ﻣﺮﺑﻮﻁ ﺑﻪ ﺗﺠﻬﻴﺰﺍﺕ ﻭ ﺭﻭﺵﻫﺎﻱ ﺍﻧﺠﺎﻡ ﺑﻴﻮﭘﺴﻲ ﺁﻭﺭﺩﻩ ﺷﺪﻩ ﺍﺳﺖ‪ .‬ﺁﺧﺮ ﻓﺼﻞ ‪ Quiz‬ﻗﺮﺍﺭ ﺩﺍﺭﺩ‪.‬‬
‫‪ : Pelvic Examination -٤‬ﺑﻌﺪ ﺍﺯ ﻣﻘﺪﻣﻪ ﺩﺭ ﻣﻮﺭﺩ ﺁﻧﺎﺗﻮﻣﻲ ﻧﺎﺣﻴﻪ ﮊﻧﺘﻴﻜﻲ )‪ (utenes , carivx , vagina , valve‬ﺑﺎ ﺗﺼﺎﻭﻳﺮ ﺭﻧﮕﻲ ﺁﻭﺭﺩﻩ ﺷﺪﻩ ﻭ ﭼﮕﻮﻧﮕﻲ ﺍﻧﺠﺎﻡ ﻣﻌﺎﻳﻨﻪ ‪ Position،‬ﺑﻴﻤﺎﺭ‪ ،‬ﺍﻧﺪﻳﻜﺎﺳﻴﻮﻥ ‪ ،‬ﻛﻨﺘﺮﺍﻳﻜﺎﺳﻴﻮﻥ ﻭ ﺗﻐﻴﻴﺮ ﻳﺎﻓﺘﻪﻫﺎ ﺁﻭﺭﺩﻩ ﺷﺪﻩ ﺍﺳﺖ‪ .‬ﻭ ﺳﭙﺲ ‪ ٦‬ﻓﻴﻠﻢ ﻣﻌﺎﻳﻨﻪ ﻟﮕﻨﻲ‬
‫ﻛﺎﻣﻞ‪ ،‬ﻣﻌﺎﻳﻨﻪ ‪ exetrnalgenifalicn‬ﺑﺎ ﭘﺎﭖ ﺁﺳﻤﻴﺮ‪ ،‬ﻣﻌﺎﻳﻨﻪ‪ rectovaginal , bimanual‬ﻭ ﭼﮕﻮﻧﮕﻲ ﮔﺬﺍﺷﺘﻦ ﺍﺳﭙﻜﻮﻟﻮﻡ ﻭ ﺗﺠﻬﻴﺰﺍﺕ ﻧﺸﺎﻥ ﺩﺍﺩﻩ ﺷﺪﻩ ﺍﺳﺖ‪.‬‬
‫ﺩﺭ ﺁﺧﺮ ‪ Quiz‬ﺁﻭﺭﺩﻩ ﺷﺪﻩ ﺍﺳﺖ‪.‬‬
‫‪ : Pap Smear -٥‬ﺍﺑﺘﺪﺍ ﺑﻌﺪ ﺍﺯ ﻣﻘﺪﻣﻪﺍﻱ ﻛﻮﺗﺎﻩ ﺩﺭ ﻣﻮﺭﺩ ﺁﻧﺎﺗﻮﻣﻲ ﻣﻨﻘﻄﻊ ﻭ ﭘﺎﺗﻮﻓﻴﺰﻳﻮﻟﻮﮊﻱ ﺑﻴﻤﺎﺭﻳﻬﺎﻱ ﻛﻪ ﻣﻲﺷﻮﺩ ﺑﺎ ﭘﺎﭖ ﺁﺳﻤﻴﺮ ﺑﺮﺭﺳﻲ ﻛﺮﺩ‪ .‬ﺍﻧﺪﻳﻜﺎﺳﻴﻮﻥ ‪ ،‬ﻛﻨﺘﺮﺍﺍﻧﺪﻳﻜﺎﺳﻴﻮﻥ ‪ Position ،‬ﺭﻭﺵ ﺍﻧﺠﺎﻡ‪ ،‬ﺍﺷﻜﺎﻻﺕ ﺗﻜﻨﻴﻜﻲ ‪ ،‬ﺗﺠﻬﻴﺰﺍﺕ ﻭ ‪ ....‬ﺷﺮﺡ ﺩﺍﺩﻩ ﺷﺪﻩ ﺍﺳﺖ‪ ٥ .‬ﻓـﻴﻠﻢ‬
‫ﺍﺯ ﭼﮕﻮﻧﮕﻲ ﻣﻌﺎﻳﻨﻪ ‪ ،‬ﮔﺬﺍﺷﺘﻦ ﺍﺳﻴﻜﻮﻟﻮﻡ ﻭ ﺍﻧﺠﺎﻡ ﭘﺎﭖ ﺍﺳﻤﻴﺮ ﻭ ﺗﺠﻬﻴﺰﺍﺕ ﺁﻥ ﺁﻭﺭﺩﻩ ﺷﺪﻩ ﺍﺳﺖ‪.‬‬
‫‪) Vaginal Secretion -٦‬ﺗﺮﺷﺢ ﻭﺍﮊﻳﻨﺎﻝ(‪ :‬ﺩﺭ ﺍﻳﻦ ﻣﺒﺤﺚ ﺍﺑﺘﺪﺍ ﻋﻠﻞ ﺗﺮﺷﺢ ﻭﺍﮊﻳﻨﺎﻝ ﻭ ﺗﺸﺨﻴﺺﻫﺎﻱ ﺍﻓﺘﺮﺍﻗﻲ ﺁﻥ ﭘﺮﺩﺍﺧﺘﻪ ﺷﺪﻩ ﺍﺳﺖ ﻭ ﺳﭙﺲ ﺗﺠﻬﻴﺰﺍﺕ ﻣﻮﺭﺩ ﻧﻴﺎﺯ‪ ،‬ﭼﮕﻮﻧﮕﻲ ﮔﺮﻓﺘﻦ ﻛﺸﺖ‪ ،‬ﺍﻧﺠﺎﻡ ﺗﺴﺖ ‪ ، KOH‬ﻗﺮﺍﺭ ﺩﺍﺩﻥ ﺗﺮﺷﺤﺎﺕ ﺑﺮ ﺭﻭﻱ ‪ slide‬ﻭ ﻣﺸﺎﻫﺪﻩ ﺁﻥ‬
‫ﺑﺎ ﻣﻴﻜﺮﻭﺳﻜﻮﭖ ﺑﺎ ﻓﻴﻠﻢ ﻭ ﺗﺼﺎﻭﻳﺮ ﺭﻧﮕﻲ ﻧﺸﺎﻥ ﺩﺍﺩﻩ ﺷﺪﻩ ﺍﺳﺖ ﻭ ‪ Quiz‬ﻧﻴﺰ ﺩﺭ ﺁﺧﺮ ﻓﺼﻞ ﻭﺟﻮﺩ ﺩﺍﺭﺩ‪.‬‬
‫‪32.3 UTEROSALPINGOGRAPHY IN GYNECOLOGY (Hysterosalpingography) It's Application in Physiological And Pathological Conditions‬‬ ‫)‪(SALEKAN E-BOOK‬‬ ‫‪2003‬‬
‫ﺍﻳﻦ ‪ CD‬ﺣﺎﻭﻱ ﻣﻄﺎﻟﺐ ﺫﻳﻞ ﺩﺭ ﺍﺭﺗﺒﺎﻁ ﺑﺎ ‪ Utero Salpingography‬ﻣﻲﺑﺎﺷﺪ‪:‬‬
‫‪ -‬ﺗﻐﻴﻴﺮﺍﺕ ﭘﺎﺗﻮﻟﻮﮊﻳﻚ ﺭﺣﻢ‬ ‫‪ -‬ﺁﻧﻮﻣﺎﻟﻲﻫﺎﻱ ﻣﺎﺩﺭﺯﺍﺩﻱ ﺭﺣﻢ ﻭ ﻟﻮﻟﻪﻫﺎﻱ ﻓﺎﻟﻮﭖ‬ ‫‪ -‬ﻋﻤﻠﻜﺮﺩ ﺭﺣﻢ ﻭ ﻟﻮﻟﻪﻫﺎﻱ ﻓﺎﻟﻮﭖ‬ ‫ﺍﺻﻮﻝ ﻛﻠﻲ ﺩﺭ ‪Uterosalpingography‬‬ ‫‪-‬‬
‫‪ -‬ﭘﺎﺗﻮﻟﻮﮊﻱ ﻟﻮﻟﻪﻫﺎﻱ ﻓﺎﻟﻮﭖ‪ ،‬ﭘﺮﻳﺘﻮﺋﻦ ﻭ ﺗﺨﻤﺪﺍﻥﻫﺎ‬ ‫‪ -‬ﺳﻞ ﺗﻨﺎﺳﻠﻲ ﻭ ﻓﻴﺴﺘﻮﻝ ﮊﻧﻴﺘﺎﻝ‬ ‫‪ -‬ﺳﻘﻂ ﻣﻜﺮﺭ ﻭ ﻗﺎﻋﺪﮔﻲ ﺩﺭﺩﻧﺎﻙ )ﺩﻳﺲ ﻣﻨﻮﺭﻩ(‬

‫ﺩﺭ ‪ CD‬ﻓﻮﻕﺍﻟﺬﻛﺮ ﺗﺼﺎﻭﻳﺮ ﺭﺍﺩﻳﻮﮔﺮﺍﻓﻴﻚ ﻣﺘﻌﺪﺩ ﻭﺍﺿﺤﻲ ﺩﺭ ﺍﺭﺗﺒﺎﻁ ﺑﺎ ‪ USG‬ﮔﻨﺠﺎﻧﺪﻩ ﺷﺪﻩ ﺍﺳﺖ‪.‬‬
‫‪33.3 Your Pregnancy, Your Newborn The Complete Guide for Expectant and New Mothers‬‬ ‫ــــــ‬

‫‪ -٤‬ﻋﻠﻮﻡ ﺁﺯﻣﺎﻳﺸﮕﺎﻫﻲ‬

‫ﻋﻨﻮﺍﻥ ‪CD‬‬ ‫ﺳﺎﻝ ﺍﻧﺘﺸﺎﺭ‬

‫‪1.4‬‬ ‫‪A Manual of Laboratory & Diagnostic Tests‬‬ ‫)‪(Frances Fischbach‬‬ ‫)‪(Sixth Edition) (SALEKAN E-BOOK‬‬ ‫ــــــ‬
‫ﺍﻳﻦ ‪ CD‬ﻛﻪ ﺩﺭ ﻣﺮﻛﺰ ﺧﺪﻣﺎﺕ ﻓﺮﻫﻨﮕﻲ ﺳﺎﻟﻜﺎﻥ ﺗﺒﺪﻳﻞ ﺑﻪ ﻛﺘﺎﺏ ﺍﻟﻜﺘﺮﻭﻧﻴﻜﻲ ﺷﺪﻩ ﺍﺳﺖ ﻣﺸﺘﻤﻞ ﺑﺮ ‪ ١٦‬ﻓﺼﻞ ﺍﺳﺖ ﻭ ﺷﺎﻣﻞ ﻣﻮﺍﺭﺩ ﺯﻳﺮ ﻣﻲﺑﺎﺷﺪ‪:‬‬

‫ﺗﻠﻔﻦ‪٠٩١٢١٣٧٢٣٦١-٦٦٩٣٦٦٩٦ :‬‬ ‫ﻧﺸﺎﻧﻲ‪ :‬ﺗﻬﺮﺍﻥ‪ ،‬ﻡ ﺍﻧﻘﻼﺏ‪ ،‬ﺥ ﻛﺎﺭﮔﺮ ﺟﻨﻮﺑﻲ‪ ،‬ﺥ ﻟﺒﺎﻓﻲﻧﮋﺍﺩ‪ ،‬ﺑﻴﻦ ﻛﺎﺭﮔﺮ ﻭ ﺟﻤﺎﻟﺰﺍﺩﻩ‪ ،‬ﺑﻦﺑﺴﺖ ﺳﻴﻤﻴﻦ‪ ،‬ﭘﻼﻙ ‪٢٣٩‬‬ ‫ﻣﺮﻛﺰ ﺧﺪﻣﺎﺕ ﻓﺮﻫﻨﮕﻲ ﺳﺎﻟﻜﺎﻥ ‪ :‬ﺍﺭﺍﺋﻪ ﻛﻨﻨﺪﺓ ﻛﺘﺎﺏ ﻭ ﺳﻲﺩﻱﻫﺎﻱ ﺗﺨﺼﺼﻲ ﭘﺰﺷﻜﻲ‬
 19
Diagnostic Testing Blood Studies Urine Studies Stool Studies
Cbemistry Studies Microbiologic Studies Immunodiagnostic Studies Nuclear Medicine Studies
Cytology, Histology, and Genetic Studies Endoscopic Studies Ultrasound Studies Pulmonary Functio and Blood Gas Studies
Prenatal Diagnosis and Tests of Fetal Well-Being Cerebrespinal Fluid Studies X-ray Studies Special Systems, Organ Functions, and Post Mortem Studies
2.4 A Slide Atlas of ATHEROSCLEROSIS (Progression and Regression) (Herbert C. Stary) 2002
‫ ﻣﻄﺎﻟﻌﻪ ﺍﻳﻦ ﻧﺮﻡ ﺍﻓﺰﺍﺭ ﺑﻪ ﻣﺘﺨﺼﺼﻴﻦ ﭘﺎﺗﻮﻟﻮﮊﻱ‬.‫ ﺍﺳﻼﻳﺪ ﺗﺨﺼﺼﻲ ﻣﺮﺍﺣﻞ ﻣﺨﺘﻠﻒ ﭘﻴﺸﺮﻓﺖ ﻭ ﭘﺴﺮﻓﺖ ﺑﻴﻤﺎﺭﻱ ﺁﺗﺮﻭﺍﺳﻜﻠﺮﻭﺯﻳﺲ ﺩﺭ ﺳﻨﻴﻦ ﻣﺨﺘﻠﻒ ﻭ ﻗﻠﺐ ﻭ ﻋﺮﻭﻕ ﻣﺨﺘﻠﻒ ﺑﺪﻥ ﺭﺍ ﺑﺎ ﺗﺼﺎﻭﻳﺮ ﻣﻴﻜﺮﻭﺳﻜﻮﭘﻲ ﻭ ﺍﻟﻜﺘﺮﻭﻧﻲ ﺑﻪ ﺯﻳﺒﺎﻳﻲ ﺑﻪ ﺗﺼﻮﻳﺮ ﻛﺸﻴﺪﻩ ﺍﺳﺖ‬۹۴ ‫ﺍﻳﻦ ﻧﺮﻡ ﺍﻓﺰﺍﺭ ﺑﺎ‬
.‫ﻭ ﻗﻠﺐ ﻭ ﻋﺮﻭﻕ ﺗﻮﺻﻴﻪ ﻣﻴﺸﻮﺩ‬
3.4 American Sodiety of Hematology (CD 1-5) (44 Annual Meeting) th 2002
CD-1: ALL -AML -ASH/ASCO Joint Symposium -Atypical Cellular Disorders
CD-2: CLL -CML -CNS Lymphoma -Cutaneous Lymphoma -E. Donnall Thomas Lecture
CD-3: Enhancing Physician/Patient Communication Regarding Hematologic Disorders -Ham-Wasserman Lecture -Hematology Grants Workshop
-Hypercoagulability: Too Many Tests, Too Much Conflicting Data -Malaria and the Red Cell -Marrow Failure
CD-4: Multi[ple Myeloma -Myelodysplastic Syndromes Non-Myeloablative Transplantation -Platelets: Thrombotic Thrombocytopenic -Purpura Plenary Policy Frum
CD-5: Presidential Symposium -Red Cell Antigens as Functional Molecules and Obstacles to Transfusion -Sickle Cell Disease -Stem Cell Transplantation: Supportive Care and
Long-Term Complications -Stem Cells: Hype and Reality Update on Epidemiology and Therapeutics for Non-Hodgkin’s Lymphoma
4.4 An Electronic Companion to Microbiology for MajorsTM (Mark L. Wheelis) Reviw , Test yourself ‫ــــــ‬
:‫ ﺷﺎﻣﻞ ﻋﻨﺎﻭﻳﻦ ﺯﻳﺮ ﻣﻲﺑﺎﺷﺪ‬CD ‫ﺍﻳﻦ‬
What Are Microorganisms? Methods of Microbiology Eukaryotic Cell Struture Metabolism & Energy Gene Regulation Microbial Ecology Disease
Classification Prokaryotic Cell Struture Growth & Reproduction Microbial Genetics Viruses Defenses Againses Infection
5.4 Atlas of HEMATOLOGY ‫ــــــ‬
:‫ ﺣﺎﻭﻱ ﻣﻮﺍﺭﺩ ﺯﻳﺮ ﻣﻲﺑﺎﺷﺪ‬CD ‫ﺍﻳﻦ‬
1. Examination of Blood Cells 2. Normal Hematopoiesis and Blood Cells 3.Dynamic Cell Morphology 4. Hematolopathology 5. Cluster of differentiation Archive 6. Self-Assessment
6.4 Atlas of Surgical Pathology (Johns Hopkins) (Jonathan I. Epstein, Neera P. Agarwal-Antal, David B. Danner, Kim M. Ruska)
7.4 Atlas of Medical Parasitology (Dr. K. Ghazvini) 2003
‫ ﻧﺎﻗﻞ اﻧﮕﻞ و ﺳﯿﮑﻞ زﻧﺪﮔﯽ و ﺗﮑﺜﯿﺮ اﻧﮕﻞ اﺳﺖ ﮐﻪ ﺟﻬﺖ اﺳﺘﻔﺎده ﮔﺮوهﻫﺎی ﻣﺨﺘﻠﻒ رﺷﺘﻪﻫﺎی ﭘﺰﺷـﮑﯽ ﺧﺼﻮﺻـﺎً رﺷـﺘﻪ ﻋﻠـﻮم‬،‫ ﺿﺎﯾﻌﺎت اﯾﺠﺎدﺷﺪه‬،‫ ﺗﺼﻮﯾﺮ رﻧﮕﯽ از اﻧﻮاع اﻧﮕﻞﻫﺎی ﺑﯿﻤﺎرﯾﺰای اﻧﺴﺎﻧﯽ ﺷﺎﻣﻞ ﺗﺼﻮﯾﺮ اﻧﮕﻞ‬2000 ‫ﻧﺮماﻓﺰار ﻓﻮق ﺣﺎوی ﺣﺪود‬
‫ ﻣﺒﺎﺣﺚ ﻣﻄﺮحﺷﺪه در اﯾﻦ ﻧﺮماﻓـﺰار‬.‫ ﺑﺴﯿﺎری از ﺗﺼﺎوﯾﺮ ﻣﻮﺟﻮد در اﯾﻦ ﻣﺠﻤﻮﻋﻪ ﻣﻨﺤﺼﺮ ﺑﻪ ﻓﺮد ﻣﯽﺑﺎﺷﺪ‬.‫ ﺗﺼﺎوﯾﺮ ﻣﺠﻤﻮﻋﻪ ﻣﺰﺑﻮر از ﻣﻨﺎﺑﻊ ﻣﺨﺘﻠﻒ ﺟﻤﻊآوری ﮔﺮدﯾﺪه اﺳﺖ ﮐﻪ ﺗﻮﺳﻂ دﮐﺘﺮ ﻗﺰوﯾﻨﯽ ﺑﺎزﻧﮕﺮی و وﯾﺮاﯾﺶ ﮔﺮدﯾﺪه اﺳﺖ‬.‫آزﻣﺎﯾﺸﮕﺎﻫﯽ ﻣﻔﯿﺪ اﺳﺖ‬
:‫ﻋﺒﺎرﺗﻨﺪ از‬
* Heart and Muscles Parasites * Eye Parasites * Case reports and updates in parasitology * Central Nervous System (CNS) Parasites * Gnito-Urinary Parasites
* Lung Parasites * Skin Parasites * Blood, Bone Marrow, Spleen Parasites * Liver and Biliary Tree Parasites * Intestinal Parasites (Helminths) * Intestinal Parasites (Protozoa)

8.4 Basic histology: TEXT & ATLAS IMAGE LIBRARY (Tenth Edition) (Luiz Carlos, Juhqueira, Jose CARNEIRO) (A Division of The McGraw-Hill Companies) 2000
1- Luiz Carlos JUNQUEIRA 2 - Jose CARNEIRO
9.4 Biochemical Interactions An electronic companion to: FUNDAMENTALS OF BIOCHEMISTRY (Donald voet, Judith G. voet, charlotte W. Pratt) (Version 1.02) 1999

:‫ ﺷﺎﻣﻞ ﻣﺒﺎﺣﺚ ﺯﻳﺮ ﺍﺳﺖ‬CD ‫ﺍﻳﻦ‬

NUCLEOTIDES AND NUCLEIC ACIDS PROTEINS: PRIMARY STRUCTURE PROTEIN FUNCTION
LIPIDS BIOLOGICAL MEMBRANES MAMMALIAN FUEL METABOLOSM: INTEGRATION AND REGULATION
GLUCOSE CATABOLISM GLYCOGEN METABOLISM AND GLUCONEOGENESIS DNA REPLICATION REPAIR, AND RECOMBINATION

٠٩١٢١٣٧٢٣٦١-٦٦٩٣٦٦٩٦ :‫ﺗﻠﻔﻦ‬ ٢٣٩ ‫ ﭘﻼﻙ‬،‫ ﺑﻦﺑﺴﺖ ﺳﻴﻤﻴﻦ‬،‫ ﺑﻴﻦ ﻛﺎﺭﮔﺮ ﻭ ﺟﻤﺎﻟﺰﺍﺩﻩ‬،‫ ﺥ ﻟﺒﺎﻓﻲﻧﮋﺍﺩ‬،‫ ﺥ ﻛﺎﺭﮔﺮ ﺟﻨﻮﺑﻲ‬،‫ ﻡ ﺍﻧﻘﻼﺏ‬،‫ ﺗﻬﺮﺍﻥ‬:‫ﻧﺸﺎﻧﻲ‬ ‫ ﺍﺭﺍﺋﻪ ﻛﻨﻨﺪﺓ ﻛﺘﺎﺏ ﻭ ﺳﻲﺩﻱﻫﺎﻱ ﺗﺨﺼﺼﻲ ﭘﺰﺷﻜﻲ‬: ‫ﻣﺮﻛﺰ ﺧﺪﻣﺎﺕ ﻓﺮﻫﻨﮕﻲ ﺳﺎﻟﻜﺎﻥ‬
 20
PHOTOSYNTHESIS LIPID METABOLISM AMINO ACID METABOLISM
NUCLEOTIDE METABOLISM NUCLEIC ACID STRUCTURE CITRIC ACID CYCLE
TRANSLATION REGULATION OF GENE EXPRESSION ENZYME KINETICS, INHIBITION, AND REGULATION
INTROCUCTION TO METABOLISM ELECTRON TRANSPORT AND OXIDATIVE PHOSPORYLATION PROTEINS: THREE-DIMENSIONAL STRUCTURE
TRANSCRIPTION AND RNA PROCESSING

10.4 BIOLOGY CONCEPTS & CONNECTIONS (Second Edition) (Richard M. Liebaert) (CAMPBELL.MITCHELL.REECE) ‫ــــــ‬
1. Introduction: The Sclentific Sindy of Life 3. The Life of the Cell 5. Cellular Repoduction & Genetics 7. Concepls of Evolution
2. The Evolution of Biological Diversity 4. Animals: Form & Function 6. Plants: Form & Function 8. Ecology

11.4 BLOOD PRINCIPLES AND PRACTICE OF HEMATOLOGY (SECOND EDITION) (ROBERT I. HANDIN SAMUEL E. LUX THOMAS P. STOSSEL) 2003

Part I: Fundamentals of Hmatology: Tools of the trade Part II: The Hematopoietic System Part III: Stem Cell Disorders Part IV: White Blood Cells
Part V: Hemostasis Part VI: Red Blood Cells Part VII: Systemic Disease Part VIII: Hematologic Therapies Part VIIII: Appendices

12.4 BRS Cell Biology CELL BIOLOGY AND HISTOLOGY (4th edition) (Leslie P. Gartner, James L. Hiatt, Judy M. Strum) (LIPPINCOTT WILLIAMS & WILKINS) 2003

:‫ ﺷﺎﻣﻞ ﻋﻨﺎﻭﻳﻦ ﺯﻳﺮ ﻣﻲﺑﺎﺷﺪ‬CD ‫ﺍﻳﻦ‬

Plasma Membrane Nucleus Cytoplasm Extracellular Matrix
Connective Tissue Cartilage and Bone Muscle Nervous Tissue
Circulatory System Lymphoid Tissue Endocrine System Skin
The Urinary System Female Reproductive System Digestive System: Oral Cavity and Alimentary Tract Special Senses
Epithelia and Glands Blood and Hemopoiesis Digestive System: Glands Comprehensive Exam
13.4 Cellular & Molecular Neurobiology (Second Edition) ‫ــــــ‬
1- Lonotropic and Metabotropic Receptors in Synaptic Transmission and Sensory Transduction 3- Neurons: Excitable and Secretory Cells that Establish Synapses
2- Somato-Dendritic Processing and Plasticity of Postsynaptic Potentials 4- Activity and Developmen of Networks: The Hippocampus as an Example
14.4 Clinical Hematology (A Victor Hoffbrand , John E Pettit) (Mosby) ‫ــــــ‬

Normal Hemopoiesis and Blood Cells Leucocyte Abnormialities Hemostasis and Bleeding Disorders Bone Marrow Transplantation Parasitic Infections Diagnosed in Blood
Anaemias Hematological Malignancies Coagulation Disorders Bone Marrow in
Blood Transfusion Further Reading Acknowledgements Non-hemopoietic Disease
15.4 Clinical Immunology ‫ــــــ‬
16.4 COMMON PROBLEMS IN CLINICAL LABORATORY MANAGEMENT (Judith A. O'brien, M.S. CLSup (NCA)) (Salekan E-Book) ‫ــــــ‬
OVERCOMING OSHA'S OBST ACLES THE OVERCOMING OSHA'S OBSTACLES THE TAMING TECHNOLOGY: LABORATORY INFORMATION SYSTEM (LIS)
COMPLYING WITH CLIA '88
EXPOSURE CONTROL PLAN CHEMICAL HYGIENE PLAN
MEETING TUBERCULOSIS CONTROL PROVIDING AND USING PERSONAL WRITING MANUALS: THE GENERAL RE-ENGINEERING FOR THE FUTURE: THE CORE LABORATORY,
REGULATIONS PROTECTIVE EQUIPMENT OPERATING PROCEDURE MANUAL ( GOPM) AUTOMATION, OUTREACH NETWORKING, AND THE MILLENNIUM BUG
WRITING MANUALS: THE STANDARD FULFILING QUALITY CONTROL GENERATING LABORATORY NUMBERS: STATISTICS LINEARITY,
PASSING PROFICEINCY TEST
OPERATING PROCEDURE MANUAL (SOPM) GUIDELINES CALIBRATION, REFERENCE, AND CRITICAL VALUES: CALCULATIONS
ESTABLISHING A QUALITY ASSURANCE SURVIVING INSPECTIONS AND ATTAINING
PURSUING PERSONNEL PERSPECTIVES
PROGRAM ACCREDIANCE MANAGING THE PHYSICIAN OFFICE LABORATORY (POL)
THE ACQUISTION AND MAINTENANCE OF MASTERING FINANCES: BILLING AND
ENCOURAGING EDUCATION
LABORATORY INSTRUMENTATION CODING TAMING TECHNOLOGY: POINT OF CARE TESTING (POCT)

17.4 Concise Histology (A data of multiple choice question in microscopic) (Bloom & Fawcett's) (Second Edition) ‫ــــــ‬
18.4 Dianostic Hematology ‫ــــــ‬

٠٩١٢١٣٧٢٣٦١-٦٦٩٣٦٦٩٦ :‫ﺗﻠﻔﻦ‬ ٢٣٩ ‫ ﭘﻼﻙ‬،‫ ﺑﻦﺑﺴﺖ ﺳﻴﻤﻴﻦ‬،‫ ﺑﻴﻦ ﻛﺎﺭﮔﺮ ﻭ ﺟﻤﺎﻟﺰﺍﺩﻩ‬،‫ ﺥ ﻟﺒﺎﻓﻲﻧﮋﺍﺩ‬،‫ ﺥ ﻛﺎﺭﮔﺮ ﺟﻨﻮﺑﻲ‬،‫ ﻡ ﺍﻧﻘﻼﺏ‬،‫ ﺗﻬﺮﺍﻥ‬:‫ﻧﺸﺎﻧﻲ‬ ‫ ﺍﺭﺍﺋﻪ ﻛﻨﻨﺪﺓ ﻛﺘﺎﺏ ﻭ ﺳﻲﺩﻱﻫﺎﻱ ﺗﺨﺼﺼﻲ ﭘﺰﺷﻜﻲ‬: ‫ﻣﺮﻛﺰ ﺧﺪﻣﺎﺕ ﻓﺮﻫﻨﮕﻲ ﺳﺎﻟﻜﺎﻥ‬
 21
This textbook, 'Diagnostic Hematology: A pattern approach', is accompanied by a CD-ROM with three knowledge-based systems applied to 237 case studies. The 3 knowledge-based systems are:
1. Professor Petrushka for peripheral blood analysis 2. Professor Fidelio for flow cytometry immunophenotyping 3. Professor Belmonte for bone marrow interpretation
19.4 Discover Biology ‫ــــــ‬
20.4 Diagnostic and Laboratory Test Reference (Seventh Edition) (Mosby) (Salekan E-Book) (Kathleen Deska Pagana, PhD, RN, Timothy J. Pagana, MD, FACS) 2005
21.4 Electronic Atlas of Parasitology (John T. Sullivan) university of the Incarnate Word 2000
22.4 EMBRYO (CD Color Atlas for Developmental Biology) (Gary C. Schoenwolf) ‫ــــــ‬
Chapter 1: Frog Embryos Chapter 2: Chick Embryos Chapter 3: Pig Embryos Chapter 4: Gametogenesis
23.4 Essential Cell Biology (with the voice of Julie Theriot designed and programmed by Christopher Thorpe) ‫ــــــ‬
24.4 Fields Virology (Forth Edition) (Volume 1) (Lippincott Williams & Wilkins) 2001
Section One: General Virology Chapter 1-22 Section Two: Specific Virus Families Chapter 23-90
25.4 Functional HISTOLOGY WHEATER'S (FOURTH EDITION) (BARBARA YOUNG, JOHN W. HEATH) (ALAN STEVENS JAMES S. LOWE) (PHILIP J. DEAKIN) ‫ــــــ‬
26.4 Genetics From Genes to Genomes (Ann Reynolds, Ph.D.) (University of Washington) 2000
5- Gen RegVlation (...‫ ﺳﻴﮕﻨﺎﻝ ﺗﺮﻧﺴﻼﻛﺸﻦ ﻭ‬،‫)ﻛﻨﺘﺮﻝ ﺍﻭﭘﺮﻭﻥ ﻻﻛﺘﻮﺯ‬ 3- Molecular Genetice 1- Transmission Genetics
6- Poplations & Evolvtion (... ‫)ﻣﺒﺎﺣﺚ ﺟﻤﻌﻴﺖ ﻭ ﺗﻜﺎﻣﻞ ﻭ ﻓﺮﻛﺎﺵ ﺍﻟﻜﻞﻫﺎ ﻭ‬ 4- Chromosomes FISH (‫ ﺗﻜﻨﻴﻚ ﻧﻘﺸﻪ ﮊﻥ‬،‫)ﻣﺒﺎﺣﺚ ﻛﺎﺭﻳﻮﺗﺎﻳﭗ‬ 2- Gentral Dogma

‫ ﺩﺭ ﭘﺎﻳﺎﻥ ﻫـﺮ‬.‫ ﺍﺟﺮﺍ ﮔﺮﺩﺩ‬Quick time ‫ ﻣﻲﺑﺎﺷﺪ ﻛﻪ ﺗﺤﺖ ﺑﺮﻧﺎﻣﺔ‬... ‫ ﻫﻴﭙﺮﻳﺪﺍﺳﻴﻮﻥ ﻛﻠﺮﻧﻴﻨﮓ ﻭ‬،DVA ‫ ﻣﻮﺗﺎﺳﻴﻮﻥ ﻭ ﺗﺮﻣﻴﻢ‬،‫ ﺍﻟﻜﺘﺮﻭﻓﻮﺭﺯ‬،PCR، ‫ﻣﻴﺘﻮﺯﻭ ﻣﻴﻮﺯ‬... ‫ ﺗﻮﺟﻪ‬،‫ ﻣﻜﺎﻧﻴﺴﻢ ﺭﻭﻧﻮﻳﺲ‬: ‫ ﻋﺪﺩ ﻭﻳﺪﺋﻮ ﻛﻠﻴﭗ ﺑﺼﻮﺭﺕ ﺍﻧﻴﻤﻴﺸﻦ ﺍﺯ ﻣﺒﺎﺣﺜﻲ ﻫﻤﭽﻮﻥ‬٢٧ ‫ ﺷﺎﻣﻞ‬CD ‫ﺍﻳﻦ‬
.‫( ﻣﻲﺑﺎﺷﺪ‬In teractive) ‫ ﻫﻤﭽﻨﻴﻦ ﺩﺍﺭﺍﻱ ﺗﻤﺮﻳﻨﺎﺕ ﺑﺼﻮﺭﺕ ﺩﻭ ﺟﺎﻧﺒﻪ ﻭ ﻓﻌﺎﻝ‬.‫ ﺩﺍﺭﺍﻱ ﻳﻚ ﻓﺼﻞ ﻣﺮﺑﻮﻁ ﺑﻪ ﺗﻌﺮﻳﻒ ﻭ ﺗﺮﺷﺢ ﻟﻔﺎﺕ ﻣﺸﻜﻞ ﻭ ﺗﺨﺼﺼﻲ ﺍﺳﺖ‬.‫ﻓﺼﻞ ﺧﻼﺻﺔ ﻣﺒﺎﺣﺚ ﺍﺭﺍﺋﻪ ﺷﺪﻩ ﺍﺳﺖ‬
.‫ ﻣﻮﺟﻮﺩ ﺍﺳﺖ ﻣﻮﺭﺩ ﺍﺳﺘﻔﺎﺩﻩ ﻗﺮﺍﺭ ﻣﻲﮔﻴﺮﺩ‬CD ‫ ﻛﻪ ﺩﺭ ﺧﻮﺩ‬Q.t. ‫( ﻭ ﻧﺼﺐ ﺑﺮﻧﺎﻣﺔ‬Setup . exe ‫ ﻻﺯﻡ ﺍﺳﺖ ﺑﻌﺪ ﺍﺯ ﻧﺼﺐ ﺁﻥ )ﺑﺎ ﺩﻭ ﺑﺎﺭ ﻛﻠﻴﻚ ﻛﺮﺩﻥ ﺑﺮ ﺭﻭﻱ‬CD ‫ ﺑﻜﺎﺭ ﺭﻓﺘﻪ ﺍﺳﺖ ﻭ ﺟﻬﺖ ﺍﺳﺘﻔﺎﺩﻩ ﺍﺯ‬CD ‫ﺁﺑﺸﻦﻫﺎﻱ ﻣﺘﻨﻮﻉ ﻭ ﺯﻳﺒﺎﻳﻲ ﺩﺭ ﺍﻳﻦ‬
27.4 Gram Stain TUTOR (ANINTERACTIVE TUTORIAL THAT TEACHES THE MICROSCOPIC EXAMINATION OF URINARY SEDIMENT) ‫ــــــ‬
(Brad Cookson, MD, PHD, Ajit Limaye, MD, Lydia Matheson, BA)
1. Introduction 2. Morphology 3. Specimen Sites 4. Case Studies 5. Exam 6. Image Atlas
28.4 HISTOLOGY EXPLORER 1999
Microscope 3D Connective Tissue Proper Nervous Tissue The Digestive System The Reproductive System Glands The Endocrine Glands
The Cell Blood and Bone Marrow The Circulatory System The Respiratory System The Mammary Giands Muscular Tissue The Ear
Epithelium The Sketetal Tissues The Lymphoid Organs The Urinary System The Eye The Skin
29.4 HUMAN HISTOLOGY CD-ROM (Alan Stevens. James Lowe) ‫ــــــ‬
30.4 Images of Disease An image database for the teaching of Pathology (Nick Hawkins, Mark Dziegielewski) ‫ــــــ‬
‫ ﻣـﻮﺭﺩ ﻧﻈـﺮ ﺑـﻪ ﺗﻮﺻـﻴﻒ ﻣﺎﻛﺮﻭﺳـﻜﻮﭘﻲ ﻭ ﻣﻴﻜﺮﻭﺳـﻜﻮﭘﻲ ﺿـﺎﻳﻌﻪ‬case ‫ ﺩﺭ ﺭﺍﺑﻄﻪ ﺑﺎ ﺗﻚ ﺗﻚ ﺑﻴﻤﺎﺭﻳﻬﺎ ﻧﻤﻮﻧﻪﻫﺎﻱ ﺑﺎﻓﺘﻲ ﺍﺭﮔﺎﻥ ﺩﺭﮔﻴﺮ ﺑﻴﻤﺎﺭﻱ ﺑﺼﻮﺭﺕ ﻣﺎﻛﺮﻭﺳﻜﻮﭘﻲ ﻭ ﻣﻴﻜﺮﻭﺳﻜﻮﭘﻲ ﺑﺎ ﺗﺼﺎﻭﻳﺮ ﺭﻧﮕﻲ ﻭﺍﺿﺢ ﻣﻮﺭﺩ ﺑﺮﺭﺳﻲ ﻗﺮﺍﺭ ﺩﺍﺩﻩ ﻭ ﺿﻤﻦ ﺍﺭﺍﺋﻪ ﺷﺮﺡ ﺣﺎﻝ‬CD ‫ﺩﺭ ﺍﻳﻦ‬
.‫ ﺑﺨﺼﻮﺹ ﺑﻪ ﺩﺳﺘﻴﺎﺭﺍﻥ ﭘﺎﺗﻮﻟﻮﮊﻱ ﻭ ﭘﺎﺗﻮﻟﻮﮊﻳﺴﺖ ﺩﻣﺎ ﺩﺭ ﺟﻬﺖ ﺗﺸﺨﻴﺺ ﭘﺎﺗﻮﻟﻮﮊﻳﻚ ﺑﻴﻤﺎﺭﻳﻬﺎ ﻛﻤﻚ ﺷﺎﻳﺎﻥ ﻣﻲﻛﻨﺪ ﻭ ﻧﻤﺎﺩﻫﺎﻱ ﻣﺨﺘﻠﻒ ﻣﻴﻜﺮﻭﺳﻜﻮﺑﻴﻚ ﺑﻴﻤﺎﺭﻳﻬﺎ ﺭﺍ ﺑﺼﻮﺭﺕ ﺟﺪﺍﮔﺎﻧﻪ ﻣﻮﺭﺩ ﺗﻮﺟﻪ ﻗﺮﺍﺭ ﻣﻲﺩﻫﺪ‬CD ‫ ﺍﻳﻦ‬،‫ﻣﻲﭘﺮﺩﺍﺯﺩ‬
31.4 Immunology (Blackwell Science) 2000
32.4 Interactive Color Atlas of Histology (Version 1.0) (Leslie P. Gartner James L. Hiatt) (LIPPINCOTT WILLIAMS & WILKINS) 2000
33.4 Interactive Embryology The Human Embryo Program (Jay Lash Ph.D.)
34.4 Laboratory Medicine: URINALYSIS (Chemical and microscopic examination of urine Atlas of Microscopic Analysis Procedures for Urinalsis) (Pesce Kaplan Pubishers Inc.) 2000
Extensive atlas of microscopic analysis: over 50 microphotographs of
Method write-up for 15 chemical urinalysis procedures Complete Specimen collection section
urine sediment, including cells, casts, and artifacts
Interpretation of urine findings in common renal and
Tables reviewing results of chemical urinalyses
lower urinary tract diseases

٠٩١٢١٣٧٢٣٦١-٦٦٩٣٦٦٩٦ :‫ﺗﻠﻔﻦ‬ ٢٣٩ ‫ ﭘﻼﻙ‬،‫ ﺑﻦﺑﺴﺖ ﺳﻴﻤﻴﻦ‬،‫ ﺑﻴﻦ ﻛﺎﺭﮔﺮ ﻭ ﺟﻤﺎﻟﺰﺍﺩﻩ‬،‫ ﺥ ﻟﺒﺎﻓﻲﻧﮋﺍﺩ‬،‫ ﺥ ﻛﺎﺭﮔﺮ ﺟﻨﻮﺑﻲ‬،‫ ﻡ ﺍﻧﻘﻼﺏ‬،‫ ﺗﻬﺮﺍﻥ‬:‫ﻧﺸﺎﻧﻲ‬ ‫ ﺍﺭﺍﺋﻪ ﻛﻨﻨﺪﺓ ﻛﺘﺎﺏ ﻭ ﺳﻲﺩﻱﻫﺎﻱ ﺗﺨﺼﺼﻲ ﭘﺰﺷﻜﻲ‬: ‫ﻣﺮﻛﺰ ﺧﺪﻣﺎﺕ ﻓﺮﻫﻨﮕﻲ ﺳﺎﻟﻜﺎﻥ‬
 22
35.4 Media Supplement for Biochemistry (FOURH EDITION) (Roy Tasker Carl Rhodes) 2000
1. Reaction mechanisms 2. Metabolic Pathways 3. Membrane Processes 4. Protein Synthesis 5. Molecular Representations
36.4 Microbes in Motion III (Dr. Gloria Delisle and Dr. Lewis Tomalty Queen's University) ‫ــــــ‬
:‫ ﻛﺘﺎﺏ ﺍﻟﻜﺘﺮﻭﻧﻴﻜﻲ ﺑﻪ ﺷﺮﺡ ﺫﻳﻞ ﻣﻲﺑﺎﺷﺪ‬١٨ ‫ ﺩﺍﺭﺍﻱ ﻳﻚ ﻛﺘﺎﺑﺨﺎﻧﻪ ﺷﺎﻣﻞ‬CD ‫ﺍﻳﻦ‬
‫ﻭﻳﺮﻭﺱﺷﻨﺎﺳﻲ‬ ‫ﺭﺍﻫﻬﺎ ﻭ ﺭﻭﺵﻫﺎﻱ ﻛﻨﺘﺮﻝ ﻭ ﻣﻬﺎﺭ ﺭﺷﺪ ﺑﺎﻛﺘﺮﻳﻬﺎ‬ ‫ﻣﻴﻜﺮﻭﺑﻬﺎﻱ ﺑﻲﻫﻮﺍﺯﻱ ﻣﺤﻴﻄﻲ‬ ‫ﻋﻤﻠﻜﺮﺩ ﺿﺪ ﻣﻴﻜﺮﻭﺑﻬﺎ‬ ‫ﭘﺎﺗﻮﮊﻧﺰ‬
‫ﺍﭘﻴﺪﻭﻣﻴﻮﻟﻮﮊﻱ‬ ‫ﺍﻧﮕﻞﺷﻨﺎﺳﻲ‬ ‫ﻣﻴﻜﺮﻭﺑﻴﻮﻟﻮﮊﻱ ﻣﺤﻴﻄﻲ‬ ‫ﺍﻳﻤﻮﻧﻮﻟﻮﮊﻱ‬ ‫ﻣﺘﺎﺑﻮﻟﻴﺴﻢ ﻣﻴﻜﺮﻭﺑﻲ‬
‫ﺑﺎﻛﺘﺮﻳﻮﻟﻮﮊﻱ‬ (... ‫ ﺗﺮﺍﻧﺴﭙﻮﺯﻭﺭﻫﺎ ﻭ‬، DNA ‫ ﺳﺎﺧﺘﺎﺭ‬،‫ﮊﻧﺘﻴﻚ )ﺑﻴﻮﺗﻜﻨﻮﻟﻮﮊﻱ‬ ‫ﺑﺎﻛﺘﺮﻳﻬﺎﻱ ﮔﺮﻡ ﻣﻨﻔﻲ‬ ‫ﻣﻘﺎﻭﻣﺖ ﺿﺪ ﻣﻴﻜﺮﻭﺑﻲ‬ ‫ﻗﺎﺭﭺﺷﻨﺎﺳﻲ‬
‫ﻭﺍﻛﺴﻦﻫﺎ‬ ‫ﺑﺎﻛﺘﺮﻳﻬﺎﻱ ﮔﺮﻡ ﻣﺜﺒﺖ‬ Miscellaneous
37.4 MICROBIOLOGY AND IMMUNOLOGY (KEN S. ROSENTHAL) (Mosby) 2002
1. TUTORIAL: I. Topics II. Systems III. Random 2. TEST
38.4 MICROBIOLOGY AND MICROBIAL INFECTIONS (Topley & Wilson's) (Albert Balows, Max sussman) (NINTH EDITION) ‫ــــــ‬
39.4 MODERN GENETIC ANALYSIS (Anthony J. F. Griffiths, William M. Gelbart, Jffrey H. Miller, Richard C. Lewontin) 1999
:‫ ﺷﺎﻣﻞ ﻋﻨﺎﻭﻳﻦ ﺯﻳﺮ ﻣﻲﺑﺎﺷﺪ‬CD ‫ﺍﻳﻦ‬
Introduction System Requirements Getting Started Reference Freeman Genetics Web Site
40.4 MOLECULAR CELL BIOLOGY 4.0 (Paul Matusdaru, Amold Berk, S. lawence Zipufsky, David Baltimore, James Damell, Harey lodish) 2000
41.4 NCCL INFOBASE Serving the World's Medical Science Community Through Voluntary Consensus 2002
42.4 PATHOLOGIC BASIS OF DISESE Interactive Case Study Companion to ROBBIMS (W. B. Saunders Company) (Sixth Edition) ‫ــــــ‬
Inflammation and Repair Fluid and Hemodynamic Disorders Genetic Disorders Diseases of Immunity Neoplasia Systemic Pathology
Infectious Disease Cardiovascular Diseases Hematopatholory Disorders Gastrointestinal Diseases Diseases of Liver, Galbladder, and Pancreas Diseases of Kidney
Genitouinary, Breast, and Pregnancy Disorders Endocrine Diseases Skeletal Disorders Neuropathology

43.4 PATHOLOGY (Alan Stevens. James Lowe) ‫ــــــ‬

44.4 Peripheral Blood TUTOR (ANINTERACTIVE TUTORIAL THAT TEACHES THE MICROSCOPIC EXAMINATION OF URINARY SEDIMENT) ‫ــــــ‬
Introduction Cell Morphologies Disease Associations Atlas Final Exam

Overview, Smear Preparation Cell Structure, Read Blood Red Blood Cells, White Cell Morphology
Stain Procedure, Smear Cells, White Blood Cells, Blood Cells, Neoplastic Disease Association
Evaluation Platelets, Artifacts, Quiz Disorder
45.4 PRINCIPLES OF Molecular Virology (THIRD EDITION) 2000
• Contents
Introduciton Particles Genomes Replication Expression Infection Pathogenesis Novel Infectious Agents
• Appendices
Glossary, Abbreviations and Pronounciations Classification of Sub-Cellular Infections Agents The History of Virology
46.4 RAPID REVIEW HISTOLOGY AND CELL BIOLOGY (E. ROBERT BURNS, M. DONALD CAVE) (MOSBY) 2002
47.4 Samter's Immunologic Diseases (SIXTH EDITION) (K. Frank Austen, M.D, Michael M. Frank, M.D., John P. Atkinson, M.D., Harvey Cantor, M.D.) ‫ــــ‬
:‫ ﻗﺴﻤﺖ ﺍﺻﻠﻲ ﺍﺳﺖ ﻛﻪ ﻫﺮ ﻗﺴﻤﺖ ﺩﺍﺭﺍﻱ ﭼﻨﺪﻳﻦ ﻓﺼﻞ ﻣﻲﺑﺎﺷﺪ ﻛﻪ ﻋﺒﺎﺭﺗﻨﺪ ﺍﺯ‬١٠ ‫ ﺍﻳﻦ ﺑﺮﻧﺎﻣﻪ ﺩﺍﺭﺍﻱ‬.‫ ﺍﺟﺮﺍ ﻣﻲﺷﻮﺩ‬Flash ‫ ﻭ‬Internet explorer ‫ ﺑﺼﻮﺭﺕ ﻳﻚ ﻛﺘﺎﺏ ﺍﻟﻜﺘﺮﻭﻧﻴﻜﻲ ﺍﺳﺖ ﻛﻪ ﺗﺤﺖ ﺑﺮﻧﺎﻣﺔ‬CD ‫ﺍﻳﻦ‬
(‫ ﺗﺸﺨﻴﺺ ﻭ ﺷﻨﺎﺳﺎﻳﻲ )ﺍﻳﻤﻨﻲ ﺫﺍﺗﻲ ﻭ ﺍﻛﺘﺴﺎﺑﻲ‬- ‫ ﻣﻜﺎﻧﻴﺰﻡﻫﺎﻱ ﻣﺆﺛﺮ ﺍﻳﻤﻨﻲ ﺩﺭ ﺍﻳﻤﻨﻲ ﺫﺍﺗﻲ ﻭ ﺍﻛﺘﺴﺎﺑﻲ‬- ‫ ﺑﻴﻤﺎﺭﻱ ﻧﻘﺺ ﺍﻳﻤﻨﻲ ﺍﻭﻟﻴﻪ‬- ‫ ﺑﻴﻤﺎﺭﻳﻬﺎﻱ ﺍﺯﺩﻳﺎﺩ ﻭ ﺗﻜﺜﻴﺮ ﺳﻠﻮﻟﻬﺎﻱ ﺍﻳﻤﻨﻲ‬- ‫ ﺑﻴﻤﺎﺭﻳﻬﺎﻱ ﺳﻴﺴﺘﻤﻴﻚ‬-
‫ ﺑﻴﻤﺎﺭﻳﻬﺎﻱ ﺍﺧﺘﺼﺎﺻﻲ ﺍﻧﺪﺍﻡ‬- ‫ ﺑﻴﻤﺎﺭﻳﻬﺎﻱ ﺁﻟﺮﮊﻳﻜﻲ‬- ‫ ﺳﻴﺴﺘﻢ ﺍﻳﻤﻨﻲ ﻓﻌﺎﻝ ﻭ ﻏﻴﺮ ﻣﺆﺛﺮ‬- ‫ ﭘﻴﻮﻧﺪ ﺍﻋﻀﺎﺀ‬- ‫ ﺍﻳﻤﻨﻲ ﺷﻨﺎﺳﻲ ﺩﺭﻣﺎﻧﻲ‬-

‫ ﻗﺪﺭﺕ ﺑﺰﺭﮔﻨﻤﺎﻳﻲ ﺗﺼﺎﻭﻳﺮ ﻭ ﻧﻤﺎﻳﺶ ﻣﻨـﺎﺑﻊ‬.‫ ﺗﻮﺍﻧﺎﻳﻲ ﺟﺴﺘﺠﻮ ﻭﺍﮊﻩﻫﺎ ﻭ ﻟﻐﺎﺕ ﺗﺨﺼﺼﻲ ﻭ ﭼﺎﭖ ﻣﺘﻮﻥ ﻛﺘﺎﺏ ﺭﺍ ﺩﺍﺭﺩ‬.‫ ﺩﺍﺭﺍﻱ ﻳﻚ ﻛﺘﺎﺑﺨﺎﻧﻪ ﺍﺯ ﺗﺼﺎﻭﻳﺮ ﻣﺮﺑﻮﻁ ﺑﻪ ﻫﺮ ﻓﺼﻞ ﻭ ﻫﺮ ﻣﻮﺿﻮﻉ ﻣﻲﺑﺎﺷﺪ ﻛﻪ ﺟﺪﺍﻭﻝ ﻭ ﻃﺮﺡﻭﺍﺭﻩﻫﺎﻱ ﻣﺮﺑﻮﻃﻪ ﺭﺍ ﺑﻪ ﻧﻤﺎﻳﺶ ﻣﻲﮔﺬﺍﺭﺩ‬CD ‫ﺍﻳﻦ‬
.‫ﻫﺮ ﻗﺴﻤﺖ ﺍﺯ ﻛﺘﺎﺏ ﺍﺯ ﻭﻳﮋﮔﻴﻬﺎﻱ ﺍﻳﻦ ﺑﺮﻧﺎﻣﻪ ﻣﻲﺑﺎﺷﺪ‬

٠٩١٢١٣٧٢٣٦١-٦٦٩٣٦٦٩٦ :‫ﺗﻠﻔﻦ‬ ٢٣٩ ‫ ﭘﻼﻙ‬،‫ ﺑﻦﺑﺴﺖ ﺳﻴﻤﻴﻦ‬،‫ ﺑﻴﻦ ﻛﺎﺭﮔﺮ ﻭ ﺟﻤﺎﻟﺰﺍﺩﻩ‬،‫ ﺥ ﻟﺒﺎﻓﻲﻧﮋﺍﺩ‬،‫ ﺥ ﻛﺎﺭﮔﺮ ﺟﻨﻮﺑﻲ‬،‫ ﻡ ﺍﻧﻘﻼﺏ‬،‫ ﺗﻬﺮﺍﻥ‬:‫ﻧﺸﺎﻧﻲ‬ ‫ ﺍﺭﺍﺋﻪ ﻛﻨﻨﺪﺓ ﻛﺘﺎﺏ ﻭ ﺳﻲﺩﻱﻫﺎﻱ ﺗﺨﺼﺼﻲ ﭘﺰﺷﻜﻲ‬: ‫ﻣﺮﻛﺰ ﺧﺪﻣﺎﺕ ﻓﺮﻫﻨﮕﻲ ﺳﺎﻟﻜﺎﻥ‬
 23
48.4 The American Society of Hematology (41st Annual Meeting and Exposition) 1999
49.4 The Cell 1.0 A Molecular Approach (Many Animations, Movies, Photos, and drawn images) (Geoffrey M. Cooper) ‫ــــــ‬
:‫ ﺷﺎﻣﻞ ﻣﺒﺎﺣﺚ ﺯﻳﺮ ﻣﻲﺑﺎﺷﺪ‬CD ‫ﺍﻳﻦ‬
Cell Overview Humman Genetic Diseases Floww of Information The Nucleus The Cell Cycle Protein Sorting and Transport
Organelles & Energy Metabolism The Cytoskeleto The Plasma Membrane The Extracellular Machine Cancer-A Family od Diseases The Meiotic Divisions
50.4 THE HUMAN GENOME PROJECT 2003
51.4 The Metabolic and Molecular Bases of Inherited Disease ____
General Themes, Amino Acids, Prophyrins and Heme, Hormones: Synthesis and Action, Defense and Immune Mechanisms, Skin, Cancer and Genetics, Organic Acids, Metals, Vitamins, Connective Tissues,
Intesine, Chromosomes and Autosomes, Peroxisomes, Blood and Blood Forming Tissue, Muscle, Neurogenetics, Carbohydrates, Lipoprotein and Lipid Metabolism disorders, Lysosomal Transport, Eye,
Signiflcant Developments in Progress, Cancer and NEW Geneticx Update
52.4 UNDERSTAND! Biochemistry (3/e Version) (Lehninger Principles of Biochemistry) 2000
1. THE BACKGROUND 4. BIOENERGETICS 7. CELLULAR ARCHITECTURE AND TRAFFIC
2. THE MOLECULES OF LIFE 5. BIOSYNTHESIS 8. THE DIVIDING CELL
3. PROTEINS IN ACTION 6. NUCLEIC ACIDS AND THEIR EXPRESSION 9. SOME IMPORTANT TECHNIQUES
53.4 UNDERSTAND! Biochemistry (VERSION 1.0) 1999

:‫ ﺷﺎﻣﻞ ﻋﻨﺎﻭﻳﻦ ﺯﻳﺮ ﻣﻲﺑﺎﺷﺪ‬CD ‫ﺍﻳﻦ‬

- QUIZE - INDEX - Web links -Minicourses:

54.4 UNDERSTAND! Biology: Biochemistry (Molecules, Cell & Genes) ‫ــــــ‬

:‫ ﻣﺸﺘﻤﻞ ﺑﺮ ﻣﺒﺎﺣﺚ ﺯﻳﺮ ﻣﻲﺑﺎﺷﺪ‬،‫ ﻓﻮﻕ‬CD
Basic Chemistry Macromolecular assembly and modification Bioenegetics Signal transduction Enzymology The flow of genetic information Metabolism Molecular biology techniques
55.4 Urinalysis TUTOR (ANINTERACTIVE TUTORIAL THAT TEACHES THE MICROSCOPIC EXAMINATION OF URINARY SEDIMENT) (Caria M. Phillips, MLM, MT(ASCP), Paul J. Henderson, MS, MT(ASCP), Claudia Bein, BS, MT(ASCP)) ‫ــــــ‬

.‫ ﻓﺼﻞ ﺭﻭﺵ ﺁﺯﻣﺎﻳﺸﺎﺕ ﻣﻴﻜﺮﻭﺳﻜﻮﭘﻲ ﻧﻤﻮﻧﻪﻫﺎﻱ ﺍﺩﺭﺍﺭﻱ ﺭﺍ ﺁﻣﻮﺯﺵ ﻣﻲﺩﻫﺪ‬٥ ‫ ﺩﺭ‬interactive ‫ﺍﻳﻦ ﺑﺮﻧﺎﻣﻪ ﺑﺼﻮﺭﺕ‬
(‫ ﻋﻔﻮﻧﺖ ﻟﻮﻟﺔ ﺍﺩﺭﺍﺭﻱ‬،‫ ﻓﻴﻠﻮﻧﻔﺮﻳﺖ‬،‫ ﺳﻨﺪﺭﻡ ﻧﻔﺮﻭﺗﻴﻚ‬.‫ ﺑﻴﻤﺎﺭﻳﻬﺎ )ﺳﻨﺪﺭﻡ ﮔﻠﻮﻣﺮﻭﻟﻮﻧﻔﺮﻳﺖ‬.٥ (‫ ﺁﺭﺗﻴﻔﻜﺖﻫﺎ‬،‫ ﺍﺭﮔﺎﻧﻴﺰﻣﻬﺎ‬،‫ ﻛﺮﻳﺴﺘﺎﻟﻬﺎ‬،‫ ﺳﺎﺧﺘﺎﺭ ﻭ ﻣﺎﻫﻴﺖ ﺭﺳﻮﺑﺎﺕ ﺍﺩﺭﺍﺭ )ﺑﺮﺭﺳﻲ ﺳﻠﻮﻟﻬﺎﻱ ﻣﻮﺟﻮﺩ ﺩﺭ ﺍﺩﺭﺍﺭ‬.٣ (‫ ﻣﻜﺎﻧﻴﺴﻢ ﻋﻤﻠﻜﺮﺩ ﻣﻴﻜﺮﻭﺳﻜﻮﭘﻲ ﻭ ﻧﻤﻮﻧﻪﻫﺎﻱ ﻣﻴﻜﺮﻭﺳﻜﻮﭘﻲ‬،‫ ﺗﻔﺴﻴﺮ ﻭ ﺍﺭﺯﻳﺎﺑﻲ ﻧﺘﺎﻳﺞ‬،‫ ﻣﻘﺪﻣﻪ )ﻋﻤﻠﻜﺮﺩ ﻛﻠﻴﻪ‬.١
.(‫ ﻫﺮ ﺳﺆﺍﻝ ﺑﻪ ﺷﻜﻞ ﻧﻤﺎﻳﺶ ﻳﻚ ﺗﺼﻮﻳﺮ ﻣﻲﺑﺎﺷﺪ ﻛﻪ ﻣﻮﺭﺩ ﺳﺆﺍﻝ ﻗﺮﺍﺭ ﻣﻲﮔﻴﺮﺩ‬.‫ ﺳﺆﺍﻻﺗﻲ ﺑﺼﻮﺭﺕ ﭼﻨﺪ ﮔﺰﻳﻨﻪﺍﻱ ﺍﺭﺍﺋﻪ ﺷﺪﻩ ﺍﺳﺖ‬،‫ ﺍﺯ ﻫﺮ ﺑﺨﺶ‬.‫ ﻣﻲﺑﺎﺷﺪ‬B ‫ ﻭ‬A ‫ ﺍﻣﺘﺤﺎﻥ ﭘﺎﻳﺎﻧﻲ )ﺷﺎﻣﻞ ﺩﻭﺳﺮﻱ ﺍﻣﺘﺤﺎﻥ‬.٤ (‫ ﻓﻬﺮﺳﺖ ﺗﺼﺎﻭﻳﺮ )ﺗﺼﺎﻭﻳﺮ ﻓﺼﻞ ﺩﻭﻡ ﺍﻳﻦ ﻛﺘﺎﺏ ﺍﻟﻜﺘﺮﻭﻧﻴﻜﻲ ﺩﺭ ﺍﻳﻦ ﻗﺴﻤﺖ ﺑﺼﻮﺭﺕ ﻣﺠﺰﺍ ﺑﻪ ﻧﻤﺎﻳﺶ ﺩﺭﻣﻲﺁﻳﺪ‬.٢

‫ ﻗﻠﺐ‬-٥

CD ‫ﻋﻨﻮﺍﻥ‬ ‫ﺳﺎﻝ ﺍﻧﺘﺸﺎﺭ‬

2.4 A Slide Atlas of ATHEROSCLEROSIS Progression and Regression (Herbert C. Stary, MD) 2002
‫ ﻣﻄﺎﻟﻌﻪ ﺍﻳﻦ ﻧﺮﻡﺍﻓﺰﺍﺭ ﺑﻪ‬.‫ ﺍﺳﻼﻳﺪ ﺗﺨﺼﺼﻲ ﻣﺮﺍﺣﻞ ﻣﺨﺘﻠﻒ ﭘﻴﺸﺮﻓﺖ ﻭ ﭘﺴﺮﻓﺖ ﺑﻴﻤﺎﺭﻱ ﺁﺗﺮﻭﺍﺳﻜﻠﺮﻭﺯﻳﺲ ﺩﺭ ﺳﻨﻴﻦ ﻣﺨﺘﻠﻒ ﻭ ﻗﻠﺐ ﻭ ﻋﺮﻭﻕ ﻣﺨﺘﻠﻒ ﺑﺪﻥ ﺭﺍ ﺑﺎ ﺗﺼﺎﻭﻳﺮ ﻣﻴﻜﺮﻭﺳﻜﻮﭘﻲ ﻭ ﺍﻟﻜﺘﺮﻭﻧﻲ ﺑﻪ ﺯﻳﺒﺎﻳﻲ ﺑﻪ ﺗﺼﻮﻳﺮ ﻛﺸﻴﺪﻩ ﺍﺳﺖ‬٩٤ ‫ﺍﻳﻦ ﻧﺮﻡﺍﻓﺰﺍﺭ ﺑﺎ‬
.‫ﻣﺘﺨﺼﺼﻴﻦ ﭘﺎﺗﻮﻟﻮﮊﻱ ﻭ ﻗﻠﺐ ﻭ ﻋﺮﻭﻕ ﺗﻮﺻﻴﻪ ﻣﻲﺷﻮﺩ‬
1.5 A visible improvement in angina treatment (VCD)
‫ــــــ‬
Post-EECP stress perfusion image, Markedly improved anterior, septal, and inferior wall perfusion.
2.5 ACCSAP (Adult Clinical Cardiology Self-Assessment Program) (C. Richard Donti, MD, Richard P. Lewis, MD) (AMERICAN COLLEGE of CARDIOLOGY) 2000
3.5 Acute Heart Failure (THE CLEVELAND CLINIC FOUNDATION) (W. Frank Peacock, MD) (The Emergency Department and the Economics of Care) 2004
4.5 American Heart Associations fighting Heart Disease and Stroke Abstracts from Scientific Sessions (Augustus O. Grant, Raymond J. Gibbons) 2002
-Basic Science -Clinical Science -Population Science

٠٩١٢١٣٧٢٣٦١-٦٦٩٣٦٦٩٦ :‫ﺗﻠﻔﻦ‬ ٢٣٩ ‫ ﭘﻼﻙ‬،‫ ﺑﻦﺑﺴﺖ ﺳﻴﻤﻴﻦ‬،‫ ﺑﻴﻦ ﻛﺎﺭﮔﺮ ﻭ ﺟﻤﺎﻟﺰﺍﺩﻩ‬،‫ ﺥ ﻟﺒﺎﻓﻲﻧﮋﺍﺩ‬،‫ ﺥ ﻛﺎﺭﮔﺮ ﺟﻨﻮﺑﻲ‬،‫ ﻡ ﺍﻧﻘﻼﺏ‬،‫ ﺗﻬﺮﺍﻥ‬:‫ﻧﺸﺎﻧﻲ‬ ‫ ﺍﺭﺍﺋﻪ ﻛﻨﻨﺪﺓ ﻛﺘﺎﺏ ﻭ ﺳﻲﺩﻱﻫﺎﻱ ﺗﺨﺼﺼﻲ ﭘﺰﺷﻜﻲ‬: ‫ﻣﺮﻛﺰ ﺧﺪﻣﺎﺕ ﻓﺮﻫﻨﮕﻲ ﺳﺎﻟﻜﺎﻥ‬
 24
5.5 Atlas of Transesophageal Echocardiography (Navin C. Nanda, MD, Michael J. Domanski) (Williams & Wilkins) ‫ــــــ‬
1. Normal Anatomy 3. Mitral Valve 5. Aortic Valve and Aorta 7. Tricuspid and Pulmonary Valves
2. Prosthetic Valves and Rings 4. Ischemic Heart Disease 6. Cardiomyopathy 8. Congenital Heart Disease
6.5 BEYOND HEART SOUNDS The Interactive Cardic Exam (John Michael Criley, MD) (VOL 1) ‫ــــــ‬
Introduction to anscultation Hemodynamics tutorial The cardiac cycle Pulse Tutorial
Frontal Chest Anatomy Mitral and aortic valve flow Introduction
The Cardinal areas of anscultation Hemodynamic changes in disease Carotid Pulses
Using the stethoscope Mitral Stenosis Jugular Venous Pulses
Aortic stenosis
7.5 Cardiac Catheterization, Angiography, and Intervention (SIXTH EDITION) (LIPPINCOTT WILLIAMS & WILKINS) 2000
.‫ ﺩﻗﻴﻘﻪ ﻓﻴﻠﻢ ﺑﻮﺩﻩ ﻭ ﻛﻠﻴﻪ ﺗﺼﺎﻭﻳﺮ ﺑﻪ ﺻﻮﺭﺕ ﺭﻧﮕﻲ ﻣﻲﺑﺎﺷﺪ‬٣٥ ‫ ﻭ‬Grossmam's Cadiac Cathetrization ....... ‫ ﺷﺸﻢ ﻛﺘﺎﺏ‬edition ‫ ﺍﻟﻜﺘﺮﻭﻧﻴﻜﻲ ﺷﺎﻣﻞ‬CD ‫ﺍﻳﻦ‬
.‫ ﻣﻲﺑﺎﺷﺪ‬Procerdue- related Findinig ‫ ﺑﻴﻤﺎﺭﻱﻫﺎﻱ ﻗﻠﺒﻲ ﻭ ﻧﺮﻣﺎﻝ ﻫﻤﺮﺍﻩ ﺑﺎ‬Case50 ‫ﻭﺟﻪ ﻣﺸﺨﺼﻪ ﺍﻳﻦ ﻛﺘﺎﺏ ﺍﻟﻜﺘﺮﻭﻧﻴﻜﻲ ﻓﻴﻠﻢ ﻭﻳﺪﺋﻮﻳﻲ ﺷﺎﻣﻞ‬
.‫ ﻓﺼﻞ ﻣﻲﺑﺎﺷﺪ‬٨ ‫ﺍﻳﻦ ﻛﺘﺎﺏ ﺍﻟﻜﺘﺮﻭﻧﻴﻜﻲ ﺷﺎﻣﻞ‬
(.... ‫ ﻗﻠﺐ ﻭ ﻣﻘﺎﻭﻣﺖ ﻋﺮﻭﻕ ﻭ‬output ‫ ﻭ‬blood flow ‫ ﺍﻧﺪﺍﺯﻩﮔﻴﺮﻱ‬-‫ ﻣﻮﺍﺭﺩ ﻫﻤﻮﺩﻳﻨﺎﻣﻴﻚ )ﺍﻧﺪﺍﺯﻩﮔﻴﺮﻱ ﻓﺸﺎﺭ‬-٣ (‫ ﻛﺎﺗﺘﺮﺍﺯﻳﺴﻮﻥ ﺗﺸﺨﻴﺼﻲ ﺩﺭ ﻛﻮﺩﻛﺎﻥ ﻭ ﻧﻮﺯﺍﺩﺍﻥ‬-Brachiel Cutdown – Percutaneous approuch) Basic ‫ ﺗﻜﻨﻴﻚﻫﺎﻱ‬-٢ ‫ ﻣﻼﺣﻈﺎﺕ ﻛﻠﻲ ﻛﺎﺗﺘﺮﻳﺰﺍﺳﻴﻮﻥ‬-١
(... ‫ ﻭﻇﻴﻔﻪ ﺩﻳﺎﺳﺘﻮﻟﻲ ﻭ ﺳﻴﺴﺘﻮﻟﻲ ﺑﻄﻨﻲﻫﺎ ﻭ‬،Ejection Fraction ‫ ﻃﻲ ﻛﺎﺗﺘﺮﺍﺯﻳﺴﻴﻮﻥ ﻗﻠﺒﻲ ﺍﻧﺪﺍﺯﻩﮔﻴﺮﻱ ﺣﺠﻢ ﺑﻄﻦﻫﺎ‬Test ‫ ﺍﺭﺯﻳﺎﺑﻲ ﻓﺎﻧﻜﺸﻨﺎﻝ ﻗﻠﺒﻲ )ﺍﺳﺘﺮﺱ‬-٥ (‫ ﺁﻧﮋﻳﻮﮔﺮﺍﻓﻲ ﺁﺋﻮﺭﺕ ﻭ ﺷﺮﻳﺎﻧﻬﺎﻱ ﻣﺤﻴﻄﻲ‬-‫ ﺗﻜﻨﻴﻚﻫﺎﻱ ﺁﻧﮋﻳﻮﮔﺮﺍﻓﻲ ) ﺁﻧﮋﻳﻮﻛﺮﻭﻧﺮﻱ – ﻭﻧﺘﺮﻳﻜﻮﻟﻮﮔﺮﺍﻓﻲ ﻗﻠﺒﻲ – ﺁﻧﮋﻳﻮﮔﺮﺍﻓﻲ ﻭﭘﻮﻟﻤﻮﻧﺮﻱ‬-٤
‫ ﺗﻜﻨﻴـﻚﻫـﺎﻱ ﻣﺪﺍﺧﻠـﻪﺍﻱ )ﺁﻧﺘﮋﻳﻮﭘﻼﺳـﺘﻲ ﻋـﺮﻭﻕ‬-٧ (... ‫ ﻭ‬intrathoracic balloon Counter Pulsation - ‫ ﺑﺮﺍﻱ ﺩﺭﻣـﺎﻥ ﺁﺭﻳﺘﻴﻤـﻲﻫـﺎ‬deivce ‫ ﻗﺮﺍﺭ ﺩﺍﺩﻥ‬-‫ ﺍﻭﻟﺘﺮﺍﺳﻮﻧﻮﮔﺮﺍﻓﻲ ﺩﺍﺧﻞ ﻋﺮﻭﻗﻲ‬-‫ )ﺍﻛﻮﻛﺎﺭﺩﻳﺎﻝ ﺑﻴﻮﭘﺴﻲ‬: Special Catheter Techniquse -٦
– ‫ )ﻃـﺮﺯ ﺷﻨﺎﺳـﺎﻳﻲ ﻭ ﻛﺎﺗﺘﺮﻳﺰﺍﺳـﻴﻮﻥ ﻭ ﺁﻧﮋﻳـﻮﮔﺮﺍﻓﻲ ﺑﻴﻤـﺎﺭﻱﻫـﺎﻱ ﺩﺭﻳﭽـﻪﺍﻱ ﻗﻠـﺐ‬:‫ ﺩﺭ ﺍﺧـﺘﻼﻻﺕ ﺍﺧﺘﺼﺎﺻـﻲ‬Profile -٨ (‫ﮔﺬﺍﺭﻱ ﻋﺮﻭﻕ ﻛﺮﻭﻧﺮ – ﻣﺪﺍﺧﻠﻪ ﺩﺭ ﻋﺮﻭﻕ ﻣﺤﻴﻄﻲ ﻭ ﻋﺮﻭﻕ ﻛﻮﺩﻛﺎﻥ‬Stent- ‫ ﺁﺗﺮﻭﻛﺘﻮﻣﻲ ﻋﺮﻭﻕ ﻛﺮﻭﻧﺮﻱ ﻭ ﺗﺮﻭﻣﺒﻜﺘﻮﻣﻲ‬-‫ﻛﺮﻭﻧﺮﻱ‬
:‫( ﻓﻴﻠﻢﻫﺎﻱ ﻭﻳﺪﺋﻮﻳﻲ ﺷﺎﻣﻞ ﺁﻧﮋﻳﻮﮔﺮﺍﻓﻲ ﻛﺎﺗﺘﺮﻳﺰﺍﺳﻴﻮﻥ ﻭ ﺍﻗﺪﺍﻣﺎﺕ ﺩﺭﻣﺎﻧﻲ‬... ‫ ﺑﻴﻤﺎﺭﻱ ﺍﻣﺒﻮﻟﻲ ﺭﻳﻪ ﻭ‬-‫ﺑﻴﻤﺎﺭﻱﻫﺎﻱ ﺷﺮﺍﺋﻴﻦ ﻛﺮﻭﻧﺮﻱ‬
‫ ﺍﺧﺘﻼﻻﺕ ﻭﻧﺘﺮﻳﻜﻮﻟﻮﮔﺮﺍﻓﻲ ﺑﻄﻦ ﭼﭗ‬- ‫ ﻏﻴﺮ ﺁﺗﺮﻭﺳﻜﺮﻭﺗﻴﻚ‬CAD ‫ ﺁﻧﻮﻣﺎﻟﻴﻬﺎ ﻭ‬- Basic ‫ ﻛﺎﺗﺘﺮﻳﺰﺍﺳﻴﻮﻥ‬-
.‫( ﻣﻲﺑﺎﺷﺪ‬.... ‫ ﻭ‬Rotabalator ‫ ﺑﺎﻟﻮﻥﮔﺬﺍﺭﻱ ﻭ ﻭﺍﻟﻮﭘﻼﺳﺘﻲ‬-‫ ﻋﻮﺍﺭﺽ‬-‫ ﮔﺬﺍﺭﻱ‬Stent) ‫ ﻣﺪﺍﺧﻼﺕ ﺩﺭﻣﺎﻧﻲ ﺷﺎﻣﻞ‬- ‫ ﺍﺧﺘﻼﻻﺕ ﺁﺋﻮﺭﺕ ﻭ ﻋﺮﻭﻕ ﻣﺤﻴﻄﻲ‬-
8.5 Cardiovascular Surgery (VCD) (CD I, II, III) 2004
Excerpted from "Medical & Surgical Controversies in CV disease: The Aorta and Peripheral Vessels"
Course Directors: Thoralf M. Sundt III, MD and Peter C. Spittell, MD
9.5 Carotid Artery Stenting (Current Practice and Techniques) (Nadim Al-Mubarak, Gary S. Roubin, Sriram S. Layer, Jiri J. Vitek) 2004

10.5 CathSAP Cardiac Catheterization and Interventional Cardiology Self-Assessment Program (Carl J. Pepine, MD, Steven E. Nissen, MD) ‫ــــــ‬
11.5 Challenging established treatment patterns in chronic heart failure A Satellite Symposium held during the ESC Heart Failure meeting 2003

12.5 Clinical TRANSESOPHAGEAL ECHOCARDIOGRAPHY (A PROBLEM- ORIENTED APPROACH) (Second Edition) (Steven N. Konstadt) 2003

13.5 Clinical Utility of Contrast Echocardiography 2001

Sonovue: An ideal contrast agent for Low MI myocardial Perfusion (Dr. Daniela Bokor, Bracco sa, Milano)
What's new in cardic echography (Dr. Luciano Agati, University "La Sapienza Roma"
Ischemic coronary artery disease (Dr. Harld Becher, John Radcliffe Hospital, Oxford)
14.5 Congestive Heart Failure (NOVARTIS) (CD I , II) ‫ــــــ‬
‫ ﺍﺑﺘﺪﺍ ﭘﺰﺷﻚ ﺳﺆﺍﻻﺗﻲ ﺍﺯ ﺑﻴﻤﺎﺭ ﻣﻲﻛﻨﺪ ﻭ ﺑﻴﻤﺎﺭ‬Case report ‫ ﺩﺭ‬.‫ ﻓﻴﻠﻢ ﻭﻳﺪﺋﻮﻳﻲ ﻭ ﻓﺎﻳﻞ ﺻﻮﺗﻲ ﻣﻲﺑﺎﺷﺪ‬،Case report ،‫ ﺷﺎﻣﻞ ﻋﻜﺲﻫﺎﻱ ﺭﻧﮕﻲ‬CD ‫ ﺍﻳﻦ‬.‫ ﻣﻲﺑﺎﺷﺪ‬Frank .H.Netter ‫ ﻣﺆﻟﻒ ﻛﺘﺎﺏ‬.‫ ﺩﺭ ﻣﻮﺭﺩ ﻗﻠﺐ ﻣﻲﺑﺎﺷﺪ‬Ciba ‫ ﺷﺎﻣﻞ ﻛﺘﺎﺏ ﺍﻟﻜﺘﺮﻭﻧﻴﻜﻲ‬CD ‫ﺍﻳﻦ ﺩﻭ‬
.‫ ﻣﻲﺑﺎﺷﺪ‬CHF ‫ ﻭ ﺗﺸﺨﻴﺺ ﺍﻓﺘﺮﺍﻗﻲ ﺑﻴﻤﺎﺭﻱ‬multiple choice test ‫ ﺍﻳﻦ ﻛﺘﺎﺏ ﺷﺎﻣﻞ‬.‫ ﺳﭙﺲ ﻣﻌﺎﻳﻨﻪ ﻓﻴﺰﻳﻜﻲ ﺑﻴﻤﺎﺭ ﺗﻮﺳﻂ ﻓﻴﻠﻢ ﻧﺸﺎﻥ ﺩﺍﺩﻩ ﺷﺪﻩ ﺍﺳﺖ‬.‫ ﺍﻃﻼﻋﺎﺕ ﺑﻴﺸﺘﺮ ﺗﻮﺳﻂ ﻛﺎﺭﺑﺮ ﺑﺎ ﻛﻠﻴﻚ ﻛﺮﺩﻥ ﺑﺮ ﺭﻭﻱ ﺩﻛﻤﻪﻫﺎ ﺭﺍ ﻣﻲﺗﻮﺍﻥ ﺑﻪ ﺩﺳﺖ ﺁﻭﺭﺩ‬.‫ﺑﻪ ﺳﻮﺍﻻﺕ ﺟﻮﺍﺏ ﻣﻲﺩﻫﺪ‬
.‫ ﻣﻲﺑﺎﺷﺪ‬CHF ‫ ﻭ ﺩﺭﻣﺎﻥ‬management ،‫ ﺗﺸﺨﻴﺺ‬.٤ CHF ‫ ﭘﺎﺗﻮﻓﻴﺰﻳﻮﻟﻮﮊﻱ‬.٣ CHF‫ ﺍﺗﻴﻮﻟﻮﮊﻱ ﻭ ﺗﻌﺮﻳﻒ ﺑﻴﻤﺎﺭﻱ‬.٢ ‫ ﻋﻤﻠﻜﺮﺩ ﻧﺮﻣﺎﻝ ﻗﻠﺐ ﻭ ﺳﻴﺴﺘﻢ ﻋﺮﻭﻗﻲ‬.١ : ‫ﻓﺼﻮﻝ ﻛﺘﺎﺏ ﺷﺎﻣﻞ‬

٠٩١٢١٣٧٢٣٦١-٦٦٩٣٦٦٩٦ :‫ﺗﻠﻔﻦ‬ ٢٣٩ ‫ ﭘﻼﻙ‬،‫ ﺑﻦﺑﺴﺖ ﺳﻴﻤﻴﻦ‬،‫ ﺑﻴﻦ ﻛﺎﺭﮔﺮ ﻭ ﺟﻤﺎﻟﺰﺍﺩﻩ‬،‫ ﺥ ﻟﺒﺎﻓﻲﻧﮋﺍﺩ‬،‫ ﺥ ﻛﺎﺭﮔﺮ ﺟﻨﻮﺑﻲ‬،‫ ﻡ ﺍﻧﻘﻼﺏ‬،‫ ﺗﻬﺮﺍﻥ‬:‫ﻧﺸﺎﻧﻲ‬ ‫ ﺍﺭﺍﺋﻪ ﻛﻨﻨﺪﺓ ﻛﺘﺎﺏ ﻭ ﺳﻲﺩﻱﻫﺎﻱ ﺗﺨﺼﺼﻲ ﭘﺰﺷﻜﻲ‬: ‫ﻣﺮﻛﺰ ﺧﺪﻣﺎﺕ ﻓﺮﻫﻨﮕﻲ ﺳﺎﻟﻜﺎﻥ‬
 25
15.5 Coronary Heart Disease (J. Hurley Myers, Ph.D., Frank H. Netter, M.D.) ‫ــــــ‬
‫ ﺁﻣﻮﺯﺵ ﺑﺎﻟﻴﻨﻲ ﻭ ﺑﻴﻤﺎﺭﻱ‬-٢ ‫ ﺁﻣﻮﺯﺵ ﭘﺰﺷﻜﻲ‬-١ :‫ﺍﻳﻦ ﺑﺮﻧﺎﻣﻪ ﺷﺎﻣﻞ ﺩﻭ ﺑﺨﺶ ﻣﻲﺑﺎﺷﺪ‬
‫ ﺗﺸﺨﻴﺺ ﻭ ﻣﺪﻳﺮﻳﺖ ﺩﺭﻣﺎﻥ‬-٤ ‫ ﺍﻧﻔﺎﺭﻛﺘﻮﺱ ﻣﻴﻮﻛﺎﺭﺩ‬-٣ ‫ ﺁﺗﺮﻭﺍﺳﻜﻠﺮﻭﺯﻳﺲ‬-٢ ‫ ﺁﻧﺎﺗﻮﻣﻲ ﻋﺮﻭﻕ ﻛﺮﻭﻧﺮﻱ‬-١ :‫ﺑﺨﺶ ﺍﻭﻝ ﺷﺎﻣﻞ‬
.‫ ﻛﺎﺭﺑﺮ ﻣﻲﺗﻮﺍﻧﺪ ﻳﺎﺩﺩﺍﺷﺖ ﺷﺨﺼﻲ ﺧﻮﺩ ﺭﺍ ﺍﺿﺎﻓﻪ ﻭ ﺫﺧﻴﺮﻩ ﻧﻤﺎﻳﺪ‬،‫ ﺩﺭ ﻫﺮ ﻳﻚ ﺍﺯ ﺍﻳﻦ ﻣﻮﺿﻮﻋﺎﺕ‬.‫ﻫﺮ ﻳﻚ ﺍﺯ ﭼﻬﺎﺭﻓﺼﻞ ﻓﻮﻕ ﺩﺍﺭﺍﻱ ﭼﻨﺪﻳﻦ ﺯﻳﺮﻓﺼﻞ ﻣﻲﺑﺎﺷﺪ ﻛﻪ ﺑﺼﻮﺭﺕ ﺗﺼﺎﻭﻳﺮ ﻫﻤﺮﺍﻩ ﺑﺎ ﺗﻮﺿﻴﺤﺎﺕ ﻣﺘﻨﻲ ﻧﻤﺎﻳﺶ ﺩﺍﺩﻩ ﻣﻲﺷﻮﺩ‬
‫ ﺁﻧﮋﻳﻮﭘﻼﺳﺘﻲ ﻭ‬-٩ ‫ ﺩﺍﺭﻭ ﺩﺭﻣﺎﻧﻲ‬-٨ ‫ ﺭﻭﺷﻬﺎﻱ ﺗﺸﺨﻴﺼﻲ‬-٧ ‫ ﺍﻧﻔﺎﺭﻛﺘﻮﺱ ﻣﻴﻮﻛﺎﺭﺩ‬-٦ ‫ ﺁﻧﮋﻳﻦ ﺻﺪﺭﻱ‬-٥ ‫ ﭘﻴﮕﻴﺮﻱ ﺍﺯ ﺑﻴﻤﺎﺭﻱ ﺍﻧﺴﺪﺍﺩ ﻋﺮﻭﻕ ﻛﺮﻭﻧﺮ‬-٤ ‫ ﭼﮕﻮﻧﮕﻲ ﺍﻧﺴﺪﺍﺩ ﺳﺮﺧﺮﮔﻬﺎﻱ ﺍﻛﻠﻴﻠﻲ‬-٣ ‫ ﻋﺮﻭﻕ ﺧﻮﻧﻲ ﻗﻠﺐ‬-٢ ‫ ﻣﻘﺪﻣﻪ‬-١ ‫ ﻣﺒﺎﺣﺚ ﺍﺭﺍﺋﻪ ﺷﺪﻩ ﺷﺎﻣﻞ‬:‫ﺩﺭ ﺑﺨﺶ ﺩﻭﻡ‬
.‫ﻫﺮ ﻗﺴﻤﺖ ﺍﺯ ﻋﻨﺎﻭﻳﻦ ﻓﻮﻕ ﺗﻮﺳﻂ ﮔﻮﻳﻨﺪﻩ )ﺑﺎ ﭘﺨﺶ ﺻﺪﺍ( ﺗﻮﺿﻴﺢ ﺩﺍﺩﻩ ﺷﺪﻩ ﺍﺳﺖ‬ (‫ﻋﻤﻞ ﺟﺮﺍﺣﻲ )ﺍﻳﻦ ﺑﺨﺶ ﺩﺍﺭﺍﻱ ﻓﻴﻠﻤﻬﺎﻱ ﻛﻮﺗﺎﻩ ﺍﺯ ﺁﻧﮋﻳﻮﮔﺮﺍﻓﻲ ﻗﻠﺐ ﻣﻲﺑﺎﺷﺪ‬
16.5 Drugs for the Heart (Sixth Edition) (Salekan E-Book) (Lionel H. Opie, Bernard J. Gersh) 2005

17.5 Dynamic Practical Electrodiography (Lippincott Williams & Wilkins) ‫ــــــ‬

18.5 ECG (Jay W. Mason, MD) ‫ــــــ‬
19.5 ECG DIAGNOSIS MADE EASY ROMEO VEGHT ‫ــــــ‬
‫ ﻓﺼﻞ ﺍﻳﻦ ﻛﺘﺎﺏ ﺷﺎﻣﻞ ﻣـﻮﺍﺭﺩ‬٩ .‫ ﺗﻮﺍﻧﺎﻳﻲ ﺟﺴﺘﺠﻮﻱ ﻧﻤﻮﺩﺍﺭﻫﺎﻱ ﻭ ﭼﺎﭖ ﻭ ﺫﺧﻴﺮﺓ ﺁﻧﻬﺎ ﻧﻴﺰ ﻭﺟﻮﺩ ﺩﺍﺭﺩ‬.‫ ﮔﻮﻧﺎﮔﻮﻥ ﺍﺳﺖ‬ECG ‫ ﻋﺪﺩ ﻧﻤﻮﺩﺍﺭ‬٣٥٠ ‫ ﺩﺍﺭﺍﻱ‬.‫ ﺍﺟﺮﺍ ﻣﻲﺷﻮﺩ‬Internet explorer ‫ ﻓﺼﻞ ﺍﺳﺖ ﻭ ﺗﺤﺖ ﺑﺮﻧﺎﻣﺔ‬٩ ‫ﺍﻳﻦ ﺑﺮﻧﺎﻣﻪ ﺑﺼﻮﺭﺕ ﻳﻚ ﻛﺘﺎﺏ ﺍﻟﻜﺘﺮﻭﻧﻴﻜﻲ ﻣﺸﺘﻤﻞ ﺑﺮ‬
:‫ﺯﻳﺮ ﺍﺳﺖ‬
1. Basic Priciples (‫ ﻫﺪﺍﻳﺖ ﺟﺮﻳﺎﻥ ﺍﻟﻜﺘﺮﻳﻜﻲ‬، ‫ ﺩﭘﻮﻻﺭﻳﺰﺍﺳﻴﻮﻥ ﻋﻀﻠﻪ‬،‫ ﻣﻮﻗﻌﻴﺖ ﺍﻟﻜﺘﺮﻭﺩﻫﺎ‬،‫ﻧﺮﻣﺎﻝ‬ 3. ECG ‫ ﻭ ﻧﺤﻮﺓ ﺿﺒﻂ‬....) Ischaemic (Coronary) heart disease 5. Conductin impairment 7. Rhythm disturbances
2. Hypertrophy 6. Chardiomyopathies and autoimmune disorders 4. Pericarditis, myocarditis and metabolic disorders 6. Pacemakers, ICDs and cardioversion Mixed ECG quizzes

‫ ﺭﺍ ﻣﻲﺯﻧﻴﻢ ﻣﺴﻴﺮ ﻧﺼﺐ ﭘﺮﺳﻴﺪﻩ ﻣﻲﺷﻮﺩ ﺩﺭ ﺻﻮﺭﺕ ﺗﻮﺍﻓـﻖ‬Next ‫ ﺳﭙﺲ‬.‫ ﺭﺍ ﺍﺟﺮﺍ ﻣﻲﻛﻨﻴﻢ‬Setup ‫ ﻓﺎﻳﻞ‬.‫ ﻣﻲﺷﻮﻳﻢ‬Setup ‫ ﺷﺪﻩ ﻭ ﺍﺯ ﺁﻧﺠﺎ ﻭﺍﺭﺩ ﺷﺎﺧﻪ‬CD ‫ ﺑﻌﺪ ﻭﺍﺭﺩ ﺩﺭﺍﻳﻮ‬.‫ ﻣﻲﺷﻮﻳﻢ‬my computer ‫ ﺭﺍ ﺩﺭﻭﻥ ﺩﺭﺍﻳﻮ ﻗﺮﺍﺭ ﺩﺍﺩﻩ ﻭ ﺳﭙﺲ ﻭﺍﺭﺩ‬CD ‫ ﺍﺑﺘﺪﺍ‬:‫( ﻃﺮﻳﻘﺔ ﻧﺼﺐ‬
.‫ ﺭﺍ ﻓﺸﺎﺭ ﻣﻲﺩﻫﻴﻢ‬Finish ‫ ﺭﺍ ﻣﻲﺯﻧﻴﻢ ﺑﺮﻧﺎﻣﻪ ﻧﺼﺐ ﻣﻲﺷﻮﺩ ﺩﺭ ﭘﺎﻳﺎﻥ‬Next
20.5 ECG-SAP III (Jay W. Mason, MD, FACC) ‫ــــــ‬
-Using ECG-SAP III -Standard Tracings -Syndromes -Computer Overreads -Serial Tracings -Stress Testing -ECG of the Month -Guidelines -Utilities
21.5 Echo Lecture (VIDEO SERIES) (7CD) (Mayo) ‫ــــــ‬
:‫ ﺑﻪ ﺻﻮﺭﺕ ﻓﻴﻠﻢ ﻣﻲﺑﺎﺷﺪ ﺷﺮﺡ ﻋﻨﺎﻭﻳﻦ ﺁﻥ ﺑﻪ ﺻﻮﺭﺕ ﺯﻳﺮ ﺍﺳﺖ‬CD ‫ ﺳﺮﻱ‬٧ ‫ﺍﻳﻦ ﻣﺠﻤﻮﻋﻪ ﻛﻪ ﺷﺎﻣﻞ‬
1. TEE in the Operating Room (Bijoy K. Khandheria, MD)
Intraoperative echocardiography has become an essential component to the surgical approach to valvular disease. Dr. Bijoy Khandheria discusses the utility of intraoperative echocardiography and its
impact on the surgical management of cardiovascular disease.
2. TEE in Adult Congenital Heart Disease (James B. Seward, M.D.)
Dr. James Seward Presents Adult Congenital Heart Disease. A generation of Children Have Grown into adulthood and Present with postoperative congenital heart disease. Transesophageal
echocardiography is extremely helpful but may not always be necessary in the assessment of adult congenital heart disease. Learn from the expert regarding appropriate use of transesophageal
echocardiography and assessment of residua and sequela of adult congenital heart disease.
3. Understanding Operative Procedures for Patients with Univentricular Heart from Palliation to Fontan (James B. Seward, M.D.)
Dr. Seward gives a detailed overview of complex anomalies and their applicable corrections. Topics included are Blalock, Mustard, Glen and Fontan corrections. Graphic depictions of each corrective
procedure, possible complications and echocardiographic example are included.
4. Mitral Valve Regurgitation: Essential Measurements. Pitfalls and Limitations. (Fletcher A. Miller, Jr., MD)
Dr. Fletcher Miller discusses and presents the current approach to the quantitative evaluation of mitral valve regurgitation. This is an excellent review of current quantitative assessment of mitral valve
regurgitation including pitfalls and limitations.
5. Mitral Vale Regurgitation: Evidence-Based Practice (A. Jamil Tajik, MD)
A Classic presentation by Dr. A. Jamil Tajik on a change in clinical practice with regard to the quantitation of regurgitation and then a change in medical management with early surgery and repair of the mitral valve.
6. Evaluating the Patient with Prothetic Valve (Fletcher A. Miller, Jr., MD)
Dr. Fletcher Miller, an expert on the echocardiographic assessment of prosthetic valves, presents a detailed in-depth review of the quantitative echo Doppler approach to the prosthetic valve. It is
important to understand the hemodynamic pitfalls and limitations of the echocardiographic assessment of cardiac prosthetic valves.
7. Stress Echocardiography and Contrast (Patricia A. Pellikka, M.D.)
Stress Echocardiography and Contrast Using illustrative cases, Dr. Pellikka gives an expert presentation and discussion on the role of contrast in stress echocardiography. Pitfalls and limitations of contrast stress
echocardiography are also discussed. New Horizons in Stress Echocardiography Dr. Pellikka, an expert in Stress echocardiography, discusses Dobutamine stress echocardiography and its role in preoperative risk
stratification. Also discussed are new advances in stress echocardiography such as color kinesis and acoustic quantification, color Doppler imaging, and strain and strain rate imaging.

٠٩١٢١٣٧٢٣٦١-٦٦٩٣٦٦٩٦ :‫ﺗﻠﻔﻦ‬ ٢٣٩ ‫ ﭘﻼﻙ‬،‫ ﺑﻦﺑﺴﺖ ﺳﻴﻤﻴﻦ‬،‫ ﺑﻴﻦ ﻛﺎﺭﮔﺮ ﻭ ﺟﻤﺎﻟﺰﺍﺩﻩ‬،‫ ﺥ ﻟﺒﺎﻓﻲﻧﮋﺍﺩ‬،‫ ﺥ ﻛﺎﺭﮔﺮ ﺟﻨﻮﺑﻲ‬،‫ ﻡ ﺍﻧﻘﻼﺏ‬،‫ ﺗﻬﺮﺍﻥ‬:‫ﻧﺸﺎﻧﻲ‬ ‫ ﺍﺭﺍﺋﻪ ﻛﻨﻨﺪﺓ ﻛﺘﺎﺏ ﻭ ﺳﻲﺩﻱﻫﺎﻱ ﺗﺨﺼﺼﻲ ﭘﺰﺷﻜﻲ‬: ‫ﻣﺮﻛﺰ ﺧﺪﻣﺎﺕ ﻓﺮﻫﻨﮕﻲ ﺳﺎﻟﻜﺎﻥ‬
 26
22.5 ECHOCARDIOGRAPHY 2-D/DOPPLER WITH COLOR FLOW IMAGING (UPDATE NO. 1) (TRANSESOPHAGEAL- ECHOCARDIOGRAPHY) ‫ــــــ‬
23.5 ECHOCARDIOGRAPHY 2-D/DOPPLER WITH COLOR FLOW IMAGING (VOLUME 1) (VCD) (ECHOCARDIOGRAPHY Normal 2-D And M-MODE EXAM)) ‫ــــــ‬
24.5 ECHOCARDIOGRAPHY 2-D/DOPPLER WITH COLOR FLOW IMAGING (VOLUME 10) (VCD) (CARDIAC MASSES) ‫ــــــ‬
25.5 ECHOCARDIOGRAPHY 2-D/DOPPLER WITH COLOR FLOW IMAGING (VOLUME 11-A,B) (VCD CD I, ii) (ECHOCARDIOGRAPHIC ASSESSMENT OF PROSTHETIC HEART VALVES) ‫ــــــ‬
26.5 ECHOCARDIOGRAPHY 2-D/DOPPLER WITH COLOR FLOW IMAGING (VOLUME 12) (VCD) (INTERVENTIONAL ECHOCARDIOGRAPHY) ‫ــــــ‬
27.5 ECHOCARDIOGRAPHY 2-D/DOPPLER WITH COLOR FLOW IMAGING (VOLUME 2) (VCD) (DOPPLER AND COLOR FLOW IMAGING: PHYSICS, INSTRUMENTATIONS AND THE NORMAL EXAM) ‫ــــــ‬
28.5 ECHOCARDIOGRAPHY 2-D/DOPPLER WITH COLOR FLOW IMAGING (VOLUME 4) (VCD) (ECHOCARDIOGRAPHY IN AORTIC VAL VE DISEASE) ‫ــــــ‬
29.5 ECHOCARDIOGRAPHY 2-D/DOPPLER WITH COLOR FLOW IMAGING (VOLUME 5) (VCD) (ECHOCARDIOGRAPHY IN CORONARY HEART DISEASE) ‫ــــــ‬
30.5 ECHOCARDIOGRAPHY 2-D/DOPPLER WITH COLOR FLOW IMAGING (VOLUME 6) (VCD) (ECHOCARDIOGRAPHY IN CONGENITAL HEART DISEASE IN THE ADULT) ‫ــــــ‬
31.5 ECHOCARDIOGRAPHY 2-D/DOPPLER WITH COLOR FLOW IMAGING (VOLUME 7) (VCD) (ECHOCARDIOGRAPHY IN CARDIOMYOPATHIES: DILATED, RESTRICTIVE AND HYPERTROPHIC) ‫ــــــ‬
32.5 ECHOCARDIOGRAPHY 2-D/DOPPLER WITH COLOR FLOW IMAGING (VOLUME 8) (VCD) (ECHOCARDIOGRAPHY IN PERICARDIAL DISEASE) ‫ــــــ‬
33.5 ECHOCARDIOGRAPHY 2-D/DOPPLER WITH COLOR FLOW IMAGING (VOLUME 9) (VCD) (ECHOCARDIOGRAPHY IN TRICUSPID AND PULMONIC VALVE DISEASE AND DESEASES OF THE AORTA) ‫ــــــ‬
34.5 ECHOCARDIOGRAPHY 2-D/DOPPLER WITH COLOR FLOW IMAGING (VOLUME3) (VCD) (ECHOCARDIOGRAPHY IN MITRAL VALVE DISEASE) ‫ــــــ‬
35.5 EchoSAP III (Echocardiography Self-Assessment Program)(Echocardiography Overview: Technique and Applications) (Volume 1) 2000
(Jemes D. Thomas, MD, Ellen Mayer-Sabik, MD)
-Introduction and Overview -Examinations -Applications -Self-Assessment Questions -Evidence-Based Medicine -Conclusions
36.5 EECP: Current Experience and Future Directions ‫ــــــ‬
37.5 Electronic Image Collection of Comprehensive Vascular and Endovascular Surgery (John W. Hallet, Joseph L. Mills, Jonothan J. Eamsbaw, Jim A Reekers) 2004
1. Background 3. claudication 5. Chronic Lower Extremity Ischemia 7. Acute Limb Ischemia 9. Upper Extremity Problems
2. Mesenteric Syndromes 4. Renovascular disease 6. Aneurysmal Disease 8. Cerebrovascular Disease 10. Venous Disease
38.5 ENDOVASCULAR TECHNIQUES (Abdominal Aortic Aneurysms) (Workshop) (l. Flessenkämper) (15th Endovascular Symposium Berlin) ‫ــــــ‬

39.5 ESC Congress 2004

TM
40.5 EVOLVING ISSUES IN THE MANAGEMENT CHD (National Lipid Education Council ) 2002

SECTION 1 SECTION II SECTION III SECTION IV SECTION V

Emerging Evidence-Based Data From Clinical Trials PAD Lipids and Risk Inflammatory Markers: Anovel Approach Use of Genomics to discover new targets for therapy Case study: Diabetes
NON-HDL-Case Secondary Targert of Therapy Lipid Management Though combination Therapy Case Study: Novel Risk Markers Examining the nonlipid effects of statins
What is it's Role in clinical practice? Case Study:Combination Therapy
Case Study: NON-HDL-C
41.5 HEART DISEASE (FIFTH EDITION) A Textbook of Cardiovascular Medicine (W.B. SAUNDERS COMPANY) ‫ــــــ‬
.‫ ﻛﺘﺎﺏ ﻣﺠﺰﺍ ﺗﺸﻜﻴﻞ ﺷﺪﻩ ﺍﺳﺖ‬٤ ‫( ﺍﺯ‬e-book) ‫ﺩﺭ ﻭﺍﻗﻊ ﺍﻳﻦ ﻛﺘﺎﺏ ﺍﻟﻜﺘﺮﻭﻧﻴﻜﻲ‬
(Mendelsohn) Reviwe and Assessment Book -٤ (Hennekens) Clinical Trials in Cardiovascular Disease -٣ (chien) Molecular Basis of Heart Disase -٢ (Braunwald) Heart Disease -١
‫ )ﺟﺴﺘﺠﻮ( ﺑﺨﺼﻮﺹ ﺑﺮﺍﻱ ﻣﺘﺨﺼﺼﻴﻦ ﻭ ﺭﺯﻳﺪﻧﺖﻫﺎﻱ ﺭﺷﺘﻪﻫﺎﻱ ﻗﻠﺐ ﻭ‬Search ‫ ﻗﺎﺑﻠﻴﺖ‬CD ‫ ﺧﺼﻮﺻﻴﺖ ﻣﻨﺤﺼﺮ ﺑﻪ ﻓﺮﺩ ﺍﻳﻦ‬.‫ ﺳﻮﺍﻝ ﻭ ﺟﻮﺍﺏ ﻣﻲﺑﺎﺷﺪ‬٧٠٦ ‫ﺩﺭ ﺁﺧﺮ ﻫﺮ ﻓﺼﻞ ﺳﻮﺍﻻﺕ ﭼﻨﺪ ﮔﺰﻳﻨﻪﺍﻱ ﺑﺎ ﺟﻮﺍﺏ ﺗﺸﺮﻳﺤﻲ ﻭ ﺭﻓﺮﺍﻧﺲ ﻛﺘﺎﺏ ﺁﻭﺭﺩﻩ ﺷﺪﻩ ﻛﻪ ﻣﺸﺘﻤﻞ ﺑﺮ‬
‫( ﻫﻤﮕﻲ‬e-book) ‫ ﺷﻜﻞ ﻭ ﻧﻤﻮﺩﺍﺭﻫﺎﻱ ﺍﻳﻦ‬.‫ ﻣﻲﺗﻮﺍﻧﺪ ﺩﺭ ﺍﻣﺘﺤﺎﻧﺎﺕ ﺍﺭﺗﻘﺎﺀ ﻭ ﺑﻮﺭﺩ ﻭ ﺍﻣﺘﺤﺎﻧﺎﺕ ﺩﺭﻭﻥ ﺑﺨﺸﻲ ﻛﻤﻚ ﻗﺎﺑﻞ ﺗﻮﺟﻬﻲ ﻧﻤﺎﻳﺪ‬CD ‫ ﺳﺮﻳﻊ ﻭ ﻭﺳﻴﻊ ﺍﻳﻦ‬Search ‫ ﻫﻢﭼﻨﻴﻦ ﻗﺎﺑﻠﻴﺖ‬.‫ﺩﺍﺧﻠﻲ ﻣﻲﺑﺎﺷﺪ ﻛﻪ ﺩﺭ ﭘﻴﺪﺍ ﻛﺮﺩﻥ ﻣﻮﺿﻮﻋﻲ ﻳﺎ ﺣﺘﻲ ﻛﻠﻤﺎﺕ ﻛﻤﻚ ﺷﺎﻳﺎﻧﻲ ﻣﻲﻧﻤﺎﻳﺪ‬
.‫ ﺷﻮﺩ‬CCU ‫ﻫﺎ ﻣﻮﺭﺩ ﺍﺳﺘﻔﺎﺩﻩ ﺍﺳﺎﺗﻴﺪ ﻭ ﺭﺯﻳﺪﻧﺖﻫﺎ ﻭ ﻛﺎﺭﻛﻨﺎ ﻥ ﺑﺨﺶﻫﺎﻱ ﻗﻠﺐ ﻭ‬club ‫ﺭﻧﮕﻲ ﺍﺳﺖ ﻭ ﻣﻲﺗﻮﺍﻧﺪ ﺑﺮﺍﻱ ﺗﺪﺭﻳﺲ ﻭ ﻳﺎ ﻛﻨﻔﺮﺍﻧﺲ ﻭ‬
42.5 HEART SOUNDS ‫ــــــ‬
43.5 HEART SOUNDS Basic Cardiac Auscultation Version 3.0 (Leonard Werner, M.D., Brian Pitts, David Gilsdorf) 2003

٠٩١٢١٣٧٢٣٦١-٦٦٩٣٦٦٩٦ :‫ﺗﻠﻔﻦ‬ ٢٣٩ ‫ ﭘﻼﻙ‬،‫ ﺑﻦﺑﺴﺖ ﺳﻴﻤﻴﻦ‬،‫ ﺑﻴﻦ ﻛﺎﺭﮔﺮ ﻭ ﺟﻤﺎﻟﺰﺍﺩﻩ‬،‫ ﺥ ﻟﺒﺎﻓﻲﻧﮋﺍﺩ‬،‫ ﺥ ﻛﺎﺭﮔﺮ ﺟﻨﻮﺑﻲ‬،‫ ﻡ ﺍﻧﻘﻼﺏ‬،‫ ﺗﻬﺮﺍﻥ‬:‫ﻧﺸﺎﻧﻲ‬ ‫ ﺍﺭﺍﺋﻪ ﻛﻨﻨﺪﺓ ﻛﺘﺎﺏ ﻭ ﺳﻲﺩﻱﻫﺎﻱ ﺗﺨﺼﺼﻲ ﭘﺰﺷﻜﻲ‬: ‫ﻣﺮﻛﺰ ﺧﺪﻣﺎﺕ ﻓﺮﻫﻨﮕﻲ ﺳﺎﻟﻜﺎﻥ‬
 27
44.5 Heart Sounds Basic Cardiac Auscultation CD-ROM to Accompany (M.D., F.A/C.P., Brian Pitts, M.D., David Gilsdorf) (Lippincott Williams & Wilkins) 2003
45.5 Highlights ESC Congress 2004

46.5 HURST'S THE HEART (R. Wayne Alexander, Robert C. Schlant, Valentin Fuster) ‫ــــــ‬
.‫ ﺩﺍﺭﺩ‬CD‫ ﻓﺼﻠﻲ ﺟﺪﺍﮔﺎﻧﻪ ﺑﺮﺍﻱ ﺷﻜﻞﻫﺎ ﻭ ﻧﻤﻮﺩﺍﺭﻫﺎﻱ ﻛﺘﺎﺏ ﻭ ﻫﻢ ﭼﻨﻴﻦ ﻓﺼﻠﻲ ﺩﻳﮕﺮ ﺑﺮﺍﻱ ﺻﺪﺍﻫﺎﻱ ﻗﻠﺒﻲ ﺑﻪ ﺻﻮﺭﺕ ﻓﺎﻳﻞ ﺻﻮﺗﻲ‬،‫ ﻓﺼﻞ‬١٦ ‫ ﻣﺸﺘﻤﻞ ﺑﺮ‬Hurst ‫ ﻛﺘﺎﺏ‬Text ‫ ﻧﻬﻢ ﻣﻲﺑﺎﺷﺪ ﻛﻪ ﻋﻼﻭﻩ ﺑﺮ‬Edition ‫ﻛﺘﺎﺏ ﺍﻟﻜﺘﺮﻭﻧﻴﻜﻲ ﺣﺎﺿﺮ‬
.‫ ﺍﺳﺘﻔﺎﺩﻩ ﻛﺮﺩ‬،(‫ ﻋﻼﻭﻩ ﺑﺮ ﺍﺳﺘﻔﺎﺩﻩ ﺷﺨﺼﻲ ﻣﻲﺗﻮﺍﻥ ﺑﺮﺍﻱ ﺗﺪﺭﻳﺲ )ﺑﺨﺼﻮﺹ ﺍﺳﺘﻔﺎﺩﻩ ﺍﺯ ﺷﻜﻞﻫﺎﻱ ﺗﻤﺎﻡ ﺭﻧﮕﻲ ﺁﻥ‬CD ‫ ﺍﺯ ﺍﻳﻦ‬.‫ ﺗﺴﺖﻫﺎﻱ ﭼﻨﺪ ﮔﺰﻳﻨﻪﺍﻱ ﻣﺮﺑﻮﻁ ﺑﻪ ﻫﺮ ﻓﺼﻞ ﻫﻤﺮﺍ ﺑﺎ ﺟﻮﺍﺏ ﮔﻨﺠﺎﻧﺪﻩ ﺷﺪﻩ ﺍﺳﺖ‬CD‫ﺩﺭ ﺁﺧﺮﺍﻳﻦ‬
47.5 Interactive Atlas of Transesophageal Color Doppler Echocardiography (Raffaele De Simone) ‫ــــــ‬
48.5 Interactive Atlas of Transesophageal Color Doppler Echocardiography (Raffaele De Simone) ‫ــــــ‬
49.5 Interactive Echocardiography: A Clinical Atlas (Th. Binder, M.D., G. Rehak,G. Porenta. M.D., Ph.D., M. Zengeneh, M.D., G. Maurer, M.D., H. Baumgartner, M.D.) University of Vienna, Austria ‫ــــــ‬
50.5 Interventional Cardiology Clinical Resource (Disc 1 & 2) (Evidence . Analysis . Recommendations . Consensus Reports) 2003

51.5 Intra-Aortic Balloon Catheter Insertion and Removal Technique (ARROW)

2002
1. INTRODUCTION 2. LAB SELECTION 3. LAB PREPARATION 4. LAB INSERTION 5. LAB CATHETER PREPARATION 6. LAB CATHETER INSERTION 7. LAB REMOVAL :‫ ﺷﺎﻣﻞ‬CD ‫ﻋﻨﺎﻭﻳﻦ ﺍﻳﻦ‬

52.5 Manual of Cardiovascular Medicine (Second Edition) (Brian P. Griffin, Eric J. Topol) 2004

53.5 Mastering Auscultation An Audio Tour to Cardiac Diagnosis Clinical Findings Diagnosis Treatment Tutorial Text Reference (Dr. Anthony Don Michael's) ‫ــــــ‬
54.5 MVP Video Journal of Cardilogy (Maria-Teresa Olivari, M.D., Antonio M. Gotto, M.D., D. Phill.) ‫ــــــ‬
‫ ﺍﻳـﻦ‬.‫ ﻳﻚ ﻣﻮﺿﻮﻉ ﺑﻪ ﺷﻜﻞ ﻣﺼﺎﺣﺒﺔ ﻋﻠﻤﻲ ﺑﺎ ﻳﻚ ﻣﺘﺨﺼﺺ ﺑﻪ ﻫﻤﺮﺍﻩ ﻧﻤـﺎﻳﺶ ﺍﺳـﻼﻳﺪ ﻭ ﻧﻤـﻮﺩﺍﺭ ﺑﺤـﺚ ﺷـﺪﻩ ﺍﺳـﺖ‬،‫ ﺩﺭ ﻫﺮ ﻗﺴﻤﺖ‬.‫ ﺩﻗﻴﻘﻪ ﺩﺭ ﺳﻪ ﻗﺴﻤﺖ ﻣﺠﺰﺍ ﺍﺭﺍﺋﻪ ﺷﺪﻩ ﺍﺳﺖ‬٤٥ ‫( ﺑﻪﻣﺪﺕ‬VCD ‫ ﻣﻲﺑﺎﺷﺪ ﻛﻪ ﺑﻪ ﺻﻮﺭﺕ ﻳﻚ ﻓﻴﻠﻢ ﺁﻣﻮﺯﺷﻲ )ﺩﺭ ﻗﺎﻟﺐ‬MVP ‫ﻫﺎﻱ ﺁﻣﻮﺯﺷﻲ‬CD ‫ﺍﻳﻦ ﺑﺮﻧﺎﻣﻪ ﺍﺯ ﺳﺮﻱ‬
:‫ﻣﻮﺿﻮﻋﺎﺕ ﺑﻪ ﺷﺮﺡ ﺯﻳﺮ ﺍﺳﺖ‬
1-Determination of Rejection in the Cardiac transplant Recipient Maria-Teresa Olivari ‫ ﺩﻛﺘﺮ‬: ‫ﻣﺼﺎﺣﺒﻪ ﺷﻮﻧﺪﻩ‬
.‫ ﺭﻭﺷﻬﺎﻱ ﺍﻳﻤﻮﻧﻮﻟﻮﮊﻳﻜﻲ )ﺁﻧﺘﻲ ﻣﻴﻮﺯﻳﻦ( ﻭ ﺩﻳﮕﺮ ﺭﻭﺷﻬﺎﻱ ﻏﻴﺮﺗﻬﺎﺟﻤﻲ ﻫﻤﺮﺍﻩ ﺑﺎ ﻧﻤﺎﻳﺶ ﺍﺳﻼﻳﺪ ﺗﻮﺿﻴﺢ ﺩﺍﺩﻩ ﺷﺪﻩ ﺍﺳﺖ‬،MRI ،‫ ﺍﻛﻮﺩﺍﭘﻠﺮ‬،‫ﭘﻴﮕﻴﺮﻱ ﻭ ﺗﺸﺨﻴﺺ ﺭﺩ ﭘﻴﻮﻧﺪ ﻗﻠﺐ ﺑﻪ ﻛﻤﻚ ﺍﻛﻮﻛﺎﺭﺩﻳﻮﮔﺮﺍﻓﻲ‬
2- Triglycerides, HDL and coronary Heat Disease Antonio Gotto ‫ ﺩﻛﺘﺮ‬:‫ﻣﺼﺎﺣﺒﻪ ﺷﻮﻧﺪﻩ‬
.‫ ﻭ ﺭﻋﺎﻳﺖ ﺍﺻﻮﻝ ﺑﻬﺪﺍﺷﺘﻲ ﺩﺭ ﺯﻣﻴﻨﺔ ﻋﺎﺭﺿﺔ ﻋﺮﻭﻕ ﻛﺮﻭﻧﺮﻱ ﺍﺭﺍﺋﻪ ﺷﺪﻩ ﺍﺳﺖ‬،‫ ﺑﻴﻤﺎﺭﻱ ﺩﻳﺎﺑﺖ ﻭ ﺭﻭﺷﻬﺎﻱ ﺩﺍﺭﻭﺩﺭﻣﺎﻧﻲ‬.‫ﻛﻠﻴﺔ ﺭﻳﺴﻚ ﻓﺎﻛﺘﻮﺭﻫﺎ ﻭ ﻋﻮﺍﻣﻞ ﻣﺆﺛﺮ ﺑﺮ ﺁﻧﻬﺎ ﺩﺭ ﻋﺎﺭﺿﺔ ﺭﮔﻬﺎﻱ ﻛﺮﻭﻧﺮﻱ ﻗﻠﺐ ﺑﺤﺚ ﺷﺪﻩ ﺍﺳﺖ‬
3- Management of Cardiac Disease in Pregnancy Carl E. Orringer ‫ ﺩﻛﺘﺮ‬:‫ﻣﺼﺎﺣﺒﻪ ﺷﻮﻧﺪﻩ‬
‫ ﺍﻓﺰﺍﻳﺶ‬،‫ ﻛﺎﺭﺩﻳﻮﻣﻴﻮﭘﺎﺗﻲ ﺩﺭ ﺑﺎﺭﺩﺍﺭﻱ‬،‫ ﺩﺭﻣﺎﻥ ﺩﺍﺭﻭﻳﻲ ﺑﻴﻤﺎﺭﺍﻥ ﻗﻠﺒﻲ ﺑﺎﺭﺩﺍﺭ‬،... ‫ ﻭ‬MRI ،‫ ﺗﺸﺨﻴﺺ ﺑﻪ ﻛﻤﻚ ﺍﻛﻮﻛﺎﺭﺩﻳﻮﮔﺮﺍﻓﻲ ﺩﺍﭘﻠﺮ‬،‫ ﺳﻤﻊ ﻗﻠﺐ ﺩﺭ ﺑﻴﻤﺎﺭﺍﻥ ﻗﻠﺒﻲ ﺑﺎﺭﺩﺍﺭ‬،‫ ﺗﻨﻔﺴﻲ‬- ‫ ﻋﻼﺋﻢ ﻗﻠﺒﻲ‬،(... ‫ ﺍﻳﺴﺖ ﻗﻠﺒﻲ ﻭ‬،‫ ﺣﺠﻢ ﺿﺮﺑﻪﺍﻱ‬، ‫ ﻓﻴﺰﻳﻮﻟﻮﮊﻱ ﻗﻠﺐ ﺩﺭ ﺯﻣﺎﻥ ﺑﺎﺭﺩﺍﺭﻱ )ﺑﺮﻭﻥﺩﻩ ﻗﻠﺒﻲ‬،‫ﺩﺭ ﺍﻳﻦ ﺑﺨﺶ‬
.‫ ﻫﻤﺮﺍﻩ ﺑﺎ ﻧﻤﺎﻳﺶ ﺍﺳﻼﻳﺪ ﻭ ﻧﻤﻮﺩﺍﺭ ﺑﺤﺚ ﻭ ﺑﺮﺭﺳﻲ ﺷﺪﻩ ﺍﺳﺖ‬... ‫ﻓﺸﺎﺭ ﺧﻮﻥ ﺩﺭ ﺑﺎﺭﺩﺍﺭﻱ ﻭ‬
55.5 MVP Video Journal of Cardiology (Anthony C. Pearson, M.D., Charles B. Higgins, M.D., William W. O'Neill, M.D.) (VCD) ‫ــــــ‬
:‫ ﺍﻳﻦ ﻣﻮﺿﻮﻋﺎﺕ ﺑﻪ ﺷﺮﺡ ﺯﻳﺮ ﺍﺳﺖ‬.‫ ﺩﺭ ﻫﺮ ﻗﺴﻤﺖ ﻳﻚ ﻣﻮﺿﻮﻉ ﺑﻪ ﺷﻜﻞ ﻣﺼﺎﺣﺒﺔ ﻋﻠﻤﻲ ﺑﺎ ﻳﻚ ﻣﺘﺨﺼﺺ ﺑﻪ ﻫﻤﺮﺍﻩ ﻧﻤﺎﻳﺶ ﺍﺳﻼﻳﻪ ﻭ ﻓﻴﻠﻢ ﻭ ﻧﻤﻮﺩﺍﺭ ﺑﺤﺚ ﻭ ﺑﺮﺭﺳﻲ ﺷﺪﻩ ﺍﺳﺖ‬.‫ ﺩﻗﻴﻘﻪ ﺩﺭ ﺳﻪ ﻗﺴﻤﺖ ﺍﺭﺍﺋﻪ ﺷﺪﻩﺍﻧﺪ‬40 ‫ ﻣﻲﺑﺎﺷﺪ ﻛﻪ ﺑﻪ ﻣﺪﺕ‬MVP ‫ﻫﺎﻱ ﺁﻣﻮﺯﺷﻲ‬CD ‫ﺍﻳﻦ ﺑﺮﻧﺎﻣﻪ ﺍﺯ ﺳﺮﻱ‬
1- The stately Art of MR in Cardiovascuvlar Disease Charles P. Higgins ‫ ﺩﻛﺘﺮ‬:‫ﻣﺼﺎﺣﺒﻪ ﺷﻮﻧﺪﻩ‬
.‫ ﺑﺤﺚ ﺷﺪﻩ ﺍﺳﺖ‬.... ‫ ﻭ‬MRI ‫ ﺩﺭ ﺑﻴﻤﺎﺭﻳﻬﺎﻱ ﻗﻠﺒﻲ ﻋﺮﻭﻗﻲ ﺑﻪ ﻫﻤﺮﺍﻩ ﻧﻤﺎﻳﺶ ﺍﺳﻼﻳﺪ ﻭ ﺗﺼﺎﻭﻳﺮ‬MRI ‫ ﻛﺎﺭﺑﺮﺩ‬،‫ ﺭﻭﺵﻫﺎﻱ ﻣﺘﻌﺪﺩ ﺗﺼﻮﻳﺮﺑﺮﺩﺍﺭﻱ ﺩﺭ ﻛﺎﺭﺩﻳﻮﻟﻮﮊﻱ‬، MRI ‫ ﺗﺎﺭﻳﺨﭽﺔ‬،‫ﺩﺭ ﺍﻳﻦ ﺑﺨﺶ‬
2. Arguing for Angioplasy in Acute Myocardial infction William w. ONeill ‫ ﺩﻛﺘﺮ‬:‫ﻣﺼﺎﺣﺒﻪ ﺷﻮﻧﺪﻩ‬
‫ ﺑﺮﺁﻭﺭﺩ ﺩﻳﺴﻚ ﺁﻧﮋﻳﻮﭘﻼﺳﺘﻲ ﻭ ﺑﻪ ﻛﻤﻚ ﻧﻤﺎﻳﺶ ﺍﺳﻼﻳﺪ ﻭ ﻓﻴﻠﻢ‬، ‫ ﺍﻧﺪﻳﻜﺎﺳﻴﻮﻥ ﺍﻧﮋﻳﻮﭘﻼﺳﺘﻲ‬، Lone PTCA ‫ ﺭﻭﺵ ﺩﺭﻣﺎﻧﻲ‬،‫ﺗﺎﺭﻳﺨﭽﻪ ﺍﻧﮋﻳﻮﭘﻼﺳﺘﻲ‬
3- Improved understanding of cardioembolic Stroke prorided by Transesophageal Echoecardiography Anthony C. Pearson :‫ ﺩﻛﺘﺮ‬:‫ﻣﺼﺎﺣﺒﻪ ﺷﻮﻧﺪﻩ‬
.‫ ﻣﺨﺘﻠﻒ ﺑﺤﺚ ﻭ ﺑﺮﺭﺳﻲ ﺷﺪﻩ ﺍﺳﺖ‬Case ‫ ﺍﺯ ﭼﻨﺪﻳﻦ‬TEE ‫ ﺑﻪ ﻫﻤﺮﺍﻩ ﻧﻤﺎﻳﺶ ﻭ ﺗﻮﺿﻴﺢ ﺍﻛﻮﻛﺎﺭﺩﻳﻮﮔﺮﺍﻡ‬،TEE ‫ ﻭ‬TEE ‫ ﻣﻘﺎﻳﺴﻪ ﺭﻭﺵ‬،TEE ‫ ﺗﺎﺭﻳﺨﭽﻪ ﺗﻜﻨﻴﻚ‬،‫ﺗﺎﺭﻳﺨﭽﺔ ﺩﺭﻣﺎﻥ ﺁﻣﭙﻮﻟﻲﻫﺎ‬
56.5 MVP VIDEO JOURNAL OF CARDIOTHORACIC SURGERY (VIDEO SEGMENT I & II) Thromboexclusion for Treatment of Descending Aortic Dissection (John A. Elefteriades, MD) ‫ــــــ‬
57.5 Perioperative Transesophageal Echocardiography (Patricia M. Applegate, Richard L. Applegate, I) 2003
1. Basics of Echocardiography 2. Clinical TEE Examination 3. Clinical Uses of Perioperative TEE 4. Unknowns 5. Perioperative

٠٩١٢١٣٧٢٣٦١-٦٦٩٣٦٦٩٦ :‫ﺗﻠﻔﻦ‬ ٢٣٩ ‫ ﭘﻼﻙ‬،‫ ﺑﻦﺑﺴﺖ ﺳﻴﻤﻴﻦ‬،‫ ﺑﻴﻦ ﻛﺎﺭﮔﺮ ﻭ ﺟﻤﺎﻟﺰﺍﺩﻩ‬،‫ ﺥ ﻟﺒﺎﻓﻲﻧﮋﺍﺩ‬،‫ ﺥ ﻛﺎﺭﮔﺮ ﺟﻨﻮﺑﻲ‬،‫ ﻡ ﺍﻧﻘﻼﺏ‬،‫ ﺗﻬﺮﺍﻥ‬:‫ﻧﺸﺎﻧﻲ‬ ‫ ﺍﺭﺍﺋﻪ ﻛﻨﻨﺪﺓ ﻛﺘﺎﺏ ﻭ ﺳﻲﺩﻱﻫﺎﻱ ﺗﺨﺼﺼﻲ ﭘﺰﺷﻜﻲ‬: ‫ﻣﺮﻛﺰ ﺧﺪﻣﺎﺕ ﻓﺮﻫﻨﮕﻲ ﺳﺎﻟﻜﺎﻥ‬
 ‫‪28‬‬
‫‪58.5 Perioperative Transesophageal Echocardiography‬‬ ‫)‪(Patricia M. Applegate, M.D., Richard L. Applegate, II‬‬ ‫‪2003‬‬

‫)‪59.5 PLUMER'S PRINCIPLES & PRACTICE OF INTERAVENOUS THERAPY (SEVEN EDITION) (Sharon M. Weinstein‬‬ ‫ــــــ‬
‫)‪60.5 Practical Perioperative Transoesophageal Echocardiography Introduction, instructions and acknowledgements (David Sidebotham, John Faris, Alan Merry, Andrew Kerr‬‬ ‫‪2003‬‬

‫)‪61.5 TEE An Intractive Exam Review on CD-ROM (CD I , II) (Lippincott Williams & Wilkins‬‬ ‫‪2002‬‬
‫)‪62.5 TEXTBOOK OF CARDIOVASCULAR MEDICINE (2 Edition) (ERIC J. TOPOL‬‬
‫‪nd‬‬
‫ــــــ‬
‫‪ CD‬ﺣﺎﺿﺮ ﻳﻜﻲ ﺍﺯ ﺑﻬﺘﺮﻳﻦ ﻛﺘﺎﺏﻫﺎﻱ ﺍﻟﻜﺘﺮﻭﻧﻴﻜﻲ ﺍﺳﺖ ﻛﻪ ﻋﻼﻭﻩ ﺑﺮ ‪ Text‬ﺩﺍﺭﺍﻱ ﻗﺎﺑﻠﻴﺖﻫﺎﻱ ﻓﻴﻠﻢ ‪ ،‬ﻋﻜﺲ ﻭ ﻓﺎﻳﻞﻫﺎﻱ ﺻﻮﺗﻲ ﺩﺭ ﻣﻮﺭﺩ ﺑﻴﻤﺎﺭﻱﻫﺎﻱ ﻗﻠﺐ ﻣﻲﺑﺎﺷﺪ‪ .‬ﺍﻳﻦ ‪ CD‬ﺷﺎﻣﻞ ﻛﺘﺎﺏ ﺩﻭ ﺟﻠـﺪﻱ ‪ Text book of Cardiovascular Medicine‬ﺍﺳـﺖ ﻛـﻪ‬
‫ﻭﺟﻮﺩ ﺻﺪﻫﺎ ﻋﻜﺲ ﻭ ﻛﻠﻴﭗ ﻭﻳﺪﺋﻮﺋﻲ ﻛﺘﺎﺏ ﺭﺍ ﺑﻪ ﺻﻮﺭﺕ ﻳﻚ ﻣﺠﻤﻮﻋﺔ ﺯﻧﺪﻩ ﺩﺭ ﺁﻭﺭﺩﻩ ﺍﺳﺖ‪) .‬ﺑﻪ ﻋﻨﻮﺍﻥ ﻣﺜﺎﻝ ﺩﺭ ﻣﻮﺭﺩ ﺗﻨﮕﻲ ﺩﺭﻳﭽﻪ ﻣﻴﺘﺮﺍﻝ ﺩﺭ ﺑﺨﺶ ﻣﺮﺑﻮﻃﻪ ﻋﻼﻭﻩ ﺑﺮ ﻣﺘﻦ ﻋﻜﺲﻫﺎﻱ ﺭﻧﮕﻲ ﺩﺭ ﺿﺎﻳﻌﻪ‪ ،‬ﺗﺼﻮﻳﺮﺑﺮﺩﺍﺭﻱﻫﺎ )ﺍﻛﻮ‪ (...‬ﻭ ﻓﺎﻳﻞﻫﺎﻱ ﺻﻮﺗﻲ‪ ،‬ﺻﺪﺍﻱ ‪ ECG,M.S‬ﻭ‬
‫ﻛﺎﺗﺘﺮﻳﺰﺍﺳﻴﻮﻥ ﺁﻥ ﺑﻪ ﺻﻮﺭﺕ ﻭﻳﺪﺋﻮﻛﻠﻴﭗ ﻧﺸﺎﻥ ﺩﺍﺩﻩ ﺷﺪﻩ ﺍﺳﺖ‪ .‬ﻣﺒﺎﺣﺚ ﻛﺘﺎﺏ ﺷﺎﻣﻞ ‪:‬‬
‫‪ -١‬ﺗﺎﺭﻳﺨﭽﻪ ﻋﻠﻢ ﻛﺎﺭﺩﻳﻮﻟﻮﮊﻱ ‪ -٢‬ﻛﺎﺭﺩﻳﻮﻟﻮﮊﻱ ﭘﻴﺸﮕﻴﺮﻱ )ﺷﺎﻣﻞ‪ :‬ﺑﻴﻮﻟﻮﮊﻱ ﺍﺗﺮﻭﺳﻜﻠﺮﻭﺯ‪ ،‬ﺭﮊﻳﻢ ﻏﺬﺍﻳﻲ ﻭ ﭼﺎﻗﻲ ﻭ ﺍﺧﺘﻼﻻﺕ ﭼﺮﺑﻲ‪ ،‬ﻭﺭﺯﺵ‪ ،‬ﻓﺸﺎﺭ ﺧﻮﻥ ﻭ ﭘﺎﺗﻮﻓﻴﺰﻳﻮﻟﻮﮊﻱ ﺁﻥ‪ ،‬ﺳﻴﮕﺎﺭ ﻛﺸﻴﺪﻥ‪ ،‬ﺩﻳﺎﺑﺖ ‪ ،‬ﺍﺳﺘﺮﻭﮊﻥ‪ ،‬ﺟﻨﺲ ﺯﻥ ﻭ ﺑﻴﻤﺎﺭﻱﻫﺎﻱ ﻗﻠﺒﻲ ‪ ،‬ﺍﺗﺎﻧﻮﻝ ﻭ ﻗﻠﺐ‪ ،‬ﺭﻓﺘﺎﺭ‬
‫ﻭ ﺷﺨﺼﻴﺖ ﺑﻴﻤﺎﺭﺍﻥ ﻗﻠﺒﻲ‪ ،‬ﻧﻮﺗﻮﺍﻧﻲ ﺑﻴﻤﺎﺭﻱﻫﺎﻱ ﻗﻠﺒﻲ( ‪ -٣‬ﻛﺎﺭﺩﻳﻮﻟﻮﮊﻱ ﺑﺎﻟﻴﻨﻲ‪) :‬ﺷﺎﻣﻞ ﺗﺎﺭﻳﺨﭽﻪ‪ ،‬ﻣﻌﺎﻳﻨﺎﺕ ﺑﺎﻟﻴﻨﻲ ‪ ،‬ﻭ ﺑﻴﻤﺎﺭﻱﻫﺎﻱ ﺍﻳﺴﻜﻤﻲ‪ ،‬ﺩﺭﻳﭽﻪﺍﻱ ‪ ،‬ﻋﻔﻮﻧﻲ ‪ ،‬ﻣﺎﺩﺭﺯﺍﺩﻱ ‪ ،‬ﺗﻮﻣﻮﺭﺍﻝ ﻗﻠﺐ ﻭ ﭘﺮﺩﻩﻫﺎﻱ ﺁﻥ ﻣﻲﺑﺎﺷﺪ ﻫﻢ ﭼﻨﻴﻦ ﺷﺎﻣﻞ ﻗﻠﺐ ﻭ ﺣﺎﻣﻠﮕﻲ‪ ،‬ﭘﻴﺮﻱ ‪ ،‬ﻛﻠﻴﻪ‪ ،‬ﻭﺭﺯﺵ ﻭ ﺗﺮﻭﻣـﺎ ﻣـﻲﺑﺎﺷـﺪ‪-(.‬‬
‫ﻣﺸﺎﻭﺭﻩ ﻧﻮﻳﺴﻲ ‪ -‬ﺩﺍﺭﻭﻫﺎﻱ ﻗﻠﺒﻲ ‪ -‬ﺍﺷﺘﺒﺎﻫﺎﺕ ﭘﺰﺷﻜﻲ ‪ -٤‬ﺗﺼﻮﻳﺮﺑﺮﺩﺍﺭﻱ ﻗﻠﺒﻲ‪ :‬ﺷﺎﻣﻞ ﻋﻜﺲ ﻭ ﻓﺎﻳﻞ ﺻﻮﺗﻲ ﻭ ﻭﻳﺪﺋﻮ ﻛﻠﻴﭗ‪) :‬ﺗﻔﺴـﻴﺮ ﻋﻜـﺲ ﺳـﺎﺩﻩ ﺭﻳـﻪ – ‪ ECG‬ﺩﺭ ﺣـﻴﻦ ﻭﺭﺯﺵ – ﺍﻛﻮﻛـﺎﺭﺩﻳﻮﮔﺮﺍﻓﻲ ‪ – transthoracic‬ﺍﺳـﺘﺮﺱ ﺍﻛﻮﻛـﺎﺭﺩﻳﻮﮔﺮﺍﻓﻲ – ﺍﺭﺯﻳـﺎﺑﻲ ﺑـﺎ ﺩﺍﭘﻠـﺮ ‪-‬‬
‫ﺍﻛﻮﻛﺎﺭﺩﻳﻮﮔﺮﺍﻓﻲ ‪ -transesophageal‬ﺗﻜﻨﻴﻚﻫﺎﻱ ﺗﺼﻮﻳﺮﺑﺮﺩﺍﺭﻱ ﻫﺴﺘﻪﺍﻱ – ‪ CT, PET , MRI‬ﻗﻠﺐ – ﺍﻛﻮﻛﺎﺭﺩﻳﻮﮔﺮﺍﻓﻲ ‪ -٥ .( intraoperative‬ﺍﻟﻜﺘﺮﻭ ﻓﻴﺰﻳﻮﻟﻮﮊﻱ ﻭ ‪ Pacing‬ﺷﺎﻣﻞ ‪) :‬ﻣﻜﺎﻧﻴﺴﻢ ﻭ ﻓﻴﺰﻳﻮﻟﻮﮊﻱ ﺁﺭﻳﺘﻤـﻲﻫـﺎ‪ ،‬ﺗﺴـﺖﻫـﺎﻱ ﺍﻟﻜﺘﺮﻭﻓﻴﺰﻭﻟـﻮﮊﻱ‪ECG‬‬
‫ﺿﺎﻳﻌﺎﺕ ﻗﻠﺒﻲ ﺍﻳﺴﻜﻤﻴﻚ ﻭ ﻏﻴﺮﺍﻳﺴﻜﻤﻴﻚ‪ ،‬ﻃﺮﺯ ﮔﺬﺍﺷﺘﻦ ‪ Pacemaker‬ﻭ ﻓﻴﺒﺮﻳﻠﻴﺘﻮﺭﻫﺎ( ‪ -٦‬ﻛﺎﺭﺩﻳﻮﻟﻮﮊﻱ ‪ invasive‬ﻭ ﺗﻜﻨﻴﻚﻫﺎﻱ ﺟﺮﺍﺣﻲ‪ :‬ﺷﺎﻣﻞ ﻋﻜـﺲ ﻭ ﻓـﻴﻠﻢ )ﺁﻧﮋﻳـﻮﮔﺮﺍﻓﻲ ﻛﺮﻭﻧـﺮﻱ‪ -‬ﻛﺎﺗﺘﺮﻳﺰﺍﺳـﻴﻮﻥ ﻗﻠﺒـﻲ ‪ Procedures ،Percutaneos ،‬ﺑـﺎﻱﭘـﺲ ﻗﻠـﺐ–‬
‫‪ -٨‬ﻛـﺎﺭﺩﻳﻮﻟﻮﮊﻱ ﻣﻠﻜـﻮﻟﻲ‬ ‫‪ Restenosis‬ﺍﭘﻴﺪﻣﻴﻮﻟﻮﮊﻱ ﻭ ﺩﺭﻣﺎﻥ– ‪ approach‬ﺑﻪ ﺑﻴﻤﺎﺭﺍﻥ ﻛﻪ ﻗﺒ ﹰ‬
‫ﻼ ﺑﺎﻱﭘﺲ ﺷﺪﻩﺍﻧﺪ – ﺍﻭﻟﺘﺮﺍﺳﻮﻧﻮﮔﺮﺍﻓﻲ ﺩﺍﺧﻞ ﻋﺮﻭﻗﻲ ﻭ ﺁﻧﮋﻳﻮﺳﻜﻮﭘﻲ ﻭ ﺍﻟﻮﻟﻮﭘﻼﺳﺘﻲ ‪ ،‬ﻃﺮﺯ ﻛﺎﺗﺘﺮﻳﺰﺍﺳﻴﻮﻥ ﺩﺭ ﺑﻴﻤﺎﺭﻱﻫﺎﻱ ﻣﺎﺩﺭﺯﺍﺩﻱ ﻗﻠﺒﻲ( ‪ -٧‬ﻧﺎﺭﺳﺎﻳﻲ ﻗﻠﺐ ﻭ ﭘﻴﻮﻧﺪ ﻗﻠﺐ‬
‫‪ :Multimedia -١٠‬ﺷﺎﻣﻞ ﻋﻜﺲ ﻭ ﺻﺪﺍﻫﺎﻱ ﻗﻠﺒﻲ )ﻧﺮﻣﺎﻝ ﻭ ﺍﺑﻨﺮﻣﺎﻝ( ﻭ ﻛﻠﻴﭗﻫﺎﻱ ﻭﻳﺪﻳﻮﺋﻲ‪.‬‬ ‫‪ -٩‬ﻭﺍﺳﻜﻮﻟﺮ ﺑﻴﻮﻟﻮﮊﻱ‬
‫ﺻﺪﺍﻫﺎﻱ ﻗﻠﺒﻲ‪ :‬ﻧﺮﻣﺎﻝ ﻭ ﺍﺑﻨﺮﻣﺎﻝ‬ ‫ﻋﻜﺲ‪ :‬ﻛﺎﺗﺘﺮﻳﺰﺍﺳﻴﻮﻥ – ‪ - CT/MRI‬ﺍﻛﻮﻛﺎﺭﺩﻳﻮﮔﺮﺍﻓﻲ – ‪ - ECG‬ﺍﻭﻟﺘﺮﺍﺳﻮﻧﻮﮔﺮﺍﻓﻲ ‪ – intravascular‬ﻧﻮﻛﻠﺌﺎﺭ – ﭘﺎﺗﻮﻟﻮﮊﻱ – ﻣﻌﺎﻳﻨﺎﺕ ﺑﺎﻟﻴﻨﻲ – ﺟﺮﺍﺣﻲ‪ -‬ﭼﺸﻢ ﻭ ﺑﻴﻤﺎﺭﻱﻫﺎﻱ ﻗﻠﺒﻲ ﻋﺮﻭﻗﻲ‪.‬‬
‫ﺷﺎﻣﻞ‪:‬‬ ‫ﻓﺼﻞﻫﺎﻱ ﺟﺪﻳﺪ ﻛﺘﺎﺏ ﻧﺴﺒﺖ ﺑﻪ ﻭﻳﺮﺍﻳﺶ ﻗﺒﻠﻲ ﻛﺘﺎﺏ ﻭ ‪CD‬‬ ‫ﻭﻳﺪﺋﻮﻛﻠﻴﭗ‪ :‬ﻛﺎﺗﺘﺮﻳﺰﺍﺳﻴﻮﻥ – ‪ – CT/MRI‬ﺍﻛﻮﻛﺎﺭﺩﻳﻮﮔﺮﺍﻓﻲ – ﺍﻟﻜﺘﺮﻭﻓﻴﺰﻳﻮﻟﻮﮊﻱ ﻭ ‪ Pacing‬ﻭ ﺍﻭﻟﺘﺮﺍﺳﻮﻧﻮﮔﺮﺍﻓﻲ ﺩﺍﺧﻞ ﻋﺮﻭﻗﻲ – ﺗﺼﺎﻭﻳﺮ ﻫﺴﺘﻪﺍﻱ – ﺟﺮﺍﺣﻲ‪.‬‬

‫‪ ، Percutaneous Coronaryintervantion‬ﻣﻼﺣﻈﺎﺕ ﺟﺮﺍﺣﻲ ﺩﺭ ﺩﺭﻣﺎﻥ ﻧﺎﺭﺳﺎﺋﻲ ﻗﻠﺐ‪ ،‬ﮊﻥﺗﺮﺍﭘﻲ ﻭ ﭘﻴﺸﺮﻓﺖﻫﺎﻱ ﻣﻠﻜﻮﻟﻲ ﺩﺭ ﻣﻮﺭﺩ ﻗﻠﺐ‬ ‫‪.‬‬ ‫‪ ،Endof-Life Care‬ﻗﻠﺐ ﻭﺭﺯﺷﻜﺎﺭﺍﻥ ‪ ،‬ﺍﺭﺯﻳﺎﺑﻲ ﺑﺎﻟﻴﻨﻲ‪ ،‬ﺳﻴﺴﺘﻢ ﻋﺼﺒﻲ ﺍﺗﻮﻧﻮﻡ‪،‬‬ ‫•‬

‫( ﻃﺮﻳﻘﻪ ﻧﺼﺐ ‪ : TEXTBOOK OF CARDIOVASCULAR MEDICINE‬ﺑﺮﺍﻱ ﻧﺼﺐ ﺑﺮﻧﺎﻣﺔ ‪ Cardiovascular Medicine‬ﺍﺑﺘﺪﺍ ‪ CD‬ﺭﺍ ﺩﺭﻭﻥ ﺩﺭﺍﻳﻮ ﻗﺮﺍﺭ ﺩﺍﺩﻩ ﻭ ﺩﺭ ﭘﻨﺠﺮﻩ ﺍﻱ ﻛﻪ ﺑﺎ ﻋﻨﻮﺍﻥ ‪ Flash‬ﺑﺎﺯ ﺷﺪﻩ ﺑﺮ ﺭﻭﻱ ﻛـﺎﺩﺭ ﺳـﻤﺖ ﭼـﭗ ﺗﺼـﻮﻳﺮ‪،‬‬
‫ﮔﺰﻳﻨﺔ ‪ Install TOPOL‬ﺭﺍ ﺍﻧﺘﺨﺎﺏ ﻛﺮﺩﻩ ﺳﭙﺲ ﭘﻨﺠﺮﺓ ﻣﺤﺎﻭﺭﻩﺍﻱ ﺩﻳﮕﺮﻱ ﺑﺎﺯ ﻣﻲﺷﻮﺩ )ﺣﺪﻭﺩﹰﺍ ‪ ٣٠-٤٠‬ﺛﺎﻧﻴﻪ ﺑﻌﺪ( ﻭ ﻣﺴﻴﺮ ﻧﺼﺐ ﺑﺮﻧﺎﻣﻪ ﺭﺍ ﻣﺸﺨﺺ ﻣﻲﻛﻨﺪ‪ .‬ﺍﻳﻦ ﻣﺴﻴﺮ ﺑﺼﻮﺭﺕ ﭘﻴﺶ ﻓﺮﺽ ‪ C:\Program files\CardioVascularMedicine‬ﺍﺳﺖ ﺩﺭ ﻗﺴـﻤﺖ ﭘـﺎﻳﻴﻦ‬
‫ﺑﺮﺭﻭﻱ ﺩﻛﻤﺔ ‪ Install‬ﻛﻠﻴﻚ ﻛﻨﻴﺪ )ﺍﮔﺮ ﺧﻮﺍﺳﺘﻴﺪ ﻣﺴﻴﺮ ﻓﻮﻕ ﺭﺍ ﺑﻪ ﺩﻟﺨﻮﺍﻩ ﻣﻲﺗﻮﺍﻧﻴﺪ ﺗﻐﻴﻴﺮ ﺩﻫﻴﺪ( ﭘﺲ ﺍﺯ ﻛﻠﻴﻚ ﺑﺮﺭﻭﻱ ‪ Install‬ﭘﻨﺠﺮﺓ ﺩﻳﮕﺮﻱ ﺑﺎﺯ ﻣﻲﺷﻮﺩ ﻭ ﺑﺮﻧﺎﻣﻪ ﺧﻮﺩﺑﺨﻮﺩ ﻧﺼﺐ ﻣﻲ ﺷﻮﺩ ﭘﺲ ﺍﺯ ﺣﺪﻭﺩ ‪ ٢٠‬ﺛﺎﻧﻴﻪ ﭘﻨﺠﺮﺓ ﺁﺧﺮ ﺑﻨـﺎﻡ ‪ Install complete‬ﻣـﻲ ﺁﻳـﺪ ﺑـﺮﺭﻭﻱ‬
‫ﺩﻛﻤﺔ ‪ Done‬ﺩﺭ ﺍﻧﺘﻬﺎ ﻛﻠﻴﻚ ﻛﻨﻴﺪ‪ .‬ﭘﺲ ﺍﺯ ﺁﻧﻜﻪ ﻣﺮﺍﺣﻞ ﻓﻮﻕ ﺍﻧﺠﺎﻡ ﭘﺬﻳﺮﻓﺖ ﺑﺮﻧﺎﻣﻪ ﻧﺼﺐ ﺷﺪﻩ ﺍﺳﺖ ﻭﻟﻲ ﺑﺮﺍﻱ ﺍﺟﺮﺍﻱ ﺁﻥ ﻧﻴﺎﺯ ﺍﺳﺖ ﺩﻭ ﺑﺮﻧﺎﻣﺔ ﻛﻤﻜﻲ ﺩﻳﮕﺮ ﻧﻴﺰ ﺑﺮ ﺭﻭﻱ ﺳﻴﺴﺘﻢ ﻋﺎﻣﻞ ﻧﺼﺐ ﺷﻮﺩ ﻛﻪ ﻋﺒﺎﺭﺗﻨﺪ ﺍﺯ‪ .Quick Time, Internet Explorer :‬ﺑﺮﺍﻱ ﻧﺼـﺐ ﺍﻳـﻦ‬
‫ﺑﺮﻧﺎﻣﻪ ﺍﺯ ﺍﻳﻨﺘﺮﻧﺖ ﺍﻛﺴﭙﻠﻮﺭﺭ ﺑﺎﻭﺭﮊﻥ ‪ 5.5‬ﺑﻪ ﺑﺎﻻ ﻣﻲﺗﻮﺍﻥ ﺍﺳﺘﻔﺎﺩﻩ ﻛﺮﺩ‪ .‬ﺿﻤﻨﹰﺎ ﺳﻴﺴﺘﻢ ﻋﺎﻣﻠﻬﺎﻱ ﭘﻴﺸﻨﻬﺎﺩﻱ ﺑﺮﺍﻱ ﺍﻳﻦ ﺑﺮﻧﺎﻣﻪ ﻭﻳﻨﺪﻭﺯﻫﺎﻱ ‪ 2000, NT, ME, 98, 95‬ﺍﺳﺖ ﻳﺎ ‪ 200 MHZ‬ﭘﺮﺩﺍﺯﺷﮕﺮ ﻭ ﺣﺪﺍﻗﻞ ‪ 32‬ﻣﮕﺎﺑﺎﻳﺖ ﺣﺎﻓﻈﻪ‪.‬‬
‫ﺩﺭ ﭘﻨﺠﺮﻩ ﺍﻱ ﻛﻪ ﭘﻴﺶ ﺭﻭﺩﺍﺭﻳﺪ )ﺍﻭﻟﻴﻦ ﭘﻨﺠﺮﻩ ﻫﻨﮕﺎﻡ ﻗﺮﺍﺭﺩﺍﺩﻥ ‪ (CD‬ﮔﺰﻳﻨﺔ ‪ Internet Explore 5.5‬ﺭﺍ ﻛﻠﻴﻚ ﻛﻨﻴﺪ‪ .‬ﺩﺭ ﭘﻨﺠﺮﻩ ﺍﻱ ﻛﻪ ﭘﻴﺶ ﺭﻭﻱ ﺷﻤﺎ ﺑﺎﺯ ﻣﻲ ﺷﻮﺩ ﺩﺭ ﻗﺴﻤﺖ ‪ I accept the agreement‬ﻛﻠﻴﻚ ﻛﻨﻴﺪ ﻭ ﺩﻛﻤﺔ ‪ Next‬ﺍﺯ ﭘﺎﺋﻴﻦ ﺭﺍ ﻓﺸﺎﺭ ﺩﻫﻴﺪ‪.‬‬
‫ﺑﺮﻧﺎﻣﻪ ﻣﺸﻐﻮﻝ ﭼﻚ ﻛﺮﺩﻥ ﺳﻴﺴﺘﻢ ﻭ ﻣﺤﺘﻮﺍﻱ ﻓﺎﻳﻞﻫﺎ ﻣﻲﺷﻮﺩ‪ .‬ﺳﭙﺲ ﭘﻨﺠﺮﺓ ﺟﺪﻳﺪﻱ ﺑﺎﺯ ﻣﻲﺷﻮﺩ ﻛﻪ ﺑﺼﻮﺭﺕ ﭘﻴﺶ ﻓﺮﺽ ﺩﻛﻤﺔ ﺑﺎﻻﻳﻲ ﻓﻌﺎﻝ ﺍﺳﺖ ﻭ ﺷﻤﺎ ﺑﺎﻳﺪ ﺩﻛﻤﺔ ‪ Next‬ﺭﺍ ﻓﺸﺎﺭ ﺩﻫﻴﺪ‪ .‬ﺣﺎﻝ ﺑﺎﻳﺪ ﻣﻨﺘﻈﺮ ﺑﻤﺎﻧﻴﺪ ﺗﺎ ﺑﺮﻧﺎﻣﻪ ﺑﺼـﻮﺭﺕ ﻛﺎﻣـﻞ ﻧﺼـﺐ ﮔـﺮﺩﺩ ﺳـﭙﺲ ﭘﻨﺠـﺮﺓ‬
‫ﺩﻳﮕﺮﻱ ﺑﺎﺯ ﺷﺪﻩ ﺩﻭﺑﺎﺭﻩ ‪ Next‬ﺭﺍ ﻓﺸﺎﺭ ﺩﺍﺩﻩ ﻭ ﺩﻛﻤﺔ ‪ finish‬ﺩﺭ ﺍﻧﺘﻬﺎ ﺯﺩﻩ ﺷﻮﺩ‪ .‬ﺩﺭ ﺍﻳﻦ ﻣﻮﻗﻊ ﻭﻳﻨﺪﻭﺯ ﺧﻮﺩﺑﺨﻮﺩ ‪ restart‬ﻣﻲﺷﻮﺩ‪ .‬ﺩﻭﺑﺎﺭﻩ ‪ CD‬ﺭﺍ ﺍﺟﺮﺍ ﻛﻨﻴﺪ )ﺍﻳﻦ ﻛﺎﺭ ﺭﺍ ﻣﻲ ﺗﻮﺍﻧﻴﺪ ﺑﺎ ﺯﺩﻥ ﺩﻛﻤﺔ ‪ Eject‬ﺩﺭﺍﻳﻮ ‪ CD‬ﻭ ﻓﺸﺮﺩﻥ ﻣﺠﺪﺩ ‪ CD‬ﺑﻪ ﺩﺭﻭﻥ ﺩﺭﺍﻳﻮ ﻭ ﻳﺎ ﺑـﺎﺯ ﻛـﺮﺩﻥ ‪ CD‬ﻭ‬
‫ﺍﺟﺮﺍﻱ ﺁﻥ ﺍﻧﺠﺎﻡ ﺩﻫﻴﺪ( ﺣﺎﻝ ﺑﻪ ﻗﺴﻤﺖ ﺳﻮﻡ ﻧﺼﺐ ﻣﻲﺭﺳﻴﻢ‪ .‬ﺑﺎﻳﺪ ﺍﺯ ﭘﻨﺠﺮﺓ ﺑﺎﺯﺷﺪﻩ )ﭘﻨﺠﺮﺓ ﺍﻭﻝ ﻫﻨﮕﺎﻡ ﻗﺮﺍﺭﺩﺍﺩﻥ ‪ ( CD‬ﺑﺮ ﺭﻭﻱ ﮔﺰﻳﻨﺔ ‪ Quick time 5‬ﻛﻠﻴﻚ ﻛﻨﻴﻢ‪ .‬ﭘﻨﺠﺮﺓ ﺟﺪﻳﺪﻱ ﻣﻲﺁﻳﺪ ﺩﻛﻤﺔ ‪ Next‬ﺭﺍ ﻓﺸﺎﺭ ﻣﻲ ﺩﻫﻴﻢ‪ .‬ﭘﻨﺠﺮﺓ ﺑﻌﺪﻱ ﻫﻢ ﺑﺎﻳﺪ ‪ Next‬ﺭﺍ ﺑﺰﻧﻴﺪ ﺗﺎ ﭘﻨﺠﺮﺓ‬
‫ﺩﻳﮕﺮﻱ ﺑﺎﺯ ﺷﻮﺩ ﺣﺎﻝ ﺩﻛﻤﺔ ‪ Agree‬ﺭﺍ ﺍﻧﺘﺨﺎﺏ ﻛﻨﻴﺪ ﻣﺴﻴﺮﻱ ﺭﺍ ﻣﻲ ﺑﻴﻨﻴﻢ ﺍﮔﺮ ﻣﻮﺍﻓﻖ ﺑﻮﺩﻳﺪ ‪ Next‬ﺭﺍ ﺑﺰﻧﻴﺪ ﻭ ﺩﺭ ﭘﻨﺠﺮﺓ ﺟﺪﻳﺪ ﺑﺼﻮﺭﺕ ﭘﻴﺶ ﻓﺮﺽ ﺩﻛﻤﺔ ﺩﻭﻡ ﺍﺯ ﺑﻴﻦ ﺳﻪ ﺩﻛﻤﻪ ﺩﺭ ﺑﺎﻻﻱ ﻛﺎﺩﺭ ﻓﻌﺎﻝ ﺍﺳﺖ ﻣﺠﺪﺩﹰﺍ ‪ Next‬ﺭﺍ ﺑﺰﻧﻴﺪ ﻭ ﺑﺎﺯ ﻧﻴﺰ ‪ Next‬ﺭﺍ ﺍﻧﺘﺨﺎﺏ ﻛﻨﻴﺪ ﺩﺭ ﭘﻨﺠﺮﺓ‬
‫ﺟﺪﻳﺪ ﻧﻴﺰ ‪ Next‬ﺭﺍ ﻓﺸﺎﺭ ﺩﻫﻴﺪ ﭘﻨﺠﺮﺓ ﺑﻌﺪﻱ ﺳﺮﻳﺎﻝ ﻭ ﻧﺎﻡ ﺷﺮﻛﺖ ﺭﺍ ﻣﻲﭘﺮﺳﺪ ﻧﻴﺎﺯﻱ ﺑﻪ ﭘﺮﻛﺮﺩﻥ ﺁﻥ ﻧﻴﺴﺖ ‪ Next‬ﺭﺍ ﺯﺩﻩ ﺗﺎ ﺑﺮﻧﺎﻣﻪ ﻧﺼﺐ ﺷﻮﺩ ﺑﺮ ﺭﻭﻱ ﭘﻨﺠﺮﺓ ﻓﻌﺎﻝ ﻣﺎ ﭘﻨﺠﺮﺓ ﺟﺪﻳﺪﻱ ﺑﺎﺯ ﻣﻲﺷﻮﺩ ﺁﻥ ﺭﺍ ﻧﻴﺰ ‪ Next‬ﺑﺰﻧﻴﺪ ﺩﻭ ﺑﺎﺭﻛﻪ ‪ Next‬ﻛﺮﺩﻳﺪ ﺍﻳﻦ ﭘﻨﺠﺮﻩ ﺭﺍ ‪ finish‬ﻛﻨﻴﺪ ﺗﺎ‬
‫ﺑﻪ ﭘﺎﻳﺎﻥ ﻛﺎﺭ ﺑﺮﺳﻴﻢ ﺁﺧﺮﻳﻦ ﭘﻨﺠﺮﻩ ﺭﺍ ﺑﺎ ﺑﺮﺩﺍﺷﺘﻦ ﺗﻴﻚﻫﺎﻱ ﺩﻭ ﻛﺎﺩﺭ ﺑﺎﻻ ‪ Close‬ﻛﻨﻴﺪ‪ .‬ﺗﻤﺎﻡ ﭘﻨﺠﺮﻩ ﻫﺎ ﺭﺍ ﺑﺮﺭﻭﻱ ﺻـﻔﺤﺔ ‪ Desktop‬ﺑﺒﻨﺪﻳـﺪ ﺑـﺮﺭﻭﻱ ﺩﻛﻤـﺔ ‪ Start‬ﻛﻠﻴـﻚ ﻛـﺮﺩﻩ ﻭﺍﺭﺩ ‪ Programs‬ﺷـﻮﻳﺪ ﻭ ﺍﺯ ﻣﻨـﻮﻱ ‪ Cardio Vascular Medicine‬ﺑﺮﻧﺎﻣـﺔ ‪Cardio‬‬
‫‪ Vascular CD‬ﺭﺍ ﺍﺟﺮﺍ ﻛﻨﻴﺪ ﻭ ﺳﭙﺲ ﺑﺮﻧﺎﻣﺔ ‪ internet explorer‬ﺭﺍ ﺑﺎﺯ ﻛﺮﺩﻩ ﻭ ﺩﺭ ﻗﺴﻤﺖ ‪ Address‬ﺧﻂ ﺯﻳﺮ ﺭﺍ ﺗﺎﻳﭗ ﻛﻨﻴﺪ‪ .‬ﺑﺮﻧﺎﻣﻪ ﺩﺭ ﻣﺤﻴﻂ ‪ internet explorer‬ﺍﺟﺮﺍ ﻣﻲﺷﻮﺩ‪.‬‬
‫‪http://127.0.0.1:83/PCIndex.htm.‬‬

‫ﺗﻠﻔﻦ‪٠٩١٢١٣٧٢٣٦١-٦٦٩٣٦٦٩٦ :‬‬ ‫ﻧﺸﺎﻧﻲ‪ :‬ﺗﻬﺮﺍﻥ‪ ،‬ﻡ ﺍﻧﻘﻼﺏ‪ ،‬ﺥ ﻛﺎﺭﮔﺮ ﺟﻨﻮﺑﻲ‪ ،‬ﺥ ﻟﺒﺎﻓﻲﻧﮋﺍﺩ‪ ،‬ﺑﻴﻦ ﻛﺎﺭﮔﺮ ﻭ ﺟﻤﺎﻟﺰﺍﺩﻩ‪ ،‬ﺑﻦﺑﺴﺖ ﺳﻴﻤﻴﻦ‪ ،‬ﭘﻼﻙ ‪٢٣٩‬‬ ‫ﻣﺮﻛﺰ ﺧﺪﻣﺎﺕ ﻓﺮﻫﻨﮕﻲ ﺳﺎﻟﻜﺎﻥ ‪ :‬ﺍﺭﺍﺋﻪ ﻛﻨﻨﺪﺓ ﻛﺘﺎﺏ ﻭ ﺳﻲﺩﻱﻫﺎﻱ ﺗﺨﺼﺼﻲ ﭘﺰﺷﻜﻲ‬
 ‫‪29‬‬
‫‪63.5‬‬ ‫‪The Netter Presenter Cardiovascular and Renal Edition‬‬ ‫)‪Images from the Netter Collection (NOVARTIS‬‬ ‫‪2003‬‬

‫‪64.5 The Physiological Orgins of HEART SOUNDS and MURMUS‬‬ ‫)‪(John Michael Criley, M.D., Conrad Zalace, David Creley‬‬ ‫ــــــ‬

‫‪General Tutorials:‬‬ ‫‪Timing of Heart Sounds‬‬ ‫‪Timing of Murmurs‬‬ ‫‪Catalog of Lesions‬‬

‫‪yInspection and Palpation‬‬ ‫‪yValve Closure Sounds and Splitting of Sounds‬‬ ‫‪ySystolic Murmurs‬‬ ‫‪yNormal‬‬
‫‪yIntriduction to Auscultation‬‬ ‫‪yOpening Sounds‬‬ ‫‪yDiastolic Murmurs‬‬ ‫‪yValvar Lesions‬‬
‫‪yEffect of Maneuvers and Perturbations‬‬ ‫‪yThird Sounds‬‬ ‫‪yContinuous Murmurs vs. “To and Fro” Murmurs‬‬ ‫‪yPericardial Disease‬‬
‫‪yHemoduction to Cardiac Imaging Modalities‬‬ ‫‪yFourth sounds‬‬ ‫‪yFriction Rubs‬‬ ‫‪yCongenital Heart Disease‬‬
‫‪yEjection Sounds‬‬ ‫‪yCardiomyopathies‬‬
‫‪yMid-Systolic Clicks‬‬ ‫‪yMyxoma‬‬

‫)…‪65.5 Vascular Vision (A Liberating Approach to Vascular health Expert Opinions in Dyslipidaemia) (Professor Philip Barter, Dr. John Kastelein,‬‬ ‫ــــــ‬
‫‪66.5 VJC Video Journal of Cardiology‬‬ ‫)‪(LAWRENCE S. COHEN, M.D, JOHN ELEFTERIADES, M.D.) (VCD‬‬ ‫ــــــ‬
‫‪1. From a new perspective: mitral valve prolapse aortic dissections and aneurysms‬‬
‫‪2. Surgical and medical management of ascending and descending aortic dissections liporoten (A): a cardiovascular risk factor‬‬
‫)‪67.5 VJC Video Journal of Cardiology (Christopher White, M.D, Michael E. Cain, M.D., Bruce D. Lindsay, M.D., Herbert Geschwind, M.D.) (VCD‬‬ ‫ــــــ‬

‫ﺍﻳﻦ ﺑﺮﻧﺎﻣﻪ ﺍﺯ ﺳﺮﻱ ‪CD‬ﻫﺎﻱ ﺁﻣﻮﺯﺷﻲ ‪ VJC‬ﻣﻲﺑﺎﺷﺪ ﻛﻪ ﺑﻪ ﺻﻮﺭﺕ ﻓﻴﻠﻢ ﺁﻣﻮﺯﺷﻲ ﺩﺭ ﻗﺎﻟﺐ ‪ VCD‬ﺑﻪ ﻣﺪﺕ ‪ 50‬ﺩﻗﻴﻘﻪ ﺩﺭ ﺳﻪ ﺑﺨﺶ ﺍﺭﺍﺋﻪ ﺷﺪﻩ ﺍﺳﺖ‪ .‬ﺩﺭ ﻫﺮ ﺑﺨﺶ ﻳﻚ ﻣﻮﺿﻮﻉ ﺑﻪ ﺷﻜﻞ ﻣﺼﺎﺣﺒﺔ ﻋﻠﻤﻲ ﺑﺎ ﻳﻚ ﻣﺘﺨﺼﺺ ﺑﻪ ﻫﻤﺮﺍﻩ ﻧﻤﺎﻳﺶ ﺍﺳﻼﻳﺪ ﻭ ﻓـﻴﻠﻢ ﻭ ﻧﻤﻮﺩﺍﺭﻫـﺎﻱ‬
‫ﻣﺘﻌﺪﺩ ﺑﺤﺚ ﻭ ﺑﺮﺭﺳﻲ ﺷﺪﻩ ﺍﺳﺖ‪ .‬ﻣﻮﺿﻮﻋﺎﺕ ﻫﺮ ﺑﺨﺶ ﺑﻪ ﺷﺮﺡ ﺯﻳﺮ ﺍﺳﺖ‪:‬‬
‫‪1-Cold lege : The Approach to Acvte and progressive Peripheral Vascular Disease‬‬ ‫ﻣﺼﺎﺣﺒﻪ ﺷﻮﻧﺪﻩ‪ :‬ﺩﻛﺘﺮ‪christoher white :‬‬

‫‪ ،‬ﺍﺳﺘﺮﭘﺘﻮﻛﻴﻨﺎﺯ ‪ ،‬ﺁﻧﮋﻳﻮﭘﻼﺳﺘﻲ ﻟﻴﺰﺭﻱ ﻭ‪ ....‬ﻧﻴﺰ ﻣﻮﺭﺩ ﺑﺮﺭﺳﻲ ﻗﺮﺍﺭ ﮔﺮﻓﺘﻪ ﺍﺳﺖ‪.‬‬ ‫‪Urokinase‬‬ ‫ﻋﻮﺍﺭﺽ ﻣﺮﺑﻮﻁ ﺑﻪ ﻋﺮﻭﻕ ﻣﺤﻴﻄﻲ ﻭ ﺭﻭﺷﻬﺎﻱ ﺩﺭﻣﺎﻧﻲ ﺁﻧﻬﺎ ﺑﺤﺚ ﺷﺪﻩ ﺍﺳﺖ ‪ .‬ﻣﺮﺍﺣﻞ ﺍﻧﺠﺎﻡ ﺁﻧﮋﻳﻮﮔﺮﺍﻓﻲ ﺑﻪ ﻫﻤﺮﺍﻩ ﻧﻤﺎﻳﺶ ﺗﺼﺎﻭﻳﺮ ﺁﻧﮋﻳﻮﺳﻜﻮﭘﻴﻚ ﻭ ﺁﻧﮋﻳﻮﮔﺮﺍﻡ ﺍﺭﺍﺋﻪ ﺷﺪﻩ ﺍﺳﺖ‪ .‬ﻛﺎﺭﺑﺮﺩﻫﺎﻱ‬

‫‪2- RADiofrgvency ablation : Ablation of AVNode reentry tachycardias‬‬ ‫ﻣﺼﺎﺣﻴﻪ ﺷﻮﻧﺪﻩ ‪ :‬ﺩﻛﺘﺮ ‪Michael E. Cain :‬‬

‫ﺍﻟﻜﺘﺮﻭﻛﺎﺭﺩﻭﻳﻮﮔﺮﺍﻡ ﺑﺎﻟﻴﺪﮔﺬﺍﺭﻱﻫﺎﻱ ﻣﺨﺘﻠﻒ‪ECG ،‬ﻫﺎﻱ ﺩﺭ ﻓﻴﺒﺮﻳﻼﺳﻴﻮﻥ ﻭ ﺑﻠﻮﻙ ‪ AV‬ﻭ ‪ ...‬ﻫﻤﺮﺍﻩ ﺑﺎ ﻧﻤﺎﻳﺶ ﺍﺳﻼﻳﺪﻫﺎ ﻭ ﺭﺍﺩﻳﻮﮔﺮﺍﻡﻫﺎﻱ ﻣﺘﻌﺪﺩ ﺑﺮﺭﺳﻲ ﻭ ﺗﻮﺿﻴﺢ ﺩﺍﺩﻩ ﺷﺪﻩ ﺍﺳﺖ‪.‬‬
‫‪3- Laser Angioplasty for coronary Atherosclerotic Disease‬‬ ‫ﻣﺼﺎﺣﺒﻪ ﺷﻮﻧﺪﻩ‪ :‬ﺩﻛﺘﺮ‪Herbert Geschwind :‬‬

‫ﻣﻜﺎﻧﻴﺰﻡ ﻋﻤﻞ ﺳﻴﺴﺘﻢ ﻟﻴﺰﺭ ﺩﺭ ﺁﻧﮋﻳﻮﭘﻼﺳﺘﻲ‪ ،‬ﻛﺎﺭﺑﺮﺩ ‪ Pulser‬ﻃﻮﻝ ﺑﺮﺝ ﺑﻬﻤﻴﻨﻪ ) ﻣﺎﻭﺭﺍﺀ ﻣﺎﺩﻭﻥ ﻗﺮﻣﺰ( ﺍﻫﺪﺍﻑ ﺍﺳﺘﻔﺎﺩﻩ ﺍﺯ ﺁﻧﮋﻳﻮﭘﻼﺳﺘﻲ ﻟﻴﺰﺭﻱ ﻭ ﻋﻮﺍﺭﺽ ﺁﻥ ﻣﺰﻳﺖ ﻫﺎ ﻭ ﻣﺤﺪﻭﺩﻳﺖﻫﺎ ﺍﻳﻦ ﺭﻭﺵ ﻭ ﻣﻘﺎﻳﺴﻪ ﺁﻥ ﺑﺎ ‪ PTCA‬ﻭ ‪ ....‬ﻣﻮﺭﺩ ﺑﺤﺚ ﻭ ﺑﺮﺭﺳﻲ ﻗﺮﺍﺭ ﮔﺮﻓﺘﻪ ﺍﺳﺖ‪.‬‬

‫‪ -٦‬ﭘﻮﺳﺖ ﻭ ﻣﻮ‬

‫ﻋﻨﻮﺍﻥ ‪CD‬‬ ‫ﺳﺎﻝ ﺍﻧﺘﺸﺎﺭ‬

‫‪1.6‬‬ ‫)‪American Cancer Society Atlas of Clinical Oncology Skin Cancer (Arthur J. Sober, MD, Frank G. Haluka, MD, phD) (Bc Decker Inc‬‬ ‫‪2001‬‬

‫ﻫﻤﭽﻨﺎﻧﻜﻪ ﻭﺍﺭﺩ ﻗﺮﻥ ‪ ٢١‬ﻣﻲﺷﻮﻳﻢ ﺷﺎﻳﻊﺗﺮﻳﻦ ﺷﻜﻞ ﺳﺮﻃﺎﻥﻫﺎ‪ ،‬ﻛﺎﻧﺴﺮﻫﺎﻱ ﭘﻮﺳﺘﻲ ﻣﻲﺑﺎﺷﺪ ﻭ ﺑﻪ ﻋﻠﺖ ﺍﻳﻨﻜﻪ ﺑﺮ ﺧﻼﻑ ﻛﺎﻧﺴﺮﻫﺎﻱ ﺩﻳﮕﺮ‪ ،‬ﻛﺎﻧﺴﺮﻫﺎﻱ ﭘﻮﺳﺖ ﺩﺭ ﻣﻌﺮﺽ ﺩﻳﺪ ﻣﻲﺑﺎﺷﺪ ﺳﺮﻳﻌﺘﺮ ﻭ ﺭﺍﺣﺖﺗﺮ ﻗﺎﺑـﻞ ﺗﺸـﺨﻴﺺ ﺍﺳـﺖ‪ .‬ﺩﺭ ﻧﺘﻴﺠـﻪ ﺩﺍﻧـﺶ ﺗﺸـﺨﻴﺺ ﻭ ﺩﺭﻣـﺎﻥ ﻭ‬
‫ﺟﻠﻮﮔﻴﺮﻱ ﺍﺯ ﺳﺮﻃﺎﻥﻫﺎﻱ ﭘﻮﺳﺘﻲ ﻣﻮﺟﺐ ﻧﮕﺎﺭﺵ ﺍﻳﻦ ﻛﺘﺎﺏ ﮔﺮﺩﻳﺪﻩ ﺍﺳﺖ‪ .‬ﻣﺸﺨﺼﺔ ﺍﻳﻦ ﻛﺘﺎﺏ ﺗﺄﻛﻴﺪ ﺑﺮ ﻧﻤﺎﻫﺎﻱ ﺑﺎﻟﻴﻨﻲ ‪ Skin cancer‬ﻣﻲﺑﺎﺷﺪ ﭼﻮﻥ ﻋﻠﻢ ﺩﺭﻣﺎﺗﻮﻟﻮﮊﻱ ﺑﺮ ﭘﺎﻳﺔ ﻣﺸﺎﻫﺪﻩ ﺑﻨﺎ ﺷﺪﻩ ﺍﺳﺖ‪ ،‬ﺑﻨﺎﺑﺮﺍﻳﻦ ﻛﺘﺎﺏ ﺩﺍﺭﺍﻱ ﺗﺼﺎﻭﻳﺮ ﺯﻳﺎﺩ ﺑﺎ ﻛﻴﻔﻴﺖ ﺑﺴﻴﺎﺭ ﺑﺎﻻﺳﺖ ﻭ ﻫﺮ ﺟﺎ ﻛﻪ ﻋﻜﺲﻫﺎ‬
‫ﺩﺭ ﺍﺭﺍﺋﻪ ﻣﻄﻠﺐ ﻛﻤﻚﻛﻨﻨﺪﻩ ﻧﺒﻮﺩﻩ ‪ text‬ﺍﺿﺎﻓﻪ ﺷﺪﻩ ﺍﺳﺖ‪ .‬ﻭ ﻋﻼﻭﻩ ﺑﺮ ﺍﻳﻦ ﻧﻜﺎﺕ ﺗﺸﺨﻴﺼﻲ‪ ،‬ﺍﭘﻴﺪﻣﻴﻮﻟﻮﮊﻱ ‪ ،‬ﺩﺭﻣﺎﻧﻲ ﻭ ﭘﻴﺸﮕﻴﺮﻱ ﺩﺭ ﻛﺘﺎﺏ ﮔﻨﺠﺎﻧﺪﻩ ﺷﺪﻩ ﺍﺳﺖ‪ .‬ﺍﻳﻦ ﻛﺘﺎﺏ ﺑﻪ ‪ ٤‬ﻗﺴﻤﺖ ﺗﻘﺴﻴﻢ ﺷﺪﻩ ﺍﺳﺖ‪:‬‬
‫ﺑﺨﺶ ‪ Basic Concept :١‬ﺷﺎﻣﻞ ﺍﭘﻴﺪﻣﻴﻮﻟﻮﮊﻱ‪ ،‬ﮊﻧﺘﻴﻚ ﻛﺎﻧﺴﺮﻫﺎﻱ ﭘﻮﺳﺘﻲ ﻭ ﻋﻮﺍﻣﻞ ﺧﻄﺮﺯﺍ ﻣﻲﺑﺎﺷﺪ‪.‬‬
‫ﺑﺨﺶ ‪ :٢‬ﺗﻈﺎﻫﺮﺍﺕ ﺑﺎﻟﻴﻨﻲ‪ :‬ﺩﺭ ﻫﺮ ﻓﺼﻞ ﺟﺪﺍﮔﺎﻧﻪ ﻧﻤﺎﻱ ﺑﺎﻟﻴﻨﻲ ﻣﻼﻧﻮﻡ )ﻓﺼﻞ ‪ (٤‬ﻭ ‪) BCE‬ﻓﺼﻞ ‪ (٥‬ﻭ ‪) Scc‬ﻓﺼﻞ ‪ (٦‬ﻟﻤﻔﻮﻡﻫﺎﻱ ﭘﻮﺳﺘﻲ )ﻓﺼﻞ ‪ (٧‬ﻭ ﻣﺎﻟﻴﻨﮕﻨﺎﻧﺴﻲﻫﺎﻱ ﭘﻮﺳﺘﻲ ﻧﺎﺷﺎﻳﻊ )ﻓﺼﻞ ‪) Merckle cell Carcinoma (٨:١‬ﻓﺼﻞ ‪ ( ٨:٢‬ﻭ ﻛﺎﭘﻮﺳﻲ ﺳﺎﺭﻛﻮﻡ )ﻓﺼﻞ ‪ (٨:٣‬ﺍﺷﺎﺭﻩ ﺷﺪﻩ ﺍﺳﺖ‪.‬‬
‫ﺑﺨﺶ ‪ Management : ٣‬ﻛﻪ ﺷﺎﻣﻞ‪ :‬ﺗﻜﻨﻴﻚ ﺑﻴﻮﭘﺴﻲ ﺍﺯ ﻣﻼﻧﻮﻡ )ﻓﺼﻞ ‪ ، (٩‬ﺗﺪﺍﺑﻴﺮ ﺟﺮﺍﺣﻲ ﻣﻼﻧﻮﻡ ﭘﻮﺳﺘﻲ )ﻓﺼﻞ ‪ ،(١١‬ﺍﺭﺯﻳﺎﺑﻲ ﻟﻤﻒﻧﻮﺩﻫﺎ ﻭ ﺑﻴﻮﭘﺴﻲ ﺍﺯ ﻟﻤﻒﻧﻮﺩ ﺩﺭ ﻣﻼﻧﻮﻡ )ﻓﺼﻞ ‪ adjuvant therapy ،(١١‬ﺩﺭ ﻣﻼﻧﻮﻡ )ﻓﺼﻞ ‪ ،(١٢‬ﺍﻳﻤﻮﻧـﻮﺗﺮﺍﭘﻲ ﺩﺭ ﻣﻼﻧـﻮﻡ )ﻓﺼـﻞ ‪ (١٣‬ﻭ ﻛﻤـﻮﺗﺮﺍﭘﻲ ‪ ،‬ﺳـﻴﺘﻮﻛﻴﻦ‬
‫ﺗﺮﺍﭘﻲ ﻭ ﺑﻴﻮﻛﻤﻮﺗﺮﺍﭘﻲ ﺩﺭ ﻣﻼﻧﻮﻡ )ﻓﺼﻞ ‪ (١٤‬ﻣﻲﺑﺎﺷﺪ‪ .‬ﻫﻤﭽﻨﻴﻦ ﺩﺭﻣﺎﻥ ﻟﻤﻔﻮﻡ ﭘﻮﺳﺘﻲ ﺍﻭﻟﻴﻪ ]‪) [MF‬ﻓﺼﻞ ‪ (١٧‬ﻣﻲﺑﺎﺷﺪ‪.‬‬
‫ﺑﺨﺶ ‪ : ٤‬ﺩﺭ ﻣﻮﺭﺩ ﭘﻴﺸﮕﻴﺮﻱ ﺍﺯ ﻛﺎﻧﺴﺮﻫﺎﻱ ﭘﻮﺳﺘﻲ ﺑﺤﺚ ﻛﺮﺩﻩ ﺍﺳﺖ‪.‬‬

‫ﺗﻠﻔﻦ‪٠٩١٢١٣٧٢٣٦١-٦٦٩٣٦٦٩٦ :‬‬ ‫ﻧﺸﺎﻧﻲ‪ :‬ﺗﻬﺮﺍﻥ‪ ،‬ﻡ ﺍﻧﻘﻼﺏ‪ ،‬ﺥ ﻛﺎﺭﮔﺮ ﺟﻨﻮﺑﻲ‪ ،‬ﺥ ﻟﺒﺎﻓﻲﻧﮋﺍﺩ‪ ،‬ﺑﻴﻦ ﻛﺎﺭﮔﺮ ﻭ ﺟﻤﺎﻟﺰﺍﺩﻩ‪ ،‬ﺑﻦﺑﺴﺖ ﺳﻴﻤﻴﻦ‪ ،‬ﭘﻼﻙ ‪٢٣٩‬‬ ‫ﻣﺮﻛﺰ ﺧﺪﻣﺎﺕ ﻓﺮﻫﻨﮕﻲ ﺳﺎﻟﻜﺎﻥ ‪ :‬ﺍﺭﺍﺋﻪ ﻛﻨﻨﺪﺓ ﻛﺘﺎﺏ ﻭ ﺳﻲﺩﻱﻫﺎﻱ ﺗﺨﺼﺼﻲ ﭘﺰﺷﻜﻲ‬
 ‫‪30‬‬
‫‪2.6‬‬ ‫)‪AQUAMIDE; Poly Acryl Amide Ged (an injectable gel for correction of soft Tissue Deficiencies‬‬ ‫ــــــ‬
‫ﺩﺭ ﺍﻳﻦ ﻭﻳﺪﺋﻮ ‪ CD‬ﺩﺭ ﻣﻮﺭﺩ ﻳﻜﻲ ﺍﺯ ﻣﻮﺍﺩ ‪ filler‬ﺑﻪ ﻛﺎﺭ ﺭﻓﺘﻪ ﺩﺭ ‪ Cosmetic Surgery‬ﺗﻮﺿﻴﺤﺎﺗﻲ ﺩﺍﺩﻩ ﺷﺪﻩ ﺍﺳﺖ‪ .‬ﺩﺭ ﺍﺑﺘﺪﺍ ﺧﻮﺍﺹ ﮊﻝ ‪ Aquamide‬ﻭ ﻛﺎﺭﺑﺮﺩﻫﺎﻱ ﺁﻥ ﻣﻮﺭﺩ ﺑﺤﺚ ﻗﺮﺍﺭ ﮔﺮﻓﺘﻪ ﻭ ﺳﭙﺲ ﻃﺮﻳﻘﻪ ﺗﺰﺭﻳﻖ ﺍﻳﻦ ﮊﻝ ﺩﺭ ﺍﺻﻼﺡ ﭼﻴﻦ ﻧﺎﺯﻭﺑﻴﺎﻝ‪ ،‬ﺗﻐﻴﻴﺮ ﺷﻜﻞ‬
‫ﻧﺎﻫﻨﺠﺎﺭﻱﻫﺎﻱ ﺑﻴﻨﻲ‪ ،‬ﺍﺯ ﺑﻴﻦﺑﺮﺩﻥ ﭼﻴﻦﻫﺎﻱ ﭘﻴﺸﺎﻧﻲ ﻭ ﺍﻃﺮﺍﻑ ﻟﺐ‪ ،‬ﭘﺮﻛﺮﺩﻥ ﻭ ﺍﺻﻼﺡ ﺿﺎﻳﻌﺎﺕ ﺁﺗﺮﻭﻓﻴﻚ ﻧﺎﺷﻲ ﺍﺯ ﺍﺳﻜﺎﺭ ﺁﺑﻠﻪﻣﺮﻏﺎﻥ ﻳﺎ ﺗﺮﻭﻣﺎﻫﺎ‪ ،‬ﮔﻮﻧﻪﮔﺬﺍﺭﻱ ﻭ ﺧﻂ ﻟﺐ ﺑﻪ ﺻﻮﺭﺕ ﻧﻮﺍﺭ ﻭﻳﺪﺋﻮﺋﻲ ﻣﻮﺭﺩ ﺑﺤﺚ ﻗﺮﺍﺭ ﮔﺮﻓﺘﻪ ﺍﺳﺖ‪.‬‬
‫‪3.6‬‬ ‫)‪ATLAS OF COSMETIC SURGERY (MICHAEL S. KAMINER, MD, JEFFREY S. DOVER, MD, FRCPC, KENNETH A. ARNDT, MD) (W.B. SAUNDERS COMPANY) (Salekan E-Book‬‬ ‫‪2002‬‬
‫ﺍﻃﻠﺲ ﺣﺎﺿﺮ ﺗﺄﻟﻴﻒ ﺩﻳﮕﺮﻱ ﺍﺯ ‪ Dr. Kenneth. Arndt‬ﻣﻲﺑﺎﺷﺪ‪ .‬ﺩﺭ ﻣﻘﺪﻣﻪ ﻛﺘﺎﺏ ‪) Dr. Leffell‬ﺍﺳﺘﺎﺩ ﺩﺭﻣﺎﺗﻮﻟﻮﮊﻱ ﻭ ﺟﺮﺍﺣﻲ ﭘﻼﺳﺘﻴﻚ ﺩﺍﻧﺸﮕﺎﻩ ‪ (Yale‬ﻣﻲﻧﻮﻳﺴﺪ‪"' :‬ﺍﻳﻦ ﻛﺘﺎﺏ ﺍﻟﻜﺘﺮﻭﻧﻴﻜﻲ ﻓﻮﻕﺍﻟﻌﺎﺩﻩ ﺟﻤﻊﺁﻭﺭﻱ ﺗﺠﺎﺭﺏ ﻣﺆﻟﻔﻴﻦ ﺑﻮﺩﻩ ﻭ ﺑﻴﺸﺘﺮ ﺑﻪ ﻣـﻮﺍﺭﺩ ﻛـﺎﺭﺑﺮﺩﻱ ﺍﺷـﺎﺭﻩ‬
‫ﺷﺪﻩ ﺍﺳﺖ ﺑﻪ ﻃﻮﺭﻳﻜﻪ ﺑﻪ ﺷﻤﺎ ﻛﻤﻚ ﻣﻲﻛﻨﺪ ﭼﮕﻮﻧﻪ ﺑﺎ ﻣﻮﻓﻘﻴﺖ ﻳﻚ ﻋﻤﻞ ‪ Cosmetic‬ﺭﺍ ﺑﺮ ﺭﻭﻱ ﺑﻴﻤﺎﺭ ﺧﻮﺩ ﺍﻧﺠﺎﻡ ﺩﻫﻴﺪ‪ Dr. Arndt .‬ﺳﺮﺩﺑﻴﺮ ﻣﺠﻠﻪ ‪ Archives of Dermatology‬ﺗﻘﺮﻳﺒﹰﺎ ﺑﻪ ﻣﺪﺕ ‪ ٢٠‬ﺳـﺎﻝ ﺍﺣﺎﻃـﺔ ﻭﺳـﻴﻌﻲ ﺩﺭ ﺟﺮﺍﺣـﻲﻫـﺎﻱ ‪ Cosmetic‬ﺩﺍﺷـﺘﻪ ﻭ ﺩﺭ‬
‫ﺷﻜﻴﻞﺑﻮﺩﻥ ﻛﺘﺎﺏ ﺳﻬﻢ ﺑﺴﺰﺍﻳﻲ ﺩﺍﺭﺩ" ﻭﻳﮋﮔﻲ ﺍﻳﻦ ﻛﺘﺎﺏ ﻧﺴﺒﺖ ﺑﻪ ﻣﻮﺍﺭﺩ ﻣﺸﺎﺑﻪ‪ ،‬ﺗﺠﺮﺑﻴﺎﺕ ﻣﺆﻟﻔﻴﻦ ﻣﻲﺑﺎﺷﺪ ﻛﻪ ﻫﻤﮕﻲ ﺑﻪ ﻋﻨﻮﺍﻥ ﺭﻓﺮﺍﻧﺲ ﺩﻳﮕﺮ ﻛﺘﺐ ﻭ ﻣﺠﻼﺕ ﭘﺰﺷﻜﻲ ﺑﻪ ﻛﺎﺭ ﻣﻲﺭﻭﺩ )ﺑﺮﺍﻱ ﻣﺜﺎﻝ ﭼﮕﻮﻧﮕﻲ ﺗﺰﺭﻳﻖ ‪ Botox‬ﻭ ﺩﺭﻣﺎﻥ ﺍﺳـﻜﺎﺭﻫﺎﻱ ﺁﻛﻨـﻪ ﻛـﻪ ﺩﺭ ﻣﺠـﻼﺕ‬
‫ﻼ ﻣﺠﻬﺰ( ﺑﻴﺎﻥ ﻧﻤﻮﺩﻩﺍﻧﺪ‪ .‬ﺑﺮﺍﻱ ﻣﺜﺎﻝ ﻣﺒﺎﺣﺚ ﺗﺰﺭﻳﻖ ‪ ، Botox‬ﻟﻴﺰﺭﺩﺭﻣـﺎﻧﻲ‬
‫‪ Archive‬ﻭ ‪ 2001 AAD‬ﻭ ‪ 2002‬ﭼﺎﭖ ﺷﺪﻩ ﺍﺳﺖ( ﻣﺆﻟﻔﻴﻦ ﻫﺪﻑ ﺍﺯ ﺗﺄﻟﻴﻒ ﺍﻳﻦ ﻛﺘﺎﺏ ﺭﺍ ﺑﻴﺎﻥ ﺗﺠﺮﺑﻴﺎﺕ ﻛﺎﺭﺑﺮﺩﻱ ﺧﻮﺩ ﺩﺭ ﺑﻴﻤﺎﺭﺳﺘﺎﻥ ‪) Harvard‬ﺑﺎ ‪ ١٣‬ﻟﻴﺰﺭ ﭘﻮﺳﺖ ﻭ‪ ١٢‬ﺍﻃﺎﻕ ﻋﻤﻞ ﺟﺮﺍﺣﻲ ﻛﺎﻣ ﹰ‬
‫ﺿﺎﻳﻌﺎﺕ ﭘﻮﺳﺘﻲ ﻭ ‪ Scar management‬ﻭ ﺑﻠﻔﺎﺭﻭﭘﻼﺳﺘﻲ ﺍﻳﻦ ﻛﺘﺎﺏ ﻛﺎﺭﺑﺮﺩﻱﺗﺮﻳﻦ ﻭ ﺑﻪ ﺍﺫﻋﺎﻥ ﻣﺘﺨﺼﺼﻴﻦ ﻭ ﺩﺳﺘﻴﺎﺭﺍﻥ ﭘﻮﺳﺖ ﺑﻬﺘﺮﻳﻦ ﻛﺘﺎﺏ ﭼﺎﭖ ﺷﺪﻩ ﺩﺭ ﺍﻳﻦ ﻣﻮﺭﺩ ﻣﻲﺑﺎﺷﺪ ﺍﺳﺘﻔﺎﺩﻩ ﺍﺯ ﺷﻜﻞﻫﺎﻱ ﺳﺎﺩﻩ ﺑﺮﺍﻱ ﺁﻣﻮﺯﺵ ﻭ ﺑﻌﻀﹰﺎ ﺭﻧﮕﻲ ﺑﻪ ﻛﻴﻔﻴﺖ ﻭ ﺭﺍﺣﺘﻲ ﺁﻣﻮﺯﺵ ﺗﻜﻨﻴﻚﻫﺎ‬
‫ﻛﻤﻚ ﺷﺎﻳﺎﻧﻲ ﺩﺭ ﺍﻳﻦ ﻛﺘﺎﺏ ﻛﺮﺩﻩ ﺍﺳﺖ‪ .‬ﻛﺘﺎﺏ ‪ Laser in Dermatology‬ﻣﺆﻟﻒ "‪ "Kenneth, Arndt‬ﺑﺰﻭﺩﻱ ﺍﺭﺍﺋﻪ ﻣﻲﺷﻮﺩ‪ .‬ﺍﻳﻦ ﻛﺘﺎﺏ ﻣﻨﺤﺼﺮﺑﻪ ﻓﺮﺩ ﺷﺎﻣﻞ ﻣﺒﺎﺣﺚ ﺯﻳﺮ ﻣﻲﺑﺎﺷﺪ‪:‬‬

‫‪PART I‬‬ ‫‪PART III‬‬

‫‪EVALUATION OF THE COSMETIC SURGERY PATIENT‬‬ ‫‪COSMETIC SURGERY PROCEDURES AND TECHNIQUES‬‬
‫‪1 The History of Cosmetic Surgery‬‬ ‫‪10 Topical Skin Care‬‬
‫‪2 The History of Cosmetic Dermatologic Surgery‬‬ ‫‪11 Lasers in the Treatment of Vascular Lesions‬‬
‫‪3 Evaluation of the Aging Face,‬‬ ‫‪12 Lasers in the Treatment of Pigmented Lesions‬‬
‫‪4 Photoaging: Mechanisms, Consequences, and Prevention‬‬ ‫‪13 Laser Hair Removal‬‬
‫‪5 Beauty and Society‬‬ ‫‪14 Liposuction‬‬
‫‪6 Psychosocial Issues and Their Relevance to the Cosmetic Surgery Patient‬‬ ‫‪15 Hair Transplantation‬‬
‫‪16 Soft Tissue Augmentation‬‬
‫‪PART II‬‬ ‫‪17 Botulinum A Exotoxin Injections for Photoaging and Hyperhidrosis,‬‬
‫‪ANESTHESIA‬‬ ‫‪18 Chemical Peels‬‬
‫‪7 Regional Anesthesia for Aesthetic Surgery‬‬ ‫‪19 Lasers in Skin Resurfacing‬‬
‫‪8 Office-Based Sedation and Monitoring‬‬ ‫‪20 Blepharoplasty‬‬
‫‪9 Postoperative Pain and Nausea Management‬‬ ‫‪21 Surgical Rhytidectomy: Face Lifts and the Endoscopic Forehead Lift‬‬
‫‪22 Leg Vein Management: Sclerotherapy, Ambulatory Phlebectomy, and Laser Surgery‬‬
‫‪23 Scar Management: Keloid, Hypertrophic, Atrophic, and Acne Scars‬‬
‫‪4.6‬‬ ‫)‪Atlas of Dermatology (Jhon's Hopkins‬‬ ‫)‪(SALEKAN E-BOOK‬‬ ‫)‪(CD I , II‬‬ ‫ــــــ‬
‫ﻼ ﺟﺎﻟﺐ ﺑﺎ ﺭﺯﻭﻟﻮﺷﻦ ﺑﺎﻻ ﺩﺭ ﺧﺼﻮﺹ ﺍﻧﻮﺍﻉ ﺿﺎﻳﻌﺎﺕ ﭘﻮﺳﺘﻲ ﻣﻲﺑﺎﺷﺪ ﻛﻪ ﺑﺮ ﻃﺒﻖ ﺣﺮﻭﻑ ﺍﻟﻔﺒﺎ ‪ Sort‬ﮔﺮﺩﻳﺪﻩ ﻭ ﻣﺤﺼﻮﻝ ﺳﺎﻝ ‪ ٢٠٠٣‬ﺩﺍﻧﺸﮕﺎﻩ ‪ Jhon's Hopkins‬ﻣﻲﺑﺎﺷﺪ‪.‬‬
‫ﺍﻃﻠﺲ ﻓﻮﻕ ﺷﺎﻣﻞ ﺑﻴﺶ ﺍﺯ ‪ ٢٥٠٠‬ﺗﺼﻮﻳﺮ ﻛﺎﻣ ﹰ‬
‫‪5.6‬‬ ‫)‪Atlas of Dermatology (T.L.Diepgen, M. Simon, A. Bittorf, M. Fartasch, G. Schuler) (with the DOIA team G. Eysenbach, J. Bauer, A. Sager) (springer‬‬ ‫‪1999‬‬

‫ﺗﺎﺭﻳﺨﭽﺔ ﺍﻃﻠﺲ ﺩﺭﻣﺎﺗﻮﻟﻮﮊﻱ ﺑﺮﻣﻲﮔﺮﺩﺩ ﺑﻪ ﺳﺎﻝ ‪ ، ١٩٩٤‬ﻛﻪ ﺷﺒﻜﺔ ﺳﺮﺍﺳﺮﻱ ﺟﻬﺎﻧﻲ ﺍﻧﻴﺘﺮﻧﺖ )‪ (www‬ﺍﻳﺠﺎﺩ ﺷﺪ‪ .‬ﺍﺯ ﺁﻥ ﺳﺎﻝ ﺑﻪ ﺑﻌﺪ ﺍﺯ ﺳﺮﺍﺳﺮ ﺟﻬﺎﻥ ﺗﺼﺎﻭﻳﺮ ﺿﺎﻳﻌﺎﺕ ﺩﺭﻣﺎﺗﻮﻟﻮﮊﻱ ﺩﺭ ﺍﻳﻦ ﺷﺒﻜﻪ ﺩﺭ ﻣﺤﻞ ‪ (DOIA) Dermatology online Atlas‬ﮔﻨﺠﺎﻧﺪﻩ ﺷﺪﻩ‬
‫ﺍﺳﺖ‪ .‬ﺩﺭ ﺍﻳﻦ ﺳﺎﻳﺖ ﺍﻳﻨﺘﺮﻧﺘﻲ ﻋﻼﻭﻩ ﺑﺮ ‪ ٣٠٠٠‬ﺗﺼﺮﻳﺮ ﺑﺎ ﻛﻴﻔﻴﺖ ﺑﺴﻴﺎﺭ ﺑﺎﻻﻱ ﺑﻴﺶ ﺍﺯ ‪ 600 DPI‬ﺗﺸﺨﻴﺺ ﺩﺭﻣﺎﺗﻮﻟﻮﮊﻱ‪ ،‬ﺍﺭﺍﺋﻪ ﺳﺨﻨﺮﺍﻧﻲﻫﺎ‪ Case report ،‬ﺻﻮﺗﻲ ﻭ ‪ ...‬ﮔﻨﺠﺎﻧﺪﻩ ﺷﺪﻩ ﺍﺳﺖ‪ .‬ﺑﻨﺎﺑﺮﺍﻳﻦ ﺍﻃﻠﺲ ﻓﻮﻕ ﺑﻪ ﺻـﻮﺭﺕ ‪ Offline‬ﺍﺯ ‪ DOIA‬ﺗﻬﻴـﻪ ﺷـﺪﻩ ﻛـﻪ ﻗﺎﺑﻠﻴـﺖ‬
‫ﺍﺗﺼﺎﻝ ﺩﺭ ﻫﺮ ﺯﻣﺎﻥ ﺑﻪ ﺻﻮﺭﺕ ‪ online‬ﺭﺍ ﺩﺍﺭﺩ‪.‬‬
‫‪6.6‬‬ ‫)‪Atlas of Differential Diagnosis in DERMATOLOGY (Klaus F. Helm, M.D., James G. Marks, Jr., M.D.‬‬ ‫ــــــ‬
‫ﺍﻳﻦ ‪ CD‬ﺑﺮ ﺧﻼﻑ ﺍﻃﻠﺲﻫﺎﻱ ﺩﻳﮕﺮ ﻛﻪ ﺑﻴﻤﺎﺭﻱﻫﺎ ﺭﺍ ﺑﺮ ﺍﺳﺎﺱ ﺣﺮﻭﻑ ﺍﻟﻔﺒﺎﻳﻲ ﻳﺎ ﭘﺎﺗﻮﻓﻴﺰﻳﻮﻟﻮﮊﻱ ﺗﻘﺴﻴﻢﺑﻨﺪﻱ ﻛﺮﺩﻩ ﺗﺄﻛﻴﺪ ﺑﻴﺸﺘﺮ ﺑﻪ ﺗﺸﺨﻴﺺ ﺑﺎﻟﻴﻨﻲ ﻭ ﺍﻓﺘﺮﺍﻕ ﺑﻴﻤﺎﺭﻱﻫﺎﻱ ﺍﺯ ﻳﻜﺪﻳﮕﺮ ﺑﻪ ﺻﻮﺭﺕ ﺗﺸﺨﻴﺺﻫﺎﻱ ﺍﻓﺘﺮﺍﻗﻲ ﺩﺍﺭﺩ‪ .‬ﺑﻪ ﻃﺮﻳﻜﻪ ﺩﺭ ﻣﻮﺭﺩ ﺗﺸﺨﻴﺺ ﻳـﻚ‬
‫ﺑﻴﻤﺎﺭ ﺗﺼﺎﻭﻳﺮ ﺑﻴﻤﺎﺭﻱﻫﺎﻱ ﺩﻳﮕﺮ ﻛﻪ ﺑﺎ ﺁﻥ ﺑﻴﻤﺎﺭﻳﻴﻲ ﺍﺷﺘﺒﺎﻩ ﻣﻲﺷﻮﺩ ﮔﺮﺩﺁﻭﺭﻱ ﺷﺪﻩ ﻭ ﺑﻪ ﺻﻮﺭﺕ ﻳﻚ ﺍﻃﻠﺲ ‪ Problem-oriented‬ﺗﻨﻈﻴﻢ ﮔﺮﺩﻳﺪﻩ ﺍﺳﺖ‪ .‬ﺍﻳﻦ ‪ CD‬ﺭﺍﺵﻫﺎ ﻭ ﻧﺌﻮﭘﻼﺳﻢﻫﺎ ﺭﺍ ﺑﺮ ﺍﺳﺎﺱ ﺷﻜﻞ ﻭ ﻣﺤﻞ ﺑﻪ ‪ ١٦‬ﻓﺼﻞ ﺗﻘﺴﻴﻢﺑﻨﺪﻱ ﺷﺪﻩ ﺩﺭ ﺍﻭﻝ ﻫﺮ ﻓﺼـﻞ ﺍﺑﺘـﺮﺍ‬
‫ﺍﻟﮕﻮﺭﻳﺘﻢ ﺭﺳﻴﺪﻥ ﺑﻪ ﺗﺸﺨﻴﺺ ﻧﺸﺎﻥ ﺩﺍﺩﻩ ﺷﺪ ﻭ ﺳﭙﺲ ﺩﺭ ﺟﺪﺍﻭﻝ ﻣﻘﺎﻳﺴﻪﺍﺱ ﺗﺸﺨﻴﺺ ﺍﻓﺘﺮﺍﻗﻴﻬﺎﻱ ﺍﻳﻦ ﺿﺎﻳﻌﺎﺕ ﻧﻤﺎﻳﺶ ﺩﺍﺩﻩ ﻣﻲﺷﻮﺩ ﻭ ﺳﭙﺲ ﺗﺼﺎﻭﻳﺮ ﺑﺎ ﻛﻴﻔﻴﺖ ﺑﺎﻻ ﺑﻪ ﺻﻮﺭﺕ ﻣﻘﺎﻳﺴﻪﺍﻱ ﻧﺸﺎﻥ ﺩﺍﺩﻩ ﻣﻲﺷﻮﺩ‪ .‬ﺩﺭ ﺁﺧﺮ ﻫﺮ ﻓﺼﻞ ﻧﻴﺰ ﺍﺗﻴﻮﻟﻮﮊﻱ‪ ،‬ﻧﻜﺎﺕ ﻣﻬﻢ ﺑﺎﻟﻴﻨﻲ ﻭ ﺩﺭﻣـﺎﻥ‬
‫ﺑﺮﺍﻱ ﻫﺮ ﺑﻴﻤﺎﺭﻱ ﺑﻪ ﺻﻮﺭ ﺟﺪﺍﮔﺎﻧﻪ ﺍﺭﺍﺋﻪ ﺷﺪﻩ ﺍﺳﺖ‪ .‬ﺍﻳﻦ ‪ CD‬ﺩﺭ ﺑﺮﻧﺎﻣﻪ ‪ Acrobat reader‬ﺍﺭﺍﺋﻪ ﺷﺪﻩ ﺍﺳﺖ‪ .‬ﺩﺭ ﺍﺑﺘﺪﺍ ﻳﻚ ﺑﺮﻧﺎﻣﻪ ﻣﺎﻟﺘﻲ ﻣﺪﻳﺎ ) ﺑﻪ ﺻﻮﺭﺕ ‪ (animation‬ﺑﺮﺍﻱ ﺁﺷﻨﺎﻳﻲ ﺑﺎ ﻣﺤﺘﻮﻳﺎﺕ ‪ CD‬ﻭ ﭼﮕﻮﻧﮕﻲ ﻛﺎﺭ ﺍﺭﺍﺋﻪ ﺷـﺪﻩ ﺍﺳـﺖ‪ .‬ﺩﺭ ﺍﻳـﻦ ‪image gallery .CD‬‬
‫ﻭﺟﻮﺩ ﺩﺍﺭﺩ ﻛﻪ ﺗﺼﺎﻭﻳﺮ ﺑﺪﻭﻥ ﺗﻮﺿﻴﺢ ﺍﺭﺍﺋﻪ ﺷﺪﻩ ﻭ ﺍﺯ ﺁﻥ ﺑﻪ ﻋﻨﻮﺍﻥ ‪ quiz‬ﻭ ﺍﺭﺯﻳﺎﺑﻲ ﺷﺨﺼﻲ ﻣﻲﺗﻮﺍﻥ ﺍﺳﺘﻔﺎﺩﻩ ﻛﺮﺩ‪ .‬ﺍﺯ ‪ index incon‬ﻛﻪ ﺑﺮ ﺍﺳﺎﺱ ﺣﺮﻭﻑ ﺍﻟﻔﺒﺎﻱ ﺍﻧﮕﻠﻴﺴﻲ ﺑﻨﺎ ﺷﺪﻩ ﻣﻲﺗﻮﺍﻥ ﺑﻪ ﺭﺍﺣﺘﻲ ﺑﺮﺍﻱ ﺟﺴﺘﺠﻮﻱ ﻣﻮﺿﻮﻉ ﺑﻴﻤﺎﺭﻱ ﻛﻤﻚ ﮔﺮﻓﺖ‪.‬‬
‫‪7.6‬‬ ‫)‪Botulinum Toxin Aesthetic Indications (Mauricio de Maio, Segio Talarico, Benjamin Ascher, Nam Ho Kim South‬‬ ‫‪2003‬‬

‫ﺗﻠﻔﻦ‪٠٩١٢١٣٧٢٣٦١-٦٦٩٣٦٦٩٦ :‬‬ ‫ﻧﺸﺎﻧﻲ‪ :‬ﺗﻬﺮﺍﻥ‪ ،‬ﻡ ﺍﻧﻘﻼﺏ‪ ،‬ﺥ ﻛﺎﺭﮔﺮ ﺟﻨﻮﺑﻲ‪ ،‬ﺥ ﻟﺒﺎﻓﻲﻧﮋﺍﺩ‪ ،‬ﺑﻴﻦ ﻛﺎﺭﮔﺮ ﻭ ﺟﻤﺎﻟﺰﺍﺩﻩ‪ ،‬ﺑﻦﺑﺴﺖ ﺳﻴﻤﻴﻦ‪ ،‬ﭘﻼﻙ ‪٢٣٩‬‬ ‫ﻣﺮﻛﺰ ﺧﺪﻣﺎﺕ ﻓﺮﻫﻨﮕﻲ ﺳﺎﻟﻜﺎﻥ ‪ :‬ﺍﺭﺍﺋﻪ ﻛﻨﻨﺪﺓ ﻛﺘﺎﺏ ﻭ ﺳﻲﺩﻱﻫﺎﻱ ﺗﺨﺼﺼﻲ ﭘﺰﺷﻜﻲ‬
 ‫‪31‬‬
‫‪8.6‬‬ ‫‪Color Atlas and synopsis of Clinical Dermatology‬‬ ‫‪Common and Serious Diseases Thomas B.‬‬ ‫)‪(Fitzpatrick, M.D. Richard Allen Johnson, M.D. Dick Suurmond, M.D‬‬ ‫ــــــ‬
‫‪9.6‬‬ ‫)‪COLOR ATLAS OF CLINICAL DERMATOLOGY COMMON AND SERIOUS DISEASES (Salekan E-Book‬‬ ‫ــــــ‬
‫)‪(Thomas B. Fitzpatrick, MD, Richard Allen Johnson, MD, Klaus Wolff, MD, Dick Suurmond, MD‬‬
‫)‪10.6 Color Atlas of Dermatoxcopy 2nd, enlarged and completely revised edition (Wilhelm Stolz. Otto Braun-Falco) (Salekan E-Book‬‬ ‫‪2001‬‬
‫‪11.6 Correction of Wrinkles & Augmentation of lip and cheek with Restylane & Perlane‬‬ ‫)‪(Natural beauty for as long as you like‬‬ ‫ــــــ‬

‫ﻳﻜﻲ ﺍﺯ ﺑﻬﺘﺮﻳﻦ ‪ Skin filler‬ﻫﺎ ﺑﺮﺍﻱ ﺭﻓﻊ ﭼﻴﻦ ﻭ ﭼﺮﻭﻙﻫﺎﻱ ﺻﻮﺭﺕ ﻛﻪ ﺳﺎﺯﮔﺎﺭﻱ ﺁﻥ ﺑﺎ ﺑﺎﻓﺖ ﺍﻧﺴﺎﻥ ‪ %١٠٠‬ﺍﺳﺖ‪ .‬ﻫﻴﺎﻧﻮﺭﻭﺗﻴﻚ ﺍﺳﻴﺪ ﺗﻮﻟﻴﺪ ﺷﺪﻩ ﺗﻮﺳﻂ ﺗﻜﻨﻴﻚ ‪ recombinant‬ﻣﻲﺑﺎﺷﺪ‪ .‬ﺍﻳﻦ ﻣﺎﺩﻩ ﺗﻮﺳﻂ ﻛﺸﻮﺭ ﺳﻮﺋﺪ ﺩﺭ ﺳﻪ ﻏﻠﻈﺖ ﺑﻪ ﻧﺎﻡﻫﺎﻱ ‪ Restyalne , Restyane fine‬ﻭ‬
‫‪ perlane‬ﻣﻲﺑﺎﺷﺪ ﻛﻪ ﺑﺮ ﺣﺴﺐ ﻧﻮﻉ ﺧﻄﻮﻁ ﺻﻮﺭﺕ )ﻇﺮﻳﻒ ﻳﺎ ﻋﻤﻴﻖ( ﺩﺭ ﺳﻄﻮﺡ ﻣﺨﺘﻠﻒ ﺩﺭﻡ ﺗﺰﺭﻳﻖ ﻣﻲﺷﻮﺩ‪ .‬ﺩﺭ ﺍﻳﻦ ‪ : VCD‬ﺍﺑﺘﺪﺍ ﻣﺮﻭﺭﻱ ﺑﺮ ﭼﮕﻮﻧﮕﻲ ﺳﺎﺧﺖ ﺍﻳﻦ ﺳﻪ ﻣﺎﺩﻩ ﺩﺍﺭﺩ ﻭ ﺳﭙﺲ ﻣﻮﺍﺭﺩ ﺍﺳﺘﻔﺎﺩﻩ ﻭ ﭼﮕﻮﻧﮕﻲ ﺗﺰﺭﻳﻖ ﻭ ﺗﻜﻨﻴﻚﻫﺎﻱ ﺗﺰﺭﻳﻖ ﺭﺍ ﺟﺪﺍﮔﺎﻧﻪ ﺑﺎ ﺗﺼﺎﻭﻳﺮ ﻛﺎﻣ ﹰ‬
‫ﻼ ﻭﺍﺿﺢ ﻧﺸﺎﻥ‬
‫ﺩﺍﺩﻩ ﺷﺪﻩ ﺍﺳﺖ‪ .٢ .‬ﺩﺭ ﻗﺴﻤﺖ ﺑﻌﺪﻱ ﺑﻪ ﺻﻮﺭﺕ ‪ animation‬ﻋﻤﻖ ﻭ ﻣﺤﻞ ﺗﺰﺭﻳﻖ ﻫﺮ ﻳﻚ ﺍﺯ ﺍﻳﻦ ﺳﻪ ﻣﺤﺼﻮﻝ ﺭﺍ ﺩﺭ ﺩﺭﻡ ﻧﺸﺎﻥ ﻣﻲﺩﻫﺪ‪ .٣ .‬ﺩﺭ ﺍﻳﻦ ﻗﺴﻤﺖ ﻃﺮﻳﻘﺔ ﺑﻲﺣﺴﻲ ﻣﻮﺿﻌﻲ ﺑﻪ ﻧﻤﺎﻳﺶ ﮔﺬﺍﺷﺘﻪ ﻣﻲﺷﻮﺩ‪ .٣ .‬ﺩﺭ ﺍﻳﻦ ﻗﺴﻤﺖ ﺗﻜﻨﻴﻚ ﺗﺰﺭﻳﻖ ‪ Reslane fine‬ﻭ ﻣﺤﻞ ﺗﺰﺭﻳﻖ ﻧﺸﺎﻥ‬
‫ﺩﺍﺩﻩ ﺷﺪﻩ ﺍﺳﺖ‪ .٤ .‬ﺩﺭ ﺍﻳﻦ ﻗﺴﻤﺖ ﺗﻜﻨﻴﻚ ﺗﺰﺭﻳﻖ ‪ Restylana‬ﻭ ﻣﺤﻞ ﺗﺰﺭﻳﻖ ﻧﺸﺎﻥ ﺩﺍﺩﻩ ﻣﻲﺷﻮﺩ‪ .٥ .‬ﺩﺭ ﺍﻳﻦ ﻗﺴﻤﺖ ﺗﻜﻨﻴﻚ ﺗﺰﺭﻳﻖ ‪ Perlane‬ﺑﺮﺍﻱ ﺭﻓﻊ ﭼﻴﻦﻫـﺎﻱ ﻋﻤﻘـﻲ )ﻣﺎﻧﻨـﺪ ﻧﺎﺯﻭﺷـﻴﺎﻝ( ﻭ ‪ fonciel contouring‬ﻣﺎﻧﻨـﺪ )‪ Lip enhan cemenl‬ﻭ ‪ (cheek enhancmeat‬ﻭ‬
‫ﺩﺭﻣﺎﻥ ‪ oral Commisure‬ﻧﺸﺎﻥ ﺩﺍﺩﻩ ﻣﻲﺷﻮﺩ‪ .٦ .‬ﺩﺭ ﺍﻳﻦ ﺑﺨﺶ ﺗﺮﻛﻴﺒﻲ ﺍﺯ ﺗﺰﺭﻳﻘﺎﺕ ﺑﺎﻻ ﺭﺍ ﺩﺭ ﻳﻚ ﺑﻴﻤﺎﺭ ﻧﺸﺎﻥ ﻣﻲﺩﻫﺪ‪ .٧ .‬ﺩﺭ ﺑﺨﺶ ﺍﻧﺘﻬﺎ ‪ followup‬ﺑﻴﻤﺎﺭ ﺗﻮﺿﻴﺢ ﺩﺍﺩﻩ ﺷﺪﻩ ﺍﺳﺖ‪ .٨ .‬ﺩﺭ ﺍﻧﺘﻬﺎﻱ ﻫﺮ ﻗﺴﻤﺖ ﺗﺼﺎﻭﻳﺮ ﻗﺒﻞ ﻭ ﺑﻌﺪ ﺍﺯ ﺗﺰﺭﻳﻖ ﻧﺸﺎﻥ ﺩﺍﺩﻩ ﺍﺳﺖ‪.‬‬
‫‪12.6 Cosmetic Surgery for FACE and BODY‬‬ ‫ــــــ‬
‫‪13.6 COSMETIC LASER SURGERY‬‬ ‫)‪PERFECT THE TECHIQUES, REDUCE THE RISKS, AND ENJOY THE RESULTS WHEN PERFORMING COSMETIC LASER SURGERY (Richard E. Fitzpatrick Mitchel P. Goldman‬‬ ‫‪2000‬‬
‫‪14.6 Cosmetic Surgery‬‬ ‫‪An Interdisciplinory Approach‬‬ ‫‪BASIC AND CLINICAL DERMATOLOGY‬‬ ‫)‪(ALAN R. SHALITA, M.D., DAVID A. NORRIS, M.D‬‬ ‫‪2001‬‬

‫ﻛﺘﺎﺏ ﻓﻮﻕ ﻛﻪ ﺩﺭ ﻣﺮﻛﺰ ﺧﺪﻣﺎﺕ ﻓﺮﻫﻨﮕﻲ ﺳﺎﻟﻜﺎﻥ ﺗﺒﺪﻳﻞ ﺑﻪ ﻛﺘﺎﺏ ﺍﻟﻜﺘﺮﻭﻧﻴﻜﻲ ﮔﺮﺩﻳﺪﻩ ﺑﻪ ﮔﻔﺘﻪ ﻣﺆﻟﻒ ﻛﺘﺎﺏ ﻛﻤﺘﺮ ﻛﺘﺎﺑﻲ ﺍﺳﺖ ﻛﻪ ﺗﻠﻔﻴﻘﻲ ﺍﺯ ﺩﺍﻧﺶ ﺩﺭﻣﺎﺗﻮﻟﻮﮊﻱ‪ ،‬ﻣﺎﮔﺰﻳﻠﻮﻓﺎﺷﻴﺎﻝ ﻭ ﺟﺮﺍﺣﻲ ﭘﻼﺳﺘﻴﻚ ﺭﺍ ﺩﺭ ﺧﻮﺩ ﮔﻨﺠﺎﻧﺪﻩ ﺍﺳﺖ‪ .‬ﺍﻳﻦ ﻛﺘﺎﺏ ﺣﺪﻭﺩ ‪ ١٠٠٠‬ﺻﻔﺤﻪﺍﻱ‪ ،‬ﺁﺧـﺮﻳﻦ ﺗﻜﻨﻴـﻚﻫـﺎﻱ ﺩﺭ‬
‫ﺩﺳﺘﺮﺱ ﺩﺭ ﺟﺮﺍﺣﻲﻫﺎﻱ ﺯﻳﺒﺎﻳﻲ ﺭﺍ ﮔﺮﺩﺁﻭﺭﻱ ﻧﻤﻮﺩﻩ ﺗﺎ ﺑﺮﺍﻱ ﻫﺮ ﺑﻴﻤﺎﺭ ﺑﻪ ﺻﻮﺭﺕ ﺍﻧﻔﺮﺍﺩﻱ ﺗﻜﻨﻴﻚ ﻣﻨﺎﺳﺐ ﺗﺼﻤﻴﻢﮔﻴﺮﻱ ﻭ ﺑﻪ ﻛﺎﺭ ﺭﻭﺩ‪ .‬ﺍﻳﻦ ﻛﺘﺎﺏ ﺩﺍﺭﺍﻱ ﻓﺼﻮﻟﻲ ﺍﺳﺖ ﻛﻪ ﺗﻮﺳﻂ ﺩﺭﻣﺎﺗﻮﻟﻮﮊﻳﺴﺖﻫﺎ ﺟﺮﺍﺣﺎﻥ ﭘﻼﺳﺘﻴﻚ ﻭ ﺟﺮﺍﺣﺎﻥ ﻓﻚ ﻭ ﺻﻮﺭﺕ ﻧﻮﺷﺘﻪ ﺷﺪﻩ ﺍﺳﺖ‪.‬‬
‫ﺍﻳﻦ ﻛﺘﺎﺏ ‪ Procedure‬ﻫﺎﻱ ﺟﺮﺍﺣﻲ ﺭﺍ ﻗﺪﻡ ﺑﻪ ﻗﺪﻡ ﺗﻮﺿﻴﺢ ﺩﺍﺩﻩ ﻭ ﺗﻤﺎﻡ ﺟﻨﺒﻪﻫﺎﻱ ﺗﻜﻨﻴﻚﻫـﺎﻱ ﺟﺮﺍﺣـﻲ ﺭﺍ ﺗﻮﺿـﻴﺢ ﺩﺍﺩﻩ ﺍﺳـﺖ‪ .‬ﺍﻃﻼﻋـﺎﺕ ‪ Pre-op‬ﻭ ‪ Post-op‬ﻭ ﻓـﺮﻡ ﺭﺿـﺎﻳﺖﻧﺎﻣـﻪ ﺩﺭ ﻫـﺮ ﻓﺼـﻞ ﺁﻭﺭﺩﻩ ﺷـﺪﻩ‪ .‬ﺩﺭ ﻫـﺮ ﻓﺼـﻞ ﺍﻧﺪﻳﻜﺎﺳـﻴﻮﻥ ﻭ‬
‫ﻛﻨﺘﺮﺍﺍﻧﺪﻳﻜﺎﺳﻴﻮﻥﻫﺎﻱ ﻫﺮ ﺗﻜﻨﻴﻚ ﺟﺮﺍﺣﻲ ﻭ ﻣﺤﺪﻭﺩﻳﺖﻫﺎﻱ ﺩﺭﻣﺎﻧﻲ ﻭ ﻋﻮﺍﺭﺽ ﻭ ﺩﺭﻣﺎﻥ ﻋﻮﺍﺭﺽ ﻭ ﺩﺭﻣﺎﻥ ﻋﻮﺍﺭﺽ ﺑﺤﺚ ﺷﺪﻩ ﺍﺳﺖ‪ .‬ﺑﻪ ﮔﻔﺘﻪ ﻣﺆﻟﻒ ﻛﺘﺎﺏ ﭼﻮﻥ ﻫﺮ ﻓﺼﻞ ﻛﺘﺎﺏ ﺗﻮﺳﻂ ﻣﺠﺮﺏﺗﺮﻥ ﺍﻓﺮﺍﺩ ﺩﺭ ﺯﻣﻴﻨﻪ ﻛﺎﺭﻱ ﺧﻮﺩ ﻧﮕﺎﺭﺵ ﻳﺎﻓﺘﻪ ﺍﺳﺖ ﻧﻜﺎﺕ ﻛﻠﻴﺪﻱ‬
‫ﻭ ﺗﻜﻨﻴﻚﻫﺎﻱ ﺍﺧﺘﺼﺎﺻﻲ ﻭ ﺍﻃﻼﻋﺎﺕ ﻛﻮﭼﻚ ﻭﻟﻲ ﺑﺎﺍﺭﺯﺵ ﺩﺭ ﻣﻮﺭﺩ ﺗﻜﻨﻴﻚﻫﺎ ﻭ ﺭﻭﺵ ﻋﻤﻞ ﺁﻭﺭﺩﻩ ﺷﺪﻩ ﺍﺳﺖ‪ .‬ﺩﺭ ﻓﺼﻞ ‪ -١‬ﻃﺮﺍﺣﻲ ﻣﻨﺎﺳﺐ ﺑﺮﺍﻱ ﻳﻚ ﺟﺮﺍﺣﻲ ﺑﺤﺚ ﺷﺪﻩ‪ .‬ﻓﺼﻞ ‪ -٢‬ﺁﻧﺎﻟﻴﺰ ﺯﻳﺒﺎﻳﻲ ﺷﻨﺎﺧﺘﻲ ﺩﺭ ﻣﻮﺭﺩ ﺩﺭﻣﺎﻥ ﺻﻮﺭﺕﻫﺎﻱ ﭘﻴﺮ ﺁﻭﺭﺩﻩ ﺷﺪﻩ‪ .‬ﻓﺼﻞ‬
‫‪ ٣‬ﺗﺎ ‪ Peel ٦‬ﺳﻄﺤﻲ ﻭ ﻋﻤﻘﻲ ﻭ ﺗﺮﻛﻴﺐ ‪ Peel‬ﻫﺎ ﻭ ﻋﻼﻭﻩ ﺑﺮ ﺁﻥ ‪) total body peel‬ﮔﺮﺩﻥ‪ Chest .‬ﻭ ﺩﺳﺖﻫﺎ ﻭ ﻣﻨﺎﻃﻖ ﺩﻳﮕﺮ( ﻧﻴﺰ ﺗﻮﺿﻴﺢ ﺩﺍﺩﻩ ﺷﺪﻩ ﺍﺳﺖ‪ .‬ﺩﺭ ﻓﺼﻞ ‪ ٦‬ﻛﻤﭙﻠﻴﻜﺎﺳﻴﻮﻥ ﻭ ﺩﺭﻣﺎﻥ ﺑﻪ ﻃﻮﺭ ﺟﺪﺍﮔﺎﻧﻪ ﺑﺤﺚ ﺷﺪﻩ ﺍﺳـﺖ‪ .‬ﺩﺭ ﻓﺼـﻮﻝ ‪ ٧‬ﻭ ‪ ٨‬ﻭ ‪ ٩‬ﻭ‬
‫‪ ٢٢‬ﻭ ‪ ٢٤‬ﻭ ‪ ٣٧‬ﺩﺭ ﻣﻮﺭﺩ ﺍﻧﻮﺍﻉ ﺩﺭﻣﺎﻥﻫﺎ ﻭ ﺗﻜﻨﻴﻚﻫﺎﻱ ﻟﻴﺰﺭ )‪ Er: YAG, Co2‬ﺿﺎﻳﻌﺎﺕ ﻋﺮﻭﻗﻲ ‪ tattoo‬ﻭ ﺿﺎﻳﻌﺎﺕ ﭘﻴﮕﻤﺎﻧﺘﻪ ‪ ( hair removal‬ﻣﻮﺭﺩ ﺑﺤﺚ ﻗﺮﺍﺭ ﮔﺮﻓﺘﻪ ﺍﺳﺖ‪ .‬ﺩﺭ ﻓﺼﻞ ‪ ٩‬ﺩﺭ ﻣﻮﺭﺩ ﻣﺆﺛﺮ ﺑﻮﺩﻥ ﻟﻴﺰﺭﻫﺎﻱ ‪ Resurfacing‬ﺻـﺤﺒﺖ ﻧﻤـﻮﺩﻩ ﺍﺳـﺖ‪.‬‬
‫ﻓﺼﻞ ‪ ١٠‬ﺑﻪ ‪ Dermabrasion‬ﺍﺧﺘﺼﺎﺹ ﺩﺍﺩﻩ ﺍﺳﺖ‪ .‬ﻓﺼﻞ ‪ ١١‬ﺍﻟﻲ ‪ ١٦‬ﺩﺭ ﻣﻮﺭﺩ ﺩﻓﻊ ﭼﻴﻦ ﻭ ﭼﺮﻭﻙﻫﺎ ﺗﻮﺳﻂ ‪ Skin filler‬ﻫﺎ )‪ Restiylans‬ﻭ‪ ، inerrall , Perlane‬ﻛـﻼﮊﻥ ﻭ ‪ (....‬ﻭ ﺗﺰﺭﻳـﻖ ﭼﺮﺑـﻲ ﻭ ﺩﺭ ﻓﺼـﻞ ‪ ١٥‬ﺍﺧﺘﺼﺎﺻـﹰﺎ ﺑـﻪ ﭼﮕـﻮﻧﮕﻲ ﺍﺳـﺘﻔﺎﺩﻩ ﺍﺯ‬
‫‪ Gortex‬ﺍﺷﺎﺭﻩ ﺷﺪﻩ ﺍﺳﺖ‪ .‬ﻓﺼﻞ ‪ ١٧‬ﺑﻪ ‪ BotulinumsToxin‬ﺍﺷﺎﺭﻩ ﺷﺪﻩ ﺍﺳﺖ‪ .‬ﺩﺭ ﻓﺼﻞ ‪ ١٨‬ﭼﮕﻮﻧﮕﻲ ﺟﺮﺍﺣﻲ ﺧﺎﻝﻫﺎ‪ Cyst ،‬ﺍﺳﻜﺎﺭ ﺑﺤﺚ ﺷﺪﻩ ﺍﺳﺖ‪ .‬ﻓﺼﻞ ‪ ١٩‬ﺍﺧﺘﺼﺎﺹ ﺑﻪ ﺍﻧـﻮﺍﻉ ‪ flap‬ﻭ ‪ Graft‬ﻫـﺎ ﺩﺍﺭﺩ‪ .‬ﻓﺼـﻮﻝ ‪ ١٢‬ﻭ ‪ ١٣‬ﻭ ‪ ٢٥‬ﺑـﻪ ﻟﻴﭙﻮﺳﺎﻛﺸـﻦ ﻭ‬
‫ﻟﻴﭙﻮﺍﻧﻔﻮﺯﻳﻮﻥ ﻭ ‪ tumescent‬ﺍﺧﺘﺼﺎﺹ ﺩﺍﺭﺩ‪ .‬ﺩﺭ ﻓﺼﻮﻝ ‪ ٣٣‬ﺗﺮﻛﻴﺐ ‪ procedure‬ﻫﺎﻱ ﺯﻳﺒﺎﻳﻲ ﻣﻮﺭﺩ ﺑﺤﺚ ﻗﺮﺍﺭ ﮔﺮﻓﺘﻪ ﺍﺳﺖ‪ .‬ﺩﺭ ﻓﺼﻮﻝ ‪ fac, Neck ٢٩-٣٢‬ﻭ ‪ lifling‬ﺑﺤﺚ ﺷﺪﻩ ﻭ ﺭﻭﺵﻫﺎﻱ ﺩﺭ ﺑﻠﻔﺎﺭﻭﭘﻼﺳﺘﻲ ‪ Brow Reyirvenation‬ﺁﺭﺭﺩﻩ ﺷﺪﻩ ﺍﺳـﺖ‬
‫ﻭ ﺩﺭ ﻓﺼﻞ ‪ ٣١‬ﺑﻠﻔﺎﺭﻭﭘﻼﺳﺘﻲ ﭘﻠﻚ ﺑﺎﻻ ﻭ ﭘﺎﻳﻴﻦ ﺍﺯ ﺩﻳﺪ ﺍﻓﺘﺎﻟﻤﻮﻟﻮﮊﻳﺴﺖﻫﺎ ﻣﻮﺭﺩ ﺑﺤﺚ ﻗﺮﺍﺭ ﮔﺮﻓﺘﻪ ﺍﺳﺖ‪ .‬ﺩﺭ ﻓﺼﻞ ‪ ٢٧‬ﻛﺘﺎﺏ ﺭﻭﺵ ﺍﺧﺘﺼﺎﺻﻲ ‪ D. Cook‬ﺑﻪ ﻧﺎﻡ ‪ The cook weekend Altrnative to face lift‬ﺍﺷﺎﺭﻩ ﺷﺪﻩ ﺍﺳﺖ‪ .‬ﻓﺼﻞ ‪ ٣٤‬ﺑﻪ ﻛﺎﺷﺖ ﻣـﻮ‬
‫ﻭ ‪ Alopecia Redechion‬ﺍﺧﺘﺼﺎﺹ ﺩﺍﺭﺩ‪ .‬ﻓﺼﻞ ‪ ٣٨‬ﻛﺘﺎﺏ ﺑﻪ ﺗﻜﻨﻴﻚﻫﺎﻱ ﻋﻜﺎﺳﻲ ﺩﺭ ﻣﻄﺐ ﺑﺮﺍﻱ ﻛﺎﺭﻫﺎﻱ ﺯﻳﺒﺎﻳﻲ ﺍﺷﺎﺭﻩ ﺩﺍﺭﺩ‪ .‬ﻓﺼﻞ ‪ ٣٩‬ﺑﻪ ﭼﮕﻮﻧﮕﻲ ﺑﺮﺧﻮﺭﺩ ﻭ ﺩﺭﻣﺎﻥ ﺑﻴﻤﺎﺭﺍﻥ ﻣﺸﻜﻞﺁﻓﺮﻳﻦ ﻭ ﻧﺎﺭﺍﺿـﻲ ﺍﺧﺘﺼـﺎﺹ ﺩﺍﺭﺩ‪ .‬ﻓﺼـﻞ ‪ ٤٠‬ﻭ ‪ ٤١‬ﺍﺧﺘﺼـﺎﺹ ﺑـﻪ‬
‫ﺍﻳﻤﭙﻼﻧﺖﻫﺎﻱ ﺻﻮﺭﺕ ﻭ ﻛﺎﺭﻫﺎﻱ ﺯﻳﺒﺎﻳﻲ ﺟﺮﺍﺣﻲﻫﺎﻱ ﻣﺎﮔﺰﻳﻠﻮﻓﺎﺳﻴﺎﻝ ﻭ ﺩﻫﺎﻥ ﻣﻮﺭﺩ ﺑﺤﺚ ﻗﺮﺍﺭ ﮔﺮﻓﺘﻪ ﺍﺳﺖ‪.‬‬
‫‪15.6‬‬ ‫‪COSMETIC‬‬ ‫‪LASER‬‬ ‫‪SURGERY‬‬ ‫‪For‬‬ ‫‪Face‬‬ ‫‪and‬‬ ‫‪Body‬‬ ‫ــــــ‬
‫)‪16.6 Cutaneous Laser Surgery (Second edition) The Art and Science of Selective Photothermolysis (Goldman, Fitzpartick‬‬ ‫ــــــ‬
‫ﻛﺘﺎﺏ ﻓﻮﻕ ﻛﻪ ﺩﺭ ﻣﺮﻛﺰ ﺧﺪﻣﺎﺕ ﻓﺮﻫﻨﮕﻲ ﺳﺎﻟﻜﺎﻥ ﺗﺒﺪﻳﻞ ﺑﻪ ﻛﺘﺎﺏ ﺍﻟﻜﺘﺮﻧﻴﻜﻲ ﮔﺮﺩﻳﺪﻩ ﻣﻜﻤﻞ ﺑﺮ ﻛﺘﺎﺏ ‪ Cutaneous Laser Surgery‬ﭼﺎﭖ ﻫﻤﻴﻦ ﻣﺆﻟﻔﻴﻦ ﻣﻲﺑﺎﺷﺪ‪ .‬ﻛﺘﺎﺏ ‪ Cutaneus Laser‬ﻳﻚ ﻛﺘﺎﺏ ‪ text‬ﺩﺭ ﺯﻣﻴﻨﺔ ﻟﻴﺰﺭ ﻣﻲﺑﺎﺷﺪ ﻭ ﻫﺮ ﻧﻮﻉ ﺍﺯ ﺗﻜﻨﻮﻟﻮﮊﻱ ﻟﻴـﺰﺭ ﺑـﺮﺍﻱ‬
‫ﺩﺭﻣﺎﻥ ﺿﺎﻳﻌﺎﺕ ﭘﻮﺳﺘﻲ ﺭﺍ ﺗﻮﺿﻴﺢ ﺩﺍﺩﻩ ﺍﺳﺖ ﻭﻟﻲ ﻛﺘﺎﺏ ‪ Cosmetic Laser Surgery‬ﻛﻤﻜﻲ ﺍﺳﺖ ﺑﺮﺍﻱ ﭘﺰﺷﻜﺎﻥ ﺑﺎ ﺗﺄﻛﻴﺪ ﺑﻴﺸﺘﺮ ﺑﺮ ﺑﺮﺧﻮﺭﺩ ﺩﺭﻣﺎﻧﻲ ﺑﺎ ﺑﻴﻤﺎﺭ‪.‬‬
‫ﻓﺼﻞ ﺍﻭﻝ ﻛﺘﺎﺏ ﻣﺮﻭﺭﻱ ﺑﺮ ‪ Laser tissue interaction‬ﻣﻲﺑﺎﺷﺪ ﻛﻪ ﻣﻲ ﺗﻮﺍﻥ ﺑﻪ ﻋﻨﻮﺍﻥ ﻳﻚ ‪ mini text book‬ﺍﺯ ﺁﻥ ﺍﺳﺘﻔﺎﺩﻩ ﻛﺮﺩ‪ .‬ﻓﺼﻞ ﺩﺭﺧﺸﺎﻥ ﻛﺘﺎﺏ ﻓﺼﻞ ‪ Wuond healing‬ﻣﻲﺑﺎﺷﺪ ﺑﻪ ﮔﻔﺘﻪ ﻣﺆﻟﻔﻴﻦ ﺍﺳﺘﻔﺎﺩﻩ ﺍﺯ ﺑﻬﺘﺮﻳﻦ ﻟﻴﺰﺭﻫﺎ ﻭ ﺑﻬﺘﺮﻳﻦ ﺗﻜﻨﻴﻚ ﻫﺎ ﺑﺪﻭﻥ ﺗﻮﺟﻪ ﺑـﻪ‬
‫‪ Post procedural wound healing‬ﻣﻨﺠﺮ ﺑﻪ ﻛﻤﺘﺮﻳﻦ ﻧﺘﻴﺠﻪ ﻣﻲﺷﻮﺩ‪ .‬ﻓﺼﻞ ‪ ٣‬ﻭ ‪ ٤‬ﻭ ‪ ٥‬ﻭ ‪ ٦‬ﻭ ﺩﺭ ﻣﻮﺭﺩ ﺍﺳﺘﻔﺎﺩﻩ ﻭ ﺗﻮﺿﻴﺢ ﻛﻤﭙﻠﻴﻜﺎﺳﻴﻮﻥ ﺍﺯ ﻟﻴﺰﺭﻫﺎﻱ ‪ co2‬ﻭ ‪ Erbium:Yag‬ﺩﺭ ‪ resurfacing‬ﻭ ‪ Er:yag‬ﺻﻮﺭﺕ ﻭ ﮔﺮﺩﻥ ﻭ ‪ chest‬ﻣـﻲﺑﺎﺷـﺪ ﻭ ﻫﻤﭽﻨـﻴﻦ ﺩﺭ ﻣـﻮﺭﺩ ﺍﺳـﺘﻔﺎﺩﻩ ﺍﺯ ﻟﻴـﺰﺭ‬
‫‪ carbon Dioxide ultrapulse‬ﻭ ‪ Er:yag‬ﺩﺭ ﺍﻃﺮﺍﻑ ﭼﺸﻢ ﺷﺮﺡ ﺩﺍﺩﻩ ﺷﺪﻩ ﺍﺳﺖ‪ .‬ﻳﻜﻲ ﺍﺯ ﻓﺼﻮﻝ ﺗﺎﺯﻩ ﻛﺘﺎﺏ ﺍﺳﺘﻔﺎﺩﻩ ‪ Nonablative Laser‬ﺩﺭ ﻣﻮﺭﺩ ﭼﻴﻦ ﻭ ﭼﺮﻭﻙ ﻫﺎﻱ ﺻﻮﺭﺕ ﻣﻲﺑﺎﺷﺪ ﻛﻪ ﻣﻘﺒﻮﻟﻴﺖ ﺭﻭﺯﺍﻓﺮﻭﻥ ﭘﻴﺪﺍ ﻛﺮﺩﻩ ﺍﺳﺖ ﻭ ﺩﺭ ﻓﺼﻞ ‪ incisional laser Surgery ٩‬ﺑﺮﺍﻱ ﻣﻮﺍﺭﺩ‬
‫ﺍﺳﺘﻔﺎﺩﻩ ﺩﺭ ﺟﺮﺍﺣﻲ ﭘﻼﺳﺘﻴﻚ ﻭ ﺑﻠﻔﺎﺭﻭﭘﻼﺳﺘﻲ ﺗﻮﺿﻴﺢ ﺩﺍﺩﻩ ﺷﺪﻩ ﺍﺳﺖ‪ .‬ﺩﺭ ﻓﺼﻞ ‪ ١٠‬ﻛﺘﺎﺏ ‪ Tinas.Alster‬ﻣﺆﻟﻒ ﻛﺘﺎﺏ ‪ manual of cutaneous laser techniques‬ﺍﺳﺘﻔﺎﺩﻩ ﺍﺯ ﻟﻴﺰﺭ ﺩﺭ ‪ Scar revision‬ﺭﺍ ﺷﺮﺡ ﺩﺍﺩﻩ ﺍﺳﺖ‪ .‬ﺩﺭ ﻓﺼﻞ ‪ ١١‬ﺟﺪﻳﺪﺗﺮﻳﻦ ﺗﻜﻨﻴﻜﻬﺎﻱ ﻣﻮﺭﺩ ﺍﺳﺘﻔﺎﺩﻩ ﺩﺭ ‪hair‬‬
‫‪] removal‬ﻣﻘﺎﻳﺴﻪ ﺁﻧﻬﺎ ﻭ ﻃﺮﺯ ﻛﺎﺭ ﻭ ﻣﻌﺮﻓﻲ ﻟﻴﺰﺭﻫﺎﻱ ﻣﻌﺘﺒﺮ ﺍﺯ ﻛﺎﺭﺧﺎﻧﻪ ﻫﺎﻱ ﻣﻌﺘﺒﺮ[ ﻣﻮﺭﺩ ﺑﺤﺚ ﻗﺮﺍﺭ ﮔﺮﻓﺘﻪ ﺍﺳﺖ ﻭﺍﺳﺘﻔﺎﺩﻩ ﺍﺯ ‪ mtense light source‬ﺩﺭ ‪ hair transplant‬ﺻﺤﺒﺖ ﺷﺪﻩ ﺍﺳﺖ‪ .‬ﺩﺭ ﻓﺼﻞ‪ ١٢‬ﺍﺳﺘﻔﺎﺩﻩ ﺟﺪﻳﺪ ﺍﺯ ﻟﻴﺰﺭ ‪ Co2‬ﻭ ‪ Er:yag‬ﺩﺭ ‪) hair transplant‬ﻛﺎﺷﺖ ﻣـﻮ(‬
‫ﺑﺤﺚ ﮔﺮﺩﻳﺪﻩ ﺍﺳﺖ‪ .‬ﺩﺭ ﻓﺼﻞ ‪ ١٣‬ﻛﺘﺎﺏ ﺩﺭﻣﺎﻥ ‪ Leg vein‬ﺑﺎ ﺍﺳﺘﻔﺎﺩﻩ ﺍﺯ ﻟﻴﺰﺭ ﺁﻭﺭﺩﻩ ﺷﺪﻩ ﺍﺳﺖ‪ .‬ﺩﺭ ﺁﺧﺮ‪ ،‬ﻣﺆﻟﻔﻴﻦ ﺍﻳﻦ ﻛﺘﺎﺏ ﺭﺍ ﺑﻪ ﻛﺎﺭﺑﺮﺩﻫﺎﻱ ﻟﻴﺰﺭ ﺑﻪ ﻋﻨﻮﺍﻥ ﻳﻚ ﺭﺍﻫﻨﻤﺎ ﺩﺭ ﺍﻧﺘﺨﺎﺏ ﻣﻨﺎﺳﺒﺘﺮﻳﻦ ﺗﻜﻨﻴﻚﻫﺎ ﺗﻮﺻﻴﻪ ﻣﻲﻧﻤﺎﻳﻨﺪ‪.‬‬

‫ﺗﻠﻔﻦ‪٠٩١٢١٣٧٢٣٦١-٦٦٩٣٦٦٩٦ :‬‬ ‫ﻧﺸﺎﻧﻲ‪ :‬ﺗﻬﺮﺍﻥ‪ ،‬ﻡ ﺍﻧﻘﻼﺏ‪ ،‬ﺥ ﻛﺎﺭﮔﺮ ﺟﻨﻮﺑﻲ‪ ،‬ﺥ ﻟﺒﺎﻓﻲﻧﮋﺍﺩ‪ ،‬ﺑﻴﻦ ﻛﺎﺭﮔﺮ ﻭ ﺟﻤﺎﻟﺰﺍﺩﻩ‪ ،‬ﺑﻦﺑﺴﺖ ﺳﻴﻤﻴﻦ‪ ،‬ﭘﻼﻙ ‪٢٣٩‬‬ ‫ﻣﺮﻛﺰ ﺧﺪﻣﺎﺕ ﻓﺮﻫﻨﮕﻲ ﺳﺎﻟﻜﺎﻥ ‪ :‬ﺍﺭﺍﺋﻪ ﻛﻨﻨﺪﺓ ﻛﺘﺎﺏ ﻭ ﺳﻲﺩﻱﻫﺎﻱ ﺗﺨﺼﺼﻲ ﭘﺰﺷﻜﻲ‬
 ‫‪32‬‬
‫)‪17.6 Cutaneous Medicine Cutaneous Manifestations of Systemic Disease (THOMAS T. PROVOST, MD, JOHN A.FLYNN, MD) (Johns Hopkins Medical Institutions Baltimore, Maryland‬‬ ‫‪2001‬‬
‫ﺑﻪ ﮔﻔﺘﺔ ﻣﺆﻟﻔﻴﻦ‪ ،‬ﺍﻳﻦ ﻛﺘﺎﺏ‪ ،‬ﺁﺭﻡ ﻭ ﻣﺸﺨﺼﻪ ﺩﭘﺎﺭﺗﻤﺎﻥ ﺩﺭﻣﺎﺗﻮﻟﻮﮊﻱ ﺩﺍﻧﺸﮕﺎﻩ ﺟﺎﻥ ﻫﺎﭘﻜﻴﻨﺰ ﻣﻲﺑﺎﺷﺪ‪ .‬ﺍﻳﻦ ﻛﺘﺎﺏ ﺑﻪ ﻋﻠﻢ ﺩﺭﻣﺎﺗﻮﻟﻮﮊﻱ ﻳﻚ ﻧﻈﺮ ﻛﻠﻲ ﻧﻪ ﻓﻘﻂ ﺑﻪ ﻋﻨﻮﺍﻥ ﭘﻮﺳﺖ ﻭ ﺿﻤﺎﺋﻢ ﺑﻠﻜﻪ ﺑﺎ ﺗﻮﺟﻪ ﺑﻪ ﺗﻈﺎﻫﺮﺍﺕ ﺩﻳﮕﺮ ﺑﻴﻤﺎﺭﻱ ﺩﺭ ﺑﺪﻥ ﺍﺷﺎﺭﻩ ﺩﺍﺭﺩ‪ .‬ﺍﻳﻦ ‪ ٧٨٢‬ﺻﻔﺤﻪﺍﻱ ﺑﺎ ‪٧٣‬‬
‫ﻓﺼﻞ ﺑﺎ ﻋﻜﺲﻫﺎﻱ ﺑﺎ ﻛﻴﻔﻴﺖ ﻋﺎﻟﻲ ﺑﻪ ﺭﺍﻫﻨﻤﺎﻳﻲ ﺑﺮﺍﻱ ﺩﺭﻣﺎﺗﻮﻟﻮﮊﻳﺴﺖﻫﺎ ﻭ ﻣﺘﺨﺼﺼﻴﻦ ﺩﺍﺧﻠﻲ ﻣﻲﺑﺎﺷﺪ‪ .‬ﻧﻜﺘﺔ ﺑﺎﺭﺯ ﺍﻳﻦ ﻛﺘﺎﺏ ﺁﻭﺭﺩﻥ ﻧﻜﺎﺕ ﻣﻬﻢ ﻛﺘﺎﺏ ﺩﺭ ﺣﺎﺷﻴﻪ ﺻﻔﺤﺎﺕ ﻣﻲﺑﺎﺷﺪ‪ .‬ﺍﻳﻦ ﻛﺘﺎﺏ ﺑﻴﻤﺎﺭﻱﻫﺎﻱ ﺩﺍﺧﻠﻲ ﻛﻪ ﺗﻈﺎﻫﺮﺍﺕ ﭘﻮﺳﺘﻲ ﺩﺍﺭﻧﺪ ﻭ ﺑﻴﻤﺎﺭﻱﻫـﺎﻱ ﭘﻮﺳـﺘﻲ ﻛـﻪ‬
‫ﻣﻲﺗﻮﺍﻧﺪ ﻋﻼﺋﻢ ﻋﻤﻮﻣﻲ ﭘﻴﺪﺍ ﻛﻨﺪ ﺭﺍ ﺗﻮﺻﻴﻒ ﻛﺮﺩﻩ ﺍﺳﺖ‪ .‬ﺗﻜﻴﻪ ﺍﻳﻦ ﻛﺘﺎﺏ ﺑﻪ ﻣﻮﺍﺭﺩ ﻛﻠﻴﺪ ﻛﻪ ﺩﺭ ﺗﺸﺨﻴﺺ ﻭ ﺩﺭﻣﺎﻥ ﻛﻤﻚ ﻣﻲﻛﻨﺪ‪ ،‬ﻣﻲﺑﺎﺷﺪ ﻭ ﺍﺯ ﻣﺒﺎﺣﺚ ﻏﻴﺮﺿﺮﻭﺭﻱ ﺍﺟﺘﻨﺎﺏ ﻛﺮﺩﻩ ﺍﺳﺖ‪.‬‬
‫‪ Dr. Richard Dobson‬ﺩﺭ ﻣﺠﻠﺔ ‪ (AAD) American etcademy of Dermatology‬ﺩﺭ ﻣﻮﺭﺩ ﺍﻳﻦ ﻛﺘﺎﺏ ﮔﻔﺘﻪ ﺍﺳﺖ‪ :‬ﺩﺭ ﮔﺬﺷﺘﺔ ﺍﻛﺜﺮ ﺩﺭﻣﺎﺗﻮﻟﻮﮊﻳﺴﺖﻫﺎ ﺑﻪ ﻋﻠﺖ ﺷﻴﻮﻉ ﺳﻴﻔﻴﻤﻴﺲ ﺑﺎ ﺑﻴﻤﺎﺭﻱﻫﺎﻱ ﺩﺍﺧﻠﻲ ﺁﺷﻨﺎ ﺑﻮﺗﺪﻩﺍﻧـﺪ ﺯﻳـﺮ ﺑـﻪ ﻗـﻮﻝ ‪Sir Willamosler‬‬
‫ﺩﺍﻧﺴﺘﻦ ﺳﻴﻔﻴﻤﻴﺲ ﺩﺍﻧﺴﺘﻦ ﻋﻠﻢ ﭘﺰﺷﻜﻲ ﺍﺳﺖ‪ .‬ﺑﺎ ﻭﺟﻮﺩ ﺍﻳﻨﺘﺮﻧﺖ ‪Procedure‬ﻫﺎﻱ ﺟﺮﺍﺣﻲ ﺩﺭ ﻋﻠﻢ ﺩﺭﻣﺎﺗﻮﻟﻮﮊﻱ ﺑﻪ ﻧﻈﺮ ﻣﻦ ‪ medical Dermatologist‬ﺩﺭ ﺁﻳﻨﺪﻩ ﺍﺯ ﺟﺎﻳﮕﺎﻩ ﻭﻳﮋﻩﺍﻱ ﺑﺮﺧﻮﺭﺩﺍﺭ ﺧﻮﺍﻫﻨﺪ ﺑﻮﺩ ﺯﻳﺮ ﺍﺑﺎ ﻭﺟﻮﺩ ﺗﻈـﺎﻫﺮﺍﺕ ﭘﻮﺳـﺘﻲ ﺑﻴﻤـﺎﺭﻱ ‪ AIDS‬ﻭ ﭘﻴﺸـﺮﻓﺖ‬
‫ﺩﺍﻧﺶ ﭘﺰﺷﻜﻲ ﺩﺭ ﻛﺎﺭﺑﺮﺩ ﺳﻴﺘﻮﻛﺴﻴﻦﻫﺎ‪ ،‬ﺁﻧﺘﻲﺑﻴﻮﺗﻴﻚ‪ ،‬ﻛﻤﻮﺗﺮﺍﭘﻲ ﻭ ﺍﻳﻤﻮﻧﻮﺳﺎﭘﺮﺳﻴﻮﻫﺎ ﻋﻠﻢ ﺩﺭﻣﺎﺗﻮﻟﻮﮊﻱ ﺑﺎﻟﻴﻨﻲ ﺑﻪ ﺍﻓﺮﺍﺩﻱ ﺑﺮﺍﻱ ﭘﺮ ﻛﺮﺩﻥ ﺧﺎﻟﻲ ﺩﺭ ﻣﺮﺍﻛﺰ ﻋﻠﻤﻲ ﻭ ﺩﺭﻣﺎﻧﻲ ﺍﺣﺘﻴﺎﺝ ﺩﺍﺭﺩ‪.‬‬
‫)‪18.6 Dermatology: A Multi-Media Teaching File (Disc 1,2) (Gross & Microscopic Symposium) (Mosby‬‬ ‫ــــــ‬
‫)‪19.6 EVIDENCE-BASED DERMATOLOGY (Howard I. Maibach, MD, Sagib J. Bashir, BSc (Hons), MB, ChB, Ann McKibbon, BSc, MLS‬‬ ‫‪2002‬‬
‫ﺍﻟﻜﺘﺮﻭﻧﻴﻜﻲ ﺑﺮ ﺍﺳﺎﺱ ﻋﻠﻢ ‪ (Evidence- Based Heatlth Care) EBMC‬ﺑﻨﺎ ﻧﻬﺎﺩﻩ ﺷﺪﻩ ﺍﺳﺖ‪ EBHC .‬ﭼﻬﺎﺭﭼﻮﺑﻲ ﺑﺮﺍﻱ ﺗﺼﻤﻴﻢﮔﻴﺮﻱ ﺩﺭ ﺑﺎﻟﻴﻨﻲ ﻭ ﺗﺤﻘﻴﻘﻲ ﺍﺭﺍﺋﻪ ﻣﻲﺩﻫﺪ‪ .‬ﻭ ‪ ٥‬ﻣﺮﺣﻠﻪ ﺩﺍﺭﺩ‪:‬‬ ‫ﺍﻳﻦ ﻛﺘﺎﺏ‬
‫‪ -١‬ﺍﻳﺠﺎﺩ ﺳﺆﺍﻝ ‪ -٢‬ﭘﻴﺪﺍ ﻛﺮﺩﻥ ﻣﺪﺍﺭﻙ ﻣﻌﺘﺒﺮ ﺑﺮﺍﻱ ﺟﻮﺍﺏ ﺑﻪ ﺁﻥ ﺳﺆﺍﻝ ‪ -٣‬ﺍﺭﺯﻳﺎﺑﻲ ﺍﻳﻨﻜﻪ ﺍﻳﻦ ﻣﻨﺎﺑﻊ ﻭ ﻣﺪﺍﺭﻙ ﺁﻳﺎ ﻣﻌﺘﺒﺮﻧﺪ ﻳﺎ ﺧﻴﺮ ‪ -٤‬ﺍﺳﺘﻔﺎﺩﻩ ﺍﺯ ﺍﻳﻦ ﻣﺪﺍﺭﻙ ﺑﺮﺍﻱ ﺗﺼﻤﻴﻢﮔﻴﺮﻱ ﺩﺭ ﺩﺭﻣﺎﻥ ﺑﻴﻤﺎﺭ‪.‬‬
‫ﺍﻳﻦ ﻛﺘﺎﺏ ﺭﻭﺷﻲ ﻣﻨﻄﻘﻲ ﺑﺮﺍﻱ ﭘﻴﺪﺍﻛﺮﺩﻥ ﺳﺆﺍﻻﺕ ﺑﻪ ﻭﺟﻮﺩ ﺁﻣﺪﻩ ﺩﺭ ﺣﻴﻦ ﻛﺎﺭ ﺑﺎﻟﻴﻨﻲ ﺍﺭﺍﺋﻪ ﻣﻲﺩﻫﺪ‪ .‬ﺩﺭ ﻓﺼﻞ ﺍﻭﻝ ﻛﺘﺎﺏ ﻫﺮ ﻳﻚ ﺍﺯ ﺍﻳﻦ ﻣﺮﺣﻠﻪ ﺑﻪ ﺗﻔﻀﻴﻞ ﺷﺮﺡ ﺩﺍﺩﻩ ﺷﺪﻩ ﺍﺳﺖ ﻛﻪ ﭼﻄﻮﺭ ﻣﻲﺗﻮﺍﻥ ﻣﺘﻮﺟﻪ ﻣﻌﺘﺒﺮ ﺑﻮﺩﻥ ﻳﻚ ﻓﺮﺿﻴﻪ ﻳﺎ ﻣﻘﺎﻟﻪ ﮔﺮﺩﻳﺪ ﻭ‪...‬‬
‫ﺩﺭ ﻓﺼﻞ ﺩﻭﻡ ﻛﺎﺭﺑﺮﺩ ﺍﻳﻦ ﻋﻠﻢ ‪ EBME‬ﺩﺭ ﺩﺭﻣﺎﺗﻮﻟﻮﮊﻱ ﺑﻴﺎﻥ ﺷﺪﻩ ﺍﺳﺖ‪ .‬ﻭ ﺩﺭ ﻓﺼﻠﻲ ﺟﺪﺍ ﻣﻨﺎﺑﻊ ﻣﻌﺘﺒﺮ ﻭ ﻗﺎﺑﻞ ﺗﻮﺟﻬﻲ ﺁﺩﺭﺱ ﺍﻳﻨﺘﺮﻧﺘﻲ ﺑﺎ ﻣﺸﺨﺼﺎﺕ ﻛﺎﻣﻞ ﺑﺮﺍﻱ ﺑﻪ ﺭﻭﺯﺑﻮﺩﻥ ﺍﻃﻼﻋﺎﺕ ﺩﺭﻣﺎﺗﻮﻟﻮﮊﻳﺴﺖﻫﺎ ﺁﻭﺭﺩﻩ ﺷﺪﻩ ﻛﻪ ﺩﺭ ﻧﺸﺮ ﻛﺘﺎﺑﻲ ﺍﻳﻦ ﻣﻨﺎﺑﻊ ﺑﺎﺍﺭﺯﺵ ﻣﺸﺎﻫﺪﻩ ﻣﻲﺷﻮﺩ‪.‬‬
‫‪20.6 Facial Lifting by "APTOS" threads Clinic of Plastic and Aesthetic Surgery‬‬ ‫ــــــ‬
‫)‪21.6 Hair Removal with Intense Pulsed Laser (IPL‬‬ ‫ــــــ‬
‫)ﻃﺮﻳﻘﺔ ﺍﺳﺘﻔﺎﺩﻩ ﺍﺯ ﻟﻴﺰﺭ‪ -‬ﻣﺤﻞﻫﺎﻳﻲ ﻛﻪ ﺑﺮﺍﻱ ﻣﻮﻫﺎﻱ ﺯﺍﺋﺪ ﺑﻪ ﻛﺎﺭ ﻣﻲﺭﻭﺩ‪ -‬ﺍﻧﺪﻳﻜﺎﺳﻴﻮﻥﻫﺎ( ‪ +‬ﻓﻴﻠﻢ ﺁﻣﻮﺯﺷﻲ‬
‫ﺍﻣﺮﻭﺯﻩ ﺭﻭﺵﻫﺎﻱ ﻭﻗﺖﮔﻴﺮ ﻭ ﺑﻌﻀﹰﺎ ﺑﺎ ﻋﺎﺭﺿﻪ ﺑﺮﺍﻱ ﺍﺯ ﺑﻴﻦﺑﺮﺩﻥ ﻣﻮﻫﺎﻱ ﺯﺍﺋﺪ ﻣﺎﻧﻨﺪ ‪ ،sharing‬ﻣﻮﺑﺮﻫﺎ‪ ،‬ﺍﻟﻜﺘﺮﻭﻟﻴﺰ ﻭ ‪ ...‬ﻛﻤﺘﺮ ﻣﻮﺭﺩ ﺍﺳﺘﻔﺎﺩﻩ ﻗﺮﺍﺭ ﻣﻲﮔﻴﺮﺩ‪ .‬ﻟﻴﺰﺭﻫﺎﻱ ﺍﺯ ﺑﻴﻦﺑﺮﻧﺪﻩ ﻣﻮﻫﺎﻱ ﺯﺍﺋﺪ ﺑﺎ ﻭﻗﺖ ﻛﻤﺘﺮ‪ ،‬ﻛﺎﺭﺍﺋﻲ ﺑﻴﺸﺘﺮ ﻭ ﻋﻮﺍﺭﺽ ﻣﺨﺘﺼﺮ ﻛﻤﻚ ﺷـﺎﻳﺎﻧﻲ ﺩﺭ ﻳـﻚ‬
‫ﺯﻧﺪﮔﻲ ﺑﺎ ﻛﻴﻔﻴﺖ ﻣﻄﻠﻮﺏ ﺑﺮﺍﻱ ﻣﺮﺍﺟﻌﻴﻦ ﺑﻪ ﭘﺰﺷﻜﺎﻥ ﺑﺨﺼﻮﺹ ﺩﺭﻣﺎﺗﻮﻟﻮﮊﻳﺴﺖﻫﺎ ﻭ ﻛﻠﻴﻨﻴﻚﻫﺎﻱ ﺯﻳﺒﺎﺋﻲ ﺩﺍﺭﺩ‪ .‬ﺍﺯ ﺟﻤﻠﻪ ﺟﺪﻳﺪﺗﺮﻳﻦ ﻟﻴﺰﺭﻫﺎﻱ ﺑﻜﺎﺭﺭﻓﺘﻪ ﻟﻴﺰﺭ ‪ IPL‬ﻣﻲﺑﺎﺷﺪ‪ .‬ﻓﻮﺍﺋﺪ ﺍﻳﻦ ﻟﻴﺰﺩ ﺩﺭ ﺍﺳﺘﻔﺎﺩﻩ ﺍﻳﻦ ﻟﻴﺰﺭ ﺩﺭ ﺑﻴﻤﺎﺭﺍﻥ ﺑﺎ ‪ Skin type‬ﺑﺎﻻ‪ Spot size ،‬ﺑﺰﺭﮔﺘﺮ ﻭ ﺩﺭ ﻧﺘﻴﺠﻪ ﻃـﻮﻝ‬
‫ﻣﺪﺕ ﻛﻤﺘﺮ ﺩﺭﻣﺎﻥ‪ Therapeatic window ،‬ﺑﺰﺭﮔﺘﺮ ﻛﻪ ﻣﻮﺟﺐ ﻋﺎﺭﺿﻪ ﻛﻤﺘﺮ ﻭ ﻛﺎﺭﻣﺪﻱ ﺑﻴﺸﺘﺮ ﻣﻲﺷﻮﺩ‪ .‬ﺩﺭ ﺍﻳﻦ ‪ CD‬ﻛﻪ ﺑﻪ ﺳﻔﺎﺭﺵ ﻛﻤﭙﺎﻧﻲ ‪ Ellipse‬ﺗﻮﻟﻴﺪ ﺷﺪﻩ ﺍﺳﺖ‪ .‬ﻣﻌﺮﻓﻲ ﻟﻴﺰﺭ ‪ ،IPL‬ﭼﮕﻮﻧﮕﻲ ﺍﺳﺘﻔﺎﺩﻩ ﺍﺯ ﻟﻴﺰﺭ‪ ،‬ﻓﻮﺍﺋﺪ ﻟﻴﺰﺭ ‪ ،IPL‬ﻣﻨﺎﻃﻘﻲ ﻛﻪ ﺩﺭ ﺁﻥ ﺍﺯ ﻟﻴﺰﺭ ‪ IPL‬ﺑـﺮﺍﻱ‬
‫ﺭﻓﻊ ﻣﻮﻫﺎﻱ ﺯﺍﺋﺪ ﺍﺳﺘﻔﺎﺩﻩ ﺷﺪﻩ ﺍﺳﺖ‪ .‬ﺩﺭ ﻫﺮ ﺑﺨﺶ ﻛﻠﻴﭗ ﻭﻳﺪﺋﻮﺋﻲ ﺍﺯ ﺑﻴﻤﺎﺭﻳﺎﻥ ﻭ ﻧﺤﻮﻩ ﺩﺭﻣﺎﻥ ﻭ ﻧﺘﺎﻳﺞ ﺩﺭﻣﺎﻥ ﺑﺎ ﻋﻜﺲ ﻭ ‪ clip‬ﻧﺸﺎﻥ ﺩﺍﺩﻩ ﺷﺪﻩ ﺍﺳﺖ‪.‬‬
‫‪22.6 HAIR TRANSPLANTATION‬‬ ‫)‪(The Art of Micrografting and Minigrafting) (Salekan E-Book‬‬ ‫‪2002‬‬
‫‪ANATOMY AND PHYSILOGY OF HAIR‬‬ ‫‪PATIENT EVALUATION‬‬ ‫‪PLANING AND PATIENT INSTRUCTUIONS‬‬ ‫‪TECHNIQUE‬‬
‫‪COMBINED FACE LIFT AND HAIR TRANSPLAYTATION‬‬ ‫‪REOPERATIVE SURGERY‬‬ ‫‪SPECIAL APPLICATIONS‬‬
‫)‪23.6 HANDBOOK OF ORAL DISEASE DIAGNOSIS AND MANAGEMENT Cripian Scully (MARTIN DUNITZ‬‬ ‫‪1999‬‬
‫ﻛﺘﺎﺏ ﻓﻮﻕ ﻛﻪ ﺩﺭ ﻣﺮﻛﺰ ﺧﺪﻣﺎﺕ ﻓﺮﻫﻨﮕﻲ ﺳﺎﻟﻜﺎﻥ ﺗﺒﺪﻳﻞ ﺑﻪ ﻛﺘﺎﺏ ﺍﻟﻜﺘﺮﻭﻧﻴﻜﻲ ﮔﺮﺩﻳﺪﻩ ﺷﺎﻣﻞ ‪ ٤٢٠‬ﺻﻔﺤﻪ ﻣﺘﻦ ﺑﻪ ﻫﻤﺮﺍﻩ ﺑﻴﺶ ﺍﺯ ‪ ٤٠٠‬ﺗﺼﻮﻳﺮ ﺭﻧﮕﻲ ﺍﺯ ﺿﺎﻳﻌﺎﺕ ﺩﻫﺎﻧﻲ ﻣﻮﺭﺩ ﺍﺳﺘﻔﺎﺩﻩ ﺩﺭﻣﺎﻟﻮﮊﻳﺴﺖﻫﺎ ﻭ ﺩﻧﺪﺍﻧﭙﺰﺷﻜﺎﻥ ﻣﻲﺑﺎﺷﺪ‪ .‬ﺍﻳﻦ ﻛﺘﺎﺏ ﻳﻪ ﺗﻨﻬﺎ ﺑﻪ ﻋﻨـﻮﺍﻥ ﺍﻃﻠـﺲ ﺑﻠﻜـﻪ ﺍﺯ‬
‫ﺟﻨﺒﺔ ﺍﺗﻴﻮﻟﻮﮊﻱ‪ ،‬ﻛﻠﻴﺪﻫﺎﻱ ﺗﺸﺨﻴﺼﻲ ﺩﺭﻣﺎﻥ ﻭ ﺩﺭ ﺻﻮﺭﺕ ﺍﻣﻜﺎﻥ ﭘﻴﺸﮕﻴﺮﻱ ﻧﻴﺰ ﺑﻪ ﺿﺎﻳﻌﺎﺕ ﺩﻫﺎﻧﻲ ﭘﺮﺩﺍﺧﺘﻪ ﺍﺳﺖ‪ .‬ﺑﻴﻤﺎﺭﻱﻫﺎﻱ ﺷﺎﻳﻊ ﻭ ﻣﻬﻢ ﺑﺎﻓﺖﻫﺎﻱ ﻧﺮﻡ ﺩﻫﺎﻧﻲ ﺩﺭ ﺍﻳﻦ ﻛﺘﺎﺏ ﺑﺤﺚ ﺷﺪﻩ ﺍﺳﺖ ﻋﻼﻭﻩ ﺑﺮ ﺍﻳﻦ ﺗﻌﺪﺍﺩﻱ ﻣﻮﺍﺭﺩ ﻧﺎﺩﺭ ﻛﻪ ﺩﺭ ﺳﻄﺢ ﺟﻬﺎﻥ ﺭﻭ ﺑﻪ ﺍﻓﺰﺍﻳﺶ ﺍﺳﺖ ﻣﻮﺭﺩ ﺑﺮﺭﺳﻲ ﻗﺮﺍﺭ‬
‫ﮔﺮﻓﺘﻪ ﺍﺳﺖ‪ .‬ﻓﺼﻞ ﺍﻭﻝ ﻛﺘﺎﺏ ﺷﺎﻣﻞ ﺑﺮﺭﺳﻲ ‪ symptom, sign‬ﺿﺎﻳﻌﺎﺕ ﺩﻫﺎﻧﻲ ﻣﻲﺑﺎﺷﺪ‪ .‬ﻓﺼﻮﻝ ﺑﻌﺪﻱ ﺷﺎﻣﻞ ﺩﺭﺩﻫﺎﻱ ﻧﺎﺣﻴﺔ ﺩﻫﺎﻥ ﺑﺎ ﻣﻨﺸﺎﺀ ﻋﺮﻭﻗﻲ ﻳﺎ ﻋﺼﺒﻲ‪ ،‬ﺷﻜﺎﻳﺎﺕ ﺩﻫﺎﻧﻲ ﺑﺎ ﻣﻨﺸﺎﺀ ﺭﻭﺍﻧﻲ‪ ،‬ﺿﺎﻳﻌﺎﺕ ﻣﺨﺎﻃﻲ‪ ،‬ﺑﺰﺍﻗﻲ‪ ،‬ﺿﺎﻳﻌﺎﺕ ﻟﺜﻪﻫﺎ‪ ،‬ﺿﺎﻳﻌﺎﺕ ﻟﺐ ﻭ ﻛـﺎﻡ ﻭ ﺿـﺎﻳﻌﺎﺕ‬
‫ﺩﻫﺎﻧﻲ ﻣﻲﺑﺎﺷﺪ‪ .‬ﺩﺭ ﻫﺮ ﻓﺼﻞ ﺍﺑﺘﺪﺍ ﺿﺎﻳﻌﺎﺕ ﺑﺮ ﺍﺳﺎﺱ ﺍﻟﻔﺒﺎﻱ ﺍﻧﮕﻠﻴﺴﻲ ﺗﻨﻈﻴﻢ ﻭ ﺳﭙﺲ ﺑﺮ ﺍﺳﺎﺱ ‪ management ،Diagnosis ،Clinical feature ،Aetiology ،Sexmainly affected ،Agemainly affected ،incidence ،Defintion‬ﺗﻘﺴﻴﻢﺑﻨﺪﻱ ﺷﺪﻩ ﺍﺳﺖ‪.‬‬
‫)‪24.6 Laser Hair Removal (David J. Goldman) (Martin Dunits‬‬ ‫‪2000‬‬
‫ﻛﺘﺎﺏ ﻓﻮﻕ ﻛﻪ ﺩﺭ ﻣﺮﻛﺰ ﺧﺪﻣﺎﺕ ﻓﺮﻫﻨﮕﻲ ﺳﺎﻟﻜﺎﻥ ﺗﺒﺪﻳﻞ ﺑﻪ ﻛﺘﺎﺏ ﺍﻟﻜﺘﺮﻭﻧﻴﻜﻲ ﮔﺮﺩﻳﺪﻩ ﻣﺮﻭﺭﻱ ﺑﺮ ﻟﻴﺰﺭﻫﺎﻱ ﻣﻮﺭﺩ ﺍﺳﺘﻔﺎﺩﻩ ﺑﺮﺍﻱ ﺑﺮﺩﺍﺷﺖ ﻣﻮﻫﺎ )‪ (hair removal‬ﻣﻲﺑﺎﺷﺪ‪ .‬ﻧﺨﺴﺘﻴﻦ ﻓﺼﻞ ﻛﺘﺎﺏ ﺍﺧﺘﺼﺎﺹ ﺑﻪ ﺑﻴﻮﻟﻮﮊﻱ ﻣﻮ ﺩﺍﺭﺩ‪ .‬ﻓﺼﻞ ﺑﻌﺪﻱ ﻛﺘﺎﺏ ﻣﺮﻭﺭﻱ ﮔﺬﺭﺍ ﺑﻪ ﻓﻴﺰﻳﻚ‬
‫ﻟﻴﺰﺭ ﻭ ﻛﺎﺭﺑﺮﺩ ﺁﻥ ﺩﺭ ‪ hair removal‬ﻣﻲﺑﺎﺷﺪ‪ .‬ﻓﺼﻞ ﺑﻌﺪﻱ ﻛﺘﺎﺏ‪ ،‬ﺑﻪ ﭼﮕﻮﻧﮕﻲ ﺁﻧﺠﺎﻡ ﺍﻟﻜﺘﺮﻭﻟﻴﺰ ﺩﺭ ﺭﻓﻊ ﻣﻮﻫﺎﻱ ﺯﺍﺋﺪ ﻭ ﻣﻘﺎﻳﺴﺔ ﺁﻥ ﺑﺎ ﻟﻴﺰﺭ ﻣﻲﭘﺮﺩﺍﺯﺩ‪ .‬ﺩﺭ ﻓﺼﻮﻝ ﺩﻳﮕﺮ ﻛﺘﺎﺏ ﺍﻧﻮﺍﻉ ﻣﺨﺘﻠﻒ ﻟﻴﺰﺭﻫﺎ ﻛﻪ ﺑﺮﺍﻱ ﺭﻓﻊ ﻣﻮﻫﺎﻱ ﺯﺍﺋﺪ ﺑﻪ ﻛﺎﺭ ﻣﻲﺭﻭﻧﺪ ﺑﺮﺭﺳﻲ ﻣﻲﮔﺮﺩﺩ‪:‬‬
‫‪1- Normal mode Ruby laser‬‬ ‫‪2- Normal mode alexandrite laser‬‬ ‫‪3- Diode laser‬‬ ‫‪4-‬‬ ‫‪ND: YAG laser‬‬ ‫‪5- Intense pulsed light‬‬
‫ﺩﺭ ﻫﺮ ﺑﺨﺶ ﻣﻘﺎﻻﺕ ﺗﺤﻘﻴﻘﻲ ﻭ ﻃﺮﻕ ﺍﺳﺘﻔﺎﺩﻩ ﺍﺯ ﻫﺮ ﻳﻚ ﺍﺯ ﺩﺳﺘﮕﺎﻫﻬﺎﻱ ﺍﻳﺰﺭ ﺁﻭﺭﺩﻩ ﺷﺪﻩ ﻭ ﺩﺭ ﺁﺧﺮ ﻫﺮ ﻓﺼﻞ ﻧﻈﺮ ﻣﺆﻟﻒ ﺩﺭ ﺧﺼﻮﺹ ﻫﺮ ﻳﻚ ﺍﺯ ﺍﻳﻦ ﺳﻴﺴﺘﻢﻫﺎ ﻣﻄﺮﺡ ﺷﺪﻩ ﺍﺳﺖ‪.‬‬
‫ﻳﻜﻲ ﺍﺯ ﻧﻜﺎﺕ ﻣﻨﺤﺼﺮ ﺑﻪﻓﺮﺩ ﻛﺘﺎﺏ ﻣﻌﺮﻓﻲ ﻟﻴﺰﺭﻫﺎﻱ ﻣﻌﺘﺒﺮ ﺍﺯ ﺷﺮﻛﺖﻫﺎﻱ ﻣﻌﺘﺒﺮ ﻭ ﻣﻘﺎﻳﺴﺔ ﺁﻧﻬﺎ ﺑﺎ ﻳﻜﺪﻳﮕﺮ ﻣﻲﺑﺎﺷﺪ ﻛﻪ ﭘﺰﺷﻚ ﺭﺍ ﺩﺭ ﺍﻧﺘﺨﺎﺏ ﺩﺳﺘﮕﺎﻩ ﻟﻴﺰﺭ ﻣﻨﺎﺳﺐ ﻳﺎﺭﻱ ﻣﻲﻛﻨﺪ ﻛﻪ ﺩﺭ ﻧﻬﺎﻳﺖ ﺑﺎ ﺍﻧﺘﺨﺎﺏ ﺻﺤﻴﺢ ﺑﻪ ﺣﺼﻮﻝ ﻧﺘﻴﺠﺔ ﺧﻮﺏ ﻛﻤﻚ ﺷﺎﻳﺎﻧﻲ ﻣﻲﻧﻤﺎﻳﺪ‪.‬‬
‫)‪25.6 MANAGEMENT OF FACIAL LINES AND WRINKLES (ANDREW BLITZER, WILLIAM J. BINDER, J. BRIAN BOYD ALASTAIR CARRUTHERS) (SALEKAN E-BOOK‬‬ ‫ــــــ‬
‫ﻛﺘﺎﺏ ﻓﻮﻕ ﻛﻪ ﺩﺭ ﻣﺮﻛﺰ ﺧﺪﻣﺎﺕ ﻓﺮﻫﻨﮕﻲ ﺳﺎﻟﻜﺎﻥ ﺗﺒﺪﻳﻞ ﺑﻪ ﻛﺘﺎﺏ ﺍﻟﻜﺘﺮﻭﻧﻴﻜﻲ ﮔﺮﺩﻳﺪﻩ ﺷﺎﻣﻞ ‪ ٢٢‬ﻓﺼﻞ ﺍﻃﻼﻋﺎﺕ ﺟﺎﻟﺒﻲ ﺩﺭ ﻣﻮﺭﺩ ﺩﺭﻣﺎﻥ ﻭ ﻧﻮﻉ ﺑﺮﺧﻮﺭﺩ ﺑﺎ ﭼﻴﻦ ﻭ ﭼﺮﻭﻙﻫﺎ )‪ (Line 8 Wrinkle‬ﻣﻮﺭﺩ ﺑﺤﺚ ﻗﺮﺍﺭ ﮔﺮﻓﺘﻪ ﻭ ﺳﭙﺲ ﺑﺎ ﺍﺳﺘﻔﺎﺩﻩ ﺍﺯ ﻓﺼﻮﻝ ﻣﺠﺰﺍ ‪ exfoliants‬ﻳﺎ‬

‫ﺗﻠﻔﻦ‪٠٩١٢١٣٧٢٣٦١-٦٦٩٣٦٦٩٦ :‬‬ ‫ﻧﺸﺎﻧﻲ‪ :‬ﺗﻬﺮﺍﻥ‪ ،‬ﻡ ﺍﻧﻘﻼﺏ‪ ،‬ﺥ ﻛﺎﺭﮔﺮ ﺟﻨﻮﺑﻲ‪ ،‬ﺥ ﻟﺒﺎﻓﻲﻧﮋﺍﺩ‪ ،‬ﺑﻴﻦ ﻛﺎﺭﮔﺮ ﻭ ﺟﻤﺎﻟﺰﺍﺩﻩ‪ ،‬ﺑﻦﺑﺴﺖ ﺳﻴﻤﻴﻦ‪ ،‬ﭘﻼﻙ ‪٢٣٩‬‬ ‫ﻣﺮﻛﺰ ﺧﺪﻣﺎﺕ ﻓﺮﻫﻨﮕﻲ ﺳﺎﻟﻜﺎﻥ ‪ :‬ﺍﺭﺍﺋﻪ ﻛﻨﻨﺪﺓ ﻛﺘﺎﺏ ﻭ ﺳﻲﺩﻱﻫﺎﻱ ﺗﺨﺼﺼﻲ ﭘﺰﺷﻜﻲ‬
 ‫‪33‬‬
‫‪ Superfical peel‬ﻣﺮﻃﻮﺏﻛﻨﻨﺪﺓ ﺁﻧﺎﻟﻮﮒﻫﺎﻱ ‪ Chemical ، Vitamins‬ﺑﺎﻓﻨﻮﻝ ﻭ ‪ ، TCA‬ﻣﻘﺎﻳﺴﻪ ‪ Peel‬ﺷﻴﻤﻴﺎﻳﻲ ﻭ ﻟﻴﺰﺭ ‪ Dermabrasion ،‬ﺍﺳﺘﻔﺎﺩﻩ ﺍﺯ ﺍﻧﻮﺍﻉ ‪ implant‬ﻫﺎﻱ ﺻﻮﺭﺕ‪ ،‬ﺍﺳﺘﻔﺎﺩﻩ ﺍﺯ ‪ Dermal Allograft‬ﻃﺮﻳﻘـﺔ ﮔﺬﺍﺷـﺘﻦ ‪ GORTEX‬ﺗـﺰﺭﻱ ﻛـﻼﮊﻥ ﻭ‬
‫ﭼﺮﺑﻲ‪ Directexcision ،‬ﭼﻴﻦ ﻭ ﭼﺮﻭﻙﻫﺎ ﺗﺼﺤﻴﺢ ﺟﺮﺍﺣﻲ ‪ facelifting, endoscopic Browloft Skeletal frame‬ﺑﻠﻔﺎﺭﻭﭘﻼﺳﺘﻲ‪ .‬ﻳﻚ ﻓﺼﻞ ﺍﺯ ﺍﻳﻦ ﻛﺘﺎﺏ ﺍﺧﺘﺼﺎﺹ ﺑﻪ ﻣﺮﻭﺭ ﻓﻴﺰﻳﻮﻟﻮﮊﻱ ﻭ ﻛﺎﺭﺑﺮﺩ ﺩﺭﻣﺎﻥ ﺗﻮﻛﺴﻴﻦ ﺑﻮﺗﻮﻟﻴﻨﻴﻮﻡ ﺩﺭ ﭘﺰﺷﻜﻲ ﻭ ﻓﺼﻞ ﺩﻳﮕـﺮ ﺑـﻪ ﻃﺮﻳﻘـﺔ‬
‫ﺍﺳﺘﻔﺎﺩﻩ ﺍﺯ ﺗﺰﺭﻳﻖ ‪ Botulinium Toxin‬ﺑﺮﺍﻱ ﺩﺭﻣﺎﻥ ﭼﻴﻦ ﻭ ﭼﺮﻭﻙﻫﺎ ﺑﺤﺚ ﻣﻲﻧﻤﺎﻳﺪ‪ .‬ﺳﭙﺲ ﺩﺭ ﻓﺼﻞ ‪ ٢٠‬ﻃﺮﻳﻘﺔ ﺍﺳﺘﻔﺎﺩﻩ ﺍﺯ ﻟﻴﺰﺭ ﻭ ‪ Botulinumtoxin‬ﺩﺭ ﺭﻓﻊ ﺧﻄﻮﻁ ﺩﺭ ﭼﺸﻢ ﺗﻮﺿﻴﺢ ﺩﺍﺩﻩ ﺷﺪﻩ ﺍﺳﺖ‪ .‬ﺩﺭ ﻓﺼﻞ ‪ ٢١‬ﻃﺮﻳﻘﺔ ﻋﻜﺲ ﮔـﺮﻓﺘﻦ ﺍﺯ ﺑﻴﻤـﺎﺭ ﺑـﻪ ﻋﻨـﻮﺍﻥ ﻳـﻚ ﺳـﻨﺪ‬
‫ﭘﺰﺷﻜﻲ ﻭ ‪ Computer imaging‬ﺑﺎ ﺩﻭﺭﺑﻴﻦﻫﺎﻱ ﺩﻳﺠﻴﺘﺎﻟﻲ ﻣﻮﺭﺩ ﺑﺤﺚ ﻗﺮﺍﺭ ﮔﺮﻓﺘﻪ ﺍﺳﺖ‪.‬‬
‫)‪26.6 MANUAL OF CUTANEOUS LASER TECHNIQUES (Second Edition) (Tinal S. Alster, M.D.) (SALEKAN E-BOOK‬‬ ‫‪2000‬‬
‫ﻛﺘﺎﺏ ﻓﻮﻕ ﻛﻪ ﺩﺭ ﻣﺮﻛﺰ ﺧﺪﻣﺎﺕ ﻓﺮﻫﻨﮕﻲ ﺳﺎﻟﻜﺎﻥ ﺗﺒﺪﻳﻞ ﺑﻪ ﻛﺘﺎﺏ ﺍﻟﻜﺘﺮﻭﻧﻴﻜﻲ ﮔﺮﺩﻳﺪﻩ ﺷﺎﻣﻞ ‪ ١٢‬ﻓﺼﻞ ﺍﺳﺖ ﻛﻪ ﻳﻜﻲ ﺍﺯ ﻛﺎﺭﺑﺮﺩﻱﺗﺮﻳﻦ ﻛﺘﺎﺏﻫﺎ ﺩﺭ ﺯﻣﻴﻨﺔ ﺩﺭﻣﺎﻥ ﺿﺎﻳﻌﺎﺕ ﭘﻮﺳﺘﻲ ﺑﺎ ﻟﻴﺰﺭ ﻣﻲﺑﺎﺷﺪ‪ .‬ﻧﮕﺎﻩ ﺍﻳﻦ ﻛﺘﺎﺏ ﺑﻴﺸﺘﺮ ﺑﺮ ﻧﻜﺎﺕ ﻋﻤﻠﻲ ﻟﻴﺰﺭ ﻭ ﺗﻜﻨﻴﻚﻫﺎ ﻭ ﻣﺸﻜﻼﺗﻲ ﺍﺳﺖ ﻛﻪ‬
‫ﺣﻴﻦ ﻭ ﺑﻌﺪ ﺍﺯ ﻋﻤﻞ ﺍﻳﺠﺎﺩ ﻣﻲﺷﻮﺩ‪ ،‬ﻣﺘﻤﺮﻛﺰ ﺷﺪﻩ ﺍﺳﺖ‪ .‬ﺩﺭ ﺍﻳﻦ ﻛﺘﺎﺏ ﺗﻮﺿﻴﺤﺎﺗﻲ ﻛﻪ ﺑﻪ ﺑﻴﻤﺎﺭ ﻗﺒﻞ ﺍﺯ ﻋﻤﻞ ﻭ ﺑﻌﺪ ﺍﺯ ﻋﻤﻞ ﺑﺎﻳﺪ ﺩﺍﺩﻩ ﺷﻮﺩ ﻭ ﻫﻤﭽﻨﻴﻦ ﭼﮕﻮﻧﮕﻲ ﺍﻧﺘﺨﺎﺏ ﺑﻴﻤﺎﺭ ﻣﻨﺎﺳﺐ )‪ (Patient selection‬ﺑﻪ ﻃﻮﺭ ﻛﺎﻣﻞ ﺷﺮﺡ ﺩﺍﺩﻩ ﺷﺪﻩ ﺍﺳﺖ‪.‬‬
‫ﺩﺭ ﺑﻌﻀﻲ ﺍﺯ ﻓﺼﻮﻝ‪ ،‬ﻛﺘﺎﺏ ﺑﻪ ﻣﻌﺮﻓﻲ ﺗﻜﻨﻴﻚﻫﺎﻱ ﺑﻪ ﻛﺎﺭﮔﻴﺮﻱ ﻟﻴﺰﺭﻫﺎ ﻭ ﻣﻌﺮﻓﻲ ﺩﺳﺘﮕﺎﻩﻫﺎﻱ ﻟﻴﺰﺭﻱ ﻣﻌﺘﺒﺮ ﻭ ﻣﻘﺎﻳﺴﺔ ﺩﺳﺘﮕﺎﻫﻬﺎﻱ ﻟﻴﺰﺭ ﻭ ﺭﻭﺵ ﺍﻧﺠﺎﻡ ﻛﺎﺭ ﺑﻪ ﻃﻮﺭ ﺟﺪﺍﮔﺎﻧﻪ ﺑﺮﺍﻱ ﻟﻴﺰﺭﻫﺎﻱ ﺍﺧﺘﺼﺎﺻﻲ ﭘﺮﺩﺍﺧﺘﻪ ﺍﺳﺖ‪ .‬ﺩﺭ ﻓﺼﻮﻝ ﺟﺪﻳﺪ ﻛﺘﺎﺏ ﻧﺴﺒﺖ ﺑﻪ ‪ edition‬ﻗﺒﻞ ﺷـﺎﻣﻞ‬
‫‪ erbium :YAG laser‬ﻭ ‪ Resurfacing‬ﺑﻠﻔﺎﺭﻭﭘﻼﺳﺘﻲ ﺑﺎ ﻟﻴﺰﺭ ﻭ ﻟﻴﻔﺘﮓ ﭘﻴﺸﺎﻧﻲ ﻫﻤﺰﻣﺎﻥ ﺑﺎ ﻟﻴﺰﺭ ﻭ ﻟﻴﺰﺭﻫﺎﻱ‪ hair removal‬ﺍﺿﺎﻓﻪ ﺷﺪﻩ ﺍﺳﺖ ﻭ ﺩﺭ ﻓﺼﻮﻝ ﺁﺧﺮ ﻛﺘﺎﺏ ﻋﻮﺍﺭﺽ ﻟﻴﺰﺭ ﻭ ﭼﮕﻮﻧﮕﻲ ﺩﺭﻣﺎﻥ ﺁﻧﻬﺎ ﺩﺭ ﻣﻮﺭﺩ ﻫﺮ ﻟﻴﺰﺭ ﺑﻪ ﻃﻮﺭ ﺟﺪﺍﮔﺎﻧﻪ ﺑﺤﺚ ﺷﺪﻩ ﺍﺳﺖ‪.‬‬
‫)‪27.6 PHYSICAL SIGNS IN DERMATOLOGY (SECOND EDITION‬‬ ‫)‪Clifford M Lawrence Neil H Cox (Joseph L Jorizzo) (SALEKAN E-BOOK‬‬ ‫ــــــ‬
‫ﻛﺘﺎﺏ ﻓﻮﻕ ﻛﻪ ﺩﺭ ﻣﺮﻛﺰ ﺧﺪﻣﺎﺕ ﻓﺮﻫﻨﮕﻲ ﺳﺎﻟﻜﺎﻥ ﺗﺒﺪﻳﻞ ﺑﻪ ﻛﺘﺎﺏ ﺍﻟﻜﺘﺮﻭﻧﻴﻜﻲ ﮔﺮﺩﻳﺪﻩ ﺷﺎﻣﻞ ﺑﻴﺶ ﺍﺯ ‪ ٧٠٠‬ﺗﺼﻮﻳﺮ ﺗﻤﺎﻡ ﺭﻧﮕﺲ ﺍﺯ ﺿﺎﻳﻌﺎﺕ ﻣﺨﺘﻠﻒ ﭘﻮﺳﺘﻲ ﻣﻲﺑﺎﺷﺪ ﻛﻪ ﺑﺮ ﺍﺳﺎﺱ ﺷﻜﻞ ﻭ ﺭﻧﮓ ﻭ ﻣﺤﻞ ﺿﺎﻳﻌﺎﺕ ﺗﻘﺴﻴﻢﺑﻨﺪﻱ ﺷﺪﻩ ﻭ ﺗﺸﺨﻴﺺﻫﺎﻱ ﺍﻓﺘﺮﺍﻓﻲ ﺁﻭﺭﺩﻩ ﺷﺪﻩ‬
‫ﺍﺳﺖ‪ .‬ﺍﻳﻦ ﻛﺘﺎﺏ ﺑﻪ ﺧﻮﺍﻧﻨﺪﻩ ﺍﻳﻦ ﺍﻣﻜﺎﻥ ﺭﺍ ﻣﻲﺩﻫﺪ ﻛﻪ ﺑﺎ ﺁﻧﺎﻟﻴﺰ ﺩﺭ ﻣﺸﺎﻫﺪﺓ ﺑﺎﻟﻴﻨﻲ ﻭ ﺍﺳﺘﻔﺎﺩﻩ ﺍﺯ ﻣﻌﻠﻮﻣﺎﺕ ﺑﻪ ﺗﺸﺨﻴﺺ ﺻﺤﻴﺢ ﺿﺎﻳﻌﺎﺕ ﺑﺮﺳﺪ‪.‬‬
‫ﺍﻳﻦ ﻛﺘﺎﺏ ﺑﻴﻤﺎﺭﻱﻫﺎ ﺭﺍ ﺑﺮ ﺍﺳﺎﺱ ﻓﻴﺰﻳﻮﭘﺎﺗﻮﻟﻮﮊﻱ )ﻋﻔﻮﻧﻲ‪ ،‬ﺍﺗﻮﺍﻳﻤﻮﻥ ﻭ ‪ ( ...‬ﺗﻘﺴﻴﻢ ﺑﻨﺪﻱ ﻧﻜﺮﺩﻩ ﺑﻠﻜﻪ ﺑﺮ ﺍﺳﺎﺱ ﺷﻜﻞ ﻭ ﻣﺤﻞ ﺿﺎﻳﻌﺎﺕ ﻓﺼﻞ ﺑﻨﺪﻱ ﺷﺪﻩ ﺍﺳﺖ‪ .‬ﻛﻪ ﺑﺮﺍﻱ ﺩﺍﻧﺸﺠﻮﻳﺎﻥ ﺩﺭﻣﺎﺗﻮﻟﻮﮊﻱ ﻳﻚ ‪ approach‬ﻋﻤﻠﻲ ﺑﺮﺍﻱ ﺭﺳﻴﺪﻥ ﺑﻪ ﺗﺸﺨﻴﺺ ﺿﺎﻳﻌﺎﺕ ﺭﺍ ﻓﺮﺍﻫﻢ ﻣﻲﻛﻨﺪ‪.‬‬
‫ﺍﻳﻦ ﻛﺘﺎﺏ ﻫﺮ ﭼﻨﺪ ﺑﻪ ﻋﻨﻮﺍﻥ ﻳﻚ ﻛﺘﺎﺏ ‪ test‬ﺩﺭﻣﺎﺗﻮﻟﻮﮊﻱ ﻧﻤﻲﺑﺎﺷﺪ ﻭﻟﻲ ﺗﻤﺎﻡ ﻣﺒﺎﺣﺚ ﻣﻬﻢ ﻭ ﺑﺴﻴﺎﺭﻱ ﺍﺯ ﻣﻮﺍﺭﺩ ﻧﺎﺩﺭ ﺩﺭﻣﺎﺗﻮﻟﻮﮊﻱ ﺩﺭ ﺁﻥ ﮔﻨﺠﺎﻧﺪﻩ ﺷﺪﻩ ﺍﺳﺖ‪ .‬ﻳﻜﻲ ﺍﺯ ﻧﻜﺎﺕ ﻣﻤﺘﺎﺯ ﺩﺭ ﻭﻳﺮﺍﻳﺶ ﺟﺪﻳﺪ ﺍﻳﻦ ﻛﺘﺎﺏ ﺁﻭﺭﺩﻥ ﺟﺪﺍﻭﻟﻲ ﺍﺳﺖ ﻛﻪ ﺩﺭ ﺁﻧﻬﺎ ﻧﻜﺎﺕ ﻛﻠﻴﺪﻱ ﺩﺭ ﺗﺸﺨﻴﺺ‬
‫ﻭ ‪pitfalls‬ﻫﺎﻱ ﺗﺸﺨﻴﺼﻲ ﺑﻴﺎﻥ ﮔﺮﺩﻳﺪﻩ ﺍﺳﺖ‪ .‬ﺩﺭ ﺣﻘﻴﻘﺖ ﺍﻳﻦ ﻛﺘﺎﺏ ﺷﺎﻣﻞ ﺍﻃﻠﺲ ﺭﻧﮕﻲ ﺿﺎﻳﻌﺎﺕ ﭘﻮﺳﺘﻲ ﻭ ﺷﺮﺡ ﻭ ﺁﻧﺎﻟﻴﺰ ﺭﺳﻴﺪﻥ ﺑﻪ ﺗﺸﺨﻴﺺ ﺿﺎﻳﻌﺎﺕ ﻭ ﺟﺪﺍﻭﻝ ﻛﻤﻚ ﻛﻨﻨﺪﻩ ﺩﺭ ﺗﺸﺨﻴﺺ ﻣﻲﺑﺎﺷﺪ ﻛﻪ ﻣﻮﺟﺐ ﺷﺪﻩ ﻳﻚ ﻛﺘﺎﺏ ﺑﺎﺍﺭﺯﺵ ﻧﻪ ﺗﻨﻬﺎ ﺑﺮﺍﻱ ﺩﺭﻣﺎﺗﻮﻟﻮﮊﻳﺴﺖﻫﺎ‬
‫ﺑﻠﻜﻪ ﺑﺮﺍﻱ ﺳﺎﻳﺮ ﭘﺰﺷﻜﺎﻥ ﻛﻪ ﺑﺎ ﺑﻴﻤﺎﺭﻱﻫﺎﻱ ﭘﻮﺳﺘﻲ ﻛﻤﺘﺮ ﺁﺷﻨﺎﻳﻲ ﺩﺍﺭﻧﺪ ﺑﻪ ﻛﺎﺭ ﺭﻭﺩ‪ .‬ﺑﻪ ﮔﻔﺘﺔ ‪ Dr. Joav Merick‬ﺗﺼﺎﻭﻳﺮ ﺁﻥ ﭼﻨﺎﻥ ﻛﻴﻔﻴﺘﻲ ﺩﺍﺭﻧﺪﻛﻪ ﮔﻮﻳﺎ ﺑﻴﻤﺎﺭ ﺩﺭ ﻣﻘﺎﺑﻞ ﺷﻤﺎ ﺍﻳﺴﺘﺎﺩﻩ ﺍﺳﺖ‪ .‬ﺑﻪ ﻋﻠﺖ ﺍﻫﻤﻴﺖ ﺍﻳﻦ ﻛﺘﺎﺏ ﺑﺎﻳﺪ ﻫﺮ ﺩﺭﻣﺎﺗﻮﻟﻮﮊﻳﺴﺘﻲ ﺍﻳﻦ ﻛﺘﺎﺏ ﺭﺍ ﻫﻤﺮﺍﻩ ﺩﺍﺷﺘﻪ‬
‫ﺑﺎﺷﺪ ﻭ ﺳﺎﻳﺮ ﺧﺎﻧﻮﺍﺩﻩﻫﺎﻱ ﭘﺮﺷﻜﻲ‪ ،‬ﻣﺘﺨﺼﻴﺼﻴﻦ ﺍﻃﻔﺎﻝ ﻭ ﺩﺍﺧﻠﻲ ﺩﺭ ﻓﻌﺎﻟﻴﺖ ﺑﺎﻟﻴﻨﻲ ﺑﻪ ﺍﻳﻦ ﻛﺘﺎﺏ ﺍﺣﺘﻴﺎﺝ ﭘﻴﺪﺍ ﺧﻮﺍﻫﻨﺪ ﻛﺮﺩ‪ .‬ﻫﺮ ﻛﺘﺎﺑﺨﺎﻧﺔ ﭘﺰﺷﻜﻲ ﺑﺎﻳﺪ ﺍﻳﻦ ﻛﺘﺎﺏ ﺭﺍ ﺩﺭ ﻗﻔﺴﻪﻫﺎﻱ ﺧﻮﺩ ﺟﺎﻱ ﺩﻫﺪ‪...‬‬
‫‪28.6 Practical MINOR SURGERY‬‬ ‫ــــ‬
‫‪29.6 Primer of Dermatopathology‬‬ ‫)‪(Third Edition) (Antoinette F. Hood, Thedore H. Kwan, Martin C. Mihm, Jr., Thomas D. Horn, Bruce R. Smoller‬‬ ‫‪2002‬‬
‫‪1. Introduction‬‬ ‫‪3. Basement Membrane Zone, Oaoillary Dermis, and Superficial Vascular Plexus‬‬ ‫‪4. Reticular Dermis‬‬ ‫‪7. Bonus Quizzes‬‬
‫‪2. Epidermis‬‬ ‫‪5. Appendages‬‬ ‫‪6. Panniculus‬‬
‫‪30.6‬‬ ‫)‪Radiosurgical Treatment of Superficial Skin Lesions (S. Randolph Waldman, M.D.‬‬ ‫ــــــ‬
‫‪31.6‬‬ ‫)‪Radiosurgical Vaporization of Dermatologic Lesions (Dr. Stephen Chiarello‬‬ ‫ــــــ‬
‫‪1- Rhinophyma‬‬ ‫‪2- Keratosis Removal‬‬ ‫)‪3. Scar Revision (Back‬‬ ‫)‪4. Basel Cell Carcinoma (Nasal Tip‬‬ ‫)‪5. Scar Revision (Nose‬‬ ‫)‪6. Basal Cell Carcinoma (Nasal Bridge‬‬
‫)‪7. Scar Revision (Lower Forehead‬‬ ‫‪8. Radiosurgery in ENT‬‬ ‫‪9. Turbinate Shrinkage‬‬ ‫‪10. Rhinoplasty‬‬ ‫‪11. Tonsillectomy‬‬ ‫‪12. Tympanoplasty‬‬
‫‪32.6‬‬ ‫‪Reconstructive Facial Plastic Surgery‬‬ ‫)‪(SALEKAN E-BOOK‬‬ ‫ــــــ‬
‫)ﻃﺮﻳﻘﺔ ﺍﺳﺘﻔﺎﺩﻩ ﺍﺯ ﻟﻴﺰﺭ‪ -‬ﻣﺤﻞﻫﺎﻳﻲ ﻛﻪ ﺑﺮﺍﻱ ﻣﻮﻫﺎﻱ ﺯﺍﺋﺪ ﺑﻪ ﻛﺎﺭ ﻣﻲﺭﻭﺩ‪ -‬ﺍﻧﺪﻳﻜﺎﺳﻴﻮﻥﻫﺎ( ‪ +‬ﻓﻴﻠﻢ ﺁﻣﻮﺯﺷﻲ‬
‫ﺍﻣﺮﻭﺯﻩ ﺭﻭﺵﻫﺎﻱ ﻭﻗﺖﮔﻴﺮ ﻭ ﺑﻌﻀﹰﺎ ﺑﺎ ﻋﺎﺭﺿﻪ ﺑﺮﺍﻱ ﺍﺯ ﺑﻴﻦﺑﺮﺩﻥ ﻣﻮﻫﺎﻱ ﺯﺍﺋﺪ ﻣﺎﻧﻨﺪ ‪ ،sharing‬ﻣﻮﺑﺮﻫﺎ‪ ،‬ﺍﻟﻜﺘﺮﻭﻟﻴﺰ ﻭ ‪ ...‬ﻛﻤﺘﺮ ﻣﻮﺭﺩ ﺍﺳﺘﻔﺎﺩﻩ ﻗﺮﺍﺭ ﻣﻲﮔﻴﺮﺩ‪.‬‬
‫ﻟﻴﺰﺭﻫﺎﻱ ﺍﺯ ﺑﻴﻦﺑﺮﻧﺪﻩ ﻣﻮﻫﺎﻱ ﺯﺍﺋﺪ ﺑﺎ ﻭﻗﺖ ﻛﻤﺘﺮ‪ ،‬ﻛﺎﺭﺍﺋﻲ ﺑﻴﺸﺘﺮ ﻭ ﻋﻮﺍﺭﺽ ﻣﺨﺘﺼﺮ ﻛﻤﻚ ﺷﺎﻳﺎﻧﻲ ﺩﺭ ﻳﻚ ﺯﻧﺪﮔﻲ ﺑﺎ ﻛﻴﻔﻴﺖ ﻣﻄﻠﻮﺏ ﺑﺮﺍﻱ ﻣﺮﺍﺟﻌﻴﻦ ﺑﻪ ﭘﺰﺷﻜﺎﻥ ﺑﺨﺼﻮﺹ ﺩﺭﻣﺎﺗﻮﻟﻮﮊﻳﺴﺖﻫﺎ ﻭ ﻛﻠﻴﻨﻴﻚﻫﺎﻱ ﺯﻳﺒﺎﺋﻲ ﺩﺍﺭﺩ‪.‬‬
‫ﺍﺯ ﺟﻤﻠﻪ ﺟﺪﻳﺪﺗﺮﻳﻦ ﻟﻴﺰﺭﻫﺎﻱ ﺑﻜﺎﺭﺭﻓﺘﻪ ﻟﻴﺰﺭ ‪ IPL‬ﻣﻲﺑﺎﺷﺪ‪ .‬ﻓﻮﺍﺋﺪ ﺍﻳﻦ ﻟﻴﺰﺩ ﺩﺭ ﺍﺳﺘﻔﺎﺩﻩ ﺍﻳﻦ ﻟﻴﺰﺭ ﺩﺭ ﺑﻴﻤﺎﺭﺍﻥ ﺑﺎ ‪ Skin type‬ﺑﺎﻻ‪ Spot size ،‬ﺑﺰﺭﮔﺘﺮ ﻭ ﺩﺭ ﻧﺘﻴﺠﻪ ﻃﻮﻝ ﻣﺪﺕ ﻛﻤﺘﺮ ﺩﺭﻣﺎﻥ‪ Therapeatic window ،‬ﺑﺰﺭﮔﺘﺮ ﻛﻪ ﻣﻮﺟﺐ ﻋﺎﺭﺿﻪ ﻛﻤﺘﺮ ﻭ ﻛﺎﺭﻣﺪﻱ ﺑﻴﺸﺘﺮ ﻣﻲﺷﻮﺩ‪.‬‬
‫ﺩﺭ ﺍﻳﻦ ‪ CD‬ﻛﻪ ﺑﻪ ﺳﻔﺎﺭﺵ ﻛﻤﭙﺎﻧﻲ ‪ Ellipse‬ﺗﻮﻟﻴﺪ ﺷﺪﻩ ﺍﺳﺖ‪ .‬ﻣﻌﺮﻓﻲ ﻟﻴﺰﺭ ‪ ،IPL‬ﭼﮕﻮﻧﮕﻲ ﺍﺳﺘﻔﺎﺩﻩ ﺍﺯ ﻟﻴﺰﺭ‪ ،‬ﻓﻮﺍﺋﺪ ﻟﻴﺰﺭ ‪ ،IPL‬ﻣﻨﺎﻃﻘﻲ ﻛﻪ ﺩﺭ ﺁﻥ ﺍﺯ ﻟﻴﺰﺭ ‪ IPL‬ﺑﺮﺍﻱ ﺭﻓﻊ ﻣﻮﻫﺎﻱ ﺯﺍﺋﺪ ﺍﺳﺘﻔﺎﺩﻩ ﺷﺪﻩ ﺍﺳﺖ‪ .‬ﺩﺭ ﻫﺮ ﺑﺨﺶ ﻛﻠﻴﭗ ﻭﻳـﺪﺋﻮﺋﻲ ﺍﺯ ﺑﻴﻤﺎﺭﻳـﺎﻥ ﻭ ﻧﺤـﻮﻩ ﺩﺭﻣـﺎﻥ ﻭ‬
‫ﻧﺘﺎﻳﺞ ﺩﺭﻣﺎﻥ ﺑﺎ ﻋﻜﺲ ﻭ ‪ clip‬ﻧﺸﺎﻥ ﺩﺍﺩﻩ ﺷﺪﻩ ﺍﺳﺖ‪.‬‬
‫‪33.6‬‬ ‫‪REFINEMENT‬‬ ‫‪IN‬‬ ‫‪HAIR‬‬ ‫‪TRANSPLANTATION:‬‬ ‫‪Micro‬‬ ‫‪and‬‬ ‫‪minigraft‬‬ ‫‪Megasession‬‬ ‫‪(Alfonso‬‬ ‫‪Barrera,‬‬ ‫)‪M.D.‬‬ ‫‪2002‬‬
‫ﺍﻳﻦ ﻛﺘﺎﺏ ﺍﻟﻜﺘﺮﻭﻧﻴﻜﻲ ﺩﺭ ﻣﻮﺭﺩ ﭘﻴﻮﻧﺪ ﻣﻮ ﺑﻪ ﺭﻭﺵ ﻣﻴﻜﺮﻭﮔﺮﺍﻓﺖ )ﮔﺮﺍﻓﺖ ‪ ١-٢‬ﻣﻮ( ﻭ ﻣﻴﻨﻲﮔﺮﺍﻓﺖ )ﮔﺮﺍﻓﺖ ‪ ٣-٤‬ﻣﻮ( ﺑﺮﺍﻱ ﻃﺎﺳﻲ ﻣﺮﺩﺍﻧﻪ ﻭ ﺩﻳﮕﺮ ﺍﺧﺘﻼﻻﺕ ﺭﻳﺰﺵ ﻣﻮ ﻣﻲﺑﺎﺷﺪ‪ .‬ﻋﻼﻭﻩ ﺑﺮ ﺗﺼﺎﻭﻳﺮ ﺭﻧﮕﻲ‪ ،‬ﺗﺼﺎﻭﻳﺮ ﮔﺮﺍﻓﻴﻜﻲ ﺑﺮﺍﻱ ﻓﻬﻢ ﻣﻄﺎﻟﺐ ﺑﻪ ﻛﺎﺭ ﺭﻓﺘﻪ ﺍﺳﺖ‪.‬‬
‫ﻓﺼﻞ ‪ -١‬ﺩﺭ ﻣﻮﺭﺩ ﺁﻧﺎﺗﻮﻣﻲ ﻭ ﻓﻴﺰﻳﻮﻟﻮﮊﻱ ﻣﻮ ﻣﻲﺑﺎﺷﺪ ﺗﺎ ﺍﻃﻼﻋﺎﺕ ﭘﺎﻳﻪﺍﻱ ﻗﺒﻞ ﺍﺯ ﺍﻧﺠﺎﻡ ﺍﻋﻤﺎﻝ ﭘﻴﻮﻧﺪ ﺑﻪ ﻧﻮﺁﻣﻮﺯﺍﻥ ﺑﺪﻫﺪ‪.‬‬
‫ﻓﺼﻞ ‪ -٢‬ﺍﻃﻼﻋﺎﺕ ﺳﻮﺩﻣﻨﺪﻱ ﺩﺭ ﻣﻮﺭﺩ ﺍﻟﮕﻮﻫﺎﻱ ﻣﺨﺘﻠﻒ ﺭﻳﺰﺵ ﻣﻮ ﻭ ﺟﺮﺍﺣﻲ ﻭ ﺍﺭﺯﻳﺎﺑﻲ ﻣﺸﻜﻼﺕ ﻓﺮﺩﻱ ﺑﻴﻤﺎﺭ ﻭ ﺑﻬﺘﺮﻳﻦ ﺭﻭﺵ ﺑﺮﺍﻱ ﺑﺮﻃﺮﻑﻛﺮﺩﻥ ﺭﻳﺰ ﻣﻮ ﻛﻤﻚ ﻣﻲﻛﻨﺪ‪.‬‬

‫ﺗﻠﻔﻦ‪٠٩١٢١٣٧٢٣٦١-٦٦٩٣٦٦٩٦ :‬‬ ‫ﻧﺸﺎﻧﻲ‪ :‬ﺗﻬﺮﺍﻥ‪ ،‬ﻡ ﺍﻧﻘﻼﺏ‪ ،‬ﺥ ﻛﺎﺭﮔﺮ ﺟﻨﻮﺑﻲ‪ ،‬ﺥ ﻟﺒﺎﻓﻲﻧﮋﺍﺩ‪ ،‬ﺑﻴﻦ ﻛﺎﺭﮔﺮ ﻭ ﺟﻤﺎﻟﺰﺍﺩﻩ‪ ،‬ﺑﻦﺑﺴﺖ ﺳﻴﻤﻴﻦ‪ ،‬ﭘﻼﻙ ‪٢٣٩‬‬ ‫ﻣﺮﻛﺰ ﺧﺪﻣﺎﺕ ﻓﺮﻫﻨﮕﻲ ﺳﺎﻟﻜﺎﻥ ‪ :‬ﺍﺭﺍﺋﻪ ﻛﻨﻨﺪﺓ ﻛﺘﺎﺏ ﻭ ﺳﻲﺩﻱﻫﺎﻱ ﺗﺨﺼﺼﻲ ﭘﺰﺷﻜﻲ‬
 ‫‪34‬‬
‫ﻓﺼﻞ ‪ -٣‬ﺩﺭ ﻣﻮﺭﺩ ﺗﺠﻬﻴﺰﺍﺕ ﻻﺯﻡ ﺑﺮﺍﻱ ﺍﻧﺠﺎﻡ ﭘﻴﻮﻧﺪ ﻣﻮ ﻭ ﻫﻤﭽﻨﻴﻦ ﺍﻃﻼﻋﺎﺗﻲ ﻛﻪ ﺑﺎﻳﺪ ﺑﻪ ﺑﻴﻤﺎﺭ ﻗﺒﻞ ﺍﺯ ﺍﻧﺠﺎﻡ ﺟﺮﺍﺣﻲ ﺩﺍﺩﻩ ﺷﻮﺩ‪.‬‬
‫ﻓﺼﻞ ‪ -٤‬ﺗﻮﺿﻴﺢ ﻗﺪﻡ ﺑﻪ ﻗﺪﻡ ﺗﻮﺳﻂ ﺗﺼﺎﻭﻳﺮ ﻭﺍﻗﻌﻲ ﻭ ﮔﺮﺍﻓﻴﻜﻲ ﺍﻧﺠﺎﻡ ﺍﻋﻤﺎﻝ ﺟﺮﺍﺣﻲ ﭘﻴﻮﻧﺪ ﻣﻮ ﺁﻭﺭﺩﻩ ﺷﺪﻩ ﻭ ﺳﭙﺲ ﺗﺼﺎﻭﻳﺮ ‪Case‬ﻫﺎﻱ ﺟﺮﺍﺣﻲﺷﺪﻩ ﺍﺯ ﺍﺑﺘﺪﺍ ﺗﺎ ﺍﻧﺘﻬﺎﻱ ﻋﻤﻞ ﻧﺸﺎﻥ ﺩﺍﺩﻩ ﺷﺪﻩ ﻭ ﺩﺭ ﻣﻮﺭﺩ ﻧﺘﺎﻳﺞ ﻫﺮ ﻳﻚ ﺑﺤﺚ ﻣﻲﺷﻮﺩ‪.‬‬
‫ﻼ ﺗﻮﺳﻂ ﺭﻭﺵﻫﺎﻱ ﺩﻳﮕﺮ ﺑﺮﺍﻱ ﻃﺎﺳﻲ ﺳﺮ ﺟﺮﺍﺣﻲ ﺷﺪﻩﺍﻧﺪ ﻧﺸﺎﻥ ﺩﺍﺩﻩ ﺷﺪﻩ ﻭ ﺗﺮﻣﻴﻢ ﺁﻧﻬﺎ ﺑﻪ ﺭﻭﺵ ﻣﻴﻨﻲ ﻭ ﻣﻴﻜﺮﻭﮔﺮﺍﻓﺖ ﺁﻭﺭﺩﻩ ﺷﺪﻩ ﺍﺳﺖ‪.‬‬ ‫ﻓﺼﻞ ‪ -٥‬ﺗﺮﻛﻴﺐ ﺟﺮﺍﺣﻲ ﭘﻴﻮﻧﺪ ﻣﻮ ﺑﺎ ﺗﻜﻨﻴﻚﻫﺎﻱ ﺩﻳﮕﺮ ﻣﺎﻧﻨﺪ ‪ face lifting‬ﻣﻲﺑﺎﺷﺪ‪ .‬ﺩﺭ ﺍﻳﻦ ﻓﺼﻞ ‪Case‬ﻫﺎﻱ ﻣﺨﺘﻠﻒ ﻛﻪ ﻗﺒ ﹰ‬
‫ﻓﺼﻞ ‪ -٦‬ﻛﺎﺭﺑﺮﺩﻫﺎﻱ ﺩﻳﮕﺮ ﻣﻴﻜﺮﻭﮔﺮﺍﻓﺖ ﻭ ﻣﻴﻨﻲﮔﺮﺍﻓﺖ ﺩﺭ ﻛﺎﺭﻫﺎﻱ ﺯﻳﺒﺎﻳﻲ ﻭ ﺟﺮﺍﺣﻲ ﭘﻼﺳﺘﻴﻚ ﺷﺮﺡ ﺩﺍﺩﻩ ﺷﺪﻩ ﺍﺳﺖ‪.‬‬
‫ﻓﺼﻞ ‪ -٧‬ﻛﺘﺎﺏ ﻛﺎﺭﺑﺮﺩ ﻣﻴﻜﺮﻭﮔﺮﺍﻓﺖ ﻭ ﻣﻴﻨﻲﮔﺮﺍﻓﺖ ﺩﺭ ﭘﻨﻬﺎﻥﻛﺮﺩﻥ ﺍﺳﻜﺎﺭﻫﺎﻱ ‪ ،Scafp‬ﺍﺻﻼﺡ ﺧﻂ ﺭﻳﺶ ﺑﺨﺼﻮﺹ ﺑﻌﺪ ﺍﺯ ‪ ،face lift‬ﻛﺎﺷﺖ ﺍﺑﺮﻭ‪ ،‬ﺳﺒﻴﻞ‪ ،‬ﺭﻳﺶ‪ ،‬ﺩﺭﻣﺎﻥ ﺁﻟﭙﻮﺳﭙﻲ ﺑﻪ ﻋﻠﺖ ﺳﻮﺧﺘﮕﻲ ﻭ ﻛﺎﺷﺖ ﻣﮋﻩ ﺁﻭﺭﺩﻩ ﺷﺪﻩ ﺍﺳﺖ‪ .‬ﻓﺼﻞ ‪ ٧‬ﺑﺮﺟﺴﺘﻪﺗـﺮﻳﻦ ﻓﺼـﻞ ﻛﺘـﺎﺏ‬
‫ﻣﻲﺑﺎﺷﺪ ﻛﻪ ﺍﻳﻦ ﻛﺘﺎﺏ ﺭﺍﺯ ﻛﺘﺐ ﻣﺸﺎﺑﻪ ﭘﻴﻮﻧﺪ ﻣﻮ ﺭﺍ ﻣﺘﻤﺎﻳﺰ ﻣﻲﻛﻨﺪ‪.‬‬
‫)‪34.6 Skin Rejuvenation with skin filler (E.E.A. Derm‬‬ ‫ــــــ‬
‫‪ CD‬ﺣﺎﺿﺮ‪ ،‬ﺭﻭﺵ ﺍﻧﺘﺨﺎﺏ‪ ،‬ﺁﻧﺴﺘﺰﻱ ﻭ ﺗﺰﺭﻳﻖ ‪ Juvederm‬ﻣﻲﺑﺎﺷﺪ‪ .‬ﺩﺭ ﺍﻳﻦ ﻭﻳﺪﺋﻮ ‪ ،CD‬ﻧﺤﻮﺓ ﺁﻧﺴﺘﺰﻱ ﺑﺪﻭﻥ ﺍﻳﻨﻜﻪ ﺁﻧﺎﺗﻮﻣﻲ ﻣﺤﻴﻂ ﻧﺎﺣﻴﻪ ﺗﺰﺭﻳﻖ ﺍﺯ ﺑﻴﻦ ﺑﺮﻭﺩ ﻧﺸﺎﻥ ﺩﺍﺩﻩ ﺷﺪﻩ ﺍﺳﺖ‪ .‬ﺳﭙﺲ ﭘﺮﻛﺮﺩﻥ ﭼﻴﻦ ﻧﺎﺯﻭﺑﻴﺎﻝ ﺑﺎ ‪ Juvederm30‬ﻭ ﺳﭙﺲ ﺍﻓﺰﺍﻳﺶ ﺣﺠﻢ ﻟﺐ ﺑﺎ‬
‫‪ Juvederm24‬ﻭ ﺍﺯ ﺑﻴﻦﺑﺮﺩﻥ ﭼﺮﻭﻙﻫﺎﻱ ﻇﺮﻳﻒ ﺑﺎ ‪ Juvederm18‬ﻧﺸﺎﻥ ﺩﺍﺩﻩ ﺷﺪﻩ ﺍﺳﺖ‪.‬‬
‫‪35.6 Textbook of Dermatology (Sixth Editions) (R.H. CHAMPION, J.L. BURTON, D.A.BURNS, S.M.BREATHNACH) (ROOK) (Software c Gention I.T. Consuliants Ltd.,) Version 1.2.0‬‬ ‫‪1998‬‬
‫ﻭﻳﺮﺍﻳﺶ ﺷﺸﻢ ﻛﺘﺎﺏ ﺩﺭﻣﺎﺗﻮﻟﻮﮊﻱ ‪ Rook‬ﺷﺎﻣﻞ ‪ ٤‬ﺟﻠﺪ ﻭ ‪ ٣٦٨٣‬ﺻﻔﺤﻪ ﻣﻲﺑﺎﺷﺪ ﺩﺭ ﺍﻳﻦ ﻭﻳﺮﺍﻳﺶ ﺗﻤﺎﻡ ﻓﺼﻞﻫﺎ ﻣﺮﻭﺭ ﺷﺪﻩ ﻭ ﺁﺧﺮﻳﻦ ﺍﻃﻼﻋﺎﺕ ﺍﺿﺎﻓﻪ ﮔﺮﺩﻳﺪﻩ ﺍﺳﺖ‪ .‬ﺑﺴﻴﺎﺭﻱ ﺍﺯ ﻓﺼﻞﻫﺎ ﺑﺎﺯﻧﻮﻳﺴﻲ ﺷﺪﻩ ﻭ ﺩﺭ ﺣﺪﻭﺩ ‪ % ٢٥ -٣٠‬ﺭﻓﺮﺍﻧﺲﻫﺎ ﺟﺪﻳﺪ ﻣﻲﺑﺎﺷﻨﺪ‪.‬‬
‫ﺩﺭ ﻫﺮ ﻓﺼﻞ ﺗﺼﺎﻭﻳﺮ ﺑﺎ ﻛﻴﻔﻴﺖ ﺑﺎﻻ ﺍﺭﺍﺋﻪ ﺷﺪﻩ ﺍﺳﺖ‪ .‬ﺍﺳﺘﻔﺎﺩﻩﻛﻨﻨﺪﮔﺎﻥ ﺍﺯ ‪ CD‬ﺍﻳﻦ ﻛﺘﺎﺏ ﻣﻲﺗﻮﺍﻧﻨﺪ ﺍﺯ ﻋﻜﺲﻫﺎﻱ ﻛﺘﺎﺏ ﺑﻪ ﻋﻨﻮﺍﻥ ‪ Slide Conference‬ﺍﺳﺘﻔﺎﺩﻩ ﻧﻤﺎﻳﻨﺪ‪ .‬ﻛﺘﺎﺏ ﺣﺎﺿﺮ ﺭﻓﺮﺍﻧﺲ ﺩﺳﺘﻴﺎﺭﻳﺎﻥ ﭘﻮﺳﺖ ﻭ ‪ Board certification‬ﻣﻲﺑﺎﺷﺪ‪.‬‬
‫)‪36.6 Textbook of Dermatology (Rook's‬‬ ‫)‪(Seven Edition) (Volume 1-4) (E-Book‬‬ ‫‪2004‬‬
‫)‪37.6 Textbook of Pediatric Dermatology (JOHN HARPER ARNOLD ORANJE NEIL PROSE) (VOLUME 1 , 2‬‬ ‫‪2000‬‬
‫ﻛﺘﺎﺏ ﻓﻮﻕ ﻛﻪ ﺩﺭ ﻣﺮﻛﺰ ﺧﺪﻣﺎﺕ ﻓﺮﻫﻨﮕﻲ ﺳﺎﻟﻜﺎﻥ ﺗﺒﺪﻳﻞ ﺑﻪ ﻛﺘﺎﺏ ﺍﻟﻜﺘﺮﻭﻧﻴﻜﻲ ﮔﺮﺩﻳﺪﻩ ﺩﺭ ﺧﺼﻮﺹ ‪ Pediatric dermatology‬ﺍﺳﺖ ﻛﻪ ﺩﺭ ﺍﻛﺜﺮ ﻛﺸﻮﺭﻫﺎ ﻳﻚ ‪ Subspeciality‬ﺟﺪﺍﮔﺎﻧﻪ ﻣﻲﺑﺎﺷﺪ‪ .‬ﻣﺆﻟﻔﻴﻦ ﺍﻳﻦ ﻛﺘﺎﺏ ﻳﻚ ‪ encyclopedic text‬ﺩﺭ ﺩﺭﻣﺎﺗﻮﻟﻮﮊﻱ‬
‫ﻼ ﻣﺸﺎﺑﻪ ﺑﻪ ﺭﻭﺵ ﻧﮕﺎﺭﺵ ﻛﺘﺎﺏ ‪ (RooK) text book of general dermatology‬ﻣﻲﺑﺎﺷﺪ‪.‬‬ ‫ﺍﻃﻔﺎﻝ ﺑﻪ ﻛﻤﻚ ‪ 185‬ﻣﺤﻘﻖ ﺍﺯ ﺳﺮﺍﺳﺮ ﺟﻬﺎﻥ ﮔﺮﺩﺁﻭﺭﻱ ﻛﺮﺩﻩﺍﻧﺪ ﻛﻪ ﺑﻪ ﻋﻨﻮﺍﻥ ‪ board cerificaition‬ﺩﺭ ﺩﺭﻣﺎﺗﻮﻟﻮﮊﻱ ﺍﻃﻔﺎﻝ ﭘﺬﻳﺮﻓﺘﻪ ﺷﺪﻩ ﺍﺳﺖ‪ .‬ﺭﻭﺵ ﻧﮕﺎﺭﺵ ﻛﺘﺎﺏ ﻛﺎﻣ ﹰ‬
‫ﺍﻳﻦ ﻛﺘﺎﺏ ﺩﺭ ﺑﺮ ﮔﻴﺮﻧﺪﺓ ﺩﺭﻣﺎﺗﻮﻟﻮﮊﻱ ﺍﺯ ﺩﻭﺭﺓ ﭘﺮﻩﻧﺎﺗﺎﻝ ﺗﺎ ‪ adolescent‬ﻣﻲﺑﺎﺷﺪ‪ .‬ﻛﺘﺎﺏ ﻣﺸﺘﻤﻞ ﺑﺮ ‪ ٢٩‬ﻓﺼﻞ ﺑﻮﺩﻩ ﻛﻪ ﺷﺎﻣﻞ ﺑﻴﻤﺎﺭﻳﻬﺎﻱ ﺷﺎﻳﻊ ﻣﺎﻧﻨﺪ ‪ Psoriasis‬ﻭ ﺑﻴﻤﺎﺭﻱﻫﺎﻱ ﻧﺎﺩﺭ ﻣﻲﺑﺎﺷﺪ‪ .‬ﻫﻤﭽﻨﻴﻦ ﺁﺧﺮﻳﻦ ﭘﻴﺸﺮﻓﺖ ﺩﺭ ﮊﻧﺘﻴﻚ ﻣﻠﻜﻮﻟﻲ ﻭ ﺭﻭﺵﻫـﺎﻱ ﺩﺭﻣـﺎﻧﻲ ﺩﺭ ﺍﻳـﻦ‬
‫ﻛﺘﺎﺏ ﮔﻨﭽﺎﻧﺪﻩ ﺷﺪﻩ ﺍﺳﺖ‪ .‬ﺩﺭ ﺑﺨﺶ ﻋﻔﻮﻧﻲ ﻛﺘﺎﺏ ﺑﻴﻤﺎﺭﻳﻬﺎﻱ ﺍﻧﺪﻣﻴﻚ ﻣﺎﻧﻨﺪ ﻟﭙﺮﻭﺯﻱ ﻭ ﻟﻴﺸﻤﺎﻧﻴﻮﺯ ﻭ ﺍﻧﺪﻣﻴﻚ ﺗﺮﭘﻮﻧﻮﻣﺎﺗﻮﺯ ﻭ ‪ ...‬ﻛﻪ ﺩﺭ ﻛﺘﺎﺏﻫﺎﻱ ﺩﺭﻣﺎﺗﻮﻟﻮﮊﻱ ﺩﻳﮕﺮ ﺑﻪ ﺍﺧﺘﺼﺎﺭ ﺑﺤﺚ ﺷﺪﻩ ﺍﺳﺖ ﺗﻮﺳﻂ ﺍﻓﺮﺍﺩ ‪ ftrsthand knowledge‬ﺗﺤﺮﻳﺮ ﮔﺮﺩﻳﺪﻩ ﺍﺳﺖ‪ .‬ﺩﺭ ﺑﺨـﺶ ﻟﻴـﺰﺭ‬
‫ﻛﺘﺎﺏ ﺍﺳﺘﻔﺎﺩﻩ ﻟﻴﺰﺭ ﺑﺮﺍﻱ ﺩﺭﻣﺎﻥ ﺿﺎﻳﻌﺎﺕ ﭘﻴﮕﻤﺎﻧﺘﻪ ﻭ ﻋﺮﻭﻗﻲ ﮔﻨﺠﺎﻧﺪﻩ ﺷﺪﻩ ﺍﺳﺖ ﻭ ﺭﻭﺵﻫﺎﻱ ‪ Sedation‬ﻭ ﺑﻴﻬﻮﺷﻲ ﺩﺭ ﺍﻃﻔﺎﻝ ﺩﺭ ﻓﺼﻞ ‪ Surgery‬ﻛﺘﺎﺏ ﺑﺤﺚ ﺷﺪﻩ ﺍﺳﺖ‪ .‬ﺩﺭ ﻓﺼﻞ ‪ Surgery‬ﺗﻜﻨﻴﻚﻫﺎﻱ ﺳﺎﺩﻩ ﻭ ﭘﻴﭽﻴﺪﺓ ﺟﺮﺍﺣـﻲ ﻣﺸـﺘﻤﻞ ﺑـﺮ ‪ tissue expansion‬ﻭ‬
‫ﺍﻧﻮﺍﻉ ﻣﺨﺘﻠﻒ ‪ ،graft‬ﻛﺸﺖ ﻛﺮﺍﺗﻴﻨﻮﺳﻴﺖﻫﺎ‪ ،‬ﺗﺪﺍﺑﻴﺮ ﺩﺭﻣﺎﻧﻲ ﻛﻠﻮﺋﻴﺪ‪ ،‬ﺍﺳﻜﺎﺭ ﻭ ﺳﻮﺧﺘﮕﻲ ﺷﺮﺡ ﺩﺍﺩﻩ ﺷﺪﻩ ﺍﺳﺖ‪ .‬ﻣﺸﺨﺼﺔ ﻣﻨﺤﺼﺮ ﺑﻪ ﻓﺮﺩ ﻛﺘﺎﺏ ﻋﻜﺲﻫﺎﻱ ﻣﺘﻨﺎﺑﻪ ﺑﺎ ﻛﻴﻔﻴﺖ ﺑﺎﻻ ﺑﻮﺩﻩ ﻛﻪ ﺑﻪ ﻋﻨﻮﺍﻥ ﻳﻚ ﺍﻃﻠﺲ ﭘﻮﺳﺖ ﺩﺭ ‪ Pediatric dermatology‬ﻛﺎﺭﺑﺮﺩ ﺩﺍﺭﺩ‪ .‬ﻭ ﺑﻪ ﮔﻔﺘـﺔ‬
‫ﻣﺆﻟﻔﻴﻦ ﺗﻼﺵ ﺯﻳﺎﺩ ﺷﺪﻩ ﻛﻪ ﺗﻈﺎﻫﺮﺍﺕ ﻣﺨﺘﻠﻒ ﭘﻮﺳﺘﻲ ﺩﺭ ﻧﮋﺍﺩﻫﺎﻱ ﻣﺨﺘﻠﻒ ﺣﺪﺍﻗﻞ ﺩﺭ ﻣﻮﺭﺩ ﺑﻴﻤﺎﺭﻱﻫﺎﻱ ﺷﺎﻳﻊ ﺟﻤﻊﺁﻭﺭﻱ ﮔﺮﺩﺩ‪.‬‬
‫‪38.6‬‬ ‫‪The‬‬ ‫‪Aging‬‬ ‫‪Face‬‬ ‫‪A‬‬ ‫‪Systematic‬‬ ‫‪Approach‬‬ ‫‪(Calvin‬‬ ‫‪M.‬‬ ‫‪Johnson,‬‬ ‫‪Jr.,‬‬ ‫‪Ramsey‬‬ ‫)‪Alsarraf‬‬ ‫)‪(CD I , II‬‬ ‫‪2002‬‬
‫‪CD I:‬‬
‫‪y The Coronal Browlift: 1. Introduction 2. The Incision‬‬ ‫‪3. The Corrugator Muscles‬‬ ‫‪4. The Procerus and frontalis‬‬ ‫‪5. Closure‬‬
‫‪y Blepharoplasty:‬‬ ‫‪1. Uooer Lids‬‬ ‫‪3. Marking and Incision 5. Skin and Muscle‬‬ ‫‪7. Fat Removal‬‬ ‫‪9. Closure‬‬
‫‪2. Lower Lids‬‬ ‫‪4. The Incision‬‬ ‫‪6. Fant Removal‬‬ ‫‪8. The Skin Pinch‬‬
‫‪CD II:‬‬
‫‪-The Deep Plane Facelift‬‬ ‫‪-Marking and Incision‬‬ ‫‪-Skin Elevation‬‬ ‫‪-The Deep Plane‬‬ ‫‪-The Submental Region‬‬ ‫‪-Resuspension‬‬ ‫‪-Closure‬‬
‫)‪39.6 Treatment of Skin Disease Comprehensive therapeutic Strategies (Mark G Lebwohl Warren R Heymann, John Berth-Jones, Ian Coulson) (SALEKAN E-BOOK) (MOSBY‬‬ ‫‪2002‬‬
‫ﻛﺘﺎﺏ ﺍﻟﻜﺘﺮﻭﻧﻴﻜﻲ ﺣﺎﺿﺮ ﺷﺎﻣﻞ ﺍﻃﻠﺲ ‪ +‬ﺍﺳﺘﺮﺍﺗﮋﻱ ﺩﺭﻣﺎﻧﻲ ‪ +‬ﺩﺍﺭﻭﺩﺭﻣﺎﻧﻲ ﺑﻴﻤﺎﺭﻱ ﭘﻮﺳﺖ ﻣﻲﺑﺎﺷﺪ( ﻣﺸﻜﻞ ﺍﺻﻠﻲ ﭘﺰﺷﻜﺎﻥ ﺩﺭ ﻣﻮﺍﺟﻬﻪ ﺑﻪ ﻳﻚ ﺑﻴﻤﺎﺭﻱ ﺑﻌﺪ ﺍﺯ ﺗﺸﺨﻴﺺ ‪ management‬ﺑﻴﻤﺎﺭﻱ ﻣﻲﺑﺎﺷﺪ‪ .‬ﭼﻪ ﺳﺆﺍﻻﺗﻲ ﺑﺎﻳﺪ ﺍﺯ ﺑﻴﻤﺎﺭ ﭘﺮﺳﻴﺪﻩ ﺷﻮﺩ ﻭ ﭼﻪ ﺁﺯﻣﺎﻳﺸﺎﺗﻲ ﺑﺎﻳﺪ‬
‫ﺩﺭﺧﻮﺍﺳﺖ ﮔﺮﺩﺩ‪ .‬ﻫﺮ ﻓﺼﻞ ﺍﺯ ﺍﻳﻦ ﻛﺘﺎﺏ ﺷﺎﻣﻞ ﻳﻚ ﺑﻴﻤﺎﺭﻱ )ﺑﻪ ﺗﺮﺗﻴﺐ ﺣﺮﻭﻑ ﺍﻟﻔﺒﺎ ﺑﺮﺍﻱ ﺩﺳﺘﻴﺎﺑﻲ ﺑﻪ ﺁﺳﺎﻥ ﺑﻪ ﺑﻴﻤﺎﺭﻱ( ﺑﻮﺩﻩ ﻭ ﻫﺮ ﻓﺼﻞ ﻭ ﺷﺎﻣﻞ‪:‬‬
‫‪ -٣‬ﺟﺪﻭﻝ ﺑﺮﺍﻱ ﺍﻳﻨﻜﻪ ﭘﺰﺷﻚ ﭼﻪ ﺁﺯﻣﺎﻳﺸﺎﺕ ﭘﺎﺭﺍﻛﻠﻴﻨﻴﻜﻲ ﺭﺍ ﺩﺭﺧﻮﺍﺳﺖ ﻛﻨﺪ )‪(specific investigations‬‬
‫‪ -٢‬ﺍﺳﺘﺮﺍﮊﻱ ﺩﺭﻣﺎﻧﻲ‪) management strategy‬ﺩﺭ ﺑﺎﻟﻴﻦ ﻭ ﻣﻌﺎﻳﻨﻪ ﻭ ﺷﺮﺡ ﺣﺎﻝ ﺑﺎﻳﺪ ﭼﻪ ﻧﻜﺎﺗﻲ ﺟﺴﺘﺠﻮ ﺷﻮﺩ(‬ ‫‪ -١‬ﺧﻼﺻﻪﺍﻱ ﺍﺯ ﺑﻴﻤﺎﺭﻱ‬
‫‪ -٤‬ﺩﺭﻣﺎﻥ )ﺑﻪ ﺗﺮﺗﻴﺐ ﺧﻂ ﺍﻭﻝ‪ ،‬ﺧﻂ ﺩﻭﻡ‪ ،‬ﺧﻂ ﺳﻮﻡ ﺩﺭﻣﺎﻥ( ﻧﻜﺘﺔ ﻣﺘﻤﺎﻳﺰﻛﻨﻨﺪﻩ ﺍﻳﻦ ﻛﺘﺎﺏ ﻧﺴﺒﺖ ﺑﻪ ﻛﺘﺎﺏﻫﺎﻱ ﺩﺭﻣﺎﻧﻲ ﺩﻳﮕﺮ ﭘﻮﺳﺖ ﺍﻟﻮﻳﺖﺑﻨﺪﻱ ﺩﺭﻣﺎﻥ ﻣﻲﺑﺎﺷﺪ‪ .‬ﺍﻳﻦ ﺍﻟﻮﻳﺖﺑﻨﺪﻱ ﺑﺮ ﺍﺳﺎﺱ ‪ evidence-Based‬ﻣﻲﺑﺎﺷﺪ ﻭ ﺍﻟﻮﻳﺖ ﺑﺮ ﺍﺳﺎﺱ ﻧﻮﻉ ﻣﻄﺎﻟﻌﺎﺕ ﺍﻧﺠﺎﻡﺷـﺪﻩ ﺩﺭ‬
‫ﻣﻘﺎﻻﺕ ﺍﺯ ‪ A-E‬ﻧﺎﻡﮔﺬﺍﺭﻱ ﺷﺪﻩ ﺍﺳﺖ‪ .‬ﺑﻪ ﻋﻨﻮﺍﻥ ﻣﺜﺎﻝ ﺩﺭ ﺩﺭﻣﺎﻥ ﺁﻛﻨﻪ ﺍﺗﺮﻭﮊﺳﻦﻫﺎﻱ ﺧﻮﺭﺍﻛﻲ )‪ (A‬ﻭ ﺍﺳﭙﻴﺮﻭﻧﻮﺍﺭﻛﺘﻮﻥ )‪ (B‬ﻧﺎﻡﮔﺬﺍﺭﻱ ﺷﺪﻩ ﻛﻪ )‪ (A‬ﻣﺸﺨﺼﻪ )‪ (double blind study‬ﺑﻮﺩﻩ ﻭ )‪ (B‬ﻣﺸﺨﺼﻪ )‪ (Clinical trial‬ﻣﻲﺑﺎﺷﺪ ﻛﻪ ﺑﻪ ﭘﺰﺷﻚ ﻛﻤـﻚ ﻣـﻲﻛﻨـﺪ ﺗـﺎ‬
‫ﻼ ﺭﻧﮕﻲ ﻣﻲﺑﺎﺷﺪ‪.‬‬
‫ﺑﺘﻮﺍﻧﺪ ﺍﺭﺯﺵ ﺩﺍﺭﻭﺩﺭﻣﺎﻧﻲ ﺭﺍ ﺑﺮ ﺍﺳﺎﺱ ﻧﻮﻉ ﻣﻄﺎﻟﻌﻪ ﺑﻴﺎﻥ ﻛﻨﺪ‪ .‬ﺳﭙﺲ ﺧﻼﺻﻪ ﻣﻘﺎﻻﺕ ﺩﺭ ﺍﺩﺍﻣﻪ ﺩﺭﻣﺎﻥ ﺫﻛﺮ ﺷﺪﻩ ﺍﺳﺖ‪ .‬ﺍﻳﻦ ﻛﺘﺎﺏ ﺷﺎﻣﻞ ‪ ٢١٣‬ﺑﻴﻤﺎﺭﻱ ﻫﻤﺮﺍﻩ ﺑﺎ ﻋﻜﺲﻫﺎﻱ ﻛﺎﻣ ﹰ‬

‫‪40.6 USING BOTULINUM TOXINS COSMETICALLY‬‬ ‫)‪(Jean Carruthers, Alastair Carruthers‬‬ ‫‪2003‬‬
‫‪Introduction‬‬ ‫‪Horizontal Forehead Lines‬‬ ‫‪Periorbitalarea Infraorbital Orbicularis Oculi‬‬ ‫‪MID and Lower Face Perioal Rhytides‬‬
‫‪Brow Injections Brow Lift‬‬ ‫‪Periorbitalarea Lateral Orbital Wrinkles‬‬ ‫‪MID and Lower Face Perioral Rhytides‬‬ ‫‪MID and Lower Face Nasalis‬‬
‫‪Cervical Injections Vertical Platysmal Bands‬‬ ‫‪Acknowledgemetns‬‬ ‫‪MID and Lower Face Mouthe Frown and Mentalis‬‬ ‫‪Cervical Injections Horizontal Necklace Lines‬‬

‫ﺗﻠﻔﻦ‪٠٩١٢١٣٧٢٣٦١-٦٦٩٣٦٦٩٦ :‬‬ ‫ﻧﺸﺎﻧﻲ‪ :‬ﺗﻬﺮﺍﻥ‪ ،‬ﻡ ﺍﻧﻘﻼﺏ‪ ،‬ﺥ ﻛﺎﺭﮔﺮ ﺟﻨﻮﺑﻲ‪ ،‬ﺥ ﻟﺒﺎﻓﻲﻧﮋﺍﺩ‪ ،‬ﺑﻴﻦ ﻛﺎﺭﮔﺮ ﻭ ﺟﻤﺎﻟﺰﺍﺩﻩ‪ ،‬ﺑﻦﺑﺴﺖ ﺳﻴﻤﻴﻦ‪ ،‬ﭘﻼﻙ ‪٢٣٩‬‬ ‫ﻣﺮﻛﺰ ﺧﺪﻣﺎﺕ ﻓﺮﻫﻨﮕﻲ ﺳﺎﻟﻜﺎﻥ ‪ :‬ﺍﺭﺍﺋﻪ ﻛﻨﻨﺪﺓ ﻛﺘﺎﺏ ﻭ ﺳﻲﺩﻱﻫﺎﻱ ﺗﺨﺼﺼﻲ ﭘﺰﺷﻜﻲ‬
 35
‫ ﺍﺭﺗﻮﭘﺪﻱ‬-٧

CD ‫ﻋﻨﻮﺍﻥ‬ ‫ﺳﺎﻝ ﺍﻧﺘﺸﺎﺭ‬

1.7 A New Generation in Cemented Hip Design (VCD) (Part I , II) (David S. Hungerford, Clayton R. Perry) ‫ــــــ‬
Segment I: Core Decomtpression Segment II: Trauma Case Studies: Retrograde Femoral Nailing
2.7 AO Image Collection AO Principles of fracture Management (T.P. Ruedi, W.M. Murphy) 2001
3.7 AO International AO Teaching Series-LCP (Thomas P. Ruedi, Prof. Michael Wagner) 2002
Foreword-Basics LCP system LCP cases Literature and studies
Methods of osteosynthesis Description Humerus Related Literature
AO Principles Implants and instruments Forearm Study results
Biomechanical Principles Application Pelvis and acetabulum
Surgical techniques Indications Femur
Operating techniques Tibia
Periprosthetic

4.7 AO Principles of Fracture Management (Thomas P. Ruedi, William M. Murphy) (CD I , II) 2001
1- AO philosophy and Its basis 2- Decision making and planning 3- Reduction and fixation techniques 4- Specific fractures 5- General topics 6- Complications
5.7 Atlas of Orthopaedics Surgery (Disk 1-6) ‫ــــــ‬
Disk 1: Condylar Plate Fixation in the Distal Femur, Malleolar Fracture Fixation, Malleolar Fracture Type B, Malleolar Fracture Type C, Tension Band Wiring on the Elbow
Femoral Neck Rfacture Large Cannulated System, Fracture of the Radius Shaft 3.5 LC-DCP, Screw Fixation and Plating
Disk 2: Techniques of Absolute Stability, Proximal Humerus Fracture, Reduction with Clamps, Posterior Wall Fracture, Posteror + Transverse Wall Fracture,
Undeamed Tibial Nail (UTN), Intraaticular Fracture of the Distal Humerus
Disk 3: Fracture of the Tibiaplateau, Tibia Fracture in Foarm LEG UTN, Reduction Techniq, The Undeamed Femoral Nail System, Dynamic Condylar Screw (DCS),
Dynamic Hip Screw (DHS), Pilon Tibial Fractures (Foamed Foot)
Disk 4: Application of Large Distractor, AO Asif External Fixator, PC-FIX Point Contact Fixator an Internal Biologicl, The Proximal Femoral Nail (PFN),
Bicondylar Fracture of Tibia Plateau, Minimal Invasive Plating of the Tibia
Disk 5: Direct and Indirect Reduction Techniques, Short Oblique Radius Fracture, Small External Fixator, Intraarticular Fracture Distal Radius, Distal Radius,
Open Reduction & Fractures of the Calcaneus, Postoperative Treatment, Internal Fixation of a Humeral Shaft Fracture
Disk 6: High Cinematography of a Butterfly Fracture, Posterior, Pelvic Fixations Symphysis Pubis & Pubic Rami, Pelvic Fixations, Anterior Plate Fixation 53028,
The Pelvic C-Clamp, Liss Less Invasive Stabilization System, LCP Locking Compression Plate
6.7 Body in Motion (Susan K. Hillman)
2003
-Anatomy -Content -Everything -Anatomy Text -Surface Anatomy Videos -Muscle Aciton Videos
7.7 CCC (Core Curriculum in Primary Care) Orthopedics/Sport Medicine Section
‫ــــــ‬
1- Introduction 2- Orthopedic Procedures: A Rheumatology's Perspective 3- Xercise and Aging A Prescripton for life 4- Foot and Ankle Problems Part Two

8.7 Click'X VenttoFix SynCage (J. Webb, O. Schwarzenbach J. Thalgott) (VCD) (AO ASIF OFFICIAL TAPE) ‫ــــــ‬

9.7 FRACTURES IN ADULTS (ROCKWOOD AND GREEN'S) ‫ــــــ‬

1- General Principles 2- Upper Extremity 3- Spine 4- Lower Extremity
10.7 FRACTURES IN CHILDREN General Principlse Upper Extremity Spine Lower Extremity (ROCKWOOD AND WILKINS) (James H. Beaty, James R. Kasser) ‫ــــــ‬
11.7 FRACTURES OF THE PELVIS AND ACETABULUM (G.F. Zinghi, A. Briccoli, P.Bungaro) (Salekan E-Book) ‫ــــــ‬
12.7 Gait Analysis an introduction (Third Edition) An interactive multi-media presentation produced using polygon software (Micheal W. Whittle) ‫ــــــ‬
33.1 Imaging of Spinal Trauma in Children (Lawrence R. Kuhns, M.D.) (University of Michigan Medical Center) ___
Principles AND TECHNIQUES ATLAS OF SPINAL INJURIES IN CHILDREN
Epidemiology Normal Spine Variants and Anatomy Special Views and Techniques Cervcal Spine Lumbar Spine
Measurements Mechanisms and Patterns of Injury Experimental and Necropsy Data Thoracic Spine Sacrococcygeal Spine
Occipitocervical Injuries Thoracic Spine Injuries Sacral Injuries Lumbar

٠٩١٢١٣٧٢٣٦١-٦٦٩٣٦٦٩٦ :‫ﺗﻠﻔﻦ‬ ٢٣٩ ‫ ﭘﻼﻙ‬،‫ ﺑﻦﺑﺴﺖ ﺳﻴﻤﻴﻦ‬،‫ ﺑﻴﻦ ﻛﺎﺭﮔﺮ ﻭ ﺟﻤﺎﻟﺰﺍﺩﻩ‬،‫ ﺥ ﻟﺒﺎﻓﻲﻧﮋﺍﺩ‬،‫ ﺥ ﻛﺎﺭﮔﺮ ﺟﻨﻮﺑﻲ‬،‫ ﻡ ﺍﻧﻘﻼﺏ‬،‫ ﺗﻬﺮﺍﻥ‬:‫ﻧﺸﺎﻧﻲ‬ ‫ ﺍﺭﺍﺋﻪ ﻛﻨﻨﺪﺓ ﻛﺘﺎﺏ ﻭ ﺳﻲﺩﻱﻫﺎﻱ ﺗﺨﺼﺼﻲ ﭘﺰﺷﻜﻲ‬: ‫ﻣﺮﻛﺰ ﺧﺪﻣﺎﺕ ﻓﺮﻫﻨﮕﻲ ﺳﺎﻟﻜﺎﻥ‬
 36
13.7 1. Interactive Spine ‫ــــــ‬
2. Interactive Hand

orthopaedics and
Sport Medicine
3. Interactive hand therapy
Interactive
4. Interactive Hip
5. Interactive Shoulder
6. Interactive Knee
7. Sports Injuries The Knee
8. Interactive Food and Ankle
9. Interactve Skeleton
14.7 Internal Fixation of a Humeral Shaft Fracture with the UHN (P.M.Rommens, J. Blum) ‫ــــــ‬
-Technical Information -Operation -Postoperative Concept -Poat-op –X-ray control - Poat-op treatment

15.7 MASTER TECHNIQUES IN ORTHOPAEDIC SURGERY RECONSTRUCTIVE KNEE SURGERY Southern California Center for Sports Medicine Long Beach, California (DOUGLAS W. JACKSON, M.D.) ‫ــــــ‬
:‫ ﺷﺎﻣﻞ‬CD ‫ ﻣﺒﺎﺣﺚ ﺍﻳﻦ‬.‫ ﻣﻄﺎﻟﺐ ﺩﺭ ﺁﻥ ﻣﻲﺑﺎﺷﺪ‬serch ‫ ﺑﻮﺩﻩ ﻭ ﻗﺎﺑﻠﻴﺖ‬TEXT ‫ ﮔﺮﺩﻳﺪﻩ ﻭ ﺷﺎﻣﻞ ﺗﻤﺎﻣﻲ ﻣﺒﺎﺣﺚ ﻛﺘﺎﺏ ﺑﻪ ﺻﻮﺭﺕ‬ebook ‫ ﻛﻪ ﺷﺎﻣﻞ ﻛﻞ ﻣﺘﻦ ﻛﺘﺎﺏ ﻓﻮﻕﺍﻟﺬﻛﺮ ﺍﺳﺖ ﻛﻪ ﺩﺭ ﻣﺮﻛﺰ ﺧﺪﻣﺎﺕ ﻓﺮﻫﻨﮕﻲ ﺳﺎﻟﻜﺎﻥ ﺗﺒﺪﻳﻞ ﺑﻪ‬CD ‫ﺍﻳﻦ‬
Operating Room Environment PART IV INTRAARTICULAR FRACTURES OF THE TIBIA AND PATELLA
PART I EXTENSOR MECHANISM PATELLOFEMORAL PROBLEMS Arthroscopic Management of Intraarticular Tibial Fractures
Arthroscopic Lateral Release of the Patella with Electrocautery Anteromedial Tibial Tubercle Arthroscopically-Assisted Fixation of Patella Fractures
Transfer Patellectomy Open Reduction Internal Fixation of Intraarticular Fractures of the Tibia
PART II MENISCUS SURGERY
Meniscus Repair: The Outside-In Technique PART V ARTICULAR CARTILAGE AND SYNOVIUM
Meniscus Repair: The Inside-Out Technique Arthroscopic Chondroplasty
Meniscus Repair: The All-Inside Arthroscopic Technique Osteochondritis Dissecans
PART III LIGAMENT INJURIES AND INSTABILITY Arthroscopic Synovectomy
Anterior Cruciate Ligament Reconstruction
Arthroscope-Assisted Posterior Cruciate Ligament Repair/Reconstruction
Posterolateral Corner Collateral Ligament Reconstruction
Surgical Technique for Knee Dislocations
High Tibial Osteotomy in Knees with Associated Chronic Ligament Deficiencies
35.1 Magnetic Resonance Imaging in Orthopedics and Sport Medicine (David W. Stoller) ‫ــــــ‬
:‫ ﺩﺭ ﺍﺭﺗﻮﭘﺪﻱ ﻭ ﻃﺐ ﻭﺭﺯﺵ ﻣﻲﺑﺎﺷﺪ ﻭ ﺷﺎﻣﻞ ﻣﺒﺎﺣﺚ ﺯﻳﺮ ﺍﺳﺖ‬MRI ‫ﺍﻳﻦ ﻧﺮﻡﺍﻓﺰﺍﺭ ﺩﺭ ﺍﺭﺗﺒﺎﻁ ﺑﺎ ﻛﺎﺭﺑﺮﺩ‬
MRI ‫ ﺗﻬﻴﺔ ﺗﺼﺎﻭﻳﺮ‬-١ MRI ‫ ﺍﺛﺮﺍﺕ ﺑﻴﻮﻟﻮﮊﻳﻚ ﻭ ﺍﻳﻤﻨﻲ ﺩﺭ‬-٦ ‫ ﺳﻪﺑﻌﺪﻱ‬MRI ‫ ﺗﻜﻨﻴﻚ ﺑﺎﺯﺳﺎﺯﻱ ﺟﻬﺖ‬-١١ ‫ ﺗﻮﻣﻮﺭﻫﺎﻱ ﺍﺳﺘﺨﻮﺍﻥ ﻭ ﺑﺎﻓﺖ ﻧﺮﻡ‬-١٦
‫ ﺟﻬﺖ ﺳﻴﺴﺘﻢ ﻣﻮﺳﻜﻮﻟﻮﺍﺳﻜﻠﺘﺎﻝ‬Echo-Planar ‫ ﺍﺻﻮﻝ ﺗﺼﻮﻳﺮﺳﺎﺯﻱ‬-٢ ‫ ﻋﻀﺮﻭﻑ ﻣﻔﺼﻠﻲ ﻭ ﺩﮊﻧﺮﺍﺳﻴﻮﻥ ﻋﻀﺮﻭﻓﻲ‬MRI -٧ (Hip) ‫ ﻣﻔﺼﻞ ﺭﺍﻥ‬-١٢ ‫ ﺁﺳﻴﺒﻬﺎﻱ ﻋﻀﻼﻧﻲ‬MRI -١٧
‫ ﺯﺍﻧﻮ‬-٣ ‫ ﻣﭻ ﭘﺎ ﻭ ﭘﺎ‬-٨ ‫ ﺷﺎﻧﻪ‬-١٣
‫ ﺁﺭﻧﺞ‬-٤ ‫ ﻣﭻ ﺩﺳﺖ ﻭ ﺩﺳﺖ‬-٩ (TMJ) ‫ ﻣﻔﺼﻞ ﻛﻤﭙﻮﺭﻭﻣﺎﻧﺪﻳﺒﻮﻻﺭ‬-١٤
Kinematic MRI -٥ ‫ ﺳﺘﻮﻥ ﻓﻘﺮﺍﺕ‬-١٠ ‫ ﺍﺯ ﻣﻐﺰ ﺍﺳﺘﺨﻮﺍﻥ‬MRI ‫ ﺗﺼﻮﻳﺮﺑﺮﺩﺍﺭﻱ‬-١٥
16.7 MATHYS ORTHOPAEDICS (VCD) (Video-Atelier Othmar Keel AG) ‫ــــــ‬
-CCA - Straight Shaft -CCE -Vault Pan -CCB -Socket -CBC Stem -RM Cup
17.7 MATHYS-ORTHOPAEDICS HIP PROSTHESES (VCD) ‫ــــــ‬

1. Cemented Stem-CCA 2. Cemented Cup-CCB 3. Cementless Steam-CBC 4. Cementless Cup-RM Cup

18.7 Operative Arthroscopy (Third Edition) (John B. McGinty) (Lippincot, Williams & Wilkins) 2003
Shoulder:
Arthroscopic Cuff Repair: -Mssive U-Shaped Tear: Subscapulais, Infraspinatus and Biceps (Stephen S. Burkhar, MD San Antonio, Texas)
-Partial: Repair of Oartial Articular Sufrace Rotator Cuff Tear (Stephen S. Burkhar, MD San Antonio, Texas), San Antonio, Texas
Slap Lesions: -Arthroscopic Repair of the Slap Lesion (Stephen S. Burkhar, MD San Antonio, Texas)

٠٩١٢١٣٧٢٣٦١-٦٦٩٣٦٦٩٦ :‫ﺗﻠﻔﻦ‬ ٢٣٩ ‫ ﭘﻼﻙ‬،‫ ﺑﻦﺑﺴﺖ ﺳﻴﻤﻴﻦ‬،‫ ﺑﻴﻦ ﻛﺎﺭﮔﺮ ﻭ ﺟﻤﺎﻟﺰﺍﺩﻩ‬،‫ ﺥ ﻟﺒﺎﻓﻲﻧﮋﺍﺩ‬،‫ ﺥ ﻛﺎﺭﮔﺮ ﺟﻨﻮﺑﻲ‬،‫ ﻡ ﺍﻧﻘﻼﺏ‬،‫ ﺗﻬﺮﺍﻥ‬:‫ﻧﺸﺎﻧﻲ‬ ‫ ﺍﺭﺍﺋﻪ ﻛﻨﻨﺪﺓ ﻛﺘﺎﺏ ﻭ ﺳﻲﺩﻱﻫﺎﻱ ﺗﺨﺼﺼﻲ ﭘﺰﺷﻜﻲ‬: ‫ﻣﺮﻛﺰ ﺧﺪﻣﺎﺕ ﻓﺮﻫﻨﮕﻲ ﺳﺎﻟﻜﺎﻥ‬
 37
19.7 Operative Arthroscopy (Third Edition) (John B. McGinty) (Lippincot, Williams & Wilkins) 2003
Hip: Southern Sport Medicine & Orthopaedic Center
Operative Hip Arthroscopy: -Dense Soft Tissue Envelope -Constrained Ball and Socket Anatomy -Thick Capsule, Limited Compliance
20.7 Operative Arthroscopy (Third Edition) (John B. McGinty) (Lippincot, Williams & Wilkins) 2003
Ankle: Ankle Arthroscopy (James Tasto M.D.)
- Ankle & Subtalar Arthroscopy
21.7 Operative Arthroscopy (Third Edition) (John B. McGinty) (Lippincot, Williams & Wilkins) 2003

Wrist: Wrist Arthroscopy (Robert Richards MD FRCSC)

-Portal Markings -Establishing the 3/4 Portal -Radiocarpal Arthroscopy
Carpal Tunnel Release
22.7 Operative Arthroscopy (Third Edition) (John B. McGinty) (Lippincot, Williams & Wilkins) 2003

Knee (CD-1): Arthroscopic meniscal repair: -suture repair -implantable fixation

Knee (CD-2): -ACL -Complex articular surface injuries -Fractures -Patellofemoral
23.7 Operative Arthroscopy (SECOND EDITION) (John B. McGinty) ‫ــــــ‬

1- Basic Principles 2- The Knee 3- The Shoulder 4- The Elbow 5- The Wrist 6- The Foot and Ankle 7- The Temporomandibular Joint 8- The Spine 9- The Hip
24.7 Operative Orthopaedics (Ninth Edition) (CAMPBELL'S) (S. TERRY CANALE) 1999
.‫ ﭼﺎﭖ ﺑﺎ ﺗﻤﺎﻣﻲ ﺗﺼﺎﻭﻳﺮ ﻣﺮﺗﺒﻂ ﺑﺎ ﻛﺘﺎﺏ ﻣﻲﺑﺎﺷﺪ‬Serch ‫ ﻛﺎﻣﻞ ﻛﺘﺎﺏ ﻛﻤﭙﻞ ﺍﺭﺗﻮﭘﺪﻱ ﻣﻲﺑﺎﺷﺪ ﻭ ﻗﺎﺑﻠﻴﺖ‬TEXT ‫ ﺷﺎﻣﻞ‬CD ‫ﺍﻳﻦ‬
25.7 OPERATIVE ORTHOPAEDICS (CAMPBELL'S) 2003
:‫ ﺷﺎﻣﻞ‬CD ‫ ﻛﺘﺎﺏ ﻛﻤﭙﻞ ﻣﻲﺑﺎﺷﺪ ﻛﻪ ﻓﻴﻠﻢﻫﺎﻱ ﺍﻳﻦ‬TEXT ‫ ﺷﺎﻣﻞ ﻋﻤﻞﻫﺎﻱ ﺟﺮﺍﺣﻲ ﻣﺮﺗﺒﻂ ﺑﺎ‬CD ‫ﺍﻳﻦ‬
Trochanteric osteotomy-hip revision Arthroscopic assisted ACL reconstruction Screw fixation SCFE Intramedullary nailing forearm fracture
Reconstruction nailing femoral fracture Chevron osteotomy hallux valgus Ligament balancing Knee arthroplasty ORIF calconeal fracture
Anterior Cervical discectomy & fusion
26.7 ORTHOPAEDIC SURGERY (Third Edition) (CHAPMAN) 2002
- Surgical Principles and Techniques - Fractures, Dislocations, Nonunions and Malunions - The Hand - The Foot
- Sport Medicine - Neoplastic, Infectious - Neurologic and Other - Joint Reconstruction, Arthritis, and Arthroplasty
- Skeletal Disorders - The Spine - Pediatric Disorders
27.7 OPERATIVE ORTHOPAEDICS (CAMPBELL'S) (Tenth Edition) (Volume 1-4) (E-Book) (S. Terry Canale, MD) 2003
28.7 PEDIATRIC ORTHOPAEDICS (Lovell and Winter's) (Fifth edition) (Salekan E-Book) (Volume II) 2001
KYPHOSIS THE UPPER LIMB SLIPPED CAPITAL FEMORAL EPIPHYSIS
DEVELOPMENTAL COXA VARA, TRANSIENT SYNOVITIS,
SPONDYLOLYSIS AND SPONDYLOLISTHESIS DEVELOPMENTAL HIP DYSPLASIA AND DISLOCATION
AND IDIOPATHIC CHONDROLYSIS OF THE HIP
THE CERVICAL SPINE LEGG-CALVE-PERTHES SYNDROME THE LOWER EXTREMITY
LEG LENGTH DISCREPANCY THE FOOT THE LIMB-DEFICIENT CHILD
SPORTS MEDICINE IN CHILDREN AND ADOLESCENTS MANAGEMENT OF FRACTURES THE ROLE OF THE ORTHOPAEDICS IN CHILD ABUSE
29.7 Photographic manual of Regional Orthopaedic and Neurological Tests ‫ــــ‬
.‫ ﻓﺼﻮﻝ ﺑﺮ ﺍﺳﺎﺱ ﻣﺤﻞ ﻣﻮﺭﺩ ﻣﻌﺎﻳﻨﻪ ﻃﺮﺍﺣﻲ ﻭ ﻗﺴﻤﺖﺑﻨﺪﻱ ﺷﺪﻩﺍﻧـﺪ‬.‫ ﺩﺭ ﻣﻮﺍﻗﻊ ﻟﺰﻭﻡ ﺗﺼﺎﻭﻳﺮ ﺁﻧﺎﺗﻮﻣﻴﻚ ﺿﺮﻭﺭﻱ ﻧﻴﺰ ﺍﺿﺎﻓﻪ ﺷﺪﻩﺍﻧﺪ‬.‫ ﺗﺼﻮﻳﺮ ﻣﻲﺑﺎﺷﺪ ﻛﻪ ﻧﺤﻮﺓ ﺍﻧﺠﺎﻡ ﺗﻤﺎﻡ ﻣﻌﺎﻳﻨﺎﺕ ﻧﻮﺭﻭﻟﻮﮊﻳﻚ ﻭ ﺍﺭﺗﻮﭘﺪﻳﻚ ﺭﺍ ﺑﺎ ﺟﺰﺋﻴﺎﺕ ﺗﻤﺎﻡ ﺭﻭﺷﻦ ﻣﻲﺳﺎﺯﺩ‬٨٥٠ ‫ ﺷﺎﻣﻞ ﺑﻴﺶ ﺍﺯ‬CD ‫ﺍﻳﻦ‬

٠٩١٢١٣٧٢٣٦١-٦٦٩٣٦٦٩٦ :‫ﺗﻠﻔﻦ‬ ٢٣٩ ‫ ﭘﻼﻙ‬،‫ ﺑﻦﺑﺴﺖ ﺳﻴﻤﻴﻦ‬،‫ ﺑﻴﻦ ﻛﺎﺭﮔﺮ ﻭ ﺟﻤﺎﻟﺰﺍﺩﻩ‬،‫ ﺥ ﻟﺒﺎﻓﻲﻧﮋﺍﺩ‬،‫ ﺥ ﻛﺎﺭﮔﺮ ﺟﻨﻮﺑﻲ‬،‫ ﻡ ﺍﻧﻘﻼﺏ‬،‫ ﺗﻬﺮﺍﻥ‬:‫ﻧﺸﺎﻧﻲ‬ ‫ ﺍﺭﺍﺋﻪ ﻛﻨﻨﺪﺓ ﻛﺘﺎﺏ ﻭ ﺳﻲﺩﻱﻫﺎﻱ ﺗﺨﺼﺼﻲ ﭘﺰﺷﻜﻲ‬: ‫ﻣﺮﻛﺰ ﺧﺪﻣﺎﺕ ﻓﺮﻫﻨﮕﻲ ﺳﺎﻟﻜﺎﻥ‬
 38
‫ ﺩﺭ ﺿـﻤﻦ ﻳـﻚ‬.‫ ﺩﺭ ﻳﻚ ﺻﻔﺤﻪ ﻳﺎ ﺩﻭ ﺻﻔﺤﻪ ﻣﻘﺎﺑﻞ ﻫﻢ ﺑﺎ ﻋﻜﺲﻫﺎﻳﻲ ﻛﻪ ﻧﺤﻮﺓ ﺍﻧﺠﺎﻡ ﻣﻌﺎﻳﻨـﻪ ﺭﺍ ﺑﻮﺿـﻮﺡ ﻧﺸـﺎﻥ ﻣـﻲﺩﻫﻨـﺪ ﺗﻮﺿـﻴﺢ ﺩﺍﺩﻩ ﺷـﺪﻩ ﺍﺳـﺖ‬Test ‫ ﻫﺮ‬.‫ﻣﻌﺎﻳﻨﺎﺕ ﺍﺯ ﻓﻘﺮﺍﺕ ﮔﺮﺩﻧﻲ ﻭ ﺍﻧﺪﺍﻡ ﻓﻮﻗﺎﻧﻲ ﺷﺮﻭﻉ ﻭ ﺑﻪ ﻓﻘﺮﺍﺕ ﻛﻤﺮﻱ ﻭ ﺍﻧﺪﺍﻡﻫﺎﻱ ﺗﺤﺘﺎﻧﻲ ﺧﺘﻢ ﻣﻲﺷﻮﻧﺪ‬
.‫ ﺍﻳﻦ ﺍﻃﻼﻋﺎﺕ ﺩﺭ ﺑﻜﺎﺭﮔﻴﺮﻱ ﺗﺴﺖﻫﺎﻱ ﺣﺴﺎﺳﺘﺮ ﻭ ﺍﺧﺘﺼﺎﺹﺗﺮ ﻛﻤﻚ ﻓﺮﺍﻭﺍﻥ ﺑﻪ ﭘﺰﺷﻚ ﻣﻲﻧﻤﺎﻳﺪ‬.‫ ﻧﻴﺰ ﺑﺮﺍﻱ ﻫﺮ ﻣﻌﺎﻳﻨﻪ ﺗﻌﺮﻳﻒ ﺷﺪﻩ ﺍﺳﺖ ﻛﻪ ﻣﻴﺰﺍﻥ ﺣﺴﺎﺳﻴﺖ ﻭ ﻗﺎﺑﻠﻴﺖ ﺍﻋﺘﻤﺎﺩ ﺑﻪ ﺁﻥ ﻣﻌﺎﻳﻨﻪ ﺭﺍ ﻣﺸﺨﺺ ﻣﻲﺳﺎﺯﺩ‬Sensitivity/Relialility Scale

45.1 Radiology imaging Bank: Orthopeadic

1. Section 2. History 3. Findings 4. Diagnosis 5. Images 6. Classification 7. Imagenumber
30.7 Range of Motion-AO Neutral-O Method ‫ــــــ‬
31.7 SPINE (VCD 1-A) (J. o' Dowd, P. Moulin, E. Morscher P. Moutin, J. Webb, M. Aebi) ‫ــــــ‬
Cervical Spine Locking Plate Posterior Plating Technique
Pedicie Identification (Conultant: J. O'Dowd) Cervical Spine Locking Plate: Corporectomy C6 (P. Moulin)
Vertebrectomy C6 (J. Webb, M. Aebi) C6 to T1 (J. Webb, M.Aebi)
CS-Titanium Locking Plate (E. Morscher P.Moutin) Cervical Spine Locking Plate (P. Moulin) Posterior Cervical Plate Fixation ( C2-T1) ( j.wEBB, M.Aebi)
32.7 SPINE (VCD 1-B) (M. Aebi, J. Webb, Ghr. Ulrich, J. Nothwang, B. Jeanneret, M. Aebi J. Webb, J. Webb, M. Aebi P. Bryne) ‫ــــــ‬
AnteriorFixation of the Dens with Cannulated Screws ( M. Aebi, J. Webb Ghr. Ulrich, J. Nothwang) U.S.S: Lumbosacral Stabilisation: Back-Opening Pedicte Screws (M. Aebi J. Webb)
Cervix: Fixation C3-C7 in Presenceb of a Laminectomy ( B. Jeanneret) USS: Lumbosacral Fusion Sacral Implants (J. Webb M.Aebi P.Bryne)
U.S.S: Lumbar Degenrrative Scotiosis Side-Opening Pedicte Screws (M.Aebi J.Webb)
33.7 SPINE (VCD 1-C) (J. Webb, M. Aebi, G.Wisner, J. Webb M. Aebi, J. Webb M. Aebi, J. O'Dowd) ‫ــــــ‬
USS: Lumbosacral Stabilisation Side Opening Pedicle Screws Universal Spine System Thoraco - Lumbar Universal Spine Right Thoracic Scoliosis: Side Opening hooks & Screws
(J.Webb, M.Aebi, G. Winsner) Fractures (J. Webb M. Aebi) System: (J.Webb, M.Aebi, J.O'Dowd)
34.7 SPINE (VCD 1-D) (J. Webb, O. Schwarzenbach, J. Thalgott & J. Webb, J. Webb) ‫ــــــ‬
Click'X (J.Webb) The Snterior Rod System (J.Thalgott & J.Webb) Contact Fusion Cage (J.Webb)
35.7 SPINE implants (CD I , II) ‫ــــ‬
.‫ ﻧﺤﻮﺓ ﺟﺮﺍﺣﻲ ﻭ ﺑﻪﻛﺎﺭﮔﺬﺍﺷﺘﻦ ﭘﺮﻭﺗﺰﻫﺎﻱ ﻣﻬﺮﻩ ﻧﺸﺎﻥ ﺩﺍﺩﻩ ﻣﻲﺷﻮﺩ ﻭ ﺍﻃﻼﻋﺎﺕ ﻛﺎﻣﻠﻲ ﺭﺍﺟﻊ ﺑﻪ ﭘﺮﻭﺗﺰﻫﺎﻱ ﺟﺎﻧﺸﻴﻦ ﺟﺴﻢ ﻣﻬﺮﻩ ﺩﺍﺩﻩ ﻣﻲﺷﻮﺩ‬CD ‫ ﺩﺭ ﺍﻳﻦ‬: CD I
.‫ ﺑﺮ ﺭﻭﻱ ﻣﻬﺮﻩﻫﺎﻱ ﻛﻤﺮﻱ ﺩﺭ ﺩﺭﻣﺎﻥ ﻣﻮﺍﺭﺩ ﺗﺮﻭﻣﺎﺗﻴﻚ ﻭ ﺍﺳﻜﻮﺍﻧﻴﻮﺭ ﻧﺸﺎﻥ ﺩﺍﺩﻩ ﻣﻲﺷﻮﺩ‬Diapasone-hook ‫ ﻧﺤﻮﻩ ﺟﺮﺍﺣﻲ ﻭ ﺑﻜﺎﺭﮔﺬﺍﺷﺘﻦ ﺩﺳﺘﮕﺎﻩ‬CD ‫ ﺩﺭ ﺍﻳﻦ‬: CD II
36.7 Surgery of the Foot and Ankle (Michael J. Coughlin, Roger A. Mann) 1999
Volume One:
1. General Considerations 2. The forefoot 3. Postural Disorders 4. Neurologic Disorders 5. Arthritic Conditions
Volume Two:
1. Miscellaneous Disorders 2. Sports Medicine 3. Pediatrics 4. Trauma
37.7 Surgery of the Knee (Third Edition) (John N. Insall, W. Norman Scott) 2001
1- VIDEO 2- PHOTOS 3- ILLUSTRATIONS 4- 3D KNEE 5-IMAGING
- Anatomy -Anatomical Aberrations -Biomechanics -Imaging -Surgical Approaches
38.7 The Adult Hip On CD ‫ــــــ‬
39.7 The Shoulder (2 nd
Edition) (Rockwood and Matsen) ‫ــــــ‬
1- Disorders of the Acromiocavicular Joint 2- Disorders of the Sternoclavicular Joint 3- Glenohumeral Instability 4- Glenohumeral Arthritis and Its Management
40.7 The Unreamed Femoral Nail System (N. Sudkamp P. Duwelius) ‫ــــــ‬

41.7 Video Collection Labor for Experimental Orthopaedics Surgery AO/ASIF VCD (CD 1-10) ‫ــــــ‬
VCD 1-A ( R Texhammar, P Holzach)
AO/ASIF Instrumentation Care and Maintenance PreOperative Preparation of the Patient Approaches to the Femur, Pelvis Knee and Elbow

٠٩١٢١٣٧٢٣٦١-٦٦٩٣٦٦٩٦ :‫ﺗﻠﻔﻦ‬ ٢٣٩ ‫ ﭘﻼﻙ‬،‫ ﺑﻦﺑﺴﺖ ﺳﻴﻤﻴﻦ‬،‫ ﺑﻴﻦ ﻛﺎﺭﮔﺮ ﻭ ﺟﻤﺎﻟﺰﺍﺩﻩ‬،‫ ﺥ ﻟﺒﺎﻓﻲﻧﮋﺍﺩ‬،‫ ﺥ ﻛﺎﺭﮔﺮ ﺟﻨﻮﺑﻲ‬،‫ ﻡ ﺍﻧﻘﻼﺏ‬،‫ ﺗﻬﺮﺍﻥ‬:‫ﻧﺸﺎﻧﻲ‬ ‫ ﺍﺭﺍﺋﻪ ﻛﻨﻨﺪﺓ ﻛﺘﺎﺏ ﻭ ﺳﻲﺩﻱﻫﺎﻱ ﺗﺨﺼﺼﻲ ﭘﺰﺷﻜﻲ‬: ‫ﻣﺮﻛﺰ ﺧﺪﻣﺎﺕ ﻓﺮﻫﻨﮕﻲ ﺳﺎﻟﻜﺎﻥ‬
 39
VCD 1-B (P Matter M.D., S.M. Perren, B Noesberger)
Approach to the Proximal Femur and Elbow After-Care Following Lower Leg Surgery Dynamic Compression Unit Approaches to the Upper Limb Reduction Techniques DCP 4.5 Compression Tibial Shaft

VCD 1-C (B Noesberger, J.Stadler, P. Holzach, Th. Ruedi)

DCP 4.5 Butterss Tibial Plateau LC-DCP 4.5 for the Distal Tbia DCP 3.5 Radius Shaft 3.5 LC-DCP DCP 4.5 Neutralization Plate of a Spiral Fracture Fracture of the Radius Shaft 3.5 LC-DCP with Shaft screws

VCD 2-A (S.M. Perren, K.M. Pfeiffer M.D.)

. Correctional Osteotomy (dist. Radius) . Basic Lag Screw Techniques . Internal Fixation of a Closed Butterfly Fracture of Right Tibia (Operation Video)
VCD 2-B (Th. Ruedi, J. Mast M.D., P.E Ochsner)
Fracture of the Lateral Tibiaplateau Indirect Reduction and Plate Fixation of a Pilon Fracture Malleolar Fracture Type B
Pilon Fracture Malleolar fracture Type A Malleolar Fracture Type C

VCD 2-C (T.Ruedi, P.Holzach, Th. Ruedi M. Schuler, P. Hozach, P Regazzoni, Th. Ruedi M.D.)
Proximal Humerus Fracture Tension Band Wiring of the Elbow Intaarticular Type C Fracture of the Distal Humerus Condylar Plate Fixation in the Distal Femur
Distal Humerus Fracture Type C 1.3 Dynamic Hip Screw Dynamic Condylar Screw (DCS) Proximal Femur

VCD 3-A (R. Ganz R.P. Jakob P.Koch, Th Ruedi M.D., P.Regazzoni)
Condylar Plate Proximal Femur Large Cannulated Screw System AO/ASIF External Fixator

VCD 3-B
Small External Fixator Using the Small Air Drill
Distractor Handling Compact Air Drive Basic Operating Procedure & Working with attachments AO Universal Femoral Nail With Distractor
Consultant Seija Pearson Intramedullary Nailing with the AO/ASIF Universal Femoral Nail

VCD 3-C (R. Frigg, D. Hontzsch, Th. Ruedi)

The Interlocking of the Universal Femoral Intramedullary Nail Intramedullary Nailing of the Tibia
Opening Procedure of the Tibial Cavity for Intramedullary Nailing Intramedullary Nailing of the Tibia with a Pseudarthrosis
The Universal Tibial Nail Mid-Shaft Tibial Fracture Locked Universal Nail

VCD4 (R. Frigg, Ch. Krettek)

UTN Unreamed Tibial Nail Distal Aiming Device for UTN

‫ ﭼﺸﻢﭘﺰﺷﻜﻲ‬-٨
CD ‫ﻋﻨﻮﺍﻥ‬ ‫ﺳﺎﻝ ﺍﻧﺘﺸﺎﺭ‬
1.8 Atlas of Clinical Oncology Tumors of the Eye and Ocular Adnexa (American Cancer Society) (Devron H. Char, MD) 2001
:‫ ﺷﺎﻣﻞ ﻣﺒﺎﺣﺚ ﺯﻳﺮ ﻣﻲﺑﺎﺷﺪ‬CD ‫ﺍﻳﻦ‬
1- LID AND CONJUNCTIVAL TUMORS 2- UVEAL AND INTRAOCULAR TUMORS 3- RETINAL AND OPTIC NERVEHEAD TUMORS 4- ORBITAL TUMORS
2.8 ATLAS OF OPHTALMOLOGY (RICHARD K. PARRISG II) (CD I , II) (Mosby) ‫ــــ‬

3.8 ATLAS OF OPHTHALOMOLGY (SUE FORDRONALD MARSH) (Mosby) ‫ــــ‬

‫ﻫﺎﻱ ﺫﻳـﻞ ﻛـﻪ ﺣـﺎﻭﻱ ﻣﻌﺘﺒﺮﺗـﺮﻳﻦ ﻭ ﺷـﻨﺎﺧﺘﻪﺷـﺪﻩﺗـﺮﻳﻦ‬CD .‫ ﺑﺪﻭﻥ ﻫﻤﺮﺍﻫﻲ ﺍﻃﻠﺲﻫﺎﻱ ﻣﺮﺑﻮﻃﻪ ﺗﺄﺛﻴﺮ ﻭ ﻛﺎﺭﺁﺋﻲ ﻻﺯﻡ ﺭﺍ ﻧﺨﻮﺍﻫﺪ ﺩﺍﺷﺖ‬text ‫ ﻣﻄﺎﻟﻌﺔ ﻛﺘﺐ‬،‫ﻼ ﻣﻌﻠﻮﻡ ﻭ ﻣﺸﺨﺺ ﺑﻮﺩﻩ‬
‫ﺍﺭﺯﺵ ﻳﻚ ﺍﻃﻠﺲ ﺧﻮﺏ ﺩﺭ ﺗﻤﺎﻣﻲ ﺷﺎﺧﻪﻫﺎﻱ ﻋﻠﻢ ﭘﺰﺷﻜﻲ ﺧﺼﻮﺻﹰﺎ ﭼﺸﻢﭘﺰﺷﻜﻲ ﻛﺎﻣ ﹰ‬

٠٩١٢١٣٧٢٣٦١-٦٦٩٣٦٦٩٦ :‫ﺗﻠﻔﻦ‬ ٢٣٩ ‫ ﭘﻼﻙ‬،‫ ﺑﻦﺑﺴﺖ ﺳﻴﻤﻴﻦ‬،‫ ﺑﻴﻦ ﻛﺎﺭﮔﺮ ﻭ ﺟﻤﺎﻟﺰﺍﺩﻩ‬،‫ ﺥ ﻟﺒﺎﻓﻲﻧﮋﺍﺩ‬،‫ ﺥ ﻛﺎﺭﮔﺮ ﺟﻨﻮﺑﻲ‬،‫ ﻡ ﺍﻧﻘﻼﺏ‬،‫ ﺗﻬﺮﺍﻥ‬:‫ﻧﺸﺎﻧﻲ‬ ‫ ﺍﺭﺍﺋﻪ ﻛﻨﻨﺪﺓ ﻛﺘﺎﺏ ﻭ ﺳﻲﺩﻱﻫﺎﻱ ﺗﺨﺼﺼﻲ ﭘﺰﺷﻜﻲ‬: ‫ﻣﺮﻛﺰ ﺧﺪﻣﺎﺕ ﻓﺮﻫﻨﮕﻲ ﺳﺎﻟﻜﺎﻥ‬
 40
‫ ﺩﺭ ﻛﻨﺎﺭﺩﺍﺷﺘﻦ ﺍﻳﻦ ﺍﻃﻠﺲﻫﺎ ﭼﻪ ﺑﻪ ﻫﻨﮕﺎﻡ ﺁﻣﻮﺯﺵ ﻭ‬.‫ ﻣﻮﺭﺩ ﻧﻈﺮ ﺩﺭ ﻛﻤﺘﺮﻳﻦ ﺯﻣﺎﻥ ﻣﻤﻜﻦ ﻣﻲﺑﺎﺷﻨﺪ‬Case ‫ ﻭ ﺟﺴﺘﺠﻮﻱ‬Search ‫ ﻋﻼﻭﻩ ﺑﺮ ﺗﻮﺍﻧﺎﺋﻲ ﺑﺰﺭﮔﻨﻤﺎﻳﻲ ﺗﺼﺎﻭﻳﺮ ﺗﺎ ﭼﻨﺪﻳﻦ ﺑﺮﺍﺑﺮ ﺑﺪﻭﻥ ﻛﺎﺳﺘﻪﺷﺪﻥ ﺍﺯ ﻛﻴﻔﻴﺖ ﺑﻲﻧﻈﻴﺮ ﺁﻥ ﺩﺍﺭﺍﻱ ﻗﺎﺑﻠﻴﺖ‬،‫ﺍﻃﻠﺲﻫﺎﻱ ﭼﺸﻢﭘﺰﺷﻜﻲ ﻣﻲﺑﺎﺷﻨﺪ‬
.‫ﻫﺎﻱ ﻧﺴﺒﺘﹰﺎ ﻧﺎﺩﺭ ﺩﺭ ﻛﻠﻴﻨﻴﻚ ﺑﺴﻴﺎﺭ ﻣﻔﻴﺪ ﻭ ﻛﻤﻚﻛﻨﻨﺪﻩ ﺧﻮﺍﻫﺪ ﺑﻮﺩ‬Case ‫ ﻭ ﻣﻮﺍﺟﻪ ﺑﻪ‬Practice ‫ﻳﺎﺩﮔﻴﺮﻱ ﺩﺭ ﺩﻭﺭﺓ ﺩﺳﺘﻴﺎﺭﻱ ﻭ ﭼﻪ ﺑﻪ ﻫﻨﮕﺎﻡ‬
4.8 Basic and Clinical Science Course Retina and Vitreous (Section 12) (American Academy of Ophthalmology) (SALEKAN E-BOOK) 2003

5.8 Basic Ophthalmology ‫ــــ‬

Physiology of the Eye
6.8 OPHTHALMOLOGY (Myron Yanoff.Jay S. Duker) (Mosby)
7.8 ‫ ﺩﻳﺪﻥ ﺍﺷﻜﺎﻝ ﺷـﻤﺎﺗﻴﻚ ﺯﻳﺒـﺎ ﻭ ﻧﻴـﺰ‬.‫ ﭘﺰﺷﻜﺎﻥ ﻋﻤﻮﻣﻲ ﻭ ﭘﺰﺷﻜﺎﻥ ﻣﺘﺨﺼﺺ ﺩﺭ ﺳﺎﻳﺮ ﺭﺷﺘﻪﻫﺎﻱ ﭘﺰﺷﻜﻲ ﻣﻲﭘﺮﺩﺍﺯﺩ‬،‫ ﻣﻜﺎﻧﻴﺴﻢ ﻋﻴﻮﺏ ﺍﻧﻜﺴﺎﺭﻱ ﻭ ﻧﻴﺰ ﺑﻴﻤﺎﺭﻱﻫﺎﻱ ﭼﺸﻢ ﺩﺭ ﺳﻄﺢ ﻧﻴﺎﺯ ﺩﺍﻧﺸﺠﻮﻳﺎﻥ ﭘﺰﺷﻜﻲ‬،‫ ﺑﻪ ﺗﻮﺿﻴﺢ ﺁﻧﺎﺗﻮﻣﻲ ﻭ ﻓﻴﺰﻳﻮﻟﻮﮊﻱ ﭼﺸﻢ ﻭ ﺭﺍﻫﻬﺎﻱ ﺑﻴﻨﺎﺋﻲ‬CD ٣ ‫ﺍﻳﻦ‬
‫ﻫﺎ ﺑﺮﺍﻱ ﻣﺘﺨﺼﺼﻴﻦ ﻣﺤﺘﺮﻡ ﭼﺸﻢﭘﺰﺷﻜﻲ ﻧﻴﺰ ﺧﺎﻟﻲ ﺍﺯ ﻟﻄﻒ ﻧﺨﻮﺍﻫﺪ ﺑﻮﺩ‬CD ‫ﺗﺼﺎﻭﻳﺮ ﺑﻴﻤﺎﺭﻱﻫﺎﻱ ﻣﺨﺘﻠﻒ ﭼﺸﻤﻲ ﻣﻮﺟﻮﺩ ﺩﺭ ﺍﻳﻦ‬
8.8 Clinical update course on Retina ‫ــــ‬

.‫ ﻣﺮﻭﺭﻱ ﺩﺍﺭﺩ ﺑﺮ ﺟﺪﻳﺪﺗﺮﻳﻦ ﻣﺘﺪﻫﺎﻱ ﺩﺭﻣﺎﻧﻲ ﺩﺭ ﻓﻴﻠﺪ ﻭ ﺗﻴﺮﻩ ﻭ ﺭﺗﻴﻦ‬،‫ ﻭ ﻓﻴﻠﻢ ﺁﻣﻮﺯﺷﻲ‬Lecture ١٥ ‫( ﻣﻲﺑﺎﺷﺪ ﻛﻪ ﺩﺭ ﻗﺎﻟﺐ‬AAO) ‫( ﻣﺘﻌﻠﻖ ﺑﻪ ﺁﻛﺎﺩﻣﻲ ﭼﺸﻢﭘﺰﺷﻜﻲ ﺁﻣﺮﻳﻜﺎ‬Lifelong education for the ophthalmologist) LEO ‫ﻫﺎﻱ ﺁﻣﻮﺯﺷﻲ‬CD ‫ ﻓﻮﻕ ﺍﺯ ﺳﺮﻱ‬CD
.‫ ﺍﺷﺎﺭﻩ ﻧﻤﻮﺩ‬... ‫ ﻭ‬endophthalmitis ،macular hole ،BRVO ،DR ،AMD ‫ ﻣﻲﺗﻮﺍﻥ ﺑﻪ ﺷﻴﻮﻩﻫﺎﻱ ﺩﺭﻣﺎﻥ‬CD ‫ﺍﺯ ﺟﻤﻠﻪ ﻣﺒﺎﺣﺚ ﻣﻄﺮﺡﺷﺪﻩ ﺩﺭ ﺍﻳﻦ‬
9.8 Clinical Update Course on Neuro-ophthalmology (Peter J. Savino, MD, Steven E. Feldon. MD, Barrett Katz, MD, Thmas L. Slamovits, MD) ‫ــــ‬
‫ ﻣـﻲﺗـﻮﺍﻥ ﺑـﻪ‬CD ‫ ﺍﺯ ﺟﻤﻠـﻪ ﻣﺒﺎﺣـﺚ ﻣﻬـﻢ ﺁﻣـﻮﺯﺵ ﺩﺍﺩﻩ ﺷـﺪﻩ ﺩﺭ ﺍﻳـﻦ‬.‫ ﺍﺯ ﺍﺳﺘﺎﺩﺍﻥ ﺻﺎﺣﺐﻧﺎﻡ ﺍﻳﻦ ﺭﺷﺘﻪ ﺁﻭﺭﺩﻩ ﺷـﺪﻩ ﺍﺳـﺖ‬Lecture ٩ ‫ ﺑﻪ ﻣﻌﺮﻓﻲ ﺭﻭﺵﻫﺎﻱ ﺗﺸﺨﻴﺼﻲ ﻭ ﺩﺭﻣﺎﻧﻲ ﮔﻠﻮﻛﻮﻡ ﻭ ﺁﺧﺮﻳﻦ ﭘﻴﺸﺮﻓﺖﻫﺎﻱ ﺣﺎﺻﻠﻪ ﺩﺭ ﺁﻧﻬﺎ ﻣﻲﭘﺮﺩﺍﺯﺩ ﻛﻪ ﺩﺭ ﻗﺎﻟﺐ‬CD ‫ﺍﻳﻦ‬
.‫ ﺍﺷﺎﺭﻩ ﻧﻤﻮﺩ‬CPC ‫ ﻭ‬LTP ،Perimetry
10.8 Clinical Orthptics (Second Edition) (SALEKAN E-BOOK) 2004

11.8 Clinical Practice in Small Incision Cataract Surgery (Phaco Manual) (VCD I , II) 2004

12.8 Complications in Phacoemulsification (SALEKAN E-BOOK) ‫ــــ‬

‫ ﺍﺷـﻜﺎﻝ ﺷـﻤﺎﺗﻴﻚ ﻭ‬.‫ ﺷﻴﻮﺓ ﺗﺸﺨﻴﺺ ﺑﻪ ﻣﻮﻗﻊ ﻭ ﭼﮕﻮﻧﮕﻲ ﺑﺮﺧﻮﺭﺩ ﺑﺎ ﺁﻧﻬﺎ ﻣـﻲﭘـﺮﺩﺍﺯﺩ‬،‫ ﻋﻮﺍﺭﺽ ﺍﺣﺘﻤﺎﻟﻲ‬، Phaco ‫ … ﺗﻤﺎﻣﹰﺎ ﺑﻪ ﺗﻮﺿﻴﺢ ﺗﻜﻨﻴﻜﻬﺎﻱ ﻣﺨﺘﻠﻒ ﻋﻤﻞ ﺟﺮﺍﺣﻲ‬, H. Gimbel ، H. Fine ‫ ﻫﺎﻱ ﺣﺎﻝ ﺣﺎﺿﺮ ﺩﺭ ﺩﻧﻴﺎ ﻣﻦﺟﻤﻠﻪ‬phacosurgen ‫ﺑﻪ ﻗﻠﻢ ﺑﺮﺟﺴﺘﻪﺗﺮﻳﻦ‬
.‫ ﺁﻥﻫﺎ ﺑﺴﻴﺎﺭ ﻛﻤﻚﻛﻨﻨﺪﻩ ﻭ ﺩﺭ ﻧﻮﻉ ﺧﻮﺩ ﺑﻲﻧﻈﻴﺮ ﺍﺳﺖ‬management ‫ﺗﺼﺎﻭﻳﺮ ﺭﻧﮕﻲ ﺁﻥ ﺩﺭ ﺩﺭﻙ ﻣﻜﺎﻧﺴﻢ ﻭ ﻋﻠﺖ ﺑﺮﻭﺯ ﻋﻮﺍﺭﺽ ﻭ ﭼﮕﻮﻧﮕﻲ ﭘﻴﺸﮕﻴﺮﻱ ﻭ ﻧﻴﺰ‬
13.8 CONTACT LENS COMPLICATIONS Efron Grading Morphs For the clinical assessment of contact lens complications (NATHAN EFRON, PHILIP MORGAN) 1999

papillary ، epithelial microcystes ،epithelial polymegethism ‫ ﻋﻮﺍﺭﺿﻲ ﭼـﻮﻥ‬Grading ‫ ﻋﻮﺍﺭﺽ ﻣﺨﺘﻠﻒ ﻧﺎﺷﻲ ﺍﺯ ﻛﺎﺭﺑﺮﺩ ﻟﻨﺰﻫﺎﻱ ﺗﻤﺎﺳﻲ ﻭ ﭼﮕﻮﻧﮕﻲ ﭘﻴﺸﺮﻓﺖ ﻭ ﺳﻴﺮ ﺁﻧﻬﺎ ﺭﺍ ﺑﻪ ﺻﻮﺭﺗﻲ ﺑﺴﻴﺎﺭ ﺯﻳﺒﺎ ﻭ ﺑﻴﺎﺩﻣﺎﻧﺪﻧﻲ ﻧﻤﺎﻳﺶ ﻣﻲﺩﻫﺪ ﺑﻄﻮﺭﻳﻜﻪ ﺗﺸﺨﻴﺺ ﻭ‬CD ‫ﺍﻳﻦ‬
.‫ ﻣﻴﺴﺮ ﻣﻲﮔﺮﺩﺩ‬... ‫ ﻭ‬conjunctivitis

14.8 Dodick Laser Photolysis (Ultra Small Incision Cataract Surgery) (Jack M. Dodik) ‫ــــ‬
Journal of Cataract & Refractive Surgery Surgical Cases Provided by Photolysis System Manufacturer
15.8 Diabetes And The Eye (Hamish MA Towler, Julian A Patterson, Susan Lightman) Department of Clinical Ophthalmology Institute of Ophthalmology University College London 2000

‫ ﻫﻤﭽﻨـﻴﻦ‬.‫ ﺁﻣﻮﺯﺵ ﺩﺍﺩﻩ ﺷﺪﻩ ﺍﺳﺖ‬text ‫ ﻭ ﺑﺎﻻﺧﺮﻩ ﻟﻴﺰﺭﺗﺮﺍﭘﻲ ﺑﻪ ﻋﻨﻮﺍﻥ ﻳﻚ ﺭﻭﺵ ﺩﺭﻣﺎﻧﻲ ﻣﻬﻢ ﺑﻪ ﻛﻤﻚ ﻋﻜﺲ ﻭ‬Fluorescein angiography ‫ ﺭﻭﺵﻫﺎﻱ ﺗﺸﺨﻴﺼﻲ ﻣﻦﺟﻤﻠﻪ‬،‫ ﭘﺎﺗﻮﻓﻴﺰﻳﻮﻟﻮﮊﻱ‬.‫ ﺍﺭﺍﺋﻪ ﻣﻲﻧﻤﺎﻳﺪ‬diabetic retinopathy ‫ ﺁﻣﻮﺯﺵ ﺟﺎﻣﻌﻲ ﺍﺯ ﻣﻘﻮﻟﺔ‬CD ‫ﺍﻳﻦ‬
.‫ ﺍﺯ ﻣﻄﺎﻟﺐ ﻣﻮﺟﻮﺩ ﺩﺭ ﺁﻥ ﻣﻲﺑﺎﺷﺪ‬Seff-test ‫ ﻣﺬﻛﻮﺭ ﺩﺍﺭﺍﻱ ﻗﺎﺑﻠﻴﺖ‬CD
16.8 DICTIONARY OF VISUAL SCIENCE AND RELATED CLINICAL TERMS (Henry W. Hofstetter, John R. Griffin, Morris S. Berman, Ronald W. Everson) 2000

17.8 Duane’s Ophthalmology (Foundations of clinical Ophthalmology) (LIPPINCOTT-RAVEN) 2004

18.8 Endoscopic Dacryocystorhinostomy (DCR) Advantages and Indications (David I. Silbert, MD FAAP) (CD I , II) ‫ــــ‬

19.8 EENT Welch Allyn Institute of Interactive Learning ‫ــــ‬

20.8 European Society of Cataract & Refractive Surgeons ROME 9th ESCRS Winter Refractive Surgery Meeting 2005

٠٩١٢١٣٧٢٣٦١-٦٦٩٣٦٦٩٦ :‫ﺗﻠﻔﻦ‬ ٢٣٩ ‫ ﭘﻼﻙ‬،‫ ﺑﻦﺑﺴﺖ ﺳﻴﻤﻴﻦ‬،‫ ﺑﻴﻦ ﻛﺎﺭﮔﺮ ﻭ ﺟﻤﺎﻟﺰﺍﺩﻩ‬،‫ ﺥ ﻟﺒﺎﻓﻲﻧﮋﺍﺩ‬،‫ ﺥ ﻛﺎﺭﮔﺮ ﺟﻨﻮﺑﻲ‬،‫ ﻡ ﺍﻧﻘﻼﺏ‬،‫ ﺗﻬﺮﺍﻥ‬:‫ﻧﺸﺎﻧﻲ‬ ‫ ﺍﺭﺍﺋﻪ ﻛﻨﻨﺪﺓ ﻛﺘﺎﺏ ﻭ ﺳﻲﺩﻱﻫﺎﻱ ﺗﺨﺼﺼﻲ ﭘﺰﺷﻜﻲ‬: ‫ﻣﺮﻛﺰ ﺧﺪﻣﺎﺕ ﻓﺮﻫﻨﮕﻲ ﺳﺎﻟﻜﺎﻥ‬
 41
21.8 Endoscopic Laser Assisted Lacrimal Surgery (Russel S. Gonnering, MD) (VCD) ‫ــــ‬

.‫ ﻓﻮﺍﻳﺪ ﺁﻥ ﺭﺍ ﺑﺮﺭﺳﻲ ﻣﻲﻧﻤﺎﻳﺪ‬،‫ ﺑﻪ ﺁﻣﻮﺯﺵ ﺍﻳﻦ ﺷﻴﻮﻩ ﻛﻤﺘﺮ ﺗﻬﺎﺟﻤﻲ ﺩﺭ ﺟﺮﺍﺣﻲ ﻣﺠﺎﺭﻱ ﺍﺷﻜﻲ ﭘﺮﺩﺍﺧﺘﻪ‬VCD ‫ ﺍﻳﻦ‬.‫ ﺑﺤﺚﻫﺎﻱ ﺯﻳﺎﺩﻱ ﺑﺮﺍﻧﮕﻴﺨﺘﻪ ﻭ ﻣﺨﺎﻟﻔﺎﻥ ﻭ ﻣﻮﺍﻓﻘﺎﻥ ﺯﻳﺎﺩﻱ ﺩﺍﺭﺩ‬endoscopic laser ‫ﺟﺮﺍﺣﻲ ﺳﻴﺴﺘﻢ ﻻﻛﺮﻳﻤﺎﻝ ﺑﻪ ﻛﻤﻚ ﺗﻜﻨﻴﻚ ﻧﺴﺒﺘﹰﺎ ﺟﺪﻳﺪ‬
22.8 Enucleation Techniques With MEDPOR Orbital Implant MCP Placement in a Vascularized MEDPOR Implant (VCD) (Charles N. S. Soparker, Peter A. D.) ‫ــــ‬
Natural Movement For Artificial Eyes With MEDPOR Biomaterial Orbit Implants ans the MEDPOR MPC Motility Coupling Post (VCD) (POREX)
23.8 Orbital Floor reconstruction using MEDPOR surgical implants

24.8 ‫ ﺁﻥ ﻭ ﻗـﺮﺍﺭﺩﺍﺩﻥ ﭘﺮﻭﺗـﺰ‬drilling ‫ ﻭ ﺩﺭ ﺍﻧﺘﻬـﺎﺏ ﺑـﻪ‬MEDPOR ‫ ﺳﭙﺲ ﺑﻪ ﻃﺮﻳﻘﺔ ﻛﺎﺷﺖ ﺍﻳﻤﭙﻼﻧـﺖ‬،enucleation ‫ ﺍﻭﻝ ﺍﺑﺘﺪﺍ ﺑﻪ ﺭﻭﺵﻫﺎﻱ‬CD ٢ .‫ ﺭﺍ ﺩﺭ ﺟﺮﺍﺣﻲﻫﺎﻱ ﺗﺮﻣﻴﻤﻲ ﺍﺭﺑﻴﺖ ﺁﻣﻮﺯﺵ ﻣﻲﺩﻫﻨﺪ‬MEDPOR ‫ ﻓﻮﻕ ﻣﺠﻤﻮﻋﹰﺎ ﺗﻜﻨﻴﻚﻫﺎﻱ ﻛﺎﺷﺖ ﺍﻳﻤﭙﻼﻧﺘﻬﺎﻱ‬VCD ٣
.‫ ﺁﻣﻮﺯﺵ ﺩﺍﺩﻩ ﻣﻲﺷﻮﺩ‬MEDPOR Surgical implant ‫ ﺳﻮﻡ ﭼﮕﻮﻧﮕﻲ ﺗﺮﻣﻴﻢ ﻭ ﺑﺎﺯﺳﺎﺯﻱ ﺩﻓﻜﺖﻫﺎﻱ ﻛﻒ ﺍﺭﺑﻴﺖ ﺑﻪ ﻛﻤﻚ‬CD ‫ ﻗﺎﺑﻞ ﻗﺒﻮﻝ ﺁﻥ ﺭﺍ ﻧﻤﺎﻳﺶ ﻣﻲﺩﻫﺪ ﺩﺭ‬Motility ‫ ﻣﻲﭘﺮﺩﺍﺯﺩ ﻭ‬MCP ‫ ﻭ‬implant ‫ﻣﺮﺑﻮﻃﻪ ﺭﻭﻱ ﻣﺠﻤﻮﻋﺔ‬
16.2 Facial Plastic & Reconstructive Surgery (Terence M. Davidson, MD) (VCD I , II) ‫ــــــ‬
25.8 FUNDAMENTALS OF CORMEAL TOPOGRAPHY ‫ــــ‬
‫ﻫﺎﻱ ﺍﺣﺘﻤﺎﻟﻲ ﻭ ﻧﻴﺰ ﺳﻴﺮ ﺗﻐﻴﻴﺮﺍﺕ ﺗﻮﭘﻮﮔﺮﺍﻓﻲ ﻭ ﺣﺎﻻﺕ ﻭ ﺑﻴﻤﺎﺭﻱﻫﺎﻱ ﻣﺨﺘﻠﻒ ﻗﺮﻧﻴﻪ ﺑﻄﻮﺭ‬artefact ،‫ ﺍﻧﻮﺍﻉ ﻣﻮﺍﺭﺩ ﻃﺒﻴﻌﻲ ﻭ ﻏﻴﺮﻃﺒﻴﻌﻲ‬،‫ ﻧﺤﻮﺓ ﺗﻔﺴﻴﺮ ﺗﻮﭘﻮﮔﺮﺍﻓﻲ ﻗﺮﻧﻴﻪ‬،‫ ﻣﻜﺎﻧﻴﺴﻢ ﻭ ﭼﮕﻮﻧﮕﻲ ﻋﻤﻠﻜﺮﺩ ﺩﺳﺘﮕﺎﻩ‬.‫ ﺟﻤﻌﹰﺎ ﺁﻣﻮﺯﺵ ﻛﺎﻣﻠﻲ ﺍﺯ ﺗﻮﭘﻮﮔﺮﺍﻓﻲ ﻗﺮﻧﻴﻪ ﺍﺭﺍﺋﻪ ﻣﻲﺩﻫﻨﺪ‬CD ‫ﺍﻳﻦ ﺩﻭ‬
.‫ ﺗﻮﺻﻴﻪ ﻣﻲﺷﻮﺩ‬OSCE ‫ ﻋﻼﻭﻩ ﺑﺮ ﻛﺎﺭﺑﺮﺩ ﻛﻠﻴﻨﻴﻜﻲ ﺁﻥ ﺟﻬﺖ ﺷﺮﻛﺖ ﺩﺭ ﺍﻣﺘﺤﺎﻧﺎﺕ‬CD ‫ ﺑﻬﺮﻩﮔﻴﺮﻱ ﺍﺯ ﺍﻳﻦ ﺩﻭ‬.‫ﺟﺎﻣﻊ ﻭ ﻗﺎﺑﻞ ﺍﺳﺘﻔﺎﺩﻩﺍﻱ ﺁﻭﺭﺩﻩ ﺷﺪﻩ ﺍﺳﺖ‬
26.8 Glaucoma Basic and Clinical Science Course (Section 10) (Salekan E-Book) 2003

27.8 Hereditary Retinal Dystrophies (Ulrich Kellner, Markus Ladewing, Christoph Heinrich) 2000

28.8 Highlights of the ASCRS 1995 Annual Meeting

29.8 Highlights of the ASCRS 1996 Annual Meeting
Cataract & Refractive Sugery

‫ ﺍﺯ ﺑﺮﺟﺴﺘﻪﺗـﺮﻳﻦ ﺍﺳـﺎﺗﻴﺪ ﻣﺎﻧﻨـﺪ‬Cataract & refractive Surgury ‫ ﺩﺭ ﺑﺎﺏ‬Lecture ‫ ﻫﺎﻱ ﻣﻘﺎﺑﻞ ﺣﺎﻭﻱ ﺩﻫﻬﺎ‬CD
30.8 Highlights of the ASCRS 1997 Annual Meeting ‫ ﻣﻲﺑﺎﺷﺪ ﻛﻪ ﺑـﻪ ﻛﻤـﻚ‬... ‫ ﻭ‬Robert J. Cionni ، Roger F. Steinert، ouglas D. Koch ، I.Howard Fine
31.8 Highlights of the ASCRS 1998 Annual Meeting Phacoemulsification ‫ ﺁﺧﺮﻳﻦ ﺗﻜﻨﻴﻚﻫﺎﻱ ﺟﺮﺍﺣﻲ ﻛﺎﺗﺎﺭﺍﻛﺖ ﺑﺮﻭﺵ‬،‫ﻓﻴﻠﻢ ﺟﺮﺍﺣﻲﻫﺎﻱ ﺍﻧﺠﺎﻡﺷﺪﻩ ﺗﻮﺳﻂ ﺍﻳﻦ ﺍﺳﺘﺎﺩﺍﻥ‬
32.8 Highlights of the ASCRS 1999 Annual Meeting ‫ﻫـﺎﻱ ﻣـﺬﻛﻮﺭ ﺑـﻪ ﻣﻨﺰﻟـﺔ ﻛﺎﺭﮔـﺎﻩ‬CD ‫ ﻣﺠﻤﻮﻋﻪ‬.‫ ﺭﺍ ﺁﻣﻮﺯﺵ ﻣﻲﺩﻫﺪ‬PRK ‫ ﻭ‬LASIK ‫ﻭ ﻧﻴﺰ ﺟﺮﺍﺣﻲ ﻛﺮﺍﺗﻮﺭﻓﺮﺍﻛﺘﻴﻮ ﺷﺎﻣﻞ‬
33.8 Highlights of the ASCRS 2000 Annual Meeting ‫ ﻭ ﭼﻪ ﺟﻬﺖ ﺑﻪ ﺭﻭﺯﺩﺭﺁﻭﺭﺩﻥ ﺍﻃﻼﻋﺎﺕ ﻭ ﻣﻬﺎﺭﺕﻫﺎﻱ‬LASIK ‫ ﻭ‬Phaco ‫ ﭼﻪ ﺑﻪ ﻣﻨﻈﻮﺭ ﺁﻣﻮﺯﺵ ﺍﻭﻟﻴﺔ‬،‫ﺁﻣﻮﺯﺷﻲ ﺍﺭﺯﺷﻤﻨﺪﻱ‬
34.8 Highlights of the ASCRS 2001 Annual Meeting .‫ﻗﺒﻠﻲ ﻣﻲﺑﺎﺷﺪ‬
35.8 Highlights of the ASCRS 2003 Annual Meeting
36.8 Highlights of the ASCRS 2005 Annual Meeting
37.8 Highlights of the XVIIth Congress of the ESCRS VIENNA'99 (EUROPEAN SOCIETY OF CATARACT & REFRACTIVE SURGEONS) ‫ــــ‬
1. Intrastromal Corneal Rings 2. Multifocal IOLs 3. Cataract Technidues 4. LASIK: Muopia & Mixed Astigmatism 5. Phakic IOLs
38.8 Illustrated Tutorials Clinical Ophthalmology (Jack J Kansski, Anne Bolton) ‫ــــ‬
39.8 Implantation of AcryFlex Foldable Lens (Surgery Performed by Dr. Jagdeep M Kakadla) (VCD) ‫ــــ‬
40.8 IMPLANTE MEDPOR MANDIBULAR (VCD), (AJL OPHTHALMIC, S.A.) ‫ــــ‬
41.8 IMPROVING SUCCESS IN FILTRATION SURGERY American Academy of Ophthalmology (BRADFORD J. SHINGLETON) ‫ــــ‬

‫ ﻫﻤﭽﻨﻴﻦ ﺑﻪ ﻣﻌﺮﻓﻲ ﺩﻭ ﺷﻴﻮﺓ ﺟﺪﻳﺪ ﺩﺭﻣﺎﻥ ﺟﺮﺍﺣﻲ ﺑﻴﻤﺎﺭﺍﻥ‬CD ‫ ﺍﻳﻦ‬.‫ ﻣﻲﺑﺎﺷﺪ ﻭ ﺟﺰﺋﻴﺎﺕ ﻫﺮ ﻛﺪﺍﻡ ﺍﺯ ﺭﻭﺵﻫﺎ ﺭﺍ ﺑﺎ ﻛﻤﻚ ﻓﻴﻠﻢﻫﺎﻱ ﺗﻬﻴﻪﺷﺪﻩ ﺍﺯ ﺍﻋﻤﺎﻝ ﺟﺮﺍﺣﻲ ﻣﺮﺑﻮﻃﻪ ﺁﻣﻮﺯﺵ ﻣﻲﺩﻫﺪ‬Filstratioh Surgery ‫ ﻳﻚ ﺩﻭﺭﺓ ﻛﺎﻣﻞ ﺁﻣﻮﺯﺷﻲ ﺩﺭ ﻣﻮﺭﺩ ﺗﻜﻨﻴﻚﻫﺎﻱ ﻣﺨﺘﻠﻒ‬CD ‫ﺍﻳﻦ‬
.‫ ﻣﻲﭘﺮﺩﺍﺯﺩ‬Viscocanalostomy ‫ ﻭ‬Deep Sclerectomy ‫ﮔﻠﻮﻛﻮﻣﻲ ﻳﻌﻨﻲ‬
42.8 Incomitant Deviatons (4 th
edition) a supplement chapter 17 of Pickwell's Binocular Vision Anomalies 2000

٠٩١٢١٣٧٢٣٦١-٦٦٩٣٦٦٩٦ :‫ﺗﻠﻔﻦ‬ ٢٣٩ ‫ ﭘﻼﻙ‬،‫ ﺑﻦﺑﺴﺖ ﺳﻴﻤﻴﻦ‬،‫ ﺑﻴﻦ ﻛﺎﺭﮔﺮ ﻭ ﺟﻤﺎﻟﺰﺍﺩﻩ‬،‫ ﺥ ﻟﺒﺎﻓﻲﻧﮋﺍﺩ‬،‫ ﺥ ﻛﺎﺭﮔﺮ ﺟﻨﻮﺑﻲ‬،‫ ﻡ ﺍﻧﻘﻼﺏ‬،‫ ﺗﻬﺮﺍﻥ‬:‫ﻧﺸﺎﻧﻲ‬ ‫ ﺍﺭﺍﺋﻪ ﻛﻨﻨﺪﺓ ﻛﺘﺎﺏ ﻭ ﺳﻲﺩﻱﻫﺎﻱ ﺗﺨﺼﺼﻲ ﭘﺰﺷﻜﻲ‬: ‫ﻣﺮﻛﺰ ﺧﺪﻣﺎﺕ ﻓﺮﻫﻨﮕﻲ ﺳﺎﻟﻜﺎﻥ‬
 42
‫ ﻣﻲﺑﺎﺷﺪ ﻛﻪ ﻋﻼﻭﻩ ﺑﺮ ﺗﻮﺿﻴﺢ ﻭ ﺗﺸﺮﻳﺢ‬... ‫ ﻭ‬Brown's ، Duane's ‫ ﻭ ﻧﻴﺰ ﺳﻨﺪﺭﻡﻫﺎﻱ‬rectus ‫ﻭ‬ oblique ‫ ﻛﻢﻛﺎﺭﻱ ﻭ ﻓﻠﺞ ﻋﻀﻼﺕ‬،‫ ﻣﻦﺟﻤﻠﻪ ﭘﺮﻛﺎﺭﻱ‬Comitant ‫ ﻣﺠﻤﻮﻋﻪﺍﻱ ﻛﻢﻧﻈﻴﺮ ﺟﻬﺖ ﻛﻤﻚ ﺑﻪ ﺩﺭﻙ ﺑﻬﺘﺮ ﻭ ﻋﻤﻴﻖﺗﺮ ﺍﻧﻮﺍﻉ ﻣﺨﺘﻠﻒ ﺍﻧﺤﺮﺍﻓﺎﺕ ﭼﺸﻤﻲ‬CD ‫ﺍﻳﻦ‬
.‫ ﺑﻪ ﺻﻮﺭﺕ ﻓﻴﻠﻢ ﺑﺮﺍﻱ ﻫﺮ ﻛﺪﺍﻡ ﺍﺯ ﺁﻧﻬﺎ ﻣﻲﭘﺮﺩﺍﺯﺩ‬Case ‫ ﻃﺒﻘﻪﺑﻨﺪﻱ ﻭ ﺗﺸﺨﻴﺺ ﺍﻓﺘﺮﺍﻗﻲ ﻫﺮ ﻧﻮﻉ ﺍﻧﺤﺮﺍﻑ ﺑﻪ ﻣﻌﺮﻓﻲ ﭼﻨﺪﻳﻦ‬،‫ ﭘﺎﺗﻮﻓﻴﺰﻳﻮﻟﻮﮊﻱ‬،‫ﻣﻜﺎﻧﻴﺴﻢ‬
43.8 Intraocular Inflammation and Uveitis (Section 9) (SALEKAN E-BOOK) 2003

44.8 LEO Clinical Update Course on Retina (H. Michael Lambert, Charles. Arr, J. Paul Diechert, Mark W. Johnson, James S. Tiedeman) ‫ــــ‬

45.8 LEO Clinical Update Course on Cataract (Stephen S. Lane, MD, Alan S. Candall, MD, Douglas D. Koch, MD, Roger F. Steinert, MD) ‫ــــ‬

46.8 LEO Clinical Update Course on Pediatric Ophthalmology and Strabismus THE AMERICAN ACADEMY OF OPHTHALMOLOGY (American Academy of Ophthalmology) 2000
‫ ﻫﻤﺮﺍﻩ ﺑـﺎ ﺍﺳـﻼﻳﺪ ﻭ ﻓـﻴﻢ ﺁﻣﻮﺯﺷـﻲ ﺍﺯ ﺍﺳـﺘﺎﺩﺍﻥ ﻣﻌﺮﻭﻓـﻲ ﻫﻤﭽـﻮﻥ‬Lecture ١٣ ‫( ﻣﻲﺑﺎﺷﺪ ﻛﻪ ﺷﺎﻣﻞ‬AAO) ‫( ﻣﺘﻌﻠﻖ ﺑﻪ ﺁﻛﺎﺩﻣﻲ ﭼﺸﻢﭘﺰﺷﻜﻲ ﺁﻣﺮﻳﻜﺎ‬Lifelong education for the ophthalmologist)LEO ‫ﻫﺎﻱ ﺍﺭﺯﺷﻤﻨﺪ ﻭ ﻣﻌﺘﺒﺮ‬CD ‫ ﻓﻮﻕ ﺍﺯ ﺳﺮﻱ‬CD
.‫ ﺍﻧﺴﺪﺍﺩ ﻣﺠﺮﺍﻱ ﺍﺷﻜﻲ ﻣﺎﺩﺭﺯﺍﺩﻱ ﻭ ﻫﻤﭽﻨﻴﻦ ﺍﻧﻮﺍﻉ ﻣﺨﺘﻠﻒ ﺍﻧﺤﺮﺍﻓﺎﺕ ﭼﺸﻤﻲ ﻭ ﺭﻭﺵﻫﺎﻱ ﺩﺭﻣﺎﻥ ﺁﻧﻬﺎ ﺍﺷﺎﺭﻩ ﻛﺮﺩ‬،ROP ،‫ ﮔﻠﻮﻛﻮﻡ ﻭ ﻛﺎﺗﺎﺭﺍﻛﺖ ﺍﻃﻔﺎﻝ‬،‫ ﻣﻲﺗﻮﺍﻥ ﺑﻪ ﺁﻣﺒﻠﻴﻮﭘﻲ‬CD ‫ ﺍﺯ ﺳﺮﻱ ﻣﺒﺎﺣﺚ ﻣﻄﺮﺡﺷﺪﻩ ﺩﺭ ﺍﻳﻦ‬.‫ ﺍﺳﺖ‬M.X.Repka ‫ ﻭ‬K.W.Wright
47.8 Loeil Prental Endoscopie du Vitre Phaco Chop (VIDEO Media) (Roussat B. Choukroun J, Boscher C, Lebuisson DA, Amar R, Escalas P) 2003
:‫ ﺷﺎﻣﻞ ﻋﻨﺎﻭﻳﻦ ﺯﻳﺮ ﻣﻲﺑﺎﺷﺪ‬CD ‫ﺍﻳﻦ‬
- Reconnaissance des structures oculaires - Anatomie endoscopique normale et Pathologique de la base du vitre anterieur - Le Phaco Chop: Pour que les noyaux durs deviennet un plaisir
- Lors des echographies prenatales Escalas P (Nantes)
- Possibilites et limites actuelles Boscher C, Lebuisson DA, Amar R (paris)
Roussat B, Choukroun J (Paris)

48.8 Manual of Eye Emergencies Diagnosis & Management (Lennox A. Webb, Jack J. Kanski) 2004
49.8 MOVIMIENTQ NATURAL PARA EL OJO ARTIFICIAL (VCD), (AJL OPHTHALMIC, S.A.) ‫ــــ‬
50.8 MVP VIDEO JOURNAL OF OPHTHALMOLOGY ‫ــــ‬

51.8 New England Eye Center Imaging in Glaucoma ‫ــــ‬

.‫ ﻭ ﻧﻴﺰ ﺑﻴﻮﻣﻴﻜﺮﻭﺳﻜﻮﭘﻲ ﺍﻭﻟﺘﺮﺍﺳﻮﻧﺪ ﺍﺷﺎﺭﻩ ﻛﺮﺩ‬OCT ،SLO ‫ ﺍﺯ ﺟﻤﻠﺔ ﺍﻳﻦ ﺭﻭﺵﻫﺎﻱ ﺗﺼﻮﻳﺮﺑﺮﺩﺍﺭﻱ ﻣﻲﺗﻮﺍﻥ ﺑﻪ‬. ‫ ﺑﺎ ﺗﻮﺟﻪ ﻭﻳﮋﻩ ﺑﻪ ﻛﺎﺭﺑﺮﺩ ﺁﻧﻬﺎ ﺩﺭ ﺑﻴﻤﺎﺭﺍﻥ ﮔﻠﻮﻛﻮﻣﻲ ﻣﻲﭘﺮﺩﺍﺯﺩ‬Optic nerve ‫ ﻓﻮﻕ ﺑﻪ ﻣﻌﺮﻓﻲ ﺟﺪﻳﺪﺗﺮﻳﻦ ﺗﻜﻨﻴﻚﻫﺎﻱ ﺗﺼﻮﻳﺮﺑﺮﺩﺍﺭﻱ ﺭﺗﻴﻦ ﻭ‬CD
52.8 New England Eye Center Photorefractive Keratectomy (PRK) Course (Helen K. WU, MD, Roger F. Steinert, MD, Michael B. Raizman, MD) ‫ــــ‬
‫ ﺍﺯ ﻣﺸﺨﺼﺎﺕ ﻟﻴـﺰﺭ ﺑـﻪ ﻛـﺎﺭ‬PRK ‫ ﻣﻲﺑﺎﺷﺪ ﻛﻠﻴﺔ ﻣﺴﺎﺋﻞ ﻭ ﻣﺒﺎﺣﺚ‬Roger F. Steinert ‫ ﻛﻪ ﻋﻤﺪﺗﹰﺎ ﺍﺯ ﺩﻛﺘﺮ‬Lecture ١٥ ‫ ﺑﻪ ﺷﻤﺎﺭ ﻣﻲﺭﻭﺩ ﻛﻪ ﺍﺯ ﻃﺮﻳﻖ‬PRK ‫ ﺗﻬﻴﻪ ﻭ ﺍﺭﺍﺋﻪ ﺷﺪﻩ ﺍﺳﺖ ﺩﺭ ﻭﺍﻗﻊ ﻳﻚ ﻛﺎﺭﮔﺎﻩ ﺁﻣﻮﺯﺷﻲ‬New England ‫ ﻓﻮﻕ ﻛﻪ ﺗﻮﺳﻂ ﻣﺮﻛﺰ ﭼﺸﻢﭘﺰﺷﻜﻲ‬CD
.‫ ﺗﺎ ﺗﻜﻨﻴﻚﻫﺎﻱ ﻋﻤﻞ ﻭ ﺑﺎﻻﺧﺮﻩ ﻋﻮﺍﺭﺽ ﺍﺣﺘﻤﺎﻟﻲ ﻭ ﺭﺍﻩﻫﺎﻱ ﭘﻴﺸﮕﻴﺮﻱ ﻭ ﺩﺭﻣﺎﻥ ﺁﻧﻬﺎ ﺭﺍ ﺁﻣﻮﺯﺵ ﺩﺍﺩﻩ ﺍﺳﺖ‬Patient sclection ‫ﺭﻓﺘﻪ‬
53.8 Ocular Therapeutics Handbook A Clinical Manual (Bruce E. Onofrey, Leonid Skorin.Jr., Nicky R. Holdeman) (SALEKAN E-BOOK) 2004

54.8 Ocular Pathology (FIFTH EDITION) (MYRON YANOFF, MD AND BEN S. FINE, MD) (Mosby) (SALEKAN E-BOOK) 2002
Basic Principles of Pathology Surgical and Nonsurgical Trauma Skin and Lacrimal Drainage System
Congenital Anomalies Nongranulomatous Inflammation: Uveltis, Endophthalmitis, Panophthalmitis, and Sequelae Granulomatous Inflammation. Conjunctive
Cornea and Sclera Uvea Lens
Neural (Sensory) Retina Vitreous Optid Nerve
Orbit Diabetes Mellitus Glaucoma
Ocular Melanotic Tumors Retinoblastoma and Pseudoglioma
55.8 Ocular Syndromes and Systemic Disease (Frederick Hampton Roy) (SALEKAN E-BOOK)

56.8 Ophthalmic Lenses & Dispensing (Mo JALIE) ‫ــــ‬

.‫ ﺟﺰﺋﻴﺎﺕ ﻭ ﻧﻜﺎﺕ ﻣﺮﺑﻮﻁ ﺑﻪ ﺗﺠﻮﻳﺰ ﻟﻨﺰ ﻭ ﭘﺮﻳﺴﻢ ﺟﻬﺖ ﺍﺻﻼﺡ ﻋﻴﻮﺏ ﺍﻧﻜﺴﺎﺭﻱ ﻭ ﺍﻧﺤﺮﺍﻓﺎﺕ ﭼﺸﻤﻲ ﺭﺍ ﻣﻮﺭﺩ ﺑﺮﺭﺳﻲ ﻗﺮﺍﺭ ﻣﻲﺩﻫﺪ‬،‫ ﭘﺮﺩﺍﺧﺘﻪ‬Refraction ‫ ﻭ‬Optic ‫ ﻓﻮﻕ ﺍﺯ ﻃﺮﻳﻖ ﺗﺼﺎﻭﻳﺮ ﺷﻤﺎﺗﻴﻚ ﺑﻪ ﺁﻣﻮﺯﺵ ﻣﻔﺎﻫﻴﻢ ﭘﺎﻳﻪ ﻭ ﻛﺎﺭﺑﺮﺩﻱ‬CD
57.8 Ophthalmic Surgery: principles and Techniques (BLACKWELL SCIENCE) (SALEKAN E-BOOK) ‫ــــ‬

٠٩١٢١٣٧٢٣٦١-٦٦٩٣٦٦٩٦ :‫ﺗﻠﻔﻦ‬ ٢٣٩ ‫ ﭘﻼﻙ‬،‫ ﺑﻦﺑﺴﺖ ﺳﻴﻤﻴﻦ‬،‫ ﺑﻴﻦ ﻛﺎﺭﮔﺮ ﻭ ﺟﻤﺎﻟﺰﺍﺩﻩ‬،‫ ﺥ ﻟﺒﺎﻓﻲﻧﮋﺍﺩ‬،‫ ﺥ ﻛﺎﺭﮔﺮ ﺟﻨﻮﺑﻲ‬،‫ ﻡ ﺍﻧﻘﻼﺏ‬،‫ ﺗﻬﺮﺍﻥ‬:‫ﻧﺸﺎﻧﻲ‬ ‫ ﺍﺭﺍﺋﻪ ﻛﻨﻨﺪﺓ ﻛﺘﺎﺏ ﻭ ﺳﻲﺩﻱﻫﺎﻱ ﺗﺨﺼﺼﻲ ﭘﺰﺷﻜﻲ‬: ‫ﻣﺮﻛﺰ ﺧﺪﻣﺎﺕ ﻓﺮﻫﻨﮕﻲ ﺳﺎﻟﻜﺎﻥ‬
 43
58.8 Ophthalmology A multimedia tutorial for Primary care physicians and medical students (Robert Johnston FRCOpth, Jonathan Boulton MA MRCP FRCOpth) ‫ــــ‬

59.8 Orbital Floor Reconstruction Using Medpor Surgical Implant (Joseph M. Serletti, MD, Paul Manson, MD) (VCD) ‫ــــ‬

60.8 PHACO TODAY (The Latest Development in Phacomulsification and Small Incision Cataract Surgery) (HOWARD FINE, MD) ‫ــــ‬
‫ ﺍﺷـﻜﺎﻝ‬.‫ ﺭﺍ ﺁﻣـﻮﺯﺵ ﻣـﻲﺩﻫـﺪ‬phacoemulsfication ‫ ﻭ‬Incisions ،Anesthesin ‫ ﺗﻜﻨﻴﻚﻫـﺎﻱ ﺟﺪﻳـﺪ‬،‫ ﺍﻳﺮﺍﺩﺷﺪﻩ ﺍﺳﺖ ﺳﻴﺮ ﺟﺮﺍﺣﻲ ﻛﺎﺗﺎﺭﺍﻛﺖ ﺑﻪ ﺭﻭﺵ ﻓﻴﻜﻮ ﺭﺍ ﻣﺮﻭﺭ ﻛﺮﺩﻩ‬I. Howard Fine ‫ ﻭ ﺍﺳﻼﻳﺪ ﻛﻪ ﻋﻤﺪﺗﹰﺎ ﺗﻮﺳﻂ‬Lecture ١٤ ‫ ﺩﺭ ﻗﺎﻟﺐ‬CD ‫ﺍﻳﻦ ﺗﻚ‬
.‫ﺷﻤﺎﺗﻴﻚ ﻭ ﺗﺼﺎﻭﻳﺮ ﺁﻭﺭﺩﻩ ﺷﺪﻩ ﺩﺭ ﺁﻥ ﺑﻪ ﺩﺭﻙ ﺑﻬﺘﺮ ﻣﻜﺎﻧﻴﺴﻢﻫﺎ ﻭ ﺗﻜﻨﻴﻜﻬﺎﻱ ﺟﺮﺍﺣﻲ ﺩﺭ ﻓﻴﻜﻮ ﻛﻤﻚ ﺯﻳﺎﺩﻱ ﻣﻲﻧﻤﺎﻳﺪ‬
61.8 Phakic Intraocular Lenses (Principles & Practice) (David R. Hardten. MD. FACS, Richard L. Lindstrom, Elizabeth A. David, MD, FACS) (SALEKAN E-BOOK) 2004

62.8 PhcoChop (Mastering Techniques, Optimizing Technology, and Avoiding Complications) David F. Chang 2004
CD-1: Hydrodissection Pearls CD-2: Learning Phacochop
CD-3: Phacodynamic Principles for PhacoChop, Vertical Chop and Cold Phaco for Brunescent Nuclel
CD-4: Strategles for PC Rupture with Nucleus Present, Bimanual Chop for Cataracts with Large Zonular Defects
63.8 Phacoemyulsification Cataract Surgery (Multimedia Oculosurgical Module) (Robert M. Schertzer, David X. Pang, MSE, Luanna R. Bartholomew, PhD) (Mosby) ‫ــــ‬
"Scleral tunnel" ‫ ﺑـﻪ ﻣﺜﺎﺑـﺔ ﻛﺎﺭﮔـﺎﻩ ﺁﻣﻮﺯﺷـﻲ ﻛـﻢﻧﻈﻴـﺮﻱ ﺩﺭ ﺯﻣﻴﻨـﺔ ﺟﺮﺍﺣـﻲ ﻛﺎﺗﺎﺭﺍﻛـﺖ ﺑـﺮﻭﺵ‬CD ‫ ﺍﻳـﻦ‬.‫ ﻣـﻲﺑﺎﺷـﺪ‬Mosby ‫( ﻣﺘﻌﻠـﻖ ﺑـﻪ ﺍﻧﺘﺸـﺎﺭﺍﺕ‬Multimedia Oulosurgical Module) MOM ‫ﻫـﺎﻱ ﺁﻣﻮﺯﺷـﻲ ﻣﻌـﺮﻭﻑ ﻭ ﻣﻌﺘﺒـﺮ‬CD ‫ ﻓﻮﻕ ﺍﺯ ﺳـﺮﻱ‬CD
.‫ ﻛﻠﻴﻪ ﻣﺮﺍﺣﻞ ﻋﻤﻞ ﺭﺍ ﺑﻪ ﺻﻮﺭﺗﻲ ﻛﺎﻣ ﹰﻼ ﻛﺎﺭﺑﺮﺩﻱ ﻭ ﻗﺎﺑﻞ ﺍﺳﺘﻔﺎﺩﻩ ﺁﻣﻮﺯﺵ ﻣﻲﺩﻫﺪ‬text ‫ ﺍﺳﺖ ﻛﻪ ﺩﺭ ﻗﺎﻟﺐ ﻓﻴﻠﻢ ﻭ‬phacoemulsification
64.8 Physiology of the Eye
Anatomy of the Eye 3-D Tour of the Eye Development of Vision Physics of Light & Color Illusions & Your Vision Common Eye Conditions
65.8 Practical Viewing of the Optic Disc (KATHLEEN B. DIGRE, M.D., JAMES J. CORBETT, M.D. 2003
Getting Ready-Preparing to View the Opic Disc What Should I Look for in the Normal Fundus? Is the Disc Swollen? Is the Disc Pale?
Amaurosis Fugax and Not So Fugax-Vaxcular Disorders of the Eye White Spots-What Are They? Hemorrhage Pigment
What is That in the Retina? Macula Practical Viewing in Children What to Look for in the Aging
Viewing the Disc in Pregnancy Practical Viewing of the Optic Disc and Retina in the Emergency Department

66.8 PROVISION INTERACTIVE: Clinical Case Studies (AAO) (Thomas A. Weingeist, MD., ph, D) ‫ــــ‬
67.8 RECONSTRUCCIÓN DE BASE ORBITAL CON IMPLANTE MEDPOR (VCD), (AJL OPHTHALMIC, S.A.) ‫ــــ‬
68.8 Refractive Surgery First interactive Symposium (Marguerite B. McDonald, MD) (American Academy of Ophthalmology) ‫ــــ‬
... ‫ ﻭ‬Roger F. Steinert ،،Jack T. Holladay :‫ ﺍﺯ ﺍﺳﺘﺎﺩﺍﻥ ﺻﺎﺣﺐﻧﺎﻡ ﺍﻳﻦ ﺭﺷﺘﻪ ﻣﻦﺟﻤﻠﻪ‬Lecture ‫ ﺍﺳﺖ ﻛﻪ ﺩﺭﺑﺮﮔﻴﺮﻧﺪﺓ ﺩﻫﻬﺎ‬Manus C. Kraff ‫ ﺑﻪ ﺳﺮﭘﺮﺳﺘﻲ ﺩﻛﺘﺮ‬ASCRS ‫ﺗﻬﻴﻪ ﺷﺪﻩ ﺍﺯ ﺍﻭﻟﻴﻦ ﺳﻤﭙﻮﺯﻳﻮﻡ ﺟﺮﺍﺣﻲ ﺭﻓﺮﺍﻛﺘﻴﻮ ﺍﻧﺠﻤﻦ‬CD ‫ ﻓﻮﻕ ﻳﻜﻲ ﺍﺯ ﻣﺠﻤﻮﻋﺔ ﺩﻭ‬CD
.PRK ‫ ﻭ‬LASIK ،phacoemulsification ‫ ﻣﺠﻤﻮﻋﺔ ﺳﺨﻨﺮﺍﻧﻲﻫﺎ ﺑﻪ ﻫﻤﺮﺍﻩ ﻓﻴﻠﻢ ﻭ ﺍﺳﻼﻳﺪﻫﺎﻱ ﺍﻳﻦ ﻣﺠﻤﻮﻋﻪ ﻣﺮﻭﺭﻱ ﺩﺍﺭﺩ ﺑﺮ ﺍﺧﺮﻳﻦ ﻭ ﺟﺪﻳﺪﺗﺮﻳﻦ ﭘﻴﺸﺮﻓﺖﻫﺎ ﺩﺭ ﺯﻣﻴﻨﺔ ﺟﺮﺍﺣﻲ ﻛﺎﺗﺎﺭﺍﻛﺖ ﺑﻪ ﺭﻭﺵ‬.‫ﻣﻲﺑﺎﺷﺪ‬
69.8 Refractive Surgery in the new millennium. ‫ــــ‬

70.8 Evolution in LASIK

LASIK: Customized Ablations and Quality of Vision ‫ــــ‬
71.8
‫ ﺗـﺎ ﺗﻜﻨﻴـﻚ‬Patient Selection ‫ ﺑﻪ ﺷﻤﺎﺭ ﻣﻲﺭﻭﺩ ﻭ ﺷﺎﻣﻞ ﺗﻤﺎﻣﻲ ﻣﺒﺎﺣﺚ ﺍﺯ ﻣﻌﺎﻳﻨﺎﺕ ﻣﻘﺪﻣﺎﺗﻲ‬LASIK ‫ ﺩﻭﺭﺓ ﺟﺎﻣﻊ ﺁﻣﻮﺯﺵ‬،‫( ﻣﻲﺑﺎﺷﺪ‬AAO) ‫( ﻣﺘﻌﻠﻖ ﺑﻪ ﺁﻛﺎﺩﻣﻲ ﭼﺸﻢﭘﺰﺷﻜﻲ ﺁﻣﺮﻳﻜﺎ‬Ophthalmology Interactive) ‫ﻫﺎﻱ ﻣﻌﺘﺒﺮ‬CD ‫ ﻛﻪ ﺍﺯ ﺳﺮﻱ‬CD ٣ ‫ﻣﺠﻤﻮﻋﺔ ﺍﻳﻦ‬ 2000
‫ﺍﻧﺠﺎﻡ ﺁﻥ ﻭ ﺑﺎﻻﺧﺮﻩ ﻋﻮﺍﺭﺽ ﺍﺣﺘﻤﺎﻟﻲ ﻭ ﻃﺮﻕ ﭘﻴﺸﮕﻴﺮﻱ ﻭ ﺩﺭﻣﺎﻥ ﺁﻧﻬﺎ ﺍﺳﺖ‬
72.8 RETINA (Stephen J. Ryan, M.D., Thomas E. Ogden, M.D.,) ‫ــــ‬
73.8 RETINA LIBRARY ‫ــــ‬
74.8 Retina & Vitneous Hereditary retinal dystrophies ‫ــــ‬
‫ ﺑـﻪ‬CD ‫ ﺩﺍﺷـﺘﻦ ﺍﻳـﻦ‬.‫ ﺗﺼﻮﻳﺮ ﺑﺎ ﻛﻴﻔﻴﺘﻲ ﻛﻢﻧﻈﻴﺮ ﻣﻮﺭﺩ ﺑﺤﺚ ﻭ ﺑﺮﺭﺳﻲ ﻗﺮﺍﺭ ﮔﺮﻓﺘﻪﺍﻧـﺪ‬١٧٠٠ ‫ ﻭ ﺑﺎﻟﻎ ﺑﺮ‬Case ٤٦٧ ‫ ﺗﻤﺎﻣﻲ ﺍﻧﻮﺍﻉ ﺩﻳﺴﺘﺮﻭﻓﻲﻫﺎﻱ ﺭﺗﻴﻦ ﺍﺯ ﺷﺎﻳﻊﺗﺮﻳﻦ ﺗﺎ ﻧﺎﺩﺭﺗﺮﻳﻦ ﺁﻧﻬﺎ ﺩﺭ ﻗﺎﻟﺐ‬.‫ ﻓﻮﻕ ﻳﻜﻲ ﺍﺯ ﺟﺎﻣﻊﺗﺮﻳﻦ ﻣﺮﺍﺟﻊ ﻣﻌﺘﺒﺮ ﺩﺭ ﺑﺎﺏ ﺍﻧﻮﺍﻉ ﻣﺨﺘﻠﻒ ﺩﻳﺴﺘﺮﻭﻓﻲﻫﺎﻱ ﺭﺗﻴﻦ ﺍﺳﺖ‬CD

٠٩١٢١٣٧٢٣٦١-٦٦٩٣٦٦٩٦ :‫ﺗﻠﻔﻦ‬ ٢٣٩ ‫ ﭘﻼﻙ‬،‫ ﺑﻦﺑﺴﺖ ﺳﻴﻤﻴﻦ‬،‫ ﺑﻴﻦ ﻛﺎﺭﮔﺮ ﻭ ﺟﻤﺎﻟﺰﺍﺩﻩ‬،‫ ﺥ ﻟﺒﺎﻓﻲﻧﮋﺍﺩ‬،‫ ﺥ ﻛﺎﺭﮔﺮ ﺟﻨﻮﺑﻲ‬،‫ ﻡ ﺍﻧﻘﻼﺏ‬،‫ ﺗﻬﺮﺍﻥ‬:‫ﻧﺸﺎﻧﻲ‬ ‫ ﺍﺭﺍﺋﻪ ﻛﻨﻨﺪﺓ ﻛﺘﺎﺏ ﻭ ﺳﻲﺩﻱﻫﺎﻱ ﺗﺨﺼﺼﻲ ﭘﺰﺷﻜﻲ‬: ‫ﻣﺮﻛﺰ ﺧﺪﻣﺎﺕ ﻓﺮﻫﻨﮕﻲ ﺳﺎﻟﻜﺎﻥ‬
 ‫‪44‬‬
‫ﻋﻨﻮﺍﻥ ﺭﻓﺮﺍﻧﺴﻲ ﻣﺼﻮﺭ ﺩﺭ ﻣﻮﺍﺟﻪ ﺑﺎ ﻣﻮﺍﺭﺩ ﮔﻮﻧﺎﮔﻮﻥ ﺩﻳﺴﺘﺮﻭﻓﻲﻫﺎﻱ ﺭﺗﻴﻦ ﺩﺭ ﻛﻠﻴﻨﻴﻚ ﺿﺮﻭﺭﻱ ﻣﻲﻧﻤﺎﻳﺪ‪.‬‬
‫)‪75.8 Refractive Surgery: A Guide to Assessment and Management (Shehzad A Naroo‬‬ ‫ــــ‬

‫)‪76.8 Stereoscopic Atlas of Macular Diseases: diagnosis and treatment (Fourth Edition) (J. Donald M. Gass, M.D.) (Mosby‬‬ ‫ــــ‬
‫‪77.8 Subjective Refraction: Cross Cylider Technique‬‬ ‫ــــ‬
‫)‪78.8 SURGICAL TECHNIQUES WITH MEDPORIMPLANTS AND THE MCP (VCD), (AJL OPHTHALMIC, S.A.‬‬ ‫ــــ‬
‫)‪79.8 ADVANCED CONCEPTS IN CATARACT SURGERY The American Society of Cataract and Refractive Surgery (ASCRS‬‬ ‫ــــ‬
‫)‪80.8 Clinical Update Course on Glaucoma (Mark B. Sherwood, MD, James D. Brandt, MD, Neil T. Choplin, MD, Joel S. Schuman, MD‬‬
‫)‪81.8 Techniques in CLEAR CORNEAL CATARACT SURGERY OPHTHALMOLOGY Interactive‬‬
‫ﻓﻴﻜﻮ ﺩﺭ ﺍﻧﻮﺍﻉ ﻣﺨﺘﻠـﻒ ﻛﺎﺗﺎﺭﺍﻛـﺖ‪،‬‬ ‫ﺗﻤﺎﻣﻲ ﻣﺮﺍﺣﻞ ﺟﺮﺍﺣﻲ ﻛﺎﺗﺎﺭﺍﻛﺖ ﺑﺮﻭﺵ ‪ "Clear cornea" Phacoemulsification‬ﺷﺎﻣﻞ ﺍﻧﺘﺨﺎﺏ ﺑﻴﻤﺎﺭ‪ ،‬ﺑﻲﺣﺴﻲ ﺗﺎﭘﻴﻜﺎﻝ ﻭ ‪ ،Prep & drape ، intracameral‬ﺍﻧﺴﺰﻳﻮﻥ ‪ capsulorrhexis ،Clear cornea‬ﻭ ﻇﺮﺍﻳﻒ ﻣﺮﺑﻮﻃﻪ‪setting ،hydrodissection ،‬‬
‫ﻛﺎﺷﺖ ‪ Foldable IOL‬ﻭ ﺑﺎﻻﺧﺮﻩ ﻋﻮﺍﺭﺽ ﺍﺣﺘﻤﺎﻟﻲ ﻭ ﻃﺮﻳﻘﺔ ﺑﺮﺧﻮﺭﺩ ﺑﺎ ﺁﻧﻬﺎ ﺩﺭ ﻣﺠﻤﻮﻋﺔ ‪ CD٣‬ﻓﻮﻕ ﺍﺯ ﻃﺮﻳﻖ ‪ ،Lecture‬ﺗﺼﺎﻭﻳﺮ ﺷﻤﺎﺗﻴﻚ ﻭ ﻓﻴﻠﻢ ﺟﺮﺍﺣﻲﻫﺎﻱ ﺍﻧﺠﺎﻡﺷﺪﻩ ﺗﻮﺳﻂ ﺍﺳﺘﺎﺩﺍﻥ ﺑﻨﺎﻡ ﺍﻳﻦ ﺭﺷﺘﻪ ﺑﻄﻮﺭ ﻛﺎﻣﻞ ﺁﻣﻮﺯﺵ ﺩﺍﺩﻩ ﻣﻲﺷﻮﺩ‪.‬‬
‫)‪82.8 Technique of Cosmetic Eyelid Surgery (A Case Study Approach) (Joseph A. Mauriello, Jr., M.D.‬‬ ‫‪2004‬‬

‫)‪83.8 TEXBOOK OF OPHTHALMOLOGY (KENNETH W.WRIGHT‬‬ ‫ــــ‬

‫)‪REVIEW QUESTIONS IN OPHTHALMOLOGY (KENNETHC. CHERN.KENNETH W. WRIGHT‬‬
‫ﺩﺭ ﺩﺳﺘﺮﺱ ﺑﻮﺩﻥ ﻛﺘﺐ ﻣﺮﺟﻊ ﺑﺼﻮﺭﺕ ﻟﻮﺡ ﻓﺸﺮﺩﻩ )‪ (CD‬ﺍﺭﺯﺵ ﺁﻧﻬﺎ ﺭﺍ ﺩﻭ ﭼﻨﺪﺍﻥ ﻣﻲﻛﻨﺪ ﺯﻳﺮﺍ ﻋﻼﻭﻩ ﺑﺮ ﺍﺷﻐﺎﻝ ﻓﻀﺎﻱ ﻛﻤﺘﺮ ﻭ ﺣﻤﻞ ﻭ ﻧﻘﻞ ﺭﺍﺣﺘﺘﺮ‪ ،‬ﺍﻣﻜﺎﻥ ﺟﺴﺘﺠﻮﻱ ﺳﺮﻳﻊ ﻣﻄﻠﺐ ﻣﻮﺭﺩ ﻧﻈﺮ ﻭ ﺍﺣﻴﺎﻧﹰﺎ ﺗﻬﻴﺔ ‪ Print‬ﺍﺯ ﺁﻥ ﻧﻴﺰ ﻓﺮﺍﻫﻢ ﺍﺳﺖ‪ .‬ﺍﺯ ﺳﻮﻱ ﺩﻳﮕﺮ‪ ،‬ﺑﻬـﺎﻱ ‪ CD‬ﺣﺘـﻲ ﺑـﺎ‬
‫ﻼ ﺑﺼﻮﺭﺕ ‪ CD‬ﻣﻌﺮﻓﻲ ﻣﻲﮔﺮﺩﺩ‪ ،‬ﺍﻧﺤﺼﺎﺭﹰﺍ ﺗﻮﺳﻂ ﺷﺮﻛﺖ ﺧﺪﻣﺎﺕ ﻓﺮﻫﻨﮕﻲ ﺳﺎﻟﻜﺎﻥ ﺑﺎ ﺩﻗﺘﻲ ﻭﺳﻮﺍﺱ ﮔﻮﻧﻪ ﺍﺯ ﺭﻭﻱ ﺁﺧﺮﻳﻦ ﺗﺠﺪﻳﺪﻧﻈﺮ ﻛﺘﺐ ‪ text‬ﺗﻬﻴﻪ ﺷﺪﻩ ﺍﺳﺖ‪،‬‬ ‫ﻛﺘﺐ ‪ text‬ﻣﻌﺎﺩﻝ ﺁﻥ ﻛﻪ ﺩﺭ ﺩﺍﺧﻞ ﻛﺸﻮﺭ ﺍﹸﻓﺴﺖ ﺷﺪﻩ ﻗﺎﺑﻞ ﻣﻘﺎﻳﺴﻪ ﻧﻤﻲﺑﺎﺷﺪ‪ .‬ﺩﻭ ﻧﻤﻮﻧﻪ ﺍﺯ ﻛﺘﺐ ﻣﺮﺟﻌﻲ ﻛﻪ ﺫﻳ ﹰ‬
‫ﺑﻄﻮﺭﻳﻜﻪ ﺗﺼﺎﻭﻳﺮ ﻭ ﻋﻜﺲﻫﺎﻱ ﻣﻮﺟﻮﺩ ﺩﺭ ﺁﻧﻬﺎ ﺩﺍﺭﺍﻱ ﻗﺎﺑﻠﻴﺖ ﺑﺰﺭﮔﻨﻤﺎﺋﻲ ﺑﻮﺩﻩ‪ ،‬ﺍﺯ ﻧﻈﺮ ﻛﻴﻔﻲ ﺑﻬﻴﭻ ﻋﻨﻮﺍﻥ ﺑﺎ ﻛﺘﺐ ﺍﻓﺴﺖ ﻣﻮﺟﻮﺩ ﺩﺭ ﺩﺍﺧﻞ ﻛﺸﻮﺭ ﻗﺎﺑﻞ ﻣﻘﺎﻳﺴﻪ ﻧﻴﺴﺖ‪.‬‬
‫)‪84.8 THE FAILING GLAUCOMA FILTER: EARLY IDENTIFICATION & TREATMENT (Bradford J. Shingleton, MD‬‬ ‫ــــ‬
‫‪ CD‬ﻓﻮﻕ ﺗﻤﺎﻣﹰﺎ ﺑﻪ ﻣﻘﻮﻟﺔ ‪ Failing Filtration Surgery‬ﭘﺮﺩﺍﺧﺘﻪ ﻭ ﻋﻠﻞ‪ ،‬ﻋﻮﺍﻣﻞ ﻣﺴﺘﻌﺪﻛﻨﻨﺪﻩ‪ ،‬ﺭﺍﻩﻫﺎﻱ ﭘﻴﺸﮕﻴﺮﻱ ﻭ ﺑﺎﻻﺧﺮﻩ ﺩﺭﻣﺎﻥﻫﺎﻱ ﻃﺒﻲ ﻭ ﺟﺮﺍﺣﻲ ﺁﻥ ﺭﺍ ﺍﺯ ﻃﺮﻳﻖ ﭼﻨﺪﻳﻦ ‪ Lecture‬ﻭ ﻓﻴﻠﻢﻫﺎﻱ ﺁﻣﻮﺯﺷﻲ ﻣﺮﺑﻮﻃﻪ ﻣﻮﺭﺩ ﺑﺮﺭﺳﻲ ﻗﺮﺍﺭ ﻣﻲﺩﻫﺪ‪ .‬ﺩﺭ ﺍﻳﻦ ‪ CD‬ﺗﻜﻨﻴـﻚﻫـﺎﻳﻲ ﻣﺎﻧﻨـﺪ ‪ Choroidal tap‬ﻭ‬
‫ﻼ ﺿﺮﻭﺭﻱ ﻣﻲﺑﺎﺷﺪ ﺑﺨﻮﺑﻲ ﺁﻣﻮﺯﺵ ﺩﺍﺩﻩ ﺷﺪﻩ ﺍﺳﺖ‪.‬‬ ‫‪ bleb revision‬ﻛﻪ ﺩﺍﻧﺴﺘﻦ ﺁﻧﻬﺎ ﺑﺮﺍﻱ ﻫﺮ ﺟﺮﺍﺡ ﮔﻠﻮﻛﻮﻣﻲ ﻛﺎﻣ ﹰ‬
‫‪85.8 The Multimedia Atlas of Videokeratography Basics of Map Interpretation‬‬ ‫)‪(MICHAEL K. SMOLEK, PH. D.‬‬ ‫ــــ‬

‫)‪86.8 The Retina ATLAS ( Yannuzzi,Green) (Mosby‬‬ ‫ــــ‬

‫)‪87.8 THE VIDEO ATLAS OF COSMETIC BLEPHAROPLASTY (8 CDs‬‬ ‫)‪(S.LBosniak‬‬ ‫ــــ‬

‫ﻣﺠﻤﻮﻋﺔ ‪ VCD ٨‬ﻓﻮﻕ ﻳﻚ ﺩﻭﺭﺓ ﻛﺎﻣﻞ ﺁﻣﻮﺯﺵ ﺟﺮﺍﺣﻲ ﭘﻠﻚ ﻣﻲﺑﺎﺷﺪ ﻛﻪ ﺗﻮﺳﻂ ﺍﺳﺘﺎﺩ ﺑﺮﺟﺴﺘﻪ ‪ S.LBosniak‬ﺁﻣﻮﺯﺵ ﺩﺍﺩﻩ ﻣﻲﺷﻮﺩ ﻭ ﺷﺎﻣﻞ ﺗﻤﺎﻣﻲ ﻣﺒﺎﺣﺚ ﺍﺯ ﺁﻧﺎﺗﻮﻣﻲ ﭘﻠﻚ ﻭ ﺭﻭﺵﻫﺎﻱ ﻣﺨﺘﻠﻒ ﺑﻲﺣﺴﻲ ﺗﺎ ﺟﺪﻳﺪﺗﺮﻳﻦ ﺗﻜﻨﻴﻚﻫﺎﻱ ﺟﺮﺍﺣﻲ ﺩﺭ ﺍﺻﻼﺡ ﻭ ﺗﺮﻣﻴﻢ ﻛﻠﻴﺔ ﻣﺴﺎﺋﻞ‬
‫ﻭ ﻣﺸﻜﻼﺕ ﭘﻠﻜﻲ ﻣﻦﺟﻤﻠﻪ‪ ،‬ﺁﻧﺘﺮﻭﭘﻴﻮﻥ‪ ،‬ﺍﻛﺘﺮﻭﭘﻴﻮﻥ‪ ،‬ﭘﺘﻮﺯ‪ ،‬ﺩﺭﻣﺎﺗﻮﺷﺎﻻﺯﻳﺲ ﻭ ‪ ...‬ﻣﻲﺑﺎﺷﺪ‪ .‬ﺍﺳﺘﻔﺎﺩﻩ ﺍﺯ ﺍﻳﻦ ﻣﺠﻤﻮﻋﻪ ﺭﺍ ﺑﺎﻳﺪ ﺑﻪ ﻣﻨﺰﻟﺔ ﮔﺬﺭﺍﻧﺪﻥ ﻳﻚ ﺩﻭﺭﻩ ﻛﺎﺭﮔﺎﻩ ﺁﻣﻮﺯﺷﻲ ﺑﻠﻔﺎﺭﻭﭘﻼﺳﺘﻲ ﺩﺍﻧﺴﺖ‪.‬‬
‫‪88.8‬‬ ‫)‪Vitreoretinal Course Bascom Palmer Eye Institute's (William E. Smiddy, Philip Rosenfeld, Patrick E. Rubsamen, Janet L.‬‬ ‫ــــ‬
‫‪ CD‬ﻓﻮﻕ ﺍﺯ ﺳﺮﻱ ‪CD‬ﻫﺎﻱ ﺁﻣﻮﺯﺷﻲ ‪ (Ophthalmology interactive) OI‬ﻣﺘﻌﻠﻖ ﺑﻪ ﺁﻛﺎﺩﻣﻲ ﭼﺸﻢﭘﺰﺷﻜﻲ ﺁﻣﺮﻳﻜﺎ )‪ ،(AAO‬ﺣﺎﻭﻱ ‪ Lecture ١٦‬ﺑﻪ ﻫﻤﺮﺍﻩ ﺍﺳﻼﻳﺪ ﻭ ﻓﻴﻢ ﺍﺯ ﺍﺳﺘﺎﺩﺍﻥ ﺑﺮﺟﺴﺘﻪﺍﻱ ﭼﻮﻥ ‪ W.E.Smiddy‬ﻭ ‪ H.W.Flynn‬ﻣﻲﺑﺎﺷﺪ ﻛـﻪ ﺑـﻪ ﻣـﺮﻭﺭ ﻭ ﻣﻌﺮﻓـﻲ‬
‫ﺁﺧﺮﻳﻦ ﺩﺳﺘﺎﻭﺭﺩﻫﺎ ﺩﺭ ﻣﻮﺭﺩ ﻣﺒﺎﺣﺚ ﻣﺨﺘﻠﻒ ﺟﺮﺍﺣﻲ ﺳﮕﻤﺎﻥ ﺧﻠﻔﻲ ﭼﺸﻢ ﻣﻲﭘﺮﺩﺍﺯﺩ‪ .‬ﺍﺯ ﺟﻤﻠﻪ ﻣﻮﺿﻮﻋﺎﺕ ﻣﻮﺭﺩ ﺑﺤﺚ ﺩﺭ ﺍﻳﻦ ‪ CD‬ﻣﻲﺗﻮﺍﻥ‪ Macular hole ،Giant retinal tear،Dislocated IOLs ،AMD , ROP ،Endophthalmitis :‬ﻭ ‪ ...‬ﺭﺍ ﻧﺎﻡ ﺑﺮﺩ‪.‬‬
‫)‪89.8 VJO Ophthalmology (I, I , III ,) (VCD) (Charles, H. Cozean, James S. Lewis, Richard J. Mackool‬‬ ‫ــــ‬

‫‪ -٩‬ﻣﻐﺰ ﻭ ﺍﻋﺼﺎﺏ‬

‫ﻋﻨﻮﺍﻥ ‪CD‬‬ ‫ﺳﺎﻝ ﺍﻧﺘﺸﺎﺭ‬

‫‪1.9‬‬ ‫)‪5 Minute Neurology Consult (SALEKAN E-BOOK) (D. Joanne Lynn‬‬ ‫‪2004‬‬

‫ﺗﻠﻔﻦ‪٠٩١٢١٣٧٢٣٦١-٦٦٩٣٦٦٩٦ :‬‬ ‫ﻧﺸﺎﻧﻲ‪ :‬ﺗﻬﺮﺍﻥ‪ ،‬ﻡ ﺍﻧﻘﻼﺏ‪ ،‬ﺥ ﻛﺎﺭﮔﺮ ﺟﻨﻮﺑﻲ‪ ،‬ﺥ ﻟﺒﺎﻓﻲﻧﮋﺍﺩ‪ ،‬ﺑﻴﻦ ﻛﺎﺭﮔﺮ ﻭ ﺟﻤﺎﻟﺰﺍﺩﻩ‪ ،‬ﺑﻦﺑﺴﺖ ﺳﻴﻤﻴﻦ‪ ،‬ﭘﻼﻙ ‪٢٣٩‬‬ ‫ﻣﺮﻛﺰ ﺧﺪﻣﺎﺕ ﻓﺮﻫﻨﮕﻲ ﺳﺎﻟﻜﺎﻥ ‪ :‬ﺍﺭﺍﺋﻪ ﻛﻨﻨﺪﺓ ﻛﺘﺎﺏ ﻭ ﺳﻲﺩﻱﻫﺎﻱ ﺗﺨﺼﺼﻲ ﭘﺰﺷﻜﻲ‬
 ‫‪45‬‬
‫ﺍﻳﻦ ‪ CD‬ﻛﻪ ﺑﺮﺍﻱ ﺍﺳﺘﻔﺎﺩﻩ ﻧﻮﺭﻭﻟﻮﮊﻳﺴﺖﻫﺎ‪ ،‬ﺭﺯﻳﺪﻧﺖﻫﺎ ﻭ ﻣﺘﺨﺼﺼﻴﻦ ﺩﺍﺧﻠﻲ ﺍﺳﺖ‪ .‬ﺑﻪ ﻋﻨﻮﺍﻥ ﺭﻓﺮﺍﻧﺲ ﺳﺮﻳﻌﻲ ﻣﻲﺑﺎﺷﺪ ﻛﻪ ﺩﺭ ﻗﺎﻟﺐ ﺳﺮﻱ ‪ 5-Minute‬ﻃﺮﺍﺣﻲ ﺷﺪﻩ ﺍﺳﺖ ﻓﺮﻣﺖ ﺩﻭﺻﻔﺤﻪﺍﻱ ﺍﺳـﺘﻔﺎﺩﻩ ﺑﻼﻓﺎﺻـﻠﻪ ﻭ ﺳـﺮﻳﻊ ﺍﺯ ﺁﻥ ﺭﺍ ﺭﺍﺣـﺖ‬
‫ﻛﺮﺩﻩ ﺍﺳﺖ‪ .‬ﺷﺎﻣﻞ ﺑﻴﺶ ﺍﺯ ‪ ٢٠٠‬ﺑﻴﻤﺎﺭﻱ ﻣﻲﺑﺎﺷﺪ ﻛﻪ ﺩﺭ ﻛﺎﺭ ﺑﺎﻟﻴﻨﻲ ﺑﻪ ﻃﻮﺭ ﺷﺎﻳﻌﻲ ﺑﺎ ﺁﻧﻬﺎ ﻣﻮﺍﺟﻪ ﻣﻲﺷﻮﻳﻢ‪ .‬ﻫﺮ ﻣﺒﺤﺚ ﺷـﺎﻣﻞ ‪ Follow up ، Medications ، Management ، Diagnosis ،Basics‬ﻭ ‪ Miscellaneous‬ﻣـﻲﺑﺎﺷـﺪ‪CD .‬‬
‫ﺷﺎﻣﻞ ﻓﺼﻮﻝ ﺯﻳﺮ ﻣﻲﺑﺎﺷﺪ‪.‬‬
‫‪-Neurologic Symptoms and Signs‬‬ ‫‪-Neurologic Diagnostic Tests‬‬ ‫‪-Neurologic Diseases and Disorders‬‬ ‫‪-Short Topics‬‬
‫‪2.9‬‬ ‫)‪55th Annual Meeting March 29-Aprill 5, American Academy of Neurology (HAWAII‬‬ ‫‪2003‬‬

‫ﺍﻳﻦ ﻧﺮﻡﺍﻓﺰﺍﺭ ﺷﺎﻣﻞ ‪ Full text‬ﺗﻤﺎﻡ ﻣﻘﺎﻻﺕ ﻭ ‪ Presentation‬ﻫﺎﻱ ﺍﺭﺍﺋﻪ ﺷﺪﻩ ﺩﺭ ﻛﻨﮕﺮﻩ ﺁﻛﺎﺩﻣﻲ ﻧﻮﺭﻭﻟﻮﮊﻱ ﺍﻣﺮﻳﻜﺎ ﺩﺭ ﺁﻭﺭﻳﻞ ‪ 2003‬ﺩﺭ ﻫﺎﻭﺍﻳﻲ ﻣﻲﺑﺎﺷﺪ‪.‬‬
‫‪3.9‬‬ ‫‪Abnormal Psychology LIVE and interactive tutorial‬‬ ‫)‪(Barlow/Durand's, Durand/Barlow's, Trull/Pharcs‬‬ ‫‪2000‬‬
‫‪4.9‬‬ ‫‪American Academy of Neurology 2004 Syllabi‬‬ ‫‪2004‬‬
‫ﺍﻳﻦ ‪ CD‬ﻛﻪ ﺣﺎﺻﻞ ﻣﻘﺎﻻﺕ ﺁﺧﺮﻳﻦ ﻛﻨﮕﺮﻩ ﺁﻛﺎﺩﻣﻲ ﻧﻮﺭﻭﻟﻮﮊﻱ ﺍﻣﺮﻳﻜﺎ ﺩﺭ ﺳﺎﻝ ‪ ٢٠٠٤‬ﻣﻲﺑﺎﺷﺪ ﺷﺎﻣﻞ ﺑﻴﺶ ﺍﺯ ‪ ١٦٠‬ﻣﻮﺿﻮﻉ ﺩﺭ ﺯﻣﻴﻨﻪﻫﺎﻱ ﻣﺨﺘﻠﻒ ﻃﺒﺎﺑﺖ ﺑﺎﻟﻴﻨﻲ ﻧﻮﺭﻭﻟﻮﮊﻱ ﻣﻲﺑﺎﺷﺪ ﻛﻪ ﻫﺮ ﻣﻮﺿﻮﻉ ﺷﺎﻣﻞ ﭼﻨﺪ ﻣﻘﺎﻟﻪ ﻭ ﻣﺒﺤﺚ ﻣﻲﮔﺮﺩﺩ‪ .‬ﺑﻌﻀﻲ ﺍﺯ ﻣﻘﺎﻻﺕ ﺍﺭﺍﺋﻪﺷﺪﻩ ﻫﻤﺮﺍﻩ ﺑﺎ‬
‫ﻓﺎﻳﻞﻫﺎ ﻭ ﺍﺳﻼﻳﺪﻫﺎﻱ ‪ Presentation‬ﻧﻴﺰ ﻣﻲﺑﺎﺷﺪ ﻛﻪ ﻛﺎﺭﺑﺮﺩ ﺁﻥ ﺭﺍ ﺑﺮﺍﻱ ﺗﺪﺭﻳﺲ ﻭ ﺍﺭﺍﺋﺔ ﻣﺠﺪﺩ ﺩﻭﭼﻨﺪﺍﻥ ﻣﻲﺳﺎﺯﺩ‪ .‬ﻓﺎﻳﻞﻫﺎ ﺍﺯ ﻃﺮﻳﻖ ‪ Java‬ﻭ ﺑﻪ ﺻﻮﺭﺕ ‪ Autorun‬ﺍﺟﺮﺍ ﻣﻲﮔﺮﺩﻧﺪ ﻗﺎﺑﻠﻴﺖ ‪ Search‬ﺑﺮ ﺍﺳﺎﺱ ﻣﻮﺿﻮﻉ ﻭ ﻧﻮﻳﺴﻨﺪﻩ ﺍﺯ ﻣﺰﺍﻳﺎﻱ ﺍﻳﻦ ﻧﺮﻡﺍﻓﺰﺍﺭ ﺍﺳﺖ‪.‬‬
‫ﻣﺒﺎﺣﺚ ﻣﻬﻢ ﻣﻄﺮﺡﺷﺪﻩ ﻋﺒﺎﺭﺗﻨﺪ ﺍﺯ‪:‬‬
‫‪Seizure and antiepilep drugs‬‬ ‫‪Bedside Neurology‬‬ ‫‪Balance and gaif disorder‬‬ ‫‪Botutinum Toxin Injection‬‬ ‫‪Stroke‬‬
‫‪Child Neurology‬‬ ‫‪Clinical EEG‬‬ ‫‪Clinical EMG‬‬ ‫‪Movement disorders‬‬ ‫‪Demyelinating dyorden‬‬
‫‪5.9‬‬ ‫)‪Advanced Therapy of HEADACHE CONQUERING HEADACHE (SECOND REVIED EDITION) An Illustrated Guide to Understanding The Treatment and Control of Headache (Alan M. Rapoport, Fred D. Sheftell‬‬ ‫ــــ‬
‫ﺍﻳﻦ ‪ CD‬ﺷﺎﻣﻞ ﺳﻪ ﻗﺴﻤﺖ ﻣﻲﺑﺎﺷﺪ‪.‬‬
‫ﻣﺘﻦ ﻓﺎﻳﻞ ‪ PDF‬ﻛﺘﺎﺏ )‪ Advanced Therapy of headache (1999‬ﺗﻮﺳﻂ ‪) Alan rappaport‬ﺍﺳﺘﺎﺩ ﻧﻮﺭﻭﻟﻮﮊﻱ ﺩﺍﻧﺸﮕﺎﻩ ‪) Fred sheftell ( Yale‬ﺍﺳﺘﺎﺩ ﺑﺨﺶ ﺭﻭﺍﻧﭙﺰﺷـﻜﻲ ﺩﺍﻧﺸـﮕﺎﻩ ‪ ( Newyork‬ﻧﻮﺷـﺘﻪ ﺷـﺪﻩ ﺍﺳـﺖ‪ .‬ﺷـﺎﻣﻞ ‪ 48‬ﻣﺒﺤـﺚ ﭘﺎﻳـﻪ ﻭ‬ ‫‪(١‬‬
‫ﻛﺎﺭﺑﺮﺩﻱ ﻣﺮﺑﻮﻁ ﺑﻪ ﺍﺻﻮﻝ ﺗﺌﻮﺭﻱ ﻭ ﻋﻤﻠﻲ ﺍﻧﻮﺍﻉ ﻣﺨﺘﻠﻒ ﺳﺮﺩﺭﺩ ﺍﺯ ﺟﻤﻠﻪ ﺗﺸﺨﻴﺺﻫﺎﻱ ﭘﻴﭽﻴﺪﻩ‪ ،‬ﺩﺭﻣﺎﻥ ﺷﺎﻣﻞ ﺩﺭﻣﺎﻧﻬﺎﻱ ﺟﺪﻳﺪ ﻭ ﻧﻴﺰ ‪ management‬ﺑﻴﻤﺎﺭﺍﻥ ﻣﻲﺑﺎﺷﺪ‪.‬‬
‫ﻣﺘﻦ ﻓﺎﻳﻞ ‪ PDF‬ﻛﺘﺎﺏ ‪ Conquering headache 1998 2nd edition‬ﺍﺯ ﻧﻮﻳﺴﻨﺪﮔﺎﻥ ﻓﻮﻕ ﻛﻪ ﺍﻃﻼﻋﺎﺗﻲ ﺩﺭ ﺁﻥ ﺟﻬﺖ ﻣﻘﺎﺑﻠﻪ ﺑﺎ ﺳﺮﺩﺭﺩ ﻭ ﺑﻬﺒﻮﺩ ﻧﺤﻮﺓ ﺯﻧﺪﮔﻲ ﺍﺭﺍﺋﻪ ﺷﺪﻩ ﺍﺳﺖ ﻛﻪ ﻫﻤﺮﺍﻩ ﺑﺎ ﺁﺧﺮﻳﻦ ﺍﻃﻼﻋﺎﺕ ﺭﺍﺟﻊ ﺑﻪ ﺗﻘﺴﻴﻢ ﺑﻨﺪﻱ ﺳﺮﺩﺭﺩﻫﺎ‪ -‬ﺩﺭﻣﺎﻧﻬـﺎﻱ ﺩﺍﺭﻭﻳـﻲ‬ ‫‪(٢‬‬
‫‪ -‬ﺗﺌﻮﺭﻱﻫﺎﻱ ﺟﺪﻳﺪ‪ -‬ﺍﺻﻮﻝ ﺗﻐﺬﻳﻪﺍﻱ ﻭﺭﺯﺷﻲ‪ -‬ﺧﻮﺍﺏ‪ -‬ﺭﻭﺵﻫﺎﻱ ﻏﻴﺮ ﺩﺍﺭﻭﻳﻲ ﺩﻳﮕﺮ ﺍﺭﺍﺋﻪ ﮔﺮﺩﻳﺪﻩ ﺍﺳﺖ‪.‬‬
‫ﻣﺘﻦ ‪ PDF‬ﺟﻤﻠﺔ ‪ Seminars in Headache mamagement‬ﻛﻪ ﺗﻮﺳﻂ ‪ James W.Lance‬ﺍﺩﺍﺭﻩ ﻣﻲﮔﺮﺩﺩ ﻭ ﺷﺎﻣﻞ ﺳﻪ ﺳﺎﻝ ﺍﺯ ﺳﺎﻝ ‪ 1996- 1998‬ﻣﻲﺑﺎﺷﺪ‪ .‬ﻣﺒﺎﺣﺚ ﺍﺭﺍﺋﻪ ﺷﺪﻩ ﻋﺒﺎﺭﺗﻨﺪ ﺍﺯ‪ :‬ﺗﺸﺨﻴﺺ‪ -‬ﺩﺭﻣﺎﻥ ﺣﺎﺩ ﻣﻴﮕﺮﻥ ﻭ ﺩﺭﻣﺎﻥ ﭘﺮﻭﻓﻴﻼﻛﺘﻴﻚ‬ ‫‪(٣‬‬
‫ﻣﺒﺎﺣﺚ ﺳﺮﺩﺭﺩﻫﺎﻱ ﻛﻼﺳﺘﺮ‪ – Post traumatic -‬ﺍﻳﺴﻜﻤﻲ ﻣﻐﺰﻱ ﻧﺎﺷﻲ ﺍﺯ ﻣﻴﮕﺮﻥ‪ -‬ﻣﻴﮕﺮﻥ ﻭ ﻫﻮﺭﻣﻮﻧﻬﺎﻱ ﺟﻨﺴﻲ‪.‬‬
‫‪6.9‬‬ ‫)‪Atlas of Functional Neuroanatomy (Dr. Walter J. Hendelman‬‬ ‫‪2000‬‬
‫‪7.9‬‬ ‫‪Boehringer Ingelheim Satellite Symposium Interanational Stroke Conference‬‬ ‫)‪(Phoenix, Arizona‬‬ ‫‪2003‬‬
‫‪8.9‬‬ ‫!‪Brainiac‬‬ ‫‪TM‬‬
‫‪Medical Multimedia Systems Presents‬‬ ‫)‪(Version 1.52‬‬ ‫)‪(An interactive digital atlas designed to assist in learning human neuroanatomy‬‬ ‫ــــ‬

‫‪9.9‬‬ ‫)‪Clinical Neurology (G David Perkin Fred H Hochberg Douglas C Miller‬‬ ‫‪1996‬‬

‫‪10.9‬‬ ‫)‪Comprehensive Textbook of PSYCHIATRY (Seventh Edition CD-ROM) (Benjamin J. Sadock, MD – Virginia A. Sadock, MD) ( LIPPINCOTT WILLIAMS & WILKINS‬‬ ‫ــــ‬

‫ﻼ ﺍﺯ ﻭﺿﻮﺡ ﺑﺎﻻﻳﻲ ﺑﺮﺧﻮﺭﺩﺍﺭﻧﺪ‪ .‬ﺍﻳﻦ ﻛﺘﺎﺏ ﺍﻟﻜﺘﺮﻭﻧﻴﻜﻲ ﻳﻚ ﻛﺘﺎﺏ ﺟﺎﻣﻊ ﻭ ﻣﺮﺟﻊ ﺩﺭ ﺯﻣﻴﻨﺔ ﺭﻭﺍﻥ ﭘﺰﺷﻜﻲ ﺍﺳـﺖ‪ .‬ﺗﺼـﺎﻭﻳﺮ ﻣﺘﻌـﺪﺩ ﺁﻣﻮﺯﺷـﻲ‪،MRI ،‬‬‫ﺍﻳﻦ ‪ CD‬ﺑﺼﻮﺭﺕ ﻳﻚ ﻛﺘﺎﺏ ﺍﻟﻜﺘﺮﻭﻧﻴﻚ ﻣﺸﺘﻤﻞ ﺑﺮ ‪ ٥٥‬ﻓﺼﻞ ﻣﻲﺑﺎﺷﺪ‪ .‬ﻫﻤﭽﻨﻴﻦ ﺣﺎﻭﻱ ‪ ٦٥٠‬ﺗﺼﻮﻳﺮ ﺁﻣﻮﺯﺷﻲ ﻭ ﻧﻴﺰ ﺟﺪﺍﻭﻝ ﻣﺘﻌﺪﺩﻱ ﺍﺳﺖ ﻛﻪ ﻛﺎﻣ ﹰ‬
‫ﻃﺮﺡﻭﺍﺭﻩﻫﺎ ﻭ ﺗﺼﺎﻭﻳﺮ ﺑﺮﺧﻲ ﺍﺯ ﺩﺍﻧﺸﻤﻨﺪﺍﻥ ﺍﻳﻦ ﺭﺷﺘﻪ‪ ،‬ﺍﺭﺍﺋﻪ ﻛﺎﻣﻞ ﻣﻨﺎﺑﻊ ﺩﺭ ﭘﺎﻳﺎﻥ ﻫﺮ ﻓﺼﻞ‪ ،‬ﻓﻬﺮﺳﺖ ﻛﺎﻣﻞ ﻣﻮﺿﻮﻋﺎﺕ‪ ،‬ﺍﺭﺍﺋﻪ ﺩﺍﺭﻭﻫﺎﻱ ﺭﻭﺍﻧﭙﺰﺷﻜﻲ ﻭ ﺍﺷﻜﺎﻝ ﺩﺍﺭﻭﺋﻲ ﻣﺨﺘﻠﻒ ﺑﻪ ﻫﻤﺮﺍﻩ ﺗﺼﻮﻳﺮ ﺁﻧﻬﺎ ﺍﺯ ﻭﻳﮋﮔﻲﻫﺎﻱ ﺍﻳﻦ ﺑﺮﻧﺎﻣﻪ ﻣﻲﺑﺎﺷﺪ‪ .‬ﺑﺮﺧﻲ ﺍﺯ ﻓﺼﻮﻝ ﺍﻳﻦ ﻛﺘﺎﺏ ﺑﻪ ﺷﺮﺡ ﺫﻳﻞ ﻣﻲﺑﺎﺷﺪ‪.‬‬
‫‪ -١‬ﺭﻭﺍﻧﭙﺰﺷﻜﻲ ﺍﻋﺼﺎﺏ ﻭ ﺭﻓﺘﺎﺭ ‪ -٢‬ﻋﻠﻮﻡ ﺍﻋﺼﺎﺏ ‪ -٣‬ﺗﺌﻮﺭﻳﻬﺎﻱ ﺷﺨﺼﻴﺖ ﻭ ﺁﺳﻴﺐﺷﻨﺎﺳﻲ ﺁﻧﻬﺎ ‪ -٤‬ﺭﻭﺷﻬﺎﻱ ﺗﺸﺨﻴﺺ ﺩﺭ ﺭﻭﺍﻥﭘﺰﺷﻜﻲ ‪ -٥‬ﻃﺒﻘﻪﺑﻨﺪﻱ ﺑﻴﻤﺎﺭﻫﺎﻱ ﻣﻐﺰﻱ ‪ -٦‬ﺑﻴﻤﺎﺭﻳﻬﺎﻱ ﺷﻨﺎﺧﺘﻲ …‪ -٧ ((Delirium Dementin,‬ﺍﺳﻜﻴﺰﻭﻓﺮﻧﻲ ‪ -٨‬ﺑﻴﻤﺎﺭﻳﻬﺎﻱ ﺍﺿﻄﺮﺍﺏ‬
‫‪ -٩‬ﺑﻴﻤﺎﺭﻳﻬﺎﻱ ‪ -١٠ Mood‬ﺑﻴﻤﺎﺭﻫﺎﻱ ﺭﻭﺍﻧﻲ ﺧﻮﺍﺏ ‪ -١١‬ﺑﻴﻤﺎﺭﻳﻬﺎﻱ ‪ -١٢ Dissociative‬ﺧﻮﺩﻛﺸﻲﻫﺎ ‪ -١٣‬ﺭﻭﺍﻥ ﭘﺰﺷﻜﻲ ﺍﻃﻔﺎﻝ ‪ -١٤‬ﺑﻴﻤﺎﺭﻫﺎﻱ ﻳﺎﺩﮔﻴﺮﻱ ‪ -١٥‬ﺑﻴﻤﺎﺭﻳﻬﺎﻱ ﺍﺭﺗﺒﺎﻃﻲ ‪ -١٦‬ﺑﻴﻤﺎﺭﻱﻫﺎﻱ ‪ Tic‬ﻋﺼﺒﻲ ‪ -١٧‬ﺑﻴﻤﺎﺭﻳﻬﺎﻱ ﺍﺿﻄﺮﺍﺏ ﺩﺭ ﻛﻮﺩﻛﺎﻥ‬
‫‪ -١٩ Adoption -١٨‬ﺭﻭﺍﻧﭙﺰﺷﻜﻲ )ﮔﺬﺷﺘﻪ ﺩﺭ ﺁﻳﻨﺪﻩ( ﻭ ‪ ...‬ﺍﻳﻦ ﺑﺮﻧﺎﻣﻪ ﺗﻮﺍﻧﺎﻳﻲ ﺟﺴﺘﺠﻮ ﺑﺮ ﺍﺳﺎﺱ ﻭﺍﮊﻩﻫﺎﻱ ﺗﺨﺼﺼﻲ ﻭ ﺍﺳﺎﻣﻲ ﺩﺍﺭﻭﻫﺎ ﺭﺍ ﺩﺍﺭﺍﺳﺖ‪ .‬ﺟﺴﺘﺠﻮﻱ ﺗﺼﺎﻭﻳﺮ‪ ،‬ﺗﻮﺍﻧﺎﻳﻲ ﭼﺎﭖ ﻣﺘﻦ ﻭ ﺗﺼﺎﻭﻳﺮ‪ ،‬ﺍﺿﺎﻓﻪ ﻧﻤﻮﺩﻥ ﻳﺎﺩﺩﺍﺷﺖﻫﺎﻱ ﺷﺨﺼﻲ ﺍﺯ ﻭﻳﮋﮔﻴﻬﺎﻱ ﺩﻳﮕﺮ ﺍﻳﻦ ﺑﺮﻧﺎﻣﻪ ﺍﺳﺖ‪.‬‬
‫‪11.9‬‬ ‫)‪Computational Neuroscience Realistic Modeling for Experimentalists (Erik De Schutter‬‬ ‫‪2001‬‬
‫‪Introduction to Equation Solving and Parameter Fitting Modeling Networks of Signalling Pathways Modeling Local and Global Calcium Signals Using Reaction-Diffusion Equations Monte Carlo‬‬
‫‪Methods for Simulating Realistic Synaptic Microphysiology Using Mcell Which Formalism to Use for Modeling voltage-Dependent Conductances? Accuate Reconstruction of Neunal Morphology‬‬

‫ﺗﻠﻔﻦ‪٠٩١٢١٣٧٢٣٦١-٦٦٩٣٦٦٩٦ :‬‬ ‫ﻧﺸﺎﻧﻲ‪ :‬ﺗﻬﺮﺍﻥ‪ ،‬ﻡ ﺍﻧﻘﻼﺏ‪ ،‬ﺥ ﻛﺎﺭﮔﺮ ﺟﻨﻮﺑﻲ‪ ،‬ﺥ ﻟﺒﺎﻓﻲﻧﮋﺍﺩ‪ ،‬ﺑﻴﻦ ﻛﺎﺭﮔﺮ ﻭ ﺟﻤﺎﻟﺰﺍﺩﻩ‪ ،‬ﺑﻦﺑﺴﺖ ﺳﻴﻤﻴﻦ‪ ،‬ﭘﻼﻙ ‪٢٣٩‬‬ ‫ﻣﺮﻛﺰ ﺧﺪﻣﺎﺕ ﻓﺮﻫﻨﮕﻲ ﺳﺎﻟﻜﺎﻥ ‪ :‬ﺍﺭﺍﺋﻪ ﻛﻨﻨﺪﺓ ﻛﺘﺎﺏ ﻭ ﺳﻲﺩﻱﻫﺎﻱ ﺗﺨﺼﺼﻲ ﭘﺰﺷﻜﻲ‬
 46
Modeling Dendritic Geometry and the Development of Nerve Connections Passive Cable Modeling-A practical Introduction Modeling Simple and Complex Active Neurons Realistic Modeling of
Small Neuronal Circuits Modeling of Interactions Between Neural Networks and Musculoskeletal System
12.9 CONTEMPORARY NEUROSURGERY A BIWEEKLY PUBLICATION FOR CLINICAL NEUROSURGICAL CONTINUING MEDICAL EDUCATION (Ali F. Krisht, MD) 2001

13.9 Core Curriculum in Primary Care Psychiatry and Pain Management Section (Micheal K. Rees, MD, MPH, Robert Birnbaum, MD, PHD, James A.D. Otis) ‫ــــ‬

‫ ﻋﻤﺪﺗﺎﹰ ﺟﻬﺖ ﭘﺎﺳﺨﮕﻮﻳﻲ ﺑﻪ ﻧﻴﺎﺯ ﻫﺎﻱ ﺁﻣﻮﺯﺷﻲ ﭘﺰﺷﻜﺎﻥ ﻃﺮﺍﺣﻲ ﺷﺪﻩ ﺍﺳﺖ ﻛﻪ ﻋﻤﺪﺓ ﻓﻌﺎﻟﻴﺘﺸﺎﻥ ﺩﺭ ﺯﻣﻴﻨﻪ ﻫﺎﻱ ﺑﺎﻟﻴﻨﻲ ﻭ ﺑﻴﻤﺎﺭﺍﻥ ﺳﺮﭘﺎﻳﻲ ﺍﺳﺖ ﺑﻪ ﻃﻮﺭﻳﻜﻪ ﺗﻤﺎﻡ ﻣﺒﺎﺣﺚ ﻭ ﻣﻔﺎﻫﻴﻢ ﺍﺭﺍﺋﻪ ﺷﺪﻩ ﺑﺮﺍﻱ ﺍﺟﺮﺍﻱ ﻋﻤﻠﻲ ﺩﺭ ﻛﻠﻴﻨﻴـﻚ ﺟﻬـﺖﺩﻫـﻲ‬CCC ‫ ﺍﺯ ﺳﺮﻱ‬CD ‫ﺍﻳﻦ‬
:‫ ﺷﺎﻣﻞ ﺩﻭ ﻣﺒﺤﺚ ﺯﻳﺮ ﻣﻲﺑﺎﺷﺪ‬.‫" ﺍﺭﺍﺋﻪ ﻣﻲﻧﻤﺎﻳﻨﺪ‬Current best Standard of therapy"‫ﺷﺪﻩﺍﻧﺪ ﻭ ﺁﺧﺮﻳﻦ ﺍﻃﻼﻋﺎﺕ ﺑﺎﻟﻴﻨﻲ ﺭﺍ ﺑﺎ ﺷﻌﺎﺭ‬
:‫ ﺍﺭﺍﺋﻪ ﻣﻲﮔﺮﺩﺩ ﻭ ﺷﺎﻣﻞ ﺳﺮ ﻓﺼﻞﻫﺎﻱ ﺯﻳﺮ ﺍﺳﺖ‬Harvard Medical School ‫ ﺍﺯ ﺩﺍﻧﺸﮕﺎﻩ‬Robert Birnbaum ‫ ﻛﻪ ﺗﻮﺳﻂ ﺩﻛﺘﺮ‬: Psychopharmacology for primay Care Medicine -١
Anxiety disorder- Panic disorder- Social phobia- Specific phobia- Obcessive & Compulsire disorder- PTSD- Generalized Anxiety disorder- Depression-Dysthymia
.‫ ﺟﺮﺍﺣﻲ( ﻣﻮﺭﺩ ﺑﺤﺚ ﻭ ﺑﺮﺭﺳﻲ ﻗﺮﺍﺭ ﮔﺮﻓﺘﻪ ﺍﺳﺖ‬-‫ ﺭﻭﺍﻧﺪﺭﻣﺎﻧﻲ‬-‫ ﻣﺨﺪﺭ‬-‫ ﺍﻧﻮﺍﻉ ﺩﺭﻣﺎﻧﻬﺎﻱ ﺩﺭﺩ )ﺩﺍﺭﻭﻳﻲ‬-‫ ﺗﺸﺨﻴﺺ ﺩﺳﺘﻪﺑﻨﺪﻱ‬-‫ ﺍﺭﺍﺋﻪ ﻣﻲﺷﻮﺩ ﻭ ﺍﺭﺯﻳﺎﺑﻲ‬Boston ‫ ﺍﺯ ﺩﺍﻧﺸﮕﺎﻩ‬James A.D. otis ‫ ﻛﻪ ﺗﻮﺳﻂ ﺩﻛﺘﺮ‬: Pain Management -٢
.‫ ﻗﺎﺑﻠﻴﺖ ﺍﻧﺘﺨﺎﺏ ﺍﺳﻼﻳﺪﻫﺎﻱ ﺩﻟﺨﻮﺍﻩ ﺟﻬﺖ ﺍﺭﺍﺋﻪ ﻭ ﻛﻨﻔﺮﺍﻧﺲ ﺟﺪﺍﮔﺎﻧﻪ ﻧﻴﺰ ﻣﻲﺑﺎﺷﺪ‬CD ‫ ﻧﺮﻡﺍﻓﺰﺍﺭ ﺍﻳﻦ‬.‫ ﺗﻌﺪﺍﺩﻱ ﺳﻮﺍﻝ ﺩﺭ ﺭﺍﺑﻄﻪ ﺑﺎ ﻣﺒﺤﺚ ﺍﺭﺍﺋﻪ ﺷﺪﻩ ﻣﻄﺮﺡ ﻭ ﭘﺎﺳﺦ ﺩﺍﺩﻩ ﺷﺪﻩ ﺍﺳﺖ‬.‫ ﻣﻲﺑﺎﺷﺪ‬print ‫ﻣﺘﻦ ﺳﺨﻨﺮﺍﻧﻲﻫﺎ ﺩﺭ ﻓﺎﻳﻞ ﺟﺪﺍﮔﺎﻧﻪﺍﻱ ﺁﻭﺭﺩﻩ ﺷﺪﻩ ﺍﺳﺖ ﻭ ﻗﺎﺑﻞ‬
14.9 Corel Medical Series Epilepsy (Alan Guberman MD, FRCP (C)) (Professor of Neurology University of Ottawa ‫ــــ‬
‫ ﻛﺎﻣـﻞ‬Quiz ‫ ﺍﻧﻴﻤﻴﺸﻦ ﻭ ﻗﻄﻌـﺎﺕ ﻭﻳـﺪﺋﻮﻳﻲ ﻭ‬-‫ ﺳﺮ ﻓﺼﻞﻫﺎﻱ ﻣﺮﺑﻮﻃﻪ ﺁﻧﺎﻟﻴﺰ ﮔﺮﺩﺩ ﻭ ﺑﺎ ﺗﺼﺎﻭﻳﺮ‬:‫ ﺩﺭ ﺍﻳﻦ ﻧﺮﻡﺍﻓﺰﺍﺭ ﺳﻌﻲ ﺷﺪﻩ ﺍﺳﺖ ﻛﻪ ﻳﻜﺴﺮﻱ ﺍﺯ ﻣﺸﻜﻼﺕ ﺷﺎﻳﻊ ﺑﻴﻤﺎﺭﺍﻥ ﻣﺒﺘﻼ ﺑﻪ ﺻﺮﻉ ﺷﺮﺡ ﺩﺍﺩﻩ ﺷﻮﺩ‬.‫ ﺍﺯ ﺩﺍﻧﺸﮕﺎﻩ ﺍﺗﺎﻭﺍ ﻃﺮﺍﺣﻲ ﻭ ﺍﺟﺮﺍ ﺷﺪﻩ ﺍﺳﺖ‬Allan Guberman ‫ﺗﻮﺳﻂ ﺩﻛﺘﺮ‬
‫ ﺷﺎﻣﻞ ﺳﺮ ﻓﺼﻞﻫﺎﻱ ﺯﻳﺮ ﺍﺳﺖ‬.‫ ﺑﻮﺩﻩ ﺍﺳﺖ‬problem based interactive ‫ ﺑﻪ ﺻﻮﺭﺕ‬review ‫ ﺳﻌﻲ ﺩﺭ ﺁﻣﻮﺯﺵ ﻭ‬.‫ ﺗﻤﺎﻣﻲ ﻣﻄﺎﻟﺐ ﺍﺯ ﻧﻘﺎﻁ ﻗﻮﺕ ﺍﻳﻦ ﻧﺮﻡﺍﻓﺰﺍﺭ ﻣﺤﺴﻮﺏ ﻣﻲﮔﺮﺩﺩ‬Print ‫ ﺍﻃﻼﻋﺎﺕ ﺑﻴﻤﺎﺭﺍﻥ ﻭ ﺗﻮﺍﻧﺎﻳﻲ ﺑﺎﺯﮔﺸﺖ ﻣﻄﺎﻟﺐ ﻭ ﻗﺎﺑﻠﻴﺖ‬-‫ ﻗﻮﻱ‬Search .‫ﮔﺮﺩﺩ‬
Definitions Topic index Epilepsy Notes Patient & Family information Epilepsy Case Study Video Reference list Epilepsy Facts What is Epilepsy Learning Objectives
15.9 CRANIAL NERVES in health and disease (Second Edition) 2002
‫ ﺷﺎﻣﻞ ﺗﺼﺎﻭﻳﺮ ﻋﺎﻟﻲ ﺁﻧﺎﺗﻮﻣﻴﻚ ﻭ ﻃﺮﺍﺣﻲﻫﺎﻱ ﺭﻧﮕﻲ ﺍﺯ ﻣﺴﻴﺮﻫﺎﻱ ﺍﻋﺼﺎﺏ ﻛﺮﺍﻧﻴﺎﻝ ﺍﺯ ﺍﻃﺮﺍﻑ ﺑﻪ ﻣﻐﺰ ﻭ ﺍﺯ ﻣﻐﺰ ﺑﻪ‬.‫ ﻣﻲﺑﺎﺷﺪ ﻛﻪ ﺗﻮﺳﻂ ﺟﻤﻌﻲ ﺍﺯ ﺍﺳﺎﺗﻴﺪ ﺟﺮﺍﺡ ﻭ ﻧﻮﺭﻭﻟﻮﮊﻳﺴﺖ ﺩﺍﻧﺸﮕﺎﻩﻫﺎﻱ ﻛﺎﻧﺎﺩﺍ ﻧﻮﺷﺘﻪ ﺷﺪﻩ ﺍﺳﺖ‬2002 ‫ ﻛﺘﺎﺏ ﻓﻮﻕ ﭼﺎﭖ‬PDF ‫ ﺷﺎﻣﻞ ﻣﺘﻦ‬CD ‫ﺍﻳﻦ‬
‫ ﻣﻄﺮﺡ ﺷﺪﻩ ﻭ ﻟـﺬﺍ ﺑـﺮﺍﻱ‬Problem-oriented ‫ ﺍﺻﻮﻝ ﺑﺤﺚ ﺑﺮ ﻣﺒﻨﺎﻱ‬.‫ ﮔﻨﺠﺎﻧﺪﻩ ﺷﺪﻩﺍﻧﺪ‬CD ‫ ﺟﻬﺖ ﺩﺭﻙ ﺑﻬﺘﺮ ﺭﻭﺍﺑﻂ ﺁﻧﺎﺗﻮﻣﻴﻚ ﻭ ﺍﺛﺮﺍﺕ ﻓﻴﺰﻳﻮﻟﻮﮊﻳﻚ ﺩﺭ‬animation ‫ ﭼﻨﺪ ﺗﺼﻮﻳﺮ‬.‫ ﺳﻨﺎﺭﻳﻮﻫﺎﻱ ﺑﺎﻟﻴﻨﻲ ﻭ ﺗﺴﺖﻫﺎﻱ ﺧﻮﺩﺁﺯﻣﺎﻳﻲ ﻣﻲﺑﺎﺷﺪ‬،‫ﺍﻃﺮﺍﻑ ﻣﻲﺑﺎﺷﺪ ﻛﻪ ﺩﺭ ﻗﺎﻟﺐ ﻣﺘﻦ‬
.‫ ﺩﺭ ﻗﺴﻤﺖ ﺩﻳﮕﺮ ﻓﻴﻠﻢ ﻣﻌﺎﻳﻨﺎﺕ ﺑﺎﻟﻴﻨﻲ ﻫﺮ ﻛﺪﺍﻡ ﺍﺯ ﺍﻋﺼﺎﺏ ﺑﺼﻮﺭﺕ ﺗﻚ ﺗﻚ ﮔﻨﺠﺎﻧﺪﻩ ﺷﺪﻩ ﺍﺳﺖ‬.‫ ﻭ ﭼﺸﻢ ﭘﺰﺷﻜﻲ ﺑﺴﻴﺎﺭ ﻣﻔﻴﺪ ﻭ ﺿﺮﻭﺭﻱ ﺑﻪ ﻧﻈﺮ ﻣﻲﺭﺳﺪ‬ENT ،‫ ﺟﺮﺍﺣﻲ ﻓﻚ ﻭ ﺻﻮﺭﺕ‬،‫ﺩﺍﻧﺸﺠﻮﻳﺎﻥ ﻭ ﺭﺯﻳﺪﻧﺖﻫﺎ ﻭ ﻣﺘﺨﺼﺼﻴﻦ ﺭﺷﺘﻪﻫﺎﻱ ﻧﻮﺭﻭﻟﻮﮊﻱ‬
16.9 Textbook of CRITICAL CARE (Salekan E-book) 2005
SECTION I RESUSCITATION AND MEDICAL EMERGENCIES
SECTION II TRAUMA
SECTION III IMAGING
SECTION IV CELL INJURY AND CELL DEATH
SECTION V INFECTIONS DISEASE
SECTION VI ENDOCTINOLOGY, METABOLISM, NUTRITION, PHARMACOLOGY
SECTION VII CARDIOVASCULAR
SECTION VIII PULMONARY
17.9 Critical Decisions in Headache Management (Giammarco. Edmeads. Dodick) (SALEKAN E-BOOK) ‫ــــ‬

18.9 CURRENT MANAGEMENT IN CHILD NEUROLOGY (SECOND EDITION) (Bernrd L. Maria, MD, MBA) 2002
Section 1: Clinical Practice Trends Section 2: The Office Visit Section 3: The Hospitalized Child
19.9 DICTIONARY OF MULTIPLE SCLEROSIS (Lance D Blumgardt) (Martin Dunitz) ‫ــــ‬

20.9 DISORDERS OF COGNITIVE FUNCTION (VCD-I) (AMERICAN ACADEMY OF NEUROLOGY) (CONTINUUM) 2002

Severe Amnesic Syndrome: Anterograde and Retrograde Amnesia Perseverative Verbal Behavior in Amnesia Semantic Memory Loss Fluctuativng Sensorium in Dementia With
Left Spatial Neglect Eye Movements in Severe Left Spatial Neglect Anosognosia for Hemiparesis Paraphasias
Broca's Aphasia Lewy Bodies Impaired Verbatim Repetition
21.9 DISORDERS OF COGNITIVE FUNCTION (VCD-II) (AMERICAN ACADEMY OF NEUROLOGY) (CONTINUUM) 2002

٠٩١٢١٣٧٢٣٦١-٦٦٩٣٦٦٩٦ :‫ﺗﻠﻔﻦ‬ ٢٣٩ ‫ ﭘﻼﻙ‬،‫ ﺑﻦﺑﺴﺖ ﺳﻴﻤﻴﻦ‬،‫ ﺑﻴﻦ ﻛﺎﺭﮔﺮ ﻭ ﺟﻤﺎﻟﺰﺍﺩﻩ‬،‫ ﺥ ﻟﺒﺎﻓﻲﻧﮋﺍﺩ‬،‫ ﺥ ﻛﺎﺭﮔﺮ ﺟﻨﻮﺑﻲ‬،‫ ﻡ ﺍﻧﻘﻼﺏ‬،‫ ﺗﻬﺮﺍﻥ‬:‫ﻧﺸﺎﻧﻲ‬ ‫ ﺍﺭﺍﺋﻪ ﻛﻨﻨﺪﺓ ﻛﺘﺎﺏ ﻭ ﺳﻲﺩﻱﻫﺎﻱ ﺗﺨﺼﺼﻲ ﭘﺰﺷﻜﻲ‬: ‫ﻣﺮﻛﺰ ﺧﺪﻣﺎﺕ ﻓﺮﻫﻨﮕﻲ ﺳﺎﻟﻜﺎﻥ‬
 47
Wernicke's Aphasia Dysexecutive Syndrome Disinhibited Behavior Grasp Response and Imitation Behavior Positive Signs of Executive Dysfunction Progressive Apraxia
Negative Signs of Executive Dysfunction Prosopognosia and Visual Agnosia Simultanagnosia Optic Ataxia Ocular Apraxia
22.9 DISORDERS OF COGNITIVE FUNCTION (VCD-III) (AMERICAN ACADEMY OF NEUROLOGY) (CONTINUUM) 2002

Basic Mental Status Examination Token Test for Auditory Comprehension Confrontation Naming Finger Constructions Luria 3-Step Test Line Cancellation Gestural Praxis
23.9 EMG Training (Kenneth Ricker, M.D.) ‫ــــ‬
‫ ﻣﺘﻦ ﻫﻤﺮﺍﻩ ﺍﻳﻦ ﻧﺮﻡﺍﻓﺰﺍﺭ ﺗﻮﺿﻴﺤﺎﺕ ﻛﺎﻓﻲ ﺩﺭ ﻣﻮﺭﺩ ﻧﺤﻮﺓ ﻛﺎﺭ‬.‫ ﺑﻴﻤﺎﺭ ﻣﺨﺘﻠﻒ ﺭﺍ ﻫﻤﺎﻧﮕﻮﻧﻪ ﻛﻪ ﻣﺎﻧﻴﺘﻮﺭ ﻣﺸﺎﻫﺪﻩ ﻣﻲﮔﺮﺩﺩ ﺑﻪ ﺗﺼﻮﻳﺮ ﻛﺸﻴﺪﻩ ﻭ ﺻﺪﺍﻱ ﺁﻥ ﺭﺍ ﭘﺨﺶ ﻣﻲﻛﻨﺪ‬٢٧ ‫ ﺍﺯ‬EMG ‫ ﻣﻮﺭﺩ‬٧٥ .‫ ﺗﻬﻴﻪ ﺷﺪﻩ ﺍﺳﺖ‬TOENNIES ‫ﺍﻳﻦ ﻧﺮﻡﺍﻓﺰﺍﺭ ﻛﻪ ﺟﻬﺖ ﺁﻣﻮﺯﺵ ﺍﻟﻜﺘﺮﻭﻣﻴﻮﮔﺮﺍﻓﻲ ﺗﻮﺳﻂ ﺷﺮﻛﺖ‬
.‫ ﺑﺮﺍﻱ ﻣﺒﺘﺪﻳﺎﻥ ﻭ ﻧﻴﺰ ﺍﻓﺮﺍﺩ ﻣﺠﺮﺏ ﺩﺭ ﺍﻳﻦ ﺯﻣﻴﻨﻪ ﺟﺎﻟﺐ ﺗﻮﺟﻪ ﺧﻮﺍﻫﺪ ﺑﻮﺩ‬CD ‫ ﻓﺎﻳﻞﻫﺎ ﺭﺍ ﻓﺮﺍﻫﻢ ﻣﻲﺁﻭﺭﺩ ﺍﻳﻦ‬Search ‫ ﺍﻣﻜﺎﻥ‬EMG glossary .‫ ﺑﻪ ﺻﻮﺭﺕ ﻳﻚ ﻓﺎﻳﻞ ﻣﺴﺘﻘﻞ ﺍﺭﺍﺋﻪ ﻣﻲﮔﺮﺩﺩ‬Case ‫ ﻫﺮ‬.‫ﺭﺍ ﺍﺭﺍﺋﻪ ﻛﺮﺩﻩ ﺍﺳﺖ ﻭ ﺳﺆﺍﻻﺗﻲ ﺭﺍ ﻣﻄﺮﺡ ﻧﻤﻮﺩﻩ ﻭ ﭘﺎﺳﺦ ﺩﺍﺩﻩ ﺍﺳﺖ‬
24.9 ENS Teaching Course ‫ــــ‬
‫ ﻋﻤﺪﺓ ﻣﺒﺎﺣﺚ ﻣﻄﺮﺡﺷﺪﻩ ﺗﺤﺖ ﻋﻨﺎﻭﻳﻦ‬.‫ ﻣﻲﺑﺎﺷﺪ ﺍﻃﻼﻋﺎﺕ ﺑﻪﺭﻭﺯ ﺭﺍ ﺩﺭ ﻣﻮﺭﺩ ﻣﺒﺎﺣﺚ ﻋﻤﺪﻩ ﻭ ﺑﺤﺚﺍﻧﮕﻴﺰ ﻧﻮﺭﻭﻟﻮﮊﻱ ﺟﺪﻳﺪ ﻭ ﻧﻴﺰ ﺩﻳﺪﮔﺎﻩ ﺟﺪﻳﺪ ﻧﺴﺒﺖ ﺑﻪ ﺑﻴﻤﺎﺭﻱﻫﺎﻱ ﺷﺎﻳﻊ ﻧﻮﺭﻭﻟﻮﮊﻱ ﺭﺍ ﺍﺭﺍﺋﻪ ﻣﻲﺩﻫﺪ‬٢٠٠٣ ‫ ﺩﺭ ﺳﺎﻝ‬ENS ‫ ﻛﻪ ﺷﺎﻣﻞ ﻣﻘﺎﻻﺕ ﺩﻭﺭﺓ ﺁﻣﻮﺯﺷﻲ ﻛﻨﮕﺮﻩ‬CD ‫ﺍﻳﻦ‬
.‫ ﻣﺨﺘﻠﻒ ﻧﻴﺰ ﻣﻲﺑﺎﺷﺪ‬Title ‫ﺯﻳﺮ ﻗﺮﺍﺭ ﻣﻲﮔﻴﺮﻧﺪ ﻛﻪ ﻫﺮ ﻛﺪﺍﻡ ﺷﺎﻣﻞ ﭼﻨﺪ‬
Dizziness and vesthg Clinical Neurophysiology Clinical Neuropathology Sleep Disorder Stroke
Neurogenetics for Clinicians NeuroSurgery for Neurologist Epilepsy Multiple Sclerosis Muscle disorders
Neuroimaging Neurology of Systemic disease Parkinson's diseane Ultrasound in Neurology Dementia
ICU in Neurology Movement discords Neuroplathies Current Treatments Neurology
25.9 EPILEPSY The Comprehensive CD-ROM (Jerome Engel, Jr., M.D., Ph.D., Timothy A. Pedley, M.D.) Lippincott Williams & Wilkins 1999
‫ ﺗﻮﺍﻧـﺎﻳﻲ‬.‫ ﮔﻨﺠﺎﻧـﺪﻩ ﺷـﺪﻩ ﺍﺳـﺖ‬CD ‫ ﺩﺭ‬imaging ‫ ﻋﻜـﺲ ﻭ‬٨٠٠ ‫ ﻫﻤﭽﻨـﻴﻦ‬.‫ ﺳﺮﻓﺼـﻞ ﻣـﻲﺑﺎﺷـﺪ‬٢٨٩ ‫ ﻛﺘﺎﺏ ﺭﺍ ﺩﺭ ﺑﺮﻣﻲﮔﻴﺮﺩ ﻛﻪ ﻣﺸـﺘﻤﻞ ﺑـﺮ‬Full text .‫ ﻃﺮﺍﺣﻲ ﺷﺪﻩ ﺍﺳﺖ‬Epilepsy: A comprehensive textBook ‫ ﻛﻪ ﺑﺮﺍﺳﺎﺱ ﻛﺘﺎﺏ‬CD ‫ﺍﻳﻦ‬
.‫ ﺭﻓﺮﺍﻧﺲ ﻛﻪ ﺗﻮﺳﻂ ﻧﻮﻳﺴﻨﺪﻩ ﺟﻤﻊﺁﻭﺭﻱ ﮔﺮﺩﻳﺪﻩ ﺍﺳﺖ ﺍﺯ ﻧﻘﺎﻁ ﻗﻮﺕ ﺍﻳﻦ ﻧﺮﻡﺍﻓﺰﺍﺭ ﻣﺤﺴﻮﺏ ﻣﻲﮔﺮﺩﺩ‬٥٠٠ ‫ ﻭ ﺧﻼﺻﻪ ﻣﻘﺎﻻﺕ ﺑﻴﺶ ﺍﺯ‬Weblink- Seasch
26.9 Essentials of Clinical Neurophysiology (Karl E. Misulis MD. PhD, Thomas C. Head MD) 2002

27.9 Foundations of NEUROBIOLOGY ‫ــــ‬

.‫ ﻗﺴﻤﺖ ﺯﻳﺮ ﺍﺳﺖ‬٥ ‫ ﻃﺮﺍﺣﻲ ﺷﺪﻩ ﺍﺳﺖ ﻭ ﺷﺎﻣﻞ‬،‫ ﻭ ﺗﻜﻤﻴﻞ ﺍﻃﻼﻋﺎﺕ ﺍﻓﺮﺍﺩﻱ ﻛﻪ ﺑﺎ ﻋﻠﻮﻡ ﻣﺮﺑﻮﻁ ﺑﻪ ﺍﻋﺼﺎﺏ ﻭ ﺑﻴﻮﻟﻮﮊﻱ ﺳﺮﻭﻛﺎﺭ ﺩﺍﺭﻧﺪ‬Self evaluattion ‫ ﺑﻪ ﻣﻨﻈﻮﺭ‬CD ‫ﺍﻳﻦ‬
‫ ﺁﻣﺎﺩﮔﻲ ﺳﺨﻨﺮﺍﻧﻲ ﻛﻪ ﺑﻪ ﻣﺎ ﺍﻣﻜﺎﻥ ﻣﻲﺩﻫـﺪ ﺑـﺎ‬-٤ Expansion Module -٣ .‫ ﺍﻧﻴﻤﻴﺸﻦﻫﺎ ﻭ ﻓﻴﻠﻢﻫﺎﻱ ﻭﻳﺪﺋﻮﻳﻲ ﺁﻣﻮﺯﻧﺪﻩ ﻭ ﺑﻴﺎﺩﻣﺎﻧﺪﻧﻲ ﺑﻪ ﻫﻤﺮﺍﻩ ﺗﻮﺿﻴﺤﺎﺕ ﻛﺘﺒﻲ ﺭﺍﺟﻊ ﺑﻪ ﻫﺮ ﻗﻄﻌﻪ ﻓﻴﻠﻢ‬-٢ .‫ ﺧﻮﺩﺁﺯﻣﺎﻳﻲﻫﺎ ﻛﻪ ﻓﻬﺮﺳﺖﺑﻨﺪﻱ ﺷﺪﻩ ﻭ ﺟﻬﺖ ﺩﺍﺭﻧﺪ‬-١
.‫ ﻣﻌﺮﻓﻲ ﺷﺪﻩﺍﻧﺪ ﻭ ﻟﻴﻨﻚﻫﺎﻱ ﻣﺘﻌﺪﺩ ﺍﺭﺍﺋﻪ ﮔﺮﺩﻳﺪﻩﺍﻧﺪ‬Neurobiology ‫ ﺳﺎﻳﺖﻫﺎﻱ ﻣﺮﺑﻮﻁ ﺑﻪ ﻋﻠﻮﻡ‬، CD ‫ ﺩﺭ ﺑﺨﺶ ﺩﻳﮕﺮﻱ ﺍﺯ‬.‫ ﻣﺨﺼﻮﺹ ﺑﻪ ﺧﻮﺩ ﺭﺍ ﺳﺎﺧﺘﻪ ﻭ ﺟﻬﺖ ﺍﺭﺍﺋﻪ ﺩﺭ ﻛﻨﻔﺮﺍﻧﺲﻫﺎ ﻳﺎ ﺗﺪﺭﻳﺲ ﺍﺯ ﺁﻧﻬﺎ ﺑﻬﺮﻩ ﺑﺒﺮﻳﻢ‬play list ، CD ‫ﺍﺷﻜﺎﻝ ﻭ ﻓﻴﻠﻢﻫﺎﻱ ﻣﻮﺟﻮﺩ ﺩﺭ‬
28.9 Foundations of Behavioural Neuroscience ‫ــــ‬
.‫ ﺑﺨﺶ ﻋﻤﺪﻩ ﺯﻳﺮ ﻣﻲﺑﺎﺷﺪ‬٥ ‫ ﺷﺎﻣﻞ‬CD ‫ﺍﻳﻦ‬
-Neural Communication - Central Nervous system -Research methods -Visual System - Control of movements
Quiz ‫ ﺩﺭ ﭼﻨﺪ ﻓﺼﻞ ﺳـﻮﺍﻻﺗﻲ ﺑـﻪ ﻋﻨـﻮﺍﻥ‬.‫ ﻓﻬﺮﺳﺖ ﺩﺭﺧﺘﭽﻪﺍﻱ ﻣﻄﺎﻟﺐ ﻛﻤﻚ ﻣﻬﻤﻲ ﺑﻪ ﻳﺎﺩﮔﻴﺮﻱ ﻋﻠﻮﻡ ﭘﺎﻳﻪ ﺍﻋﺼﺎﺏ ﻣﻲﻧﻤﺎﻳﺪ‬.‫ ﻛﺎﻣﻞ ﻣﻲﺑﺎﺷﺪ‬glossary , Search ‫ ﻫﻤﺮﺍﻩ ﺑﺎ ﻣﻮﺗﻮﺭ‬.‫ﺣﺎﻭﻱ ﺗﺼﺎﻭﻳﺮﻱ ﺑﺎ ﻃﺮﺍﺣﻲ ﻋﺎﻟﻲ ﻭ ﺍﺳﺘﻔﺎﺩﻩ ﺭﺍﺣﺖ ﺟﻬﺖ ﻓﻬﻢ ﺟﺰﺋﻴﺎﺕ ﭘﻴﭽﻴﺪﻩ ﻭ ﺭﻳﺰ ﺳﺎﺧﺘﻤﺎﻥﻫﺎﻱ ﻧﻮﺭﻭﻧﻲ ﻣﻲﺑﺎﺷﺪ‬
.‫ﻣﻄﺮﺡ ﺷﺪﻩﺍﻧﺪ ﻛﻪ ﺟﻬﺖ ﺗﻜﻤﻴﻞ ﺁﻣﻮﺧﺘﻪﻫﺎ ﻭ ﻳﺎﺩﮔﻴﺮﻱ ﻣﻨﺎﺳﺐ ﺍﺳﺖ‬
29.9 FUNDAMENTALS OF HUMAN NEURAL STRUCTURE (S. Mark Williams) (Sylvius TM
2.0) ‫ــــ‬

30.9 General depression and its pharmacological treatment (Professor Brain Leonard) (VCD)

31.9 Guidelines (American Academy of Neurology) (SALEKAN E-BOOK) 2004

.‫ ﺑﺎ ﺩﺳﺘﺮﺳﻲ ﺁﺳﺎﻥ ﺩﺭ ﺍﺧﺘﻴﺎﺭ ﻛﺎﺭﺑﺮ ﻗﺮﺍﺭ ﻣﻲﺩﻫﺪ‬Offline ‫ ﺩﺭ ﺁﻣﺪﻩ ﺍﺳﺖ ﻛﻪ ﻛﻠﻴﻪ ﻣﻘﺎﻻﺕ ﺭﺍ ﺑﻪ ﺻﻮﺭﺕ‬Salekan E-Book ‫ ﺩﺭ ﻗﺎﻟﺐ‬Search ‫ ﻫﺎﻱ ﺗﺸﺨﻴﺼﻲ ﺩﺭﻣﺎﻧﻲ ﺁﻛﺎﺩﻣﻲ ﻧﻮﺭﻭﻟﻮﮊﻱ ﺁﻣﺮﻳﻜﺎ ﻣﻲﺑﺎﺷﺪ ﺑﻪ ﺻﻮﺭﺕ ﻓﺎﻳﻞ ﻗﺎﺑﻞ‬Guidline ‫ ﻛﻪ ﺷﺎﻣﻞ ﺁﺧﺮﻳﻦ‬CD ‫ﺍﻳﻦ‬
- Brain Injury & Brain Death - Child Neurology - Dementia - Epilepsy - Headache - Movement Disorders - Multiple Sclerosis - Neuroimaging - Neuromuscular - Stroke and Vascular Neurology -Technology Assessment
32.9 Human Brain Cancer: Diagnostic Decisions (Lauren A. Langford, MD, Dr. med,) American Medical Association ‫ــــ‬

33.9 Interactive Guide to Human Neuroanatomy (Mark F. Bear, Barry W. Connors, Michael A. Paradiso) 2002
Atlas: -Surface Anatomy of Brain -Cross-Sectional Anatomy of Brain -The Spinal Cord -The Anatomy Nervous System -The Cranial Nerves -The Blood Supply to the Brain
Exam:I -Surface Anatomy of the Brain -Cross-Sectional Anatomy of the Brain -Comprehensive Exam
34.9 ICU Syllabus ‫ــــ‬

٠٩١٢١٣٧٢٣٦١-٦٦٩٣٦٦٩٦ :‫ﺗﻠﻔﻦ‬ ٢٣٩ ‫ ﭘﻼﻙ‬،‫ ﺑﻦﺑﺴﺖ ﺳﻴﻤﻴﻦ‬،‫ ﺑﻴﻦ ﻛﺎﺭﮔﺮ ﻭ ﺟﻤﺎﻟﺰﺍﺩﻩ‬،‫ ﺥ ﻟﺒﺎﻓﻲﻧﮋﺍﺩ‬،‫ ﺥ ﻛﺎﺭﮔﺮ ﺟﻨﻮﺑﻲ‬،‫ ﻡ ﺍﻧﻘﻼﺏ‬،‫ ﺗﻬﺮﺍﻥ‬:‫ﻧﺸﺎﻧﻲ‬ ‫ ﺍﺭﺍﺋﻪ ﻛﻨﻨﺪﺓ ﻛﺘﺎﺏ ﻭ ﺳﻲﺩﻱﻫﺎﻱ ﺗﺨﺼﺼﻲ ﭘﺰﺷﻜﻲ‬: ‫ﻣﺮﻛﺰ ﺧﺪﻣﺎﺕ ﻓﺮﻫﻨﮕﻲ ﺳﺎﻟﻜﺎﻥ‬
 ‫‪48‬‬
‫ﺩﺭ ﺍﻳﻦ ‪ CD‬ﻛﻪ ﺟﻬﺖ ﺍﺳﺘﻔﺎﺩﻩ ﭘﺰﺷﻜﺎﻧﻲ ﻛﻪ ﺑﺎ ﺑﻴﻤﺎﺭﺍﻥ ﺑﺪﺣﺎﻝ ﻭ ﺑﺴﺘﺮﻱ ﺩﺭ ‪ ICU‬ﺳﺮﻭﻛﺎﺭ ﺩﺍﺭﻧﺪ‪ ،‬ﻃﺮﺍﺣﻲ ﺷﺪﻩ ﺍﺳﺖ‪ ،‬ﺁﺧﺮﻳﻦ ﻣﻘﺎﻻﺕ ﻣﻨﺘﺸﺮﻩ ﻭ ﻧﻴﺰ ﻣﻘﺎﻻﺕ ﻣﻬﻢ ﻗﺒﻠﻲ ﺩﺭ ﺯﻣﻴﻨﻪﻫﺎﻱ ﻣﺨﺘﻠـﻒ ‪ ICU Patient Care‬ﺍﺯ ﻣﻨـﺎﺑﻊ ﻭ ﻣﺠـﻼﺕ ﻣﺨﺘﻠـﻒ ﺗـﺎ ﺳـﺎﻝ ‪٢٠٠٤‬‬
‫ﺟﻤﻊﺁﻭﺭﻱ ﻭ ﺑﻪ ﺻﻮﺭﺕ ﻓﺎﻳﻞ ‪ PDF‬ﺑﺎ ﻗﺎﺑﻠﻴﺖ ‪ Search‬ﻗﻮﻱ ﺍﺟﺮﺍ ﺷﺪﻩ ﺍﺳﺖ‪ .‬ﺳﺮﻓﺼﻞﻫﺎﻱ ﻋﻤﺪﻩ ﻋﺒﺎﺭﺗﻨﺪ ﺍﺯ‪:‬‬
‫‪Anemia and blood Transfusion‬‬ ‫‪ARDS‬‬ ‫‪Ethics‬‬ ‫‪Fever Wokup‬‬ ‫‪Hemodynamics‬‬ ‫‪RARS‬‬ ‫‪Weaning‬‬
‫‪Hyperghycemia and Ihsulia‬‬ ‫‪Hypothermia for cardiac arrest‬‬ ‫‪Impaired cognition‬‬ ‫‪Liver disease‬‬ ‫‪Mechanical Vetitation‬‬ ‫‪Sedation‬‬ ‫‪From Mechanical Vetitation‬‬
‫‪Non invasive Ventilation‬‬ ‫‪Nutritions‬‬ ‫‪Pneumonia‬‬ ‫‪Pulmonary Embolism‬‬ ‫‪Renal failure‬‬ ‫‪Sepsis‬‬

‫‪35.9‬‬ ‫)‪InterBRAIN (Martin C. hirsh) (Springer‬‬ ‫ــــ‬

‫‪1. Gross Anatomy‬‬ ‫‪2. Vessels and Meninges‬‬ ‫‪3. Brain Slices‬‬ ‫‪4. Microscopical Sections‬‬ ‫‪5. Functional Systems‬‬
‫‪36.9‬‬ ‫‪International Symposium ON 10 Years Betaferon‬‬ ‫‪2003‬‬
‫‪ CD‬ﻓﻮﻕ ﻛﻪ ﻣﺎﺣﺼﻞ ﺳﻤﭙﻮﺯﻳﻮﻡ ﭘﺮﺍﮒ ﺩﺭ ﺳﺎﻝ ‪ ٢٠٠٣‬ﺩﺭ ﻣﻮﺭﺩ ﺗﺠﺮﺑﻪ ﺩﻩﺳﺎﻟﺔ ﻣﺼﺮﻑ ﺑﺘﺎﻓﺮﻭﻥﻫﺎ ﺩﺭ ﺩﺭﻣﺎﻥ ‪ MS‬ﻣﻲﺑﺎﺷﺪ ﺷﺎﻣﻞ ﺗﻤﺎﻡ ﻣﺒﺎﺣﺚ ﻣﻄﺮﺡﺷﺪﻩ ﺩﺭ ﺍﻳﻦ ﻛﻨﮕﺮﻩ ﺍﺳﺖ‪ .‬ﻋﻨﺎﻭﻳﻦ ﻣﺒﺎﺣﺚ ﻋﺒﺎﺭﺗﻨﺪ ﺍﺗﺰ‪:‬‬
‫ﺗﺎﺭﻳﺨﭽﺔ ﺩﺭﻣﺎﻥ ﻣﺪﺭﻥ ‪MS‬‬ ‫ﺍﻫﻤﻴﺖ ﺑﺎﻟﻴﻨﻲ ﻳﺎﻓﺘﻪﻫﺎﻱ ﻧﺮﻭﭘﺎﺗﻮﻟﻮﮊﻳﻚ ‪MS‬‬ ‫ﺁﻣﻮﺧﺘﻪﻫﺎﻱ ﻣﺎﻟﻮﺯ ﻣﻄﺎﻟﻌﺎﺕ ﺑﺎﻟﻴﻨﻲ ﺩﺭﺑﺎﺭﺓ ﻓﺎﻛﺘﻮﺭﻫﺎﻱ ﭘﺮﻭﮔﻨﻮﺳﺘﻴﻚ‬ ‫‪Geomics and Proteomics‬‬ ‫ﺩﺭﻣﺎﻥ ﺳﻤﭙﺘﻮﻣﺎﺗﻴﻚ ﻭ ﺗﻮﺍﻧﺒﺨﺸﻲ ﺩﺭ ‪MS‬‬
‫ﺑﺘﺎﻓﺮﻭﻥ ﺩﺭ ﺩﺭﻣﺎﻥ ‪Primary Progressive MS‬‬ ‫ﻧﻘﺶ ‪ Stem Cell Transplant‬ﺩﺭ ﺩﺭﻣﺎﻥ ‪Aggressive MS‬‬ ‫ﺍﻳﻨﺘﺮﻓﺮﻭﻥ ﺩﻭﺯ ﺑﺎﻻ ﻳﺎ ﭘﺎﻳﻴﻦ؟‬ ‫ﻧﺘﺎﻳﺞ ﻣﻄﺎﻟﻌﺎﺕ ‪ BENEFIT‬ﻭ ‪BEYOND‬‬ ‫ﺍﻓﻖﻫﺎﻱ ﺟﺪﻳﺪ‬
‫‪37.9‬‬ ‫‪MANAGING STRESS‬‬ ‫‪2002‬‬
‫‪38.9‬‬ ‫)‪Manual of Pain Management (Carol A. Warfield, Hilary J. Fausett) (Second Edition) (SALEKAN E-BOOK‬‬ ‫ــــ‬
‫ﺍﻳﻦ ‪ CD‬ﺑﺎ ﻓﺮﻣﺖ ﺧﺎﺹ ﺧﻮﺩ ﻛﻪ ﻧﺤﻮﺓ ﺍﺳﺘﻔﺎﺩﻩ ﺍﺯ ﺁﻥ ﺭﺍ ﺭﺍﺣﺖ ﻧﻤﻮﺩﻩ ﺍﺳﺖ‪ .‬ﺯﻣﻨﻴﺔ ﻛﺎﻣﻠﻲ ﺑﺮﺍﻱ ﻣﻄﺎﻟﻌﻪ ﻧﺤﻮﺓ ﺍﺩﺍﺭﻩ ﺑﻴﻤﺎﺭﺍﻥ ﻣﺒﺘﻼ ﺑﻪ ﺩﺭﺩﻫﺎﻱ ﻗﺴﻤﺖﻫﺎﻱ ﻣﺨﺘﻠﻒ ﺑﺪﻥ ﺭﺍ ﻓﺮﺍﻫﻢ ﻣﻲﺁﻭﺭﺩ‪ .‬ﺩﺭ ﻓﺼﻞ ﺍﻭﻝ ﻧﻈﺮﻳﻪﻫﺎﻱ ﻋﻤﺪﺓ ﻓﻴﺰﻭﻟﻮﮊﻱ ﺩﺭﺩ ﻣﻄﺮﺡ ﺷﺪﻩ ﺍﺳﺖ‪.‬‬
‫ﻋﻤﺪﻩ ﺍﻳﻦ ‪ CD‬ﺗﻮﺻﻴﻔﻲ ﺍﺯ ﺳﻨﺪﺭﻡﻫﺎﻱ ﺷﺎﻳﻊ ﺩﺭﺩ ﺍﺳﺖ ﻛﻪ ﺑﺮ ﺍﺳﺎﺱ ﺁﻧﺎﺗﻮﻣﻲ ﺑﺎﻟﻴﻨﻲ ﻛﻼﺳﻪﺑﻨﺪﻱ ﺷﺪﻩﺍﻧﺪ‪ .‬ﻓﺼﻞ ﺑﻌﺪﻱ ﺑﺮ ﺭﻭﻱ ﺩﺭﻣﺎﻥﻫﺎ ﻭ ‪Procedure‬ﻫﺎﻳﻲ ﻛﻪ ﺑﺮ ﺭﻭﻱ ﺑﻴﻤﺎﺭﻳﺎﻥ ﺩﺭﺩﻣﻨﺪ ﺑﻪ ﻛﺎﺭ ﻣﻲﺭﻭﻧﺪ‪ ،‬ﻣﺘﻤﺮﻛﺰ ﻛﺮﺩﻩ ﺍﺳـﺖ‪ .‬ﺩﺭﻣـﺎﻥ ﺩﺭﺩ ﻛﻮﺩﻛـﺎﻥ‪ ،‬ﺳـﺎﻟﻤﻨﺪﺍﻥ ﻭ ﻧﻴـﺰ‬
‫ﺑﻴﻤﺎﺭﺍﻥ ﻣﺒﺘﻼ ﺑﻪ ‪ HIV‬ﻧﻴﺰ ﺁﻭﺭﺩﻩ ﺷﺪﻩ ﺍﺳﺖ‪.‬‬
‫‪-Understanding pain‬‬ ‫‪-Pain by Anatomic Location‬‬ ‫‪-Common Painful Syndromes‬‬ ‫‪-Pain Management‬‬
‫‪39.9‬‬ ‫)‪Microneurosurgery (M. G. Yasargil) Cassette 1 Aneurysms (VCD) (Thieme AV‬‬ ‫)‪(CD I, II , III , IV‬‬ ‫ــــ‬

‫‪40.9‬‬ ‫)‪Migraine Current Approaches To Treatment (Dr. Andrew Dowson‬‬ ‫‪2001‬‬

‫‪41.9‬‬ ‫)‪Movement Disorders Society Official Journal of The Movement Disorder Society Published by John Wiley & Sons, Ins VCD (I, II‬‬ ‫‪2002‬‬

‫‪42.9‬‬ ‫)‪Needle Electromyography (Daniel Dumitru, M.D., PhD.‬‬ ‫‪2002‬‬

‫ﺍﻳﻦ ‪ CD‬ﻛﻪ ﺑﺮ ﺍﺳﺎﺱ ﻛﺘﺎﺏ ‪ Needle EMG‬ﻧﻮﺷﺘﺔ ‪ Daniel Dumitru‬ﺩﺭ ﺳﺎﻝ ‪ ٢٠٠٢‬ﻃﺮﺍﺣﻲ ﻭ ﺍﺟﺮﺍ ﮔﺮﺩﻳﺪﻩ ﺍﺳﺖ‪ .‬ﺷﺎﻣﻞ ﻣﺘﻦ ﻛﺘﺎﺏ ﺑﻌﻼﻭﺓ ‪ EMG Video Library‬ﺍﺳﺖ‪ ٣٣ .‬ﻓﺎﻳﻞ ﻣﺨﺘﻠﻒ ﺷﺎﻣﻞ ﺍﻣﻮﺍﺝ ﻧﺮﻣﺎﻝ ﻭ ﻏﻴﺮﻧﺮﻣﺎﻝ ﻣﺨﺘﻠﻒ ﺍﺭﺍﺋﻪ ﮔﺮﺩﻳﺪﻩ ﺍﺳﺖ‪.‬‬
‫ﺗﺼﺎﻭﻳﺮ ﺍﺭﺍﺋﻪﺷﺪﻩ ﺍﻃﻼﻋﺎﺕ ﻛﺎﻓﻲ ﺩﺭ ﻣﻮﺭﺩ ﻧﺤﻮﺓ ﺍﺟﺮﺍﻱ ‪ EMG‬ﻭ ‪Pitfull‬ﻫﺎﻱ ﺁﻥ ﺩﺭ ﺍﺧﺘﻴﺎﺭ ﻗﺮﺍﺭ ﻣﻲﺩﻫﻨﺪ‪ .‬ﻗﺎﺑﻠﻴﺖ ‪ Glossary , Search‬ﻗﻮﻱ ﻧﻴﺰ ﺍﺯ ﻣﺰﺍﻳﺎﻱ ﻧﺮﻡﺍﻓﺰﺍﺭ ﻓﻮﻕ ﻣﺤﺴﻮﺏ ﻣﻲﮔﺮﺩﺩ‪.‬‬
‫‪43.9‬‬ ‫)‪NEUROANATOMY-3D-Stereoscopic Atlas of the Human Brain (Martin C. Hirsch, Thomas Kramer) (Springer‬‬ ‫‪1999‬‬
‫ﺩﺭ ﺍﻳﻦ ﻧﺮﻡﺍﻓﺰﺍﺭ ﺗﺼﺎﻭﻳﺮ ﺳﻪ ﺑﻌﺪﻱ ﻭ ﺑﺴﻴﺎﺭ ﺩﻗﻴﻘﻲ ﺍﺯ ﺳﻴﺴﺘﻢ ﻋﺼﺒﻲ ﻣﺮﻛﺰﻱ ﺍﺭﺍﺋﻪ ﺷﺪﻩ ﺍﺳﺖ ﻛﻪ ﺑﺎ ﺗﻮﺟﻪ ﺑﻪ ﻗﺪﺭﺕ ﺑﺎﻻﻱ ﻧﺮﻡﺍﻓﺰﺍﺭ ﻗﺎﺩﺭﻳﻢ ﺍﺯ ﻫﺮ ﺟﻬﺖ ﺩﻟﺨﻮﺍﻩ ﺑﻪ ﺗﺼﻮﻳﺮ ‪ Gross‬ﻣﻐﺰ ﺑﻨﮕﺮﻳﻢ‪ .‬ﺑﺎ ﺩﺭﻧﻈﺮﮔﺮﻓﺘﻦ ﺍﻳﻨﻜﻪ ﺗﻚ ﺗﻚ ﺍﺟﺰﺍﻱ ﺳﻴﺴﺘﻢ ﻋﺼﺒﻲ ﺭﺍ ﻣﺮﺣﻠﻪ ﺑﻪ ﻣﺮﺣﻠﻪ ﻣﻲﺗﻮﺍﻥ ﺑﻪ ﺗﺼﻮﻳﺮ ﻗﺒﻠﻲ ﺍﺿﺎﻓﻪ ﻭ‬
‫ﻳﺎ ﻛﻢ ﻛﺮﺩ‪ ،‬ﺟﺰﺋﻴﺎﺕ ﺍﺭﺗﺒﺎﻃﺎﺕ ﺳﻴﺴﺘﻢﻫﺎﻱ ﻋﻤﻠﻜﺮﺩﻱ ﻣﺨﺘﻠﻒ ﺑﻪ ﻭﺿﻮﺡ ﻣﺸﺨﺺ ﻣﻲﺷﻮﺩ‪ .‬ﺗﺼﺎﻭﻳﺮ ﻭ ﺑﺮﺵﻫﺎ ﺑﺴﻴﺎﺭ ﻫﻮﺷﻤﻨﺪﺍﻧﻪ ﻭ ﻫﻨﺮﻣﻨﺪﺍﻧﻪ ﻃﺮﺍﺣﻲ ﮔﺸﺘﻪﺍﻧﺪ ﻭ ﺩﺍﻧﺸﺠﻮﻳﺎﻥ‪ ،‬ﭘﺰﺷﻜﺎﻥ ﻭ ﻣﺘﺨﺼﺼﻴﻦ ﺩﺭﮔﻴﺮ ﺑﺎ ﺳﻴﺴﺘﻢ ﻋﺼﺒﻲ ﺁﻧﺮﺍ ﺗﺠﺮﺑﺔ ﺟﺪﻳﺪﻱ ﺍﺭﺯﻳﺎﺑﻲ ﻛﺮﺩﻩﺍﻧﺪ‪.‬‬
‫‪44.9‬‬ ‫‪Neurofunctional Systems 3D‬‬ ‫ــــ‬

‫‪45.9‬‬ ‫)‪Neurological surgery (julian R. Youmans , MD Editor-in-Chief) (Fourth Edition) (Y.O.U.M.A.N.S‬‬ ‫ــــ‬

‫)‪46.9 Neurology (Baker's clinical on CD-ROM‬‬ ‫‪2001‬‬

‫‪47.9 New Analgesic Options: Overcoming Obstacles to Pain Relief‬‬ ‫‪2002‬‬

‫‪- MD, NP, PA, RN Answer Sheet‬‬ ‫‪-Pharmacist Answer Sheet‬‬ ‫‪-Back Pain -Fibromyalgia‬‬ ‫‪-OA Pain‬‬ ‫‪-Post Op Pain‬‬ ‫‪-Trauma‬‬ ‫‪-References‬‬
‫‪25.7 Photographic manual of Regional Orthopaedic and Neurological Tests‬‬ ‫ــــ‬
‫ﺍﻳﻦ ‪ CD‬ﺷﺎﻣﻞ ﺑﻴﺶ ﺍﺯ ‪ ٨٥٠‬ﺗﺼﻮﻳﺮ ﻣﻲﺑﺎﺷﺪ ﻛﻪ ﻧﺤﻮﺓ ﺍﻧﺠﺎﻡ ﺗﻤﺎﻡ ﻣﻌﺎﻳﻨﺎﺕ ﻧﻮﺭﻭﻟﻮﮊﻳﻚ ﻭ ﺍﺭﺗﻮﭘﺪﻳﻚ ﺭﺍ ﺑﺎ ﺟﺰﺋﻴﺎﺕ ﺗﻤﺎﻡ ﺭﻭﺷﻦ ﻣﻲﺳﺎﺯﺩ‪ .‬ﺩﺭ ﻣﻮﺍﻗﻊ ﻟﺰﻭﻡ ﺗﺼﺎﻭﻳﺮ ﺁﻧﺎﺗﻮﻣﻴﻚ ﺿﺮﻭﺭﻱ ﻧﻴﺰ ﺍﺿﺎﻓﻪ ﺷﺪﻩﺍﻧﺪ‪ .‬ﻓﺼﻮﻝ ﺑﺮ ﺍﺳﺎﺱ ﻣﺤﻞ ﻣﻮﺭﺩ ﻣﻌﺎﻳﻨﻪ ﻃﺮﺍﺣﻲ ﻭ ﻗﺴﻤﺖﺑﻨﺪﻱ ﺷﺪﻩﺍﻧـﺪ‪.‬‬
‫ﻣﻌﺎﻳﻨﺎﺕ ﺍﺯ ﻓﻘﺮﺍﺕ ﮔﺮﺩﻧﻲ ﻭ ﺍﻧﺪﺍﻡ ﻓﻮﻗﺎﻧﻲ ﺷﺮﻭﻉ ﻭ ﺑﻪ ﻓﻘﺮﺍﺕ ﻛﻤﺮﻱ ﻭ ﺍﻧﺪﺍﻡﻫﺎﻱ ﺗﺤﺘﺎﻧﻲ ﺧﺘﻢ ﻣﻲﺷﻮﻧﺪ‪ .‬ﻫﺮ ‪ Test‬ﺩﺭ ﻳﻚ ﺻﻔﺤﻪ ﻳﺎ ﺩﻭ ﺻﻔﺤﻪ ﻣﻘﺎﺑﻞ ﻫﻢ ﺑﺎ ﻋﻜﺲﻫﺎﻳﻲ ﻛﻪ ﻧﺤﻮﺓ ﺍﻧﺠﺎﻡ ﻣﻌﺎﻳﻨـﻪ ﺭﺍ ﺑﻮﺿـﻮﺡ ﻧﺸـﺎﻥ ﻣـﻲﺩﻫﻨـﺪ ﺗﻮﺿـﻴﺢ ﺩﺍﺩﻩ ﺷـﺪﻩ ﺍﺳـﺖ‪ .‬ﺩﺭ ﺿـﻤﻦ ﻳـﻚ‬

‫ﺗﻠﻔﻦ‪٠٩١٢١٣٧٢٣٦١-٦٦٩٣٦٦٩٦ :‬‬ ‫ﻧﺸﺎﻧﻲ‪ :‬ﺗﻬﺮﺍﻥ‪ ،‬ﻡ ﺍﻧﻘﻼﺏ‪ ،‬ﺥ ﻛﺎﺭﮔﺮ ﺟﻨﻮﺑﻲ‪ ،‬ﺥ ﻟﺒﺎﻓﻲﻧﮋﺍﺩ‪ ،‬ﺑﻴﻦ ﻛﺎﺭﮔﺮ ﻭ ﺟﻤﺎﻟﺰﺍﺩﻩ‪ ،‬ﺑﻦﺑﺴﺖ ﺳﻴﻤﻴﻦ‪ ،‬ﭘﻼﻙ ‪٢٣٩‬‬ ‫ﻣﺮﻛﺰ ﺧﺪﻣﺎﺕ ﻓﺮﻫﻨﮕﻲ ﺳﺎﻟﻜﺎﻥ ‪ :‬ﺍﺭﺍﺋﻪ ﻛﻨﻨﺪﺓ ﻛﺘﺎﺏ ﻭ ﺳﻲﺩﻱﻫﺎﻱ ﺗﺨﺼﺼﻲ ﭘﺰﺷﻜﻲ‬
 ‫‪49‬‬
‫‪ Sensitivity/Relialility Scale‬ﻧﻴﺰ ﺑﺮﺍﻱ ﻫﺮ ﻣﻌﺎﻳﻨﻪ ﺗﻌﺮﻳﻒ ﺷﺪﻩ ﺍﺳﺖ ﻛﻪ ﻣﻴﺰﺍﻥ ﺣﺴﺎﺳﻴﺖ ﻭ ﻗﺎﺑﻠﻴﺖ ﺍﻋﺘﻤﺎﺩ ﺑﻪ ﺁﻥ ﻣﻌﺎﻳﻨﻪ ﺭﺍ ﻣﺸﺨﺺ ﻣﻲﺳﺎﺯﺩ‪ .‬ﺍﻳﻦ ﺍﻃﻼﻋﺎﺕ ﺩﺭ ﺑﻜﺎﺭﮔﻴﺮﻱ ﺗﺴﺖﻫﺎﻱ ﺣﺴﺎﺳﺘﺮ ﻭ ﺍﺧﺘﺼﺎﺹﺗﺮ ﻛﻤﻚ ﻓﺮﺍﻭﺍﻥ ﺑﻪ ﭘﺰﺷﻚ ﻣﻲﻧﻤﺎﻳﺪ‪.‬‬
‫‪48.9‬‬ ‫)‪Principles of Neurology (6th Edition) (Raymond D. Adams, M.A., M.D.‬‬ ‫‪1998‬‬

‫‪49.9‬‬ ‫‪PROFESS‬‬ ‫ــــ‬

‫ﺍﻳﻦ ‪ CD‬ﻛﻪ ﻣﺎﺣﺼﻞ ﺳﻤﭙﻮﺯﻳﻮﻡ ﭘﻴﺸﮕﻴﺮﻱ ﺍﺯ ﺳﻜﺘﻪﻫﺎﻱ ﻣﻐﺰﻱ ﺩﺭ ‪ International Stroke Conference‬ﺩﺭﺁﺭﻳﺰﻭﻧﺎﻱ ﺍﻣﺮﻳﻜﺎ ﺩﺭ ﺳﺎﻝ ‪ ٢٠٠٣‬ﻣﻲﺑﺎﺷﺪ ﭼﺎﻟﺶﻫﺎﻱ ﭘﻴﺶﺭﻭ ﺩﺭ ﺩﺭﻣﺎﻥ ﻭ ﭘﻴﺸﮕﻴﺮﻱ ﺍﺯ ﺳﻜﺘﻪﻫﺎﻱ ﻣﺠﺪﺩ ﻣﻐﺰﻱ ﺭﺍ ﻣﻄﺮﺡ ﻛﺮﺩﻩ ﻭ ﺁﺧﺮﻳﻦ ﺭﮊﻳﻢﻫﺎﻱ ﺩﺭﻣـﺎﻧﻲ‬
‫ﻭﻳﺮﻭﺗﺮﻛﻞﻫﺎﻱ ﻣﻮﺟﻮﺩ ﺭﺍ ﺩﺭ ﻗﺎﻟﺐ ‪Lecture‬ﻫﺎ‪ ،‬ﺳﺆﺍﻝ ﻭ ﺟﻮﺍﺏ ﻭ ﺧﻼﺻﻪ ﻣﻘﺎﻻﺕ ﺍﺭﺍﺋﻪ ﻛﺮﺩﻩ ﺍﺳﺖ‪ .‬ﻓﻬﺮﺳﺖ ﺳﺨﻨﺮﺍﻧﻲﻫﺎ ﻋﺒﺎﺭﺗﻨﺪ ﺍﺯ‪:‬‬
‫‪ -‬ﺍﻃﻼﻋﺎﺗﻲ ﻛﻪ ﺩﺭﺑﺎﺭﺓ ﺩﻳﭙﺮﻳﺪﺍﻣﻮﻝ ﻭﺟﻮﺩ ﺩﺍﺭﺩ‪ - .‬ﭼﺮﺍ ﺑﺮﺧﻮﺭﺩ ﺑﺎ ‪ CVA‬ﻣﺘﻔﺎﻭﺕ ﺍﺯ ‪ MI‬ﺍﺳﺖ‪ - .‬ﺁﻳﺎ ﺩﺭﻣﺎﻥ ﻣﺮﻛﺐ ﺁﻧﺘﻲﭘﻜﺪﺗﻲ ﺧﻄﺮﻧﺎﻙ ﺍﺳﺖ ﻳﺎ ﻣﻔﻴﺪ؟ ‪ -‬ﺁﻳﺎ ﺁﻧﮋﻳﻮﺗﺎﻧﻴﻦ ‪ II‬ﺩﻳﺴﻜﺎﻓﺎﻛﺘﻮﺭ ﻣﺴﺘﻘﻠﻲ ﺑﺮﺍﻱ ﺳﻜﺘﻪ ﺍﺳﺖ؟ ‪ -‬ﺭﮊﻳﻢ ﺩﺭﻣﺎﻧﻲ ﭘﻴﺸﮕﻴﺮﻱ ﺍﺯ ﺳﻜﺘﻪ ﺩﻭﻡ‪.‬‬
‫‪50.9‬‬ ‫‪Psychotropics‬‬ ‫‪2000‬‬
‫ﺩﺍﻳﺮ‪õ‬ﺍﻟﻤﻌﺎﺭﻑ ﻛﺎﻣﻠﻲ ﺍﺯ ﺗﻤﺎﻡ ﻣﻮﺍﺩ ﻭ ﺩﺍﺭﻭﻫﺎﻱ ﻣﻮﺛﺮ ﺑﺮ ﺳﻴﺴﺘﻢ ﻣﻲﺑﺎﺷﺪ ﻛﻪ ﺷﺎﻣﻞ ﺑﺨﺸﻬﺎﻱ ﺯﻳﺮ ﻣﻲﺷﻮﺩ‪ :‬ﺳﻮﻧﻮﮔﺮﺍﻓﻲ ﺩﺍﺭﻭﻳﻲ‪ -‬ﻋﻮﺍﺭﺽ ﺟﺎﻧﺒﻲ‪ -‬ﺗﺪﺍﺧﻼﺕ ﺩﺍﺭﻭﻳﻲ‪ -‬ﻓﻬﺮﺳﺖ ﺍﺳﺎﻣﻲ ﺭﺍﻳﺞ ﺧﻴﺎﺑﺎﻧﻲ ﺩﺍﺭﻭﻫﺎ‪ -‬ﺍﺻﻮﻝ ﺗﺮﻙ ﺩﺍﺭﻭ‪ ،‬ﻣﻨﺤﻨﻲﻫﺎﻱ ﻧﻴﻤﻪ ﻋﻤﺮ ﺩﺍﺭﻭﻳﻲ‪ -‬ﺍﻳﻨﺪﻛﺲ‬
‫ﺑﺎ ﻣﺮﺍﺟﻌﻪ ﺑﻪ ﻫﺮ ﻛﺪﺍﻡ ﺍﺯ ﻣﻨﻮﮔﺮﺍﻑﻫﺎ ﻣﻲﺗﻮﺍﻥ ﺍﺯ ﺳﺎﺧﺘﻤﺎﻥ ﺷﻴﻤﻴﺎﻳﻲ‪ -‬ﻓﺮﻣﻮﻝ ﺷﻴﻤﻴﺎﻳﻲ‪ -‬ﻣﻮﺍﺭﺩ ﻭ ﻧﺤﻮﺓ ﺍﺳﺘﻔﺎﺩﺓ ﺑﺎﻟﻴﻨﻲ ﺷﺮﻛﺖﻫﺎﻱ ﺳﺎﺯﻧﺪﻩ ﻭ ﻧﺎﻡﻫﺎﻱ ﺗﺠﺎﺭﻱ ﻭ ﻧﻴﺰ ﺭﻓﺮﻧﺲﻫﺎﻱ ﻣﻄﺎﻟﻌﺎﺗﻲ ﻫﺮ ﻣﺎﺩﺓ ﺳﺎﻳﻜﻮﺗﺮﻭﭖ ﺍﻃﻼﻉ ﭘﻴﺪﺍ ﻛﺮﺩ‪.‬‬
‫‪51.9‬‬ ‫)‪Psychiatry: 1200 Questions To Help Youpass the Boatds (Salekan E-Book‬‬ ‫‪2005‬‬

‫‪52.9‬‬ ‫)‪Recognizing Extrapyramidal Symptoms (VCD‬‬ ‫‪2001‬‬

‫‪- Clinical Examples of Acute Dystonia‬‬ ‫‪- Akathisia‬‬ ‫‪- Parkinsonism‬‬ ‫‪- and Tardive- Dyskinesia‬‬ ‫ﻣﺒﺎﺣﺚ ﺍﻳﻦ ‪ CD‬ﺷﺎﻣﻞ‪:‬‬
‫‪53.9‬‬ ‫‪Rune Aaslid TCD Simulator Version 2.1‬‬ ‫‪2001‬‬
‫ﺍﻳﻦ ﻧﺮﻡ ﺍﻓﺰﺍﺭ ﻳﻚ ﺷﺒﻴﻪ ﺳﺎﺯ ﺑﺮﺭﺳﻲﻫﺎﻱ ﺩﺍﭘﻠﺮ ﺍﻳﻨﺘﺮﺍﻛﺮﺍﻧﻴﺎﻝ ﻭﺍﻛﺴﺘﺮﺍﻛﺮﺍﻧﻴﺎﻝ ﻣﻲﺑﺎﺷﺪ ﻛﻪ ﺗﻮﺳﻂ ﻣﺨﺘﺮﻉ ‪ ، TCD‬ﺁﻗﺎﻱ ‪ Rune Aaslid‬ﺩﺭ ﺍﻳﻦ ‪ CD‬ﺍﺭﺍﺋﻪ ﮔﺮﺩﻳﺪﻩ ﺍﺳﺖ‪ .‬ﺷﺎﻣﻞ ﻣﺘﻨﻲ ﺍﺳﺖ ﻛﻪ ﻧﺤﻮﺓ ﺍﺳﺘﻔﺎﺩﻩ ﺍﺯ ‪ CD‬ﺭﺍ ﺁﻣﻮﺯﺵ ﻣﻲﺩﻫﺪ‪ .‬ﺍﺻﻮﻝ ﺩﺍﭘﻠﺮ ﺳـﻮﻧﻮﮔﺮﺍﻓﻲ‪-‬‬
‫ﺁﻧﺎﺗﻮﻣﻲ‪ -‬ﻫﻤﻮﺩﻳﻨﺎﻣﻴﻚ ﻭ ﻣﻮﺍﺭﺩ ﭘﺎﺗﻮﻟﻮﮊﻱ ﻋﺮﻭﻕ ﻣﻐﺰﻱ ﺭﺍ ﺗﻮﺿﻴﺢ ﻣﻲﺩﻫﺪ‪ .‬ﻗﺎﺑﻠﻴﺖﻫﺎﻱ ﻓﺮﺍﻭﺍﻧﻲ ﺍﺯ ﺟﻤﻠﻪ ﺍﻳﻦ ﻣﻮﺍﺭﺩ ﺭﺍ ﺩﺍﺭﺍ ﺍﺳﺖ‪ :‬ﻧﻤﺎﻳﺶ ﺍﺳﭙﻜﺘﺮﻭﻡ ﺩﺍﭘﻠﺮ‪ -‬ﻧﻤﺎﻳﺶ ﻣﺤﻞ ﺗﺎﺑﺶ ﻭ ﺯﺍﻭﻳﻪ ﺗﺎﺑﺶ ﺍﻣﻮﺍﺝ‪ -‬ﻣﻮﻧﻴﺘﻮﺭﻳﻨﮓ‪ -‬ﺗﺼـﻮﻳﺮ ‪ – CBF‬ﺁﻧـﺎﺗﻮﻣﻲ ﻭ ﭘـﺎﺗﻮﻟﻮﮊﻱﻫـﺎﻱ ﻣﺨﺘﻠـﻒ‪،‬‬
‫ﻛﻨﺘﺮﻝ ﻛﺎﺭﺩﻳﻮ ﻭﺍﺳﻜﻮﻻﺭ‪ -‬ﺗﺄﺛﻴﺮ ﺗﻐﻴﻴﺮ ﺿﺮﺑﺎﻥ ﻗﻠﺐ‪ -‬ﺗﺄﺛﻴﺮ ﺗﻐﻴﻴﺮ ﺗﻨﻔﺲ‪ HITS -‬ﻭ ﺑﺎﻻﺧﺮﻩ ﺩﻳﺪ ﺳﻪ ﺑﻌﺪﻱ ﻛﻪ ﺗﺠﺴﻢ ﻣﻮﻗﻌﻴﺖ ﻓﻀﺎﻳﻲ ﻋﺮﻭﻕ ﺩﺭ ﺩﺍﺧﻞ ﺟﻤﺠﻤﻪ ﺭﺍ ﺳﻬﻞ ﻣﻲﻧﻤﺎﻳﺪ‪ .‬ﺍﻳﻦ ‪ CD‬ﻳﻜﻲ ﺍﺯ ﺑﻬﺘﺮﻳﻦ ﻭ ﻣﺆﺛﺮﺗﺮﻳﻦ ﺍﺑﺰﺍﺭﻫﺎﻱ ﺁﻣﻮﺯﺵ ‪ TCD‬ﺍﺳﺖ ﻛﻪ ﺗﻮﺳـﻂ ﺍﺳـﺎﺗﻴﺪ ﻭ‬
‫ﺩﺍﻧﺸﺠﻮﻳﺎﻥ ﻣﻮﺭﺩ ﺍﺳﺘﻔﺎﺩﻩ ﻗﺮﺍﺭ ﻣﻲﮔﻴﺮﺩ‪ .‬ﻣﻔﺎﻫﻴﻢ ﭘﻴﭽﻴﺪﻩ ﺩﺍﭘﻠﺮ ﻋﺮﻭﻕ ﻣﻐﺰﻱ ﺭﺍ ﺑﺼﻮﺭﺕ ﻣﻠﻤﻮﺱ ﺩﺭ ﺍﺧﺘﻴﺎﺭ ﻋﻼﻗﻪﻣﻨﺪﺍﻥ ﻗﺮﺍﺭ ﻣﻲﺩﻫﺪ‪.‬‬
‫‪54.9‬‬ ‫‪Stroke‬‬ ‫ــــ‬
‫‪Overview of Stroke: 1. Stroke in Perspective 2. Pathogenesis & Pathophysiology 3. Evaluation & Diagnosis 4. Interventions 5. Thrombolytic Therapy Studies‬‬
‫‪IV Tissue Plasminogen Activator(t-PA) Studies: 1. Recent Multicenter, IV Streptokinase (SK) Studies‬‬
‫‪Ultra Rapid Response: 1. Increasing Public/Professional Awareness 2. Modifying Care Patterns 3. Stroke Care Systems 4. Assessing Critical Resources‬‬
‫‪Case Studies‬‬
‫‪31.7 SPINE implants‬‬ ‫)‪(CD I , II‬‬ ‫ــــ‬
‫‪ : CD I‬ﺩﺭ ﺍﻳﻦ ‪ CD‬ﻧﺤﻮﺓ ﺟﺮﺍﺣﻲ ﻭ ﺑﻪﻛﺎﺭﮔﺬﺍﺷﺘﻦ ﭘﺮﻭﺗﺰﻫﺎﻱ ﻣﻬﺮﻩ ﻧﺸﺎﻥ ﺩﺍﺩﻩ ﻣﻲﺷﻮﺩ ﻭ ﺍﻃﻼﻋﺎﺕ ﻛﺎﻣﻠﻲ ﺭﺍﺟﻊ ﺑﻪ ﭘﺮﻭﺗﺰﻫﺎﻱ ﺟﺎﻧﺸﻴﻦ ﺟﺴﻢ ﻣﻬﺮﻩ ﺩﺍﺩﻩ ﻣﻲﺷﻮﺩ‪.‬‬
‫‪ : CD II‬ﺩﺭ ﺍﻳﻦ ‪ CD‬ﻧﺤﻮﻩ ﺟﺮﺍﺣﻲ ﻭ ﺑﻜﺎﺭﮔﺬﺍﺷﺘﻦ ﺩﺳﺘﮕﺎﻩ ‪ Diapasone-hook‬ﺑﺮ ﺭﻭﻱ ﻣﻬﺮﻩﻫﺎﻱ ﻛﻤﺮﻱ ﺩﺭ ﺩﺭﻣﺎﻥ ﻣﻮﺍﺭﺩ ﺗﺮﻭﻣﺎﺗﻴﻚ ﻭ ﺍﺳﻜﻮﺍﻧﻴﻮﺭ ﻧﺸﺎﻥ ﺩﺍﺩﻩ ﻣﻲﺷﻮﺩ‪.‬‬
‫‪55.9‬‬ ‫)‪TEXTBOOK of CLINICAL NEUROLOGY (Christopher G. Goetz, MD, Eric J. Pappert, MD) (W.B. Saunders Company‬‬ ‫‪1999‬‬
‫‪56.9 The Cerefy‬‬ ‫)‪Atlas of Brain Anatomy An interactive tool for students, teachers, and researchers (Wieslaw L. Nowinski, A. Thirunavuukarasuu, R. Nick Bryan‬‬
‫‪TM‬‬
‫ــــ‬
‫ﺍﻳﻦ ﻧﺮﻡﺍﻓﺰﺍﺭ ﺑﺎ ﺍﺳﺘﻔﺎﺩﻩ ﺍﺯ ﺗﺼﺎﻭﻳﺮ ‪ MRI‬ﺩﺭ ﺳﻪ ﺟﻬﺖ‪ ،‬ﻃﺮﺍﺣﻲﻫﺎﻱ ﺭﻧﮕﻲ ﻭ ﺳﻴﺴﺘﻢ ﻧﺎﻣﮕﺬﺍﺭﻱ ﻣﺎ ﺭﺍ ﻗﺎﺩﺭ ﻣﻲﺳﺎﺯﺩ ﺑﺮﺍﺣﺘﻲ ﻫﺮ ﺳﺎﺧﺘﻤﺎﻥ ﺩﺍﺧﻠﻲ ﻣﻐﺰﻱ ﺭﺍ ﺩﺭ ‪ ٣‬ﺟﻬﺖ ﺑﻄﻮﺭ ﻫﻤﺰﻣﺎﻥ ﻣﺸﺎﻫﺪﻩ ﻧﻤﺎﻳﻴﻢ‪ .‬ﺟﻬﺖ ﺗﺠﺴﻢ ﻓﻀﺎﻳﻲ ﺑﻬﺘﺮ ﻭ ﻋﻤﻠﻴﺎﺕ ﺍﺳﺘﺮﺗﻮﺗﺎﻛﺴﻲ ﻣـﻲﺗـﻮﺍﻥ‬
‫‪ Grid‬ﺧﺎﺻﻲ ﺭﺍ ﺑﺮ ﺭﻭﻱ ﺗﺼﻮﻳﺮ ﻗﺮﺍﺭ ﺩﺍﺩ ﻭ ﻓﺎﺻﻠﻪﻫﺎﻱ ﺩﻟﺨﻮﺍﻩ ﺭﺍ ﺍﻧﺪﺍﺯﻩﮔﻴﺮﻱ ﻧﻤﻮﺩ‪ .‬ﺩﺭ ﻗﺴﻤﺖ ﺗﺴﺖ ﻛﻪ ﺑﻪ ﺻﻮﺭﺕ ‪ interactive‬ﻭ ﺑﺴﻴﺎﺭ ﺟﺬﺍﺏ ﻃﺮﺍﺣﻲ ﺷﺪﻩ ﺍﺳﺖ ﺍﺭﺯﻳﺎﺑﻲ ﻣﻔﺎﻫﻴﻢ ﻭ ﺁﻣﻮﺧﺘﻪﻫﺎ ﻣﻘﺪﻭﺭ ﻣﻲﮔﺮﺩﺩ‪ .‬ﺩﺭ ﻗﺴﻤﺖ ‪ Glossory‬ﺗﻮﺿﻴﺢ ﻛﺎﻣﻠﻲ ﺭﺍﺟﻊ ﺑﻪ ﻫﺮ ﻛﺪﺍﻡ‬
‫ﺍﺯ ﻣﻨﺎﻃﻖ ﺁﻧﺎﺗﻮﻣﻴﻚ ﻣﻮﺭﺩ ﺍﺷﺎﺭﻩ ﺍﺭﺍﺋﻪ ﺷﺪﻩ ﺍﺳﺖ‪ .‬ﺍﻳﻦ ‪ CD‬ﻣﻮﺭﺩ ﺍﺳﺘﻔﺎﺩﻩ ﺍﻓﺮﺍﺩﻳﻜﻪ ﻧﻮﺭﻭﺁﻧﺎﺗﻮﻣﻲ‪ ،‬ﻧﺮﻭﻟﻮﮊﻱ‪ -‬ﺟﺮﺍﺣﻲ ﺍﻋﺼﺎﺏ‪ -‬ﻧﺮﻭﺭﺍﺩﻳﻮﻟﻮﮊﻱ‪ -‬ﻋﻠﻮﻡ ﻧﺮﻭﺳﺎﻳﻨﺲ ﻭ ﺭﻭﺍﻧﭙﺰﺷﻜﻲ ﻣﻲﺁﻣﻮﺯﻧﺪ ﻳﺎ ﺁﻣﻮﺯﺵ ﻣﻲﺩﻫﻨﺪ ﻗﺮﺍﺭ ﻣﻲﮔﻴﺮﺩ‪.‬‬
‫)‪57.9 The Clinical Diagnosis of Alzheimer's Disease (An Interactive Guide for Family Physician‬‬
‫ﺗﺸﺨﻴﺼﻲ ﻭ ﺩﺭﻣﺎﻧﻲ ﭼﻨﺪﻱ ﻣﻲﺑﺎﺷﺪ‪ .‬ﺷﺎﻣﻞ ‪ ٨‬ﻣﺒﺤﺚ ﻋﻤﺪﺓ ﺯﻳﺮ ﺍﺳﺖ‪:‬‬ ‫ﺗﻮﺳﻂ ﮔﺮﻭﻩ ‪ Alzheimer disease group‬ﺑﻴﻤﺎﺭﺳﺘﺎﻥ ‪ RiverView‬ﻛﺎﻧﺎﺩﺍ ﺗﻬﻴﻪ ﮔﺮﺩﻳﺪﻩ ﺍﺳﺖ‪ .‬ﭼﻨﺪﻳﻦ ﻗﻄﻌﻪ ﻓﻴﻠﻢ ﺁﻣﻮﺯﺷﻲ ﺭﺍﺟﻊ ﺑﻪ ﻧﺤﻮﺓ ﻣﺼﺎﺣﺒﻪ ﺑﺎ ﺑﻴﻤﺎﺭﺍﻥ ﻣﺒﺘﻼ ﺑﻪ ﺁﻟﺰﺍﻳﻤﺮ ﻭ ‪Flowchart‬‬ ‫ــــ‬
‫ﺷﺮﺡ ﺣﺎﻝ‬ ‫ﺑﺮﺭﺳﻲ ﺷﻨﺎﺧﺘﻲ‬ ‫ﺑﺮﺭﺳﻲ ﺭﺍﺩﻳﻮﻟﻮﮊﻳﻚ‬ ‫‪Case Studies‬‬ ‫ﻣﻌﺮﻓﻲ‬ ‫ﻣﻌﺎﻳﻨﺎﺕ ﺑﺎﻟﻴﻨﻲ‬ ‫ﺑﺮﺭﺳﻲ ﺁﺯﻣﺎﻳﺸﮕﺎﻫﻲ‬ ‫ﺗﺸﺨﻴﺺ ﺑﺎﻟﻴﻨﻲ‬
‫‪58.9‬‬ ‫)‪THE HUMAN BRAIN (Marion Hall David Robinson‬‬ ‫ــــ‬
‫‪59.9‬‬ ‫)‪THE HUMAN NERVOUS SYSTEM (Springer‬‬ ‫ــــ‬

‫ﺗﻠﻔﻦ‪٠٩١٢١٣٧٢٣٦١-٦٦٩٣٦٦٩٦ :‬‬ ‫ﻧﺸﺎﻧﻲ‪ :‬ﺗﻬﺮﺍﻥ‪ ،‬ﻡ ﺍﻧﻘﻼﺏ‪ ،‬ﺥ ﻛﺎﺭﮔﺮ ﺟﻨﻮﺑﻲ‪ ،‬ﺥ ﻟﺒﺎﻓﻲﻧﮋﺍﺩ‪ ،‬ﺑﻴﻦ ﻛﺎﺭﮔﺮ ﻭ ﺟﻤﺎﻟﺰﺍﺩﻩ‪ ،‬ﺑﻦﺑﺴﺖ ﺳﻴﻤﻴﻦ‪ ،‬ﭘﻼﻙ ‪٢٣٩‬‬ ‫ﻣﺮﻛﺰ ﺧﺪﻣﺎﺕ ﻓﺮﻫﻨﮕﻲ ﺳﺎﻟﻜﺎﻥ ‪ :‬ﺍﺭﺍﺋﻪ ﻛﻨﻨﺪﺓ ﻛﺘﺎﺏ ﻭ ﺳﻲﺩﻱﻫﺎﻱ ﺗﺨﺼﺼﻲ ﭘﺰﺷﻜﻲ‬
 50
60.9 The Massachusetts General Hospital Handbook of Pain Management (Second Edition) (Jane Ballantyne, Scott M. Fishman, Salahadin Abdi) (SALEKAN-E-book) ‫ــــ‬
I. General Considerations II. Diagnosis of Pain III. Therapeutic Options: Pharmacologic Approaches IV. Therapeutic Options: Nonpharmacologic Approaches
V. Acute Pain VI. Chronic Pain VII. Pain Due to Cancer VIII. Special Situations - Apendices - Subject Index
61.9 The Movement Disorder Society's Guide to Botulinum Toxin Injections 2002
،‫ ﺑﺎ ﺍﻧﺘﺨﺎﺏ ﺳﻨﺪﺭﻡ ﺑﺎﻟﻴﻨﻲ ﻳﺎ ﻋﻀﻠﺔ ﺩﻟﺨﻮﺍﻩ ﺍﺯ ﻟﻴﺴﺖ‬.‫ ﻋﻀﻼﺕ ﻭ ﺳﻨﺪﺭﻡﻫﺎﻱ ﺑﺎﻟﻴﻨﻲ ﻣﺮﺑﻮﻁ ﺑﻪ ﺁﻥ ﻗﺴﻤﺖ ﻓﻌﺎﻝ ﻣﻲﺷﻮﻧﺪ‬.‫ ﺩﺭ ﻛﺎﺩﺭ ﺍﻭﻝ ﺗﺼﻮﻳﺮ ﻛﻠﻲ ﺑﺪﻥ ﺍﺭﺍﺋﻪ ﺷﺪﻩ ﻛﻪ ﻗﺴﻤﺖ ﻣﻮﺭﺩ ﻧﻈﺮ ﺟﻬﺖ ﺗﺰﺭﻳﻖ ﺭﺍ ﺍﻧﺘﺨﺎﺏ ﻣﻲﻧﻤﺎﻳﻲ‬.‫ ﻧﺮﻡﺍﻓﺰﺍﺭ ﺁﻣﻮﺯﺵ ﻧﺤﻮﺓ ﺗﺰﺭﻳﻖ ﺑﻮﺗﻮﻟﻴﻨﻮﻡ ﺗﻮﻛﺴﻴﻦ ﻣﻲﺑﺎﺷﺪ‬:‫ ﺍﻭﻝ‬CD
.‫ ﺗﻌﺪﺍﺩ ﺗﺰﺭﻳﻘﺎﺕ ﻭ ﺍﺣﺘﻴﺎﻃﺎﺕ ﻻﺯﻡ ﻧﻴﺰ ﺍﺭﺍﺋﻪ ﮔﺮﺩﻳﺪﻩﺍﻧﺪ‬-‫ ﻧﺤﻮﺓ ﻭﺭﻭﺩ ﺳﻮﺯﻥ‬-‫ ﻣﺸﺨﺼﺎﺕ ﺳﻮﺯﻥ ﻭ ﻧﺤﻮﺓ ﻓﻌﺎﻝﻛﺮﺩﻥ ﻋﻀﻠﻪ‬-‫ ﻧﺤﻮﺓ ﻳﺎﻓﺘﻦ ﻋﻀﻠﻪ‬-‫ ﺟﺰﺋﻴﺎﺕ ﺗﻜﻨﻴﻚ ﺗﺰﺭﻳﻖ ﻣﺎﻧﻨﺪ ﻧﺤﻮﺓ ﻧﺸﺴﺘﻦ ﺑﻴﻤﺎﺭ‬.‫ﻓﻴﻠﻢ ﻧﺤﻮﺓ ﺗﺰﺭﻳﻖ ﺑﻬﻤﺮﺍﻩ ﺩﻳﺎﮔﺮﺍﻡ ﺁﻧﺎﺗﻮﻣﻴﻚ ﻧﻤﺎﻳﺶ ﺩﺍﺩﻩ ﻣﻲﺷﻮﻧﺪ‬
‫ ﺩﺭ ﭼﺎﺭﺕﻫﺎﻱ ﺭﻧﮕﻲ ﻣﺮﺑﻮﻁ ﺑﻪ ﻫﺮ ﺑﻴﻤﺎﺭ ﻣﺤﻞ ﻭ ﻣﻘﺪﺍﺭ ﺗﺰﺭﻳﻖ‬.‫ ﺑﺮ ﺣﺴﺐ ﺍﻟﻔﺒﺎ ﺩﺳﺘﻴﺎﺑﻲ ﺑﻪ ﺳﻮﺍﺑﻖ ﺑﻴﻤﺎﺭ ﺭﺍ ﻣﻤﻜﻦ ﻣﻲﺳﺎﺯﺩ‬Search ‫ ﻧﺮﻡﺍﻓﺰﺍﺭ ﺍﺳﺘﻔﺎﺩﻩ ﺍﺯ ﺑﻮﺗﻮﻟﻴﻨﻮﻡ ﺗﻮﻛﺴﻴﻦ ﺩﺭ ﻛﻠﻴﻨﻴﻚ ﻣﻲﺑﺎﺷﺪ ﻛﻪ ﺑﺎﻧﻚ ﺍﻃﻼﻋﺎﺗﻲ ﺩﺭ ﻣﻮﺭﺩ ﻫﺮ ﺑﻴﻤﺎﺭ ﺭﺍ ﺗﺸﻜﻴﻞ ﺩﺍﺩﻩ ﻭ ﺑﺎ ﻗﺎﺑﻠﻴﺖ‬:‫ ﺩﻭﻡ‬CD
.‫ ﺑﻪ ﭘﺰﺷﻜﺎﻥ ﺩﺭ ﺟﻤﻊﺁﻭﺭﻱ ﻳﺎﻓﺘﻪﻫﺎ ﻭ ﻛﻼﺳﻪﺑﻨﺪﻱ ﺁﻧﻬﺎ ﺟﻬﺖ ﺍﺳﺘﻔﺎﺩﻩ ﺑﻌﺪﻱ ﻭ ﺗﺤﻘﻴﻘﺎﺕ ﻛﻤﻚ ﺷﺎﻳﺎﻧﻲ ﻣﻲﻛﻨﺪ‬CD ‫ ﺍﻳﻦ‬.‫ ﻣﻮﺟﻮﺩ ﺍﺳﺖ‬CD ‫ ﺁﻣﻮﺯﺷﻲ ﺟﻬﺖ ﺭﺍﻫﻨﻤﺎﻳﻲ ﺑﻴﻤﺎﺭﺍﻥ ﻭ ﺍﻃﻼﻋﺎﺕ ﺑﻴﺸﺘﺮ ﺩﺭ‬PDF ‫ ﻓﺎﻳﻞ‬.‫ﻣﺸﺨﺺ ﺷﺪﻩ ﻭ ﺩﺭ ﺣﺎﻓﻈﻪ ﺫﺧﻴﺮﻩ ﻣﻲﮔﺮﺩﻧﺪ‬
62.9 Understanding and Diagnosing Restless Legs Syndrome ‫ــــ‬
.‫ ﺩﺭ ﺩﺳﺘﺮﺱ ﻣﻲﺑﺎﺷﺪ‬PDF ‫ ﺁﺧﺮﻳﻦ ﺍﻃﻼﻋﺎﺕ ﻭ ﻳﺎﻓﺘﻪﻫﺎ ﺩﺭ ﻣﻮﺭﺩ ﺑﻴﻤﺎﺭﻱ ﺳﻨﺪﺭﻡ ﭘﺎﻫﺎﻱ ﺑﻲﻗﺮﺍﺭ ﻭ ﺭﻭﺵﻫﺎﻱ ﺩﺭﻣﺎﻧﻲ ﻣﺨﺘﻠﻒ ﺍﻥ ﺑﺤﺚ ﺷﺪﻩ ﻭ ﺑﻪ ﺻﻮﺭﺕ ﻓﺎﻳﻞﻫﺎﻱ‬.‫ ﻃﺮﺍﺣﻲ ﻭ ﺍﺟﺮﺍ ﺷﺪﻩ ﺍﺳﺖ‬RLS Foundation ‫ ﻛﻪ ﺗﻮﺳﻂ ﻫﻴﺌﺖ ﻋﻠﻤﻲ‬CD ‫ﺩﺭ ﺍﻳﻦ‬
.‫ ﻳﺎﻓﺖ ﻣﻲﺷﻮﺩ‬CD ‫ﻫﻤﭽﻨﻴﻦ ﻳﻚ ﻓﻴﻠﻢ ﺁﻣﻮﺯﺷﻲ ﺩﺭﺑﺎﺭﺓ ﺍﻳﻦ ﺳﻨﺪﺭﻡ ﻭ ﺗﻈﺎﻫﺮﺍﺕ ﺑﺎﻟﻴﻨﻲ ﺁﻥ ﻭ ﺗﺪﺍﺑﻴﺮ ﺩﺭﻣﺎﻧﻲ ﻣﺨﺘﻠﻒ ﻧﻴﺰ ﺩﺭ ﺍﻳﻦ‬
63.9 VCD 1.1: Neuroradiology Practice Techniques 2002
VCD 1.2: MR Spectroscopy Techniques
VCD 1.3: Oral Cavity
VCD 2.1: I- Oral Carity II- Imaging the Larynx
VCD 2.2: I- Extramucosal Spaces (Suprahyoid) II- Extraaxial Adult Tumors III- Head and Neck Case Review
VCD 3.1: I- Head and Neck Case Review II- Vascular Disease
VCD 3.2: I- Stroke Imaging (CT, CTA, CTP) II- AVMS
VCD 4.1:
VCD 4.2:
VCD 4.3:
VCD 5.1: I- Spinal Interventions II- Brain Case Review
VCD 5.2: I-Temporal Bone External and Middle Ear II- Irbit
Neuroradiology Review

VCD 6.1: I-Orbit II- Temporal Bone Inner Ear

Video CD Collection
The John Hopkins

VCD 6.2: Spaces of the Neck (Infrahyoid)

VCD 6.3: Head and Neck Case Review
VCD 7.1: I- Cancer of the Nesopharynx II- Brain Case Review
VCD 7.2: I- Brain (Molecular Imaging II- Congenital Imaging (part 1)
VCD 8.3: I- Demyelinating Disorders II- Congenital Imaging (part 2)
VCD 8.4: I- Carotid Imaging (part 1) II- Pediatric Brain Tumors
VCD 9.1: I- Pediatric Brain Tumors II- Hemorrhage/Head Trauma
VCD 9.2: Carotid Imaging (part2)
VCD 9.3: Brain Case Review
VCD 10.1: Anatomy and DJD Spine
VCD 10.2: Extradural (Non-DJD) Spine Sinus CT
VCD 11.1: I- Intradural Extramedullary Spine II- Spine Trauma
VCD 11.2: I- Intradural Intramedullary Spine II- Spine Infection and Inflammation
VCD 12.1: I- Spine Case Review
VCD 12.2: New Techniques (Diffusion Tensor Imaging)
VCD 12.3: Functional Imaging
VCD 13.1: Functional Imaging
VCD 13.2: MR Spectroscopic Imaging
VCD 13.3: An overview of 3.0 Tesla Imaging
64.9 Thinking a head (Critical question in ms therapy) 2001

٠٩١٢١٣٧٢٣٦١-٦٦٩٣٦٦٩٦ :‫ﺗﻠﻔﻦ‬ ٢٣٩ ‫ ﭘﻼﻙ‬،‫ ﺑﻦﺑﺴﺖ ﺳﻴﻤﻴﻦ‬،‫ ﺑﻴﻦ ﻛﺎﺭﮔﺮ ﻭ ﺟﻤﺎﻟﺰﺍﺩﻩ‬،‫ ﺥ ﻟﺒﺎﻓﻲﻧﮋﺍﺩ‬،‫ ﺥ ﻛﺎﺭﮔﺮ ﺟﻨﻮﺑﻲ‬،‫ ﻡ ﺍﻧﻘﻼﺏ‬،‫ ﺗﻬﺮﺍﻥ‬:‫ﻧﺸﺎﻧﻲ‬ ‫ ﺍﺭﺍﺋﻪ ﻛﻨﻨﺪﺓ ﻛﺘﺎﺏ ﻭ ﺳﻲﺩﻱﻫﺎﻱ ﺗﺨﺼﺼﻲ ﭘﺰﺷﻜﻲ‬: ‫ﻣﺮﻛﺰ ﺧﺪﻣﺎﺕ ﻓﺮﻫﻨﮕﻲ ﺳﺎﻟﻜﺎﻥ‬
 51
‫ ﺩﺍﺧﻠﻲ‬-١٠

CD ‫ﻋﻨﻮﺍﻥ‬ ‫ﺳﺎﻝ ﺍﻧﺘﺸﺎﺭ‬

1.10 (AGA Postgraduate Course) A Day and Night in the Life of a Gastroenterologist 2003
Esophagus and Stomach Liver Pancreas and Biliary Tract Nutrition GI Malignancy Small Bowel and Colon Clinical Challenge Sessions
2.10 3DClinic (Version 1.0) Seeing is Understanding ___
‫ ﺷﻤﺎ‬Desktop ‫( ﺑﺮ ﺭﻭﻱ‬2D Clinic) Icon .‫ ﻛﻨﻴﺪ‬Restart ‫ ﺳﭙﺲ ﺳﻴﺴﺘﻢ ﺭﺍ‬.‫( ﺭﺍ ﺑﻬﻤﺮﺍﻩ ﺍﺳﻢ ﺧﻮﺩ ﻭﺍﺭﺩ ﻧﻤﺎﻳﻴﺪ‬SN: BI-B25600000-131) ‫ ﻣﻮﺟﻮﺩ ﺍﺳﺖ ﻧﺼﺐ ﻧﻤﻮﺩﻩ ﻭ ﺳﭙﺲ ﺩﺭ ﻗﺴﻤﺖ ﺩﻭﻡ‬CD‫ ﺭﺍ ﻛﻪ ﺩﺭ‬QTS ‫ ﺍﺑﺘﺪﺍ‬Autorun ‫ﺟﻬﺖ ﻧﺼﺐ ﺍﻳﻦ ﻧﺮﻡﺍﻓﺰﺍﺭ ﺑﻌﺪ ﺍﺯ ﺷﺮﻭﻉ ﺑﺮﻧﺎﻣﻪ ﺑﻪ ﺻﻮﺭﺕ‬
-Cardiovascular - ‫ ﺍﻳﻦ ﻧﺮﻡﺍﻓﺰﺍﺭ ﺑﺎ ﺍﺳﺘﻔﺎﺩﻩ ﺍﺯ ﻋﻜﺲﻫﺎ ﻭ ﻓﻴﻠﻢﻫﺎﻱ ﺳﻪﺑﻌﺪﻱ ﺟﺬﺍﺏ ﻣﻔﺎﻫﻴﻢ ﻣﺨﺘﻠﻒ ﻣﺮﺑﻮﻁ ﺑﻪ ﺳﻴﺴﺘﻢﻫﺎﻱ ﻣﺨﺘﻠـﻒ ﺑـﺪﻥ ﺍﺯ ﺟﻤﻠـﻪ‬.‫ ﺑﻌﺪ ﺍﺯ ﻧﺼﺐ ﺑﺮﻧﺎﻣﻪ ﺑﻪ ﻃﻮﺭ ﻛﺎﻣﻞ ﺩﺭ ﻛﺎﻣﭙﻴﻮﺗﺮ ﺣﻔﻆ ﺧﻮﺍﻫﺪ ﺷﺪ‬.‫ ﻛﻪ ﺑﺎ ﺍﻧﺘﺨﺎﺏ ﻭ ﺍﺟﺮﺍﻱ ﺁﻥ ﻣﻨﻮﻱ ﺍﺻﻠﻲ ﻇﺎﻫﺮ ﻣﻲﺷﻮﺩ‬.‫ﻇﺎﻫﺮ ﺧﻮﺍﻫﺪ ﺷﺪ‬
‫ ﻛﻪ ﺑﻪ ﺍﻧﺘﺨﺎﺏ ﺷﻤﺎ ﻧﻤﺎﻳﺶ ﺩﺍﺩﻩ‬3D ‫ ﻓﻴﻠﻢﻫﺎﻱ‬.‫ ﻧﺸﺎﻥ ﻣﻲﺩﻫﺪ‬Disorder ‫ ﻭ‬Healthy ‫ ﺭﺍ ﺩﺭ ﺩﻭ ﺣﺎﻟﺖ‬Gastrointestinal -Musculoskeletal -Respiratory -Nervous -Urinary -Sensory -Endocrine -Lymphatic -Skin
‫ ﺍﺿﺎﻓﻪﻛﺮﺩﻥ ﻧﻜﺎﺕ ﻣﻬﻢ ﺑﺎ ﻣﺎﺭﻛﺮ ﻭ ﻧﻴﺰ ﺗﺎﻳﭗ ﺑﺮ ﺭﻭﻱ ﻋﻜﺲﻫﺎ ﺍﺯ ﻗﺎﺑﻠﻴﺖﻫﺎﻱ ﺟﺎﻟﺐ ﺍﻳـﻦ‬،‫ ﻗﺎﺑﻠﻴﺖ ﻧﮕﻬﺪﺍﺷﺘﻦ ﻓﻴﻠﻢ ﺩﺭ ﻟﺤﻈﻪ ﺩﻟﺨﻮﺍﻩ‬.‫ﻣﻲﺷﻮﻧﺪ ﻗﺴﻤﺖﻫﺎﻱ ﺑﺴﻴﺎﺭ ﺟﺎﻟﺐ ﻭ ﺁﻣﻮﺯﻧﺪﻩﺍﻱ ﺍﺯ ﺳﻴﺴﺘﻢﻫﺎﻱ ﻣﺨﺘﻠﻒ ﺑﺪﻥ ﺩﺭ ﺣﺎﻟﺖ ﻧﺮﻣﺎﻝ ﻭ ﺑﻴﻤﺎﺭﻱ ﺍﺭﺍﺋﻪ ﻣﻲﺩﻫﺪ ﻛﻪ ﺑﻪ ﺩﺭﻙ ﺑﻬﺘﺮ ﻣﻮﺿﻮﻉ ﻛﻤﻚ ﺷﺎﻳﺎﻧﻲ ﻣﻲﻧﻤﺎﻳﺪ‬
.‫ ﺷﻤﺎ ﺩﺭ ﺻﻮﺭﺕ ﺗﻤﺎﻳﻞ ﻣﻲﺗﻮﺍﻧﻴﺪ ﭘﺮﻳﻨﺖ ﻭ ﺍﺳﻼﻳﺪ ﺑﺎ ﻛﻴﻔﻴﺖ ﺑﺎﻻ ﺍﺯ ﺗﺼﺎﻭﻳﺮ ﺗﻬﻴﻪ ﻓﺮﻣﺎﺋﻴﺪ‬.‫ﻧﺮﻡﺍﻓﺰﺍﺭ ﻣﻲﺑﺎﺷﺪ‬
3.10 Adult Airway Management Principles & Techniques American Association (afael A. Ortega, M.D., Harold Arkoff, M.D.) ‫ــــ‬
4.10 Advanced Therapy of INFLAMMATORY BOWEL DISEASE (Theodore M. Bayless, MD, Stephen B. Hanauer, MD) 2001
5.10 AGA Postgraduate Course CONTROVERSIES And CLINICAL CHALLENGES in Pancreatic Diseases ‫ــــ‬
(An Intensive Two-Day Course Covering A Diversity of Topics Related to the Pancreas)
-Expanded Content -Includes Results of the Q&A -Section Challenge Sessions
Atlas of GASTROINTESTINAL in Health and Disease (Marvin M. Schuster, Michael D. Crowell, Kenneth L. Koch)
6.10
Part 1: Physiologic Basis of Gastrointestinal Motility Part 2: Motility Test for the Gastrointestinal Tract
7.10 Atlas of GASTROINTESTINAL MOTILITY in Health and Disease (Second Edition) 2002
(Marvin M. Schuster, MD, FACP, FAPA, FACG, Michael D. Crowell, PhD, FACG, Kenneth L. Koch, MD)
Part I: Physiologic Basic of Gastrointestinal Motility Part II: Motility Tests for The Gastrointestinal Tract
8.10 Atlas of Clinical Oncology Soft Tissue Sarcomas American Cancer Sosiety (Raphael E. Pollock, MD, Phd) 2002
9.10 Atlas of Clinical Oncology Cancer of the Lower Gastrointestinal Tract (Christopher G. Willett, MD) 2001
10.10 Atlas of Clinical Rheumatology (2 Edition) (David J. Nashel, Chief, Rheumatology Section Va Medical Center, Washington, Professor of Medicine Georgetown University)
nd
‫ــــــ‬
1. Clinical Atlas of Rheumatic Diseases 3. Physical Examination 5. Physical Findings Instructional Module Radiography
2. Radiograph Intrerpretation Instructional Module 4. Procures 6. Aspiration/Injection Instructional Module
11.10 Atlas of INTERNAL MEDICINE (Eugene Braunwald) ‫ــــــ‬
12.10 CANCER Principles & Practice of Oncology (6th Edition) (Vincent T. DeVita, Jr., Samuel Hellman, Steven A. Rosenberg) ‫ــــــ‬
13.10 Case Studies in GASTROENTEROLOGY (Second Edition) (Ingram Roberts, MD) ‫ــــــ‬
14.10 CD-ATLAS OF DIAGNOSTIC ONCOLOGY ‫ــــــ‬
15.10 Clinical Endocarinology (G. Michael Besser MD, DSc, FRCP, Michael O. Thorner MB BS, DSc, FRCP) ‫ــــــ‬
Adrenals Gonads Growth Hormone Assay Imaging Techniques Pancreas
Ectopic Humoral Syndromes Gastrointestinal Tract Lipids and Lipoproteins Thyroid & Parathyroide Pituitary and Hypothalamus
16.10 Clinical Immunology PRINCIPLES AND PRACTICE (Second Edition) (Robert R Rich, Thomas A Fleisher, William T Shearer, Brain L Kotzin, Harry W Schroeder) ‫ــــــ‬
:‫ ﺑﺨﺶ ﻣﻲﺑﺎﺷﺪ‬١١ ‫ ﺍﻳﻦ ﺑﺮﻧﺎﻣﻪ ﺷﺎﻣﻞ‬.‫ ﺍﺭﺍﺋﻪ ﺷﺪﻩ ﺍﺳﺖ‬Rich ‫ ﻧﻮﺷﺘﺔ ﺩﻛﺘﺮ‬Clinical Immunology ‫ﺍﻳﻦ ﺑﺮﻧﺎﻣﻪ ﺑﺮﺍﺳﺎﺱ ﻛﺘﺎﺏ‬
‫ ﺭﻭﺷﻬﺎﻱ ﺗﺸﺨﻴﺼﻲ ﺩﺭ ﺍﻳﻤﻮﻧﻮﻟﻮﮊﻱ‬-٧ ‫ ﺑﻴﻤﺎﺭﻳﻬﺎﻱ ﺍﻳﻤﻮﻧﻮﻟﻮﮊﻳﻜﻲ‬-٦ ‫ ﺑﻴﻤﺎﺭﻳﻬﺎﻱ ﺁﻟﺮﮊﻳﻜﻲ‬-٥ ‫ ﺳﻴﺴﺘﻢ ﺩﻓﺎﻋﻲ ﺫﺍﺗﻲ ﻭ ﺍﻛﺘﺴﺎﺑﻲ‬-٤ ‫ ﻋﻔﻮﻧﺖ ﻭ ﺳﻴﺴﺘﻢ ﺍﻳﻤﻨﻲ‬-٣ ‫ ﻣﻜﺎﻧﻴﺴﻢﻫﺎﻱ ﺩﻓﺎﻋﻲ ﻣﻴﺰﺑﺎﻥ ﻭ ﺍﻟﺘﻬﺎﺏ‬- ٢ ‫ ﺍﺻﻮﻝ ﺗﺸﺨﻴﺼﻲ ﺍﻳﻤﻨﻲ‬-١
‫ ( ﺫﺧﻴﺮﻩ ﻭ ﻧﮕﻬﺪﺍﺭﻱ‬Slide vision ‫ ﻫﺮ ﺍﺳﻼﻳﺪ ﺭﺍ ﻣﻲﺗﻮﺍﻥ ﺩﺭ ﻳﻚ ﻓﺎﻳﻞ )ﺗﺤﺖ ﺑﺮﻧﺎﻣﺔ‬drag & drop ‫ ﺑﺎ ﺭﻭﺵ‬.‫ ﻭﺍﮊﻩ ﻭ ﻟﻐﺎﺕ ﺭﺍ ﺩﺍﺭﺳﺖ ﻭ ﻧﻴﺰ ﺗﺼﺎﻭﻳﺮ ﻭ ﺍﺳﻼﻳﺪﻫﺎ ﺭﺍ ﻣﻲﺗﻮﺍﻥ ﭼﺎﭖ ﻧﻤﻮﺩ‬Search ‫ ﺍﻳﻦ ﺑﺮﻧﺎﻣﻪ ﻗﺎﺑﻠﻴﺖ‬.‫ ﺍﺳﻼﻳﺪﻫﺎﻱ ﻣﺘﻌﺪﺩﻱ ﻫﻤﺮﺍﻩ ﺑﺎ ﺗﻮﺿﻴﺢ ﺍﺭﺍﺋﻪ ﺩﺍﺩﻩ ﺷﺪﻩ ﺍﺳﺖ‬،‫ﺩﺭ ﻫﺮﺑﺨﺶ‬
.‫ ﺍﺟﺮﺍ ﻣﻲﺷﻮﺩ‬Slide vision ‫ ﺍﺟﺮﺍ ﻣﻲﺷﻮﺩ ﻭ ﺗﺤﺖ‬Autorun ‫ ﺍﻳﻦ ﺑﺮﻧﺎﻣﻪ ﺑﺼﻮﺭﺕ‬.‫ ﻫﻤﭽﻨﻴﻦ ﻣﻲﺗﻮﺍﻥ ﺍﺳﻼﻳﺪﻫﺎﻱ ﺩﻳﮕﺮﻱ ﺭﺍ ﺑﻪ ﺍﻳﻦ ﺑﺮﻧﺎﻣﻪ ﺍﺿﺎﻓﻪ ﻳﺎ ﺣﺬﻑ ﻛﺮﺩ‬.‫ﻧﻤﻮﺩ‬

٠٩١٢١٣٧٢٣٦١-٦٦٩٣٦٦٩٦ :‫ﺗﻠﻔﻦ‬ ٢٣٩ ‫ ﭘﻼﻙ‬،‫ ﺑﻦﺑﺴﺖ ﺳﻴﻤﻴﻦ‬،‫ ﺑﻴﻦ ﻛﺎﺭﮔﺮ ﻭ ﺟﻤﺎﻟﺰﺍﺩﻩ‬،‫ ﺥ ﻟﺒﺎﻓﻲﻧﮋﺍﺩ‬،‫ ﺥ ﻛﺎﺭﮔﺮ ﺟﻨﻮﺑﻲ‬،‫ ﻡ ﺍﻧﻘﻼﺏ‬،‫ ﺗﻬﺮﺍﻥ‬:‫ﻧﺸﺎﻧﻲ‬ ‫ ﺍﺭﺍﺋﻪ ﻛﻨﻨﺪﺓ ﻛﺘﺎﺏ ﻭ ﺳﻲﺩﻱﻫﺎﻱ ﺗﺨﺼﺼﻲ ﭘﺰﺷﻜﻲ‬: ‫ﻣﺮﻛﺰ ﺧﺪﻣﺎﺕ ﻓﺮﻫﻨﮕﻲ ﺳﺎﻟﻜﺎﻥ‬
 52
17.10 CLINICAL ONCOLOGY (Raymond E. Lenhard, J. MD, Robert T. Osteen, MD, Ted Gansler, MD) 2001

18.10 Colonoscopy New Technology & Technique (CB Williams, JD Waye, Y Sakai) ‫ــــــ‬
19.10 Comprehensive Clinical Endocrinology G. Michael Besser MD, DSc, FRCP, Michael O. Thorner 2000
Hypothalamus and Pituitary, Thyroid, Adrenal, Control of Blood glucose and its disturbance, gonad and growth, General conditions-basic, General conditions-
clinical, Imaging, Patient Perspectives on endocrine Diseases
20.10 COMPREHENSIVE MANAGEMENT OF Chronic Obstructive Pulmonary Disease (Jean Bourbeau, MD, MSc, FRCPC, Diane Nault, RN, MSc, Elizabet Borycki) 2002
21.10 Core Curriculum in Primary Care Metabolic Diseases Section ‫ــــــ‬
.‫ ﺑﻨﺎ ﻧﻬﺎﺩﻩ ﺷﺪﻩ ﺍﺳﺖ‬Harvard ‫ﻫﺎﻳﻲ ﻣﻲﺑﺎﺷﺪ ﻛﻪ ﺑﺮﺍﻱ ﺁﻣﻮﺯﺵ ﻣﺪﺍﻭﻡ ﺩﺳﺘﻴﺎﺭﺍﻥ ﻭ ﻣﺘﺨﺼﺼﻴﻦ ﻫﺮ ﺭﺷﺘﻪ ﺗﻮﺳﻂ ﺍﻋﻀﺎﺀ ﻫﻴﺌﺖ ﻋﻠﻤﻲ ﺩﺍﻧﺸﮕﺎﻩ ﭘﺰﺷﻜﻲ‬CD ‫ ﻣﺠﻤﻮﻋﻪﺍﻱ ﺍﺯ‬CCC
‫ ﺳـﺆﺍﻻﺕ ﻣﺮﺑﻮﻃـﻪ ﺑـﻪ ﺻـﻮﺭﺕ‬،‫ ﺩﺭ ﺁﺧـﺮ ﻫـﺮ ﺳـﺨﻨﺮﺍﻧﻲ ﻭ ﻣﺒﺤﺜـﻲ‬.‫ ﻫﺮ ﻛﺪﺍﻡ ﺍﺯ ﺍﻳﻦ ﺳﺨﻨﺮﺍﻧﻲﻫﺎ ﻋﻼﻭﻩ ﺑﺮ ﺍﺳﻼﻳﺪﻫﺎﻱ ﺁﻣﻮﺯﺷﻲ ﻣﺘﻦ ﺳﺨﻨﺮﺍﻧﻲ ﻧﻴﺰ ﺩﺭ ﺩﺳﺘﺮﺱ ﻛـﺎﺭﺑﺮ ﻣـﻲﺑﺎﺷـﺪ‬.‫ ﺣﺎﺿﺮ ﺩﺭ ﻣﻮﺭﺩ ﺑﻴﻤﺎﺭﻱ ﺩﺍﺧﻠﻲ ﻭ ﻗﻠﺐ ﻭ ﻋﺮﻭﻕ ﺭﺍ ﮔﺮﺩﺁﻭﺭﻱ ﻛﺮﺩﻩ ﺍﺳﺖ‬CD
.‫ ﺑﻪ ﺻﻮﺭﺕ ﺩﺭﺳﻨﺎﻣﻪ ﺁﻣﻮﺯﺷﻲ ﻣﻮﺟﻮﺩ ﺍﺳﺖ‬CD ‫ ﻣﺒﺎﺣﺚ ﺯﻳﺮ ﺩﺭ‬.‫ ﺳﭙﺲ ﺧﻼﺻﻪ ﻫﺮ ﺳﺨﻨﺮﺍﻧﻲ ﺑﻪ ﺻﻮﺭﺕ ﻳﻚ ﻣﻘﺎﻟﻪ ﭼﺎﭘﻲ ﺩﺭ ﻣﺠﻼﺕ ﻋﻠﻤﻲ ﻭ ﺭﻭﺯﻧﺎﻣﻪﻫﺎ ﺁﻭﺭﺩﻩ ﺷﺪﻩ ﺍﺳﺖ‬.‫ﭼﻬﺎﺭﮔﺰﻳﻨﻪﺍﻱ ﺑﺮﺍﻱ ﺍﺭﺯﻳﺎﺑﻲ ﻛﺎﺭﺑﺮ ﺁﻭﺭﺩﻩ ﺷﺪﻩ ﺍﺳﺖ‬
‫ ﻣﺘﺎﺑﻮﻟﻴﺴﻢ ﺁﻫﻦ‬-٤ (‫ ﻧﮕﺮﺷﻲ ﻋﻤﻠﻲ )ﻗﺴﻤﺖ ﺩﻭﻡ‬:‫ ﺩﻳﺎﺑﺖ ﻣﻠﻴﺘﻮﺱ‬-٣ (‫ ﻧﮕﺮﺷﻲ ﻋﻤﻠﻲ )ﻗﺴﻤﺖ ﺍﻭﻝ‬:‫ ﺩﻳﺎﺑﺖ ﻣﻠﻴﺘﻮﺱ‬-٢ ‫ﻫﺎ ﻭ ﺑﻴﻤﺎﺭﻱﻫﺎﻱ ﻗﻠﺐ ﻭ ﻋﺮﻭﻕ‬Lipid -١
22.10 Differential Diagnosis (Seventh Edition) (LC Gupta Abhitabh Gupta Abhishek Gupta) (Salekan E-Book) 2005
-Common Signs and Symptoms -Causes -Differentiating Tables -Essentials of Diagnosis
-Staging of Diseases -Syndromes -Synonyms -Investigations
23.10 Digestive Diseases Self-Education Program (A Core Curriculum and Self-Assessment in Gastroenterology and Hepatology) ‫ــــــ‬

24.10 Diseases of the Liver (8th Edition) (Lippincott Williams & Wilkins) ‫ــــــ‬
General Considerations The Consequences of Liver Disease The Cholestasis Disorders Viral Hepatitis Immunology of Liver
Autoimmune Liver Disease Alcohol and Drug-Luduced Disease Genetic and Metabolic Disease Vascular Disease and Trauma
The Liver in Pregnancy and Childhood Infections and Granulomatous Disorders Transplantation Benign and Malignant Tumors
26.1 EBUS Endo Bronchial Ultrasound (Heinrich D. Becher, MD. Fccp) ‫ــــــ‬
- Basic Introduction -Bronchial Anatomy -Interactive Sonography -Product Information
25.10 ESAP (Endocrinology Self-Assessment Program) (Clark T. Sawin, MD, Kathryn A. Martin, MD) (The Endocrine Society) 2003
26.10 Evidence-Based Asthma Management PATHOPHYSIOLOGY/DIAGNOSIS/MANAGEMENT (7 edition)
TH
2001
‫ ﺁﺳﻢ ﻳﻚ ﺑﻴﻤﺎﺭﻱ ﺷﺎﻳﻊ ﭘﺰﺷﻜﻲ ﺍﺳﺖ ﻛﻪ ﺷـﻴﻮﻉ ﺭﻭ‬.‫ ﻣﻲﺑﺎﺷﺪ ﻛﻪ ﺑﻪ ﻣﺘﺨﺼﺼﻴﻦ ﻛﻤﻚ ﻣﻲﻛﻨﺪ ﺗﺎ ﺑﻬﺘﺮﻳﻦ ﺩﺭﻣﺎﻥ ﺭﺍ ﺑﺮ ﺍﺳﺎﺱ ﺩﺭﻳﺎﻓﺖ ﺷﺨﺼﻲ ﺧﻮﺩ ﺍﺯ ﺟﺪﻳﺪﺗﺮﻳﻦ ﺩﺭﻣﺎﻥﻫﺎﻱ ﻣﻮﺟﻮﺩ ﺩﺭ ﻣﻘﺎﻻﺕ ﻭ ﻛﺘﺎﺏﻫﺎ ﺭﺍ ﺍﻧﺘﺨﺎﺏ ﻛﺮﺩﻩ ﻭ ﺑﻪ ﻛﺎﺭ ﺑﺮﺩ‬Evidence-Based in medicin ‫ﺍﻳﻦ ﻛﺘﺎﺏ ﺍﺯ ﺳﺮﻱ ﻛﺘﺎﺏﻫﺎﻱ‬
.‫ ﺁﻣﺎﺭﮔﻴﺮﻱﻫﺎ ﻭ ﻣﻄﺎﻟﻌﺎﺕ ﻧﺸﺎﻥ ﺩﺍﺩﻩ ﺷﺪﻩ ﻛﻪ ﺍﻓﺰﺍﻳﺶ ﺷﻴﻮﻉ ﺁﺳﻢ ﻭﺍﻗﻌﻲ ﺑﻮﺩﻩ ﻭ ﺑﺎ ﺍﺯ ﻛﺎﺭﺍﻓﺘﺎﺩﮔﻲ ﺑﻴﻤﺎﺭ ﻫﻤﺮﺍﻩ ﺑﻮﺩﻩ ﻛﻪ ﻧﺸﺎﻥﺩﻫﻨﺪﻩ ﺩﺭﻣﺎﻥ ﺗﺎ ﻛﺎﻣﻞ ﺍﻳﻦ ﺑﻴﻤﺎﺭﺍﻥ ﺍﺳﺖ‬.‫ﺑﻪ ﺍﻓﺰﺍﻳﺶ ﺩﺍﺭﺩ‬
:‫ ﻛﺘﺎﺏ ﺍﻟﻜﺘﺮﻭﻧﻴﻜﻲ ﺣﺎﺿﺮ ﺷﺎﻣﻞ ﻣﺒﺎﺣﺚ ﺯﻳﺮ ﻣﻲﺑﺎﺷﺪ‬.‫ﺍﻳﻦ ﻛﺘﺎﺏ ﺑﺎ ﺁﻭﺭﺩﻥ ﻣﻘﺎﻻﺕ ﺑﺮ ﺍﺳﺎﺱ ﻣﻌﺘﺒﺮﺑﻮﺩﻥ ﻭ ﺩﺭﺟﻪﺑﻨﺪﻱ ﺍﻋﺘﺒﺎﺭ ﻣﻘﺎﻻﺕ ﭘﺰﺷﻚ ﻣﺘﺨﺼﺺ ﺭﺍ ﻛﻤﻚ ﻣﻲﻛﻨﺪ ﺗﺎ ﺩﺭ ﺩﺭﻣﺎﻥ ﺑﻴﻤﺎﺭﻱ ﺁﺳﻢ ﺑﻬﺘﺮﻳﻦ ﻭ ﻛﻢﻋﺎﺭﺿﻪﺗﺮﻳﻦ ﺩﺭﻣﺎﻥ ﺭﺍ ﺑﺮﺍﻱ ﻫﺮ ﺑﻴﻤﺎﺭ ﺟﺪﺍﮔﺎﻧﻪ ﺍﻧﺘﺨﺎﺏ ﻧﻤﺎﻳﺪ‬
1. Natural History and Epidemiology 9. Genetics of Asthma 17. Cellular and Pathologic Characteristics
2. Diagnosis 10. Role of the Outdoor Environment 18. Role of Indoor Aeroallergens
3. Role of Childhood Infection 11. Diagnosis and Management of Occupational Asthma 19. Principles of Asthma Management in Adults
4. Management of Persistent Asthma in Childhood 12. Mechanisms of Action of 2-Agonists and Short-Acting 2 Therapy 20. Role of Long-Acting 2-Adrenergic Agents
5. Use of Theophylline and Anticholinergic Therapy 13. Environmental Control and Immunotherapy 21. Role of Inhaled Corticosteroids
6. Leukotriene Modifiers 14. Alternative Anti-inflammatory Therapies 22. Exercise-Induced Bronchoconstriction
7. Acute Life-Threatening Asthma 15. Management of Asthma in the Intensive Care Unit 23. Severe Acute Asthma in Children
8. Role of Asthma Education 16. Asthma Unresponsive to Usual Therapy 24. Measures of Outcome

27.10 EVIDENCE-BASED DIABETES CARE (Hertzel C. Gerstein, MD, R. Brain Haynes, MD,) 2001
1- EVIDENCE 2- DEFINITION AND IMPORTANCE OF DIABETES MELLITUS 3- ETIOLOGIC CLASSIFICATION OF DIABETES
4- PREVENTION AND SCREENING FOR DIABETES MELLITUS 5- LONG-TERM CONSEQUENCES OF DIABETES 6- DELIVERY OF CARE
28.10 EVIDENCE-BASED Diagnosis: A Handbook of Clinical Prediction Rules (Mark Ebell, MD, MS) (Springer-Verlag) 2001

٠٩١٢١٣٧٢٣٦١-٦٦٩٣٦٦٩٦ :‫ﺗﻠﻔﻦ‬ ٢٣٩ ‫ ﭘﻼﻙ‬،‫ ﺑﻦﺑﺴﺖ ﺳﻴﻤﻴﻦ‬،‫ ﺑﻴﻦ ﻛﺎﺭﮔﺮ ﻭ ﺟﻤﺎﻟﺰﺍﺩﻩ‬،‫ ﺥ ﻟﺒﺎﻓﻲﻧﮋﺍﺩ‬،‫ ﺥ ﻛﺎﺭﮔﺮ ﺟﻨﻮﺑﻲ‬،‫ ﻡ ﺍﻧﻘﻼﺏ‬،‫ ﺗﻬﺮﺍﻥ‬:‫ﻧﺸﺎﻧﻲ‬ ‫ ﺍﺭﺍﺋﻪ ﻛﻨﻨﺪﺓ ﻛﺘﺎﺏ ﻭ ﺳﻲﺩﻱﻫﺎﻱ ﺗﺨﺼﺼﻲ ﭘﺰﺷﻜﻲ‬: ‫ﻣﺮﻛﺰ ﺧﺪﻣﺎﺕ ﻓﺮﻫﻨﮕﻲ ﺳﺎﻟﻜﺎﻥ‬
 53
-Cardiovascular Diseases -Endocrinology -Gastroenterology -Gynecology and Obstetrics -Hematology/Oncology -Infectious Disease
-Musculoskeletal -Neurology -Pulmonary Diseas -Renal Disease -Surgery and Trauma
29.10 Gastric Cancer Diagnosis and Treatment (An interactive Training Program) (J.R. Siewert, D.Kelsen, K. Maruyama) (Springer) 2000

30.10 Gastroenterology Endoscopy (2nd Edition) ‫ــــ‬

31.10 Gastrointestinal and Liver Disease Pathophysiology/Diagnosis/Management (7 edition) (Sleisenger & Fordtran's)
th
2002
Esophagus Liver Nutrition in gastroenterology Topics involving multiple organs Biology of the Gastrointestinal Tract and Liver Stomach and duodenum
Pancreas Biliary tract Approach to patients with symptoms and signs Small and Large Intestine Vasculature and Supporting Structures Psychosocial
32.10 HARRISON'S 15 McGraw-Hill presents ‫ــــ‬
32.1 Imaging of Diffuse Lung Disease (David A. Lynch, MB, John D. Newell Jr, MD, FCCP, Jin Seong Lee, MD) 1998
: ‫ ﺑﻌﻀﻲ ﻓﺼﻮﻝ ﻛﺘﺎﺏ ﺷﺎﻣﻞ‬.‫( ﺩﺭ ﺍﻃﻔﺎﻝ ﻭ ﺑﺎﻟﻐﻴﻦ ﺩﺭ ﻣﻮﺭﺩ ﺑﻴﻤﺎﺭﻱﻫﺎﻱ ﻣﻨﺘﺸﺮ ﺭﻳﻪ ﻣﻲﺑﺎﺷﺪ‬.... ‫ ﻭ‬MRI,CT-Xray) ‫ ﭘﺎﺗﻮﻓﻴﺰﻳﻮﻟﻮﮊﻱ ﻭ ﺗﻔﺴﻴﺮ ﻋﻜﺲﺑﺮﺩﺍﺭﻱ‬، ‫ ﺷﺮﺡ ﺣﺎﻝ‬،‫ ﻛﻪ ﺑﻪ ﮔﻔﺘﻪ ﻣﺆﻟﻔﻴﻦ ﺷﺎﻣﻞ ﺗﻠﻔﻴﻘﻲ ﺍﺯ ﻣﻌﺎﻳﻨﻪ‬.‫( ﻣﻲﺑﺎﺷﺪ‬DLN) ‫ ﻓﺼﻞ ﺍﺯ ﺑﻴﻤﺎﺭﻱﻫﺎﻱ ﻣﻨﺘﺸﺮ ﺭﻳﻪ‬١١ ‫ ﺣﺎﺿﺮ ﺷﺎﻣﻞ‬CD
‫ﺍﺭﺯﻳﺎﺑﻲ ﭘﺎﺗﻮﻟﻮﮊﻱ ﺑﻴﻤﺎﺭﻫﺎﻱ ﺭﻳﻪ‬ DLD‫ﺑﻴﻤﺎﺭﻱﻫﺎﻱ ﺷﻐﻠﻲ ﻭ ﻣﺤﻴﻄﻲ ﻭ‬ ‫ﭘﻴﻮﻧﺪ ﺭﻳﻪ‬ ‫ﺗﺼﻮﻳﺮ ﺑﺮﺩﺍﺭﻱ ﻋﺮﻭﻕ ﺭﻳﻮﻱ‬ ‫ ﻛﻮﺩﻛﺎﻥ‬DLD ‫ﺗﺼﻮﻳﺮﺑﺮﺩﺍﺭﻱ‬
‫ ﺁﻧﻬﺎ ﺑﻪ ﻃﻮﺭ ﻣﺠﺰﺍ ﻣﻲﺑﺎﺷﺪ‬X-Ray,CT ‫ ﻭ ﻣﻘﺎﻳﺴﻪ‬DLD ‫ﺗﺸﺨﻴﺺ ﺍﻓﺘﺮﺍﻗﻲ ﺭﺍﺩﻳﻮﻟﻮﮊﻱ‬ ‫ﺗﺼﻮﻳﺮﺑﺮﺩﺍﺭﻱ ﺭﺍﻫﻬﺎﻱ ﻫﻮﺍﺋﻲ‬ ‫ﺗﺼﻮﻳﺮﺑﺮﺩﺍﺭﻱ ﺁﻣﻔﻴﺰﻡ‬ ‫ﺗﺼﻮﻳﺮﺑﺮﺩﺍﺭﻱ ﺑﻴﻤﺎﺭﻱﻫﺎﻱ ﺍﻧﻔﻴﻠﺘﺮﺍﺗﻴﻮ ﺭﻳﻪ‬
.‫ ﻗﻠﺐ ﻭ ﺭﺍﺩﻳﻮﻟﻮﮊﻱ ﻣﻲﺩﻫﺪ‬، ‫ ﺭﻳﻪ‬،‫ ﺑﻮﺩﻩ ﻭ ﺑﻪ ﮔﻔﺘﻪ ﻣﺆﻟﻔﻴﻦ ﻧﮕﺎﻫﻲ ﺟﺪﻳﺪ ﺑﻪ ﻣﺘﺨﺼﺼﻴﻦ ﻭ ﺭﺯﻳﺪﻧﺖﻫﺎﻱ ﺩﺍﺧﻠﻲ‬Acrobat Reader ‫ﺍﻳﻦ ﻛﺘﺎﺏ ﺩﺭ ﺑﺮﻧﺎﻣﻪ‬
33.10 INFECTIOUS DISEASES (W Edmund Farrar, Martin J Wood, John A Innes, Hugh Tubbs) ‫ــــ‬
The Head and Neck Lower Respiratory Tract The Nervous System The Gastrointestinal Tract The liver and Biliary Tract
The Urinary Tract The Genital Tract Bones and Joints The Cardiovascular System Bacterial Infections
Vira, Fungal and Ectoparasitic Infections The Eye Systemic Infections HIV Infection and Aids Acknowledgements
34.10 Linear ECHO ENDOSCOPY Tome I anatomy (Dr. Marc Giovannini) ‫ــــ‬
-Equipment -Environment -Echo-anatomy
35.10 Menopausal Osteoporosis (Neill Musselwhlte, M.D., Herman Rose, M.D.) ‫ــــــ‬
:‫ ﻣﻄﺎﻟﺐ ﺟﺎﻟﺒﻲ ﺩﺭ ﺭﺍﺑﻄﻪ ﺑﺎ ﻣﻨﻮﭘﻮﺯ ﻭ ﺍﺳﺘﺌﻮﭘﺮﻭﺯ ﺍﺭﺍﺋﻪ ﺷﺪﻩ ﺍﺳﺖ ﻛﻪ ﻋﻨﺎﻭﻳﻦ ﺁﻥ ﺑﻪ ﺷﺮﺡ ﺯﻳﺮ ﻣﻲﺑﺎﺷﺪ‬CD ‫ﺩﺭ ﺍﻳﻦ‬
‫ ﺳﺆﺍﻻﺕ ﺟﺪﻳﺪ ﻣﻄﺮﺡﺷﺪﻩ ﺩﺭ ﺍﻳﻦ ﺯﻣﻴﻨﻪ‬-٦ ‫ ﺍﺳﺘﺌﻮﭘﺮﻭﺯ‬-٥ Impact of osteobrosis -٤ ‫ ﻧﮕﺮﺍﻧﻲﻫﺎﻱ ﺑﻴﻤﺎﺭﻳﺎﻥ‬-٣ ‫ ﺭﻭﺵ ﺟﻠﻮﮔﻴﺮﻱ ﺍﺯ ﻋﻮﺍﺭﺽ ﺁﻥ‬-٢ ‫ ﻣﻨﻮﭘﻮﺯ ﻭ ﻧﺤﻮﺓ ﺑﺮﺧﻮﺭﺩ ﺑﺎ ﺁﻥ‬-١
36.10 MKSAP® 12 (American College of Physiciance-American Sosiety Internal Medicine) 2001
-Gastroenterology and Hepatology - Endocrinology and Metabolism -Infectious Disease Medicine - Rheumatology - Oncology - Hematology - Cardiovascular Medicine - Pulmonary Medicine
-Neurology - Dermatology - Nephrology -Hospital-Based Medicine and Critical Care - Ambulatory Medicine

37.10 Oxford Textbook of Medicine (OTM) (Weatherall, Ledingham, Weatherall) ‫ــــ‬

‫ ﺍﻳﻦ ﺑﺮﻧﺎﻣﻪ ﻳﻚ ﻣﻨﺒﻊ ﻭ ﻣﺮﺟﻊ ﻗﻮﻱ ﺑﻪ ﻣﻨﻈﻮﺭ ﻣﺸﺎﻭﺭﻩ ﺩﺭ ﻣﻌﺎﻳﻨـﺎﺕ ﺭﻭﺯﻣـﺮﻩ ﻭ ﭘﺎﺳـﺦ‬.‫ ﺗﻤﺎﻣﻲ ﻣﺒﺎﺣﺚ ﻋﻠﻮﻡ ﭘﺎﻳﻪ ﻭ ﻣﻬﺎﺭﺗﻬﺎﻱ ﺑﺎﻟﻴﻨﻲ ﻣﺮﺑﻮﻁ ﺑﻪ ﻃﺐ ﺩﺍﺧﻠﻲ ﻭ ﺗﺨﺼﺺﻫﺎﻱ ﻭﺍﺑﺴﺘﻪ ﺭﺍ ﺩﺭﺑﺮ ﻣﻲﮔﻴﺮﺩ‬CD ‫ ﺍﻳﻦ‬.‫ ﺗﺼﻮﻳﺮ ﺍﺭﺍﺋﻪ ﺷﺪﻩ ﺍﺳﺖ‬٢٥٠٠ ‫ ﺻﻔﺤﻪ ﻭ‬٥٠٠ ‫ ﻓﺼﻞ ﺩﺭ‬٣٣ ‫ﺍﻳﻦ ﺑﺮﻧﺎﻣﻪ ﺑﺼﻮﺭﺕ ﻳﻚ ﻛﺘﺎﺏ ﺍﻟﻜﺘﺮﻭﻧﻴﻜﻲ ﻣﺸﺘﻤﻞ ﺑﺮ‬
:‫ ﺍﺯ ﻣﺰﻳﺖﻫﺎﻱ ﺍﻳﻦ ﺑﺮﻧﺎﻣﻪ ﻣﻲﺗﻮﺍﻥ ﺑﻪ ﻣﻮﺍﺭﺩ ﺯﻳﺮ ﺍﺷﺎﺭﻩ ﻛﺮﺩ‬.‫ ﻣﻘﺎﻟﻪﻧﻮﻳﺲ ﻭ ﻣﺤﻘﻖ ﻣﻌﺘﺒﺮ ﺩﺭ ﺳﺮﺗﺎﺳﺮ ﺟﻬﺎﻥ ﺍﺳﺘﻔﺎﺩﻩ ﺷﺪﻩ ﺍﺳﺖ‬٥٨٠ ‫ ﺩﺭ ﻧﻮﺷﺘﻦ ﺍﻳﻦ ﻛﺘﺎﺏ ﺍﻟﻜﺘﺮﻭﻧﻴﻜﻲ ﺍﺯ‬.‫ ﻣﻲﺑﺎﺷﺪ‬،‫ﺳﺆﺍﻻﺗﻲ ﻛﻪ ﺧﺎﺭﺝ ﺗﺨﺼﺺ ﭘﺰﺷﻜﺎﻥ ﻣﻄﺮﺡ ﻣﻲﺷﻮﺩ‬
‫ ﺩﺭ‬.‫ ﺑﻴﻤﺎﺭﻳﻬـﺎﻱ ﻣﻘـﺎﺭﺑﺘﻲ‬،‫ ﻣﻌﺎﻟﺠﺎﺕ ﺩﻭﺭﻩﺍﻱ‬،‫ ﭘﺰﺷﻜﻲ ﭘﻴﺮﻱ‬،‫ ﭘﺰﺷﻜﻲ ﻗﺎﻧﻮﻧﻲ‬،‫ ﭘﺰﺷﻜﻲ ﻭﺭﺯﺷﻲ‬.‫ ﺑﻴﺸﺘﺮ ﻣﻔﺎﻫﻴﻢ ﺑﻴﻤﺎﺭﻳﻬﺎﻱ ﻋﻔﻮﻧﻲ ﻣﺮﺑﻮﻁ ﺑﻪ ﺩﺭﺳﻨﺎﻣﻪ ﭘﺰﺷﻜﻲ ﺭﺍ ﭘﻮﺷﺶ ﻣﻲﺩﻫﺪ‬.‫ ﺩﺍﻣﻨﺔ ﻣﺒﺎﺣﺚ ﻭ ﻣﻮﺿﻮﻋﺎﺕ ﺍﺯ ﻗﺒﻞ ﻭﺳﻴﻊﺗﺮ ﺷﺪﻩ ﺍﺳﺖ‬.‫ﮔﺮﺩﺁﻭﺭﻱ ﻏﻴﺮﺗﻜﺮﺍﺭﻱ ﻣﺒﺎﺣﺚ ﻋﻠﻮﻡ ﭘﺎﻳﻪ ﻭ ﻋﻠﻮﻡ ﺑﺎﻟﻴﻨﻲ‬
.‫ ﻣﻮﺭﺩ ﺑﺤﺚ ﺩﻗﻴﻖ ﻭ ﻣﻮﺷﻜﺎﻓﺎﻧﻪ ﻗﺮﺍﺭ ﻧﮕﺮﻓﺘﻪ ﺍﺳﺖ‬،‫ ﺍﺧﺘﻼﻻﺕ ﻭ ﺑﻴﻤﺎﺭﻳﻬﺎﻱ ﺍﻋﺘﻴﺎﺩ ﻭ ﺭﻭﺍﻥﭘﺰﺷﻜﻲ ﺩﺭ ﻣﻌﺎﻳﻨﺎﺕ ﻋﻤﻮﻣﻲ‬،‫ ﺗﻐﺬﻳﻪ‬،‫ ﺑﻬﺪﺍﺷﺖ ﻣﺤﻴﻂ ﻭ ﻣﺸﺎﻏﻞ‬.‫ ﺑﻴﻤﺎﺭﻳﻬﺎﻱ ﺑﺎﺭﺩﺍﺭﻱ‬،CD ‫ﺍﻳﻦ‬
‫ ﻗﺪﺭﺕ ﺗﻐﻴﻴﺮ ﺍﻧﺪﺍﺯﺓ ﻗﻠﻤﻬﺎﻱ ﻣﺘﻮﻥ ﻭ ﭼﺎﭘﮕﺮ ﻭ ﻧﻴﺰ ﻗﺪﺭﺕ ﭼﺎﭖ ﻣﺘﻦ ﻭ ﺟﺴﺘﺠﻮﻱ ﻛﻠﻤـﺎﺕ ﻭ ﻭﺍﮊﻩﻫـﺎﻱ ﺗﺨﺼﺼـﻲ ﻭ ﺩﺳﺘﺮﺳـﻲ ﺁﺳـﺎﻥ ﺑـﻪ‬.‫ ﺭﺍ ﻧﻴﺰ ﺟﺪﺍﮔﺎﻧﻪ ﻣﺸﺎﻫﺪﻩ ﻧﻤﻮﺩ‬CD ‫ ﻛﻪ ﻣﻲﺗﻮﺍﻥ ﺗﻤﺎﻣﻲ ﺗﺼﺎﻭﻳﺮ‬،‫ ﻫﺮ ﻓﺼﻞ ﺩﺍﺭﺍﻱ ﺗﺼﺎﻭﻳﺮﻱ ﻣﻲﺑﺎﺷﺪ‬.‫ ﻣﻨﺎﺑﻊ ﺁﻥ ﻗﻴﺪ ﺷﺪﻩ ﺍﺳﺖ‬،‫ﺩﺭ ﭘﺎﻳﺎﻥ ﻫﺮ ﻓﺼﻞ ﻛﺘﺎﺏ‬
.‫ ﻃﺮﺍﺣﻲ ﺷﺪﻩ ﺍﺳﺖ‬CD ‫ ﺳﺆﺍﻻﺕ ﭼﻨﺪﮔﺰﻳﻨﻪﺍﻱ )ﻛﻪ ﺑﺼﻮﺭﺕ ﺟﺪﺍﮔﺎﻧﻪ ﺍﺟﺮﺍ ﻣﻲﺷﻮﺩ( ﻭ ﻓﻬﺮﺳﺖ ﺗﻔﺼﻴﻠﻲ ﺍﺯ ﻣﻨﺪﺭﺟﺎﺕ ﻛﺘﺎﺏ ﻧﻴﺰ ﺩﺭ ﺍﻳﻦ‬.‫ﺟﺪﺍﻭﻝ ﻭ ﺗﺼﺎﻭﻳﺮ ﺍﺯ ﻭﻳﮋﮔﻲﻫﺎﻱ ﺍﻳﻦ ﺑﺮﻧﺎﻣﻪ ﺍﺳﺖ‬
38.10 Parenting Guide ‫ــــــ‬
39.10 Pre-Colonoscopy Education Program (Dr. Michael Shaw, Dr. Oliver cass Dr. James Reynolds Patricia Tomshine, Rn) ‫ــــ‬
- Reason for Colonoscopy - The Colon and The Colonoscope - Preparations - Day of the Procedure - About the Procedure -After the Procedur - Minor Complicaions - Major Complications

٠٩١٢١٣٧٢٣٦١-٦٦٩٣٦٦٩٦ :‫ﺗﻠﻔﻦ‬ ٢٣٩ ‫ ﭘﻼﻙ‬،‫ ﺑﻦﺑﺴﺖ ﺳﻴﻤﻴﻦ‬،‫ ﺑﻴﻦ ﻛﺎﺭﮔﺮ ﻭ ﺟﻤﺎﻟﺰﺍﺩﻩ‬،‫ ﺥ ﻟﺒﺎﻓﻲﻧﮋﺍﺩ‬،‫ ﺥ ﻛﺎﺭﮔﺮ ﺟﻨﻮﺑﻲ‬،‫ ﻡ ﺍﻧﻘﻼﺏ‬،‫ ﺗﻬﺮﺍﻥ‬:‫ﻧﺸﺎﻧﻲ‬ ‫ ﺍﺭﺍﺋﻪ ﻛﻨﻨﺪﺓ ﻛﺘﺎﺏ ﻭ ﺳﻲﺩﻱﻫﺎﻱ ﺗﺨﺼﺼﻲ ﭘﺰﺷﻜﻲ‬: ‫ﻣﺮﻛﺰ ﺧﺪﻣﺎﺕ ﻓﺮﻫﻨﮕﻲ ﺳﺎﻟﻜﺎﻥ‬
 54
40.10 Principles & Practice of Infectious Diseases A Harcourt Health Sciences Company 2000
:‫ ﺷﺎﻣﻞ ﺳﻪ ﺑﺨﺶ ﺍﺻﻠﻲ ﺍﺳﺖ‬CD ‫ ﺍﻳﻦ‬.‫ ﻭ ﺷﺎﻣﻞ ﺗﻤﺎﻣﻲ ﻣﻔﺎﻫﻴﻢ ﺍﺳﺎﺳﻲ ﻭ ﺟﺎﺭﻱ ﺩﺭ ﻣﻴﻜﺮﻭﺑﻴﻮﻟﻮﮊﻱ ﻭ ﺩﺭﻣﺎﻥ ﻋﻮﺍﺭﺽ ﻋﻔﻮﻧﻲ ﺍﺳﺖ‬.‫ ﺗﺼﻮﻳﺮ ﻣﻲﺑﺎﺷﺪ‬٨٠٠ ‫ ﺟﺪﻭﻝ ﻭ‬٨٠٠ ‫ ﺑﺼﻮﺭﺕ ﻳﻚ ﻛﺘﺎﺏ ﺍﻟﻜﺘﺮﻭﻧﻴﻜﻲ ﻫﻤﺮﺍﻩ ﺑﺎ ﺑﻴﺶ ﺍﺯ‬CD ‫ﺍﻳﻦ‬
1- Browse Mandell, Douglas & Bennett s .‫ﻛﻪ ﻣﺘﻦ ﺍﺻﻠﻲ ﻛﺘﺎﺏ ﺭﺍ ﺷﺎﻣﻞ ﻣﻲﺷﻮﺩ‬
2- Subject index Search: .‫ﺑﺮ ﺍﺳﺎﺱ ﺣﺮﻭﻑ ﺍﻟﻔﺒﺎ ﻭﺍﮊﻩﻫﺎﻱ ﺗﺨﺼﺼﻲ ﺭﺍ ﭘﻴﺪﺍ ﻧﻤﻮﺩ ﻭ ﺑﻪ ﻓﺼﻞ ﻭ ﻣﺒﺎﺣﺚ ﻣﺮﺑﻮﻁ ﺑﻪ ﺁﻥ ﺩﺭ ﻛﺘﺎﺏ ﻣﻨﺘﻘﻞ ﺷﺪ‬
3- Help ‫ ﺍﺭﺍﺋﻪ ﺷﺪﻩ ﺍﺳﺖ‬CD ‫ﻃﺮﻳﻘﺔ ﺍﺳﺘﻔﺎﺩﻩ ﺍﺯ‬
،‫ ﻋﺮﻭﻗﻲ‬-‫ ﻋﻔﻮﻧﺖﻫﺎﻱ ﺩﺳﺘﮕﺎﻩ ﻗﻠﺒﻲ‬،‫ ﻋﻔﻮﻧﺘﻬﺎﻱ ﺑﺮﻭﻧﺸﻴﻮﻟﻬﺎ‬،‫ ﻋﻔﻮﻧﺘﻬﺎﻱ ﻓﻮﻗﺎﻧﻲ ﺗﻨﻔﺴﻲ‬،‫( ﻋﻼﺋﻢ ﻭ ﻧﺸﺎﻧﻪﻫﺎﻱ ﻛﻠﻴﻨﻴﻜﻲ )ﺗﺐ‬٢ (‫ ﺍﭘﻴﺪﻣﻴﻮﻟﻮﮊﻱ ﺭﻭﺷﻬﺎﻱ ﺩﺭﻣﺎﻧﻲ‬،‫ ﻣﻜﺎﻧﻴﺰﻡﻫﺎﻱ ﺩﻓﺎﻋﻲ ﻣﻴﺰﺑﺎﻥ‬،‫( ﺍﺻﻮﻝ ﺍﻭﻟﻴﻪ ﺩﺭ ﺗﺸﺨﻴﺺ ﻭ ﺩﺭﻣﺎﻥ ﺑﻴﻤﺎﺭﻳﻬﺎﻱ ﻋﻔﻮﻧﻲ )ﻋﻮﺍﻣﻞ ﻣﻴﻜﺮﻭﺑﻲ‬١
(... ‫ ﺟﺮﺍﺣﻲ ﻭ ﻋﻔﻮﻧﺘﻬﺎﻱ ﺗﺮﻭﻣﺎ ﻭ‬،‫ ﻋﻔﻮﻧﺘﻬﺎﻱ ﻣﻴﺰﺑﺎﻧﻬﺎﻱ ﺧﺎﺹ‬،‫ )ﻋﻔﻮﻧﺘﻬﺎﻱ ﺑﻴﻤﺎﺭﺳﺘﺎﻧﻲ‬،Special problems (٤ (.... ‫ ﺑﻴﻤﺎﺭﻳﻬﺎﻱ ﻣﻴﻮﭘﻼﺳﻢﻫﺎ ﻭ‬،‫ ﺑﻴﻤﺎﺭﻳﻬﺎﻱ ﭘﺮﻳﻮﻥﻫﺎ‬،‫( ﺑﻴﻤﺎﺭﻳﻬﺎﻱ ﻋﻔﻮﻧﻲ ﻭ ﻋﻮﺍﻣﻞ ﻭ ﻋﻠﻞ ﺁﻧﻬﺎ )ﺑﻴﻤﺎﺭﻳﻬﺎﻱ ﻭﻳﺮﻭﺳﻲ‬٣ (....... ‫ﻋﻔﻮﻧﺘﻬﺎﻱ ﺳﻴﺴﺘﻢ ﻋﺼﺒﻲ ﻭ‬
.‫( ﻗﺮﺍﺭ ﻣﻲﮔﻴﺮﻧﺪ‬CD ‫ ﻗﺎﺑﻞ ﺍﺟﺮﺍ ﻣﻲﺑﺎﺷﺪ ﻛﻪ ﺩﺭ ﻫﻨﮕﺎﻡ ﻧﺼﺐ ﺁﻥ ﺑﺮ ﺭﻭﻱ ﻛﺎﻣﭙﻴﻮﺗﺮ ﺷﻤﺎ )ﺍﺯ ﻃﺮﻳﻖ‬Java VM ‫ ﻭ‬internet explver ‫ﺍﻳﻦ ﺑﺮﻧﺎﻣﻪ ﺗﺤﺖ‬

41.10 Rheumatology (John H. Klippel.Paul A Dieppe) ‫ــــ‬

-Rheumatic Diseases -Signs and Symptoms -Rheumatoid Arthritis and Spondylopathy -Infection and Arthritis
-Regional Pain Problems -Connective Tissue Disorders -Disorders of Bone, Cartilage -Management of Rheumatic Disease
42.10 TEXTBOOK OF Gastroenterology (Third Edition) ATLAS OF Gastroenterology (Second Edition) (David H. Alpers, MD, Loren Laine, MD) ‫ــــ‬

43.10 Textbook of Rheumatology (Kelley's) (W.B. Saunders Company) 2001

Section I BIOLOGY OF THE NORMAL JOINT Section II IMMUNE AND INFLAMMATORY RESPONSES
Section III EVALUATION OF THE PATIENT Section IV MUSCULOSKELETAL PAIN AND EVALUATION
Section V DIAGNOSTIC TESTS AND PROCEDURES Section VI SPECIAL ISSUES
Section VII CLINICAL PHARMACOLOGY Section VIII RHEUMATOID ARTHRITIS
Section IX SPONDYLOARTHROPATHIES Section X SYSTEMIC LUPUS ERYTHEMATOSUS AND RELATED SYNDROMES
Section XI VASCULITIC SYNDROMES Section XII SCLERODERMA AND MIXED CONNECTIVE TISSUE DISEASES
Section XIII STRUCTURE, FUNCTION, AND DISEASE OF MUSCLE Section XIV RHEUMATIC DISEASES OF CHILDHOOD
Section XVI OSTEOARTHRITIS, POLYCHONDRITIS, AND HERITABLE
Section XV CRYSTAL-ASSOCIATED SYNOVITIS
DISORDERS
Section XVII ARTHRITIS RELATED TO INFECTION Section XVIII ARTHRITIS ACCOMPANYING SYSTEMIC DISORDERS
Section XIX DISORDERS OF BONE AND STRUCTURAL PROTEIN Section XX TUMORS INVOLVING JOINTS
Section XXI RECONSTRUCTIVE SURGERY FOR RHEUMATIC DISEASE
44.10 Textbook of TRAVEL MEDICINE and HEALTH (Herbert L. Dupont, M.D., Robert Steffen, M.D.) (B.C.DECKER INC) ‫ــــ‬
‫ ﺩﺭ ﺯﻣﺎﻥ ﻣﺴﺎﻓﺮﺕ ﺑﻪ ﻣﻨﺎﻃﻖ ﻣﺨﺘﻠﻒ ﺍﻣﻜﺎﻥ ﺍﺑﺘﻼ ﺑﻪ ﺑﺮﺧﻲ ﺑﻴﻤﺎﺭﻳﻬﺎ ﺑﺎ ﺗﻮﺟﻪ ﺑـﻪ ﺷـﺮﺍﻳﻂ ﺍﭘﻴـﺪﻣﻴﻜﻲ ﻭ‬.‫ ﻧﻮﺷﺘﻪ ﺷﺪﻩ ﺍﺳﺖ‬Steffen ‫ ﻭ ﺩﻛﺘﺮ‬Dupont ‫ ﻭ ﺗﻮﺳﻂ ﺩﻛﺘﺮ‬.‫ ﺻﻔﺤﻪ ﻣﻲﺑﺎﺷﺪ‬٣٧٠ ‫ ﻓﺼﻞ ﺩﺭ‬٣٤ ‫ﺍﻳﻦ ﺑﺮﻧﺎﻣﻪ ﺑﺼﻮﺭﺕ ﻳﻚ ﻛﺘﺎﺏ ﺍﻟﻜﺘﺮﻭﻧﻴﻜﻲ ﺍﺳﺖ ﻛﻪ ﺷﺎﻣﻞ‬
‫ ﺩﺭ ﻣﺴﺎﻓﺮﺍﻥ ﻣﺨﺘﻠﻒ ﺩﺭ ﻛﺸﻮﺭﻫﺎﻱ ﮔﻮﻧﺎﮔﻮﻥ ﻣﻮﺭﺩ ﺑﺤﺚ‬. . . ‫ ﺍﺛﺮﺍﺕ ﻭﺍﻛﺴﻴﻨﺎﺳﻴﻮﻥ ﻭ ﺁﻣﺎﺭ ﻣﺮﮒ ﻭ ﻣﻴﺮ ﻭ‬،‫ ﺷﻴﻮﻩﻫﺎﻱ ﺩﺭﻣﺎﻧﻲ‬،‫ ﺑﻴﻤﺎﺭﻳﻬﺎﻱ ﻧﺎﺷﻲ ﺍﺯ ﺣﻮﺍﺩﺙ‬.‫ ﺑﻴﻤﺎﺭﻳﻬﺎﻱ ﻣﻘﺎﺭﺑﺘﻲ ﺍﺯ ﺍﻳﻦ ﺟﻤﻠﻪ ﻫﺴﺘﻨﺪ‬،‫ ﻭﺑﺎ‬،‫ ﺍﻳﺪﺯ‬،‫ ﺗﻴﻔﻮﺋﻴﺪ‬،‫ ﻫﭙﺎﺗﻴﺖ‬،‫ ﺑﻴﻤﺎﺭﻳﻬﺎﻳﻲ ﻣﺜﻞ ﻣﺎﻻﺭﻳﺎ‬.‫ﺍﻧﺪﻣﻴﻚ ﺑﻴﺸﺘﺮ ﻣﻲﺷﻮﺩ‬
.‫ ﻗﺮﺍﺭ ﮔﺮﻓﺘﻪ ﺍﺳﺖ‬CD ‫ﻭ ﺑﺮﺭﺳﻲ ﺩﺭ ﺍﻳﻦ‬
57.9 The Massachusetts General Hospital Handbook of Pain Management (Second Edition) (Jane Ballantyne, Scott M. Fishman, Salahadin Abdi) (SALEKAN-E-book) ‫ــــ‬
:‫ ﺷﺎﻣﻞ ﻋﻨﺎﻭﻳﻦ ﺯﻳﺮ ﻣﻲﺑﺎﺷﺪ‬CD ‫ﻗﺴﻤﺖﻫﺎﻱ ﻣﺨﺘﻠﻒ ﺍﻳﻦ‬
I. General Considerations II. Diagnosis of Pain III. Therapeutic Options: Pharmacologic Approaches IV. Therapeutic Options: Nonpharmacologic Approaches
V. Acute Pain VI. Chronic Pain VII. Pain Due to Cancer VIII. Special Situations - Apendices - Subject Index
45.10 UEGW Gastroenterology Week 10th United European (Geneva, Switzerland) ‫ــــ‬

46.10 UEGW IBS: Management not myth 2003

:‫ ﺷﺎﻣﻞ ﻋﻨﺎﻭﻳﻦ ﺯﻳﺮ ﻣﻲﺑﺎﺷﺪ‬CD ‫ﺍﻳﻦ‬
1. IBS: the clinician's view 2. IBS: care, cost and consequences 3. Diagnosis: identigy, Probe, eliminate 4. Tegaserod: a world of experience 5. Chairman's summary

47.10 Upper GI Endoscopy An Interactive Aducasional Program Video Segments of Common Pathologics of the Upper Gl tract (Iencludes Educational text) ‫ــــ‬

48.10 UpToDate CLINICAL REFERENCE LIBRARY 13.1 (CD I , II) (Burton D. Rose, MD, Joseph M. Rush, MD) 2005

٠٩١٢١٣٧٢٣٦١-٦٦٩٣٦٦٩٦ :‫ﺗﻠﻔﻦ‬ ٢٣٩ ‫ ﭘﻼﻙ‬،‫ ﺑﻦﺑﺴﺖ ﺳﻴﻤﻴﻦ‬،‫ ﺑﻴﻦ ﻛﺎﺭﮔﺮ ﻭ ﺟﻤﺎﻟﺰﺍﺩﻩ‬،‫ ﺥ ﻟﺒﺎﻓﻲﻧﮋﺍﺩ‬،‫ ﺥ ﻛﺎﺭﮔﺮ ﺟﻨﻮﺑﻲ‬،‫ ﻡ ﺍﻧﻘﻼﺏ‬،‫ ﺗﻬﺮﺍﻥ‬:‫ﻧﺸﺎﻧﻲ‬ ‫ ﺍﺭﺍﺋﻪ ﻛﻨﻨﺪﺓ ﻛﺘﺎﺏ ﻭ ﺳﻲﺩﻱﻫﺎﻱ ﺗﺨﺼﺼﻲ ﭘﺰﺷﻜﻲ‬: ‫ﻣﺮﻛﺰ ﺧﺪﻣﺎﺕ ﻓﺮﻫﻨﮕﻲ ﺳﺎﻟﻜﺎﻥ‬
 55
:‫ ﺷﺎﻣﻞ‬CD ‫ﻋﻨﺎﻭﻳﻦ ﺍﻳﻦ‬
Adult Primary Care Allwrgy and Immonology Cardiology Critical Care Drug Information Enodcrinoology Family Medicine Rheumatology
Women's Health
Gastroenterology Gynecology Hematology Infections Disease Nephrology Oncology Pediatrics Pulmonology
TM
49.10 YEAR BOOK of RHEUMATOLOGY, ARTHRITI, AND MUSCULOSKELETAL DISEASE (Richrd S. Panush, MD) (SALEKAN E-BOOK) 2003

Health Sciences, Epidemiology, Economics, & Arthritis Care Systemic Lupus Erythematosus and Related Disorders
Rheumatoid Arthritis Vasculitis and Systemic Rheumatic Diseases and Other Related Disorders
Systemic Selerosis and Related Disorders Osteoarthritis, Crystal-Related Arthropathies, Osteoporosis, Infectious Arthritides, and Spondyloarthropathies
Regional Pain Syndromes, Non-Articular Musculoskeletal Disorders, and Fibromyalgia Miscellaneous Topics

‫ ﺍﻃﻔﺎﻝ‬-١١
CD ‫ﻋﻨﻮﺍﻥ‬ ‫ﺳﺎﻝ ﺍﻧﺘﺸﺎﺭ‬
1.11 A Major Contributor to Neonatal Infant Morbidity and Mortality (SURVANTA) (Part I , II) (Alan J. Gold, MD, J. Harry Gunkel, Arvin M. Overbach) ‫ــــ‬
2.11 Atlas of Pediatric Gastrointestinal Disease ‫ــــ‬
3.11 Basic Mechanisms of Pediatric Respiratory Disease (Second Edition) (Gabriel G. Haddad,MD, Steven H. Abman, MD) 2002
Genetic and Developmental Biology of the Respiratory System Structure-Function Relations of the Respiratory System During Development
Developmental Physiology of the Respiratory System Inflammation and Pulmonary Defense Mechanisms
4.11 Child Development, 9/e (John W. Santrock) 2001
18.9 CURRENT MANAGEMENT IN CHILD NEUROLOGY (SECOND EDITION) (Bernrd L. Maria, MD, MBA) 2002
Section 1: Clinical Practice Trends Section 2: The Office Visit Section 3: The Hospitalized Child
5.11 EVIDENCE-BASED PEDIATRICS (William Feldmam, MD, FRCPC) (B.C. Decker Inc.) 2000
6.11 PEDIATRIC GASTROINTESTINAL DISEASE Pathophysiology . Diagnosis . Management (Third Edition) ‫ــــ‬
7.11 TEXTBOOK OF NEONATAL RESUSCITATION (4TH EDITION MULTIMEDIA CD-ROM) ‫ــــ‬

‫ ﻋﻤﻮﻣﻲ‬:١٢
CD ‫ﻋﻨﻮﺍﻥ‬ ‫ﺳﺎﻝ ﺍﻧﺘﺸﺎﺭ‬
1.12 1. Review for USMLE NMS® (Step 1) ‫ــــ‬
2. Review for USMLE NMS® (Step 2)
3. Review for USMLE NMS® (Step 3)
2.12 A.D.A.M. PracticePractical Review Anatomy – Create New Test – Open Existing Test ‫ــــ‬
‫ ﺳﺆﺍﻝ ﺍﻣﺘﺤﺎﻧﻲ ﺑﻮﺩﻩ ﻛﻪ ﺑﻪﻣﻨﻈﻮﺭ ﻳﺎﺩﺁﻭﺭﻱ‬١٥٠٠٠ ‫ ﺩﺍﺭﺍﻱ ﺑﻴﺶ ﺍﺯ‬.‫( ﻣﻲﺑﺎﺷﺪ‬X-ray ‫ ﻃﺮﺍﺣﻲ ﺷﺪﻩ ﻭ‬،‫ ﺗﺼﻮﻳﺮ ﺁﻧﺎﺗﻮﻣﻴﻜﻲ )ﺗﺼﺎﻭﻳﺮ ﻭﺍﻗﻌﻲ‬٥٠٠ ‫ ﺍﻳﻦ ﺑﺮﻧﺎﻣﻪ ﺷﺎﻣﻞ ﺑﻴﺶ ﺍﺯ‬.‫ﻫﺪﻑ ﺍﻳﻦ ﺑﺮﻧﺎﻣﻪ ﻣﺮﻭﺭ ﻣﺒﺎﺣﺚ ﺁﻧﺎﺗﻮﻣﻲ ﻭ ﻣﺤﻚ ﺯﺩﻥ ﺍﻃﻼﻋﺎﺕ ﻛﺎﺭﺑﺮ ﺩﺭ ﺍﻳﻦ ﺯﻣﻴﻨﻪ ﺍﺳﺖ‬
‫ﺏ( ﻣﺒﺎﺣﺚ ﻣﺮﺑﻮﻁ ﺑﻪ ﺩﺳﺘﮕﺎﻩﻫﺎﻱ ﺑﺪﻥ‬ ‫ﺍﻟﻒ( ﻣﺒﺎﺣﺚ ﻣﺮﺑﻮﻁ ﺑﻪ ﻧﻮﺍﺣﻲ ﺁﻧﺎﺗﻮﻣﻴﻜﻲ‬ :‫ ﻗﺴﻤﺖ ﻣﺒﺎﺣﺚ ﺍﺭﺍﺋﻪ ﺷﺪﻩﺍﻧﺪ‬٢ ‫ ﺩﺭ‬،CD ‫ ﺩﺭ ﺍﻳﻦ‬Review Anatomy ‫ ﺩﺭ ﭘﻨﺠﺮﺓ ﺍﺻﻠﻲ‬.‫ﻭ ﻣﺮﻭﺭ ﻣﻄﺎﻟﺐ ﻃﺮﺍﺣﻲ ﺷﺪﻩ ﺍﺳﺖ‬
:‫ ﻣﺒﺎﺣﺚ ﻣﻄﺮﺡ ﺷﺪﻩ ﺩﺭ ﺑﺨﺶ ﻧﻮﺍﺣﻲ ﺁﻧﺎﺗﻮﻣﻴﻜﻲ ﺷﺎﻣﻞ‬.‫ﻫﺮ ﻗﺴﻤﺖ ﺭﺍ ﻛﻪ ﻣﺸﺨﺺ ﻧﻤﺎﻳﻴﺪ ﺗﺼﺎﻭﻳﺮ ﻭ ﺳﺆﺍﻻﺕ ﺍﻣﺘﺤﺎﻧﻲ ﺁﻥ ﺑﺨﺶ ﺍﺭﺍﺋﻪ ﺧﻮﺍﻫﺪ ﺷﺪ‬
.‫ ﺁﻧﺎﺗﻮﻣﻲ ﺍﻧﺪﺍﻡ ﺗﺤﺘﺎﻧﻲ‬-٧ ‫ ﺁﻧﺎﺗﻮﻣﻲ ﻟﮕﻦ ﺧﺎﺻﺮﻩ‬-٦ ‫ ﺁﻧﺎﺗﻮﻣﻲ ﺷﻜﻢ‬-٥ ‫ ﺁﻧﺎﺗﻮﻣﻲ ﻗﻔﺴﻪ ﺳﻴﻨﻪ‬-٤ ‫ ﺁﻧﺎﺗﻮﻣﻲ ﺗﻨﻪ‬-٣ ‫ ﺁﻧﺎﺗﻮﻣﻲ ﺍﻧﺪﺍﻡ ﻓﻮﻗﺎﻧﻲ‬-٢ ‫ ﺁﻧﺎﺗﻮﻣﻲ ﺳﺮ ﻭ ﮔﺮﺩﻥ‬-١
‫ ﻗﺪﺭﺕ ﺑﺰﺭﮔﻨﻤﺎﻳﻲ ﺗﺼﺎﻭﻳﺮ ﻭ ﻧﻴﺰ ﺣﺬﻑ ﻭ ﺍﺿﺎﻓﻪ ﻧﻤﻮﺩﻥ ﺗﺼﺎﻭﻳﺮ ﻣﻮﺭﺩ ﺩﻟﺨـﻮﺍﻩ ﻭ ﻧﻤـﺎﻳﺶ‬.‫ ﺷﻤﺎ ﻣﻲﺗﻮﺍﻧﻴﺪ ﻧﻮﻉ ﻣﻘﻄﻊ ﺁﻧﺎﺗﻮﻣﻴﻜﻲ ﺭﺍ ﺩﺭ ﻫﺮ ﻗﺴﻤﺖ ﻣﺸﺨﺺ ﺍﻧﺘﺨﺎﺏ ﻧﻤﺎﻳﻴﺪ‬.‫ ﺑﻄﻮﺭ ﺟﺪﺍﮔﺎﻧﻪ ﻧﺸﺎﻥ ﺩﺍﺩﻩ ﻣﻲﺷﻮﺩ‬Related images ‫ﺗﺼﺎﻭﻳﺮ ﻭﺍﺑﺴﺘﻪ ﺑﻪ ﻫﺮ ﺑﺤﺚ ﺍﺯ ﻃﺮﻳﻖ ﺩﻛﻤﺔ‬
‫ ﭘﺎﺳﺦ ﺳﺆﺍﻻﺕ ﺑﻪ‬Show Results ‫ ﺑﺎ ﺯﺩﻥ ﻛﻠﻴﺪ‬،‫ ﻳﻚ ﺗﺼﻮﻳﺮ ﺁﻧﺎﺗﻮﻣﻴﻜﻲ ﺑﻪ ﻧﻤﺎﻳﺶ ﺩﺭﻣﻲﺁﻳﺪ ﻭ ﻧﺎﻡ ﺑﺨﺸﻲ ﺍﺯ ﺁﻥ ﻣﻮﺭﺩ ﺳﺆﺍﻝ ﺍﺳﺖ‬text ‫ ﺩﺭ ﭘﻨﺠﺮﺓ‬Start test ‫ ﻧﺤﻮﺓ ﺍﻣﺘﺤﺎﻧﺎﺕ ﺑﺪﻳﻦ ﺻﻮﺭﺕ ﺍﺳﺖ ﻛﻪ ﺑﺎ ﻓﻌﺎﻝ ﻧﻤﻮﺩﻥ‬.‫ ﺗﺼﻮﻳﺮ ﺩﺭ ﺍﻳﻦ ﺑﺮﻧﺎﻣﻪ ﻭﺟﻮﺩ ﺩﺍﺭﺩ‬٤ ‫ ﻭ‬٢ ،١ ‫ﻫﻤﺰﻣﺎﻥ‬
‫ ﺍﺑﺘﺪﺍ ﺷﻤﺎ ﺩﺳﺘﮕﺎﻩ ﻳﺎ ﻧﺎﺣﻴﺔ‬،‫ ﺩﺭ ﻧﻮﻉ ﺩﻳﮕﺮﻱ ﺍﺯ ﺍﻣﺘﺤﺎﻧﺎﺕ ﺍﻳﻦ ﺑﺮﻧﺎﻣﻪ‬.‫ ﺭﺍ ﺧﻮﺩ ﻣﻲﺗﻮﺍﻧﻴﺪ ﺑﻪ ﺩﻟﺨﻮﺍﻩ ﺗﻨﻈﻴﻢ ﻧﻤﺎﻳﻴﺪ‬CD ‫ ﺯﻣﺎﻥ ﭘﺎﺳﺦ ﺑﻪ ﻫﺮ ﺳﺆﺍﻝ ﺩﺭ ﺍﻣﺘﺤﺎﻧﺎﺕ ﺍﻳﻦ‬.‫ ﻗﺎﺑﻠﻴﺖ ﺍﺿﺎﻓﻪ ﻧﻤﻮﺩﻥ ﻳﺎﺩﺩﺍﺷﺖﻫﺎﻱ ﺷﺨﺼﻲ ﺑﻪ ﻫﺮ ﺗﺼﻮﻳﺮ ﻧﻴﺰ ﻭﺟﻮﺩ ﺩﺍﺭﺩ‬.‫ﻫﻤﺮﺍﻩ ﻧﻤﺮﺓ ﻧﻬﺎﻳﻲ ﺍﺭﺍﺋﻪ ﻣﻲﺷﻮﺩ‬
‫ ﺯﻣﺎﻥ ﺑﺎﻗﻴﻤﺎﻧﺪﻩ ﺑﺮﺍﻱ ﻫﺮ ﺳﺆﺍﻝ ﺩﺭ ﺣﻴﻦ ﺍﻣﺘﺤﺎﻥ ﺩﺭ ﺣﺎﻝ ﻧﻤﺎﻳﺶ‬.‫ ﺩﺭ ﻫﺮ ﺳﺆﺍﻝ ﻧﺎﻡ ﺑﺨﺸﻲ ﺍﺯ ﻳﻚ ﺗﺼﻮﻳﺮ ﺁﻧﺎﺗﻮﻣﻴﻜﻲ ﻣﻮﺭﺩﻧﻈﺮ ﺍﺳﺖ‬.‫ ﺍﻣﺘﺤﺎﻥ ﺷﺮﻭﻉ ﻣﻲﺷﻮﺩ‬Start ‫ﺁﻧﺎﺗﻮﻣﻴﻜﻲ ﻣﻮﺭﺩﻧﻈﺮ ﺭﺍ ﺍﻧﺘﺨﺎﺏ ﻣﻲﻧﻤﺎﻳﻴﺪ )ﻭ ﻧﻴﺰ ﺯﻣﺎﻥ ﭘﺎﺳﺦ ﻫﺮ ﺳﺆﺍﻝ ﺭﺍ ﻣﺸﺨﺺ ﻣﻲﻛﻨﻴﺪ( ﺑﺎ ﺯﺩﻥ ﻛﻠﻴﺪ‬
.‫ ﺍﺟﺮﺍ ﻣﻲﺷﻮﺩ‬Autorun ‫ ﻣﻲﺑﺎﺷﺪ ﻭ ﺑﺼﻮﺭﺕ‬Olson ‫ ﻭ ﺩﻛﺘﺮ‬Pawlina ‫ ﻧﻮﺷﺘﺔ ﺩﻛﺘﺮ‬CD ‫ ﺍﻳﻦ‬.‫ﺍﺳﺖ‬

٠٩١٢١٣٧٢٣٦١-٦٦٩٣٦٦٩٦ :‫ﺗﻠﻔﻦ‬ ٢٣٩ ‫ ﭘﻼﻙ‬،‫ ﺑﻦﺑﺴﺖ ﺳﻴﻤﻴﻦ‬،‫ ﺑﻴﻦ ﻛﺎﺭﮔﺮ ﻭ ﺟﻤﺎﻟﺰﺍﺩﻩ‬،‫ ﺥ ﻟﺒﺎﻓﻲﻧﮋﺍﺩ‬،‫ ﺥ ﻛﺎﺭﮔﺮ ﺟﻨﻮﺑﻲ‬،‫ ﻡ ﺍﻧﻘﻼﺏ‬،‫ ﺗﻬﺮﺍﻥ‬:‫ﻧﺸﺎﻧﻲ‬ ‫ ﺍﺭﺍﺋﻪ ﻛﻨﻨﺪﺓ ﻛﺘﺎﺏ ﻭ ﺳﻲﺩﻱﻫﺎﻱ ﺗﺨﺼﺼﻲ ﭘﺰﺷﻜﻲ‬: ‫ﻣﺮﻛﺰ ﺧﺪﻣﺎﺕ ﻓﺮﻫﻨﮕﻲ ﺳﺎﻟﻜﺎﻥ‬
 ‫‪56‬‬
‫‪3.12‬‬ ‫‪Atlas of Clinical Medicine‬‬ ‫)‪(Version 2.0) (Forbes. Jackson‬‬ ‫ــــ‬
‫‪Infection‬‬ ‫‪Cardiovascular Renal‬‬ ‫‪Gastrointestinal‬‬ ‫‪Blood‬‬
‫‪Joints and Bones Respiratory‬‬ ‫‪Endocrine, Metabolic and Nutritional‬‬ ‫‪Liver and Pancreas‬‬ ‫‪Nerve and Muscle‬‬
‫‪4.12‬‬ ‫)‪CECIL TEXTBOOK of MEDICINE (21st Edition‬‬ ‫‪2001‬‬
‫‪Part I MEDICINE AS A LEARNED AND HUMANE PROFESSION‬‬ ‫‪Part‬‬ ‫‪II SOCIAL AND ETHICAL ISSUES IN MEDICINE‬‬
‫‪Part III AGING AND GERIATRIC MEDICINE‬‬ ‫‪Part‬‬ ‫‪IV PREVENTIVE HEALTH CARE‬‬
‫‪Part V PRINCIPLES OF EVALUATION AND MANAGEMENT‬‬ ‫‪Part‬‬ ‫‪VI PRINCIPLES OF HUMAN GENETICS‬‬
‫‪Part VII CARDIOVASCULAR DISEASES‬‬ ‫‪Part‬‬ ‫‪VIII RESPIRATORY DISEASES‬‬
‫‪Part IX CRITICAL CARE MEDICINE‬‬ ‫‪Part‬‬ ‫‪X RENAL AND GENITOURINARY DISEASES Part XI GASTROINTESTINAL DISEASES‬‬
‫‪Part XII DISEASES OF THE LIVER, GALLBLADDER, AND‬‬ ‫‪BILE DUCTS‬‬
‫‪Part XIII HEMATOLOGIC DISEASES‬‬ ‫‪Part XIV ONCOLOGY‬‬
‫‪Part XV METABOLIC DISEASES‬‬ ‫‪Part XVI NUTRITIONAL DISEASES‬‬
‫‪Part XVII ENDOCRINE DISEASES‬‬ ‫‪Part XVIII WOMEN'S HEALTH‬‬
‫‪Part XIX DISEASES OF BONE AND BONE MINERAL METABOLISM‬‬ ‫‪Part XX DISEASES OF THE IMMUNE SYSTEM‬‬
‫‪Part XXI MUSCULOSKELETAL AND CONNECTIVE TISSUE DISEASES‬‬ ‫‪Part XXII INFECTIOUS DISEASES‬‬
‫‪Part XXIII HIV AND THE ACQUIRED IMMUNODEFICIENCY SYNDROME‬‬ ‫‪Part XXIV DISEASES OF PROTOZOA AND METAZOA‬‬
‫‪Part XXV NEUROLOGY‬‬ ‫‪Part XXVI EYE, EAR, NOSE, AND THROAT DISEASES‬‬
‫‪Part XXVII SKIN DISEASES‬‬ ‫‪Part XXVIII LABORATORY REFERENCE INTERVALS AND VALUES‬‬
‫‪5.12‬‬ ‫‪BEST MEDICAL COLLECTION‬‬ ‫‪2003‬‬
‫ﺍﻳﻦ ‪ CD‬ﺩﺍﺭﺍﻱ ‪ ٧‬ﺑﺮﻧﺎﻣﺔ ﻣﺨﺘﻠﻒ ﻣﻲﺑﺎﺷﺪ‪ ،‬ﻛﻪ ﻫﺮ ﻳﻚ ﺭﺍ ﺑﺎﻳﺪ ﺑﻄﻮﺭ ﺟﺪﺍﮔﺎﻧﻪ ﺍﺯ ﻓﺎﻳﻞ ﻣﺮﺑﻮﻁ ﺍﻧﺘﺨﺎﺏ‪ ،‬ﻧﺼﺐ ﻭ ﺍﺟﺮﺍ ﻧﻤﻮﺩ‪ .‬ﺍﻳﻦ ﺑﺮﻧﺎﻣﻪﻫﺎ ﻋﺒﺎﺭﺗﻨﺪ ﺍﺯ ‪:‬‬
‫‪ -٧‬ﻧﺮﻡﺍﻓﺰﺍﺭ ﺳﻼﻣﺖ ‪Health soft‬‬ ‫‪ -١‬ﺩﻳﻜﺸﻨﺮﻱ ﭘﺰﺷﻜﻲ‪ -٢ ،‬ﻃﺐ ﺳﻮﺯﻧﻲ‪ -٥ ،Health manger -٤ ،Multimedia workout -٣ ،‬ﺩﺍﺭﻭﻫﺎﻱ ﻧﺴﺨﻪﺍﻱ )‪) medical Drug Reference -٦ ،(Prescription Drugs‬ﻣﺮﺟﻊ ﭘﺰﺷﻜﻲ ﺩﺍﺭﻭﻳﻲ(‬
‫‪ -١‬ﻧﺮﻡﺍﻓﺰﺍﺭ ﺩﻳﻜﺸﻨﺮﻱ ﭘﺰﺷﻜﻲ‪ :‬ﻣﻔﺎﻫﻴﻢ ﻭﺍﮊﻩﻫﺎ ﻭ ﺍﺻﻄﻼﻋﺎﺕ ﭘﺰﺷﻜﻲ ﺭﺍ ﻣﻲﺗﻮﺍﻥ ﺗﻮﺳﻂ ﺍﻳﻦ ﺑﺮﻧﺎﻣﻪ ﺟﺴﺘﺠﻮ ﻧﻤﻮﺩ‪ .‬ﻫﻤﭽﻨﻴﻦ ﺩﻭ ﻓﺼﻞ ﺑﺼﻮﺭﺕ‪ :‬ﺍﻟﻒ( ﺳﻼﻣﺖ ﺧﺎﻧﻮﺍﺩﻩ ﺏ( ﺳﻼﻣﺖ ﻛﻮﺩﻛﺎﻥ ﺩﺭ ﺍﻳﻦ ﺑﺮﻧﺎﻣﻪ ﻭﺟﻮﺩ ﺩﺍﺭﺩ ﻛﻪ ﻫﺮ ﻗﺴﻤﺖ ﺩﺍﺭﺍﻱ ﻋﻨﺎﻭﻳﻦ ﻭ ﻣﻄﺎﻟﺒﻲ ﺑﺼﻮﺭﺕ ‪ text‬ﻣﻲﺑﺎﺷﺪ‪.‬‬
‫‪ -٢‬ﻃــﺐ ﺳــﻮﺯﻧﻲ ‪ :‬ﺷــﺎﻣﻞ ‪ ٩‬ﻓﺼــﻞ ﻣــﻲﺑﺎﺷــﺪ ﻛــﻪ ﺭﻭﺵ ﻛــﺎﺭ ﺑــﺎ ﻭﺳــﺎﻳﻞ ﻭ ﻧﺤــﻮﺓ ﺩﺭﻣــﺎﻥ ﺑﻴﻤﺎﺭﻳﻬــﺎ‪ ،‬ﺑﺼــﻮﺭﺕ ﺗﻮﺿــﻴﺤﺎﺕ ﻣﺘﻨــﻲ ﺍﺭﺍﺋــﻪ ﺷــﺪﻩ ﺍﺳــﺖ‪ .‬ﻳــﻚ ﻓــﻴﻠﻢ ﺭﺍﺟــﻊ ﺑــﻪ ﻃــﺐ ﺳــﻮﺯﻧﻲ ﻧﻴــﺰ ﻟﺤــﺎﻅ ﺷــﺪﻩ ﺍﺳــﺖ‪ .‬ﺍﻳــﻦ ﺑﺮﻧﺎﻣــﻪ ﻣﺤﺼــﻮﻝ ﺷــﺮﻛﺖ‬
‫‪ Hopkins technology‬ﺳﺎﻝ ‪ ١٩٩٧‬ﻣﻲﺑﺎﺷﺪ‪.‬‬
‫‪ -٣‬ﺑﺮﻧﺎﻣﺔ ‪ workout‬ﻧﺴﺨﺔ ‪ :١‬ﺑﺎ ﻭﺍﺭﺩ ﻧﻤﻮﺩﻥ ﻣﺸﺨﺼﺎﺕ ﻓﺮﺩﻱ )ﺳﻦ‪ ،‬ﻗﺪ‪ ،‬ﻭﺯﻥ‪ ،‬ﺟﻨﺴﻴﺖ‪ ،‬ﻣﻴﺰﺍﻥ ﺍﻧﺮﮊﻱ ﭘﺎﻳﺔ ﻣﻮﺭﺩ ﻧﻴﺎﺯ ﻭ ‪ (...‬ﺍﻳﻦ ﺑﺮﻧﺎﻣﻪ ﺭﮊﻳﻢ ﻏﺬﺍﻳﻲ ﻣﻨﺎﺳﺐ‪ ،‬ﻧﻮﻉ ﻧﺮﻣﺶ ﺍﻭ ﻣﻮﺭﺩﻧﻈﺮ ﺭﺍ ﺑﻪ ﺷﻤﺎ ﺍﺭﺍﺋﻪ ﻣﻲﺩﻫﺪ‪ .‬ﺍﻳـﻦ ﺑﺮﻧﺎﻣـﻪ ﻣﺤﺼـﻮﻝ ﺳـﺎﻝ ‪ ١٩٩٤‬ﺍﺳـﺖ ﻭ ﺩﺍﺭﺍﻱ‬
‫ﭼﻨﺪﻳﻦ ﻓﻴﻠﻢ ﺁﻣﻮﺯﺷﻲ ﺍﺯ ﻧﺤﻮﺓ ﺍﻧﺠﺎﻡ ﻧﺮﻣﺶﻫﺎ ﻧﻴﺰ ﻣﻲﺑﺎﺷﺪ‪.‬‬
‫‪ :Health manager -٤‬ﺍﻳﻦ ﺑﺮﻧﺎﻣﻪ ﺩﺭ ﺣﻘﻴﻘﺖ ﺍﻃﻼﻋﺎﺕ ﺑﻴﻤﺎﺭﻱ ﻭ ﺳﻼﻣﺘﻲ ﺷﻐﻠﻲ ﺍﻓﺮﺍﺩ ﺭﺍ ﻣﺪﻳﺮﻳﺖ ﻣﻲﻛﻨﺪ‪ .‬ﺑﺮﻧﺎﻣﻪﺍﻱ ﺍﺳﺖ ﺟﻬﺖ ﺿﺒﻂ ﻭ ﻧﮕﻬﺪﺍﺭﻱ ﻭﻗﺎﻳﻊ ﭘﺰﺷﻜﻲ ﻭ ﺩﺭﻣﺎﻧﻲ ﺷﺨﺼﻲ‪ ،‬ﻟﻴﺴﺖ ﺩﺍﺭﻭﻫﺎﻱ ﻣﻮﺭﺩ ﺍﺳﺘﻔﺎﺩﺓ ﻓﺮﺩ‪ ،‬ﺩﺍﺭﻭﻫـﺎﻱ ﺁﻟـﺮﮊﻱ ﻭ ﻳـﻚ ﻛﺘـﺎﺏ ﺁﺩﺭﺱ ﺍﺯ‬
‫ﻣﺮﺍﻛﺰ ﻣﻬﻢ ﺑﻬﺪﺍﺷﺘﻲ ﻭ ﺩﺭﻣﺎﻧﻲ‪ .‬ﺯﻣﺎﻥ ﺗﺠﺪﻳﺪ ﻭ ﺗﻌﻮﻳﺾ ﻧﺴﺨﺔ ﭘﺰﺷﻜﻲ ﻭ ﻣﺮﺍﺟﻌﻪ ﺑﻪ ﺩﻧﺪﺍﻧﭙﺰﺷﻚ ﺩﺭ ﺟﺪﺍﻭﻟﻲ ﻣﺸﺨﺺ ﻣﻲﺷﻮﺩ‪.‬‬
‫‪ -٥‬ﺩﺍﺭﻭﻫﺎﻱ ﻧﺴﺨﻪﺍﻱ‪ :‬ﺍﻳﻦ ﺑﺮﻧﺎﻣﻪ ﺗﻮﺿﻴﺤﺎﺕ ﻣﺨﺘﺼﺮﻱ ﺭﺍﺟﻊ ﺑﻪ ﺩﺍﺭﻭﻫﺎ ﻭ ﺍﻃﻼﻋﺎﺕ ﻓﺎﺭﻣﺎﻛﻮﻟﻮﮊﻳﻜﻲ ﻣﺮﺑﻮﻃﻪ ﺍﺭﺍﺋﻪ ﻣﻲﺩﻫﺪ‪ .‬ﻣﺤﺼﻮﻝ ﺷﺮﻛﺖ ‪ Quanta Press‬ﺳﺎﻝ ‪ ١٩٩٢‬ﻣﻲﺑﺎﺷﺪ‪.‬‬
‫‪ -٦‬ﻣﺮﺟﻊ ﭘﺰﺷﻜﻲ ﺩﺍﺭﻭﻳﻲ ﻧﺴﺨﺔ ‪ :٢‬ﺍﺯ ﺳﻪ ﺭﺍﻩ ﻣﻲﺗﻮﺍﻥ ﻭﺍﺭﺩ ﺍﻳﻦ ﺑﺮﻧﺎﻣﻪ ﺷﺪ ﻭ ﺍﺯ ﺁﻥ ﺍﺳﺘﻔﺎﺩﻩ ﻧﻤﻮﺩ‪:‬‬
‫ﺏ( ﺑﺎ ﺍﺳﺘﻔﺎﺩﻩ ﺍﺯ ﻣﻴﻠﺔ ﺟﺴﺘﺠﻮ‪ ،‬ﻧﺎﻡ ﺩﺍﺭﻭ ﺭﺍ ﺗﺎﻳﭗ ﻧﻤﻮﺩﻩ ﻭ ﺁﻧﺮﺍ ﺑﻴﺎﺑﻴﺪ ﺝ( ﺑﺎ ﺍﺳﺘﻔﺎﺩﻩ ﺍﺯ ﻛﻠﻴﻪ ‪ ،Class‬ﮔﺮﻭﻫﻬﺎﻱ ﺩﺍﺭﻭﻳﻲ ﻣﺨﺘﻠﻒ ﻣﻌﺮﻓﻲ ﻣﻲﮔﺮﺩﻧﺪ‪.‬‬ ‫ﺍﻟﻒ( ﻟﻴﺴﺖ ﺩﺍﺭﻭﻫﺎ‪ :‬ﺩﺍﺭﻭﻱ ﻣﻮﺭﺩﻧﻈﺮ ﺭﺍ ﺍﻧﺘﺨﺎﺏ ﻧﻤﺎﻳﻴﺪ ﻭ ﺍﻃﻼﻋﺎﺕ ﻻﺯﻡ ﺭﺍ ﺩﺭﻳﺎﻓﺖ ﻛﻨﻴﺪ‪.‬‬
‫ﺩﺭﻣﻮﺭﺩ ﻫﺮ ﺩﺍﺭﻭ‪ ،‬ﻣﻘﺪﺍﺭ ﻣﺼﺮﻑ ﺭﻭﺯﺍﻧﻪ‪ ،‬ﺍﺛﺮﺍﺕ ﺟﺎﻧﺒﻲ‪ ،‬ﺍﺷﻜﺎﻝ ﻣﺨﺘﻠﻒ ﺩﺍﺭﻭ ﻭ ﻫﺸﺪﺍﺭﻫﺎﻱ ﻻﺯﻡ ﺩﺭﻣﻮﺭﺩ ﺍﺛﺮﺍﺕ ﺳﻮﺀ ﺁﻥ‪ ،‬ﺭﻭﺷﻬﺎﻱ ﻧﮕﻬﺪﺍﺭﻱ ﺩﺍﺭﻭ ﻭ ‪ . . .‬ﺍﺭﺍﺋﻪ ﺷﺪﻩ ﺍﺳﺖ‪ .‬ﺍﻳﻦ ﺑﺮﻧﺎﻣﻪ ﻣﺤﺼﻮﻝ ﺷﺮﻛﺖ ‪ Parsons Technology‬ﺳﺎﻝ ‪ ١٩٩٥‬ﻣﻲﺑﺎﺷﺪ‪.‬‬
‫‪ -٧‬ﻧﺮﻡﺍﻓﺰﺍﺭ ﺳﻼﻣﺖ )‪ : (Healthsoft‬ﺍﻳﻦ ﻧﺮﻡﺍﻓﺰﺍﺭ ﺷﺎﻣﻞ ﺳﻪﺑﺨﺶ )ﺳﻪ ﺑﺮﻧﺎﻣﻪ( ﻣﺴﺘﻘﻞ ﻣﻲﺑﺎﺷﺪ‪:‬‬
‫ﺍﻟﻒ( ﺍﻳﻦ ﺑﺮﻧﺎﻣﻪ ﺷﺎﻣﻞ ﺗﻮﺿﻴﺤﺎﺗﻲ ﺭﺍﺟﻊ ﺑﻪ ﺍﻋﻤﺎﻝ ﺟﺮﺍﺣﻲ‪ ،‬ﻣﺮﺍﻗﺒﺖﻫﺎﻱ ﭘﺲ ﺍﺯ ﻋﻤﻞ‪ ،‬ﺍﻋﻤﺎﻟﻲ ﻛﻪ ﺩﺭ ﺯﻣﺎﻥ ﺍﻭﺭﮊﺍﻧﺲ ﺑﺎﻳﺪ ﺍﻧﺠﺎﻡ ﺩﺍﺩ ﻭ ‪ . . .‬ﺍﻳﻦ ﺑﺮﻧﺎﻣﻪ ﺩﺍﺭﺍﻱ ﺗﺼﺎﻭﻳﺮ ﻣﺘﻌﺪﺩ ﻭ ﻧﻴﺰ ﺗﻠﻔﻆ ﺻﺤﻴﺢ ﺍﺻﻄﻼﺣﺎﺕ ﭘﺰﺷﻜﻲ ﻧﺎﺁﺷﻨﺎ ﻧﻴﺰ ﻣـﻲﺑﺎﺷـﺪ‪ ،‬ﺑـﺎ ﺍﺳـﺘﻔﺎﺩﻩ ﺍﺯ ﻓﻬﺮﺳـﺖ‬
‫ﺍﻟﻔﺒﺎﻳﻲ ﻣﻲﺗﻮﺍﻥ ﺍﻃﻼﻋﺎﺗﻲ ﺭﺍﺟﻊ ﺑﻪ ﻫﺮ ﻭﺍﮊﻩ ﺭﺍ ﭘﻴﺪﺍ ﻧﻤﻮﺩ‪.‬‬
‫ﺏ( ﺩﺭ ﺍﻳﻦ ﺑﺮﻧﺎﻣﻪ‪ ،‬ﻋﻠﺖ ﺑﻴﻤﺎﺭﻳﻬﺎ‪ ،‬ﻋﻼﺋﻢ ﻭ ﻧﺸﺎﻧﻪﻫﺎﻱ ﺑﻴﻤﺎﺭﻳﻬﺎ‪ ،‬ﭘﻴﺸﮕﻴﺮﻱ‪ ،‬ﻣﺮﺍﻗﺒﺖﻫﺎﻱ ﺑﻬﺪﺍﺷﺘﻲ‪ ،‬ﺭﻭﺷﻬﺎﻱ ﺻﺤﻴﺢ ﻣﻌﺎﻟﺠﻪ ﻭ ﻧﻴﺰ ﺯﻣﺎﻥ ﻻﺯﻡ ﺑﺮﺍﻱ ﻣﺮﺍﺟﻌﻪ ﺑﻪ ﭘﺰﺷﻚ ﺁﻭﺭﺩﻩ ﺷﺪﻩ ﺍﺳﺖ‪.‬‬
‫ﺝ( ﺩﺭ ﺍﻳﻦ ﺑﺮﻧﺎﻣﻪ ﺍﻃﻼﻋﺎﺗﻲ ﺭﺍﺟﻊ ﺑﻪ ﺩﺍﺭﻭﻫﺎﻱ ﮊﻧﺘﻴﻚ ﺍﺭﺍﺋﻪ ﺷﺪﻩ ﺍﺳﺖ‪ .‬ﺍﺛﺮﺍﺕ ﺟﺎﻧﺒﻲ ﺩﺍﺭﻭﻫﺎ‪ ،‬ﻭﺍﻛﻨﺶ ﻧﺎﺳﺎﺯﮔﺎﺭﻱ ﺗﺪﺍﺧﻞ ﺩﺍﺭﻭﻳﻲ ﻭ ‪ . . .‬ﺩﺭ ﺍﻳﻦ ‪ CD‬ﺍﺷﺎﺭﻩ ﺷﺪﻩ ﺍﺳﺖ‪ .‬ﺍﻟﺒﺘﻪ ﺍﻳﻦ ﺍﻃﻼﻋﺎﺕ ﺗﻨﻬﺎ ﺟﻨﺒﺔ ﺁﮔﺎﻫﻲ ﺩﺍﺩﻥ ﺑﻪ ﻛﺎﺭﺑﺮ ﺭﺍ ﺩﺍﺷﺘﻪ ﻭ ﻧﻮﻳﺴﻨﺪﻩ ﻭ ﺷﺮﻛﺖ ﺗﻮﻟﻴﺪ ﻛﻨﻨﺪﺓ‬
‫‪ CD‬ﻫﻴﭻ ﺗﻮﺻﻴﻪﺍﻱ ﺩﺭ ﺍﻳﻦ ﺧﺼﻮﺹ ﺍﺭﺍﺋﻪ ﻧﻤﻲﺩﻫﻨﺪ‪ .‬ﺩﺭ ﺍﻳﻦ ﺑﺮﻧﺎﻣﻪ ﻋﻼﻭﻩ ﺑﺮ ﺍﺭﺍﺋﺔ ﻧﺎﻣﻬﺎﻱ ﮊﻧﺘﻴﻚ ﻭ ﺗﺠﺎﺭﻱ‪ ،‬ﮔﺮﻭﻫﻬﺎﻱ ﺩﺍﺭﻭﺋﻲ ﻭ ﻣﻮﺍﺭﺩ ﻛﺎﺭﺑﺮﺩﻱ ﺁﻧﻬﺎ ﺍﺭﺍﺋﻪ ﺷﺪﻩ ﺍﺳﺖ‪ .‬ﻣﻘﺪﺍﺭ ﻣﺼﺮﻑ ﺩﺍﺭﻭ‪ ،‬ﻋﻼﺋﻢ ﻭ ﻧﺸﺎﻧﻪﻫﺎﻱ ‪ Dverdose‬ﺩﺍﺭﻭﻫﺎ‪ ،‬ﻣﻮﺍﺭﺩ ﻣﻨﻊ ﻣﺼـﺮﻑ ﺁﻧﻬـﺎ ﻭ‬
‫ﺗﻠﻔﻆ ﺻﺤﻴﺢ ﻧﺎﻡ ﺩﺍﺭﻭ ﺁﻭﺭﺩﻩ ﺷﺪﻩ ﺍﺳﺖ‪.‬‬

‫ﺗﻠﻔﻦ‪٠٩١٢١٣٧٢٣٦١-٦٦٩٣٦٦٩٦ :‬‬ ‫ﻧﺸﺎﻧﻲ‪ :‬ﺗﻬﺮﺍﻥ‪ ،‬ﻡ ﺍﻧﻘﻼﺏ‪ ،‬ﺥ ﻛﺎﺭﮔﺮ ﺟﻨﻮﺑﻲ‪ ،‬ﺥ ﻟﺒﺎﻓﻲﻧﮋﺍﺩ‪ ،‬ﺑﻴﻦ ﻛﺎﺭﮔﺮ ﻭ ﺟﻤﺎﻟﺰﺍﺩﻩ‪ ،‬ﺑﻦﺑﺴﺖ ﺳﻴﻤﻴﻦ‪ ،‬ﭘﻼﻙ ‪٢٣٩‬‬ ‫ﻣﺮﻛﺰ ﺧﺪﻣﺎﺕ ﻓﺮﻫﻨﮕﻲ ﺳﺎﻟﻜﺎﻥ ‪ :‬ﺍﺭﺍﺋﻪ ﻛﻨﻨﺪﺓ ﻛﺘﺎﺏ ﻭ ﺳﻲﺩﻱﻫﺎﻱ ﺗﺨﺼﺼﻲ ﭘﺰﺷﻜﻲ‬
 57
6.12 Clinical Examination ‫ــــــ‬
Skin, nails & hair Respiratory system Heart & cardiovascular system Male genitalia Nervous system
Ear, nose & throah Femal breast & genittalia Abdomen Bones, joints & muscle Infants & children
7.12 CMDT CURREAT Medical Diagnosis & Treatment ‫ــــــ‬
8.12 Endoscopic Assessment of Esophagitis According to the Los Angeles Classification System ‫ــــــ‬
:‫ ﻣﺒﺎﺣﺚ ﺯﻳﺮ ﻣﻲﺑﺎﺷﺪ‬:‫ ﺷﺎﻣﻞ‬CD ‫ﻋﻨﺎﻭﻳﻦ ﺍﻳﻦ‬
y Definitions 1: Mucosal Break 2: Los Angeles Classification 3: Complicatins y Viewing Area 1 :Slide Viewer 2: Slide Gallery 3:Video Gallery
y Quiz 1: International Working Group 2: On Endoscopic Assessment of Esophagitis
9.12 GRIFFITH'S 5-MINUTE CLINICAL CONSULT 2002
‫ ﺑﻴﺶ ﺍﺯ ﻫﺰﺍﺭ ﻋﻨﻮﺍﻥ ﺑﻴﻤﺎﺭﻱ ﺑﻪ ﺗﺮﺗﻴﺐ ﺍﻟﻔﺒﺎ ﺗﺮﺗﻴﺐ ﻳﺎﻓﺘـﻪ ﺍﺳـﺖ‬.‫ ﮔﺮﺩﺁﻭﺭﻱ ﺷﺪﻩ ﺍﺳﺖ‬.... ‫ ﻭ‬ENT ‫ ﭼﺸﻢ ﻭ‬،‫ ﺟﺮﺍﺣﻲ‬،‫ ﭘﻮﺳﺖ‬،‫ ﺯﻧﺎﻥ‬،‫ ﺑﺮﺍﻱ ﭘﺰﺷﻜﺎﻥ ﻭ ﻣﺘﺨﺼﺼﻴﻦ ﻭ ﺩﺳﺘﻲ`ﺍﺭﺍﻥ ﺑﺮﺍﻱ ﻣﺮﻭﺭ ﺳﺮﻳﻊ ﻭﻟﻲ ﺟﺎﻣﻊ ﺩﺭ ﻣﻮﺭﺩ ﺑﻴﻤﺎﺭﻱﻫﺎﻱ ﻋﻤﺪﻩ ﺩﺍﺧﻠﻲ‬CD ‫ ﺍﻳﻦ‬،‫ﺑﻪ ﮔﻔﺘﺔ ﻣﺆﻟﻔﻴﻦ‬
.‫ ﻧﻤﻮﺩﺍﺭ ﻭ ﺟﺪﻭﻝ ﻣﻲﺑﺎﺷﺪ‬،‫ ﺷﺎﻣﻞ ﺗﻮﺿﻴﺢ ﺑﻴﻤﺎﺭﻱﻫﺎ )ﺩﺭ ﺯﻳﺮ ﺁﻭﺭﺩﻩ ﺷﺪﻩ ﺍﺳﺖ( ﻭ ﻋﻜﺲﻫﺎﻱ ﺭﻧﮕﻲ‬CD ‫ ﺍﻳﻦ‬.‫ ﻧﻔﺮ ﻣﺘﺨﺼﺼﻴﻦ ﻣﺠﺮﺏ ﺩﺭ ﮔﺮﺩﺁﻭﺭﻱ ﺍﻳﻦ ﻣﺠﻤﻮﻋﻪ ﻫﻤﻜﺎﺭﻱ ﺩﺍﺷﺘﻪﺍﻧﺪ‬٣٣٠ ‫ ﺑﻴﺶ ﺍﺯ‬.‫ﻛﻪ ﺩﺭ ﻫﺮ ﻋﻨﻮﺍﻥ ﺟﺰﺋﻴﺎﺕ ﻛﺎﻓﻲ ﺑﺮﺍﻱ ﺗﺸﺨﻴﺺ ﻭ ﺩﺭﻣﺎﻥ ﻭ ﭘﻴﮕﻴﺮﻱ ﺑﻴﻤﺎﺭﻱ ﻭﺟﻮﺩ ﺩﺍﺭﺩ‬
:‫ ﻣﺸﺮﻭﺡ ﻋﻨﺎﻭﻳﻦ ﻋﺒﺎﺭﺗﻨﺪ ﺍﺯ‬.‫ ﻗﺴﻤﺖ ﻓﺮﻋﻲ ﺑﻪ ﺗﻔﻀﻴﻞ ﺗﻮﺿﻴﺢ ﺩﺍﺩﻩ ﺷﺪﻩ ﺍﺳﺖ‬٣٦ ‫ ﻗﺴﻤﺖ ﺍﺻﻠﻲ ﻭ‬٦ ‫ﻋﻨﻮﺍﻥ ﻫﺮ ﺑﻴﻤﺎﺭﻱ ﺩﺭ‬
6- MISCELLANEOUS 5- FOLLOW-UP 4- MEDICATION 3- TREATMENT 2- DIAGNOSIS 1- BASICS
• Associated conditions • Monitoring • Drugs of choice • Genral measures • Differential • Description
• Age-related factors • Prevention • Contraindications • Surgical measures • Laboratory • Genetics
• Pregnancy • Complications • Precautions • Activity • Pathological findings • Prevalence
• Synonyms • Prognosis • Interactions • Diet • Special tests • Age
• ICD-9-CM
• Alternate drugs • Patient education • Imaging • Signs and symptoms
• See also
• Other notes • Causes
• Abbreviations • Risk factors
• References
10.12 HEALTH ASSESSMENT (Gaylene Bouska Altman, RN, Ph.D., Karrin Johnson, RN, Robert W. Wallach, MD) 2002
.‫ ﺑﺨﺶ ﺭﺍﺟﻊ ﺑﻪ ﺍﺭﺯﻳﺎﺑﻲ ﺳﻼﻣﺖ ﻭ ﺁﺯﻣﺎﻳﺸﺎﺕ ﻭ ﻣﻌﺎﻳﻨﺎﺕ ﻓﻴﺰﻳﻜﻲ ﻣﻲﺑﺎﺷﺪ‬٤ ‫ﺍﻳﻦ ﺑﺮﻧﺎﻣﻪ ﺷﺎﻣﻞ‬
.‫ ﺗﺼﻮﻳﺮ ﻃﺮﺍﺣﻲ ﺷﺪﻩ ﺍﺯ ﺩﺳﺘﮕﺎﻫﻬﺎ ﻭ ﺍﻧﺪﺍﻣﻬﺎﻱ ﺑﺪﻥ ﺑﻪ ﻫﻤﺮﺍﻩ ﺍﻃﻼﻋﺎﺕ ﻣﺘﻨﻲ ﺩﺭ ﺍﻳﻦ ﺑﺨﺶ ﺗﻤﺎﻣﻲ ﻣﻄﺎﻟﺐ ﺁﻧﺎﺗﻮﻣﻲ ﻭ ﻓﻴﺰﻳﻮﻟﻮﮊﻱ ﻣﺮﻭﺭ ﺷﺪﻩ ﺍﺳﺖ‬٥٩ ‫ ﻗﺴﻤﺖ ﻫﻤﺮﺍﻩ ﺑﺎ‬١٧٥ ‫ ﺷﺎﻣﻞ‬: ‫ ﻣﺮﻭﺭﻱ ﺑﺮ ﺁﻧﺎﺗﻮﻣﻲ ﻭ ﻓﻴﺰﻳﻮﻟﻮﮊﻱ‬:١ ‫ﺑﺨﺶ‬
.‫ ﻫﻤﭽﻨﻴﻦ ﻋﻤﻠﻜﺮﺩ ﻭ ﺳﺎﺧﺘﺎﺭﻫﺎﻱ ﻗﻠﺐ ﻧﻴﺰ ﺑﺤﺚ ﺷﺪﻩ ﺍﺳﺖ‬.‫ ﺩﺭ ﺍﻳﻦ ﺑﺨﺶ ﺻﺪﺍﻫﺎﻱ ﻗﻠﺐ ﻭ ﺭﻳﻪ )ﺩﺭ ﺣﺎﻟﺖ ﺳﻼﻣﺘﻲ ﻭ ﺑﻴﻤﺎﺭﻱ( ﺩﺭ ﻫﻨﮕﺎﻡ ﻣﻌﺎﻳﻨﺔ ﻣﺮﻳﺾ ﺍﺭﺍﺋﻪ ﺷﺪﻩ ﺍﺳﺖ‬:‫ ﺻﺪﺍﻫﺎﻱ ﻗﻠﺐ ﻭ ﺭﻳﻪ‬:٢ ‫ﺑﺨﺶ‬
.‫ ﻭﺿﻌﻴﺖ ﺑﻴﻤﺎﺭﻱ ﺁﻧﻬﺎ )ﺑﺼﻮﺭﺕ ﺳﺆﺍﻝ ﻭ ﺟﻮﺍﺏ( ﺗﻮﺳﻂ ﻛـﺎﺭﺑﺮ ﻣﺸـﺨﺺ ﻣـﻲﺷـﻮﺩ‬،‫ ﻣﺨﺘﻠﻒ ﭘﺲ ﺍﺯ ﺍﺭﺍﺋﻪ ﺷﺮﺡ ﺣﺎﻝ‬Case ٢٠ .‫ ﺩﺭ ﺍﻳﻦ ﺑﺨﺶ ﺑﺼﻮﺭﺕ »ﺑﺮﺭﺳﻲ ﻭ ﻣﻄﺎﻟﻌﺔ ﻣﻮﺭﺩﻱ« ﺍﺭﺍﺋﻪ ﺷﺪﻩ ﺍﺳﺖ‬:‫ ﻣﻬﺎﺭﺗﻬﺎﻱ ﺣﻴﺎﺗﻲ ﺩﺭ ﺍﺭﺯﻳﺎﺑﻲ ﺳﻼﻣﺘﻲ ﻭ ﻣﻌﺎﻳﻨﺎﺕ ﻓﻴﺰﻳﻜﻲ‬:٣ ‫ﺑﺨﺶ‬
.‫ﻫﺪﻑ ﺍﺯ ﺍﻳﻦ ﺑﺨﺶ ﺍﻓﺰﺍﻳﺶ ﻗﺪﺭﺕ ﻭ ﻣﻬﺎﺭﺕ ﺍﺭﺯﻳﺎﺑﻲ ﺩﺍﻧﺸﺠﻮﻳﺎﻥ ﺩﺭ ﺗﺸﺨﻴﺺ ﺑﻴﻤﺎﺭﻳﻬﺎﺳﺖ‬
.‫ ﺩﺭ ﺍﻳﻦ ﺑﺨﺶ ﻳﻚ ﺑﺮﻧﺎﻣﺔ ﺁﻣﻮﺯﺷﻲ ﻣﺼﻮﺭ ﻫﻤﺮﺍﻩ ﺑﺎ ﺍﺭﺍﺋﻪ ﺗﻌﺎﺭﻳﻒ ﻭ ﺍﺻﻄﻼﺣﺎﺕ ﻣﺮﺑﻮﻁ ﺑﻪ ﻣﻌﺎﻳﻨﺎﺕ ﺍﺭﺍﺋﻪ ﺷﺪﻩ ﺍﺳﺖ‬،‫ ﻓﺼﻞ ﻣﻲﺑﺎﺷﺪ‬٢C‫ ﺁﺷﻨﺎﻳﻲ ﺑﺼﺮﻱ ﺑﺎ ﻣﻌﺎﻳﻨﺎﺕ ﻓﻴﺰﻳﻜﻲ؛ ﻛﻪ ﺩﺍﺭﺍﻱ‬:٤ ‫ﺑﺨﺶ‬
.‫ﺩﺭ ﺍﻳﻦ ﺑﺮﻧﺎﻣﻪ ﺩﺭ ﻫﺮ ﭼﻬﺎﺭ ﺑﺨﺶ ﺍﻣﺘﺤﺎﻥ ﺑﺼﻮﺭﺕ ﺳﺆﺍﻻﺕ ﭼﻨﺪ ﮔﺰﻳﻨﻪﺍﻱ ﻧﻴﺰ ﻭﺟﻮﺩ ﺩﺍﺭﺩ‬
11.12 MCCQE Review Nots and Lecture Series (Marcus Law & Brain Rotengberg( 2000
Section Menu: Anesthesia, Cardiology, Color Atlas, Community Med, Dermatololgy, Diagnostic Imaging, Emergency, Endocrinology, Family Medicinne, Gastroenterology,
General Surgery, Geriatrics, Gynecology, Hematology, Infectious Disease, Nephrology, Neurology, Neurosurgery, Obstetrics, Ophthalmology, Orthopedics, Otolaryngology,
Pediatrics, Plastic Surgery, Psychiatry, Respirology, Rheumatology, Urology
12.12 Medical Dictionary (Dorland's) (by W. B. Saunders) 2000
13.12 MEDICAL Encyclopedia For Health Consumers (With Atlas) ‫ــــ‬
TM
14.12 MedStudy (The Best Internal Medicine Board Review)
2000
1. The Most Board Specific 2. The Most Powerful 3. The Most Effective 4. The Most Talked About

٠٩١٢١٣٧٢٣٦١-٦٦٩٣٦٦٩٦ :‫ﺗﻠﻔﻦ‬ ٢٣٩ ‫ ﭘﻼﻙ‬،‫ ﺑﻦﺑﺴﺖ ﺳﻴﻤﻴﻦ‬،‫ ﺑﻴﻦ ﻛﺎﺭﮔﺮ ﻭ ﺟﻤﺎﻟﺰﺍﺩﻩ‬،‫ ﺥ ﻟﺒﺎﻓﻲﻧﮋﺍﺩ‬،‫ ﺥ ﻛﺎﺭﮔﺮ ﺟﻨﻮﺑﻲ‬،‫ ﻡ ﺍﻧﻘﻼﺏ‬،‫ ﺗﻬﺮﺍﻥ‬:‫ﻧﺸﺎﻧﻲ‬ ‫ ﺍﺭﺍﺋﻪ ﻛﻨﻨﺪﺓ ﻛﺘﺎﺏ ﻭ ﺳﻲﺩﻱﻫﺎﻱ ﺗﺨﺼﺼﻲ ﭘﺰﺷﻜﻲ‬: ‫ﻣﺮﻛﺰ ﺧﺪﻣﺎﺕ ﻓﺮﻫﻨﮕﻲ ﺳﺎﻟﻜﺎﻥ‬
 ‫‪58‬‬
‫)‪15.12 Natural Medicine Instructions for Patients (Lara U. Pizzorno, Joseph E. Pizzorno, Jr, Michael T. Murray‬‬ ‫‪2002‬‬
‫‪16.12 Patient Teaching Aids‬‬ ‫‪2002‬‬

‫ﻧﺮﻡﺍﻓﺰﺍﺭ ﺁﻣﻮﺯﺵ ﺟﻬﺖ ﺍﺳﺘﻔﺎﺩﻩ ﺑﻴﻤﺎﺭﺍﻥ ﻭ ﭘﺰﺷﻜﺎﻥ ﺩﺭ ﺭﺷﺘﻪﻫﺎﻱ ﻣﺨﺘﻠﻒ ﻃﺮﺍﺣﻲ ﺷﺪﻩ ﺍﺳﺖ ﻛﻪ ﺁﻣﻮﺯﺵﻫﺎﻱ ﻻﺯﻡ ﺭﺍ ﺩﺭ ﺑﺎﺑﺖ ﺍﻗﺪﺍﻣﺎﺕ ﺣﻤﺎﻳﺘﻲ‪ ،‬ﺍﻗﺪﺍﻣﺎﺕ ﺗﺸﺨﻴﺺ ﻭ ﺩﺭﻣﺎﻧﻲ ﺩﺭﺑﺮ ﺩﺍﺭﺩ‪ .‬ﻣﻄﺎﻟﺐ ﺑﺮ ﺍﺳﺎﺱ ﻣﻮﺿﻮﻉ ﻭ ﺑﻴﻤﺎﺭﻱ ﺩﺳﺘﻪﺑﻨﺪﻱ ﺷﺪﻩﺍﻧﺪ ﻭ ﻫﺮ ﻣﻄﻠﺐ ﺣـﺪﻭﺩ ﻳـﻚ‬
‫ﺻﻔﺤﻪ ﻣﻲﺑﺎﺷﺪ‪ .‬ﺻﻔﺤﺎﺕ ﻗﺎﺑﻞ ‪ Print‬ﻭ ﺍﺭﺍﺋﻪ ﺑﻪ ﺑﻴﻤﺎﺭﺍﻥ ﻫﺴﺘﻨﺪ‪ .‬ﺍﺳﺘﻔﺎﺩﻩ ﺍﺯ ﺍﻳﻦ ﻧﺮﻡﺍﻓﺰﺍﺭ ﻧﻘﺶ ﺑﻴﻤﺎﺭ ﺭﺍ ﺩﺭ ﻓﺮﺁﻳﻨﺪ ﺩﺭﻣﺎﻥ ﺗﻘﻮﻳﺖ ﻛﺮﺩﻩ ﻭ ﺩﻳﺪﮔﺎﻩ ﻋﻠﻤﻲ ﻭ ﻣﻨﺎﺳﺒﻲ ﺑﻪ ﻭﻱ ﻣﻲﺩﻫﺪ ﻛﻪ ﺑﻪ ﺭﻭﻧﺪ ﻛﻠﻲ ﺳﻼﻣﺖ ﻭ ﺑﻬﺒﻮﺩ ﻛﻤﻚ ﺑﺴﺰﺍﻳﻲ ﺩﺍﺭﺩ‪ .‬ﻗﺎﺑﻠﻴﺖ ‪ Search‬ﻗـﻮﻱ ﻭ ﻧﻴـﺰ‬
‫ﺍﺿﺎﻓﻪﻛﺮﺩﻥ ﻧﻮﺷﺘﻪ ﺑﻪ ﻣﺘﻦ ﺍﺯ ﻣﺰﺍﻳﺎﻱ ﺍﻳﻦ ﻧﺮﻡﺍﻓﺰﺍﺭ ﻣﺤﺴﻮﺏ ﻣﻲﮔﺮﺩﺩ‪ .‬ﺣﺪﻭﺩ ‪ ٤٠٠‬ﺳﺮﻓﺼﻞ ﻛﻪ ﻫﺮ ﻛﺪﺍﻡ ﺷﺎﻣﻞ ﭼﻨﺪ ‪ Tapic‬ﻋﻤﺪﻩ ﻭ ﺷﺎﻳﻊ ﻣﻲﺑﺎﺷﺪ ﺭﺍ ﻣﻲﺗﻮﺍﻥ ﺑﺮﺍﺣﺘﻲ ﺩﺭ ﺍﻳﻦ ﻧﺮﻡﺍﻓﺰﺍﺭ ﻳﺎﻓﺖ‪.‬‬
‫)‪17.12 Practical General Practice (Guidelines for effective clinical management) (Alex Khot, Andrew Polmear‬‬ ‫)‪(Third Edition‬‬ ‫ــــ‬
‫)‪18.12 RAPID REVIEW FOR USMLE STEP 1 (Mosby‬‬ ‫‪2002‬‬
‫‪Sciences:‬‬ ‫‪y Anatomy y Behavioral Science y Biochemistry y Histology/Cell Biology y Microbiology/Immunology y Neuroscience y Pathology y Pharmocology y Physiology y Randomize All‬‬
‫‪19.12 SPSS 12.0 for Windows‬‬ ‫‪2003‬‬

‫)‪20.12 Textbook of Physical Diagnosis HISTORY AND EXAMINATION (Fourth Edition) (Mark H. Swartz, M.D.) (W.B. SAUNDERS COMPANY‬‬ ‫‪2002‬‬

‫‪21.12 The Basics for Interns‬‬ ‫ــــ‬

‫ﺍﻳﻦ ﺑﺮﻧﺎﻣﻪ ﺷﺎﻣﻞ ‪ ٦‬ﻓﺼﻞ ﺍﺻﻠﻲ ﺍﺳﺖ‪:‬‬
‫‪) airway Management‬ﺍﺭﺯﻳﺎﺑﻲ ﻣﺴﻴﺮ ﺭﺍﻫﻬﺎﻱ ﻫﻮﺍﻳﻲ‪ ،‬ﻛﻨﺘﺮﻝ ﻣﺴﻴﺮ ﺭﺍﻫﻬﺎﻱ ﻫﻮﺍﻳﻲ ﺩﺭ ‪ Apnea‬ﻭ ‪ hypoxia‬ﻭ ‪ ، . . .‬ﺍﺑﺰﺍﺭﻫﺎﻱ ﻣﻮﺭﺩ ﺍﺳﺘﻔﺎﺩﻩ ﺩﺭ ﻣﺴﻴﺮﻫﺎﻱ ﻫﻮﺍﻳﻲ ﺑﻴﻨﻲ ﻭ ﺩﻫﺎﻥ‪ ،‬ﺭﻭﺷﻬﺎﻱ ﺑﻴﻬﻮﺷﻲ‪ ،‬ﻭ ﻧﻴﺘﻼﺳﻴﻮﻥ ﻣﺎﺳﻚ ﻛﻴﺴﻪﺍﻱ‪ ،‬ﻟﻮﻟﻪﮔﺬﺍﺭﻱ ﻧﺎﻱ ﺗﺮﺍﻛﻨﻮﺗﻮﻣﻲ(‬ ‫‪-١‬‬
‫ﺗﻔﺴﻴﺮ ﻭ ﺍﺭﺯﻳﺎﺑﻲ ﺍﻭﻟﻴﺔ ﺗﺼﻮﻳﺮ ﺭﺍﺩﻳﻮﻟﻮﮊﻱ )ﺷﺎﻣﻞ ﺗﺼﺎﻭﻳﺮ ‪ – Chest x-ray‬ﺗﺼﺎﻭﻳﺮ ‪ Abdominal x-ray‬ﻭ ‪(CT-scan‬‬ ‫‪-٢‬‬
‫ﻣﺪﻳﺮﻳﺖ ﺟﺮﺍﺣﻲ ﺯﺧﻢﻫﺎ )ﺷﺎﻣﻞ ﻧﺦﻫﺎﻱ ﺟﺮﺍﺣﻲ – ﻣﻌﺮﻓﻲ ﺍﺑﺰﺍﺭ ﻭ ﻭﺳﺎﻳﻞ ﺟﺮﺍﺣﻲ – ﻧﻤﺎﻳﺶ ﻧﺤﻮﺓ ﺍﻧﻮﺍﻉ ﺑﺨﻴﻪ ﺯﺩﻥﻫﺎ‪ ،‬ﺭﻭﺵ ﭘﺎﻧﺴﻤﺎﻥ ﺯﺧﻢﻫﺎ ‪( . . .‬‬ ‫‪-٣‬‬
‫ﺩﺳﺘﺮﺳﻲ ﺑﻪ ﺷﺮﻳﺎﻥﻫﺎ )ﺷﺎﻣﻞ ﺷﺮﻳﺎﻥ ﺭﺍﺩﻳﺎﻝ – ﺷﺮﻳﺎﻥ ﻓﻤﻮﺭﺍﻝ(‬ ‫‪-٤‬‬
‫ﺩﺳﺘﺮﺳﻲ ﻭ ﺑﻜﺎﺭﮔﻴﺮﻱ ﺳﻴﺎﻫﺮﮒﻫﺎ )ﻣﻌﺮﻓﻲ ﻭﺳﺎﻳﻞ ﺟﻬﺖ ﺩﺳﺘﺮﺳﻲ ﻃﻮﻻﻧﻲ ﻣﺪﺕ ﺑﻪ ﺳﻴﺎﻫﺮﮒﻫﺎ‪ -‬ﺍﺭﺯﻳﺎﺑﻲ ﭘﻴﺶ ﺍﺯ ﻋﻤﻞ ﻭ ﺗﺪﺍﺭﻛﺎﺕ ﻻﺯﻡ – ﺁﻧﺎﺗﻮﻣﻲ ﻭ ﺗﻜﻨﻴﻚﻫﺎﻱ ﺑﺮﺷﻲ ﺳﻴﺎﻫﺮﮒﻫﺎ ﻭ ﺍﻳﻤﭙﻠﻨﺖﻫﺎﻱ ﺯﻳﺮﭘﻮﺳﺘﻲ ﻭ ‪( . . .‬‬ ‫‪-٥‬‬
‫ﺩﺭ ﻧﺎﮊ ﻭ ﺗﺨﻠﻴﻪ ﭘﻠﻮﺭﺍﻝ ‪) :‬ﻣﻮﺍﺭﺩ ﺍﺳﺘﻌﻤﺎﻝ‪ ،‬ﻧﺤﻮﺓ ﺍﻧﺠﺎﻡ ﻋﻤﻞ‪ ،‬ﺗﻜﻨﻴﻚ ﺗﻮﺭﺍﺳﻨﺘﺰ‪ ،‬ﺗﻜﻨﻴﻚ ﺗﻴﻮﺏ ﺗﻮﺭﺍﻛﻮﺳﺘﻮﻣﻲ (‬ ‫‪-٦‬‬
‫ﺗﻤﺎﻣﻲ ﻣﺒﺎﺣﺚ ﻋﻨﻮﺍﻥ ﺷﺪﻩ ﺩﺭ ﺑﺎﻻ ﺑﺼﻮﺭﺕ ﻓﻴﻠﻤﻐﻬﺎﻱ ﺁﻣﻮﺯﺷﻲ ﻭ ﺗﺼﺎﻭﻳﺮ ﻣﺘﻌﺪﺩ ﻫﻤﺮﺍﻩ ﺑﺎ ﺗﻮﺿﻴﺤﺎﺕ ﮔﻮﻳﻨﺪﻩ ﺍﺭﺍﺋﻪ ﺷﺪﻩ ﺍﺳﺖ‪ .‬ﺍﻳﻦ ﻓﻴﻠﻤﻐﻬﺎﻱ ﺁﻣﻮﺯﺷﻲ ﻳﺎ ﺑﺼﻮﺭﺕ ﻭﺍﻗﻌﻲ ﺍﺳﺖ ﻭ ﻧﺤﻮﺓ ﺍﻧﺠﺎﻡ ﻋﻤﻞ ﺑﺮﺭﻭﻱ ﻣﺮﻳﺾ ﺩﻗﻴﻘﹰﺎ ﻧﻤﺎﻳﺶ ﺩﺍﺩﻩ ﺷﺪﻩ ﺍﺳﺖ ﻭ ﻳﺎ ﺑﺼﻮﺭﺕ ﺍﻧﻴﻤﻴﺸﻦ ﺍﺳﺖ‪.‬‬ ‫‪-٧‬‬
‫)‪22.12 The MERCK MANUAL of Medical Information (Second Edition) (Mark H. Beers, MD) (CD I , II) (Salekan E-Book‬‬ ‫‪2003‬‬

‫)‪23.12 Understanding Lung Sounds (Audio CD‬‬ ‫ــــ‬

‫)‪24.12 UNDERSTANDING PATHOPHYSIOLOGY (Second Edition) (Sue E. Huether, Kathryn L. McCance‬‬ ‫ــــ‬
‫)‪25.12 Virtual Medical Office CHALLENGE (to accompany Bonewit-West Clinical Procedures for Medical Assistants, 5 Edition‬‬
‫‪th‬‬
‫)‪(W.B. Saunders Company‬‬ ‫ــــ‬
‫ﺍﻳﻦ ﻧﺮﻡﺍﻓﺰﺍﺭ ﺑﺎ ﺍﺳﺘﻔﺎﺩﻩ ﺍﺯ ‪CaseStudy‬ﻫﺎﻱ ﻣﺘﻌﺪﺩ ﻣﻄﺮﺡﺷﺪﻩ ﻛﺎﺭﺑﺮ ﺭﺍ ﺑﻪ ﺍﺳﺘﻔﺎﺩﻩ ﺑﺎﻟﻴﻨﻲ ﺍﺯ ﺍﻃﻼﻋﺎﺕ ﺍﺭﺍﺋﻪﺷﺪﻩ ﺩﺭ ﻛﺘﺐ ﺭﻓﺮﺍﻧﺲ ﻋﺎﺩﺕ ﻣﻲﺩﻫﺪ‪ .‬ﺩﺭ ﻋﻴﻦ ﺣﺎﻝ ﺷﻴﻮﺓ ﺣﻞ ﻣﺸﻜﻼﺕ‪ ،‬ﻗﺪﺭﺕ ﺗﺼﻤﻴﻢﮔﻴﺮﻱ ﺑﻪ ﺿﺮﺍﻓﺖﻫﺎﻱ ‪ Critical‬ﻭ ‪Triage‬‬
‫ﻛﻪ ﺍﺯ ﻣﻬﻤﺘﺮﻳﻦ ﻣﻬﺎﺭﺕﻫﺎ ﺑﺎﻟﻴﻨﻲ ﭘﺰﺷﻜﺎﻥ ﻭ ﻛﺎﺩﺭ ﭘﺰﺷﻜﻲ ﻣﺤﺴﻮﺏ ﻣﻲﮔﺮﺩﺩ‪ ،‬ﺩﺭ ﻃﻲ ﻣﺮﺍﺣﻞ ﻣﺘﻌﺪﺩ ﻭ ﺑﻪ ﺻﻮﺭﺕ ﻋﻤﻠﻲ ﻭ ﺳﻤﻌﻲ ﺑﺼﺮﻱ ﺁﻣﻮﺯﺵ ﻭ ﺗﻤﺮﻳﻦ ﻣﻲﮔﺮﺩﻧﺪ‪ .‬ﺍﻳﻦ ‪ CD‬ﺷﺎﻣﻞ ﭼﻬﺎﺭ ﺳﺮﻓﺼﻞ ﻋﻤﺪﻩ ﺑﻪ ﻗﺮﺍﺭ ﺯﻳﺮ ﺍﺳﺖ‪:‬‬
‫‪- Case Study‬‬ ‫‪- Clinical Skills‬‬ ‫‪- Challenge Status‬‬ ‫‪-Help‬‬
‫ﺗﻐﺬﻳﻪ‬
‫)‪26.12 Contemporary Nutrition Food Wise (Food Wise, Weight Manager‬‬ ‫‪2002‬‬
‫)‪27.12 Food Works (College Edition‬‬ ‫___‬
‫)‪28.12 INTRODUCTION TO NUTRIOTION AND METABOLISM (Third Edition) (DAVID A Bender‬‬ ‫‪2002‬‬

‫ﺗﻠﻔﻦ‪٠٩١٢١٣٧٢٣٦١-٦٦٩٣٦٦٩٦ :‬‬ ‫ﻧﺸﺎﻧﻲ‪ :‬ﺗﻬﺮﺍﻥ‪ ،‬ﻡ ﺍﻧﻘﻼﺏ‪ ،‬ﺥ ﻛﺎﺭﮔﺮ ﺟﻨﻮﺑﻲ‪ ،‬ﺥ ﻟﺒﺎﻓﻲﻧﮋﺍﺩ‪ ،‬ﺑﻴﻦ ﻛﺎﺭﮔﺮ ﻭ ﺟﻤﺎﻟﺰﺍﺩﻩ‪ ،‬ﺑﻦﺑﺴﺖ ﺳﻴﻤﻴﻦ‪ ،‬ﭘﻼﻙ ‪٢٣٩‬‬ ‫ﻣﺮﻛﺰ ﺧﺪﻣﺎﺕ ﻓﺮﻫﻨﮕﻲ ﺳﺎﻟﻜﺎﻥ ‪ :‬ﺍﺭﺍﺋﻪ ﻛﻨﻨﺪﺓ ﻛﺘﺎﺏ ﻭ ﺳﻲﺩﻱﻫﺎﻱ ﺗﺨﺼﺼﻲ ﭘﺰﺷﻜﻲ‬
 59
29.12 Multimedia Workout (Jeffrey S. Smith, Joseph D. Cook) ‫ــــ‬
30.12 NUTRIENTS IN FOOD (Elizabet S. Hands) 2002
31.12 THE FOOD LOVER'S ENCYCLOPEDIA Culinary Techniques Recipes Nutrition Foods ‫ــــ‬

‫ ﺩﺍﺭﻭﺋﻲ‬-١٣

CD ‫ﻋﻨﻮﺍﻥ‬ ‫ﺳﺎﻝ ﺍﻧﺘﺸﺎﺭ‬

1.13 A Primer on Quality in the Analytical Laboratory (John Kenkel) ‫ــــ‬

2.13 American DRUG INDEX (FACTS AND COMPARISONS) 2001

3.13 Appleton and Lange's Quick Review PHARMACY (Twelfth Edition) (Joyce A. Generali, Christine A. Berger) ___
-Parmaceutics/Pharmokinetics -Pharmacology -Microbiology and Public Health -Chemistry and Biochemistry -Physiology/Pathology -Clinical Pharmacy
4.13 Basic Concepts in Biochemistry A Student's Survival Guid (Hiram F. Gilbert, Ph.D.) (Second Edition) ‫ــــ‬
5.13 Bioethics for Scientists (Professor John Bryant D. Linda Baggott La Velle, Revd Dr John Searle) ‫ــــ‬
6.13 British Pharmacopoeia (version 6.0) 2002
Vol 1: -Notices -Preface -British Pharmacopoeia Commision -Introduction -General Notices -Monographs: Meidicinal and Pharmaceutical Substances
Vol 2: -Notices -General Notices -Monographs -Infrared Reference Spectra -Appendices -Supplementary Chapters
British Pharmacopoeia (Veterinary): -Preface -British Pharmacopoeia Commission -Introduction -General Notices -Monographs -Infrared Reference Spectra -Appendics
7.13 Characterization of Nanophase Materials (Zhong Lin Wang) (Salekan E-Book) ‫ــــ‬
8.13 Chem Office (Renate Buergin Schaller) ___

9.13 Chemometrics Data Analysis for the Laboratory and Chemical Plant Richard G. Brereton (University of Bristol, UK) 2003
10.13 Cleanroom Design (Second Edition) (Second Edition)
th
11.13 CLINICAL DRUG THERAPY Rationnales for Nursing Practice (7 Edition) (ANNE COLLINS ABRAMS) (Lippincott Williams & Wilkins) ___
-Dosage Calc Challenge! -Animations -NCLEX Questions -Monographs of 100 Most Commonly Prescribed Drug -Preventing Medication Errors Video -Patient Teaching Sheets
12.13 Common Fragrance and Flavor Materials (Kurt Bauer, Dorothea Garbe, Horst Surburg) ‫ــــ‬
13.13 DERIVATIZATION REACTIONS FOR HPLC (Georgelunn, Louise C. Hellwic) ___

14.13 Dosages and Solutions CD Conpanion (Virginia Daugherty, RN, MSN, Diana Romans, RN, BSN) (Harcourt Health Sciences) 2000
-Mathematics Review -Introducing Drug Measures -How to Read a Drug Label -Calculatin Dosages -Comprehensive Posttest
15.13 DRU ERUPTION REFERENCE MANUAL (The Parthenon Publishing Group) (Jerome Z. Litt, MD) 2004
Search by: - Drug Name -Reactions -Interactions -Categories -Company -Multiple Search -Printing -Common -Reaciton
16.13 DRUG CONSULT (Mosby) ___
Drug Identifier 2003
17.13
Find Products by: -Drug name -Imprint -NDC code -Manufacturer name
18.13 Drug-Membrane Interactions Analysis, Drug Distribution, Modeling (Joachim K. Seydel, Michael Wiese) 2002
19.13 Encyclopedic Dictionary of Named Processes in Chemical Technology (Ed. Alan E. Comyns) ‫ــــ‬

٠٩١٢١٣٧٢٣٦١-٦٦٩٣٦٦٩٦ :‫ﺗﻠﻔﻦ‬ ٢٣٩ ‫ ﭘﻼﻙ‬،‫ ﺑﻦﺑﺴﺖ ﺳﻴﻤﻴﻦ‬،‫ ﺑﻴﻦ ﻛﺎﺭﮔﺮ ﻭ ﺟﻤﺎﻟﺰﺍﺩﻩ‬،‫ ﺥ ﻟﺒﺎﻓﻲﻧﮋﺍﺩ‬،‫ ﺥ ﻛﺎﺭﮔﺮ ﺟﻨﻮﺑﻲ‬،‫ ﻡ ﺍﻧﻘﻼﺏ‬،‫ ﺗﻬﺮﺍﻥ‬:‫ﻧﺸﺎﻧﻲ‬ ‫ ﺍﺭﺍﺋﻪ ﻛﻨﻨﺪﺓ ﻛﺘﺎﺏ ﻭ ﺳﻲﺩﻱﻫﺎﻱ ﺗﺨﺼﺼﻲ ﭘﺰﺷﻜﻲ‬: ‫ﻣﺮﻛﺰ ﺧﺪﻣﺎﺕ ﻓﺮﻫﻨﮕﻲ ﺳﺎﻟﻜﺎﻥ‬
 60
20.13 European Pharmacopoeia (4th Edition) ___

21.13 FIRE AND EXPLOSION HAZARDS HANDBOOK OF INDUSTRIAL CHEMICALS (Tatyana A. Davletshina Nicholas P. Cheremisinoff, Ph.D.) ‫ــــ‬

22.13 Fluid Flow for Chemical Engineers (Second edition) (Professor F. A. Holland Dr R. Bragg) ‫ــــ‬

23.13 From Genome To Therapy: Integrating New Technologies with Drug Development ‫ــــ‬

24.13 GoodMan and Gilmans's CD-ROM ___

25.13 Handbook of Solvents (George Wypych) ‫ــــ‬

26.13 HERBAL MEDICINE Expanded Commission E Monographs (INTEGRATIVMEDICINE) ___

27.13 Herbal Remedy FINDER ___

28.13 HPLC and CE METHODS for Pharmaceutical Analysis (Version 2.0) (George Lunn) (John Wiley and ons) 2000
29.13 Patient Education Guide to Oncology Drugs Name Search – Categories – Comparisons ___
(Gail M. Wilkes, RNC, MS, AOCN, Terri B. Ades, RN, MS, AOCN)
30.13 PDQ PHARMACOLOGY (GORDON E. JOHNSON, PHD) 2002
PDR® Electronic Library™ PHYSICIANS DESK REFERENCE (Thomson Medical Economics). 2004
‫ ﺍﺭﺍﺋﻪ ﺷﺪﻩﺍﻧﺪ ﺍﺯ ﻣﻌﺘﺒﺮﺗﺮﻳﻦ ﻭ ﺟﺪﻳﺪﺗﺮﻳﻦ ﻣﺮﺍﺟﻊ ﺩﺍﺭﻭﺷﻨﺎﺳﻲ ﻣﻲﺑﺎﺷﻨﺪ‬CD ‫( ﻓﺎﺭﻣﺎﻛﻮﻟﻮﮊﻱ ﻛﻪ ﺑﻪ ﺻﻮﺭﺕ‬PDR, PDQ) ‫ ﺩﻭ ﺭﻓﺮﺍﻧﺲ‬.‫ ﻭﺟﻮﺩ ﻳﻚ ﺭﻓﺮﺍﻧﺲ ﺟﺎﻣﻊ ﻭ ﻣﻌﺘﺒﺮ ﺍﻃﻼﻋﺎﺕ ﺩﺍﺭﻭﺋﻲ ﺿﺮﻭﺭﻱ ﻣﻲﻧﻤﺎﻳﺪ‬،‫ ﺻﺮﻓﻨﻈﺮ ﺍﺯ ﻧﻮﻉ ﺗﺨﺼﺺ‬،‫ﺩﺭ ﻣﻄﺐ ﺭﻭﻱ ﻣﻴﺰ ﻛﺎﺭ ﻫﺮ ﭘﺰﺷﻚ‬
.‫ ﺭﺍ ﺑﻪ ﺩﺳﺖ ﺁﻭﺭﺩ‬... ‫ ﻋﻮﺍﺭﺽ ﺟﺎﻧﺒﻲ ﻭ‬،‫ ﻛﻨﺘﺮﺍﺍﻧﺪﻳﻜﺎﺳﻴﻮﻥﻫﺎ‬،‫ ﺍﻧﺪﻳﻜﺎﺳﻴﻮﻥﻫﺎ‬،‫ﻛﻪ ﺑﺎ ﺍﺳﺘﻔﺎﺩﻩ ﺍﺯ ﺁﻧﻬﺎ ﻣﻲﺗﻮﺍﻥ ﺩﺭ ﻛﻤﺘﺮﻳﻦ ﺯﻣﺎﻥ ﻣﻤﻜﻦ ﻛﻠﻴﺔ ﺍﻃﻼﻋﺎﺕ ﻻﺯﻡ ﺩﺭ ﻣﻮﺭﺩ ﺩﺍﺭﻭﻱ ﻣﻮﺭﺩ ﻧﻈﺮ ﻣﻦﺟﻤﻠﻪ ﺩﻭﺯﺍﮊ‬

PDQ Pharmacology ‫( ﻃﺮﻳﻘﺔ ﻧﺼﺐ‬

.‫ ﻛﻨﻴﺪ‬Next ‫ ﭘﻨﺠﺮﺓ ﺟﺪﻳﺪﻱ ﺑﺎﺯ ﻣﻲﺷﻮﺩ‬.‫ ﺭﺍ ﺍﻧﺘﺨﺎﺏ ﻛﻨﻴﺪ‬١ ‫ ﺑﻨﺎﺑﺮﺍﻳﻦ ﮔﺰﻳﻨﺔ‬.‫ ﺭﺍ ﻧﺼﺐ ﻛﻨﻴﻢ‬Acroba Reader ‫ ﭘﻨﺠﺮﻩﺍﻱ ﻇﺎﻫﺮ ﻣﻲﺷﻮﺩ ﺑﺮﺍﻱ ﺷﺮﻭﻉ ﻣﻲﺑﺎﻳﺴﺘﻲ ﺑﺮﻧﺎﻣﺔ‬.‫ ﺑﺮﻧﺎﻣﻪ ﺑﺼﻮﺭﺕ ﺍﺗﻮﻣﺎﺗﻴﻚ ﺍﺟﺮﺍ ﻣﻲﺷﻮﺩ‬،‫ ﺭﺍ ﺩﺭﻭﻥ ﺩﺭﺍﻳﻮ ﻗﺮﺍﺭ ﻣﻲﺩﻫﻴﻢ‬CD ‫ﺍﺑﺘﺪﺍ‬
.‫ ﻗﺎﺑﻞ ﺍﺟﺮﺍ ﺍﺳﺖ‬Adobe Aerobat Reader ‫( ﺍﻳﻦ ﺑﺮﻧﺎﻣﻪ ﺗﺤﺖ ﺑﺮﻧﺎﻣﺔ‬Start) ‫ ﺭﺍ ﺍﺯ ﺍﻭﻟﻴﻦ ﭘﻨﺠﺮﻩ ﺍﻧﺘﺨﺎﺏ ﻛﻨﻴﺪ‬٢ ‫ ﺑﺮﺍﻱ ﺍﺟﺮﺍﻱ ﺑﺮﻧﺎﻣﺔ ﺍﺻﻠﻲ ﮔﺰﻳﻨﺔ‬.‫ ﺭﺍ ﻓﺸﺎﺭ ﺩﻫﻴﺪ‬OK ‫ ﺩﺭ ﻧﻬﺎﻳﺖ‬.‫ ﻛﻨﻴﺪ‬Next ‫ﭘﻨﺠﺮﺓ ﻓﻌﻠﻲ ﻣﺴﻴﺮ ﻧﺼﺐ ﺭﺍ ﻣﺸﺨﺺ ﻣﻲﻛﻨﺪ ﺩﺭ ﺻﻮﺭﺕ ﺗﻮﺍﻓﻖ ﺑﺎ ﺁﻥ‬
31.13 PDR for Herbal Medicines (Third Edition) (David Heber, MD. Phd, Facp, FACN) 2004

32.13 PHARMACOLOGY (Thomas L. Pazderink, Laszlo Kerecsen, Mrugshkumar K. Shah) (Mosby) 2003
33.13 PHYSICANAS' CANCER CHEMOTHERAPHY DRUG MANUAL (Jones & Bartlett) 2004
- Principles of Cancer Chemotheraphy - Physician's Cancer Chemotherapy Drug Manual 2004 - Guidelines for Chemotherapy and Dosing Modifications
- Common Chemotherapy Regimens in Clinical Practice - Antimetic Agents for the Treatment of Chemotherapy-Induced Nausea and Vomiting
34.13 The Analysis of Controlled Substances (Michael D. Cole) (Wiley) 2003
35.13 The Aqueous Cleaning Handbook A Guide to Critical-cleaning Procedures, Techniques, and Validation) 2002
36.13 The Constituents of Medicinal Plant (2nd Edition) (An introduction to the chemistry and therapeutics of herbal medicine) 2004

37.13 The Herbalist (David L. Hoffman) ___

-Basic Principles -Human Systems -Actions -Herbal Materia Medica
38.13 THE MERCK INDEX on CD-ROM (Version 12:3) 2000
39.13 USP 27-NF 22 Through Supplement Two (U.S. PHARMACOPEIA) (The standard of Quality) (The United States Phamocopeial Convention, Inc) 2004

40.13 Workplace Safety Volume 4 of the Savety at Work Series (John Ridley, John Channing) ‫ــــ‬

٠٩١٢١٣٧٢٣٦١-٦٦٩٣٦٦٩٦ :‫ﺗﻠﻔﻦ‬ ٢٣٩ ‫ ﭘﻼﻙ‬،‫ ﺑﻦﺑﺴﺖ ﺳﻴﻤﻴﻦ‬،‫ ﺑﻴﻦ ﻛﺎﺭﮔﺮ ﻭ ﺟﻤﺎﻟﺰﺍﺩﻩ‬،‫ ﺥ ﻟﺒﺎﻓﻲﻧﮋﺍﺩ‬،‫ ﺥ ﻛﺎﺭﮔﺮ ﺟﻨﻮﺑﻲ‬،‫ ﻡ ﺍﻧﻘﻼﺏ‬،‫ ﺗﻬﺮﺍﻥ‬:‫ﻧﺸﺎﻧﻲ‬ ‫ ﺍﺭﺍﺋﻪ ﻛﻨﻨﺪﺓ ﻛﺘﺎﺏ ﻭ ﺳﻲﺩﻱﻫﺎﻱ ﺗﺨﺼﺼﻲ ﭘﺰﺷﻜﻲ‬: ‫ﻣﺮﻛﺰ ﺧﺪﻣﺎﺕ ﻓﺮﻫﻨﮕﻲ ﺳﺎﻟﻜﺎﻥ‬
 61
‫ ﺯﺑﺎﻥ‬:١٤

CD ‫ﻋﻨﻮﺍﻥ‬ ‫ﺳﺎﻝ ﺍﻧﺘﺸﺎﺭ‬

1.14 BUILDING A MEDICAL VOCABULARY (FIFTH EDITION) (FEGGY C. LEONARD) (W.B. Saunders Company) 2001
2.14 ELECTRONIC MEDICAL DICTIONARY (STEDMAN'S) (LIPPINCOTT WILLIAMS & WILKINS) 2001
3.14 English Family (Merriam-Webster) ‫ــــ‬
4.14 Entertainment Collection ‫ــــ‬

5.14 How to Prepare for TOEFL ‫ــــ‬

6.14 Learn To Speak English Dictionary & Grammer (CD1-4) ‫ــــ‬
7.14 Mad About English Spelling (Interactive Learning) ‫ــــ‬
8.14 Medical Information on the Internet (A Guide for Health Professionals) (Second Edition) (Robert Kiley) ‫ــــ‬

Why use the Internet? Getting Wired Finding what you want The top ten medical resources
Internetive Learning E-mail, discussion lists and newsgroups The quality issue Consumer health information
The future Appendix A: Finding more information information Appendix B: Netscape Navigator and Internet Appendix C: Optimising your computer
Appendix D: Configuring TCP/IP Appendix E: Glossary
9.14 Preparation For the TOEFL (Dictionary Crossword Puzzle Matching Game) ‫ــــ‬
10.14 Preparing for the GRE Writing Assessment ‫ــــ‬
What does the GRE General Test measure? The GRE General Test is designed to measuregeneral knowledge and reasoning skills in three areas that are important
for a academic achievement: Verbal Ability Quantitative Ability Analytical Ability
11.14 Speak Fluent Series ‫ــــ‬

12.14 Studying a Study Texting a Test (Fourth Edition) (Richard K. Riegelman) ‫ــــ‬
Accreditation Statement Instructions to Users Lippincott Williams & Wilkins Continuing Medical Education CME User assessment Faculty Credentials/Disclosure
Designation Statement Target Audience Test-CME Needs Assessment Glossary Learning Objectives
13.14 The AMERICAN HERITAGE® TALKING DICTIONARY (Daniel Finkel) ‫ــــ‬
14.14 THE LANGUAGE OF MEDICINE (6
TH
EDITION) (W.B. Saunders Company) 2000
1. Word Ports (Chapters 1-4) 2.Body Systems (Chapter 5-18) 3. Specialties (Chapter 19-22)

15.14 TriplePlayPlus! ENGLISH (Syracuse Languag Systems) ‫ــــ‬

16.14 Users' Guides To The Medical Literature (A manual for Evidence-Based Clinical Practice) (Gordon Guyatt, MD, Drummond Rennie, MD, Robert Hayward, MD) 2002

‫ ﺟﺮﺍﺣﻲ‬-١٥

CD ‫ﻋﻨﻮﺍﻥ‬ ‫ﺳﺎﻝ ﺍﻧﺘﺸﺎﺭ‬

1.15 1. Reflux Disease and Nissen Fundoplication (Philip E. Donahue, MD) (VCD) ‫ــــ‬
2. Supraceliac Aortic-Celiac Axix-Superior Mesenteric Artery Bypass (Gregorio A. Sicard, Charles B. Anderson)

٠٩١٢١٣٧٢٣٦١-٦٦٩٣٦٦٩٦ :‫ﺗﻠﻔﻦ‬ ٢٣٩ ‫ ﭘﻼﻙ‬،‫ ﺑﻦﺑﺴﺖ ﺳﻴﻤﻴﻦ‬،‫ ﺑﻴﻦ ﻛﺎﺭﮔﺮ ﻭ ﺟﻤﺎﻟﺰﺍﺩﻩ‬،‫ ﺥ ﻟﺒﺎﻓﻲﻧﮋﺍﺩ‬،‫ ﺥ ﻛﺎﺭﮔﺮ ﺟﻨﻮﺑﻲ‬،‫ ﻡ ﺍﻧﻘﻼﺏ‬،‫ ﺗﻬﺮﺍﻥ‬:‫ﻧﺸﺎﻧﻲ‬ ‫ ﺍﺭﺍﺋﻪ ﻛﻨﻨﺪﺓ ﻛﺘﺎﺏ ﻭ ﺳﻲﺩﻱﻫﺎﻱ ﺗﺨﺼﺼﻲ ﭘﺰﺷﻜﻲ‬: ‫ﻣﺮﻛﺰ ﺧﺪﻣﺎﺕ ﻓﺮﻫﻨﮕﻲ ﺳﺎﻟﻜﺎﻥ‬
 62
2.15 Advanced Therapy in THORACIC SURGERY (Kenneth L. Franco, MD, Joe B. Putnam Jr., MD) ‫ــــ‬
3.15 Aesthetic Department ‫ــــ‬
ARTECOLL: Injectable micro-Implant, for long lasting levelling of facial wrinkles and folds
M-Implants By Rofil THE BEAUTY PHILOSOPHY: M-Implantans by Rofil you and your patients with the highest quality mammary implants in every option possible.
4.15 American Collage of Surgeons ACS Surgery Principles & Practice (CDI , II) ‫ــــ‬
5.15 Aspects of Electrosurgery (Dr. Anthony C. Easty, PhD PEng CCE) Department Medical Engineering ‫ــــ‬
6.15 Atlas of Liposuction (Tolbert s. Wilkinson, MD) (Salekan E-Book) 2005
7.15 Atlas of RENAL TRANSPLANTATION (Prof. Legndre, Martin, Helenon, Lebranchu, Halloran, Nochy) ‫ــــــ‬
-Histopathology -surgery -clinical section -imaging -immunology -immunosupperssive
8.15 Basic Surgical Skills (David A. Sherris. M.D., Eugene B. Kern, M.D.) (Mayo Clinic) ‫ــــ‬
9.15 Breast-Augmentation with NovagoldTM The PVP-Hydrogel Filled Implant ‫ــــ‬

10.15 Case Presentations In Plastic Surgery (Christopher Stone, Consultant Plastic Surgeon) 2004

11.15 Cholecystectomy by Laparoscopy (Department of Surgery Hospitalor Saint-Avold France) (VCD) ‫ــــ‬
1. Appendicectomy 2. Highly Selective Vagotomy 3. Taylor's Operation
12.15 Clinical Surgery (Second Edition) (Michael M. Henry, Jeremy N. Thompson) (Salekan E-Book) 2005
12.3 Core Curriculum in Primary Care Gynecology (Michael, Isaac Schiff, Keith, Thomas, Annekathryn) ‫ــــــ‬
13.15 Core Curriculum in Primary Care Gynecology (Michael, Isaac Schiff, Keith, Thomas, Annekathryn) ‫ــــــ‬

14.15 VCD 1: Rhinophyma (9:52) - Alloderm Lip Augmentation (14:04) - Collagen Injection Sequence
‫ــــ‬
COMPREHENSIVE FACIAL REJUVENATION

15.15 VCD 2: Full-Face Jessner’s/35% Trichloroacetic Acid Pell (31:21)

(A practical and systematic guide to surgical

16.15 VCD 3: Combined Resurfacing Technique for Aone Scarring (10:18) ‫ــــ‬
Botox Reconstitution and Injection Sequence (20:53) - Carbon Dioxide Laser Resurfacing (8:10)
2000
management of the aging face)

17.15 VCD 4: Postoperative Care of the Chemical Peel Patient (31:21)

18.15 VCD 5: Transconjunctival Lower-Lid Blepharoplasty (9:05) ‫ــــ‬
Skin-Muscle Flap Lower-Lid Blepharoplasty with Midface Extension (16:20)
19.15 VCD 6: Follicular Transfer Hair Transplantation Session (30:20) ‫ــــ‬

20.15 VCD 7: Upper-Lid Blepharoplasty (11:25) - Chin Augmentation with Gore-Tex Alloplast (13:21) ‫ــــ‬
21.15 VCD 8: Minimal Incision Brow and Midface Lift (31:02) ‫ــــ‬
22.15 VCD 9: Primary Facelift (37:17) ‫ــــ‬
23.15 VCD 10: Secondary Facelift with Gore-Tex Sling (30:21) ‫ــــ‬

24.15 ‫ــــ‬
VCD 11: Scalp Reduction Sessions (31:47)

٠٩١٢١٣٧٢٣٦١-٦٦٩٣٦٦٩٦ :‫ﺗﻠﻔﻦ‬ ٢٣٩ ‫ ﭘﻼﻙ‬،‫ ﺑﻦﺑﺴﺖ ﺳﻴﻤﻴﻦ‬،‫ ﺑﻴﻦ ﻛﺎﺭﮔﺮ ﻭ ﺟﻤﺎﻟﺰﺍﺩﻩ‬،‫ ﺥ ﻟﺒﺎﻓﻲﻧﮋﺍﺩ‬،‫ ﺥ ﻛﺎﺭﮔﺮ ﺟﻨﻮﺑﻲ‬،‫ ﻡ ﺍﻧﻘﻼﺏ‬،‫ ﺗﻬﺮﺍﻥ‬:‫ﻧﺸﺎﻧﻲ‬ ‫ ﺍﺭﺍﺋﻪ ﻛﻨﻨﺪﺓ ﻛﺘﺎﺏ ﻭ ﺳﻲﺩﻱﻫﺎﻱ ﺗﺨﺼﺼﻲ ﭘﺰﺷﻜﻲ‬: ‫ﻣﺮﻛﺰ ﺧﺪﻣﺎﺕ ﻓﺮﻫﻨﮕﻲ ﺳﺎﻟﻜﺎﻥ‬
 63
25.15 Core Curriculum in Primary Care Patient Evaluation for Non-Cardiac Surgery and Gynecology and Urology (Michael K. Rees, MD, MPH) ‫ــــ‬

.‫ ﺑﻨﺎ ﻧﻬﺎﺩﻩ ﺷﺪﻩ ﺍﺳﺖ‬Harvard ‫ﻫﺎﻳﻲ ﻣﻲﺑﺎﺷﺪ ﻛﻪ ﺑﺮﺍﻱ ﺁﻣﻮﺯﺵ ﻣﺪﺍﻭﻡ ﺩﺳﺘﻴﺎﺭﺍﻥ ﻭ ﻣﺘﺨﺼﺼﻴﻦ ﻫﺮ ﺭﺷﺘﻪ ﺗﻮﺳﻂ ﺍﻋﻀﺎﺀ ﻫﻴﺌﺖ ﻋﻠﻤﻲ ﺩﺍﻧﺸﮕﺎﻩ ﭘﺰﺷﻜﻲ‬CD ‫ ﻣﺠﻤﻮﻋﻪﺍﻱ ﺍﺯ‬CCC
‫ ﺳﺆﺍﻻﺕ ﻣﺮﺑﻮﻃﻪ ﺑﻪ ﺻـﻮﺭﺕ ﭼﻬﺎﺭﮔﺰﻳﻨـﻪﺍﻱ‬،‫ ﺩﺭ ﺁﺧﺮ ﻫﺮ ﺳﺨﻨﺮﺍﻧﻲ ﻭ ﻣﺒﺤﺜﻲ‬.‫ ﻫﺮ ﻛﺪﺍﻡ ﺍﺯ ﺍﻳﻦ ﺳﺨﻨﺮﺍﻧﻲﻫﺎ ﻋﻼﻭﻩ ﺑﺮ ﺍﺳﻼﻳﺪﻫﺎﻱ ﺁﻣﻮﺯﺷﻲ ﻣﺘﻦ ﺳﺨﻨﺮﺍﻧﻲ ﻧﻴﺰ ﺩﺭ ﺩﺳﺘﺮﺱ ﻛﺎﺭﺑﺮ ﻣﻲﺑﺎﺷﺪ‬.‫ ﺯﻧﺎﻥ ﻭ ﺍﻭﺭﻭﮊﻱ ﺭﺍ ﮔﺮﺩﺁﻭﺭﻱ ﻛﺮﺩﻩ ﺍﺳﺖ‬،‫ ﺣﺎﺿﺮ ﺩﺭ ﻣﻮﺭﺩ ﺟﺮﺍﺣﻲ‬CD
:‫ ﺷﺎﻣﻞ ﻣﺒﺎﺣﺚ ﺯﻳﺮ ﻣﻲﺑﺎﺷﺪ‬.‫ ﺳﭙﺲ ﺧﻼﺻﻪ ﻫﺮ ﺳﺨﻨﺮﺍﻧﻲ ﺑﻪ ﺻﻮﺭﺕ ﻳﻚ ﻣﻘﺎﻟﻪ ﭼﺎﭘﻲ ﺩﺭ ﻣﺠﻼﺕ ﻋﻠﻤﻲ ﻭ ﺭﻭﺯﻧﺎﻣﻪﻫﺎ ﺁﻭﺭﺩﻩ ﺷﺪﻩ ﺍﺳﺖ‬.‫ﺑﺮﺍﻱ ﺍﺭﺯﻳﺎﺑﻲ ﻛﺎﺭﺑﺮ ﺁﻭﺭﺩﻩ ﺷﺪﻩ ﺍﺳﺖ‬
Male impotence ‫ ﻋﻘﻴﻤﻲ ﻣﺮﺩﺍﻥ‬-٣ .(AUB) ‫ﺍﺭﺯﻳﺎﺑﻲ ﺧﻮﻧﺮﻳﺰﻱﻫﺎﻱ ﺍﺑﻨﺮﻣﺎﻝ ﺭﺣﻢ‬ -٢ ‫ ﭼﮕﻮﻧﻪ ﻳﻚ ﺑﻴﻤﺎﺭ ﺭﺍ ﺑﺮﺍﻱ ﺍﻋﻤﺎﻝ ﺟﺮﺍﺣﻲ )ﺑﺠﺰ ﺟﺮﺍﺣﻲ ﻗﻠﺐ( ﺍﺭﺯﻳﺎﺑﻲ ﻭ ﺁﻣﺎﺩﻩ ﻛﻨﻴﻢ؟‬-١

.‫ ﺁﻭﺭﺩﻩ ﺷﺪﻩ ﺍﺳﺖ‬text ‫ ﺳﺆﺍﻻﺕ ﺷﻨﻮﻧﺪﮔﺎﻥ ﻭ ﺟﻮﺍﺏ ﺳﺨﻨﺮﺍﻥ ﻧﻴﺰ ﺑﻪ ﺻﻮﺭﺕ‬،‫ﺩﺭ ﺁﺧﺮ ﻫﺮ ﺳﺨﻨﺮﺍﻧﻲ‬
26.15 FACIAL SURGERY Plastic and Reconstructive ‫ــــ‬

27.15 LAPAROTOMY (Royal Society of Medicine in association with Royal College of Surgeons of England) (VCD) ‫ــــ‬
28.15 Lipostructure (Sydncy Coleman, M.D.) (byron) (VCD) ‫ــــ‬
29.15 Lower Body Lift (Abdominoplasty) (Lockwood, M. d., Kansas Gity) (VCD) (CD I , II) ‫ــــ‬
30.15 MALAR AUGMINTATION (CLINICAL MIRASIERRA MADRID) (Ulrich T. Hinderer Dr. Juan L. Del Rio) (VCD) ‫ــــ‬

31.15 Mammary augmention by High-Cohesive Silicon Gel Implant (Igar Nicchajev, Goran Jurell) ‫ــــ‬

32.15 Mastery of Endoscopic & Laparoscopic Surgery (Second Edition) 2005

33.15 NMS Surgery Tutor (Dereck Mooney, T. Mack Brown, Cristian Jansenson, Denise Riedlinger) 2000
34.15 Open Repair of Abdominal Wall Hernias Using Prosthetic materials (Arthur I. Gilbert, M.D.) ‫ــــ‬

-Small Bowel Obstrution Immediately Following Laparoscopic Herniorraphy (Karl A. Zucher, MD)
-VJGS Case Study: Laparoscopic Loop Ilestomy for Temporary Fecal Diversion (Steven D. Wexner, Petachia Reissman)
-VJGS Consultants Corner: Managed Care Update, Pt, III (Michael A. Wood)
35.15 Plastic and Reconstructive Breast Surgery (Second Edition) (Volume 1 , 2) ‫ــــ‬

36.15 Plug Repair for Inguinal Hernias ‫ــــ‬

1- First Case: Inguinal Hernia type "Direct" 2- Second Case: Injuinal Hernia type "Indirect"
25.6 Practical MINOR SURGERY ‫ــــ‬
37.15 Principles of Surgery (Eight Edition) (Schwartz's) (E-Book) (CD I , II) 2005
Part1: Basic Considerations Part II: Specific Considerations
38.15 SCHWARTZ'S PRINCIPLES OF SURGERY (8th Edition) (F. Charles Brunicardi, Dana K. Andersen, Timothy R. Billiar) (Salekan e-book) (CD I, II) 2005

39.15 Single Puncture Laparoscopic Technique (Marco Pelosi, MD) (VCD) ‫ــــ‬
40.15 Structural Fat Grafting (Sydney R. Caleman) (E-book & Film) 2004

41.15 Submitted Subject: Transvaginal Sonographic Assessment of Pelvic Pathology: Preoperative Evaluation (Frances R. Batzer, MD) ‫ــــ‬
42.15 SURGERY (John D Corson, Robin CN Willimson) (Launching Slide Vision) (Mosby)
‫ــــ‬
-Surgical Principles and Critical Care -Trauma -Gastrointestinal surgery -Vascular Surgery -Brast and Endoceine Surgery -Transplantation Surgery -Allied Surgical Specialties

٠٩١٢١٣٧٢٣٦١-٦٦٩٣٦٦٩٦ :‫ﺗﻠﻔﻦ‬ ٢٣٩ ‫ ﭘﻼﻙ‬،‫ ﺑﻦﺑﺴﺖ ﺳﻴﻤﻴﻦ‬،‫ ﺑﻴﻦ ﻛﺎﺭﮔﺮ ﻭ ﺟﻤﺎﻟﺰﺍﺩﻩ‬،‫ ﺥ ﻟﺒﺎﻓﻲﻧﮋﺍﺩ‬،‫ ﺥ ﻛﺎﺭﮔﺮ ﺟﻨﻮﺑﻲ‬،‫ ﻡ ﺍﻧﻘﻼﺏ‬،‫ ﺗﻬﺮﺍﻥ‬:‫ﻧﺸﺎﻧﻲ‬ ‫ ﺍﺭﺍﺋﻪ ﻛﻨﻨﺪﺓ ﻛﺘﺎﺏ ﻭ ﺳﻲﺩﻱﻫﺎﻱ ﺗﺨﺼﺼﻲ ﭘﺰﺷﻜﻲ‬: ‫ﻣﺮﻛﺰ ﺧﺪﻣﺎﺕ ﻓﺮﻫﻨﮕﻲ ﺳﺎﻟﻜﺎﻥ‬
 64
43.15 Surgery of the Liver & Biliary Tract 3e: Selected Operative Procedures (L.H. BLUMGART, Y. FONG) (W.B. Saunders) 2000
-Hepatic Procedures -Biliary Procedures -Special Procedures
44.15 The Distal Splenorenal Shunt: Effective or Obsolete? (VIDEO JOURNAL OF GENERAL SURGERY) (Layton Fredrick Rikkers, M.D.) (VCD) ‫ــــ‬
- Options for Treating Portal Hypertension -Ideal Candidates for Distal Splenorenal Shunt -Components of Distal Splenorenal Shunt Procedure
-HIPS Advantages -HIPS Disadvantages -Distal Splenorenal Shunt Patency
45.15 The Ileana Pull-through Operative Prpcedure of Ulcerative Colitis: Eliminating the Permanent Ileostomy (Eric W. Fonkalseud, M.D.) (VCD) ‫ــــ‬

46.15 The Massachusetts General Hospital Handbook of Pain Management (Second Edition) (Jane Ballantyne, Scott M. Fishman, Salahadin Abdi) (SALEKAN-E-book) ‫ــــ‬
- General Considerations - Diagnosis of Pain - Therapeutic Options: Pharmacologic Approaches - Therapeutic Options: Nonpharmacologic Approaches
- Acute Pain - Chronic Pain - Pain Due to Cancer - Special Situations - Apendices - Subject Index
47.15 TISSUE ADHESIVES In Wound Care (James V. Quinn, M.D., FACEP) ‫ــــ‬
48.15 Tissue Glues in Cosmetic Surgery (RENATO SALTZ, M.D., DEAN M. TORIUMI, M.D.) (Salekan E-Book) 2004

49.15 Tolaryngology Surgery for Fronatal Sinus Disease (Professor & Chairman, Bobby R. Alford, M.D.) (VCD) ‫ــــ‬

50.15 Video Journal General Surgery (VCD) ‫ــــ‬

1. Reflux Disease and Nissen Fundoplication (Philip E. Donahue, MD)
2. Supraceliac Aortic-Celiac Axis-Superior Mesenteric Artery Bypass (Gregorio, Leonardo, Brent, Charles)

51.15 Video Journal General Surgery (VCD) ‫ــــ‬

1. Open Repair of Abdominal Wall Hernias Using Prosthetic materials (Arthur I. Gilbert, M.D.)
2. Small Bowel Obstrution Immediately Following Lapatoscopic Herniorraphy (Karl A. Zucker, MD)
3. Laparoscopic Loop Ileostomy For Temporary Fecal Diversion (Steven D. Wxner, MD, Petachia Reissman, MD)
4. Consultants Corner: Managed Care Update, Pt, III (Michael A. Wood)

‫ ﺩﻧﺪﺍﻧﭙﺰﺷﻜﻲ‬-١٦

CD ‫ﻋﻨﻮﺍﻥ‬ ‫ﺳﺎﻝ ﺍﻧﺘﺸﺎﺭ‬

1.16 Burkect's Oral Medicine Diagnosis and Treatment ‫ــــ‬

‫ ﻣﻼﺣﻈﺎﺕ ﺩﻧﺪﺍﻧﭙﺰﺷﻜﻲ ﺩﺭ ﺑﻴﻤﺎﺭﺍﺕ ﺩﺍﺭﺍﻱ ﺑﻴﻤﺎﺭﻱ ﺳﻴﺴﺘﻤﻴﻚ‬- ‫ ﺁﻧﻬﺎ‬Manage ‫ﺍﺧﺘﻼﻻﺕ ﺗﻤﭙﻮﺭﻭﻣﻨﺪﻣﺒﻮﻻﺭ ﻭ‬- ‫ﻛﺮﺩﻥ ﺑﻴﻤﺎﺭﺍﻥ‬Mange ‫ ﭼﮕﻮﻧﮕﻲ ﺗﺸﺨﻴﺺ ﻭ‬-
2.16 Caratera's Clinical PERIODONTOLOGY 9th Edition ‫ــــ‬
PDL ‫– ﻧﺤﻮﻩ ﺩﺭﻣﺎﻥ ﺑﻴﻤﺎﺭﻱﻫﺎﻱ ﻟﺜﻪ ﻭ‬ ... ‫ ﻭ‬PPL ‫ ﻃﺒﻘﻪﺑﻨﺪﻱ ﺑﻴﻤﺎﺭﻱ ﻟﺜﻪ ﻭ‬- ‫ ﺑﺮﺭﺳﻲ ﺍﻧﻮﺍﻉ ﻟﺜﻪ ﻧﺮﻣﺎ‬- ‫ ﺩﻧﺪﺍﻧﭙﺰﺷﻜﻲ ﻭ ﭘﺮﻳﻮﺩﻭﻧﺘﻮﻟﻮﮊﻱ‬Textbook -
3.16 COLOR ATLAS OF Dental Medicine Aesthetic Dentistry (Josef Schnidsedes) ‫ــــ‬
:‫ﻋﻨﺎﻭﻳﻦ ﻣﻬﻢ ﺍﻳﻦ ﻧﺮﻡﺍﻓﺰﺍﺭ ﻋﺒﺎﺭﺗﻨﺪ ﺍﺯ‬
‫( – ﺑﺮﺭﺳﻲ ﺍﻧﻮﺍﻉ ﻭﻧﻴﺮﻭ ﺭﻭﺵﻫﺎ ﻭ ﺍﺻﻮﻝ ﻭﻧﻴﺮﻛﺮﺍﻭﻥ‬PFM) -(‫ ﻛﺎﻣﭙﺎﺯﻳﺖ ﺍﻓﻴﻠﻪ )ﻣﺰﺍﻳﺎ ﻭ ﻣﻌﺎﻳﺐ‬-‫ ﺩﺭﻣﺎﻥﻫﺎﻱ ﻗﺒﻞ ﺍﺯ ﺗﺮﻣﻴﻢ‬-‫ ﺑﺮﺭﺳﻲ ﺍﻧﻮﺍﻉ ﺳﺮﺍﻣﻴﻚ ﻛﺮﺍﻭﻥﻫﺎ‬-‫ ﺑﺮﺭﺳﻲ ﺍﻧﻮﺍﻉ ﻣﺘﺎﻝ ﻛﺮﺍﻭﻧﻬﺎ ﻭ ﺭﻭﺵﻫﺎﻱ ﻛﺮﺍﻭﻥﻛﺮﺩﻥ‬-‫ ﺩﻧﺪﺍﻧﭙﺰﺷﻜﻲ ﺯﻳﺒﺎﻳﻲ‬-‫ﺍﻃﻠﺲ ﺭﻧﮕﻲ ﺩﺭﻣﺎﻥﻫﺎﻱ ﺩﻧﺪﺍﻧﻲ‬
4.16 Color Atlas of Endodontics (William T. Johnson DDS.MS) ‫ــــ‬
(Retreatment) ‫ – ﺩﺭﻣﺎﻥ ﻣﺠﺪﺩ‬... ‫ ﺁﻣﺎﺩﻩﻛﺮﺩﻥ ﻛﺎﻧﺎﻝ ﻭ‬- ‫ ﺗﺸﺨﻴﺺ ﻭ ﺍﻧﺪﺍﺯﻩﮔﻴﺮﻱ ﻃﻮﻝ ﻛﺎﻧﺎﻝ ﺭﻳﺸﻪ‬- Acsess ‫ ﺭﻭﺵﻫﺎﻱ‬- ‫ ﺭﻭﺵﻫﺎﻱ ﺗﺸﺨﻴﺺ‬-
5.16 Contemporary Orthodontics PROFFIT ‫ــــ‬
.. ‫ ﻭ‬TMJ ‫ ﺍﺧﺘﻼﻻﺕ‬- ‫ ﻣﻜﺎﻧﻴﺴﻢﻫﺎ ﻭ ﺑﻴﻮﻣﻜﺎﻧﻴﺴﻢﻫﺎ‬- ‫ ﺗﺸﺨﻴﺺ ﻭ ﻃﺮﺡ ﺩﺭﻣﺎﻥ‬- ‫ ﻧﺤﻮﻩ ﺗﻜﺎﻣﻞ ﺍﻳﺮﺍﺩﺍﺕ ﺍﺭﺗﻮﺩﻭﻧﺴﻲ‬- ‫ ﻣﺸﻜﻼﺕ ﺍﺭﺗﻮﺩﻭﻧﺴﻲ‬- ‫ ﺍﺭﺗﻮﺩﻭﻧﺴﻲ ﺩﺭ ﺩﻧﺪﺍﻧﭙﺰﺷﻜﻲ‬Textbook - ‫ ﺍﺭﺗﻮﺩﻭﻧﺴﻲ ﻧﻮﻳﻦ‬-
6.16 Craniofacial Development ‫ــــ‬
... ‫ ﻣﻨﺪﻳﺒﻮﻝ ﻭ‬- ‫ ﺳﻴﻨﻮﺱﻫﺎﻱ ﭘﺎﺭﺍﻧﺎﺯﺍﻝ‬-

٠٩١٢١٣٧٢٣٦١-٦٦٩٣٦٦٩٦ :‫ﺗﻠﻔﻦ‬ ٢٣٩ ‫ ﭘﻼﻙ‬،‫ ﺑﻦﺑﺴﺖ ﺳﻴﻤﻴﻦ‬،‫ ﺑﻴﻦ ﻛﺎﺭﮔﺮ ﻭ ﺟﻤﺎﻟﺰﺍﺩﻩ‬،‫ ﺥ ﻟﺒﺎﻓﻲﻧﮋﺍﺩ‬،‫ ﺥ ﻛﺎﺭﮔﺮ ﺟﻨﻮﺑﻲ‬،‫ ﻡ ﺍﻧﻘﻼﺏ‬،‫ ﺗﻬﺮﺍﻥ‬:‫ﻧﺸﺎﻧﻲ‬ ‫ ﺍﺭﺍﺋﻪ ﻛﻨﻨﺪﺓ ﻛﺘﺎﺏ ﻭ ﺳﻲﺩﻱﻫﺎﻱ ﺗﺨﺼﺼﻲ ﭘﺰﺷﻜﻲ‬: ‫ﻣﺮﻛﺰ ﺧﺪﻣﺎﺕ ﻓﺮﻫﻨﮕﻲ ﺳﺎﻟﻜﺎﻥ‬
 ‫‪65‬‬
‫‪7.16‬‬ ‫‪Critical Decisious in Periodoutology‬‬ ‫)‪(Walte R.B.HALL‬‬ ‫ــــ‬
‫‪ -‬ﺩﺭﻣﺎﻥﻫﺎﻱ ﺟﺮﺍﺣﻲ ﻣﻮﺭﺩ ﻧﻴﺎﺯ ﺩﺭ ﭘﺮﻳﻮﺩﻭﻧﺘﻴﻜﺲ ﻭ ﺯﻳﺒﺎﻳﻲ‬ ‫‪ -‬ﻃﺮﺡ ﺩﺭﻣﺎﻥﻫﺎﻱ ﻣﻮﺭﺩ ﻧﻴﺎﺯ‬ ‫‪ -‬ﺑﺮﺭﺳﻲﻫﺎﻱ ﭘﺮﻳﻮﺩﻭﻧﺘﺎﻝ ‪ -‬ﺳﺎﺑﻘﻪ ﺑﻴﻤﺎﺭ ‪ -‬ﻧﺤﻮﻩ ﺷﻨﺎﺳﺎﻳﻲ ﺿﺎﻳﻌﺎﺕ‬
‫‪8.16‬‬ ‫‪Dental Assisting‬‬ ‫ــــ‬
‫‪ -‬ﺁﻣﻮﺯﺵ ﺑﻪ ﺻﻮﺭﺕ ﺗﺼﻮﻳﺮﻱ ‪ -‬ﻛﻠﻴﻪ ﺭﻭﺵﻫﺎﻱ ﻛﻨﺘﺮﻝ ﻋﻔﻮﻧﺖ ﺩﺭ ﻣﻄﺐ ‪ -‬ﺭﻭﺵﻫﺎﻱ ﻓﻠﻮﺭﺍﻳﺪﺗﺮﺍﭘﻲ ‪ -‬ﺭﻭﺵﻫﺎﻱ ﻣﻌﺎﻳﻨﻪ ﻭ ‪ Position‬ﺑﻴﻤﺎﺭ ﻭ ﺩﻧﺪﺍﻧﭙﺰﺷﻚ ‪ -‬ﺭﻭﺵ ﺻﺤﻴﺢ ﺍﺳﺘﻔﺎﺩﻩ ﺍﺯ ‪) Instroment‬ﻗﻠﻢﻫﺎ( ‪ -‬ﺭﻭﺵ ﻧﺼﺐ ﺭﺍﺑﺮﺩﻡ ﻭ ﺍﺳﺘﻔﺎﺩﻩ ﺻﺤﻴﺢ ﺍﺯ ﺁﻥ‬
‫‪ -‬ﺭﻭﺵﻫﺎﻱ ﺻﺤﻴﺢ ﺭﺍﺩﻳﻮﮔﺮﺍﻓﻲ ﮔﺮﻓﺘﻦ ﻭ ﻧﺤﻮﻩ ﻇﻬﻮﺭ ﺁﻧﻬﺎ ﻭ ﻛﻨﺘﺮﻝ ﻋﻔﻮﻧﺖ ﺗﺎﺭﻳﻜﺨﺎﻧﻪ ‪ -‬ﭘﺮﻳﻮﺩﻭﻧﺘﺎﻝ ‪ Dessing‬ﻭ ﻧﺤﻮﻩ ﺑﺮﺩﺍﺷﺘﻦ ﺁﻥ‬
‫‪9.16‬‬ ‫‪Dental Implant System‬‬ ‫ــــ‬
‫‪ -‬ﺍﻳﻨﺘﺮﻭﻣﻨﺖ ‪ -‬ﺁﻧﺎﻟﻴﺰ ﻭ ﺑﺮﺭﺳﻲ ﺭﻭﺵ ﻛﺎﺭ ‪ -‬ﺍﻋﻤﺎﻝ ﺟﺮﺍﺣﻲ ‪ -‬ﺗﺮﻣﻴﻢ ﻭ ﺁﻣﻮﺯﺵ ﺑﻴﻤﺎﺭ‬
‫‪10.16‬‬ ‫)‪Dental Implant System Fixed Implant Restorations (ITI Dental Implant System) (VCD‬‬ ‫ــــ‬
‫‪11.16‬‬ ‫‪Endodontics‬‬ ‫ــــ‬
‫‪ -‬ﺍﻳﻨﺘﺪﻭﻣﻨﺖﻫﺎﻱ ﺟﺪﻳﺪ – ‪ Shaping - Cleaning‬ﻭ ﺁﺩﺍﭘﺘﻪﻛﺮﺩﻥ ﺭﻭﺕﻛﺎﻧﺎﻝ ﻭ ‪...‬‬
‫‪12.16‬‬ ‫)‪Endodontics 5th Edition (John I. Ingle, DDS, MSD, Leif K. Bakland, DDS‬‬ ‫ــــ‬
‫‪13.16‬‬ ‫)‪ESSENTIAL OF ORAL MEDICINE (Silverman, Roy Eversole, Truelove‬‬ ‫ــــ‬
‫‪ -‬ﺑﺮﺭﺳﻲ ﺩﺭ ﺩﻫﺎﻥ ﺳﺮ ﻭ ﺻﻮﺭﺕ ﻫﻤﺮﺍﻩ ﺑﺎ ﺗﺼﺎﻭﻳﺮ ﺁﻣﻮﺯﺷﻲ ﻫﻤﺮﺍﻩ ﺑﺎ ‪Case‬ﻫﺎﻱ ﻣﺨﺘﻠﻒ ﻭ ﭘﺮﺳﺶ ﻭ ﭘﺎﺳﺦ‬ ‫‪ -‬ﻧﻜﺎﺕ ﺿﺮﻭﺭﻱ ﻓﺎﺭﻣﺎﻛﻮﻣﻮﺭﻋﻲ‬ ‫ﺑﺮﺭﺳﻲ ﺑﻴﻤﺎﺭﻱﻫﺎﻱ ﺳﻴﺴﺘﻤﻴﻚ ﻭ ﺗﻈﺎﻫﺮﺍﺕ ﺩﻫﺎﻧﻲ ﺁﻧﻬﺎ‬
‫‪14.16‬‬ ‫)‪ESTHETIC DENTISTRY 2th Edition (Dennet W. Aschheim, Barry G. Dale‬‬ ‫ــــ‬
‫‪ -٥‬ﺭﺯﻳﻨﺖﻫﺎﻱ ﭼﺴﺒﻨﺪﻩ ‪ -٦‬ﺑﻠﻴﭽﻴﻨﮓ )ﺳﻔﻴﺪﻛﺮﺩﻥ ﺩﻧﺪﺍﻥﻫﺎ( ‪ -٧‬ﺍﻳﻤﭙﻠﻨﺖ ﻭ ﺟﺮﺍﺣﻲ ﺩﻫﺎﻥ ﻭ ﺻﻮﺭﺕ‬ ‫‪ -٣‬ﭼﻴﻨﻲ ﻓﻮﻝﻛﺮﺍﻭﻥ ‪ -٤‬ﻭﻳﻨﻴﺮ )‪(PFM‬‬ ‫‪ -٢‬ﺳﺮﺍﻣﻴﻚ‪ -‬ﻣﺘﺎﻝ‬ ‫ﺍﺻﻮﻝ ﻭ ﺗﻜﻨﻴﻚﻫﺎﻱ‪-١ :‬ﺗﺮﻣﻴﻢﻫﺎﻱ ﻛﺎﻣﭙﺎﺯﻳﺖ‬
‫‪15.16‬‬ ‫)‪Esthetic Implant Dentistry (Daniel Buser, Hans Peter Hirt) (VCD‬‬ ‫ــــ‬
‫‪16.16‬‬ ‫)‪ESTHETIC IMPLANT DENTISTRY (Daniel A. Bases, Urs.E.Belses‬‬ ‫ــــ‬
‫‪ -٢‬ﺍﻳﻤﭙﻠﻨﺖ ﺩﻧﺪﺍﻧﻲ ﺗﻴﺘﺎﻧﻴﻮﻡ ﺑﺎ ﭘﻮﺷﺶ ‪TPS‬‬ ‫‪ -١‬ﺟﺎﻳﮕﺰﻳﻨﻲ ﺗﻚﺩﻧﺪﺍﻧﻲ ﺑﺎ ﺍﻳﻤﭙﻠﻨﺖ ‪ITI‬‬
‫ﺩﺭ ﺍﻳﻦ ﻧﺮﻡﺍﻓﺰﺍﺭ ﺗﻮﺿﻴﺤﺎﺕ ﻛﺎﻣﻞ ﻭ ﻧﺤﻮﺓ ﺟﺎﻳﮕﺬﺍﺭﻱ ﺍﻳﻤﭙﻠﻨﺖ – ﻣﺰﺍﻳﺎ ﻭ ﻣﻌﺎﻳﺐ ﺍﻧﻮﺍﻉ ﺍﻳﻤﭙﻠﻨﺖﻫﺎ‪ -‬ﺑﺮﺭﺳﻲ ﺑﺎﻓﺖ ﻧﺮﻡ ﻗﺒﻞ ﺍﺯ ﺍﻧﺠﺎﻡ ﺍﻳﻤﭙﻠﻨﺖ ﻭ ﺑﺮﺭﺳﻲ ﺩﺭﺻﺪ ﻣﻮﻓﻘﻴﺖ ﻧﺸﺎﻥ ﺩﺍﺩﻩ ﺷﺪﻩ ﺍﺳﺖ‪.‬‬
‫‪17.16‬‬ ‫)‪Esthetic in Dentistry (Vol 1- Vol 2‬‬ ‫ــــ‬
‫‪ -‬ﻣﺎﻝ ﺍﻛﻠﻮﮊﻱ‬ ‫‪ -‬ﻣﺸﻜﻼﺕ ﺯﻳﺒﺎﻳﻲ ﺗﻚﺩﻧﺪﺍﻧﻲ ‪ -‬ﺍﺯ ﺩﺳﺖﺩﺍﺩﻥ ﺩﻧﺪﺍﻥ‬
‫‪18.16‬‬ ‫)‪ESTHETICS IN DENTISTRY (Second Edition‬‬ ‫‪PRINCIPLES COMMUNICATIONS TREATMENT METHODS‬‬ ‫‪1998‬‬
‫‪19.16‬‬ ‫‪Glossary of Orthodontic Terms‬‬ ‫)‪(John Daskalogiannakis‬‬ ‫ــــ‬
‫‪20.16‬‬ ‫)‪Guide to Physical Examination (Mosby‬‬ ‫ــــ‬
‫ﺍﻳﻦ ﻧﺮﻡﺍﻓﺰﺍﺭ ﺑﺮﺭﺳﻲ ﺑﻬﺪﺍﺷﺖ ﺩﻫﺎﻧﻲ ﻭ ﺑﺮﺭﺳﻲ ﭼﻨﺪﻳﻦ ‪ Case‬ﻫﻤﺮﺍﻩ ﺑﺎ ﻋﻜﺲﻫﺎ ﻭ ﺭﺍﺩﻳﻮﮔﺮﺍﻓﻲﻫﺎﻱ ﺩﻫﺎﻧﻲ ﺭﺍ ﺗﻮﺿﻴﺢ ﻣﻲﺩﻫﺪ‪.‬‬
‫‪21.16‬‬ ‫‪Implant Medpor Mandibular A method to Restore Skeletal Support to the Lower Face‬‬ ‫)‪(Oscar M. Ramirez M.D., F.A.C.S.) (POREX) (VCD‬‬ ‫ــــ‬
‫‪22.16‬‬ ‫‪ITI Dental Implant‬‬ ‫)‪(CD I , II , III‬‬ ‫ــــ‬
‫‪ -‬ﻧﺤﻮﻩ ﺟﺮﺍﺣﻲ ﻟﺜﻪ ﻭ ﻓﻚ ﻭ ﺁﻣﺎﺩﻩﺳﺎﺯﻱ ﻣﺤﻞ‬ ‫‪ -‬ﻭﺳﺎﻳﻞ ﻣﻮﺭﺩ ﻧﻴﺎﺯ‬ ‫‪ -‬ﻛﻠﻴﻪ ﻣﺮﺍﺣﻞ ﺁﻣﺎﺩﻩﺳﺎﺯﻱ‬
‫‪23.16‬‬ ‫)‪ITI TE Solution ITI TE Implant (DENTAL IMPLANT SYSTEM) (Daniel Buser) (Disk 1-3‬‬ ‫‪2004‬‬
‫‪24.16‬‬ ‫‪Journal of Esthetic & Restorative Dentistry‬‬
‫‪ -٦‬ﺑﺮﺭﺳﻲ ﺭﻭﺵﻫﺎ ‪ -٧‬ﺍﻧﺪﻳﻜﺎﺳﻴﻮﻥﻫﺎ ‪ -٨‬ﺑﻠﻴﭽﻴﻨﮓ‬ ‫‪ -٣‬ﺳﺮﺍﻣﻴﻚ ﺍﻳﻨﻠﻪ ﻭ ﺍﻧﻠﻪ ‪ -٤‬ﻛﺎﻣﭙﺎﺯﻳﺖ ﺭﺯﻳﻦ ‪ -٥‬ﻛﺎﻣﭙﺎﺯﻳﺖ ﺭﺯﻳﻦ ‪Packable‬‬ ‫‪ -١‬ﺑﺮﺭﺳﻲ ﻛﺎﻣﻞ ﺍﻧﻮﺍﻉ ﺍﻧﻮﺍﻉ ﺗﺮﻳﺲﻫﺎ ‪ -٢‬ﮊﻭﺭﻧﺎﻝ ﺩﻧﺪﺍﻧﭙﺰﺷﻜﻲ ﺗﺮﻣﻴﻤﻲ ﻭ ﺯﻳﺒﺎﻳﻲ‬ ‫ــــ‬
‫‪ Crown -١١‬ﺗﻤﺎﻡ ﺳﺮﺍﻣﻴﻚ‬ ‫‪Post -١٠‬‬ ‫‪ -٩‬ﻋﻜﺲﻫﺎﻱ ﻛﺎﻣﻞ ﺍﺯ ﻣﺮﺍﺣﻞ ﺗﺮﻣﻴﻢ ﻫﻤﺮﺍﻩ ﺑﺎ ﺗﻮﺿﻴﺤﺎﺕ‬
‫‪25.16‬‬ ‫)‪LINGUAL ORTHODONTICS (Rafi Romano) (TO EXPLORE THE CD-ROM‬‬ ‫‪1998‬‬
‫‪26.16‬‬ ‫)‪Local Anesthesia in Dentistry (VCD‬‬ ‫ــــ‬
‫‪ -‬ﺑﺮﺭﺳﻲ ﺭﻭﺵﻫﺎﻱ ﺻﺤﻴﺢ ﻫﻤﺮﺍﻩ ﺑﺎ ﺗﺼﺎﻭﻳﺮﻱ ﮔﻮﻳﺎ ﺑﻪ ﺻﻮﺭﺕ ﻋﻤﻠﻲ ‪ -‬ﺧﻄﺮﺍﺕ ﻣﻮﺟﻮﺩ ﻭ ﺍﻳﺮﺍﺩﺍﺕ‬ ‫‪ -‬ﺭﻭﺵﻫﺎﻱ ﻣﺨﺘﻠﻒ ﺗﺰﺭﻳﻖ ﺑﺎ ﺍﻫﺪﺍﻑ ﻣﺘﻔﺎﻭﺕ ﺑﺮﺍﻱ ﺑﻲﺣﺴﻲ ﻧﻮﺍﺣﻲ ﻣﺨﺘﻠﻒ ﺩﻧﺪﺍﻥﻫﺎ ﻭ ﻟﺜﻪ ﻭ ﺑﺎﻓﺖ ﻧﺮﻡ‬

‫ﺗﻠﻔﻦ‪٠٩١٢١٣٧٢٣٦١-٦٦٩٣٦٦٩٦ :‬‬ ‫ﻧﺸﺎﻧﻲ‪ :‬ﺗﻬﺮﺍﻥ‪ ،‬ﻡ ﺍﻧﻘﻼﺏ‪ ،‬ﺥ ﻛﺎﺭﮔﺮ ﺟﻨﻮﺑﻲ‪ ،‬ﺥ ﻟﺒﺎﻓﻲﻧﮋﺍﺩ‪ ،‬ﺑﻴﻦ ﻛﺎﺭﮔﺮ ﻭ ﺟﻤﺎﻟﺰﺍﺩﻩ‪ ،‬ﺑﻦﺑﺴﺖ ﺳﻴﻤﻴﻦ‪ ،‬ﭘﻼﻙ ‪٢٣٩‬‬ ‫ﻣﺮﻛﺰ ﺧﺪﻣﺎﺕ ﻓﺮﻫﻨﮕﻲ ﺳﺎﻟﻜﺎﻥ ‪ :‬ﺍﺭﺍﺋﻪ ﻛﻨﻨﺪﺓ ﻛﺘﺎﺏ ﻭ ﺳﻲﺩﻱﻫﺎﻱ ﺗﺨﺼﺼﻲ ﭘﺰﺷﻜﻲ‬
 66
27.16 Local Anesthesia in Dentistry (Dr. Markus D. W. Lipp Wolfgang Kelm) (VCD) ‫ــــ‬
28.16 My Orthodontics ‫ــــ‬
‫ ﺩﺍﺭﺍﻱ ﻟﻴﻨﻚﻫﺎﻱ ﻣﺘﻌﺪﺩ ﻭ ﺁﺩﺭﺱﻫﺎﻱ ﺟﺎﻟﺐ ﺳﺎﻳﺖﻫﺎﻱ ﺍﺭﺗﻮﺩﻭﻧﺴﻲ‬- ‫ ﻣﺮﺍﻗﺒﺖﻫﺎﻱ ﺣﻴﻦ ﺩﺭﻣﺎﻥ‬، ‫ ﻧﺘﺎﻳﺞ ﺣﺎﺻﻠﻪ ﺍﺯ ﺩﺭﻣﺎﻥ‬- ‫ ﺑﻌﺪ ﺍﺯ ﺩﺭﻣﺎﻥ‬، ‫ ﻃﻲ ﺩﺭﻣﺎﻥ‬، ‫ ﻗﺒﻞ ﺍﺯ ﺩﺭﻣﺎﻥ‬- ‫ﺑﺮﺭﺳﻲ ﻣﺮﺍﺣﻞ ﻣﻌﺎﻳﻨﻪ‬-
29.16 Oral Disease Diagnosis & Treatment ‫ــــ‬
‫ ﻛﻴﺴﺖﻫﺎ ﻭ ﺗﻮﻣﻮﺭﻫﺎ‬- ‫ ﺿﺎﻳﻌﺎﺕ ﺑﺎﻓﺖ ﻫﻤﺒﻨﺪ‬- ‫ ﺍﺧﺘﻼﻻﺕ ﺭﻧﮕﺪﺍﻧﻪﺍﻱ‬- ‫ ﺷﺮﺍﻳﻂ ﺯﺧﻢﻫﺎ‬- ‫ ﺑﻴﻤﺎﺭﻱﻫﺎﻱ ﻭﺯﻳﻜﻮﻟﻮﺑﻮﻟﻮﺯ‬- ‫ ﺿﺎﻳﻌﺎﺕ ﺳﻔﻴﺪ ﺁﺑﻲ ﻗﺮﻣﺰ‬- ‫ ﺑﺮﺭﺳﻲ ﺍﻧﻮﺍﻉ ﺿﺎﻳﻌﺎﺕ ﺩﻫﺎﻥ‬-
30.16 Oral Pathology 4th edition ‫ــــ‬
‫ ﻣﻄﺎﻟﻌﺔ ﺟﺰﺋﻴﺎﺕ ﻭ ﻣﻼﺣﻈﺎﺕ ﻭ ﻣﺸﺨﺼﺎﺕ ﺑﻴﻤﺎﺭ ﻫﻤﺮﺍﻩ ﺑﺎ ﺗﺼﻮﻳﺮ‬- ‫ ﺑﺮﺭﺳﻲ ﺑﻪ ﺻﻮﺭﺕ ﺁﺯﻣﻮﻥ ﻫﻤﺮﺍﻩ ﺑﺎ ﺟﻮﺍﺏ ﺻﺤﻴﺢ‬- ‫ ﻣﺘﻔﺎﻭﺕ‬Case ٥٠ ‫ ﺑﺮﺭﺳﻲ ﺑﻴﺶ ﺍﺯ‬-
31.16 Orthodontics Current Principles and Techniques (Third Edition) (Thomas M. Graber, Robert L. Vanaradall, Jr.) ‫ــــ‬

32.16 Orthodontics & Paediatric Dentistry ‫ــــ‬

TMJ ‫ ﻣﺎﻝ ﺍﻛﻠﻮﮊﻥ ﻭ ﺍﺧﺘﻼﻻﺕ‬- Mixed dentition- ‫ ﻣﺎﻝ ﺍﻛﻠﻮﮊﻥ‬-
33.16 Orthodontics Priociples & Techniques 3th Edition ‫ــــ‬
‫ ﻭ ﺑﻴﻮﻣﻜﺎﻧﻴﺴﻢﻫﺎ‬TMJ ‫ ﺍﺧﺘﻼﻻﺕ‬- ‫ ﻓﻴﺰﻳﻮﻟﻮﮊﻱ ﺍﺳﺘﺨﻮﺍﻥ‬- ‫ ﻭﺍﻛﻨﺶﻫﺎﻱ ﺑﺎﻓﺖﻫﺎ‬- ‫ ﺗﺸﺨﻴﺺ ﻭ ﻃﺮﺡ ﺩﺭﻣﺎﻥ ﺩﺭ ﺍﺭﺗﻮﺩﻭﻧﺴﻲ ﻭ ﺗﻜﻨﻴﻚﻫﺎﻱ ﺩﺭﻣﺎﻥ‬-
34.16 Pathways of the PMP (8th Edition) ‫ــــ‬
Part I: The Art of Endodoutics Part II: The Science of Endodoutics Part III: Related Clinical Topics
35.16 PDQ ORAL DISEASE Diagnosis and Treatment (James J. Sciubba, DMD, PhD, Joseph A. Regezi, DDS, MS , Roy S. Rogers III, MD) ‫ــــ‬
36.16 PERIODONTAL MEDICINE (L.F. Rose, R.J.Genco, B.L. Mealey, D.W. Cohen) 2000
37.16 Periodontal Surgery ‫ــــ‬
‫ ﺩﺭﻣﺎﻥﻫﺎ ﻭ ﺁﻣﻮﺯﺵ ﺑﻬﺪﺍﺷﺖ ﭘﺲ ﺍﺯ ﺩﺭﻣﺎﻥ‬- ‫ ﺑﺮﺭﺳﻲ ﺍﻧﻮﺍﻉ ﺑﻴﻤﺎﺭﻱﻫﺎﻱ ﭘﺮﻳﻮﺩﻭﻧﺸﻴﻢ‬- ‫ ﺑﺮﺭﺳﻲ ﺗﺤﻠﻴﻞ ﻟﺜﻪ ﺩﺭ ﺑﻴﻤﺎﺭﻱﻫﺎﻱ ﭘﺮﻳﻮﺩﻭﻧﺘﺎﻝ ﻛﻮﺭﺗﺎﮊ‬- ‫ ﺣﺬﻑ ﭘﺎﻛﺖ ﭘﺮﻳﻮﺩﻭﻧﺘﺎﻝ‬- ‫ ﺟﺮﺍﺣﻲ ﭘﺮﻳﻮﺩﻭﻧﺘﺎﻝ‬-
38.16 Periodontal Surgery Clinical Atlas ‫ــــ‬

39.16 Removal Orthodontics Apliances ‫ــــ‬

.‫ ﻫﻤﺮﺍﻩ ﺑﺎ ﻣﺮﺍﺣﻞ ﻻﺑﺮﺍﺗﻮﺍﺭﻱ ﻭ ﺗﻮﺿﻴﺤﺎﺕ ﻛﺎﻣﻞ ﻭ ﺗﺼﻮﻳﺮﻫﺎﻱ ﻛﺎﻣﻞ ﺍﺯ ﺗﻤﺎﻡ ﻣﺮﺍﺣﻞ‬III ‫ ﻭ‬II ‫ ﻭ‬I ‫ ﻣﺨﺘﻠﻒ ﺍﻋﻢ ﺍﺯ ﻛﻼﺱ‬Case ‫ﺑﺮﺭﺳﻲ ﺩﻫﻬﺎ‬
40.16 Saunders Dental Assisting (Multimedia Resource) (Second Edition) (Doni L. Bird , Debbie S. Robinson) 2003
41.16 Strauman Dental Implant System (VCD)
‫ــــ‬
‫ ﺍﻳﻤﭙﻠﻨﺖ ﭼﻨﺪ ﺩﻧﺪﺍﻧﻲ ﻣﺎﮔﺰﻳﻠﺪ‬- ‫ ﭘﻴﻦﮔﺬﺍﺭﻱ ﺩﺭ ﺍﺳﺘﺨﻮﺍﻥ ﺍﻟﻮﺋﻞ‬- ‫ ﻧﺤﻮﻩ ﺁﻣﺎﺩﻩﺳﺎﺯﻱ ﻧﺴﺞ ﻧﺮﻡ ﻭ ﺳﺨﺖ ﺑﺮﺍﻱ ﺍﺳﺘﻘﺮﺍﺭ ﺍﻳﻤﭙﻠﻨﺖ‬-
42.16 The Center of Education, Teaching and Research for Oral Implant Reconstruction (Prof. Dr. Hns L. Grafelmann) (CD I , II) ‫ــــ‬
-Pitt-Easy BIO OSS -Phase TPS Cylinder Implant - Vertical Load
43.16 The Entegra Dental Implant System Entegra Surgical Videos (Robert Schroering) ‫ــــ‬
44.16 The IMZ Implant System (VCD) (Dr. Karl-Ludwing Ackermann, Dr. Axel Kirsch) (CD I , II) ‫ــــ‬
45.16 Toothcolored Restoratives ‫ــــ‬
‫ ﻭ ﺩﻧﺪﺍﻥ ﻧﻴﺎﺯﻣﻨﺪ ﺑﻪ ﺗﺮﻣﻴﻢ‬Case ‫ ﻧﺤﻮﻩ ﺗﺸﺨﻴﺺ ﻭ ﺍﻧﺘﺨﺎﺏ‬- ‫ ﺍﺻﻮﻝ ﻭ ﺗﻜﻨﻴﻚﻫﺎ‬- ‫ ﺑﺮﺭﺳﻲ ﻣﻮﺍﺩ ﻣﺨﺘﻠﻒ ﺩﺭ ﺗﺮﻣﻴﻢ ﻫﻤﺮﻧﮓ ﻣﺰﺍﻳﺎ ﻭ ﻣﻌﺎﻳﺐ‬-
46.16 TOOTH-COLORED RESTORATIVES Ninth Edition (Principles and Techniques) (Harry F. Albers, DDS) 2002
47.16 Treatment Planning in Dentistry
‫ــــ‬
‫ ﺩﺍﺭﺍﻱ ﺁﺯﻣﻮﻥﻫﺎﻱ ﺟﺎﻟﺐ ﻭ ﻛﺎﻣﻞ‬- ‫ﻫﺎﻱ ﻣﺨﺘﻠﻒ ﻫﻤﺮﺍﻩ ﺑﺎ ﭘﺮﻭﻧﺪﻩﻫﺎﻱ ﻛﺎﻣﻞ‬Case ‫ ﺑﺮﺭﺳﻲ‬-
48.16 Treatment Planning in Dentistry (Stephen Stefanac, D.D.S., M.S.Sam Nesbit, D.D.S., M.S.) ‫ــــ‬
49.16 UCD Implant
‫ــــ‬
... ‫ ﻧﺤﻮﻩ ﺟﺎﻳﮕﺬﺍﺭﻱ ﭘﻴﻦﻫﺎ ﻭ‬- ‫ ﺁﻣﺎﺩﻩﺳﺎﺯﻱ ﻧﺴﺞ ﻧﺮﻡ ﻭ ﻧﺤﻮﻩ ﺍﻳﺠﺎﺩ ﻓﻠﭗ ﻭ ﻧﺤﻮﻩ ﺁﻣﺎﺩﻩﺳﺎﺯﻱ ﻧﺴﺞ ﺍﺳﺘﺨﻮﺍﻥ‬- ‫ ﺭﻭﺵﻫﺎﻱ ﺑﻲﺣﺴﻲ‬-

٠٩١٢١٣٧٢٣٦١-٦٦٩٣٦٦٩٦ :‫ﺗﻠﻔﻦ‬ ٢٣٩ ‫ ﭘﻼﻙ‬،‫ ﺑﻦﺑﺴﺖ ﺳﻴﻤﻴﻦ‬،‫ ﺑﻴﻦ ﻛﺎﺭﮔﺮ ﻭ ﺟﻤﺎﻟﺰﺍﺩﻩ‬،‫ ﺥ ﻟﺒﺎﻓﻲﻧﮋﺍﺩ‬،‫ ﺥ ﻛﺎﺭﮔﺮ ﺟﻨﻮﺑﻲ‬،‫ ﻡ ﺍﻧﻘﻼﺏ‬،‫ ﺗﻬﺮﺍﻥ‬:‫ﻧﺸﺎﻧﻲ‬ ‫ ﺍﺭﺍﺋﻪ ﻛﻨﻨﺪﺓ ﻛﺘﺎﺏ ﻭ ﺳﻲﺩﻱﻫﺎﻱ ﺗﺨﺼﺼﻲ ﭘﺰﺷﻜﻲ‬: ‫ﻣﺮﻛﺰ ﺧﺪﻣﺎﺕ ﻓﺮﻫﻨﮕﻲ ﺳﺎﻟﻜﺎﻥ‬
 67
‫ ﻓﻴﺰﻳﻮﻟﻮﮊﻱ‬:١٧
CD ‫ﻋﻨﻮﺍﻥ‬ ‫ﺳﺎﻝ ﺍﻧﺘﺸﺎﺭ‬
1.17 ANATOMY & PHYSIOLOGY (5 Edition) th
(Gary A. Thibodeau, Kevin T. Patton) ‫ــــ‬
2.17 BODY WORKS 6.0 A 3D Journey Through The Human Anatomy ‫ــــ‬
3.17 Interactive Physilogy MUSCULAR SYSTEM (A. D. A. M. Benjamin/Cummings) (Marvin J. Branstrom, Ph.D.) ‫ــــ‬
-Anatomy Review: Skeletal Muscle Tissue -The Neuromuscular Junction -Sliding Filament Theory -Muscle Metabolism -Contraction of Motor Units -Contraction of Whole Musle
4.17 InterActive PHYSIOLOGY Cardiovascular System ‫ــــ‬

The Heart Blood Vessels

Anatomy Review: The Heart Intrinsic Conduction System Anatomy Review: Blood Blood Pressure Regulation
Cardiac Action Potential Vessel Structure and Function Autoregulation and Capillary Dynamics
Cardiac Cycle Measuring Blood Pressure
Cardiac Output Factors that Affect Blood Pressure
5.17 Interactive PHYSIOLOGY for Windows Urinary System Version 1.0 ‫ــــ‬
‫ﺏ( ﻋﺮﻭﻕ ﺧﻮﻧﻲ‬ ‫ ﺍﻟﻒ( ﻗﻠﺐ‬.‫ﺍﻳﻦ ﺑﺮﻧﺎﻣﻪ ﺩﺍﺭﺍﻱ ﺩﻭ ﻣﺒﺤﺚ ﻣﺠﺰﺍ ﻣﻲﺑﺎﺷﺪ ﻭ ﺍﻫﺪﺍﻑ ﺁﻣﻮﺯﺷﻲ ﺩﺭ ﺍﺑﺘﺪﺍﻱ ﻫﺮ ﻓﺼﻞ ﺍﺭﺍﺋﻪ ﺷﺪﻩ ﺍﺳﺖ‬
‫ ﺧـﻮﺩﺗﻨﻈﻴﻤﻲ ﻭ ﺩﻳﻨﺎﻣﻴـﻚ‬،‫ ﺗﻨﻈـﻴﻢ ﻓﺸـﺎﺭ ﺧـﻮﻥ‬،‫ ﻓﺎﻛﺘﻮﺭﻫﺎﻱ ﻣـﺆﺛﺮ ﺑـﺮﺭﻭﻱ ﻓﺸـﺎﺭ ﺧـﻮﻥ‬،‫ ﺍﻧﺪﺍﺯﻩﮔﻴﺮﻱ ﻓﺸﺎﺭ ﺧﻮﻥ‬،‫ ﺳﺎﺧﺘﺎﺭ ﻭ ﻋﻤﻠﻜﺮﺩ ﻋﺮﻭﻕ ﺧﻮﻧﻲ‬:‫ ﺏ( ﻋﺮﻭﻕ ﺧﻮﻧﻲ ﺷﺎﻣﻞ ﻣﺒﺎﺣﺚ‬.‫ ﭼﺮﺧﺔ ﻗﻠﺒﻲ ﻭ ﺑﺮﻭﻥﺩﻩ ﻗﻠﺒﻲ‬،‫ ﭘﺘﺎﻧﺴﻴﻞ ﻋﻤﻞ ﻗﻠﺒﻲ‬،‫ ﺳﻴﺴﺘﻢ ﻫﺪﺍﻳﺘﻲ ﻗﻠﺐ‬،‫ ﺁﻧﺎﺗﻮﻣﻲ ﻗﻠﺐ‬:‫ﺍﻟﻒ( ﻗﻠﺐ ﺷﺎﻣﻞ ﻣﺒﺎﺣﺚ‬
.‫ ﺩﺍﺭﺍﻱ ﻳﻚ ﻓﻬﺮﺳﺘﻲ ﺍﺯ ﺍﺻﻄﻼﺣﺎﺕ ﺍﺳﺖ ﻭ ﻫﺮ ﻭﺍﮊﻩ ﺭﺍ ﻣﺨﺘﺼﺮﹰﺍ ﺗﻮﺿﻴﺢ ﻣﻲﺩﻫﺪ‬CD ‫ ﺍﻳﻦ‬.‫ ﺩﺭ ﻫﺮ ﻗﺴﻤﺖ ﺍﺯ ﺍﻳﻦ ﺑﺮﻧﺎﻣﻪ ﺭﺋﻮﺱ ﻣﻄﺎﻟﺐ ﺍﺭﺍﺋﻪ ﺷﺪﻩ ﺍﺳﺖ ﻭ ﮔﻮﻳﻨﺪﻩ ﺁﻧﻬﺎ ﺭﺍ ﺑﻴﺎﻥ ﻣﻲﻛﻨﺪ‬.‫ﻣﻮﻳﺮﮒﻫﺎ‬
.‫ ﺳﺆﺍﻻﺕ ﭼﻨﺪ ﮔﺰﻳﻨﻪﺍﻱ ﺍﺭﺍﺋﻪ ﺷﺪﻩ ﺍﺳﺖ ﻭ ﭘﺎﺳﺦﻫﺎﻱ ﻧﺎﺻﺤﻴﺢ ﺑﺎ ﺭﻧﮓ ﻗﺮﻣﺰ ﻣﺸﺨﺺ ﻣﻲﺷﻮﻧﺪ‬،‫( ﺩﺭ ﻫﺮ ﻳﻚ ﺍﺯ ﻣﺒﺎﺣﺚ ﻓﻮﻕ‬Quiz) ‫ﺩﺭ ﺑﺨﺶ ﺍﻣﺘﺤﺎﻥ‬
6.17 Interactive Physiology RESPIRATORY SYSTEM (A. D. A. M. Benjamin/Cummings) (Andrea K. Salmi) ‫ــــ‬
-Anatomy Reviw: Respiratory Structures -Pulmonary Ventilation -Gas Exchange -Gas Transport -Control of Respiration
7.17 MedWorks Anatomy & Physilogy ‫ــــ‬
Anatomy Y Physiology: The Nervous System
Cells and Tissues The Integumentary System Body Chemistry The Skeletal System The Muscula System
Overview Organization
Cardiovascular System: The Cardiovascular System, The Lymphatic and Immune
The Endocrine System The Respiratory System The Digestive System The Urinary System
Blood Heart System
Somatic and Autonomic The Peripheral Nervous The central Nervous The Reproductive
The Sensory Organs Inheritance
Systems Systems System System
.‫ ﺍﻧﺘﺨﺎﺏ ﻭ ﺍﺟﺮﺍ ﻛﻨﻴﺪ‬Medwork ‫ ﺭﺍ ﺍﺯ ﻣﺴﻴﺮ ﺩﺍﻳﺮﻛﺘﻮﺭﻱ‬Setup.exe ‫ ﻓﺎﻳﻞ‬،‫ﺑﺮﺍﻱ ﺍﺟﺮﺍ‬
8.17 Panorama of Anatomy & Physiology Structure & Function of the Body (Eleven Edition) (Gary A. Thibodeau, Kevin T. Patton) ‫ــــ‬
9.17 Range of Motion-AO Neutral-0 Method Measurement and Documentation (Time) ‫ــــ‬
10.17 The Interactive Skeleton Tutorial (Dr. peter Abrahams of cambridger University, UK.) ‫ــــــ‬
1. Head 2. Spine 3. Ribs 4. Upper Limb 5. Lower Limb
11.17 World of SPORT examined ‫ــــ‬
12.17 Interactive Guide to Human Neuroanatomy (Mark F. Bear, Barry W. Connors, Michael A. Paradiso) 2002

Atlas: -Surface Anatomy of Brain -Cross-Sectional Anatomy of Brain -The Spinal Cord -The Anatomy Nervous System -The Cranial Nerves -The Blood Supply to the Brain
Exam:I -Surface Anatomy of the Brain -Cross-Sectional Anatomy of the Brain -Comprehensive Exam
13.17 Sobotta (Atlas of Human Anatomy) (Urban & Schwarzenbery) 2002
1. General Anatomy 2. Head and neck 3. Upper Limb 4. Brain and Spine Cord 5. Eye 6. Ear 7. Thoracic and Abdominal Wall 8. Thoracic Oegans 9. Lower Limb

٠٩١٢١٣٧٢٣٦١-٦٦٩٣٦٦٩٦ :‫ﺗﻠﻔﻦ‬ ٢٣٩ ‫ ﭘﻼﻙ‬،‫ ﺑﻦﺑﺴﺖ ﺳﻴﻤﻴﻦ‬،‫ ﺑﻴﻦ ﻛﺎﺭﮔﺮ ﻭ ﺟﻤﺎﻟﺰﺍﺩﻩ‬،‫ ﺥ ﻟﺒﺎﻓﻲﻧﮋﺍﺩ‬،‫ ﺥ ﻛﺎﺭﮔﺮ ﺟﻨﻮﺑﻲ‬،‫ ﻡ ﺍﻧﻘﻼﺏ‬،‫ ﺗﻬﺮﺍﻥ‬:‫ﻧﺸﺎﻧﻲ‬ ‫ ﺍﺭﺍﺋﻪ ﻛﻨﻨﺪﺓ ﻛﺘﺎﺏ ﻭ ﺳﻲﺩﻱﻫﺎﻱ ﺗﺨﺼﺼﻲ ﭘﺰﺷﻜﻲ‬: ‫ﻣﺮﻛﺰ ﺧﺪﻣﺎﺕ ﻓﺮﻫﻨﮕﻲ ﺳﺎﻟﻜﺎﻥ‬
 68
Past (‫ ﺍﺟـﺮﺍ ﺷـﺪﻩ‬Setup ‫ )ﻫﻤﺎﻥ ﻣﺴﻴﺮﻱ ﻛـﻪ‬C:\Urban ‫ ﺭﺍ ﻛﭙﻲ ﻛﺮﺩﻩ ﻭ ﺩﺭ‬Sobotta 1.5Crack ‫ ﻭ ﺳﭙﺲ‬Crack ‫ ﻭﺍﺭﺩ ﺩﺍﻳﺮﻛﺘﻮﺭﻱ‬،‫ ﭘﺲ ﺍﺯ ﺍﺗﻤﺎﻡ‬.‫ ﺁﺑﻲﺭﻧﮓ ﺭﺍ ﺍﺟﺮﺍ ﻣﻲﻛﻨﻴﻢ‬Setup ، English ‫ ﺟﻬﺖ ﻧﺼﺐ ﺍﻳﻦ ﻧﺮﻡﺍﻓﺰﺍﺭ ﺍﺑﺘﺪﺍ ﺍﺯ ﺩﺍﻳﺮﻛﺘﻮﺭﻱ‬:‫( ﻃﺮﻳﻘﺔ ﻧﺼﺐ‬
.‫ ﺣﺎﻝ ﻧﺮﻡﺍﻓﺰﺍﺭ ﻓﻮﻕ ﻗﺎﺑﻞ ﺧﻮﺍﻧﺪﻥ ﻭ ﺍﺟﺮﺍﺳﺖ‬.‫ﻣﻲﻛﻨﻴﻢ‬
14.17 Student Companion CD-ROM for Principles of Anatomy & Physiology (Tenth Edition) (John Willey & Sons, INC.) 2003
15.17 Therapeutic Exercise for Lumbopelvic Stabilization A motor Control Approach for the Treatment and Prevention of low back pain 2004
(Second Edition) (Carolyn Richardson, Paul W. Hodges, Julie Hides) (Salekan E-Book)
16.17 Gray's Anatomy The Anatomical Basis of Clinical Practice (Thirty-Ninth Edition) (Susan Standring) (CD I , II) (Salekan E-Book) 2005

‫ ﭘﺮﺳﺘﺎﺭﻱ‬:١٨
CD ‫ﻋﻨﻮﺍﻥ‬ ‫ﺳﺎﻝ ﺍﻧﺘﺸﺎﺭ‬
1.18 The Oncology Nursing Society presents THE ADVANCED PRACTICE ONCOLOGY NURSING REVIEW ‫ــــ‬
2.18 Textbook of MEDICAL SURGUCAL NURSING (Ninth Edition) (Katherine H. Dimmock) Student Self Study Disk to Accompany BRUNNER & SUDDARTH'S ‫ــــ‬
3.18 Focus on Nursing Pharmacology (Lippincott Williams & Wilkins) 2000
4.18 Wongs ESSENTIALS OF Pediatric Nursing (Mosby) A Harcoun Health Sciences Company 2001
5.18 Maternal, Neonatal and Women's Health Nursing By Delmar, a division of Thomson Learning 2002
6.18 Nursing Care of Infants and Children (Seven Edition) 2003

:‫ ﺷﺎﻣﻞ ﻋﻨﺎﻭﻳﻦ ﺯﻳﺮ ﻣﻲﺑﺎﺷﺪ‬CD ‫ﺍﻳﻦ‬

- Childre, Their Families, and the Nurse - Assessment of the Child and Family - Family-Centered Care of the Newborn - Family-Centered Care of the Infant
- Family-Centered Care of the Young Child - Family-Centered Care of the School-Age Child - Family-Centered Care of the Adolescent - Family-Centered Care of the Child with Special Needs
- The Child who is Hospitalized - The Child with Disturbance of Fluid and Electrolytes - The Child with Problems Related to Transfer of Oxygen and Nutrients
- The Child with Problems Related to Production & Circulation of Blood - The Child with Disturbance of Regulatory Mechanisms - The Child With a Problem that Interfers with Physical Mobility
7.18 McMinn's Interactive Clinical Anatomy ‫ــــ‬
8.18 INRERACTIVE ATLAS OF CLINICAL ANATOMY (Illustrations by Frank H. Netter, M.D.) ‫ــــ‬

‫ ﻓﻴﺰﻳﻮﺗﺮﺍﭘﻲ‬-١٩
CD ‫ﻋﻨﻮﺍﻥ‬ ‫ﺳﺎﻝ ﺍﻧﺘﺸﺎﺭ‬
1.19 BACK STABILITY Christopher M. Norris, MSc, MCSP, Director, Norris Associates, Manchester, UK) (Salekan E-Book) ‫ــــ‬
2.19 Clinical Tests for the Musculoskeletal System (Klaus Buckup, KlinikumDortmund Orthopaedic Hospital Dortmund Germany) (Salekan E-Book) 2004
3.19 DIET & FITNESS ‫ــــ‬
4.19 DIGITAL SHIATSU ‫ــــ‬
:‫ ﻗﺴﻤﺖ ﻣﻲ ﺑﺎﺷﺪ ﻛﻪ ﺑﻪ ﺷﺮﺡ ﺯﻳﺮ ﺍﺳﺖ‬٦ ‫ﺍﻳﻦ ﺑﺮﻧﺎﻣﻪ ﺩﺍﺭﺍﻱ‬

‫ ﺭﺍﻫﻨﻤﺎ‬- ‫ ﺍﺳﺎﺱ ﻭ ﻣﺒﺎﻧﻲ ﻣﺎﺳﺎﮊ ﺩﺭﻣﺎﻧﻲ‬- ‫ ﺟﺴﺘﺠﻮ‬- (therapies) ‫ ﻣﻮﺍﺭﺩ ﻛﺎﺭﺑﺮﺩ ﻣﺎﺳﺎﮊ ﺩﺭﻣﺎﻧﻲ‬- (self- shiatsu) ‫ ﺧﻮﺩ ﻣﺎﺳﺎﮊ ﺩﺭﻣﺎﻧﻲ‬- (total body) ‫ ﻣﺎﺳﺎﮊ ﺩﺭﻣﺎﻧﻲ ﺗﻤﺎﻣﻲ ﺑﺪﻥ‬-

٠٩١٢١٣٧٢٣٦١-٦٦٩٣٦٦٩٦ :‫ﺗﻠﻔﻦ‬ ٢٣٩ ‫ ﭘﻼﻙ‬،‫ ﺑﻦﺑﺴﺖ ﺳﻴﻤﻴﻦ‬،‫ ﺑﻴﻦ ﻛﺎﺭﮔﺮ ﻭ ﺟﻤﺎﻟﺰﺍﺩﻩ‬،‫ ﺥ ﻟﺒﺎﻓﻲﻧﮋﺍﺩ‬،‫ ﺥ ﻛﺎﺭﮔﺮ ﺟﻨﻮﺑﻲ‬،‫ ﻡ ﺍﻧﻘﻼﺏ‬،‫ ﺗﻬﺮﺍﻥ‬:‫ﻧﺸﺎﻧﻲ‬ ‫ ﺍﺭﺍﺋﻪ ﻛﻨﻨﺪﺓ ﻛﺘﺎﺏ ﻭ ﺳﻲﺩﻱﻫﺎﻱ ﺗﺨﺼﺼﻲ ﭘﺰﺷﻜﻲ‬: ‫ﻣﺮﻛﺰ ﺧﺪﻣﺎﺕ ﻓﺮﻫﻨﮕﻲ ﺳﺎﻟﻜﺎﻥ‬
 69
.‫ ﺩﺭ ﺗﺼﺎﻭﻳﺮ ﻃﺮﺡﻭﺍﺭﻫﺎﻱ ﻧﻘﺎﻁ ﺣﺴﺎﺱ ﻛﻪ ﺩﺭ ﻣﺎﺳﺎﮊ ﺩﺭﻣﺎﻧﻲ ﻣﻮﺭﺩ ﺗﻮﺟﻪ ﻗﺮﺍﺭ ﻣﻲﮔﻴﺮﺩ ﻧﻤﺎﻳﺶ ﺩﺍﺩﻩ ﺷﺪﻩ ﺍﺳﺖ‬.‫ ﺩﺭ ﺍﻳﻦ ﻗﺴﻤﺖ ﺭﻭﺵ ﻣﺎﺳﺎﮊ ﺻﺤﻴﺢ ﻭ ﻋﻤﻠﻲ ﺗﻤﺎﻣﻲ ﺑﺪﻥ ﻫﻤﺮﺍﻩ ﺑﺎ ﻧﻤﺎﻳﺶ ﻓﻴﻠﻢ ﻭ ﺗﻮﺿﻴﺤﺎﺕ ﮔﻮﻳﻨﺪﻩ ﻭ ﻣﺘﻦ ﭼﺎﭘﻲ ﺍﺭﺍﺋﻪ ﻣﻲ ﺷﻮﺩ‬-١
.‫ ﻫﻤﺮﺍﻩ ﺑﺎ ﻧﻤﺎﻳﺶ ﻓﻴﻠﻢ ﻭ ﺗﻮﺿﻴﺤﺎﺕ ﮔﻮﻳﻨﺪﻩ ﺩﺭ ﺩﻭ ﻗﺴﻤﺖ ﺭﻭﺵ ﻣﺎﺳﺎﮊ ﺩﺭﻣﺎﻧﻲ ﺍﺭﺍﺋﻪ ﺷﺪﻩ ﺍﺳﺖ‬-٢
(... ‫ ﮔﺮﻓﺘﮕﻲ ﻭ ﻛﺮﺍﻣﭗ ﭘﺎ ﻭ‬، ‫ ﻗﺎﻋﺪﮔﻲ‬، ‫ ﺍﺳﻬﺎﻝ‬، ‫ ﻳﺎﺋﺴﮕﻲ‬، ‫ ﺑﻴﻤﺎﺭﻳﻬﺎﻱ ﻛﻠﻴﻮﻱ‬، ‫ ﺑﻴﻤﺎﺭﻳﻬﺎﻱ ﻛﺒﺪﻱ‬، ‫ ﺧﻮﻥ ﺩﻣﺎﻍ‬،‫ ﺳﻴﻨﻮﺯﻳﺖ‬،‫ ﺩﺭﺩ ﻗﻔﺴﻪ ﺳﻴﻨﻪ ﻓﻠﺞ ﺻﻮﺭﺕ‬،‫ ﺁﺭﺗﺮﻳﻮﺍﺳﻜﻠﺮﻭﺯ‬: ‫ ) ﺷﺎﻣﻞ‬.‫ ﻣﻮﺭﺩ ﺗﻮﺿﻴﺢ ﺩﺍﺩﻩ ﺷﺪﻩ ﺍﺳﺖ‬٢٢ ‫ ﻣﻮﺍﺭﺩ ﻛﺎﺭﺑﺮﺩ ﻣﺎﺳﺎﮊ ﺩﺭﻣﺎﻧﻲ ﺩﺭ‬-٣
‫ ﺗﻮﺿﻴﺢ ﺩﺍﺩﻩ ﺷﺪﻩ ﺍﺳﺖ‬Namikoshi ‫ ﺍﺻﻮﻝ ﻣﺎﺳﺎﮊ ﺩﺭﻣﺎﻧﻲ ﻭ ﺭﻭﺷﻬﺎﻱ ﻛﻼﺳﻴﻚ ﺁﻥ ﻭ ﻧﻴﺰ ﺗﺎﺭﻳﺨﭽﻪ ﻣﺘﺪ‬-٤
.‫ ﺑﺮ ﺍﺳﺎﺱ ﺣﺮﻭﻑ ﺍﻟﻔﺒﺎﻳﻲ ﻣﻲ ﺗﻮﺍﻥ ﻭﺍﮊﻩﻫﺎﻱ ﺗﺨﺼﺼﻲ ﻣﻮﺭﺩ ﻧﻈﺮ ﺧﻮﺩ ﺭﺍ ﭘﻴﺪﺍ ﻧﻤﻮﺩ ﻭ ﺑﺎ ﻛﻠﻴﻚ ﻧﻤﻮﺩﻥ ﺑﺮ ﺭﻭﻱ ﺁﻥ ﺑﻪ ﺁﻥ ﻣﺒﺎﺣﺚ ﻣﻨﺘﻘﻞ ﺷﺪ‬-٥
.‫ ﺍﺟﺮﺍ ﻣﻲ ﺷﻮﺩ‬Autorun ‫ﺍﻳﻦ ﺑﺮﻧﺎﻣﻪ ﺑﻪ ﺻﻮﺭﺕ‬

.‫ ﻧﺼﺐ ﻣﻲ ﺷﻮﺩ‬program ‫ ﺩﺭ ﮔﺰﻳﻨﻪ‬Lifestyle softuare Group ‫ ﺩﺭ ﻧﻬﺎﻳﺖ ﺍﻳﻦ ﺑﺮﻧﺎﻣﻪ ﺑﻪ ﻧﺎﻡ‬،‫ ﺩﻭ ﺑﺎﺭ ﻛﻠﻴﻚ ﻧﻤﺎﺋﻴﺪ ﻭ ﻣﺮﺍﺣﻞ ﻧﺼﺐ ﺭﺍ ﭘﻴﮕﻴﺮﻱ ﻛﻨﻴﺪ‬Setup.exe ‫ ﺟﻬﺖ ﻧﺼﺐ ﺍﻳﻦ ﺑﺮﻧﺎﻣﻪ ﻻﺯﻡ ﺍﺳﺖ ﺑﺮ ﺭﻭﻱ ﺁﻳﻜﻮﻥ‬:‫( ﻃﺮﻳﻘﺔ ﻧﺼﺐ‬
.‫ ﻛﻠﻴﻚ ﻧﻤﺎﺋﻴﺪ‬install.exe ‫ ﺑﺮﺍﻱ ﻧﺼﺐ ﺁﻳﻜﻮﻥ‬.‫ ﻛﺎﻣﭙﻴﻮﺗﺮ ﺷﻤﺎ ﺑﻪ ﻛﺎﺭ ﻣﻲ ﺭﻭﺩ‬Desktop ‫ ﻧﻴﺰ ﻭﺟﻮﺩ ﺩﺍﺭﺩ ﻛﻪ ﺑﺮﺍﻱ ﺳﻔﺎﺭﺷﻲ ﻧﻤﻮﺩﻥ ﺻﻔﺤﻪ‬Jurassic Park Entertainment ‫ ﻳﻚ ﺑﺮﻧﺎﻣﻪ ﺟﺎﻧﺒﻲ ﺑﻪ ﻧﺎﻡ‬CD ‫ﺩﺭ ﺍﻳﻦ‬
5.19 EXERCISE THERAPY PREVENTION AND TREATMENT OF DISEASE ( John Gormley and Juliette Hussey)
( 2005
6.19 Fibromyalgia Syndrome Bodywork Management Strategies ___
٥ ‫ ﺳﭙﺲ ﺍﺭﺯﻳﺎﺑﻲ ﻭ ﺩﺭﻣﺎﻥ ﻓﻴﺒﺮﻭﻣﻴﺎﻟﮋﻳﺎ ﺑﺮ ﺍﺳﺎﺱ ﭘﺮﻭﺳﻪ ﺩﺭﻣﺎﻧﻲ ﭘﻴﺸﻨﻬﺎﺩ ﺷﺪﻩ ﺁﻣﻮﺯﺵ ﺩﺍﺩﻩ ﻣﻲﺷﻮﺩ ﺑﺪﻳﻦﺻﻮﺭﺕ ﻛﻪ ﺩﺭ ﻣﺮﺍﺣﻞ ﻣﺨﺘﻠﻒ ﺍﺭﺯﻳﺎﺑﻲ ﻛﻪ ﺷـﺎﻣﻞ‬.‫ ﻛﻪ ﺩﺭ ﺯﻣﻴﻨﺔ ﺗﻜﻨﻴﻚﻫﺎﻱ ﺩﺳﺘﻲ ﺍﺳﺖ ﻣﻌﺮﻓﻲ ﺷﺪﻩ ﺍﺳﺖ‬Leon Chitow ‫ ﺍﺑﺘﺪﺍ ﺗﻌﺪﺍﺩﻱ ﺍﺯ ﻛﺘﺐ‬CD ‫ﺩﺭ ﺍﻳﻦ‬
.‫ﺑﺨﺶ ﻣﻲﺑﺎﺷﺪ ﺑﺎ ﺗﺄﻛﻴﺪ ﺑﺮ ﻣﻬﺎﺭﺕﻫﺎﻱ ﻟﻤﺲ ﻧﺸﺎﻥ ﺩﺍﺩﻩ ﺷﺪﻩ ﺍﺳﺖ‬
Assessment Methodes
- Manual Thermal Diagnosis - Skin on Fascia Adherence - Hyperalgesic Skin Zones reduced Skin elasticity - Drag palpation for increased hydrosis - Neuro muscular Technique Evaluation (NMT)
rd
7.19 Fundamentale of Sensation ad Perception (3 Edition) (M.W. Levine) ‫ــــ‬
:‫ ﻋﻨﻮﺍﻥ ﺯﻳﺮ ﻣﻲﺑﺎﺷﺪ‬١٦ ‫ ﺷﺎﻣﻞ‬CD ‫ﻣﺤﺘﻮﺍﻱ ﺍﻳﻦ‬
Introduction and instructions Threshold experiment or Signal Detection Specializations of the Vertebrate eye Retinal Cells responding to light
Brain anatomy, Blink Suppression, or Cortical Demonstratuins of Fourier
Afterimages Cortical columns or Equiluminant demos
Cell responses components
Depth from motion of random dots Optical IIIusions and Constancies Motion demonstrations Color mixing or Opponent cells
Traveling waves on the basilar
Pitch and Loudness of tones Speech sounds of Mystery phrase Muscle spindle feedback
membrane
Gnglion Cells responding to light Motions from form of Impossible figures Mechanics of the middle and inner ear Taste-influenced by vision
8.19 Health & Fitness (DataSel Software, Inc) ‫ــــ‬
1. Getting Started 2. The Exercise Demonstration Screen 3. Strength 4. Stretch 5. Equipment 6. Muscles 7. Workouts 8. Setup 9. Technical Support
9.19 Interactive Atlas of Human Anatomy ‫ــــ‬
10.19 Introduction to Massage Therapy (Mary Beth Braum, Steplianic Simonsoon) (Salekan E-Book) 2005
11.19 MANIPULATION OF THE SPINE, THORAX AND PELVIS An Osteopatic Perspective (Peter Gibbons, Philip Tehan) ‫ــــــ‬

‫ ﺍﻳﻦ ﻓﻴﻠﻢﻫﺎ ﺩﺭ ﺩﻭ ﺑﺨﺶ ﻛﻠﻲ ﺑﻪ ﺷﺮﺡ ﺫﻳـﻞ‬.‫ ﻓﻘﺴﺔ ﺳﻴﻨﻪ ﻭ ﻟﮕﻦ ﺧﺎﺻﺮﻩ ﻣﻲﺑﺎﺷﺪ‬،‫ ﺑﻴﻤﺎﺭﻱﻫﺎﻱ ﺍﺳﺘﺨﻮﺍﻧﻲ ﺳﺘﻮﻥ ﻓﻘﺮﺍﺕ‬manipulation ‫ ﻗﻄﻌﻪ ﻓﻴﻠﻢ ﺁﻣﻮﺯﺷﻲ ﻛﻮﺗﺎﻩ ﺩﺭ ﺧﺼﻮﺹ ﺗﻜﻨﻴﻚﻫﺎ ﻭ ﻧﺤﻮﺓ ﻣﻌﺎﻳﻨﺔ ﻓﻴﺰﻳﻜﻲ ﻭ‬٣٤ ‫ ﺑﺼﻮﺭﺕ ﻧﻤﺎﻳﺶ‬CD ‫ﺍﻳﻦ‬
:‫ﺍﺭﺍﺋﻪ ﺷﺪﻩ ﺍﺳﺖ‬

‫ ﺑﺨﺶ ﺍﻭﻝ‬: HVLA thrust techniques-spine and thorax - Cervical and cervicothoracie spine -Thoracic spine and rib cage -Lumbar and thora Columbar spine
‫ ﺑﺨﺶ ﺩﻭﻡ‬: HVLA thrust techniques-pelvis
.‫ ﺍﺟﺮﺍ ﻣﻲﺷﻮﺩ‬Autorun ‫ ﺑﻪ ﺻﻮﺭﺕ‬CD ‫ ﺍﻳﻦ‬.‫ ﺭﺍ ﺑﺮ ﺭﻭﻱ ﺑﻴﻤﺎﺭ ﻧﻤﺎﻳﺶ ﻣﻲﺩﻫﺪ‬manipulafion ‫ ﭘﺰﺷﻚ ﻣﺘﺨﺼﺺ ﻧﺤﻮﺓ ﺍﻧﺠﺎﻡ ﻣﻌﺎﻳﻨﻪ ﻭ‬،‫ﺩﺭ ﻫﺮ ﻗﻄﻌﻪ ﻓﻴﻠﻢ‬
12.19 Massage Therapy Review (interactive Edition) (Mosby) ‫ـــــ‬
13.19 Men's Health GET RID OF THAT GUT

٠٩١٢١٣٧٢٣٦١-٦٦٩٣٦٦٩٦ :‫ﺗﻠﻔﻦ‬ ٢٣٩ ‫ ﭘﻼﻙ‬،‫ ﺑﻦﺑﺴﺖ ﺳﻴﻤﻴﻦ‬،‫ ﺑﻴﻦ ﻛﺎﺭﮔﺮ ﻭ ﺟﻤﺎﻟﺰﺍﺩﻩ‬،‫ ﺥ ﻟﺒﺎﻓﻲﻧﮋﺍﺩ‬،‫ ﺥ ﻛﺎﺭﮔﺮ ﺟﻨﻮﺑﻲ‬،‫ ﻡ ﺍﻧﻘﻼﺏ‬،‫ ﺗﻬﺮﺍﻥ‬:‫ﻧﺸﺎﻧﻲ‬ ‫ ﺍﺭﺍﺋﻪ ﻛﻨﻨﺪﺓ ﻛﺘﺎﺏ ﻭ ﺳﻲﺩﻱﻫﺎﻱ ﺗﺨﺼﺼﻲ ﭘﺰﺷﻜﻲ‬: ‫ﻣﺮﻛﺰ ﺧﺪﻣﺎﺕ ﻓﺮﻫﻨﮕﻲ ﺳﺎﻟﻜﺎﻥ‬
 70
STAGE 1: BEGINNERS LEVEL STAGE 2: INTERMEDIATE LEVEL STAGE 3: ADVANCED LEVEL
14.19 MUSCLE ENERGY TECHNIQUES ADVANCED SOFT TISSUE TECHNIQUES (Second Edition) 2001
.‫ ﺗﺼﻮﻳﺮ ﻭﻳﺪﺋﻮﺋﻲ ﻭﺟﻮﺩ ﺩﺍﺭﺩ‬٣٠ ‫ ﻓﺼﻞ ﺑﻪ ﻫﻤﺮﺍﻩ‬٨ ‫ ﻟﺌﻮﻥ ﭼﻴﺘﻮ ﻣﺸﺘﻤﻞ ﺑﺮ‬Muscle Energy Techniques ‫ ﻣﺘﻦ ﻛﺎﻣﻞ ﻛﺘﺎﺏ‬CD ‫ﺩﺭ ﺍﻳﻦ‬
‫ ﺩﺭ ﺍﻳﻦ ﺗﻜﻨﻴﻚ ﺑﻴﻤﺎﺭ ﻧﻘﺶ ﻓﻌﺎﻟﻲ ﺩﺭ ﺍﺻﻼﺡ ﺍﺧﺘﻼﻻﺕ ﻋﻤﻠﻜﺮﺩﻱ ﺑﺮ ﻋﻬـﺪﻩ ﺩﺍﺭﺩ ﻭ‬.‫ ﻳﻜﻲ ﺍﺯ ﺭﻭﺵﻫﺎﻱ ﺩﺭﻣﺎﻥ ﺩﺳﺘﻲ ﺍﺳﺖ ﻛﻪ ﺩﺭ ﺁﻥ ﺍﺯ ﺍﻧﻘﺒﺎﺽ ﺍﺭﺍﺩﻱ ﻋﻀﻠﻪ ﺩﺭ ﻳﻚ ﺟﻬﺖ ﻛﻨﺘﺮﻝ ﺷﺪﻩ ﻭ ﺩﻗﻴﻖ ﺑﺎ ﺷﺪﺕﻫﺎﻱ ﻣﺨﺘﻠﻒ ﻭ ﺩﺭ ﺑﺮﺍﺑﺮ ﻧﻴﺮﻭﻱ ﺩﺭﻣﺎﻧﮕﺮ ﺍﺳﺘﻔﺎﺩﻩ ﻣﻲﺷﻮﺩ‬MET
:‫ ﺍﻳﻦ ﺗﻜﻨﻴﻚ ﻛﺎﺭﺑﺮﺩ ﺑﺎﻟﻴﻨﻲ ﺯﻳﺎﺩﻱ ﺩﺍﺭﺩ ﻛﻪ ﻣﻲﺗﻮﺍﻥ ﺑﻪ ﻣﻮﺍﺭﺩ ﺯﻳﺮ ﺍﺷﺎﺭﻩ ﻛﺮﺩ‬.‫ ﺑﺎﻋﺚ ﻛﺎﻫﺶ ﺗﻮﻥ ﻳﺎ ﻣﻬﺎﺭ ﻋﻀﻼﺕ ﻛﻮﺗﺎﻩﺷﺪﻩ ﻭ ﺗﻘﻮﻳﺖ ﻋﻀﻼﺕ ﺿﻌﻴﻒ ﻣﻲﺷﻮﺩ‬Reciprocal inhibtion ‫ ﻳﺎ‬Post isometric Relaxation ‫ﺗﺮﺍﭘﻴﺴﺖ ﺑﺎ ﺍﺳﺘﻔﺎﺩﻩ ﺍﺯ‬
‫ ﮔﻴﺮﺍﻓﺘﺎﺩﮔﻲ ﻣﻨﻴﺴﻚ ﻭ ﻋﺪﻡ ﺗﻄﺎﺑﻖ ﻛﺎﻣﻞ ﺳﻄﻮﺡ‬،‫ ﺍﺻﻼﺡ ﻣﻮﺍﻧﻊ ﻣﻜﺎﻧﻴﻜﻲ ﺩﺍﺧﻞ ﻣﻔﺼﻞ ﻣﺜﻞ ﺁﺭﺗﺮﻳﺖ‬،‫ ﻛﺎﻫﺶ ﺍﺩﻡ ﻣﻮﺿﻌﻲ‬،‫ ﺍﺯ ﺑﻴﻦﺑﺮﺩﻥ ﭼﺴﺒﻨﺪﮔﻲ ﻣﺘﻌﺎﻗﺐ ﺍﺣﺘﻘﺎﻥ ﻭﺭﻳﺪﻱ‬،‫ ﺭﻓﻊ ﺍﺣﺘﻘﺎﻥﻫﺎﻱ ﻭﺭﻳﺪﻱ‬،‫ ﺗﻘﻮﻳﺖ ﻋﻀﻼﺕ ﺿﻌﻴﻒ‬،‫ﻛﺸﺶ ﻋﻀﻼﺕ ﻛﻮﺗﺎﻩ ﻭ ﺍﺳﭙﺎﺳﺘﻴﻚ‬
‫ﻣﻔﺼﻠﻲ ﻭ ﻫﻤﭽﻨﻴﻦ ﻣﺘﺤﺮﻙﻧﻤﻮﺩﻥ ﻣﻔﺎﺻﻞ ﻣﺤﺪﻭﺩ‬
15.19 Myofascial Release Techniques (John F. Barnes, PT) (VCD I , II) ‫ــــــ‬
16.19 Orthopaedics for Nurses (John Ebnezar) (Salekan E-Book) ‫ــــ‬
17.19 Orthopedic Massage Theory and Technique (Whitney Lowe Leon Chaitow) 2003
18.19 Palpation Skill in Assessment and Tr eatment Fibromyalgia Syndrome (Leon Chaitow) ‫ــــــ‬
19.19 Physical Education and the Study of Sport (Bob Davis, Ros Bull, Jan Roscoe, Dennis Roscoe) (Mosby) ‫ــــــ‬
1- Physical Education and the Study of Sport 2- Synoptic Questions Harcourt Health Sciences 3- The Project Personal Performance Profile
rd
20.19 Physical Rehabilitatioon of the Injured Athlete 3 Edition (James R. Andrews, Gary I., Harrison, Kevin) (Salekan E-Book) 2004
21.19 Positional Release Techniques ADVANCED SOFT TISSUE TECHNIQUES (Leon Chaitow) (Harcourt) (Second Edition) ‫ــــــ‬
.‫ ﺗﺼﻮﻳﺮ ﻭﻳﺪﺋﻮﺋﻲ ﺍﺯ ﺗﻜﻨﻴﻚﻫﺎﻱ ﺍﻋﻤﺎﻝﺷﺪﻩ ﻭﺟﻮﺩ ﺩﺍﺭﺩ‬٣١ ‫ ﻓﺼﻞ ﻫﻤﺮﺍﻩ ﺑﺎ‬١٢ ‫ ﻟﺌﻮﻥ ﭼﻴﺘﻮ ﻣﺸﺘﻤﻞ ﺑﺮ‬Positional Release ‫ ﻣﺘﻦ ﻛﺎﻣﻞ ﻛﺘﺎﺏ‬CD ‫ﺩﺭ ﺍﻳﻦ‬
‫ ﺑﻪ ﻋﻨﻮﺍﻥ ﻳﻜﻲ ﺍﺯ ﺗﻜﻨﻴﻚﻫﺎﻱ ﻣﺆﺛﺮ ﺩﺭ ﺩﺭﻣﺎﻥ ﺑﺎﻓﺖ ﻫﻤﺒﻨﺪ ﻣﻨﺎﻃﻘﻲ ﻛﻪ ﺩﺭ ﻟﻤﺲ ﻫﺎﻳﭙﺮﺗﻮﻥ ﻳﺎ ﻛﻮﺗﺎﻩ ﺷﺪﻩﺍﻧﺪ ﺑﻜﺒﺎﺭ ﻣﻲﺭﻭﺩ ﻭ ﭼﻮﻥ ﺍﺳﺎﺱ ﺁﻥ ﻗﺮﺍﺭﺩﺍﺩﻥ ﺑﺎﻓﺖ ﻫﻤﺒﻨﺪ ﻳﺎ ﻋﻀﻠﻪ ﺩﺭ ﺭﺍﺣﺖﺗﺮﻥ ﻭﺿﻌﻴﺖ ﻣﻲﺑﺎﺷﺪ ﺑﻪﻛﺎﺭﺑﺮﺩﻥ ﺁﻥ ﺩﺭ ﻣﻮﺍﺭﺩﻳﻜﻪ ﺑﻪ‬Positional Release
.‫ ﻟﺬﺍ ﺩﺭ ﺩﺭﻣﺎﻥ ﺑﻴﻤﺎﺭﺍﻥ ﻣﺒﺘﻼ ﺑﻪ ﻣﺸﻜﻼﺕ ﻣﺎﺳﻜﻠﻮﺍﺳﻜﻠﺘﺎﻝ ﺑﺴﻴﺎﺭ ﻣﺆﺛﺮ ﺍﺳﺖ‬.‫ﻋﻠﺖ ﺍﺳﭙﺎﺳﻢ ﻳﺎ ﺍﻟﺘﻬﺎﺏ ﺑﺎﻓﺖ ﻫﻤﺒﻨﺪ ﺑﺴﻴﺎﺭ ﺩﺭﺩﻧﺎﻙ ﺍﺳﺖ ﺑﺮﺍﻱ ﺑﻴﻤﺎﺭ ﻗﺎﺑﻞ ﺗﺤﻤﻞ ﻣﻲﺑﺎﺷﺪ‬
Spontaneous Positional relese variations The evolution of dysfunction Unloading and Proprioceptive taping
Modified strain/counterstrain technique Learning SCS SCS for muscle pain (plus INTT and self-treatment)
Goodheart and Morrison's Positional release variations and lift techniques SCS (and SCS variations) in hospital settings The Mulligan concept: NAGs, SNAGs, MWMs, etc.
Functional technique Facilitated Positional release (FPR) Cranial and TMJ Positional release methods
22.19 Power Touch ‫ــــــ‬
23.19 Principles of Manual Therapy (A Manual Therapy Approach to Musculoskeletal Dyslimction) (Salekan E-Book) 2005
24.19 Surface and Living Anatomy (Gordon Joslin SOtJ) 2002
.‫ ﺩﺭ ﻛﻨﺎﺭ ﻫﺮ ﻳﻚ ﺍﺯ ﻣﺘﻦﻫﺎﻱ ﻣﺮﺑﻮﻃﻪ ﻋﻜﺲﻫﺎﻱ ﺭﻧﮕﻲ ﻭﺟﻮﺩ ﺩﺍﺭﺩ ﻛﻪ ﺑﻪ ﻭﺳﻴﻠﺔ ﻣﺎﺭﻛﺮﻫﺎﻳﻲ ﻣﻨﺎﻃﻖ ﻣﺮﺑﻮﻃﻪ ﺭﺍ ﻧﺸﺎﻥ ﻣﻲﺩﻫﻨﺪ‬.‫ ﻣﻨﻄﻘﻪ ﺁﻧﺎﺗﻮﻣﻴﻜﻲ ﺭﺍ ﻣﺮﺣﻠﻪ ﺑﻪ ﻣﺮﺣﻠﻪ ﺗﻮﺿﻴﺢ ﻣﻲﺩﻫﺪ‬٢٢٦ ‫ ﻣﺘﻦ ﻛﺎﻣﻞ ﺁﻧﺎﺗﻮﻣﻲ ﺳﻄﺤﻲ ﻗﺴﻤﺖﻫﺎﻱ ﻣﺨﺘﻠﻒ ﺑﺪﻥ ﻭﺟﻮﺩ ﺩﺍﺭﺩ ﻭ ﭘﻴﺪﺍﻛﺮﺩﻥ‬CD ‫ﺩﺭ ﺍﻳﻦ‬
25.19 The Complete Acupuncture ‫ــــ‬
26.19 The Principles of Harmonic Techniques (Eyal Lederman) (VCD) ‫ــــــ‬
‫ ﺑﺮ ﺍﻳﻦ ﺍﺳﺎﺱ ﻛﻪ ﻫﺮ ﺳﻴﺴﺘﻤﻲ ﻳﻚ ﻓﺮﻛﺎﻧﺲ ﻧﻮﺳﺎﻥ ﻃﺒﻴﻌﻲ ﺩﺍﺭﺩ ﭼﻨﺎﻧﭽﻪ ﺍﻳﻦ ﺗﻜﻨﻴﻚﻫﺎﻱ ﺩﺭﻣﺎﻧﻲ ﺩﺭ ﻣﺤﺪﻭﺩﺓ ﻓﺮﻛﺎﻧﺲ ﺑﺎﻓﺖﻫﺎ‬.‫ ﻣﻌﺮﻓﻲ ﺷﺪ‬Eyal Lederman ‫ﻫﺎﺭﻣﻮﻧﻴﻚ ﺗﻜﻨﻴﻚ ﺑﻪ ﻋﻨﻮﺍﻥ ﻳﻚ ﺗﻜﻨﻴﻚ ﺩﺭﻣﺎﻧﻲ ﻣﺆﺛﺮ ﺩﺭ ﺯﻣﻴﻨﻪ ﺗﻜﻨﻴﻚﻫﺎﻱ ﻣﺎﻧﻮﺍﻝ )ﺩﺳﺘﻲ( ﺑﻪ ﻭﺳﻴﻠﺔ‬
:‫ ﺑﺨﺶ ﻧﺸﺎﻥ ﺩﺍﺩﻩ ﺷﺪﻩ ﺍﺳﺖ‬٤ ‫ ﺍﺻﻮﻝ ﻭ ﺭﻭﺵ ﺍﺳﺘﻔﺎﺩﻩ ﺍﺯ ﺍﻳﻦ ﺗﻜﻨﻴﻚ ﺩﺭ ﻣﻔﺎﺻﻞ ﻣﺨﺘﻠﻒ ﺩﺭ‬CD ‫ ﺩﺭ ﺍﻳﻦ‬.‫ﻭ ﺗﻮﺩﻩﻫﺎﻱ ﺑﺪﻥ ﺍﻋﻤﺎﻝ ﺷﻮﻧﺪ ﺑﺎﻋﺚ ﺍﻳﺠﺎﺩ ﺭﺯﻭﻧﺎﻧﺲ ﺷﺪﻩ ﺑﺎ ﺻﺮﻑ ﺍﻧﺮﮊﻱ ﻛﻤﺘﺮ ﺗﻮﺳﻂ ﺩﺭﻣﺎﻧﮕﺮ ﺩﺍﻣﻨﻪ ﺣﺮﻛﺘﻲ ﻣﻨﺎﺳﺐ ﺩﺭ ﺑﻴﻤﺎﺭ ﺍﻳﺠﺎﺩ ﻣﻲﺷﻮﺩ‬
1- The Principles of Harmonic Technique 3- The Principles of Harmonic Technique Using Pelvic Mass Oscillations
2- The Principles of Harmonic Technique Using Thoracic Mass Oscillations 4- The Principles of harmonic Technique Using Appendicular Oscillations
27.19 YOGA for YOU (Anatomy) ‫ــــ‬

٠٩١٢١٣٧٢٣٦١-٦٦٩٣٦٦٩٦ :‫ﺗﻠﻔﻦ‬ ٢٣٩ ‫ ﭘﻼﻙ‬،‫ ﺑﻦﺑﺴﺖ ﺳﻴﻤﻴﻦ‬،‫ ﺑﻴﻦ ﻛﺎﺭﮔﺮ ﻭ ﺟﻤﺎﻟﺰﺍﺩﻩ‬،‫ ﺥ ﻟﺒﺎﻓﻲﻧﮋﺍﺩ‬،‫ ﺥ ﻛﺎﺭﮔﺮ ﺟﻨﻮﺑﻲ‬،‫ ﻡ ﺍﻧﻘﻼﺏ‬،‫ ﺗﻬﺮﺍﻥ‬:‫ﻧﺸﺎﻧﻲ‬ ‫ ﺍﺭﺍﺋﻪ ﻛﻨﻨﺪﺓ ﻛﺘﺎﺏ ﻭ ﺳﻲﺩﻱﻫﺎﻱ ﺗﺨﺼﺼﻲ ﭘﺰﺷﻜﻲ‬: ‫ﻣﺮﻛﺰ ﺧﺪﻣﺎﺕ ﻓﺮﻫﻨﮕﻲ ﺳﺎﻟﻜﺎﻥ‬
 71
‫ ﺍﻭﺭﮊﺍﻧﺲ ﻭ ﺑﻴﻬﻮﺷﻲ‬:٢٠

CD ‫ﻋﻨﻮﺍﻥ‬ ‫ﺳﺎﻝ ﺍﻧﺘﺸﺎﺭ‬

1.20 American College of Surgons ACS Surgery Principles & Pracitce (CD I , II) (E-Book) 2004
2.20 Advanced Pediatric Life Support: The Critical First Hour CPR and ACLS Review (David G. Nichols, MD) ‫ــــــ‬
:‫ ﺭﻳﻮﻱ ﭘﻴﺸﺮﻓﺘﻪ ﺩﺭ ﻛﻮﺩﻛﺎﻥ ﻭ ﺑﺎﻟﻐﻴﻦ ﺷﺮﺡ ﻣﻲﺩﻫﺪ‬-‫ ﺩﺭ ﻣﻮﺭﺩ ﺍﺣﻴﺎﺀ ﻗﻠﺒﻲ‬CD ‫ﺍﻳﻦ‬
1: Initial Evaluation, 2: Airway Management, 3: Epiglottitis and Gidup, 4: Respiratory Failure, 5: Advanced Pediatric CPR, 6: Resuscitative Drugs
3.20 ANESTHESIA (Ronald D. Miller, MD) (Fifth Edition) 2000
4.20 Anesthesiology (The Journal of the American Society of Anesthesiologists, Inc) Abstracts of Scientific Papers 2002
5.20 Anesthesiology (The Journal of the American Society of Anesthesiologists, Inc) Abstracts of Scientific Papers 2000
6.20 Clinical Procedures in EMERGENCY MEDICINE (4th Edition) (James R. Roberts, MD, Jerris R. Hedges, MD, MS) (E-Book) (CD I, II) 2004
7.20 Emergency Medical Training (MedEMT) Victory Technology, Inc. Presents (DISC ONE, TWO) ‫ــــــ‬
MedEMT Overview Emergency Medical Services (EMS) The Well-Being of the EMT-Basic Anatomy and Physiology-Part 1 Anatomy and Physology-Part 2
Medical Terminology Vital Signs and SAMPLE History Lifting and Moving Patients Airway Management Patient Assessment
Medical and Behaval Care I Medical and Behavioral Care II Obstetric and Gynecological Care Trauma Infants and Children
Operations Appendix A: Video/Animation List Appendix B: Victory Products
8.20 EMERGENCY MEDICINE A COMPREHENSIVE STUDY GUIDE (Rosen's ) (Volume 1-3) (Sixth Edition) (Judith E. Tintinall, MD, MS) 2004
9.20 EMT-Basic Slide Set Slide Program Guide (John A. Stouffer, EMT-P, Richard S. Bennett, RN, EMT-P, BSN) (Mosby) 1999
10.20 Peripheral Regional Anaesthesia Tutorial in the Ulm Rehabilitation hospital (Prof. Dr. Med. H. Mehrkens) (VCD) (CD I , II) ‫ـــــ‬
1. Anatomical Fundamentals 2. Peripheral Neve Stimulation 3. Regional Anaesthesia 4. Upper, Lower Extremity 5. Peripheral Neve Blocks 6. Peripheral Neve
Blocks
11.20 The American Academy of Pediatric (David G. Nichols, MD Associate Professor of Anesthesiology and Clinical Care Medicine) ‫ــــــ‬
-Intitial Steps in Resuscitation -Ventilating the Infant -Chest Compressions -Endotracheal Intubaion
12.20 The Lipponcott-Raven Interactive Anesthesia Library on CD-ROM (Version 2.0) (Paul G. Barash, MD) ‫ـــــ‬
13.20 The Massachusetts General Hospital Handbook of Pain Management (Salekan E-Book) ‫ـــــ‬
‫ ﺳـﺮﻭﻛﺎﺭ‬،‫ ﺑﻪ ﻋﻠﺖ ﺩﺳﺘﻴﺎﺑﻲ ﺭﺍﺣﺖ ﭘﺰﺷﻜﺎﻧﻲ ﻛﻪ ﺑﺎ ﺑﻴﻤـﺎﺭﺍﻥ ﺩﺭﺩﻣﻨـﺪ‬Poacet guide ‫ ﺍﺯ‬Edition ‫ ﺍﻳﻦ‬.‫ ﺩﺭ ﺍﺧﺘﻴﺎﺭ ﻛﺎﺭﺑﺮ ﻗﺮﺍﺭ ﻣﻲﺩﻫﺪ‬،‫ ﺍﺟﺮﺍ ﻣﻲﮔﺮﺩﻧﺪ‬Mass.Gen ‫ ﺩﻳﺪﮔﺎﻩ ﻛﺎﻣﻞ ﻭ ﻣﻔﻴﺪﻱ ﺍﺯ ﺍﻃﻼﻋﺎﺗﻲ ﻛﻪ ﺩﺭ ﺩﺭﻣﺎﻥ ﻣﺆﺛﺮ ﺩﺭﺩ ﻣﻮﺭﺩ ﻧﻴﺎﺯ ﻣﻲﺑﺎﺷﻨﺪ ﻭ ﺩﺭ ﺑﻴﻤﺎﺭﺍﻥ‬CD ‫ﺍﻳﻦ‬
.‫ ﻣﺰﻣﻦ ﻭ ﺩﺭﺩ ﻛﺎﻧﺴﺮ ﺭﺍ ﭘﻮﺷﺶ ﻣﻲﺩﻫﺪ‬،‫ ﻣﻮﺍﻟﻴﺘﻪﺍﻱ ﺩﺭﻣﺎﻧﻲ ﻣﺨﺘﻠﻒ ﺭﺍ ﻣﻮﺭﺩ ﺑﺤﺚ ﻗﺮﺍﺭ ﻣﻲﺩﻫﺪ ﻭ ﺟﻨﺒﻪﻫﺎﻱ ﻣﺨﺘﻠﻒ ﺩﺭﺩ ﺍﻋﻢ ﺍﺯ ﺣﺎﺩ‬CD ‫ ﺍﻳﻦ‬،‫ ﺑﺎ ﻣﺮﻭﺭ ﻣﺒﺎﺣﺚ ﻋﻤﺪﺓ ﺩﺭﺩ‬.‫ ﻣﺸﻬﻮﺭ ﻣﻲﺑﺎﺷﺪ‬،‫ﺩﺍﺭﻧﺪ‬
.‫ ﺍﻃﻼﻋﺎﺕ ﺩﺍﺭﻭﻳﻲ ﻛﺎﻣﻞ ﻣﻲﺑﺎﺷﺪ‬- ‫ﺩﺭﺩ ﺻﻮﺭﺕ‬- ‫ ﻣﺪﺍﺧﻼﺕ ﺭﺍﺩﻳﻮﺗﺮﺍﭘﻲ ﻭ ﺭﺍﺩﻳﻮﻓﺎﺭﻣﺎﺳﻲ ﺑﺮﺍﻱ ﺩﺭﺩﻫﺎﻱ ﻛﺎﻧﺴﺮ‬- ‫ ﻣﺪﺍﺧﻼﺕ ﺟﺮﺍﺣﻲ ﻭ ﺟﺮﺍﺣﻲ ﺍﻋﺼﺎﺏ‬- :‫ﺷﺎﻣﻞ‬
48.9 New Analgesic Options: Overcoming Obstacles to Pain Relief 2002
- MD, NP, PA, RN Answer Sheet -Pharmacist Answer Sheet -Back Pain -Fibromyalgia -OA Pain -Post Op Pain -Trauma -References
11.20 Textbook of CRITICAL CARE (Salekan E-book) 2005
SECTION I RESUSCITATION AND MEDICAL EMERGENCIES
SECTION II TRAUMA
SECTION III IMAGING
SECTION IV CELL INJURY AND CELL DEATH
SECTION V INFECTIONS DISEASE
SECTION VI ENDOCTINOLOGY, METABOLISM, NUTRITION, PHARMACOLOGY
SECTION VII CARDIOVASCULAR
SECTION VIII PULMONARY
12.20 Miller's Anesthesia (Vol I & II) (Salekan E-book) 2005

٠٩١٢١٣٧٢٣٦١-٦٦٩٣٦٦٩٦ :‫ﺗﻠﻔﻦ‬ ٢٣٩ ‫ ﭘﻼﻙ‬،‫ ﺑﻦﺑﺴﺖ ﺳﻴﻤﻴﻦ‬،‫ ﺑﻴﻦ ﻛﺎﺭﮔﺮ ﻭ ﺟﻤﺎﻟﺰﺍﺩﻩ‬،‫ ﺥ ﻟﺒﺎﻓﻲﻧﮋﺍﺩ‬،‫ ﺥ ﻛﺎﺭﮔﺮ ﺟﻨﻮﺑﻲ‬،‫ ﻡ ﺍﻧﻘﻼﺏ‬،‫ ﺗﻬﺮﺍﻥ‬:‫ﻧﺸﺎﻧﻲ‬ ‫ ﺍﺭﺍﺋﻪ ﻛﻨﻨﺪﺓ ﻛﺘﺎﺏ ﻭ ﺳﻲﺩﻱﻫﺎﻱ ﺗﺨﺼﺼﻲ ﭘﺰﺷﻜﻲ‬: ‫ﻣﺮﻛﺰ ﺧﺪﻣﺎﺕ ﻓﺮﻫﻨﮕﻲ ﺳﺎﻟﻜﺎﻥ‬
 72
SECTION I: INTRODUCTION
SECTION II: SCIENTIFIC PRINCIPLES
SECTION III: ANESTHESIA
VOLUME 2
SECTION IV: SUB SPECIAL TV
SECTION V: CRITICAL CARE MEDICINE
SECTION VI: ANCILLARY
RESPONSIBILITIES AND PROBLEMS
COMPANION VIDEO CD-ROM
Video 1 Patient Positioning in Anesthesia
Video 2 Code Blue Simulation
13.20 NEW YORK SCHOOL OF REGIONAL ANESTHESIA PERIPHERAL NERVE BLOCKS PRINCIPLES AND PRACTICE 2004
-TRAINING IN PERIPHERAL NERVE BLOCKS - ESSENTIAL REGIONAL ANESTHESIA ANATOMY -EQUIPMENT AND PATIENT MONITORING IN REGIONAL ANESTHESIA
-PERIPHERAL NERVE STIMULATORS AND NERVE STIMULATION -CLINICAL PHARMACOLOGY OF LOCAL ANESTHETICS
-NEUROLOGIC COMPLICATIONS OF PERIPHERAL NERVE BLOCKS -KEYS TO SUCCESS WITH PERIPHERAL NERVE BLOCKS -CERVICAL PLEXUS BLOCK
-INTERSCALENE BRACHIAL PLEXUS BLOCK -INFRACLAVICULAR BRACHIAL PLEXUS BLOCK -AXILLARY BRACHIAL PLEXUS BLOCK
-INTRAVENOUS REGIONAL BLOCK OF THE UPPER EXTREMITY -CUTANEOUS NERVE BLOCKS OF THE UPPER EXTREMITY -THORACIC PARAVERTEBRAL BLOCK
-THORACOLUMBAR PARAVERTEBRAL BLOCK -LUMBAR PLEXUS BLOCK - SCIATIC BLOCK: POSTERIOR APPROACH 234
-SCIATIC BLOCK: ANTERIOR APPROACH 252 -FEMORAL NERVE BLOCK -POPLITEAL BLOCK: INTERTENDINOUS APPROACH -POPLITEAL BLOCK: LATERAL APPROACH
-ANKLE BLOCK - WRIST BLOCK -CUTANEOUS NERVE BLOCKS OF THE LOWER EXTERMITY -DIGITAL BLOCK
14.20 Interactive Regional Anesthesia ‫ــــــ‬

‫؛ ﺍﻭﺭﻭﻟﻮﮊﻱ‬٢١

CD ‫ﻋﻨﻮﺍﻥ‬ ‫ﺳﺎﻝ ﺍﻧﺘﺸﺎﺭ‬

22.21 Adult and Pediatric Urology (Jay Y. Gillenwater, john T. Grayhack, Stuart S. Howards, Michael E. Mitchell) 2002
Adult Urology Adult Urology Continued Pediatric Urology Video Library
22.21 Advanced Therapy of Prostate Disease (Martin I. Resnick, MD, Ian M. Thompson, MD) 2000
.‫ ﺭﻓﺮﺍﻧﺲﻫﺎ ﺩﺭ ﻣﻮﺭﺩ ﭼﮕﻮﻧﮕﻲ ﺗﺸﺨﻴﺺ ﻭ ﺩﺭﻣﺎﻥ ﺑﻴﻤﺎﺭﻱﻫﺎﻱ ﭘﺮﻭﺳﺘﺎﺕ ﻣﻲﺑﺎﺷﺪ‬.‫ ﺑﻮﺩﻩ ﻭ ﻳﻜﻲ ﺍﺯ ﺑﻬﺘﺮﻳﻦ ﺭﻓﺮﺍﻧﺲﻫﺎ ﺩﺭ ﻣﻮﺭﺩ ﭼﮕﻮﻧﮕﻲ ﺗﺸﺨﻴﺺ ﻭ ﺩﺭﻣﺎﻥ ﺑﻴﻤﺎﺭﻱﻫﺎﻱ ﭘﺮﻭﺳﺘﺎﺕ ﻣﻲﺑﺎﺷﺪ‬Acrobat reader ‫ ﺻﻔﺤﻪﺍﻱ ﺩﺭ ﻣﺤﻴﻂ‬٦٤٨ ‫ﺍﻳﻦ ﻛﺘﺎﺏ‬
.‫ ﻓﺼﻞ ﻣﻲﺑﺎﺷﺪ‬٧١ ‫ﺍﻳﻦ ﻛﺘﺎﺏ ﺍﻟﻜﺘﺮﻭﻧﻴﻜﻲ ﺷﺎﻣﻞ‬
،‫ ﻏﺮﺑـﺎﻟﮕﺮﻱ ﻛﺎﻧﺴـﺮ ﭘﺮﻭﺳـﺘﺎﺕ‬-٩ ‫ ﻭ‬١١ ‫ ﻭ‬١٢ ‫ ﻓﺼـﻮﻝ‬.‫ ﻓﺎﻛﺘﻮﺭﻫـﺎﻱ ﻣﻠﻜـﻮﻟﻲ ﺩﺭ ﺍﺭﺯﻳـﺎﺑﻲ ﻛﺎﻧﺴـﺮ ﭘﺮﻭﺳـﺘﺎﺕ‬-٨ ‫ ﻓﺼـﻞ‬.‫ ﺍﻟﮕـﻮﺭﻳﺘﻢ ﺍﺭﺯﻳـﺎﺑﻲ ﺧﻄـﺮ ﭘﺮﻭﺳـﺘﺎﺕ ﻛﺎﻧﺴـﺮ ﺷـﺮﺡ ﺩﺍﺩﻩ ﺷـﺪﻩ ﺍﺳـﺖ‬-٧ ‫ ﻓﺼـﻞ‬.‫ ﺍﭘﻴﺪﻣﻴﻮﻟﻮﮊﻱ ﻛﺎﻧﺴـﺮ ﭘﺮﻭﺳـﺘﺎﺕ ﺷـﺮﺡ ﺩﺍﺩﻩ ﺷـﺪﻩ ﺍﺳـﺖ‬٦-١ ‫ﻓﺼﻮﻝ‬
.‫ ﺭﺍﺩﻳﻜﺎﻝ ﭘﺮﻭﺳﺘﺎﺗﻜﺘﻮﻣﻲ‬:‫ﺁﻣﺎﺩﮔﻲ ﺑﻴﻤﺎﺭ ﺑﺮﺍﻱ‬-١٩ ‫ ﻓﺼﻞ‬،‫ ﻛﺎﻧﺴﺮ ﭘﺮﻭﺳﺘﺎﺕ‬staging ‫ ﺗﺸﺨﻴﺺ ﻭ‬-١٧-١٨ ‫ ﻓﺼﻞ‬.‫ ﺗﺎﺭﻳﺨﭽﺔ ﻓﻴﺰﻳﻮﻟﻮﮊﻱ ﭘﺮﻭﺳﺘﺎﺕ ﻭ ﺗﺎﺭﻳﺨﭽﺔ ﭘﺎﺗﻮﺑﻴﻮﻟﻮﮊﻱ ﻛﺎﻧﺴﺮ ﭘﺮﻭﺳﺘﺎﺕ ﺑﻴﺎﻥ ﺷﺪﻩ ﺍﺳﺖ‬-١٣-١٦ ‫ ﻓﺼﻮﻝ‬.‫ ﺍﺑﺰﺍﺭﻫﺎﻱ ﺗﺸﺨﻴﺼﻲ‬-١٠ ‫ﻓﺼﻞ‬
(TNM) Staging ‫ ﺩﺭ ﻫـﺮ ﻓﺼـﻞ‬-٣٩-٣٠ ‫ ﻭ ﻫﻮﺭﻣﻮﻧﺎﻝﺗﺮﺍﭘﻲ ﻭ ﻛﺮﺍﻳﺮﺗﺮﺍﭘﻲ ﻛﺎﻧﺴﺮﻫﺎﻱ ﻣﺨﺘﻠـﻒ ﭘﺮﻭﺳـﺘﺎﺕ‬Brachy therapy ،‫ ﺭﺍﺩﻳﻮﺗﺮﺍﭘﻲ‬-٢٩-٢٤ .Radical Perianal Prostatectomy -٢٣ .‫ﻫﺎﻱ ﻣﺨﺘﻠﻒ ﺩﺭ ﺭﻭﺵﻫﺎﻱ ﺟﺮﺍﺣﻲ ﺁﻧﻬﺎ‬Stage -٢٢ ‫ ﻭ‬٢١ ‫ ﻭ‬٢٠
-٤٧ ‫ ﻛﻼﮊﻥﺗﺮﺍﭘﻲ ﺑﺮﺍﻱ ﺑﻲﺍﺧﺘﻴﺎﺭﻱ ﺑﻌﺪ ﺍﺯ ﻋﻤﻞ ﺟﺮﺍﺣﻲ ﭘﺮﻭﺳﺘﺎﺕ‬-٤٥ ‫ ﺁﺭﺗﻴﻔﻴﺸﺘﺎﻝ‬genitourinary ‫ ﺍﺳﻔﻨﻜﺘﺮ‬-٤٤ ... ‫ ﻭ ﻫﻮﺭﻣﻮﻥﺗﺮﺍﭘﻲ ﻭ‬PSA ‫ ﭼﮕﻮﻧﮕﻲ ﺍﺭﺯﻳﺎﺑﻲ ﺑﻴﻤﺎﺭﺍﻥ ﺑﻌﺪ ﺍﺯ ﻋﻤﻞ ﭘﺮﻭﺳﺘﺎﺗﻜﺘﻮﻣﻲ ﺑﺎ‬-٤٠-٤٣ ‫ﺟﺪﺍﮔﺎﻧﻪ ﺷﺮﺡ ﻭ ﺭﻭﺵ ﺩﺭﻣﺎﻥ ﺁﻥ ﻧﻴﺰ ﺗﻮﺿﻴﺢ ﺩﺍﺩﻩ ﺷﺪﻩ ﺍﺳﺖ‬
‫ ﭘﺎﺗﻮﻓﻴﺰﻳﻮﻟﻮﮊﻱ ﺍﻧﺴﺪﺍﺩ ﻣﺠـﺮﺍﻱ ﺧﺮﻭﺟـﻲ ﻣﺜﺎﻧـﻪ ﻭ‬-٥٤ .‫ ﻧﺴﺒﺖ ﺍﻭﺭﻭﺩﻳﻨﺎﻣﻴﻚ ﻭ ﺍﺑﻨﺮﻣﺎﻟﻲﻫﺎﻱ ﺩﻳﮕﺮ‬-٥٢-٥٣ . BPH ‫ ﻧﮕﺮﺵ ﺳﻠﻮﻟﻲ ﻭ ﻫﻮﺭﻣﻮﻧﻲ ﺑﻪ‬-٥١ ‫ ﺟﻠﻮﮔﻴﺮﻱ ﺍﺯ ﻋﻮﺩ ﻛﺎﻧﺴﺮ ﺑﺎ ﺷﻴﻤﻲﺩﺭﻣﺎﻧﻲ ﻭ ﺭﺍﺩﻳﻮﺗﺮﺍﭘﻲ‬-٥٠-٤٨ ‫ ﻭ ﺍﻧﻮﺭﻛﺘﺎﻝ‬erction ‫ ﺗﺪﺍﺑﻴﺮ ﺩﺭﻣﺎﻧﻲ ﺑﺮﺍﻱ ﻋﻮﺍﺭﺽ‬-٤٦
‫ ﺭﻭﺵﻫـﺎﻱ ﻣﺨﺘﻠـﻒ ﺟﺮﺍﺣـﻲ ﺩﺭ‬-٦٠-٦٦ ‫ ﺭﺩﻭﻛﺘـﺎﺯ‬5α ‫ ﻣﻬﺎﺭﻛﻨﻨﺪﻩﻫـﺎﻱ‬-٥٩ BPH ‫ ﺁﻣﺎﺩﮔﻲ ﻭ ﺍﻧﺘﺨﺎﺏ ﺩﺭﻣﺎﻥ ﻣﻨﺎﺳﺐ ﺑﺮﺍﻱ‬/‫ ﺭﻭﺵﻫﺎﻱ ﺍﺭﺯﻳﺎﺑﻲ‬-٥٧-٥٨ ‫ ﻛﻲ ﺑﺎﻳﺪ ﻣﺪﺍﺧﻠﻪ ﻛﺮﺩ؟‬:BPH -٥٦ BPH ‫ ﺟﻠﻮﮔﻴﺮﻱ ﺍﺯ ﭘﻴﺸﺮﻓﺖ ﻭ ﻋﻮﺍﺭﺽ ﺑﻠﻨﺪﻣﺪﺕ‬-٥٥ Voding ‫ﺍﺧﺘﻼﻝ ﺩﺭ‬
.‫ ﻓﺎﻛﺘﻮﺭﻫﺎﻱ ﻣﺆﺛﺮ ﺩﺭ ﭘﺮﻭﮔﻨﻮﺯ ﻭ ﺟﺪﻳﺪﺗﺮﻳﻦ ﺩﺭﻣﺎﻥﻫﺎ ﺩﺭ ﭘﺮﻭﺳﺘﺎﺕ‬،‫ ﺗﺸﺨﻴﺺ ﺍﻓﺘﺮﺍﻗﻲ‬،‫ ﭘﺎﺗﻮﻓﻴﺰﻳﻮﻟﻮﮊﻱ‬:‫ ﭘﺮﻭﺳﺘﺎﺕ‬-٦٧-٧١ .(‫ ﭘﺮﻭﺳﺘﺎﺗﻜﺘﻮﻣﻲ‬open ‫ ﻭ ﻓﻴﺘﻮﺗﺮﺍﭘﻲ ﻭ‬TUIP ،TUFP ،‫ ﻟﻴﺰﺗﺮﺍﭘﻲ‬،needle Ablation ‫ ﺷﺎﻣﻞ )ﺗﺮﺍﻧﺲ ﺍﻭﺭﺗﺮﺍﻝ‬BPH
5.15 Atlas of RENAL TRANSPLANTATION (Prof. Legndre, Martin, Helenon, Lebranchu, Halloran, Nochy) ‫ــــــ‬
-Histopathology -surgery -clinical section -imaging -immunology -immunosupperssive
22.21 AUA Vide Digest The American Urogical association (AUA) Impotence and Infertility ‫ـــــ‬
.‫ ﻣﻲﺑﺎﺷﺪ‬Infertilitey ‫ ﻭ‬Impotence ‫ ﻛﻪ ﺷﺎﻣﻞ ﻣﺒﺎﺣﺚ‬.‫( ﻣﻲﺑﺎﺷﺪ‬AUA video digest) ‫ ﺷﺎﻣﻞ ﻳﻜﻲ ﺍﺯ ﺳﺮﻱ ﻓﻴﻠﻢﻫﺎﻱ ﺁﻣﻮﺯﺷﻲ ﺍﻧﺠﻤﻦ ﺍﻭﺭﻭﻟﻮﮊﻳﺴﺖﻫﺎﻱ ﺁﻣﺮﻳﻜﺎ‬CD ‫ﺍﻳﻦ‬

٠٩١٢١٣٧٢٣٦١-٦٦٩٣٦٦٩٦ :‫ﺗﻠﻔﻦ‬ ٢٣٩ ‫ ﭘﻼﻙ‬،‫ ﺑﻦﺑﺴﺖ ﺳﻴﻤﻴﻦ‬،‫ ﺑﻴﻦ ﻛﺎﺭﮔﺮ ﻭ ﺟﻤﺎﻟﺰﺍﺩﻩ‬،‫ ﺥ ﻟﺒﺎﻓﻲﻧﮋﺍﺩ‬،‫ ﺥ ﻛﺎﺭﮔﺮ ﺟﻨﻮﺑﻲ‬،‫ ﻡ ﺍﻧﻘﻼﺏ‬،‫ ﺗﻬﺮﺍﻥ‬:‫ﻧﺸﺎﻧﻲ‬ ‫ ﺍﺭﺍﺋﻪ ﻛﻨﻨﺪﺓ ﻛﺘﺎﺏ ﻭ ﺳﻲﺩﻱﻫﺎﻱ ﺗﺨﺼﺼﻲ ﭘﺰﺷﻜﻲ‬: ‫ﻣﺮﻛﺰ ﺧﺪﻣﺎﺕ ﻓﺮﻫﻨﮕﻲ ﺳﺎﻟﻜﺎﻥ‬
 ‫‪73‬‬
‫ﻗﺴﻤﺖ ﺍﻭﻝ ‪ :Impotence‬ﺍﻟﻒ( ﺍﺑﺘﺪﺍ ﺩﺭ ﻣﻮﺭﺩ ﺭﻭﺵﻫﺎﻱ ﺗﺸﺨﻴﺼﻲ ﻭ ﺳﭙﺲ ﺍﻧﺘﺨﺎﺏ ﺩﺭﻣﺎﻥ ﻣﻨﺎﺳﺐ ﺁﻥ ﺑﻴﺎﻥ ﺷﺪﻩ ﻭ ﺳﭙﺲ ﺩﺭ ﺣﻴﻦ ﻧﺸﺎﻥﺩﺍﺩﻥ ﻓﻴﻠﻢ ﺁﻣﻮﺯﺵ ﺗﻮﺳﻂ ﺍﺳﺎﺗﻴﺪ ﻣﺮﺑﻮﻃﻪ ﺩﺍﺩﻩ ﺷﺪﻩ ﺍﺳﺖ‪(Diagnosis8 treatment option) .‬‬
‫ﺏ( ‪ :Penile Venous Ligation‬ﺩﺭ ﺍﻳﻦ ﻗﺴﻤﺖ ﭼﮕﻮﻧﮕﻲ ﺍﻧﺠﺎﻡ ﻋﻤﻞ ﺟﺮﺍﺣﻲ ﺑﺎ ﺗﻮﺿﻴﺢ ﺣﻴﻦ ﻋﻤﻞ ﺑﺎ ﻓﻴﻠﻢ ﻧﺸﺎﻥ ﺩﺍﺩﻩ ﺷﺪﻩ ﺍﺳﺖ‪.‬‬

‫ﻗﺴﻤﺖ ﺩﻭﻡ ‪ :Rectal Probe Electroejaculation :Infertiliry‬ﺩﺭ ﺍﻳﻦ ﻗﺴﻤﺖ ﭘﺎﺗﻮﻓﻴﺰﻳﻮﻟﻮﮊﻱ ‪ ejaculation‬ﻣﻮﺭﺩ ﺑﺤﺚ ﻗﺮﺍﺭ ﮔﺮﻓﺘﻪ ﻭ ﺳﭙﺲ ﺗﺠﻬﻴﺰﺍﺕ ﻭ ﺩﺳﺘﮕﺎﻩﻫﺎﻱ ﻣﻮﺭﺩ ﻧﻴﺎﺯ ﻭ ﻃﺮﺯ ﻛـﺎﺭ ﺁﻧﻬـﺎ ﺑـﺎ ﻓـﻴﻠﻢ ﻧﺸـﺎﻥ ﺩﺍﺩﻩ ﺷـﺪﻩ ﻭ ﺳـﭙﺲ ﻃﺮﻳﻘـﻪ ﺍﻧﺠـﺎﻡ‬
‫ﭘﺮﻭﺏﮔﺬﺍﺭﻱ ﻭ ﺍﻳﺠﺎﺩ ‪ ejaculation‬ﺑﻪ ﻧﻤﺎﻳﺶ ﺩﺭﺁﻣﺪﻩ ﺍﺳﺖ‪.‬‬
‫‪22.21 BLADDER BIOPSY INTERPRETATIONS‬‬ ‫)‪(Jonathan I. Epstein, M.D., Mahul B. Amin, M.D., Victor E. Reuter, M.D.‬‬ ‫)‪(CD I, II) (SALEKAN E-BOOK‬‬ ‫‪2004‬‬

‫ﺍﻳﻦ ﻛﺘﺎﺏ ﻛﻪ ﺩﺭ ﻣﺮﻛﺰ ﺧﺪﻣﺎﺕ ﻓﺮﻫﻨﮕﻲ ﺳﺎﻟﻜﺎﻥ ﺗﺒﺪﻳﻞ ﺑﻪ ﻛﺘﺎﺏ ﺍﻟﻜﺘﺮﻭﻧﻴﻜﻲ ﮔﺮﺩﻳﺪﻩ ﺍﺳﺖ ﺷﺎﻣﻞ ﻣﺒﺎﺣﺚ ﺯﻳﺮ ﻣﻲﺑﺎﺷﺪ‪:‬‬
‫‪Normal Blodder Anatomy and Variants of Normal‬‬ ‫‪Papillary Urothelial Neoplasms with Inverted Growth‬‬
‫‪Flat Urothelial Lesions‬‬
‫‪histology‬‬ ‫‪Patterns‬‬
‫‪Conventional Morphologic, Prognostic, and Predictive Factors and Reporting of‬‬
‫‪Invasive Urothelial Carcinoma‬‬ ‫‪Glandular Lesions‬‬
‫‪Bladder Cancer‬‬
‫‪Squamous Lesions‬‬ ‫‪Cystitis‬‬ ‫‪Mesenchymal Tumors and Tumor-Like Lesions‬‬
‫‪Miscellaneous Nontumors and Tumors‬‬ ‫‪Second ary Tumors of the Bladder‬‬
‫‪22.21 Bristol Urological Institute‬‬ ‫)‪(Computer Aided Learning Program‬‬ ‫ــــــ‬
‫ﺑﻪ ﮔﻔﺘﺔ ﻣﺆﻟﻔﻴﻦ ﺍﻳﻦ ‪ CD‬ﺑﺮﺍﻱ ﺍﻓﺰﺍﻳﺶ ﻣﻌﻠﻮﻣﺎﺕ ﺣﻔﻈﻲ ﻧﻴﺴﺖ ﺑﻠﻜﻪ ﻫﺪﻑ ﺍﻳﻦ ‪ CD‬ﺍﺭﺯﻳﺎﺑﻲ ﺩﺍﻧﺶ ﺍﻭﺭﻭﻟﻮﮊﻱ ﻫﺮ ﺷﺨﺺ ﻭ ﭼﮕﻮﻧﮕﻲ ﻓﻬﻢ ﻣﻄﺎﻟﺐ ﻭ ﻛﻢ ﺑﻪ ﺑﻬﺘﺮﻓﻬﻤﻴﺪﻥ ﻭ ﺗﺼﻤﻴﻢ ﮔﺮﻓﺘﻦ ﺩﺭ ﻣﻮﺭﺩ ﻣﺒﺎﺣﺚ ﺍﻭﺭﻭﻟﻮﮊﻱ ﺍﺳﺖ‪.‬‬
‫ﺍﻳﻦ ‪ CD‬ﺷﺎﻣﻞ ﺗﺴﺖﻫﺎﻱ ‪ ٤‬ﮔﺰﻳﻨﻪﺍﻱ ﺍﺳﺖ ﻭ ﺷﺎﻣﻞ ﻣﺒﺎﺣﺚ‪:‬‬
‫‪ -١٠‬ﻛﺎﻧﺴﺮ ﭘﺮﻭﺳﺘﺎﺕ‬ ‫‪ -٩‬ﺍﺧﺘﻼﻻﺕ ﺍﺳﻜﺮﻭﺗﻮﻡ‬ ‫‪ -٨‬ﺑﻲﺍﺧﺘﻴﺎﺭﻱ ﺍﺩﺭﺍﺭ‬ ‫‪ -٦‬ﻋﻘﻴﻤﻲ ﻣﺮﺩﺍﻥ ‪ -٧‬ﺳﻨﮓﻫﺎﻱ ﻛﻠﻴﻮﻱ‬ ‫‪ -٥‬ﻫﻤﺎﺗﻮﺭﻱ‬ ‫‪ -٤‬ﻋﻼﺋﻢ ﺩﺳﺘﮕﺎﻩ ﺍﺩﺭﺍﺭﻱ ﺗﺤﺘﺎﻧﻲ‬ ‫‪ -٣‬ﺗﺮﻭﻣﺎﻱ ﻛﻠﻴﻪ‬ ‫‪impotence -٢‬‬ ‫‪ -١‬ﻣﻌﺎﻳﻨﻪ ﺑﻴﻤﺎﺭﺍﻥ ﺍﻭﺭﻭﻟﻮﮊﻱ‬
‫‪ -١‬ﺩﺭ ﻫﺮ ﻋﻨﻮﺍﻥ ﺍﺑﺘﺪﺍ ﻣﻘﺪﻣﻪﺍﻱ ﺩﺭ ﻣﻮﺭﺩ ﺑﻴﻤﺎﺭﻱ ﻭ ﺍﺧﺘﻼﻻﺕ ﻣﺮﺑﻮﻃﻪ ﺁﻭﺭﺩﻩ ﺷﺪﻩ ﺍﺳﺖ‪ -٢ .‬ﺳﭙﺲ ﺍﻫﺪﺍﻓﻲ ﻛﻪ ﺑﺎ ﻣﻄﺎﻟﻌﻪ ﺍﻳﻦ ﻗﺴﻤﺖ ﺍﺯ ﺑﻴﻤﺎﺭﻱ ﺑﺎﻳﺪ ﺑﻪ ﺩﺳﺖ ﺁﻭﺭﺩ ﺑﻴﺎﻥ ﺷﺪﻩ ﺍﺳﺖ‪ -٣ .‬ﺩﺭ ﻗﺴﻤﺖ ﺳﻮﻡ ﺍﺑﺘﺪﺍ ﺷﺮﺡ ﺣﺎﻝ ﺑﻴﻤﺎﺭﻱ ﻭ ﺳﭙﺲ ﺗﺼﺎﻭﻳﺮ ﺭﻧﮕـﻲ‪ ،‬ﺭﺍﺩﻳـﻮﮔﺮﺍﻓﻲ‪،‬‬
‫ﺳﻮﻧﻮﮔﺮﺍﻓﻲ‪ ،‬ﭘﺎﺗﻮﻟﻮﮊﻱ ﻫﺮ ﺍﺧﺘﻼﻝ ﺩﺭ ﺻﻔﺤﻪﺍﻱ ﺟﺪﺍﮔﺎﻧﻪ ﺁﻭﺭﺩﻩ ﺷﺪﻩ ﻭ ﺳﺆﺍﻻﺕ ‪٤‬ﺟﻮﺍﺑﻲ ﺑﺮ ﺁﻥ ﻓﺮﺍﻫﻢ ﮔﺮﺩﻳﺪﻩ ﺍﺳﺖ‪ .‬ﺩﺭ ﺁﺧﺮ ﻧﻴﺰ ﺑﻪ ﻣﻌﻠﻮﻣﺎﺕ ﺷﺨﺺ ‪ Score‬ﺩﺍﺩﻩ ﻣﻲﺷﻮﺩ‪.‬‬
‫‪22.21 CAMPBELL'S UROLOGY‬‬ ‫‪2003‬‬
‫‪Urologic Examination and‬‬ ‫‪Physiology, Pathology, and Management of‬‬ ‫‪Infections and Inflammations of the‬‬ ‫& ‪Voiding Function‬‬
‫‪Anatomy‬‬
‫‪Diagnostic Techniques‬‬ ‫‪Upper Urinary Tract Diseases‬‬ ‫‪Genitourinary Tract‬‬ ‫‪Dysfunction‬‬
‫‪Benign Prostatic‬‬ ‫‪Reproductive Function and‬‬
‫‪Sexual Function and Dysfunction‬‬ ‫‪Pediatric Urology‬‬ ‫‪Oncology‬‬
‫‪Hyperplasia‬‬ ‫‪Dysfunction‬‬
‫‪Carcinoma of the‬‬
‫‪Urinary Lithiasis and Endourology‬‬ ‫‪Urologic Surgery‬‬ ‫‪Pathology Atlas‬‬ ‫‪Radiology Atlas‬‬
‫‪Prostate‬‬
‫‪Study Guide‬‬ ‫‪Additional Media‬‬
‫)‪22.21 Core Curriculum in Primary Care Patient Evaluation for Non-Cardiac Surgery and Gynecology and Urology (Michael K. Rees, MD, MPH‬‬ ‫ــــــ‬

‫‪ CCC‬ﻣﺠﻤﻮﻋﻪﺍﻱ ﺍﺯ ‪CD‬ﻫﺎﻳﻲ ﻣﻲﺑﺎﺷﺪ ﻛﻪ ﺑﺮﺍﻱ ﺁﻣﻮﺯﺵ ﻣﺪﺍﻭﻡ ﺩﺳﺘﻴﺎﺭﺍﻥ ﻭ ﻣﺘﺨﺼﺼﻴﻦ ﻫﺮ ﺭﺷﺘﻪ ﺗﻮﺳﻂ ﺍﻋﻀﺎﺀ ﻫﻴﺌﺖ ﻋﻠﻤﻲ ﺩﺍﻧﺸﮕﺎﻩ ﭘﺰﺷﻜﻲ ‪ Harvard‬ﺑﻨﺎ ﻧﻬﺎﺩﻩ ﺷﺪﻩ ﺍﺳﺖ‪.‬‬
‫‪ CD‬ﺣﺎﺿﺮ ﺩﺭ ﻣﻮﺭﺩ ﺟﺮﺍﺣﻲ‪ ،‬ﺯﻧﺎﻥ ﻭ ﺍﻭﺭﻭﮊﻱ ﺭﺍ ﮔﺮﺩﺁﻭﺭﻱ ﻛﺮﺩﻩ ﺍﺳﺖ‪ .‬ﻫﺮ ﻛﺪﺍﻡ ﺍﺯ ﺍﻳﻦ ﺳﺨﻨﺮﺍﻧﻲﻫﺎ ﻋﻼﻭﻩ ﺑﺮ ﺍﺳﻼﻳﺪﻫﺎﻱ ﺁﻣﻮﺯﺷﻲ ﻣﺘﻦ ﺳﺨﻨﺮﺍﻧﻲ ﻧﻴﺰ ﺩﺭ ﺩﺳﺘﺮﺱ ﻛﺎﺭﺑﺮ ﻣﻲﺑﺎﺷﺪ‪ .‬ﺩﺭ ﺁﺧﺮ ﻫﺮ ﺳﺨﻨﺮﺍﻧﻲ ﻭ ﻣﺒﺤﺜﻲ‪ ،‬ﺳﺆﺍﻻﺕ ﻣﺮﺑﻮﻃﻪ ﺑـﻪ ﺻـﻮﺭﺕ ﭼﻬﺎﺭﮔﺰﻳﻨـﻪﺍﻱ‬
‫ﺑﺮﺍﻱ ﺍﺭﺯﻳﺎﺑﻲ ﻛﺎﺭﺑﺮ ﺁﻭﺭﺩﻩ ﺷﺪﻩ ﺍﺳﺖ‪ .‬ﺳﭙﺲ ﺧﻼﺻﻪ ﻫﺮ ﺳﺨﻨﺮﺍﻧﻲ ﺑﻪ ﺻﻮﺭﺕ ﻳﻚ ﻣﻘﺎﻟﻪ ﭼﺎﭘﻲ ﺩﺭ ﻣﺠﻼﺕ ﻋﻠﻤﻲ ﻭ ﺭﻭﺯﻧﺎﻣﻪﻫﺎ ﺁﻭﺭﺩﻩ ﺷﺪﻩ ﺍﺳﺖ‪ .‬ﺷﺎﻣﻞ ﻣﺒﺎﺣﺚ ﺯﻳﺮ ﻣﻲﺑﺎﺷﺪ‪:‬‬
‫‪Male impotence‬‬ ‫‪ -٣‬ﻋﻘﻴﻤﻲ ﻣﺮﺩﺍﻥ‬ ‫ﺍﺭﺯﻳﺎﺑﻲ ﺧﻮﻧﺮﻳﺰﻱﻫﺎﻱ ﺍﺑﻨﺮﻣﺎﻝ ﺭﺣﻢ )‪.(AUB‬‬ ‫‪-٢‬‬ ‫‪ -١‬ﭼﮕﻮﻧﻪ ﻳﻚ ﺑﻴﻤﺎﺭ ﺭﺍ ﺑﺮﺍﻱ ﺍﻋﻤﺎﻝ ﺟﺮﺍﺣﻲ )ﺑﺠﺰ ﺟﺮﺍﺣﻲ ﻗﻠﺐ( ﺍﺭﺯﻳﺎﺑﻲ ﻭ ﺁﻣﺎﺩﻩ ﻛﻨﻴﻢ؟‬
‫‪12.3‬‬ ‫)‪Core Curriculum in Primary Care Gynecology (Michael, Isaac Schiff, Keith, Thomas, Annekathryn‬‬ ‫ــــــ‬
‫)‪22.21 Core Curriculum in Primary Care Nephrology (Michael K. Rees, MD, MPH‬‬ ‫ــــــ‬

‫‪ CCC‬ﻣﺠﻤﻮﻋﻪﺍﻱ ﺍﺯ ‪CD‬ﻫﺎﻳﻲ ﻣﻲﺑﺎﺷﺪ ﻛﻪ ﺑﺮﺍﻱ ﺁﻣﻮﺯﺵ ﻣﺪﺍﻭﻡ ﺩﺳﺘﻴﺎﺭﺍﻥ ﻭ ﻣﺘﺨﺼﺼﻴﻦ ﻫﺮ ﺭﺷﺘﻪ ﺗﻮﺳﻂ ﺍﻋﻀﺎﺀ ﻫﻴﺌﺖ ﻋﻠﻤﻲ ﺩﺍﻧﺸﮕﺎﻩ ﭘﺰﺷﻜﻲ ‪ Harvard‬ﺑﻨﺎ ﻧﻬﺎﺩﻩ ﺷﺪﻩ ﺍﺳﺖ‪.‬‬
‫‪ CD‬ﺣﺎﺿﺮ ﻣﻄﺎﻟﺒﻲ ﺍﺯ ﻧﻮﺭﻭﻟﻮﮊﻱ ﺑﻪ ﺻﻮﺭﺕ ﺍﺳﻼﻳﺪ‪ ،‬ﺳﺨﻨﺮﺍﻧﻲ ‪ ،‬ﻧﻤﻮﺩﺍﺭ ﻭ ﺍﻟﮕﻮﺭﻳﺘﻢﻫﺎﻱ ﺗﺸﺨﻴﺼﻲ ﺭﺍ ﮔﺮﺩﺁﻭﺭﻱ ﻛﺮﺩﻩ ﺍﺳﺖ‪.‬‬

‫ﺗﻠﻔﻦ‪٠٩١٢١٣٧٢٣٦١-٦٦٩٣٦٦٩٦ :‬‬ ‫ﻧﺸﺎﻧﻲ‪ :‬ﺗﻬﺮﺍﻥ‪ ،‬ﻡ ﺍﻧﻘﻼﺏ‪ ،‬ﺥ ﻛﺎﺭﮔﺮ ﺟﻨﻮﺑﻲ‪ ،‬ﺥ ﻟﺒﺎﻓﻲﻧﮋﺍﺩ‪ ،‬ﺑﻴﻦ ﻛﺎﺭﮔﺮ ﻭ ﺟﻤﺎﻟﺰﺍﺩﻩ‪ ،‬ﺑﻦﺑﺴﺖ ﺳﻴﻤﻴﻦ‪ ،‬ﭘﻼﻙ ‪٢٣٩‬‬ ‫ﻣﺮﻛﺰ ﺧﺪﻣﺎﺕ ﻓﺮﻫﻨﮕﻲ ﺳﺎﻟﻜﺎﻥ ‪ :‬ﺍﺭﺍﺋﻪ ﻛﻨﻨﺪﺓ ﻛﺘﺎﺏ ﻭ ﺳﻲﺩﻱﻫﺎﻱ ﺗﺨﺼﺼﻲ ﭘﺰﺷﻜﻲ‬
 74
‫ ﺳﭙﺲ ﺧﻼﺻـﻪ‬.‫ ﺳﺆﺍﻻﺕ ﻣﺮﺑﻮﻃﻪ ﺑﻪ ﺻﻮﺭﺕ ﭼﻬﺎﺭﮔﺰﻳﻨﻪﺍﻱ ﺑﺮﺍﻱ ﺍﺭﺯﻳﺎﺑﻲ ﻛﺎﺭﺑﺮ ﺁﻭﺭﺩﻩ ﺷﺪﻩ ﺍﺳﺖ‬،‫ ﺩﺭ ﺁﺧﺮ ﻫﺮ ﺳﺨﻨﺮﺍﻧﻲ ﻭ ﻣﺒﺤﺜﻲ‬.‫ﻫﺮ ﻛﺪﺍﻡ ﺍﺯ ﺍﻳﻦ ﺳﺨﻨﺮﺍﻧﻲﻫﺎ ﻋﻼﻭﻩ ﺑﺮ ﺍﺳﻼﻳﺪﻫﺎﻱ ﺁﻣﻮﺯﺷﻲ ﻣﺘﻦ ﺳﺨﻨﺮﺍﻧﻲ ﻧﻴﺰ ﺩﺭ ﺩﺳﺘﺮﺱ ﻛﺎﺭﺑﺮ ﻣﻲﺑﺎﺷﺪ‬
.‫ﻫﺮ ﺳﺨﻨﺮﺍﻧﻲ ﺑﻪ ﺻﻮﺭﺕ ﻳﻚ ﻣﻘﺎﻟﻪ ﭼﺎﭘﻲ ﺩﺭ ﻣﺠﻼﺕ ﻋﻠﻤﻲ ﻭ ﺭﻭﺯﻧﺎﻣﻪﻫﺎ ﺁﻭﺭﺩﻩ ﺷﺪﻩ ﺍﺳﺖ‬
.‫ ﻣﻮﺟﻮﺩ ﺍﺳﺖ‬CD ‫ﻣﺒﺎﺣﺚ ﺯﻳﺮ ﺩﺭ ﺍﻭﺭﻭﻟﻮﮊﻱ ﺩﺭ ﺍﻳﻦ‬
1- How to erahcate Renal mass/Tumor 2- Drugs vs Diet in Modifying Renal failure 3- Treatment of Mypertension-Special Case 4-Clinical Application of Renal Physiology
22.21 Cystectomy and Construction an Ileocecal Neobladder for Urethral Voiding (John A. Libertino MD, FACS) ‫ــــــ‬
22.21 Erectile Dysfunciton Current Investigation and Management (lan Eardley, Drishna Sethia) ‫ــــ‬
22.21 Hot Topics in UROLOGY (Roger S Kirby, Michael P O'Leary) (SALEKAN E-BOOK) 2004

Premature ejaculation Michael P O'Leary New developments for the treatment of erectile dysfunction: Present and Future Erectile dysfunction and cardiovascular disease
Angiogenesis as a diagnostic and therapeutic tool in urological
Chemoprevention of prostate cancer Apoptosis in the prostate
malignancy
Robotic surgery and nanotechnology Marginally worse? Positive resection limits after radical prostatectomy Adjuvant therapy for prostate cancer
Bisphosphonates: a potential new treatment strategy in prostate cancer I mmunotherapy for prostate What,s hot and whats not - the medical management of BPH
Three-dimensional imaging of the upper urinary tract Future prospects for .. nephron conservation in renalcel I carcinoma Urethral stricture surgery: the state of the art
Reducing medical errors in urology Management of female sexual dysfunction Laparoscopic radical prostatectomy
Antisense therapy in oncology: current The overactive bladder Organ preserving therapies for penile carcinomas
22.21 Male and Famale Sexual Dysfunction (Allen D. Seftel) (Salkan E-Book) 2004
22.21 Pelvic Floor Exercises for Erectile Dysfunction (Grace Dorey phD MSCP) 2004
22.21 PRIMER ON KIDNEY DISEASES (Second Edition) (NATINAL KINDEY FOUNDATION SCIENTIFIC ADVISORY BOARD) ‫ــــ‬
.‫ ﺻﻔﺤﻪ ﻣﻲﺑﺎﺷﺪ‬٥١٧ ‫ ﻓﺼﻞ ﻭ ﻣﺸﺘﻤﻞ ﺑﺮ‬١١ ‫ ﺷﺎﻣﻞ‬.‫ﺍﻳﻦ ﻛﺘﺎﺏ ﺍﻟﻜﺘﺮﻭﻧﻴﻚ ﺩﺭ ﻣﺤﻴﻂ ﺍﻛﺮﻭﺑﺎﺕ ﺍﺟﺮﺍ ﺷﺪﻩ ﺍﺳﺖ‬
.‫ ﺗﻜﻨﻴﻚ ﺗﺼﻮﻳﺮﺑﺮﺩﺍﺭﻱ ﺍﺯ ﻛﻠﻴﻪ ﻣﻲﺑﺎﺷﺪ‬،‫ ﭘﺮﻭﺗﺌﻴﻦ ﺍﺩﺭﺍﺭﻱ‬،‫ ﻫﻤﺎﺗﻮﺭﻱ‬،U/A ، ‫ ﺍﺭﺯﻳﺎﺑﻲ ﻓﺎﻧﻜﺸﻦ ﻛﻠﻴﻪ‬، ‫ ﻓﻴﺰﻳﻮﻟﻮﮊﻱ‬،‫ ﺁﻧﺎﺗﻮﻣﻲ‬:‫ ﺳﺎﺧﺘﻤﺎﻥ ﻭﻓﺎﻧﻜﺸﻦ ﻛﻠﻴﻪ ﻭ ﺍﺭﺯﻳﺎﺑﻲ ﺑﺎﻟﻴﻨﻲ ﻛﻠﻴﻪ ﺷﺎﻣﻞ‬-١ ‫ﻓﺼﻞ‬
.‫ ﻣﻨﻴﺰﻳﻮﻡ ﻭ ﺩﻳﻮﺭﺗﻴﻚ ﻣﻲﺑﺎﺷﺪ‬، ‫ ﺍﺧﺘﻼﻻﺕ ﻣﺘﺎﺑﻮﻟﻴﺴﻢ ﭘﺘﺎﺳﻴﻢ ﻭ ﻛﻠﻴﺴﻴﻢ‬،‫ ﺍﻟﻜﺎﻟﻮﺯﻣﺘﺎﺑﻮﻟﻴﻚ‬،‫ ﺍﺳﻴﺪﻭﺯ‬،‫ ﻫﻴﭙﻮﻭﻫﻴﺒﺮﻧﺎﺗﻮﻣﻲ‬:‫ ﺍﺧﺘﻼﻻﺕ ﺍﺳﻴﺪ ﻭ ﺑﺎﺯ ﻭ ﺍﻟﻜﺘﺮﻭﻧﻴﻚ ﺷﺎﻣﻞ‬-٢ ‫ﻓﺼﻞ‬
.‫ ﻧﻔﺮﻭﭘﺎﺗﺎ ﻣﻲﺑﺎﺷﺪ‬IGA ‫ ﻭ ﺳﻨﺪﺭﻭﻡ ﮔﻮﺩﭘﺎﺳﭽﺮ ﻭ‬MGN ،FSGN ،MPGN ،MCD ،‫ ﺍﻳﻤﻮﻧﻮﭘﺎﺗﻮﮊﻧﺰ ﺑﻴﻤﺎﺭﻱ ﺍﻱ ﮔﻠﻮﻣﺮﻭﻱ‬:‫ ﺷﺎﻣﻞ‬Glomerular Diseuse -٣ ‫ﻓﺼﻞ‬
.‫ ﻣﻲﺑﺎﺷﺪ‬.... ‫ ﻭ ﺑﻴﻤﺎﺭﻱﻫﺎﻱ ﻛﻠﻴﻪ ﻭ‬HIV ‫ ﺩﻳﺎﺑﺘﻴﻚ ﻧﻔﺮﻭﭘﺎﺗﻲ ﻭ‬،‫ ﻭ ﺑﻴﻤﺎﺭﻱﻫﺎﻱ ﺭﻭﻣﺎﺗﻴﺴﻤﻲ ﻭ ﻛﻠﻴﻪ‬SLE ،‫ ﻭ ﺍﺳﻜﻮﻟﻴﺖﻫﺎ ﻭ ﻛﻠﻴﻪ‬PSGN ،‫ ﻭ ﺑﻴﻤﺎﺭﻱﻫﺎﻱ ﻛﺒﺪﻱ‬CHF ‫ ﻛﻠﻴﻪ ﺩﺭ‬:‫ ﻛﻠﻴﻪ ﻭ ﺑﻴﻤﺎﺭﻱﻫﺎﻱ ﺳﻴﺴﺘﻤﻴﻚ ﻣﻲﺑﺎﺷﺪ ﺷﺎﻣﻞ‬-٤ ‫ﻓﺼﻞ‬
.‫ ﻭ ﺩﺭﻣﺎﻥ ﻣﻲﺑﺎﺷﺪ‬approach ،‫ ﻋﻠﻞ‬،‫ ﭘﺎﺗﻮﻓﻴﺰﻳﻮﻟﻮﮊﻱ‬:‫ ﻧﺎﺭﺳﺎﺋﻲ ﺣﺎﺩ ﻛﻠﻴﻪ ﺷﺎﻣﻞ‬-٥ ‫ﻓﺼﻞ‬
‫ ﻭ ﻛﻠﻴﻪ ﻭ ﻣﻮﺍﺭﺩ ﺩﺍﺭﻭﻱ ﺩﺭﻣﺎﻧﻲ ﺩﺭ ﻧﺎﺭﺳﺎﺋﻲ ﻛﻠﻴﻪ‬NSAID ‫ ﺷﺎﻣﻞ‬:‫ ﺩﺍﺭﻭﻫﺎﻱ ﻭ ﻛﻠﻴﻪ‬-٦ ‫ﻓﺼﻞ‬
‫ ﻭ ﺑﻴﻤﺎﺭﻱﻫﺎﻱ ﻛﺴﻴﺘﻴﻚ ﻛﻠﻴﻪ‬Alport ‫ ﺳﻨﺪﺭﻭﻡ‬،‫ ﻛﻠﻴﻪ‬Cystic ‫ ﺑﻴﻤﺎﺭﻱﻫﺎﻱ‬،Sickle cell ‫ ﻧﻔﺮﻭﭘﺎﺗﻲ‬:‫ ﺍﺧﺘﻼﻻﺕ ﺍﺭﺛﻲ ﻛﻠﻴﻪ‬-٧ ‫ﻓﺼﻞ‬
.‫ ﻋﻔﻮﻧﺖﻫﺎﻱ ﻛﻠﻴﻮﻱ ﺍﻧﺴﺪﺍﺩ ﻣﺠﺎﺭﻱ ﻭ ﺳﺮﻃﺎﻥﻫﺎﻱ ﻛﻠﻴﻪ ﻭ ﻣﺠﺎﺭﻱ ﺁﻥ‬، ‫ ﻋﻔﻮﻧﺖﻫﺎﻱ ﻛﻠﻴﻮﻱ‬،‫ ﺍﮔﺰﺍﻻﺕ ﺳﻨﮓﻫﺎﻱ ﻛﻠﻴﻮﻱ‬،‫ ﺑﻴﻤﺎﺭﻱ ﻛﻠﻴﻪ ﻭ ﻟﻴﺘﻴﻮﻡ ﺳﺮﺏ‬:‫ ﻧﻔﺮﻭﭘﺎﺗﻲ ﺗﻮﺑﻮﻟﻮﺍﻳﻨﺘﺮﺳﺘﻴﺸﻴﻞ ﻭ ﺍﺧﺘﻼﻻﺕ ﻣﺠﺎﺭﻱ ﺍﺩﺍﺭﻱ ﺷﺎﻣﻞ‬-٨ ‫ﻓﺼﻞ‬
.‫ ﻛﻠﻴﻪ ﺩﺭ ﭘﻴﺮﻱ‬،‫ ﻛﻠﻴﻪ ﺩﺭ ﺣﺎﻣﻠﮕﻲ‬،‫ ﻛﻠﻴﻪ ﻭ ﻣﻮﺍﺭﺩ ﺧﺎﺹ ﺷﺎﻣﻞ‚ ﻛﻠﻴﻪ ﺩﺭ ﻧﻮﺯﺍﺩﺍﻥ ﻭ ﻛﻮﺩﻛﺎﻥ‬-٩ ‫ﻓﺼﻞ‬
.‫ ﻭ ﭘﻴﻮﻧﺪ ﻛﻠﻴﻪ ﻭ ﭼﮕﻮﻧﮕﻲ ﺩﺍﺭﻭﺩﻣﺎﻧﻲ ﺩﺭ ﺁﻧﻬﺎ‬CRF ‫ ﻏﺪﺩﻱ‬،‫ ﻫﻤﺎﺗﻮﻟﻮﮊﻱ‬،‫ ﻋﺼﺒﻲ‬،‫ ﺗﻈﺎﻫﺮﺍﺕ ﻗﻠﺒﻲ‬،CRF ‫ ﭘﻴﺶﺁﮔﻬﻲ ﻭ ﺗﻐﺬﻳﻪ‬،‫ ﻫﻤﻮﺩﻳﺎﻟﻴﺰ ﻭ ﻫﻤﻮﻓﻴﻠﺘﺮﺍﺳﻴﻮﻥ ﺩﻳﺎﻟﻴﺰ ﺻﻔﺎﺗﻲ‬،‫ ﺳﻨﺪﺭﻭﻡ ﺍﻭﺭﻣﻲ‬:‫ ﻧﺎﺭﺳﺎﺋﻲ ﻣﺰﻣﻦ ﻛﻠﻴﻪ ﻭ ﺩﺭﻣﺎﻥ ﺷﺎﻣﻞ‬-١٠ ‫ﻓﺼﻞ‬
.‫ ﻭ ﺩﺭﻣﺎﻥ ﻓﺸﺎﺭ ﺧﻮﻥ‬Renovascular ‫ ﻓﺸﺎﺭ ﺧﻮﻥ‬،‫ ﻓﺸﺎﺭ ﺧﻮﻥ ﺍﺳﺎﺳﻲ‬،‫ ﭘﺎﻧﻮﮊﻧﺰ‬:‫ ﻓﺸﺎﺭ ﺧﻮﻥ ﺷﺎﻣﻞ‬-١١ ‫ﻓﺼﻞ‬
22.21 The Journal of UROLOGY (Spring & Summer) (CD I, II) (Official Journal of the American Urological Association) 2003
CD I: - Clinical Urology -Pediatric Urology -Investigative Urology -Urological Survey
CD II: - Clinical Urology -Pediatric Urology -Investigative Urology -Urological Survey -CME Participant Assessment Test and Course Evaluation
22.21 Urogynecology: Evaluation and Treatment of Urinary Incontinence (Bruce Rosenzweig, MD, Jeffrey S. Levy, MD, Donald R. Ostergard, MD) ‫ــــــ‬
.‫ ﻭﺟﻮﺩ ﺩﺍﺭﺩ‬CD ‫ﻼ ﺭﻧﮕﻲ ﺑﻮﺩﻩ ﻭ ﺗﻮﺿﻴﺤﺎﺕ ﺑﻪ ﺻﻮﺭﺕ ﻧﻮﺷﺘﺎﺭﻱ ﻭ ﻓﺎﻳﻞ ﺻﻮﺗﻲ ﻛﻪ ﺑﺮ ﺭﻭﻱ ﻫﺮ ﻗﺴﻤﺖ ﺍﺯ ﺍﻳﻦ‬
‫ ﻛﻪ ﺑﻪ ﺻﻮﺭﺕ ﺗﺼﺎﻭﻳﺮ ﻛﺎﻣ ﹰ‬CD ‫ﺍﻳﻦ‬

٠٩١٢١٣٧٢٣٦١-٦٦٩٣٦٦٩٦ :‫ﺗﻠﻔﻦ‬ ٢٣٩ ‫ ﭘﻼﻙ‬،‫ ﺑﻦﺑﺴﺖ ﺳﻴﻤﻴﻦ‬،‫ ﺑﻴﻦ ﻛﺎﺭﮔﺮ ﻭ ﺟﻤﺎﻟﺰﺍﺩﻩ‬،‫ ﺥ ﻟﺒﺎﻓﻲﻧﮋﺍﺩ‬،‫ ﺥ ﻛﺎﺭﮔﺮ ﺟﻨﻮﺑﻲ‬،‫ ﻡ ﺍﻧﻘﻼﺏ‬،‫ ﺗﻬﺮﺍﻥ‬:‫ﻧﺸﺎﻧﻲ‬ ‫ ﺍﺭﺍﺋﻪ ﻛﻨﻨﺪﺓ ﻛﺘﺎﺏ ﻭ ﺳﻲﺩﻱﻫﺎﻱ ﺗﺨﺼﺼﻲ ﭘﺰﺷﻜﻲ‬: ‫ﻣﺮﻛﺰ ﺧﺪﻣﺎﺕ ﻓﺮﻫﻨﮕﻲ ﺳﺎﻟﻜﺎﻥ‬
 ‫‪75‬‬
‫‪ ٤ Urogynechology‬ﻗﺴﻤﺖ ﻣﺠﺰﺍ ﺩﺍﺭﺩ ﺷﺎﻣﻞ‪:‬‬
‫‪Consideration for the OB/GYN Generalist‬‬ ‫‪-٤‬‬ ‫‪won surgical & surgical Management‬‬ ‫‪-٣‬‬ ‫‪Evaluation -٢‬‬ ‫‪Introduction Definigg Incontinence‬‬ ‫‪-١‬‬
‫‪Patient misconceptions y‬‬ ‫‪affected women y‬‬ ‫‪ y‬ﺗﺸﺨﻴﺺ ‪incontince‬‬ ‫ﺍﻳﻦ ﻗﺴﻤﺖ ﺧﻮﺩ ﺷﺎﻣﻞ ﻣﺒﺎﺣﺚ‪:‬‬ ‫‪:Introduction & Defining Incontince (١‬‬
‫‪Types of incontinernce y‬‬ ‫‪incontinence awareness y‬‬
‫‪ (٢‬ﺍﺭﺯﻳﺎﺑﻲ ﺑﻴﻤﺎﺭﺍﻥ ﺑﺎ ‪:incontinency‬‬
‫‪Cystoscopy y uroflowmetry y Postvoid residual y Cystometrogram y Pad test y‬‬ ‫‪ y Voiding diary y‬ﺗﺎﺭﻳﺨﭽﻪ ‪ y‬ﻣﻌﺎﻳﻨﺎﺕ ﺑﺎﻟﻴﻨﻲ‬ ‫‪un , u/s y‬‬
‫‪Pessary test y‬‬ ‫‪Multi-Channel urodynamics y‬‬

‫‪ (٣‬ﺗﺪﺍﺑﻴﺮ ﺩﺭﻣﺎﻧﻲ ﺟﺮﺍﺣﻲ ﻭ ﻏﻴﺮ ﺟﺮﺍﺣﻲ ﺩﺭ ‪: Stress urinary incontinence‬‬

‫ﺍﻳﻦ ﻗﺴﻤﺖ ﺷﺎﻣﻞ ﺍﻟﮕﻮﺭﻳﺘﻢ ﺗﺼﻤﻴﻢﮔﻴﺮﻱ ﺩﺭ ﻣﻮﺭﺩ ﺭﻭﺵ ﺩﺭﻣﺎﻧﻲ ﻣﻲﺑﺎﺷﺪ ﻭ ﺳﭙﺲ ﺭﻭﺵ ﺩﺭﻣﺎﻧﻲ ﻏﻴﺮﺟﺮﺍﺣﻲ ))‪ biofeedback, Beharioral modification‬ﻭ ﺩﺭﻣـﺎﻥﻫـﺎﻱ ﺩﺍﺭﻭﺋـﻲ ‪ funetional electrieal Stimalation‬ﻭ ‪ (....‬ﺑﺤـﺚ ﺷـﺪﻩ‬
‫ﺍﺳﺖ‪.‬‬
‫ﺭﻭﺵﻫﺎﻱ ﺟﺮﺍﺣﻲ‪ :‬ﺍﺑﺘﺪﺍ ﺩﺭ ﻣﻮﺭﺩ ﺭﻭﺵﻫﺎﻱ ﺍﻧﺠﺎﻡ ﺟﺮﺍﺣﻲ ﺑﺤﺚ ﺷﺪﻩ ﻭ ﺳﭙﺲ ‪ Procedure‬ﺍﻋﻤﺎﻝ ﺟﺮﺍﺣﻲ ﺷﺮﺡ ﺩﺍﺩﻩ ﺷﺪﻩ ﺍﺳﺖ‪ .‬ﺩﺭ ﻗﺴﻤﺖﻫﺎﻱ ﺑﻌﺪﻱ ﻣﻘﺎﻳﺴﻪ ﺩﺭﺻﺪ ﻣﻮﻓﻘﻴﺖ ﺭﻭﺵﻫﺎ ﺫﻛﺮ ﺷﺪﻩ ﻭ ﺩﺭ ﺁﺧﺮ ‪ Complication‬ﺍﻳـﻦ ﺭﻭﺵﻫـﺎ‬
‫ﺗﻮﺿﻴﺢ ﺩﺍﺩﻩ ﺷﺪﻩ ﺍﺳﺖ‪.‬‬

‫‪: Consideration for the OB/Gyn Generalist (٤‬‬

‫‪eystometry y‬‬ ‫‪incontinrence management to private patients y‬‬ ‫‪Non surgical therapy y‬‬ ‫‪urogynechology as a subdiscipline y‬‬ ‫ﺩﺭ ﺍﻳﻦ ﻓﺼﻞ‪:‬‬
‫ﻣﻮﺭﺩ ﺑﺤﺚ ﻗﺮﺍﺭ ﮔﺮﻓﺘﻪ ﺍﺳﺖ‪.‬‬ ‫‪Allied Staff y‬‬ ‫‪equipment cost ySet-up requirement y‬‬ ‫‪Urodynamics y‬‬ ‫‪professional consideration y‬‬
‫‪22.21 Smith's‬‬ ‫‪General Urology‬‬ ‫)‪(Sixteenth edition) (Emil A. Tanagho, Jack W. Mcaninch) (Salekan E-Book‬‬ ‫‪2004‬‬
‫‪22.21 Glenn's Urologic Surgery‬‬ ‫)‪(Sixth Edition) (Sam D. Graham, James F. Glenn,) (Salekan E-Book‬‬ ‫‪2004‬‬
‫‪22.21 The Kidney‬‬ ‫)‪(Volume 1-2‬‬ ‫)‪Seven Edition (Barry M. Brenner) (E-Book‬‬ ‫ــــ‬
‫ﺍﻳﻦ ﻛﺘﺎﺏ ﺍﻟﻜﺘﺮﻭﻧﻴﻜﻲ ﺷﺎﻣﻞ ﺩﻭ ﺟﻠﺪ ﺍﺳﺖ ‪.‬‬
‫ﺩﺭ ﺍﻧﺘﻬﺎﻱ ﻫﺮ ﺑﺨﺶ ﻛﺘﺎﺏ‪ ،‬ﺗﺼﺎﻭﻳﺮ ﻣﺮﺑﻮﻃﻪ ﺑﺎ ﻭﺿﻮﺡ ﺑﺎﻻ ﺁﻭﺭﺩﻩ ﺷﺪﻩ ﺍﺳﺖ‪ .‬ﻛﻴﻔﻴﺖ ﺑﺎﻻﻱ ﺗﺼﺎﻭﻳﺮ‪ ،‬ﺍﻳﻦ ﺍﻣﻜﺎﻥ ﺭﺍ ﻓﺮﺍﻫﻤﻲ ﻣﻲﺳﺎﺯﺩ ﺗﺎ ﺍﺳﺘﻔﺎﺩﻩ ﺍﺯ ﺁﻧﻬﺎ ﺩﺭ ﺳﻤﻴﻨﺎﺭﻫﺎ ﻭ ﻫﻤﻴﻨﻄﻮﺭ ﺟﻬﺖ ﺁﻣﻮﺯﺵ ﻣﻨﺎﺳﺐ ﺑﺎﺷﺪ‪ .‬ﺍﻳﻦ ﺟﻠﺪ ﺩﺍﺭﺍﻱ ﺩﻭ ﺑﺨﺶ ﺍﺳﺖ‪:‬‬

‫‪ -١‬ﻗﺴﻤﺖﻫﺎﻱ ﻣﺨﺘﻠﻒ ﻛﻠﻴﻪ ﻃﺒﻴﻌﻲ ﻭ ﻋﻤﻠﻜﺮﺩ ﻫﺮ ﻳﻚ ﺍﺯ ﺍﻳﻦ ﺑﺨﺶﻫﺎ ﺩﺭ ﺍﻳﻦ ﺑﺨﺶ ﻣﺒﺎﺣﺜﻲ ﻫﻤﭽﻮﻥ ﺁﻧﺎﺗﻮﻣﻲ ﻛﻠﻴﻪ‪ ،‬ﺭﺷﺪ ﻭ ﺑﻠﻮﻍ ﻛﻠﻴﻪ‪ ،‬ﺍﺻﻮﻝ ﻣﺘﺎﺑﻮﻟﻴﻚ ﺍﻧﺘﻘﺎﻝ ﻳﻮﻥ‪ ،‬ﺟﺮﻳﺎﻥ ﺧﻮﻥ ﻛﻠﻴﻪ‪ ،‬ﺍﻧﺘﻘﺎﻝ ﻛﻠﻴﻮﻱ ﮔﻠﻮﻛﺰ‪ ،‬ﺍﺳﻴﺪ ﺁﻣﻴﻨﻪ‪ ،‬ﺳﺪﻳﻢ‪ ،....‬ﻛﻨﺘﺮﻝ ﺗﺮﺷﺢ ﻛﻠﻴـﻮﻱ ﭘﺘﺎﺳـﻴﻢ ﻭ ‪....‬‬
‫ﺩﻫﻬﺎ ﻋﻨﻮﺍﻥ ﺩﻳﮕﺮ ﻣﻄﺮﺡ ﺷﺪﻩﺍﻧﺪ‪.‬‬
‫‪ -٢‬ﺍﺧﺘﻼﻝ ﺩﺭ ﻛﻨﺘﺮﻝ ﺣﺠﻢ ﻣﺎﻳﻊ ﺑﺪﻥ‪ :‬ﻛﻨﺘﺮﻝ ﺣﺠﻢ ﺧﺎﺭﺝ ﺳﻠﻮﻟﻲ ﻭ ﭘﺎﺗﻮﻓﻴﺰﻳﻮﻟﻮﮊﻱ ﺍﺩﻡ‪ ،‬ﻋﻮﺍﻣﻞ ﻣﺆﺛﺮ ﺑﺮ ﻫﻤﻮﺳﺘﺎﺯ ﻣﺎﻳﻊ‪ ،‬ﻓﺎﻛﺘﻮﺭﻫﺎﻱ ﻣﺆﺛﺮ ﺑﺮ ﺗﻮﺑﺮﻝ ﻛﻠﻴﻪ‪ ،AVP ،‬ﭘﺮﻭﺳﺘﺎﮔﻼﻧﺪﻳﻦﻫﺎ‪ ،‬ﺍﺩﻡ ﺩﺭ ﺳﻴﺮﻭﺯ‪ ،‬ﺍﺩﻡ ﺩﺭ ‪ ،CHF‬ﺩﻳﺎﺑﺖ ﺑﻲﻣﺰﻩ ﻭ ﺍﻧﻮﺍﻉ ﺁﻥ‪ ،‬ﻫﻴﭙﻮﻧﺎﺗﺮﻣﻲ ﻭ ﺍﻳﺘﻮﻟﻮﮊﻱﻫـﺎﻱ‬
‫ﻣﺨﺘﻠﻒ ﺁﻥ‪ ،‬ﺍﺧﺘﻼﻻﺕ ﺍﺳﻴﺪ ﻭ ﺑﺎﺯ‪ ،‬ﺍﺧﺘﻼﻻﺕ ﺗﻮﺍﺯﻥ ﭘﺘﺎﺳﻴﻢ‪ ،‬ﺑﺮﺧﻮﺭﺩ ﺑﺎ ﺑﻴﻤﺎﺭ ﻣﺒﺘﻼ ﺑﻪ ﻫﻴﭙﻮﻭﻫﻴﭙﺮﻛﺎﺳﻤﻲ‪ ،‬ﺍﺧﺘﻼﻻﺕ ﻛﻠﺴﻴﻢ ﻭ ﻓﺴﻔﺮ ﻭ ‪ ....‬ﺩﻫﻬﺎ ﻣﻄﻠﺐ ﺩﻳﮕﺮ ﺩﺭ ﺍﻳﻦ ﺑﺨﺶ‪ ،‬ﺩﺭ ﺩﺳﺘﺮﺱ ﻣﻲﺑﺎﺷﻨﺪ‪.‬‬
‫ﺟﻠﺪ ‪ ٢‬ﻛﺘﺎﺏ ﺷﺎﻣﻞ ‪ ٣‬ﻗﺴﻤﺖ ﺍﺳﺖ‪:‬‬
‫ﺍﻟﻒ( ﭘﺎﺗﻮﻓﻴﺰﻳﻮﻟﻮﮊﻱ ﺑﻴﻤﺎﺭﻱﻫﺎﻱ ﻛﻠﻴﻪ‪ :‬ﻣﺒﺎﺣﺜﻲ ﭼﻮﻥ‪ :‬ﺍﺭﺯﻳﺎﺑﻲ ﺑﺎﻟﻴﻨﻲ ﺩﺭ ﺑﻴﻤﺎﺭﻱﻫﺎﻱ ﻛﻠﻴﻪ‪ ،‬ﺑﻴﻤﺎﺭﻱﻫﺎﻱ ﮔﻠﻮﻣﺮﻭﻟﻲ ﺍﻭﻟﻴﻪ ﻭ ﺛﺎﻧﻮﻳﻪ‪ ،‬ﻋﻔﻮﻧﺖﻫﺎﻱ ﺍﺩﺭﺍﺭﻱ‪ ،‬ﻧﻔﺮﻭﭘﺎﺗﻲ ﺗﻮﻛﺴﻴﻚ ﻭ ‪ ....‬ﺩﻫﻬﺎ ﻣﻄﻠﺐ ﺩﻳﮕﺮ‪.‬‬
‫ﺏ( ﭘﺎﺗﻮﮊﻧﺰ ﺑﻴﻤﺎﺭﻱﻫﺎﻱ ﻛﻠﻴﻪ‪ :‬ﻧﺌﻮﭘﻼﺯﻱ ﻛﻠﻴﻪ‪ ،‬ﻫﻴﭙﺮﺗﺎﻧﺴﻴﻮﻥ )ﺍﻭﻟﻴﻪ ‪ (renovascular‬ﺍﻭﺭﻱ‪ ،‬ﺍﺳﺘﺌﻮﺩﺳﻴﺘﺮﻭﻓﻲ ﺭﻧﺎﻝ ﻭ ‪ ...‬ﺍﺯ ﺟﻤﻠﻪ ﻣﺒﺎﺣﺚ ﻣﻄﺮﺡ ﺷﺪﻩ ﻣﻲﺑﺎﺷﻨﺪ‪.‬‬
‫ﺝ( ﺑﺮﺧﻮﺭﺩ ﺑﺎ ﺑﻴﻤﺎﺭ ﻣﺒﺘﻼ ﺑﻪ ﻧﺎﺭﺳﺎﻳﻲ ﻛﻠﻴﻮﻱ‪ :‬ﺍﻧﻮﺍﻉ ﺩﻳﺎﻟﻴﺰ‪ ،‬ﺍﻳﻤﻮﻧﻮﻟﻮﮊﻱ ﭘﻴﻮﻧﺪ‪ ،‬ﺍﻧﻮﺍﻉ ﺩﺍﺭﻭﻫﺎﻱ ﺩﻳﻮﺭﺗﻴﻚ ﻭ ‪ ....‬ﺩﺭ ﺍﻳﻦ ﺑﺨﺶ ﺑﺤﺚ ﺷﺪﻫﺎﻧﺪ‪.‬‬

‫‪ : ٢٢‬ﮐﺎﻧﺴﺮ‬

‫ﻋﻨﻮﺍﻥ ‪CD‬‬ ‫ﺳﺎﻝ ﺍﻧﺘﺸﺎﺭ‬

‫‪1.22‬‬ ‫‪Adult and Pediatric Urology‬‬ ‫)‪(Jay Y. Gillenwater, john T. Grayhack, Stuart S. Howards, Michael E. Mitchell‬‬ ‫‪2002‬‬
‫‪Adult Urology‬‬ ‫‪Adult Urology Continued‬‬ ‫‪Pediatric Urology‬‬ ‫‪Video Library‬‬

‫ﺗﻠﻔﻦ‪٠٩١٢١٣٧٢٣٦١-٦٦٩٣٦٦٩٦ :‬‬ ‫ﻧﺸﺎﻧﻲ‪ :‬ﺗﻬﺮﺍﻥ‪ ،‬ﻡ ﺍﻧﻘﻼﺏ‪ ،‬ﺥ ﻛﺎﺭﮔﺮ ﺟﻨﻮﺑﻲ‪ ،‬ﺥ ﻟﺒﺎﻓﻲﻧﮋﺍﺩ‪ ،‬ﺑﻴﻦ ﻛﺎﺭﮔﺮ ﻭ ﺟﻤﺎﻟﺰﺍﺩﻩ‪ ،‬ﺑﻦﺑﺴﺖ ﺳﻴﻤﻴﻦ‪ ،‬ﭘﻼﻙ ‪٢٣٩‬‬ ‫ﻣﺮﻛﺰ ﺧﺪﻣﺎﺕ ﻓﺮﻫﻨﮕﻲ ﺳﺎﻟﻜﺎﻥ ‪ :‬ﺍﺭﺍﺋﻪ ﻛﻨﻨﺪﺓ ﻛﺘﺎﺏ ﻭ ﺳﻲﺩﻱﻫﺎﻱ ﺗﺨﺼﺼﻲ ﭘﺰﺷﻜﻲ‬
 76
2.22 American Cancer Society Atlas of Clinical Oncology (Cancer of the Female Lowe Genital Tract) (Patricia J. Eifel, M.D. Charles Levenback, M.D.) (SALEKAN E-BOOK) 2001

‫ ﺁﺧﺮﻳﻦ ﺗﻐﻴﻴـﺮﺍﺕ ﺩﺭ ﺩﺭﻣـﺎﻥﻫـﺎﻱ ﭘﺬﻳﺮﻓﺘـﻪﺷـﺪﻩ ﺑـﺮﺍﻱ ﻛﺎﻧﺴـﺮ ﻣﻬـﺎﺟﻢ‬.‫ ﺍﺭﺯﻳﺎﺑﻲ ﻭ ﺩﺭﻣﺎﻥ ﻛﺎﻧﺴﺮﻫﺎ ﺩﺳﺘﮕﺎﻩ ﺗﻨﺎﺳﻠﻲ ﺗﺤﺘﺎﻧﻲ ﺯﻧﺎﻥ ﻣﻲﺑﺎﺷﺪ‬،‫ ﺗﺸﺨﻴﺺ‬،‫ﺍﻳﻦ ﻛﺘﺎﺏ ﺍﻟﻜﺘﺮﻭﻧﻴﻜﻲ ﺑﻪ ﮔﻔﺘﺔ ﻣﺆﻟﻔﻴﻦ ﺑﻪ ﻣﻨﻈﻮﺭ ﻓﺮﺍﻫﻢﻛﺮﺩﻥ ﻣﺮﻭﺭ ﻭ ﺁﻧﺎﻟﻴﺰ ﺑﻴﻮﻟﻮﮊﻱ‬
.‫ ﻭ ﻳﻚ ﺑﺎﺯﻧﮕﺮﻱ ﻛﻠﻲ ﺩﺭ ﻫﻤﻪ ﻣﺒﺎﺣﺚ ﺁﻭﺭﺩﻩ ﺷﺪﻩ ﺷﺪﻩ ﺍﺳﺖ‬Cervix
Chemotherapy in Curative Surgical Treatment of Invasive Cervical
Surgery for Vulvar Cancer Diagnostic Imaging Epidemiology
Management Cancer
Radiation Therapy for Invasive Cervical
Post-treatment Surveillance Radiation Therapy for Vulvar Cancer Screening for Neoplasms Pathology
Cancer
Radical Management of Recurrent Cervical Treatment of Squamous Intraepithelial Molecular Biology
Palliative Care Acute Effects of Radiation Therapy
Cancer Lesions
Late Complications of Pelvic Radiation Anatomy and Natural
Management of Vaginal Cancer Invasive Carcinoma of the Cervix
Therapy History
3.22 American Cancer Society Atlas of Clinical Oncology Skin Cancer (Arthur J. Sober, MD, Frank G. Haluka, MD, phD) (Bc Decker Inc) 2001

‫ ﺩﺭ ﻧﺘﻴﺠـﻪ ﺩﺍﻧـﺶ ﺗﺸـﺨﻴﺺ ﻭ ﺩﺭﻣـﺎﻥ ﻭ‬.‫ ﻛﺎﻧﺴﺮﻫﺎﻱ ﭘﻮﺳﺖ ﺩﺭ ﻣﻌﺮﺽ ﺩﻳﺪ ﻣﻲﺑﺎﺷﺪ ﺳﺮﻳﻌﺘﺮ ﻭ ﺭﺍﺣﺖﺗﺮ ﻗﺎﺑـﻞ ﺗﺸـﺨﻴﺺ ﺍﺳـﺖ‬،‫ ﻛﺎﻧﺴﺮﻫﺎﻱ ﭘﻮﺳﺘﻲ ﻣﻲﺑﺎﺷﺪ ﻭ ﺑﻪ ﻋﻠﺖ ﺍﻳﻨﻜﻪ ﺑﺮ ﺧﻼﻑ ﻛﺎﻧﺴﺮﻫﺎﻱ ﺩﻳﮕﺮ‬،‫ ﻣﻲﺷﻮﻳﻢ ﺷﺎﻳﻊﺗﺮﻳﻦ ﺷﻜﻞ ﺳﺮﻃﺎﻥﻫﺎ‬٢١ ‫ﻫﻤﭽﻨﺎﻧﻜﻪ ﻭﺍﺭﺩ ﻗﺮﻥ‬
‫ ﺑﻨﺎﺑﺮﺍﻳﻦ ﻛﺘﺎﺏ ﺩﺍﺭﺍﻱ ﺗﺼﺎﻭﻳﺮ ﺯﻳﺎﺩ ﺑﺎ ﻛﻴﻔﻴﺖ ﺑﺴﻴﺎﺭ ﺑﺎﻻﺳﺖ ﻭ ﻫﺮ ﺟﺎ ﻛﻪ ﻋﻜﺲﻫﺎ‬،‫ ﻣﻲﺑﺎﺷﺪ ﭼﻮﻥ ﻋﻠﻢ ﺩﺭﻣﺎﺗﻮﻟﻮﮊﻱ ﺑﺮ ﭘﺎﻳﺔ ﻣﺸﺎﻫﺪﻩ ﺑﻨﺎ ﺷﺪﻩ ﺍﺳﺖ‬Skin cancer ‫ ﻣﺸﺨﺼﺔ ﺍﻳﻦ ﻛﺘﺎﺏ ﺗﺄﻛﻴﺪ ﺑﺮ ﻧﻤﺎﻫﺎﻱ ﺑﺎﻟﻴﻨﻲ‬.‫ﺟﻠﻮﮔﻴﺮﻱ ﺍﺯ ﺳﺮﻃﺎﻥﻫﺎﻱ ﭘﻮﺳﺘﻲ ﻣﻮﺟﺐ ﻧﮕﺎﺭﺵ ﺍﻳﻦ ﻛﺘﺎﺏ ﮔﺮﺩﻳﺪﻩ ﺍﺳﺖ‬
:‫ ﻗﺴﻤﺖ ﺗﻘﺴﻴﻢ ﺷﺪﻩ ﺍﺳﺖ‬٤ ‫ ﺍﻳﻦ ﻛﺘﺎﺏ ﺑﻪ‬.‫ ﺩﺭﻣﺎﻧﻲ ﻭ ﭘﻴﺸﮕﻴﺮﻱ ﺩﺭ ﻛﺘﺎﺏ ﮔﻨﺠﺎﻧﺪﻩ ﺷﺪﻩ ﺍﺳﺖ‬، ‫ ﺍﭘﻴﺪﻣﻴﻮﻟﻮﮊﻱ‬،‫ ﻭ ﻋﻼﻭﻩ ﺑﺮ ﺍﻳﻦ ﻧﻜﺎﺕ ﺗﺸﺨﻴﺼﻲ‬.‫ ﺍﺿﺎﻓﻪ ﺷﺪﻩ ﺍﺳﺖ‬text ‫ﺩﺭ ﺍﺭﺍﺋﻪ ﻣﻄﻠﺐ ﻛﻤﻚﻛﻨﻨﺪﻩ ﻧﺒﻮﺩﻩ‬
.‫ ﮊﻧﺘﻴﻚ ﻛﺎﻧﺴﺮﻫﺎﻱ ﭘﻮﺳﺘﻲ ﻭ ﻋﻮﺍﻣﻞ ﺧﻄﺮﺯﺍ ﻣﻲﺑﺎﺷﺪ‬،‫ ﺷﺎﻣﻞ ﺍﭘﻴﺪﻣﻴﻮﻟﻮﮊﻱ‬Basic Concept :١ ‫ﺑﺨﺶ‬
.‫( ﺍﺷﺎﺭﻩ ﺷﺪﻩ ﺍﺳﺖ‬٨:٣ ‫ ( ﻭ ﻛﺎﭘﻮﺳﻲ ﺳﺎﺭﻛﻮﻡ )ﻓﺼﻞ‬٨:٢ ‫ )ﻓﺼﻞ‬Merckle cell Carcinoma (٨:١ ‫( ﻭ ﻣﺎﻟﻴﻨﮕﻨﺎﻧﺴﻲﻫﺎﻱ ﭘﻮﺳﺘﻲ ﻧﺎﺷﺎﻳﻊ )ﻓﺼﻞ‬٧ ‫( ﻟﻤﻔﻮﻡﻫﺎﻱ ﭘﻮﺳﺘﻲ )ﻓﺼﻞ‬٦ ‫ )ﻓﺼﻞ‬Scc ‫( ﻭ‬٥ ‫ )ﻓﺼﻞ‬BCE ‫( ﻭ‬٤ ‫ ﺩﺭ ﻫﺮ ﻓﺼﻞ ﺟﺪﺍﮔﺎﻧﻪ ﻧﻤﺎﻱ ﺑﺎﻟﻴﻨﻲ ﻣﻼﻧﻮﻡ )ﻓﺼﻞ‬:‫ ﺗﻈﺎﻫﺮﺍﺕ ﺑﺎﻟﻴﻨﻲ‬:٢ ‫ﺑﺨﺶ‬
‫ ﺳـﻴﺘﻮﻛﻴﻦ‬، ‫( ﻭ ﻛﻤـﻮﺗﺮﺍﭘﻲ‬١٣ ‫ ﺍﻳﻤﻮﻧـﻮﺗﺮﺍﭘﻲ ﺩﺭ ﻣﻼﻧـﻮﻡ )ﻓﺼـﻞ‬،(١٢ ‫ ﺩﺭ ﻣﻼﻧﻮﻡ )ﻓﺼﻞ‬adjuvant therapy ،(١١ ‫ ﺍﺭﺯﻳﺎﺑﻲ ﻟﻤﻒﻧﻮﺩﻫﺎ ﻭ ﺑﻴﻮﭘﺴﻲ ﺍﺯ ﻟﻤﻒﻧﻮﺩ ﺩﺭ ﻣﻼﻧﻮﻡ )ﻓﺼﻞ‬،(١١ ‫ ﺗﺪﺍﺑﻴﺮ ﺟﺮﺍﺣﻲ ﻣﻼﻧﻮﻡ ﭘﻮﺳﺘﻲ )ﻓﺼﻞ‬، (٩ ‫ ﺗﻜﻨﻴﻚ ﺑﻴﻮﭘﺴﻲ ﺍﺯ ﻣﻼﻧﻮﻡ )ﻓﺼﻞ‬:‫ ﻛﻪ ﺷﺎﻣﻞ‬Management : ٣ ‫ﺑﺨﺶ‬
.‫( ﻣﻲﺑﺎﺷﺪ‬١٧ ‫[ )ﻓﺼﻞ‬MF] ‫ ﻫﻤﭽﻨﻴﻦ ﺩﺭﻣﺎﻥ ﻟﻤﻔﻮﻡ ﭘﻮﺳﺘﻲ ﺍﻭﻟﻴﻪ‬.‫( ﻣﻲﺑﺎﺷﺪ‬١٤ ‫ﺗﺮﺍﭘﻲ ﻭ ﺑﻴﻮﻛﻤﻮﺗﺮﺍﭘﻲ ﺩﺭ ﻣﻼﻧﻮﻡ )ﻓﺼﻞ‬
.‫ ﺩﺭ ﻣﻮﺭﺩ ﭘﻴﺸﮕﻴﺮﻱ ﺍﺯ ﻛﺎﻧﺴﺮﻫﺎﻱ ﭘﻮﺳﺘﻲ ﺑﺤﺚ ﻛﺮﺩﻩ ﺍﺳﺖ‬: ٤ ‫ﺑﺨﺶ‬
4.22 Atlas of Clinical oncology Breast Cancer (American Cancer Society ) (David J Winchester, MD, David P Winchester, MD) 2000
:‫ ﺷﺎﻣﻞ ﻣﺒﺎﺣﺚ ﺯﻳﺮ ﻣﻲﺑﺎﺷﺪ‬CD ‫ﻋﻨﺎﻭﻳﻦ ﺍﻳﻦ‬
yGenetics, Natural History, and DNA-Based Genetic Counseling in Hereditary Brast Cancer y Breast Cancer Risk and Management: Chemoprevention, Surgery, and Surveillance
y Screening and Diagnostic Imaging yImaging-Directed y Breast Biopsy yHistophathology of Malignant Breast Disease yUnusual Breast Pathology y Prognostic and Predictive Markers in Breast
Cancer y Surgical Management of Ductal Carcinoma In Situ yEvaluation and Surgical Management of Stage I and II Breast Cancer y Locally Advanced Breast Cancer y Breast Reconstruction
5.22 Atlas of Clinical Oncology Cancer of the Lower Gastrointestinal Tract (Christopher G. Willett, MD) 2001
6.22 Atlas of DIAGNOSTIC ONCOLOGY ‫ــــ‬
7.22 CANCER Principles & Practice of Oncology (7th Edition) (Vincent T. Devita, Jr., Samuel Hellman, Steven A. Rosenberg) ‫ــــ‬
8.22 Gastric Cancer Diagnosis and Treatment (An interactive Training Program) (J.R. Siewert, D.Kelsen, K. Maruyama) (Springer) 2000
9.22 Handbook of Cancer Combination Chemotherapy ‫ــــ‬
10.22 Holland.frei CANCER 6 MEDICINE (volume 2) (Danald W. Kufe, MD, Raphael E. Pollock, Md, PHD) 2003
11.22 Human Brain Cancer: Diagnostic Decisions (Lauren A. Langford, MD, Dr. med,) American Medical Association ‫ــــ‬
12.22 PHYSICANAS' CANCER CHEMOTHERAPHY DRUG MANUAL (Jones & Bartlett) 2004
:‫ﺍﻳﻦ ﻧﺮﻡﺍﻓﺰﺍﺭ ﺩﺭ ﻣﻮﺭﺩ ﻋﻨﺎﻭﻳﻦ ﺯﻳﺮ ﺑﺤﺚ ﻣﻲﻛﻨﺪ‬

- Principles of Cancer Chemotheraphy - Physician's Cancer Chemotherapy Drug Manual 2004 - Guidelines for Chemotherapy and Dosing Modifications
- Common Chemotherapy Regimens in Clinical Practice - Antimetic Agents for the Treatment of Chemotherapy-Induced Nausea and Vomiting

٠٩١٢١٣٧٢٣٦١-٦٦٩٣٦٦٩٦ :‫ﺗﻠﻔﻦ‬ ٢٣٩ ‫ ﭘﻼﻙ‬،‫ ﺑﻦﺑﺴﺖ ﺳﻴﻤﻴﻦ‬،‫ ﺑﻴﻦ ﻛﺎﺭﮔﺮ ﻭ ﺟﻤﺎﻟﺰﺍﺩﻩ‬،‫ ﺥ ﻟﺒﺎﻓﻲﻧﮋﺍﺩ‬،‫ ﺥ ﻛﺎﺭﮔﺮ ﺟﻨﻮﺑﻲ‬،‫ ﻡ ﺍﻧﻘﻼﺏ‬،‫ ﺗﻬﺮﺍﻥ‬:‫ﻧﺸﺎﻧﻲ‬ ‫ ﺍﺭﺍﺋﻪ ﻛﻨﻨﺪﺓ ﻛﺘﺎﺏ ﻭ ﺳﻲﺩﻱﻫﺎﻱ ﺗﺨﺼﺼﻲ ﭘﺰﺷﻜﻲ‬: ‫ﻣﺮﻛﺰ ﺧﺪﻣﺎﺕ ﻓﺮﻫﻨﮕﻲ ﺳﺎﻟﻜﺎﻥ‬
 ‫‪77‬‬

‫ﻃﺮﻳﻘﺔ ﻣﺸﺎﻫﺪﻩ ﻓﻴﻠﻢﻫﺎﻱ ‪ VCD‬ﺗﻮﺳﻂ ﻛﺎﻣﭙﻴﻮﺗﺮ ‪:‬‬

‫ﺍﺑﺘﺪﺍ ﺑﻪ ‪ my computer‬ﺭﻓﺘﻪ ﻭ ﻭﺍﺭﺩ ﺩﺭﺍﻳﻮ ‪ CD-ROM‬ﺩﺳﺘﮕﺎﻩ ﺷﻮﻳﺪ ﺳﭙﺲ ﺑﺎ ﺩﻭﺑﺎﺭ ﻛﻠﻴﻚ ﺑﺮ ﺭﻭﻱ ‪ Xing player‬ﺑﺮﻧﺎﻣﻪ ‪ Xing‬ﺭﺍ ﻧﺼﺐ ﻛﻨﻴﺪ‪ .‬ﺍﺯ ﺭﻭﻱ ‪ Xing Mpeg Player ، desktop‬ﺭﺍ ﺑﺎﺯ ﻛﺮﺩﻩ ‪ ،‬ﺳﭙﺲ ﺍﺯ ﺭﻭﻱ ﻣﻨـﻮﻱ‬
‫‪ Open ، File‬ﺭﺍ ﺍﻧﺘﺨﺎﺏ ﻛﻨﻴﺪ‪ .‬ﺩﺭ ﻗﺴﻤﺖ ‪ Look in‬ﺩﺭﺍﻳﻮ ‪ CD-Rom‬ﺩﺳﺘﮕﺎﻩ ﺧﻮﺩ ﺭﺍ ﺍﻧﺘﺨﺎﺏ ﻛﺮﺩﻩ ﻭ ﺩﺭ ﻗﺴﻤﺖ ‪ Video CD ( *.dat) . Files of type‬ﺭﺍ ﺍﻧﺘﺨﺎﺏ ﻛﻨﻴﺪ‪ ،‬ﺳﭙﺲ ﺑﻪ ﺩﺍﻳﺮﻛﺘﻮﺭﻱ ‪ Mpegav‬ﺭﻓﺘﻪ ﻭ ‪ Avseq01‬ﺭﺍ‬
‫ﺍﻧﺘﺨﺎﺏ ﻛﺮﺩﻩ ﻭ ‪ Open‬ﺭﺍ ﺑﺰﻧﻴﺪ‪.‬‬

‫ﻃﺮﻳﻘﻪ ﻧﺼﺐ ﻧﺮﻡ ﺍﻓﺰﺍﺭﻫﺎﻱ ‪: E-book‬‬

‫ﺑﺎ ﺍﺯ ﻗﺮﺍﺭ ﺩﺍﺩﻥ ﺳﻲ ﺩﻱ ‪ E-book‬ﺩﺭ ﺩﺭﺍﻳﻮ ‪ CD-Rom‬ﺻﻔﺤﻪ ‪ PCA pdf book setup‬ﺑﻪ ﺻﻮﺭﺕ ‪ Autorun‬ﺑﺎﺯ ﻣﻲﺷﻮﺩ ‪.‬‬ ‫‪-١‬‬
‫ﺩﺭ ﺻﻮﺭﺗﻲ ﻛﻪ ﺍﻭﻟﻴﻦ ﺑﺎﺭ ﺍﺳﺖ ﻛﻪ ‪ CD‬ﻫﺎﻱ ‪ E-book‬ﺍﻳﻦ ﺷﺮﻛﺖ ﺭﺍ ﺩﺭ ﺩﺳﺘﮕﺎﻩ ﻣﻲﮔﺬﺍﺭﻳﺪ “ ﺑﺎ ﺍﻧﺘﺨﺎﺏ ﮔﺰﻳﻨﻪ ‪ Acrobat Reader Installation‬ﺑﺮﻧﺎﻣﻪ ‪ Acrobat‬ﺭﺍ ﻧﺼﺐ ﻭ ﻣﺮﺍﺣـﻞ ﺁﻥ ﺭﺍ ﺗـﺎ ﺍﻧﺘﻬـﺎ ﻃـﻲ ﻛﻨﻴـﺪ“ ﺩﺭ ﻏﻴـﺮ‬ ‫‪-٢‬‬
‫ﺍﻳﻨﺼﻮﺭﺕ ﺑﻪ ﻣﺮﺣﻠﻪ ‪ ٣‬ﺑﺮﻭﻳﺪ ‪.‬‬
‫ﻣﻨﻮﻱ ‪ Execute The Program‬ﺭﺍ ﺍﻧﺘﺨﺎﺏ ﻛﻨﻴﺪ‪.‬‬ ‫‪-٣‬‬
‫ﺑﺎ ﺍﻧﺘﺨﺎﺏ ﻧﺎﻡ ﻛﺘﺎﺏ‪ ،‬ﮔﺰﻳﻨﻪ ‪ View‬ﺭﺍ ﺍﻧﺘﺨﺎﺏ ﻛﻨﻴﺪ‪.‬‬ ‫‪-٤‬‬
‫ﺑﺮﻧﺎﻣﻪ ‪ Acrobat‬ﺑﺎﺯ ﻣﻲﺷﻮﺩ ﻭ ﻛﺘﺎﺏ ﺭﺍ ﻣﻲﺗﻮﺍﻧﻴﺪ ﻣﻄﺎﻟﻌﻪ ﺑﻔﺮﻣﺎﺋﻴﺪ‪.‬‬ ‫‪-٥‬‬
‫ﺑﺮﺍﻱ ﺍﺟﺮﺍﻱ ﺑﺮﻧﺎﻣﻪ ﻻﺯﻡ ﺍﺳﺖ ﻛﻪ ﺩﺭﺍﻳﻮ \‪ C:‬ﺩﺳﺘﮕﺎﻫﺘﺎﻥ ﺣﺪﺍﻗﻞ ‪ 500‬ﻣﮕﺎﺑﺎﻳﺖ ﻓﻀﺎﻱ ﺧﺎﻟﻲ ﺩﺍﺷﺘﻪ ﺑﺎﺷﺪ ﺩﺭ ﻏﻴﺮ ﺍﻳﻨﺼﻮﺭﺕ ﺑﻌﺪ ﺍﺯ ﺯﺩﻥ ‪ View‬ﺩﺳﺘﮕﺎﻩ ‪ Error 110‬ﺭﺍ ﻣﻲﺩﻫﺪ‪.‬‬ ‫‪-٦‬‬

‫ﺍﺳﺎﻣﻲ ﻛﺘﺎﺏ‪/‬ﻧﻮﻳﺴﻨﺪﻩ‬ ‫ﻗﻴﻤﺖ )ﺭﻳﺎﻝ( ﺗﻌﺪﺍﺩ ﻣﺠﻠﺪﺍﺕ‬

‫‪RADIOLOGY‬‬
‫‪1.‬‬ ‫)‪Pediatric Radiology (The Requestions) (Hans Blickman‬‬ ‫ﺗﻚ ﺟﻠﺪﻱ‬ ‫‪200,000‬‬
‫‪2.‬‬ ‫)‪Differential Diagnosis in Conventioanl Gastrointestinal Readiology (Francis A. Burgener, Marti Konnano‬‬ ‫ﺗﻚ ﺟﻠﺪﻱ‬ ‫‪240,000‬‬
‫‪3.‬‬ ‫)‪Dynamic Radiology of the Abdomen: Normal and Pathologic Anatomy (Morton A. Meyers, 5 Edition Springer Verla‬‬ ‫‪th‬‬
‫ﺗﻚ ﺟﻠﺪﻱ‬ ‫‪500,000‬‬
‫‪4.‬‬ ‫)‪Primary Care Radiology (Mettker, Guibert EAU. VO.SS', URBINA‬‬ ‫ﺗﻚ ﺟﻠﺪﻱ‬ ‫‪250,000‬‬
‫‪5.‬‬ ‫)‪Textbook of Uroradiology (N. Reed Dunnick, MD, Carl M. Sandler, Md, Jeffrey H. Newhouse, MD, Estephen Amis', JR., MD‬‬ ‫ﺗﻚ ﺟﻠﺪﻱ‬ ‫‪400,000‬‬
‫‪6.‬‬ ‫)‪Head and Neck Radiology a Teaching File (Anthony a Mancusd, Hiroya Ojiri, Ronald G. Quisling)(Lippincottt Williams & Wilkins‬‬ ‫ﺗﻚ ﺟﻠﺪﻱ‬ ‫‪400,000‬‬
‫‪7.‬‬ ‫)‪Essentials of Skeletal Radiology (Terry R. Yochum; Lindsay J. Rowe‬‬ ‫ﺩﻭ ﺟﻠﺪﻱ‬ ‫‪700,000‬‬
‫‪8.‬‬ ‫)‪Textbook of Radiology & Imaging (David Stutton) (2003‬‬ ‫ﺩﻭ ﺟﻠﺪﻱ‬ ‫‪1,400,000‬‬

‫ﺗﻠﻔﻦ‪٠٩١٢١٣٧٢٣٦١-٦٦٩٣٦٦٩٦ :‬‬ ‫ﻧﺸﺎﻧﻲ‪ :‬ﺗﻬﺮﺍﻥ‪ ،‬ﻡ ﺍﻧﻘﻼﺏ‪ ،‬ﺥ ﻛﺎﺭﮔﺮ ﺟﻨﻮﺑﻲ‪ ،‬ﺥ ﻟﺒﺎﻓﻲﻧﮋﺍﺩ‪ ،‬ﺑﻴﻦ ﻛﺎﺭﮔﺮ ﻭ ﺟﻤﺎﻟﺰﺍﺩﻩ‪ ،‬ﺑﻦﺑﺴﺖ ﺳﻴﻤﻴﻦ‪ ،‬ﭘﻼﻙ ‪٢٣٩‬‬ ‫ﻣﺮﻛﺰ ﺧﺪﻣﺎﺕ ﻓﺮﻫﻨﮕﻲ ﺳﺎﻟﻜﺎﻥ ‪ :‬ﺍﺭﺍﺋﻪ ﻛﻨﻨﺪﺓ ﻛﺘﺎﺏ ﻭ ﺳﻲﺩﻱﻫﺎﻱ ﺗﺨﺼﺼﻲ ﭘﺰﺷﻜﻲ‬
 ‫‪78‬‬
‫)ﺍﻭﺭﮊﻳﻨﺎﻝ(‬
‫‪9.‬‬ ‫)‪Radiology Reviw Manual (Fourth Edition) (Wolfgang Dahnert) (2003‬‬ ‫ﺗﻚ ﺟﻠﺪﻱ‬ ‫‪400,000‬‬
‫)‪10. Forensic Radiology (B. G. Brogdon MD‬‬ ‫ﺗﻚ ﺟﻠﺪﻱ‬ ‫‪300,000‬‬
‫)‪11. The Core Curriculum Neuroradiology (Mauricio Castillo) (Lippincott Williams & Wilkins‬‬ ‫ﺗﻚ ﺟﻠﺪﻱ‬ ‫‪400,000‬‬
‫)‪12. Diagnostic Neuroradiology (Anne G. Osborn) (Mosby‬‬ ‫ﺗﻚ ﺟﻠﺪﻱ‬ ‫‪500,000‬‬
‫)‪13. Bone and Joint Disorders (Conventional Radiologic Differentioal Diagnosis) (Francis A. Burgener Marti Kormano‬‬ ‫ﺗﻚ ﺟﻠﺪﻱ‬ ‫‪300,000‬‬
‫)‪14. Atlas of Radiologic Measurement (Theodore E. Keats, Christopher Sistrom) (Mosby‬‬ ‫ﺗﻚ ﺟﻠﺪﻱ‬ ‫‪400,000‬‬

‫در اﯾﻦ ﮐﺘﺎب ‪ ،‬ﻗﺴﻤﺖ اﻋﻈﻢ ﺟﺪاول و ﻧﻤﻮدارﻫﺎی ﻣﻌﻢ ﮐﺎرﺑﺮدی ﻣﺮﺗﺒﻂ ﺑﺎ اﻧﺪازهﮔﯿﺮیﻫﺎی رادﯾﻮﻟﻮژی و ﺗﺼﻮﯾﺮﺑﺮداری در ‪ 14‬ﻣﺒﺤﺚ و در ‪ 630‬ﺻﻔﺤﻪ ﮔﺮدآوری ﮔﺮدﯾﺪه و ﻣﯽﺗﻮاﻧﺪ ﺑﻪ ﻋﻨﻮان ﯾﮏ اﺑﺰار ﺑﺴﯿﺎر ﻣﻬﻢ در ﺗﻔﺴﯿﺮ ﻧﻮاﺣﯽﻫـﺎی‬
‫ﻣﺨﺘﻠﻒ ﻣﻮرد اﺳﺘﻔﺎده ﻗﺮار ﮔﯿﺮد‪ .‬ﻓﺼﻮل اﯾﻦ ﮐﺘﺎب ﺑﻪ ﻗﺮار ذﯾﻞ ﻣﯽﺑﺎﺷﻨﺪ‪:‬‬
‫‪ -‬ﻣﺤﺘﻮﯾﺎت اﯾﻨﺘﺮاﮐﺮاﻧﯿﺎل ‪ -‬ﺟﻤﺠﻤﻪ ﺣﻔﺮه ادرﺑﯿﺖ و ﺳﯿﻨﻮسﻫﺎی ﭘﺎراﻧﺎﻣﺎل ‪ -‬ﻣﺤﺘﯿﺎت ادرﺑﯿﺖ ﺻﻮرت و ﮔﺮدن ‪ -‬ﺳﺘﻮن ﻓﻘﺮات و ﻣﺤﺘﻮﯾﺎت آن ‪ -‬اﻧﺪام ﻓﻮﻗﺎﻧﯽ ‪ -‬ﻟﮕﻦ و ﻣﻔﺎﺻﻞ ‪ - Hip‬اﻧﺪام ﺗﺤﺘﺎﻧﯽ‬
‫‪ -‬ﺑﯿﻮﻣﺘﺮی و ﭘﻠﻮﺳﯿﺘﺮی در ﺟﺮﯾﺎن ﺣﺎﻣﻠﮕﯽ ‪ -‬ﺳﯿﺴﺘﻢ ﻋﺮوﻗﯽ و ﻟﻨﻔﺎوی‬ ‫‪ -‬ﺗﻮراﮐﺲ‪ ،‬رﯾﻪﻫﺎ‪ ،‬ﻣﺪﯾﺎﺳﺘﻦ و ﺟﻨﺐ ‪ -‬دﺳﺘﮕﺎه ﮔﻮارش ‪ -‬دﺳﺘﮕﺎه ادراری‪ -‬ﺗﻨﺎﺳﻠﯽ‬ ‫‪ -‬ﻗﻠﺐ و ﻋﺮوق ﺑﺰرگ‬ ‫‪ -‬ﺑﻠﻮغ اﺳﮑﻠﺘﯽ‬
‫)‪15. Radiobiology for the Radiologist (Fifthe Edition‬‬ ‫ﺗﻚ ﺟﻠﺪﻱ‬ ‫‪400,000‬‬
‫)‪16. Anatomy Positioning & Procedures Workbook (Steven G. Hayes‬‬ ‫ﺗﻚ ﺟﻠﺪﻱ‬ ‫‪470,000‬‬
‫)‪17. Atlas of Normal Roentgen Variants That May Simulate disease (Seven Edition) (Theodere E. Keats & Mark W. Anderson) (Mosby‬‬ ‫ﺗﻚ ﺟﻠﺪﻱ‬ ‫‪700,000‬‬
‫ﻣﺒﺎﻧﻲ ﺍﺳﺎﺳﻲ ﺩﺭ ﺳﻮﻧﻮﮔﺮﺍﻓﻲ ﺩﺍﭘﻠﺮ ﻭ ﺗﺠﻬﻴﺰﺍﺕ ﺁﻥ )ﺗﺮﺟﻤﻪ ﻭ ﮔﺮﺩﺁﻭﺭﻱ‪ :‬ﺩﻛﺘﺮ ﭘﺮﻭﻳﻦ ﻋﻠﻲﭘﻮﺭ( ‪18.‬‬ ‫ﺗﻚ ﺟﻠﺪﻱ‬ ‫‪50,000‬‬
‫ﺍﺻﻮﻝ ﺗﺸﺨﻴﺼﻲ ﻭ ﺩﺭﻣﺎﻧﻲ ﺑﻴﻤﺎﺭﻱﻫﺎﻱ ﭘﺴﺘﺎﻥ )ﺩﻛﺘﺮ ﻣﻌﺼﻮﻣﻪ ﮔﻴﺘﻲ‪ ،‬ﺩﻛﺘﺮ ﺍﻟﻬﺎﻡ ﺭﺣﻴﻤﻴﺎﻥ‪ ،‬ﺩﻛﺘﺮ ﻋﻠﻲ ﻋﺮﺏ ﺧﺮﺩﻣﻨﺪ( ‪19.‬‬ ‫ﺗﻚ ﺟﻠﺪﻱ‬ ‫‪180,000‬‬
‫ﺷﺎﻳﻌﺘﺮﻳﻦﻫﺎ‪ ،‬ﻧﺎﺩﺭﺗﺮﻳﻦﻫﺎ‪ ،‬ﺗﺸﺨﻴﺺﻫﺎﻱ ﺍﻓﺘﺮﺍﻗﻲ‪ ،‬ﺑﻬﺘﺮﻳﻦ ﺭﻭﺵ ﺗﺸﺨﻴﺺ ﺑﻴﻤﺎﺭﻱﻫﺎ )ﺗﺄﻟﻴﻒ‪ :‬ﺩﻛﺘﺮ ﺍﺣﻤﺪ ﻋﻠﻴﺰﺍﺩﻩ( ‪20.‬‬ ‫ﺗﻚ ﺟﻠﺪﻱ‬ ‫‪50,000‬‬
‫)‪21. Radiographic Anatomy Positioning and Procedures Workbook (Second Edition) (volume I , II) (Steven G. Hayes, Sr.‬‬ ‫ﺩﻭ ﺟﻠﺪﻱ‬ ‫‪380,000‬‬
‫)‪22. Gastrointestinal Radiology A Pattern Approach (4 Edition‬‬ ‫‪th‬‬
‫)‪(Ronald L. Eisenberg‬‬ ‫)‪(Lippincott Williams & Wilkins) (2003‬‬ ‫ﺗﻚ ﺟﻠﺪﻱ‬ ‫‪600,000‬‬

‫اﯾﻦ ﮐﺘﺎب ﻣﺠﻤﻮﻋﮥ ﮐﺎﻣﻠﯽ از ﻣﺒﺎﺣﺚ ﻣﺨﺘﻠﻒ ﻣﺮﺗﺒﻂ ﺑﺎ ﺗﺼﻮﯾﺮﺑﺮداری دﺳﺘﮕﺎه ﮔﻮارش ﻣﯽﺑﺎﺷﺪ‪ .‬ﻣﻄﺎﻟﺐ اﯾﻦ ﮐﺘﺎب در ‪ 80‬ﻣﺒﺤﺚ ‪ 10 ،‬ﻓﺼﻞ ﺗﺪوﯾﻦ ﮔﺮدﯾﺪه و ﺣﺪود ‪ 1200‬ﺻﻔﺤﻪ ﺣﺠﻢ دارد روش اراﺋﻪ ﻣﻄﺎﻟﺐ در اﯾﻦ ﮐﺘﺎب ﺑﻪ‬
‫ﺻﻮرت ‪ Pattern Approach‬ﺑﻮده و ﺧﻮاﻧﻨﺪه را ﻗﺎدر ﻣﯽﺳﺎزد ﺗﺎ اﻟﮕﻮﻫﺎی ﺗﺼﻮﯾﺮﺑﺮداری ﻣﺨﺘﻠﻒ دﺳﺘﮕﺎه ﮔﻮارش را دﺳﺘﻪﺑﻨﺪی ﻧﻤﻮده و ﺗﺸﺨﯿﺺﻫﺎی اﻓﺘﺮاﻗﯽ ﻫﺮ ﮐﺪام را ﺑﻪ ﺧﻮﺑﯽ از دﯾﮕﺮ اﻟﮕﻮﻫﺎ ﺗﻤﯿﺰ دﻫﺪ‪.‬‬
‫)‪23. Imaging Atlas of Human Anatomy (Third Edition) (Jamie Weir, Peter H. Abrahams) (2003‬‬ ‫ﺗﻚ ﺟﻠﺪﻱ‬ ‫‪250,000‬‬
‫)‪24. Pediatric Sonography (Third Edition) (Thieme) (Francis A. Burgener, Steven P. Meyers) (2004‬‬ ‫ﺗﻚ ﺟﻠﺪﻱ‬ ‫‪600,000‬‬
‫)‪25. Musculoskeletal Imaging Companion (Thomas H. Berquist) (2002‬‬ ‫ﺗﻚ ﺟﻠﺪﻱ‬ ‫‪500,000‬‬
‫)‪26. Practical Guide to Abdominal & Pelvic MRI (John R. Leyendecker, Jeffrey J. Brown‬‬ ‫ﺗﻚ ﺟﻠﺪﻱ‬

‫ﺗﻠﻔﻦ‪٠٩١٢١٣٧٢٣٦١-٦٦٩٣٦٦٩٦ :‬‬ ‫ﻧﺸﺎﻧﻲ‪ :‬ﺗﻬﺮﺍﻥ‪ ،‬ﻡ ﺍﻧﻘﻼﺏ‪ ،‬ﺥ ﻛﺎﺭﮔﺮ ﺟﻨﻮﺑﻲ‪ ،‬ﺥ ﻟﺒﺎﻓﻲﻧﮋﺍﺩ‪ ،‬ﺑﻴﻦ ﻛﺎﺭﮔﺮ ﻭ ﺟﻤﺎﻟﺰﺍﺩﻩ‪ ،‬ﺑﻦﺑﺴﺖ ﺳﻴﻤﻴﻦ‪ ،‬ﭘﻼﻙ ‪٢٣٩‬‬ ‫ﻣﺮﻛﺰ ﺧﺪﻣﺎﺕ ﻓﺮﻫﻨﮕﻲ ﺳﺎﻟﻜﺎﻥ ‪ :‬ﺍﺭﺍﺋﻪ ﻛﻨﻨﺪﺓ ﻛﺘﺎﺏ ﻭ ﺳﻲﺩﻱﻫﺎﻱ ﺗﺨﺼﺼﻲ ﭘﺰﺷﻜﻲ‬
 ‫‪79‬‬
‫‪SONOGRAPHY‬‬
‫)‪27. Ultrasonography in Urology A Practical Approach to Clinical Problems (Edward I. Bluth-Peter H.‬‬ ‫ﺗﻚ ﺟﻠﺪﻱ‬ ‫‪350,000‬‬
‫‪28. Seminars in Ultrasound CT and MR‬‬ ‫ﺗﻚ ﺟﻠﺪﻱ‬ ‫‪70,000‬‬
‫)‪29. Diagnostic Ultrasound (Rumack, Wilson, Charboneau) (2005‬‬ ‫ﺩﻭ ﺟﻠﺪﻱ‬ ‫‪1,400,000‬‬
‫ﭼﺎپ اول اﯾﻦ ﮐﺘﺎب ﮐﻪ در ﺳﺎل ‪ 1991‬ﺑﻪ ﭘﺎﯾﺎن رﺳﯿﺪ و ﺑﻪ ﻋﻨﻮان راﯾﺞﺗﺮﯾﻦ ﻣﺮﺟﻊ ﺳﻮﻧﻮﮔﺮاﻓﯽ در ﺟﻬﺎن ﻣﯽﺑﺎﺷﺪ‪ .‬از آﻧﺠﺎ ﮐﻪ داﻧﺶ ﺳﻮﻧﻮﮔﺮاﻓﯽ در ﻃﻮل ‪ 6‬ﺳﺎل ﮔﺬﺷﺘﻪ ﭘﯿﺸﺮﻓﺖﻫﺎی ﺑﺴﯿﺎری داﺷﺘﻪ اﺳﺖ ﻧﯿـﺎز ﺑـﻪ ﺑـﺎزﻧﮕﺮی در‬
‫اﯾﻦ ﮐﺘﺎب اﺣﺴﺎس ﻣﯽﺷﺪ‪.‬‬
‫در اﯾﻦ ﮐﺘﺎب ﺑﯿﺶ از ﯾﮑﺼﺪ ﻧﻮﯾﺴﻨﺪه ﻣﺘﺨﺼﺺ درﺳﻮﻧﻮﮔﺮاﻓﯽ ﺗﻼش ﮐﺮدهاﻧﺪ ﺗﺎ آﺧﺮﯾﻦ دﺳﺘﺎوردﻫﺎی داﻧﺶ ﺳﻮﻧﻮﮔﺮاﻓﯽ در زﻣﯿﻨﻪ ﺗﺼﻮﯾﺮﺑﺮداری‪ ،‬ﺗﺸﺨﯿﺺ و ﮐﺎرﺑﺮد آﻧﻬﺎ را ﺑﻪ رﺷـﺘﻪ ﺗﺤﺮﯾـﺮ درآوردهاﻧـﺪ‪ .‬ﻓﺼـﻮل ﮐﺘـﺎب ﺷـﺎﻣﻞ‬
‫ﻫﯿﺴﺘﺮوﺳﻮﻧﻮﮔﺮاﻓﯽ ﻻﭘﺎروﺳﮑﻮﭘﯿﮏ ﺳﻮﻧﻮﮔﺮاﻓﯽ و ﺗﮑﻨﯿﮏﻫﺎی ﺑﯿﻮﭘﯽ ﺗﺤﺖ ﻫﺪاﯾﺖ ﺳﻮﻧﻮﮔﺮاﻓﯽ ﻧﯿﺰ ﻣﯽﺑﺎﺷﺪ‪ .‬در ﮐﻠﯽ ‪ %25‬ﺑﻪ ﺣﺠﻢ ﮐﻠﯽ ﮐﺘﺎب اﻓﺰوده ﺷﺪه اﺳﺖ ﺑﺤﺚ ﻋﻤﺪه اﻓﺰاﯾﺶ ﺣﺠﻢ ﻣﺮﺑﻮط ﺑﻪ ﺳﻮﻧﻮﮔﺮاﻓﯽ زﻧﺎن و زاﯾﻤﺎن ﻣﯽﺑﺎﺷﺪ‪.‬‬
‫ﺗﻌﺪاد زﯾﺎدی از ﺗﺼﺎوﯾﺮ ﺟﺎﯾﮕﺰﯾﻦ ﺷﺪهاﻧﺪ و ﺑﯿﺶ از ‪ 450‬ﺗﺼﻮﯾﺮ ﺗﻤﺎم رﻧﮕﯽ در وﯾﺮاﯾﺶ ﺟﺪﯾﺪ وﺟﻮد دارد‪ .‬ﺗﻐﯿﯿﺮات ﺟﺪﯾﺪی ﺑﺮای ﺳﻬﻮﻟﺖ ﺧﻮاﻧﺪن و درک ﻣﻄﻠﺐ در ﺳﺎﺧﺘﺎر وﯾﺮاﯾﺶ اﻧﺠﺎم ﺷـﺪه اﺳـﺖ‪ .‬ﮐﺪﺑﻨـﺪیﻫـﺎی رﻧﮕـﯽ ﻣﻄﺎﻟـﺐ و‬
‫ﺟﺪاول ‪ highlight‬ﺷﺪه ﺑﺮای ﻧﮑﺎت ﮐﻠﯿﺪی ﺗﺸﺨﯿﺼﯽ اﻧﺠﺎم ﺷﺪه اﺳﺖ‪ .‬ﻣﻄﺎﻟﺐ ﻣﻬﻢﺗﺮ درﺷﺖﺗﺮ ﻧﻮﺷﺘﻪ ﺷﺪهاﻧﺪ و ﻣﺮاﺟﻊ اﺳﺘﻔﺎده ﺷﺪه ﺑﻪ ﺻﻮرت دﻗﯿﻖﺗﺮی ﺑﺎزﻧﻮﯾﺴﯽ ﺷﺪهاﻧﺪ‪ .‬اﯾﻦ ﮐﺘﺎب در دو ﺟﻠﺪ ﻧﻮﺷﺘﻪ ﺷﺪه اﺳـﺖ‪ .‬ﺟﻠـﺪ اول ﺷـﺎﻣﻞ‬
‫ﭘﻨﺞ ﻓﺼﻞ ﻣﯽﺑﺎﺷﺪ ﻓﺼﻞ اول ﺷﺎﻣﻞ ﻓﯿﺰﯾﮏ و اﺛﺮات ﺑﯿﻮﻟﻮژﯾﮏ ﺳﻮﻧﻮﮔﺮاﻓﯽ و ﻣﻮاد ﺣﺎﺟﺐ در ﺳﻮﻧﻮﮔﺮاﻓﯽ ﻣﯽﺑﺎﺷﺪ‪ .‬ﻓﺼﻞ دوم ﺷﺎﻣﻞ ﺳﻮﻧﻮﮔﺮاﻓﯽ ﺳﻮﻧﻮﮔﺮاﻓﯽ ﺷﮑﻢ و ﻟﮕﻦ‪ ،‬ﺗﻮراﮐﺲ و روشﻫﺎی ﻣﺪاﺧﻠﻪای )‪ (interrcntional‬ﻣﯽﺑﺎﺷـﺪ‪.‬‬
‫ﻓﺼﻞ ﺳﻮم ﺳﻮﻧﻮﮔﺮاﻓﯽ ‪ Intraoperative‬و ﻻﭘﺎراﺳﮑﻮﭘﯿﮏ را ﺷﺮح ﻣﯽدﻫﺪ ﻓﺼﻞ ﭼﻬﺎرم ﺗﺼﻮﯾﺮﺑﺮداری اﻋﻀﺎء ﮐﻮﭼﮏ )‪ (small part‬را اراﺋﻪ ﻣﯽﮐﻨﺪ‪ .‬ﮐﻪ ﺷﺎﻣﻞ ﮐﺎروﺗﯿﺪ‪ ،‬ﺷﺮﯾﺎنﻫﺎ و ورﯾﺪﻫﺎی ﻣﺤﯿﻄﯽ اﺳﺖ‪ .‬ﺟﻠـﺪ دوم ﮐﺘـﺎب ﺷـﺎﻣﻞ‬
‫ﻓﺼﻞ ﭘﻨﺠﻢ ﮐﻪ ﺑﺤﺚ ﮐﺎﻣﻞ ﺳﻮﻧﻮﮔﺮاﻓﯽ زﻧﺎن و ﻣﺎﻣﺎﯾﯽ اﺳﺖ و ﻧﻬﺎﯾﺘﺎً ﻓﺼﻞ ﺷﺸﻢ ﺳﻮﻧﻮﮔﺮاﻓﯽ اﻃﻔﺎل اﺳﺖ‪ .‬ﺑﺨﺶ ﺟﺪﯾﺪ در ﻣﻮرد ﺳﻮﻧﻮﮔﺮاﻓﯽ داﭘﻠﺮ اﻃﻔﺎل و ﺳﻮﻧﻮﮔﺮاﻓﯽ ﻣﺪاﺧﻠﻪای در اﻃﻔﺎل ﺑﻪ اﯾﻦ ﻓﺼﻞ اﻓﺰوده ﺷﺪه اﺳﺖ‪ .‬ﺧﻮاﻧﺪن اﯾـﻦ‬
‫ﮐﺘﺎب ﻣﺘﺨﺼﺼﯿﻦ و دﺳﺘﯿﺎران رادﯾﻮﻟﻮژی داﻧﺸﺠﻮﯾﺎن ﭘﺰﺷﮑﯽ و ﺳﻮﻧﻮﮔﺮاﻓﻬﺎ ﺗﻮﺻﯿﻪ ﻣﯽﮔﺮدد‪.‬‬
‫)‪30. Diagnostic Ultrasound (John P. McBany Gorgon, B. Gorgon, MD) (2005‬‬ ‫ﺗﻚ ﺟﻠﺪﻱ‬ ‫ﺯﻳﺮ ﭼﺎﭖ‬
‫)‪31. Ultrasound A Practical Approach to Clinical Problems (Edward Bluth, Peter H. Arger Carol B. Benson, Philip W. Rails, Marilyan) (Thieme‬‬ ‫ﺗﻚ ﺟﻠﺪﻱ‬ ‫‪500,000‬‬
‫)‪32. Breast Ultrasound (A. Thomas Stavros, MD, FACR) (2004‬‬ ‫ﺗﻚ ﺟﻠﺪﻱ‬ ‫‪800,000‬‬
‫)‪33. Musculosceletal Ultrasound (Thomas R. Nelson, Donal B. downey, Dolores H. Pretorius, A aron Fenster‬‬ ‫ﺗﻚ ﺟﻠﺪﻱ‬ ‫‪500,000‬‬
‫)‪34. The Core Curriculum Ultrasound (William E. Brant) (Lippincott Williams & Wilkins‬‬ ‫ﺗﻚ ﺟﻠﺪﻱ‬ ‫‪400,000‬‬
‫‪35. Ultrasound in Obstetrics and Gynecology (Eberhard Merz) (Thieme) (Vol.1: Obstetrics‬‬ ‫‪2005‬‬ ‫ﺗﻚ ﺟﻠﺪﻱ‬ ‫‪800,000‬‬
‫)‪36. Color Atlas of Ultrasound Anatomy (B. Block) (Thieme) (2004‬‬ ‫‪450,000‬‬
‫‪CT‬‬
‫)‪37. Fundamentals of Body CT (Second Edition) (Webb & Brant & Helms‬‬ ‫ﺗﻚ ﺟﻠﺪﻱ‬ ‫‪250,000‬‬
‫‪38. Body CT A Practical Approach‬‬ ‫ﺗﻚ ﺟﻠﺪﻱ‬ ‫‪240,000‬‬
‫)‪39. High Resolution CT of the Lung (W. Richard Webb‬‬ ‫ﺗﻚ ﺟﻠﺪﻱ‬ ‫‪280,000‬‬
‫)‪40. High Resolution CT of the Chest Comprehensive Atlas (Second Edition) (Eric J. ster, Stephen J. Swensen)(Lippincott Williams&Wilkins‬‬ ‫ﺗﻚ ﺟﻠﺪﻱ‬ ‫‪320,000‬‬
‫)‪41. Pediatric Body CT (Marilyn J. Siegel‬‬ ‫ﺗﻚ ﺟﻠﺪﻱ‬ ‫‪320,000‬‬
‫)‪42. CT Teaching Manual (Marthias Hofer) (Thieme) (2000‬‬ ‫ﺗﻚ ﺟﻠﺪﻱ‬ ‫‪250,000‬‬
‫)‪43. CT Teaching Manual (A Systematic Approach to CT Reading) (Second Edition) (Thieme) (2005‬‬ ‫ﺗﻚ ﺟﻠﺪﻱ‬ ‫‪550,000‬‬

‫ﺗﻠﻔﻦ‪٠٩١٢١٣٧٢٣٦١-٦٦٩٣٦٦٩٦ :‬‬ ‫ﻧﺸﺎﻧﻲ‪ :‬ﺗﻬﺮﺍﻥ‪ ،‬ﻡ ﺍﻧﻘﻼﺏ‪ ،‬ﺥ ﻛﺎﺭﮔﺮ ﺟﻨﻮﺑﻲ‪ ،‬ﺥ ﻟﺒﺎﻓﻲﻧﮋﺍﺩ‪ ،‬ﺑﻴﻦ ﻛﺎﺭﮔﺮ ﻭ ﺟﻤﺎﻟﺰﺍﺩﻩ‪ ،‬ﺑﻦﺑﺴﺖ ﺳﻴﻤﻴﻦ‪ ،‬ﭘﻼﻙ ‪٢٣٩‬‬ ‫ﻣﺮﻛﺰ ﺧﺪﻣﺎﺕ ﻓﺮﻫﻨﮕﻲ ﺳﺎﻟﻜﺎﻥ ‪ :‬ﺍﺭﺍﺋﻪ ﻛﻨﻨﺪﺓ ﻛﺘﺎﺏ ﻭ ﺳﻲﺩﻱﻫﺎﻱ ﺗﺨﺼﺼﻲ ﭘﺰﺷﻜﻲ‬
 80
44. Spiral CT (Eliot K Fishman & R. Brocke Jeffrey) ‫ﺗﻚ ﺟﻠﺪﻱ‬ 400,000
45. Helical (Spiral) computed Tomography (A Practical Approach to Clinical Protocols) (Paul M. Silverman) ‫ﺗﻚ ﺟﻠﺪﻱ‬ 250,000
46. Norma findings in CT and MRI (Torsten B. Moeller, EmilReif) (Thieme) ‫ﺗﻚ ﺟﻠﺪﻱ‬ 300,000
47. CT and MR Imaging of the Whole Body (John R. Haaga, MD) (2003) ‫ﺩﻭ ﺟﻠﺪﻱ‬ 1,000,000
48. Multidetector CT (Principles, Techniques, & Clinical Applications) (Elliot K. Fissman, R. Brooke Jeffrey, JR.) ‫ﺗﻚ ﺟﻠﺪﻱ‬ 550,000
49. Spiral and Multislice Computed Tomography of the Body (Aart J. Van der Molen Cornelia M. Schaefer-Prokop) (Thieme) (2003) ‫ﺗﻚ ﺟﻠﺪﻱ‬ 800,000
MRI
50. MRI of the Musculoskeletal System (Thomas H. Berquist) ‫ﺗﻚ ﺟﻠﺪﻱ‬ 600,000
51. MRI of the Musculoskeletal System MRI Teaching file Series (Karence K Cahn, Mini Pathria) ‫ﺗﻚ ﺟﻠﺪﻱ‬ 240,000
52. MRI of the Head and Neck MRI Teaching file Series (Jrffrey S. Ross) ‫ﺗﻚ ﺟﻠﺪﻱ‬ 240,000
53. MRI of the Spine MRI Teaching file Series (Jeffrey S. Ross) ‫ﺗﻚ ﺟﻠﺪﻱ‬ 240,000
54. MRI of the Brain I & II MRI Teaching file Series (Michel Brant, Zawadzki and…) ‫ﺩﻭ ﺟﻠﺪﻱ‬ 480,000
55. MRI the basics fray h. Hashemi and William g. bradley, Jr.) (Williams & Wilkins) ‫ﺗﻚ ﺟﻠﺪﻱ‬ 35,000
56. MRI Principles (Donald G. Mitcell, MD) ‫ﺗﻚ ﺟﻠﺪﻱ‬ 190,000
57. Clinical Pelvic Imaging CT, Ultrasound, and MRI (Arnold C. Friedman, MD) ‫ﺗﻚ ﺟﻠﺪﻱ‬ 300,000
58. Magnetic Resonance in Medicine The Basic Textbook of the European Magnetic Resonance Forum (Peter A. Rinck) ‫ﺗﻚ ﺟﻠﺪﻱ‬ 105,000
59. Magnetic Resonance in diagnosis of C.N.S. disorders (vaso antunavic, gradimir dragutinovic, zvonimir lec) (Thieme) ‫ﺗﻚ ﺟﻠﺪﻱ‬ 450,000
60. Section and MRI anatomy of the human body (slobodan marinkovic, milan milisavljevic, dieter sehellinger, vaso antunovic) (Thieme) ‫ﺗﻚ ﺟﻠﺪﻱ‬ 450,000
61. PRACTICAL GUIDE TO ABDOMINAL & PELVIC MRI (JOHN R. LEYENDECHER, JEFFERY J. BROWN) ‫ﺗﻚ ﺟﻠﺪﻱ‬ 450,000
Doppler
62. Vascular diagnosis with Ultrasound Clinical References With Case Studies (Hennerici, Neuerburg-Heusler)(Thieme) ‫ﺗﻚ ﺟﻠﺪﻱ‬ 600,000
63. Introduction to Vascular Ultrasonography (Fourth Edition) (Zwiebel) (James Saunders) ‫ﺗﻚ ﺟﻠﺪﻱ‬ 600,000
‫ ﺗﺼﻮﻳﺮﺑﺮﺩﺍﺭﻱ ﻭ ﺳﻮﻧﻮﮔﺮﺍﻓﻲ ﺩﺍﭘﻠﺮ ﺭﺍ ﺍﺯ ﻧﻈﺮ ﺩﻭﺭ ﻧﺪﺍﺷﺘﻪ ﻭ ﺍﻳﻦ ﺭﻭﺵ ﺭﺍ ﺑﻪ ﻋﻨﻮﺍﻥ ﻳﻚ ﺷﻴﻮﻩ ﺁﻟﺘﺮﻧﺎﺗﻴﻮ ﻏﻴﺮﺗﻬﺎﺟﻤﻲ ﻛﺎﺭﺁﻣﺪ ﻣﻮﺭﺩ ﺑﺮﺭﺳﻲ ﻋﺮﻭﻕ ﺑﺪﻥ ﺩﺭ ﻛﻨـﺎﺭ ﺁﻧﮋﻳـﻮﮔﺮﺍﻓﻲ‬، ‫ﭘﻴﺸﺮﻓﺖﻫﺎﻱ ﺍﺧﻴﺮ ﺩﺭ ﻋﺮﺻﻪ ﺭﺍﺩﻳﻮﻟﻮﮊﻱ‬
‫ ﻭ ﺷـﺎﻣﻞ ﺳﺮﻓﺼـﻞﻫـﺎﻱ‬.‫ ﻣﺒﺤﺚ ﺟﺰﺋﻲﺗﺮ( ﺑﻪ ﺑﺤﺚ ﻭ ﺑﺮﺭﺳﻲ ﺁﺧﺮﻳﻦ ﺩﺳﺘﺎﻭﺭﺩﻫﺎﻱ ﺳﻮﻧﻮﮔﺮﺍﻓﻲ ﺩﺍﭘﻠﺮ ﺩﺭ ﺗﺸﺨﻴﺺ ﭘﺎﺗﻮﻟﻮﮊﻱ ﻭ ﺍﺭﮔﺎﻥﻫﺎﻱ ﺑﺪﻥ ﻣﻲﭘﺮﺩﺍﺯﺩ‬٣١ ‫ ﺑﺨﺶ ﺍﺻﻠﻲ )ﻣﺸﺘﻤﻞ ﺑﺮ‬٥ ‫ ﺍﻳﻦ ﻛﺘﺎﺏ ﺩﺭ‬.‫ﻗﺮﺍﺭ ﺩﺍﺩﻩ ﺍﺳﺖ‬
:‫ﺫﻳﻞ ﻣﻲﺑﺎﺷﺪ‬
‫ ﻭ ﺗﺠﻬﻴﺰﺍﺕ ﻻﺯﻡ‬B-mode ‫ ﻓﻴﺰﻳﻚ ﺩﺍﭘﻠﺮ ﻭ ﺳﻮﻧﻮﮔﺮﺍﻓﻲ‬.٢ ‫ ﻧﻜﺎﺕ ﻗﺎﺑﻞ ﺗﻮﺟﻪ ﻫﻤﻮﺩﻳﻨﺎﻣﻴﻚ ﻣﺮﺑﻮﻁ ﺑﻪ ﺑﻴﻤﺎﺭﻱﻫﺎﻱ ﻋﺮﻭﻕ ﻣﺤﻴﻄﻲ‬.١ :‫ ﺍﺻﻮﻝ ﺳﻮﻧﻮﮔﺮﺍﻓﻲ ﺩﺍﭘﻠﺮ‬-‫ﺍﻟﻒ‬
‫ ﻣﻮﺍﺩ ﺣﺎﺟﺐ ﺳﻮﻧﻮﮔﺮﺍﻓﻴﻚ‬.٥ ‫ ﻧﻘﺶ ﺩﺍﭘﻠﺮ ﺭﻧﮕﻲ ﺩﺭ ﺗﺸﺨﻴﺺ ﺑﻴﻤﺎﺭﻱﻫﺎﻱ ﻋﺮﻭﻗﻲ‬.٤ ‫ ﺁﻧﺎﻟﻴﺰ ﻃﻴﻒ )ﻣﻮﺝ( ﻓﺮﻛﺎﻧﺲ ﺩﺍﭘﻠﺮ‬.٣

٠٩١٢١٣٧٢٣٦١-٦٦٩٣٦٦٩٦ :‫ﺗﻠﻔﻦ‬ ٢٣٩ ‫ ﭘﻼﻙ‬،‫ ﺑﻦﺑﺴﺖ ﺳﻴﻤﻴﻦ‬،‫ ﺑﻴﻦ ﻛﺎﺭﮔﺮ ﻭ ﺟﻤﺎﻟﺰﺍﺩﻩ‬،‫ ﺥ ﻟﺒﺎﻓﻲﻧﮋﺍﺩ‬،‫ ﺥ ﻛﺎﺭﮔﺮ ﺟﻨﻮﺑﻲ‬،‫ ﻡ ﺍﻧﻘﻼﺏ‬،‫ ﺗﻬﺮﺍﻥ‬:‫ﻧﺸﺎﻧﻲ‬ ‫ ﺍﺭﺍﺋﻪ ﻛﻨﻨﺪﺓ ﻛﺘﺎﺏ ﻭ ﺳﻲﺩﻱﻫﺎﻱ ﺗﺨﺼﺼﻲ ﭘﺰﺷﻜﻲ‬: ‫ﻣﺮﻛﺰ ﺧﺪﻣﺎﺕ ﻓﺮﻫﻨﮕﻲ ﺳﺎﻟﻜﺎﻥ‬
 81
‫ ﺍﺭﺯﻳﺎﺑﻲ ﺳﻮﻧﻮﮔﺮﺍﻓﻴﻚ ﭘﻼﻙ ﻛﺎﺭﻭﺗﻴﺪ‬.٩ ‫ ﺷﺮﺍﺋﻴﻦ ﻛﺎﺭﻭﺗﻴﺪ ﻧﺮﻣﺎﻝ ﻭ ﺗﻜﻨﻴﻚﻫﺎﻱ ﺍﺭﺯﻳﺎﺑﻲ ﺩﺍﭘﻠﺮ ﻛﺎﺭﻭﺗﻴﺪ‬.٨ ‫ ﺁﻧﺎﺗﻮﻣﻲ ﻧﺮﻣﺎﻝ ﻋﺮﻭﻕ ﻣﻐﺰﻱ‬.٧ ‫ ﻣﻘﻴﺎﺱ ﺩﺭ ﺳﻮﻧﻮﮔﺮﺍﻓﻲ ﺩﺍﭘﻠﺮ ﻋﺮﻭﻕ ﻣﻐﺰﻱ‬.٦ :‫ ﻋﺮﻭﻕ ﻣﻐﺰﻱ‬-‫ﺏ‬
(TCD) ‫ ﺳﻮﻧﻮﮔﺮﺍﻓﻲ ﺩﺍﭘﻠﺮ ﺗﺮﺍﻧﺲ ﻛﺮﺍﻧﻴﺎﻝ‬.١٣ ‫ ﺍﺭﺯﻳﺎﺑﻲ ﺍﻭﻟﺘﺮﺍﺳﻮﻧﻴﻚ ﻋﺮﻭﻕ ﻭ ﺭﺗﺒﺮﺍﻝ‬.١٢ ( ‫ ﺩﻳﺴﻜﻨﺴﻴﻮﻥ‬-‫ ﻣﻮﺿﻮﻋﺎﺕ ﻣﺘﻔﺮﻗﻪ ﺑﺎ ﻛﺎﺭﻭﺗﻴﺪ )ﺷﺎﻣﻞ ﺍﺳﺪﺍﺩ‬.١١ ‫ ﺍﺭﺯﻳﺎﺑﻲ ﺩﺍﭘﻠﺮ ﺗﻨﮕﻲ ﻛﺎﺭﻭﺗﻴﺪ‬.١٠
‫ ﻧﻘﺶﻫﺎﻱ ﻓﻴﺰﻳﻮﻟﻮﮊﻳﻚ ﺟﻬﺖ ﺍﺭﺯﻳﺎﺑﻲ ﺑﻴﻤﺎﺭﻱﻫﺎﻱ ﺷﺮﻳﺎﻧﻲ ﺍﻧﺪﺍﻡ ﺗﺤﺘﺎﻧﻲ‬.١٦ ‫ ﺁﻧﺎﺗﻮﻣﻲ ﺷﺮﻳﺎﻧﻲ ﺍﻧﺪﺍﻡﻫﺎ‬.١٥ ‫ ﻧﻘﺶ ﺭﻭﺵﻫﺎﻱ ﻏﻴﺮﺗﻬﺎﺟﻤﻲ ﺩﺭ ﭘﻲﮔﻴﺮﻱ ﺑﻴﻤﺎﺭﻱﻫﺎﻱ ﺷﺮﻳﺎﻧﻲ ﺍﻧﺪﺍﻡﻫﺎ‬.١٤ :‫ ﺷﺮﻳﺎﻥﻫﺎﻱ ﺍﻧﺪﺍﻡﻫﺎ‬-‫ﺝ‬
‫ ﺳﻮﻧﻮﮔﺮﺍﻓﻲ ﺩﺍﭘﻠﺮ ﺷﺮﻳﺎﻥﻫﺎﻱ ﺍﻧﺪﺍﻡ ﺗﺤﺘﺎﻧﻲ‬.١٨ ‫ ﺍﺭﺯﻳﺎﺑﻲ ﺷﺮﻳﺎﻥﻫﺎﻱ ﺍﻧﺪﺍﻡ ﻓﻮﻗﺎﻧﻲ‬.١٧
(‫ ﺍﺭﺯﻳﺎﺑﻲ ﻭﺭﻳﺪﻫﺎﻱ ﺍﻧﺪﺍﻡﻫﺎ )ﺟﻨﺒﻪﻫﺎﻱ ﺗﻜﻨﻴﻜﻲ‬.٢٢ ‫ ﺗﺮﻣﻴﻨﻮﻟﻮﮊﻱ ﻭ ﻛﺎﺭﺍﻛﺘﺮﻫﺎﻱ ﻧﺮﻣﺎﻝ‬.٢١ ‫ ﺁﻧﺎﺗﻮﻣﻲ ﻭﺭﻳﺪﻱ ﺍﻧﺪﺍﻡﻫﺎ‬.٢٠ ‫ ﻣﻘﻴﺎﺱ ﺳﻮﻧﻮﮔﺮﺍﻓﻲ ﺩﺍﭘﻠﺮ ﺩﺭ ﺍﺭﺯﻳﺎﺑﻲ ﻭﺭﻳﺪﻫﺎﻱ ﺍﻧﺪﺍﻡﻫﺎ‬.١٩ :‫ ﻭﺭﻳﺪﻫﺎﻱ ﺍﻧﺪﺍﻡﻫﺎ‬-‫ﺩ‬
‫( ﻭ ﭘﺎﻣﻮﻟﻮﮊﻱ ﻏﻴﺮﻭﺭﻳﺪﻱ ﺍﻧﺪﺍﻡ‬AVF) ‫ ﻓﻴﺴﺘﻮﻝ ﺷﺮﻳﺎﻧﻲ ﻭﺭﻳﺪﻱ‬.٢٤ ‫ ﺗﺮﻭﻣﺒﻮﺯ ﻭﺭﻳﺪﻱ‬.٢٣
‫ ﺍﺧﺘﻼﻻﺕ ﻋﺮﻭﻗﻲ ﻛﺒﺪ‬.٢٩ ‫ ﺍﺭﺯﻳﺎﺑﻲ ﺍﻭﻟﺘﺮﺍﺳﻮﻧﻴﻚ ﺷﺮﻳﺎﻥﻫﺎﻱ ﺍﺣﺸﺎﺋﻲ‬.٢٨ ‫ ﺷﺮﻳﺎﻥﻫﺎﻱ ﺍﻳﻠﻴﺎﻙ‬،‫ ﺁﺋﻮﺭﺕ‬.٢٧ ‫ ﺁﻧﺎﺗﻮﻣﻲ ﻭ ﻧﻤﺎﻫﺎﻱ ﻧﺮﻣﺎﻝ ﺳﻮﻧﻮﮔﺮﺍﻓﻴﻚ ﺩﺍﭘﻠﺮ ﻋﺮﻭﻕ ﺷﻜﻤﻲ‬.٢٦ :‫ ﻋﺮﻭﻕ ﺷﻜﻤﻲ‬-‫ه‬
Penis ‫ ﺳﻮﻧﻮﮔﺮﺍﻓﻲ ﻣﻌﻤﻮﻟﻲ ﻭ ﺩﺍﭘﻠﺮ‬.٣١ (‫ ﻭ ﻛﻠﻴﺔ ﭘﻴﻮﻧﺪﻱ‬Native ‫ ﺍﺭﺯﻳﺎﺑﻲ ﺩﺍﭘﻠﺮ ﻋﺮﻭﻕ ﻛﻠﻴﻮﻱ )ﻣﺮﺑﻮﻁ ﺑﻪ ﻛﻠﻴﺔ‬.٣٠
64. Teaching Manual of Color Duplex Sonography A Wokbook in color duplex ultrasound and echocardiographer (Matthias Hofer) (Thieme) (2005) ‫ﺗﻚ ﺟﻠﺪﻱ‬ 550,000
65. Vascular Ultrasound of the Neck an Interpretive atlas (Antonio Alayon)(Lippincott Williams & Wilkins) ‫ﺗﻚ ﺟﻠﺪﻱ‬ 400,000
66. Duplex Scanning in Vascular Disorders (Third Edition) (D. Eugene Strandness, Jr.) ‫ﺗﻚ ﺟﻠﺪﻱ‬ 600,000
67. Doppler Ultrasound in Gynecology and Obstetrics (Christof Sohn, Hans-Joachim Voigt, Klaus Vetter) (2004) ‫ﺗﻚ ﺟﻠﺪﻱ‬ 500,000
Imaging
68. Skeletal Imaging Atlas of the Spine and Extremities (John A. M. Donald Resnick, MD) ‫ﺗﻚ ﺟﻠﺪﻱ‬ 500,000
69. Imaging for Surgeons ‫ﺗﻚ ﺟﻠﺪﻱ‬ 90,000
70. Imaging of the Newborn, Infant and Young Child (Fourth Edition) (Leonard E. Swischuk) (2004) ‫ﺗﻚ ﺟﻠﺪﻱ‬ 600,000
71. Thoracic Imaging A Practical Approach (Richard H. slone Fernando R. Gutier) ‫ﺗﻚ ﺟﻠﺪﻱ‬ 250,000
72. Gastrointestinal Imaging, Case Review (Peter J. Feczko, Obert d. Halperi) ‫ﺗﻚ ﺟﻠﺪﻱ‬ 250,000
73. Imaging in Hepatobiliary and Pancreatic Disease A Practical Clinical Approach (Dirk Van Leeuwen, Jacques Reeders, Joe Ariyama) ‫ﺗﻚ ﺟﻠﺪﻱ‬ 500,000
74. Aids Imaging A Practical Clinical Approach (J WA J. Reeders, J. R. Mathieson) ‫ﺗﻚ ﺟﻠﺪﻱ‬ 420,000
75. Special Procedures in diagnostic Imaging (C'lark's)(A. Stewart Whitley, Chrissie W. Alsop Adrin D. Moore) ‫ﺗﻚ ﺟﻠﺪﻱ‬ 350,000
76. Breast Imaging (Second Edition) (David B. Kopans) ‫ﺗﻚ ﺟﻠﺪﻱ‬ 500,000
77. The Core curriculum Breast Imaging (Gilda Cardenosa) ‫ﺗﻚ ﺟﻠﺪﻱ‬ 4 00,000
78. Neuroimaging I & II (William It. On'ison, jr) ‫ﺩﻭ ﺟﻠﺪﻱ‬ 900,000
79. Fundamentals of Neuroimaging (William w. Woodruff.M.D.) ‫ﺗﻚ ﺟﻠﺪﻱ‬ 360,000
80. Atlas of Musculoskeletal Imaging (Thomas Lee Pope, Jr. Stephen Loehr)(Thieme) ‫ﺗﻚ ﺟﻠﺪﻱ‬ 420,000
81. Atlas of Head and Neck Imaging (The Extracranial Head and Neck) (Suresh K. Mukherji, Vincent chong) ‫ﺗﻚ ﺟﻠﺪﻱ‬ 500,000
82. Magnetic Resonance Imaging of Orthopeadic Trauma (Stephen J. Eustace)(Lippincott Williams & Wilkins) ‫ﺗﻚ ﺟﻠﺪﻱ‬ 250,000
83. Pediatric Gastrointestinal Imaging and Intervention (David A. Stringer-Paul S. Babyn MDCM) ‫ﺗﻚ ﺟﻠﺪﻱ‬ 500,000

٠٩١٢١٣٧٢٣٦١-٦٦٩٣٦٦٩٦ :‫ﺗﻠﻔﻦ‬ ٢٣٩ ‫ ﭘﻼﻙ‬،‫ ﺑﻦﺑﺴﺖ ﺳﻴﻤﻴﻦ‬،‫ ﺑﻴﻦ ﻛﺎﺭﮔﺮ ﻭ ﺟﻤﺎﻟﺰﺍﺩﻩ‬،‫ ﺥ ﻟﺒﺎﻓﻲﻧﮋﺍﺩ‬،‫ ﺥ ﻛﺎﺭﮔﺮ ﺟﻨﻮﺑﻲ‬،‫ ﻡ ﺍﻧﻘﻼﺏ‬،‫ ﺗﻬﺮﺍﻥ‬:‫ﻧﺸﺎﻧﻲ‬ ‫ ﺍﺭﺍﺋﻪ ﻛﻨﻨﺪﺓ ﻛﺘﺎﺏ ﻭ ﺳﻲﺩﻱﻫﺎﻱ ﺗﺨﺼﺼﻲ ﭘﺰﺷﻜﻲ‬: ‫ﻣﺮﻛﺰ ﺧﺪﻣﺎﺕ ﻓﺮﻫﻨﮕﻲ ﺳﺎﻟﻜﺎﻥ‬
 ‫‪82‬‬
‫)‪84. Modern Head and Neck Imaging Medical Radiology, Diolopy, Nostic Imaging (S. K. Mukhetji, J. A. castelijins)(Springer‬‬ ‫ﺗﻚ ﺟﻠﺪﻱ‬ ‫‪260,000‬‬
‫)‪85. Variants and Pitfalls in Body Imaging (Ali Shirkhoda)(Lippincot Williams & Wilkin's‬‬ ‫ﺗﻚ ﺟﻠﺪﻱ‬ ‫‪500,000‬‬
‫‪86. Clinical Imaging‬‬ ‫ﺗﻚ ﺟﻠﺪﻱ‬ ‫‪580,000‬‬
‫)‪87. Diagnostic Imaging Brain (Osborn) (2004‬‬ ‫ﺗﻚ ﺟﻠﺪﻱ‬ ‫‪1,100 ,000‬‬
‫ﻣﺪﺕ ﻃﻮﻻﻧﻲ ﺑﻮﺩ ﻛﻪ ﻧﻮﺭﻭﻟﻮﮊﻳﺴﺖﻫﺎ‪ ،‬ﻧﻮﺭﻭﺭﺍﺩﻳﻮﻟﻮﮊﻳﺴﺖﻫﺎ‪ ،‬ﻧﻮﺭﻭﭘﺎﺗﻮﻟﻮﮊﻳﺴﺖﻫﺎ ﻭ ﺟﺮﺍﺣﺎﻥ ﺍﻋﺼﺎﺏ ﻣﻨﺘﻈﺮ ﻛﺘﺎﺏ ﺟﺪﻳﺪﻱ ﺍﺯ ﺩﻛﺘﺮ "‪ "Ann Osborn‬ﺑﻮﺩﻧﺪ‪ .‬ﺍﻳﻦ ﻛﺎﺭ ﺟﺪﻳﺪ ﻧﻤﺎﻳﺎﻧﮕﺮﻱ ﺍﺯ ﻛﺘﺐ ﻣﺮﺟﻊ ﺩﺭ ﻗﺮﻥ ‪ ٢١‬ﻣﻲﺑﺎﺷﺪ ﻛﻪ ﺩﻳﮕﺮ ﻣﺎﻧﻨﺪ ﻛﺘﺎﺏﻫﺎﻱ‬
‫ﻗﺪﻳﻤﻲﺗﺮ ﺍﻃﻼﻋﺎﺕ ﺑﺴﻴﺎﺭ ﺯﻳﺎﺩ ﺭﺍ ﺑﻪ ﺻﻮﺭﺕ ﻓﺸﺮﺩﻩ ﻭ ﺑﺎ ﺗﺼﺎﻭﻳﺮ ﺍﻧﺪﻙ ﺍﺭﺍﺋﻪ ﻧﻤﻲﺩﻫﺪ ﺑﻠﻜﻪ ﺑﺎ ‪ format‬ﻣﺪﺭﻥ ﻭ ﭘﻴﺸﺮﻓﺘﻪ ﺧﻮﺩ ﺩﻭ ﺑﺮﺍﺑﺮ ﺍﻃﻼﻋﺎﺕ ﻭ ﭼﻬﺎﺭ ﺑﺮﺍﺑﺮ ﺗﺼﺎﻭﻳﺮ ﺑﻴﺸﺘﺮﻱ ﺑﺮﺍﻱ ﻫﺮ ﺗﺸﺨﻴﺺ ﺩﺍﺭﺩ‪ .‬ﻛﻴﻔﻴﺖ ﺗﺼﺎﻭﻳﺮ ﻭ ﮔﺮﺍﻓﻴـﻚﻫـﺎ ﻭﺍﻗﻌـﹰﺎ ﻋﺎﻟﻴﺴـﺖ ﻭ‬
‫ﺟﻬﺖ ﺑﻬﺘﺮﻧﺸﺎﻥﺩﺍﺩﻥ ﺗﺼﺎﻭﻳﺮ ﺁﻧﺎﺗﻮﻣﻴﻚ ﻭ ﭘﺎﺗﻮﻟﻮﮊﻳﻚ ﺍﺳﺘﻔﺎﺩﺓ ﺯﻳﺎﺩﻱ ﺍﺯ ﺭﻧﮓﻫﺎ ﺷﺪﻩ ﺍﺳﺖ‪ .‬ﺍﺑﺘﻜﺎﺭ ﺩﻳﮕﺮ ﺩﺭ ﺍﻳﻦ ﻛﺘﺎﺏ ﺍﻳﻦ ﺍﺳﺖ ﻛﻪ ﻣﻮﺍﺭﺩ ﻭ ﺗﺼﺎﻭﻳﺮ ﻣﺸﺎﺑﻪ ﻭ ﺗﺸﺨﻴﺺﻫﺎﻱ ﺍﻓﺘﺮﺍﻕ ﺭﺍ ﺩﺭ ﻫﻤﺎﻥ ﻓﺼﻞ ﺟﻬﺖ ﺑﺮﺭﺳﻲ ﺑﻴﺸﺘﺮ ﺍﺭﺍﺋﻪ ﻧﻤﻮﺩﻩ ﺍﺳﺖ‪ .‬ﺷﺎﻳﺪ ﺑﺘـﻮﺍﻥ‬
‫ﮔﻔﺖ ﻛﻪ ﺍﻳﻦ ﻛﺘﺎﺏ ﻳﻚﺟﻠﺪﻱ "ﺍﻳﻨﺘﺮﻧﺖ" ﻧﻮﺭﻭﻟﻮﮊﻱ ﻭ ﺑﻴﻤﺎﺭﻱﻫﺎﻱ ‪ CNS‬ﻣﻲﺑﺎﺷﺪ‪ :‬ﻛﺎﻣﻞ‪ ،‬ﻣﻮﺟﺮ ﻭ ﺑﺮﻭﺯ ﺑﻄﻮﺭﻳﻜﻪ ﺣﺘﻲ ﻛﻠﻤﻪﺍﻱ ﺭﺍ ﻧﻤﻲﺗﻮﺍﻥ ﻳﺎﻓﺖ ﻛﻪ ﺍﺿﺎﻓﻲ ﻧﮕﺎﺷﺘﻪ ﺷﺪﻩ ﺑﺎﺷﺪ‪.‬‬
‫‪PART I (Pathology-based diagnoses): Congenital malformations-Trauma Sulianachnoid hemorrhage and‬‬
‫‪Aneurisms-Stroke-Vascular Malformations Neoplasm's and Tumor in lesions-Primary Non-neoplastic cysts-‬‬
‫‪Infection and Demyelinating Disease-Metabolic/Degenerative Disorders, Inhenited-Toxic/Metabolic/Degenesative‬‬
‫‪Disorders, Acquired‬‬
‫‪PART II (Anatomy-based Diagnoses): Ventricles and Cysterns-Sella and Pitutary-CPA-IAC-Skull, Scalp and‬‬
‫‪Meninges‬‬
‫ﺗﻮﺿﻴﺤﺎﺕ ﺍﺭﺍﺋﻪﺷﺪﻩ ﺩﺭ ﻣﻮﺭﺩ ﻫﺮ ﺑﻴﻤﺎﺭﻱ ﺷﺎﻣﻞ ﻋﻨﺎﻭﻳﻦ ﺯﻳﺮ ﻣﻲﺑﺎﺷﺪ‪:‬‬
‫‪Terminology-Imaging Findings-Differentioal Diagnosis-Pathology Clinical Issues-Selected references-Imaging‬‬
‫‪Gallery-Key Facts‬‬
‫ﻫﺮ ﺟﺎﻳﻲ ﻛﻪ ﻻﺯﻡ ﺑﻮﺩﻩ ﺍﺳﺖ ﺗﻮﺿﻴﺤﺎﺕ ﺿﺮﻭﺭﻱ ﺍﺯ ﺁﻧﺎﺗﻮﻣﻲ‪ ،‬ﺟﻨﻴﻦﺷﻨﺎﺳﻲ ﻭ ﭘﺎﺗﻮﻟﻮﮊﻱ ﺁﻭﺭﺩﻩ ﺷﺪﻩ ﺗﺎ ﺑﻪ ﺧﻮﺍﻧﻨﺪﻩ ﺩﺭﻙ ﺗﺸﺨﻴﺺ ﻭ ﻣﻮﻗﻌﻴﺖ ﻛﻤﻚ‬
‫ﻧﻤﺎﻳﺪ‪ .‬ﻗﺴﻤﺖ ‪ Key Facts‬ﺧﻼﺻﻪﺍﻱ ﺟﺎﻣﻊ ﺑﺮﺍﻱ ﻣﺮﻭﺭ ﺳﺮﻳﻊ ﻭ ﺁﺳﺎﻥ ﻣﻲﺑﺎﺷﺪ‪.‬‬
‫ﺑﻪ ﻧﻈﺮ ﻣﻲﺭﺳﺪ ﻛﻪ ﻛﺘﺎﺏ "‪ "Diagnostic Imaging Brain Osborn 2004‬ﻣﻨﺒﻊ ﺑﺴﻴﺎﺭ ﻏﻨﻲ ﻭ ﻣﺆﺛﺮ ﺍﺯ ﻣﻄﺎﻟﺐ ﻋﻠﻤﻲ ﺟﺪﻳﺪ ﺑـﺮﺍﻱ ﺩﺍﻧﺸـﺠﻮﻳﺎﻥ‪-‬‬
‫ﺭﺯﻳﺪﻧﺖﻫﺎ ﻭ ﻣﺘﺨﺼﺼﻴﻦ ﺭﺷﺘﻪﻫﺎﻱ ﻣﺮﺑﻮﻃﻪ ﺍﻋﻢ ﺍﺯ ﻧﻮﺭﻭﻟﻮﮊﻱ‪ ،‬ﺟﺮﺍﺣﻲ ﺍﻋﺼﺎﺏ‪ ،‬ﺭﺍﺩﻳﻮﻟﻮﮊﻱ ﻭ ﭘﺎﺗﻮﻟﻮﮊﻱ ﺑﺎﺷﺪ‪.‬‬

‫‪88. Diagnostic Imaging Orthopaedics‬‬ ‫)‪(Stoller.Tirman Bredella) (2004‬‬ ‫ﺗﻚ ﺟﻠﺪﻱ‬ ‫‪900,000‬‬
‫)‪89. Diagnostic Imaging Head and Neck (Harnsberger) (2004‬‬ ‫ﺗﻚ ﺟﻠﺪﻱ‬ ‫‪1,000 ,000‬‬

‫)‪90. Cranial Neuroimaging and Clinical Neuroanatomy Atlas of MR Imaging and Computed Tomography (Hans-Joachim Kretschmann‬‬ ‫ﺗﻚ ﺟﻠﺪﻱ‬ ‫‪1,350 ,000‬‬
‫ﺍﻳﻦ ﻛﺘﺎﺏ ﭼﺎﭖ ﺳﻮﻡ ﻛﺘﺎﺏ ‪ Cranial Neuroimaging and Clinical Neuroanatomy‬ﺩﺭ ﺳﺎﻝ ‪ 2004‬ﻣﻲﺑﺎﺷﺪ‪ .‬ﺗﻤﺎﻣﻲ ﻓﺼﻮﻝ ﻛﺘﺎﺏ ﺗﻐﻴﻴﺮ ﻭ ﺑﺎﺯﻧﻮﻳﺴﻲ ﺷﺪﻩ ﺍﺳﺖ ‪ .‬ﺑﻲﮔﻤﺎﻥ ﺑﻪ ﻋﻨﻮﺍﻥ ﻳﻲ ﺍﺯ ﺑﻬﺘﺮﻳﻦ ﻣﻨﺎﺑﻊ ﺑﺮﺍﻱ ﻓﻬـﻢ ﻭ ﺩﺭﻙ ﺁﻧـﺎﺗﻮﻣﻲ ﻣﺴـﻴﺮﻫﺎﻱ‬
‫ﻋﺼﺒﻲ ﻭ ﺳﺎﺧﺘﻤﺎﻥﻫﺎﻱ ﻋﺮﻭﻗﻲ ﻣﻲﺑﺎﺷﺪ‪ .‬ﺗﺼﺎﻭﻳﺮ ﺑﺰﺭﮒ ﻭ ﺻﻔﺤﻪﺁﺭﺍﻳﻲ ﺧﻮﺏ ﺁﻥ ﺍﺟﺎﺯﻩ ﺍﺳﺘﻔﺎﺩﻩ ﺁﺳﺎﻥ ﻭ ﺩﺳﺘﺮﺳﻲ ﺳﺮﻳﻊ ﺭﺍ ﻣﻴﺴﺮ ﻣﻲﺳﺎﺯﺩ‪.‬‬
‫ﻣﻘﺪﻣﻪ ﻛﺘﺎﺏ ﺷﺎﻣﻞ ﺑﺤﺚ ﮔﺴﺘﺮﺩﻩﺍﻱ ﺩﺭ ﻣﻮﺭﺩ ﺁﺯﻣﻮﻥﻫﺎﻱ ﻧﻮﺭﻭﻟﻮﮊﻱ ﻭ ﺍﻧﺪﻳﻜﺎﺳﻴﻮﻥﻫﺎﻱ ﺁﻧﻬﺎﺳﺖ‪ .‬ﻭ ﺭﺍﻫﻨﻤﺎﻱ ﺧﻮﺑﻲ ﺑﺮﺍﻱ ﻧﻮﺭﻭﻟﻮﮊﻳﺴﺖﻫﺎﻱ ﺑﺎﻟﻴﻨﻲ ﺟﻬﺖ ﺍﺳﺘﻔﺎﺩﻩ ﺻﺤﻴﺢ ﻭ ﺑﺠﺎ ﺍﺯ ﺁﺯﻣﻮﻥﻫﺎﻱ ﻋﺼﺒﻲ ﻣﻲﺑﺎﺷﺪ‪.‬‬
‫ﭼﺎﭖ ﺟﺪﻳﺪ ﻛﺘﺎﺏ ﺣﺎﻭﻱ ﺗﺼﺎﻭﻳﺮ ﺟﺪﻳﺪ ﺩﺭ ﻣﻮﺭﺩ ﺳﺎﺧﺘﻤﺎﻥﻫﺎﻱ ﻋﺮﻭﻗﻲ ﺣﻔﺮﻩ ﺣﻠﻘﻲ ﺍﺳﺖ‪ .‬ﮔﺴﺘﺮﺵ ﺳﺮﻳﻊ ‪ MRI‬ﻭ ﺗﺼﺎﻭﻳﺮ ‪ NeuroFunctional‬ﻧﻴﺎﺯ ﺑﻴﺸﺘﺮ ﺑﻪ ﺍﻳﻦ ﻧﻮﻉ ﺑﺤﺚﻫﺎﻱ ﻛﺎﺭﺑﺮﺩﻱ ﺗﺼﻮﻳﺮﺑﺮﺩﺍﺭﻱ ﺭﺍ ﺩﺍﺭﺩ ﺑـﺎ ﻣﺮﺍﺟﻌـﻪ ﺑـﻪ ﺍﻳـﻦ ﻛﺘـﺎﺏ ﻣـﻲﺗـﻮﺍﻥ ﺍﺯ‬
‫ﺳﺎﺧﺘﻤﺎﻥﻫﺎﻱ ﺩﻗﻴﻖ ﻋﺮﻭﻕ ﺗﺮ ﻣﺴﻴﺮﻫﺎﻱ ﺍﻟﻴﺎﻑ ﻋﺼﺒﻲ ﻭ ﻣﺴﻴﺮ ﺍﻋﺼﺎﺏ ﻛﺮﺍﻧﻴﺎﻝ ﺁﮔﺎﻫﻲ ﻳﺎﻓﺖ ﻭ ﻋﻼﻳﻢ ﺑﺎﻟﻴﻨﻲ ﺑﺴﻴﺎﺭﻱ ﺭﺍ ﺑﺎ ﻳﺎﻓﺘﻪﻫﺎﻱ ﺗﺼﻮﻳﺮﺑﺮﺩﺍﺭﻱ ﻣﻄﺎﺑﻘﺖ ﺩﺍﺩ‪ .‬ﺗﺼﺎﻭﻳﺮ ﺳﻲﺗﻲﺍﺳﻜﻦ ﻭ ‪ MRI‬ﺩﺭ ﻣﻘﺎﻃﻊ ﻛﺮﻭﻧﺎﻝ‪ ،‬ﺍﮔﺰﻳﺎﻝ‪ ،‬ﺳﺎﮊﻳﺘﺎﻝ ﺑﻪ ﻧﻤﺎﻳﺶ ﮔﺬﺍﺷﺘﻪ ﺷﺪﻩ ﺍﺳﺖ‬
‫ﻛﻪ ﺑﺎ ﻛﺪﺑﻨﺪﻱ ﺭﻧﮕﻲ ﻭ ﺩﻳﺎﮔﺮﺍﻡﻫﺎﻱ ﺷﻤﺎﺗﻴﻚ ﻣﻄﺎﺑﻘﺖ ﺩﺍﺩﻩ ﺷﺪﻩ ﺍﺳﺖ‪ .‬ﺍﺳﺘﻔﺎﺩﻩ ﺍﺯ ﺍﻳﻦ ﻛﺘﺎﺏ ﺗﻤﺎﻣﻲ ﻣﺘﺨﺼﺼﻴﻦ ﺭﺍﺩﻳﻮﻟﻮﮊﻱ‪ ،‬ﻧﻮﺭﻭﻟﻮﮊﻳﺴﺖﻫﺎ ﻭ ﺟﺮﺍﺣﺎﻥ ﺍﻋﺼﺎﺏ ﺗﻮﺻﻴﻪ ﻣﻲﮔﺮﺩﺩ‪.‬‬
‫)‪91. DIAGNOSTIC MUSCULOSKELETAL IMAGING (THEODORE T. MILLER, MARK E. SCHWEITZER) (2005‬‬ ‫ﺗﻚ ﺟﻠﺪﻱ‬ ‫‪450,000‬‬
‫)‪92. Orthopedic IMAGING (A Pracitcal Approach) (ADAM GREENSPAN) (Michael W. Chapman) (2004‬‬ ‫ﺗﻚ ﺟﻠﺪﻱ‬ ‫‪700,000‬‬
‫)‪93. Aids to RADIOLOCIAL DIFFERENTIAL DIAGNOSIS (Forth Edition) (Stephen Chapman and Richard Nakielny) (2003‬‬ ‫ﺗﻚ ﺟﻠﺪﻱ‬ ‫‪250,000‬‬
‫)‪94. Teaching Atlas of Brain Imaging (Nancy J. Fischbein, William P. Dillon, A. James Barkovich‬‬ ‫ﺗﻚ ﺟﻠﺪﻱ‬ ‫‪500,000‬‬

‫ﺗﻠﻔﻦ‪٠٩١٢١٣٧٢٣٦١-٦٦٩٣٦٦٩٦ :‬‬ ‫ﻧﺸﺎﻧﻲ‪ :‬ﺗﻬﺮﺍﻥ‪ ،‬ﻡ ﺍﻧﻘﻼﺏ‪ ،‬ﺥ ﻛﺎﺭﮔﺮ ﺟﻨﻮﺑﻲ‪ ،‬ﺥ ﻟﺒﺎﻓﻲﻧﮋﺍﺩ‪ ،‬ﺑﻴﻦ ﻛﺎﺭﮔﺮ ﻭ ﺟﻤﺎﻟﺰﺍﺩﻩ‪ ،‬ﺑﻦﺑﺴﺖ ﺳﻴﻤﻴﻦ‪ ،‬ﭘﻼﻙ ‪٢٣٩‬‬ ‫ﻣﺮﻛﺰ ﺧﺪﻣﺎﺕ ﻓﺮﻫﻨﮕﻲ ﺳﺎﻟﻜﺎﻥ ‪ :‬ﺍﺭﺍﺋﻪ ﻛﻨﻨﺪﺓ ﻛﺘﺎﺏ ﻭ ﺳﻲﺩﻱﻫﺎﻱ ﺗﺨﺼﺼﻲ ﭘﺰﺷﻜﻲ‬
 ‫‪83‬‬
‫‪The Radiologic Clinics of North America‬‬
‫)‪95. The Radiologic Clinics of North America Imaging of Obstructive Pulmonary Disease (W. Richard Webb.M.D.‬‬ ‫ﺗﻚ ﺟﻠﺪﻱ‬ ‫‪150,000‬‬
‫)‪96. The Radiologic Clinics of North America Neonatal Imaging (Janet L. ST. Rife, M.D.‬‬ ‫ﺗﻚ ﺟﻠﺪﻱ‬ ‫‪115,000‬‬
‫)‪97. The Radiologic Clinics of North America Lung Cancer (Claudia I. Henschke. Phil, M.D.‬‬ ‫ﺗﻚ ﺟﻠﺪﻱ‬ ‫‪140,000‬‬
‫)‪98. The Radiologic Clinics of North America Interventional Procedures in Musculoskeletal Radio I Interventional Techniques (Jamshid Tehranzadeh, MD‬‬ ‫ﺗﻚ ﺟﻠﺪﻱ‬ ‫‪100,000‬‬
‫)‪99. The Radiologic Clinics of North America Interventional Procedures in Musculoskeletal Radio II Advanced Arthrography (Jamshid Tehranzadeh‬‬ ‫ﺗﻚ ﺟﻠﺪﻱ‬ ‫‪200,000‬‬
‫)‪100. The Radiologic Clinics of North America Advances in Emergency Radiology I & II (Robert A. Novell‬‬ ‫ﺩﻭ ﺟﻠﺪﻱ‬ ‫‪120,000‬‬
‫)‪101. The Radiologic Clinics of North America Cardiac Radiology (Lawrence M. Boxt. MD‬‬ ‫ﺗﻚ ﺟﻠﺪﻱ‬ ‫‪150,000‬‬
‫)‪102. The Radiologic Clinics of North America Interventional Chest Radiology (Jeffrey S. Klein, M.D.‬‬ ‫ﺗﻚ ﺟﻠﺪﻱ‬ ‫‪150,000‬‬

‫‪Imaging of the newborn, infant, and young child‬‬ ‫)‪(LEONARD E. SWISCHUK, M. D.) (FIFTH EDITION‬‬ ‫)‪(2004‬‬

‫‪Borderlands of Normal and Early Pathological Finding in Skeletal Radiography‬‬ ‫)‪(Fifth revised edition‬‬
‫)‪(Juergen Freyschmidt, Joachim Brossmann, Juergen Wiens, Andreas Sternberg‬‬ ‫)‪(Thieme‬‬
‫‪Clinical Imaging‬‬ ‫‪(Ronald L. Eisenberg, Amelda County‬‬ ‫)ﺭﺋﻴﺲ ﺩﭘﺎﺭﺗﻤﺎﻥ ﺭﺍﺩﻳﻮﻟﻮﮊﻱ ﻭ ﭘﺮﻭﻓﺴﻮﺭ ﺭﺍﺩﻳﻮﻟﻮﮊﻱ ﻛﻠﻴﻨﻴﻜﺎﻝ‬
‫ﻗﻴﻤﺖ‪ 600,000 :‬ﺭﻳﺎﻝ‬
‫)‪(an atlas of differential diagnosis) (Lippincott Williums & Wilkins‬‬ ‫)‪(Forth Edition‬‬ ‫)‪(2003‬‬

‫ﻼ ‪multiple‬‬ ‫ﺍﻳﻦ ﻛﺘﺎﺏ ﺷﺎﻣﻞ ﻣﺒﺎﺣﺚ ﻻﺯﻡ ﻭ ﺩﺭ ﻋﻴﻦ ﺣﺎﻝ ﻛﺎﻣﻞ ﻭ ﻛﺎﺭﺑﺮﺩﻱ ﺩﺭ ﺍﺭﺗﺒﺎﻁ ﺑﺎ ﺗﺸﺨﻴﺺﻫﺎﻱ ﺍﻓﺘﺮﺍﻗﻲ ﻣﺮﺑﻮﻁ ﺑﻪ ﻧﻤﺎﻫﺎﻱ ﮔﻮﻧﺎﮔﻮﻥ ﺭﺍﺩﻳﻮﻟﻮﮊﻱ ﻭ ﺗﺼﻮﻳﺮﺑﺮﺩﺍﺭﻱ ﻣﻲﺑﺎﺷﺪ ﻭ ﺩﺭ ﻣﻮﺭﺩ ﺗﺸﺨﻴﺺﻫﺎﻱ ﺍﻓﺘﺮﺍﻗﻲ ﻣﺨﺘﻠﻒ ﻣﺮﺑﻮﻁ ﺑﻪ ﻫﺮ ﻧﻤـﺎﻱ ﺭﺍﺩﻳﻮﮔﺮﺍﻓﻴـﻚ )ﺑﻌﻨـﻮﺍﻥ ﻣـﺜ ﹰ‬
‫‪ (Pulmonary nodules‬ﺗﺼﺎﻭﻳﺮ ﻣﺮﺗﺒﻂ ﺑﻪ ﻫﺮ ﺗﺸﺨﻴﺺ ﺍﻓﺘﺮﺍﻗﻲ ﺭﺍ ﺑﻄﻮﺭ ﺟﺪﺍﮔﺎﻧﻪ ﺑﻪ ﻧﻤﺎﻳﺶ ﺩﺭﺁﻣﺪﻩ ﻭ ﺩﺭ ﻣﻮﺭﺩ ﻫﺮ ﻛﺪﺍﻡ ﻧﻴﺰ ﺗﻮﺿﻴﺤﺎﺕ ﻻﺯﻡ ﺑﺎ ﻧﮕﺎﺭﺷﻲ ﺑﺴﻴﺎﺭ ﻗﺎﺑﻞ ﻓﻬﻢ ﺫﻛﺮ ﮔﺮﺩﻳﺪﻩ ﺍﺳﺖ‪ .‬ﺍﻳﻦ ﻛﺘﺎﺏ ﺗﻘﺮﻳﺒﹰﺎ ﺷـﺎﻣﻞ ﺗﺸـﺨﻴﺺﻫـﺎﻱ ﺍﻓﺘﺮﺍﻗـﻲ ﻣﺮﺑـﻮﻁ ﺑـﻪ ﺭﺍﺩﻳﻮﻟـﻮﮊﻱ ﻭ‬
‫ﺗﺼﻮﻳﺮﺑﺮﺩﺍﺭﻱ ﻛﻞ ﺑﺪﻥ ﺑﻮﺩﻩ ﻭ ﺗﻜﻨﻴﻚﻫﺎﻱ ﻣﺨﺘﻠﻒ ‪) Imaging‬ﺍﺯ ﻗﺒﻴﻞ ‪ ، Plain film‬ﻣﻄﺎﻟﻌﺎﺕ ﺑﺎ ﻛﻨﺘﺮﺍﺳﺖ‪ ،‬ﺳﻮﻧﻮﮔﺮﺍﻓﻲ‪ MRI ، CTScan ،‬ﻭ ‪ (...‬ﺩﺭ ﺁﻥ ﻟﺤﺎﻅ ﺷﺪﻩ ﺍﺳﺖ‪ .‬ﻓﻬﺮﺳﺖ ﻛﻠﻲ ﻣﺮﺑﻮﻁ ﺑﻪ ﻓﺼﻮﻝ ﻣﺨﺘﻠﻒ ﺍﻳﻦ ﻛﺘﺎﺏ ﺑﻪ ﺷﺮﺡ ﺫﻳﻞ ﻣﻲﺑﺎﺷﺪ‪:‬‬
‫‪ -٦‬ﺍﻟﮕﻮﻫﺎﻱ ﺭﺍﺩﻳﻮﮔﺮﺍﻓﻴﻚ ﺳﺘﻮﻥ ﻓﻘﺮﺍﺕ‬ ‫‪ -١‬ﺍﻟﮕﻮﻫﺎﻱ ﺭﺍﺩﻳﻮﮔﺮﺍﻓﻴﻚ ‪Chest‬‬
‫‪ -٧‬ﺍﻟﮕﻮﻫﺎﻱ ﺭﺍﺩﻳﻮﮔﺮﺍﻓﻴﻚ ﺟﻤﺠﻤﻪ‬ ‫‪ -٢‬ﺍﻟﮕﻮﻫﺎﻱ ﺭﺍﺩﻳﻮﮔﺮﺍﻓﻴﻚ ﻗﻠﺐ ﻭ ﻋﺮﻭﻕ‬
‫‪ -٨‬ﺑﻴﻤﺎﺭﻱﻫﺎﻱ ‪ Breast‬ﻭ ﻣﺎﻣﻮﮔﺮﺍﻓﻲ‬ ‫‪ -٣‬ﺍﻟﮕﻮﻫﺎﻱ ﺭﺍﺩﻳﻮﮔﺮﺍﻓﻴﻚ ‪Gastrointestinal‬‬
‫‪ -٩‬ﺳﻮﻧﻮﮔﺮﺍﻓﻲ ﺟﻨﻴﻦ‬ ‫‪ -٤‬ﺍﻟﮕﻮﻫﺎﻱ ﺭﺍﺩﻳﻮﮔﺮﺍﻓﻴﻚ ‪Genitourinary‬‬
‫‪ -٥‬ﺍﻟﮕﻮﻫﺎﻱ ﺭﺍﺩﻳﻮﮔﺮﺍﻓﻴﻚ ﺍﺳﻜﺘﺎﻝ‬

‫ﺿﻤﻨﹰﺎ ﺩﺭ ﻣﻮﺭﺩ ﻫﺮ ﻛﺪﺍﻡ ﺍﺯ ﻓﺼﻞﻫﺎﻱ ﻓﻮﻕﺍﻟﺬﻛﺮ‪ ،‬ﺩﺭ ﺍﺑﺘﺪﺍﻱ ﻫﺮ ﻓﺼﻞ‪ ،‬ﻓﻬﺮﺳﺖ ﻛﺪﺩﺍﺭ ﻭﻳﮋﻩﺍﻱ ﺩﺭ ﺍﺭﺗﺒﺎﻁ ﺑﺎ ﻧﺸﺎﻧﻪﻫﺎﻱ ﺭﺍﺩﻳﻮﻟﻮﮊﻳﻚ ﻣﺮﺑﻮﻁ ﺑﻪ ﻣﺒﺤﺚ ﻣﺬﻛﻮﺭ ﺁﻭﺭﺩﻩ ﺷﺪﻩ ﺍﺳﺖ ﻛﻪ ﺩﺭ ﺗﺴﻬﻴﻞ ﻭ ﺗﺴﺮﻳﻊ ﺍﺳﺘﻔﺎﺩﻩ ﺍﺯ ﺍﻳﻦ ﻛﺘـﺎﺏ ﺑﺴـﻴﺎﺭ ﻣـﺆﺛﺮ ﺧﻮﺍﻫـﺪ ﺑـﻮﺩ‪ .‬ﻣﻄﺎﻟﻌـﻪ ﺍﻳـﻦ ﻛﺘـﺎﺏ‬
‫ﺍﺭﺯﺷﻤﻨﺪ ﺑﺮﺍﻱ ﺷﺮﻛﺖ ﺩﺭ ﺍﻣﺘﺤﺎﻧﺎﻥ ﺑﺮﺩ ﺗﺨﺼﺺ ﺭﺍﺩﻳﻮﻟﻮﮊﻱ ﻭ ﻫﻤﭽﻨﻴﻦ ﻛﺎﺭ ﻋﻤﻠﻲ ﺩﺭ ﻣﺆﺳﺴﺎﺕ ﺭﺍﺩﻳﻮﻟﻮﮊﻱ ﺑﺴﻴﺎﺭ ﻣﻔﻴﺪ ﺧﻮﺍﻫﺪ ﺑﻮﺩ‪.‬‬

‫ﺗﻠﻔﻦ‪٠٩١٢١٣٧٢٣٦١-٦٦٩٣٦٦٩٦ :‬‬ ‫ﻧﺸﺎﻧﻲ‪ :‬ﺗﻬﺮﺍﻥ‪ ،‬ﻡ ﺍﻧﻘﻼﺏ‪ ،‬ﺥ ﻛﺎﺭﮔﺮ ﺟﻨﻮﺑﻲ‪ ،‬ﺥ ﻟﺒﺎﻓﻲﻧﮋﺍﺩ‪ ،‬ﺑﻴﻦ ﻛﺎﺭﮔﺮ ﻭ ﺟﻤﺎﻟﺰﺍﺩﻩ‪ ،‬ﺑﻦﺑﺴﺖ ﺳﻴﻤﻴﻦ‪ ،‬ﭘﻼﻙ ‪٢٣٩‬‬ ‫ﻣﺮﻛﺰ ﺧﺪﻣﺎﺕ ﻓﺮﻫﻨﮕﻲ ﺳﺎﻟﻜﺎﻥ ‪ :‬ﺍﺭﺍﺋﻪ ﻛﻨﻨﺪﺓ ﻛﺘﺎﺏ ﻭ ﺳﻲﺩﻱﻫﺎﻱ ﺗﺨﺼﺼﻲ ﭘﺰﺷﻜﻲ‬
 ‫‪84‬‬

‫‪Atlas of Normal Roentgen Variants that may Simulate Disease‬‬ ‫)‪(Mosby Inc.) (2001‬‬ ‫)‪(Seventh Edition‬‬ ‫‪1307‬‬ ‫ﺗﻌﺪﺍﺩ ﺻﻔﺤﺎﺕ‬
‫‪(Theodore E. Keats M.D.‬‬ ‫)ﺩﺍﻧﺸﻴﺎﺭ ﺭﺍﺩﻳﻮﻟﻮﮊﻱ ﺩﺍﻧﺸﮕﺎﻩ ﻭﻳﺮﺟﻴﻨﻴﺎ ‪ , Mark W. Anderson M.d.‬ﭘﺮﻭﻓﺴﻮﺭ ﺭﺍﺩﻳﻮﻟﻮﮊﻱ ﺩﺍﻧﺸﮕﺎﻩ ﻭﻳﺮﺟﻴﻨﻴﺎ‬ ‫ﻗﻴﻤﺖ‪ 700,000 :‬ﺭﻳﺎﻝ‬

‫ﺩﺭ ﺍﻳﻦ ﻛﺘﺎﺏ ‪ ،‬ﺑﺎ ﻛﻤﻚ ﺗﺼﺎﻭﻳﺮ ﺭﺍﺩﻳﻮﮔﺮﺍﻓﻴﻚ ﻣﺘﻌﺪﺩ‪ ،‬ﺑﺎ ﻧﻤﺎﻫﺎﻱ ﻣﺨﺘﻠﻒ ﻭﺍﺭﻳﺎﺳﻴﻮﻥﻫﺎﻱ ﻧﺮﻣﺎﻝ ﺭﺍﺩﻳﻮﻟﻮﮊﻱ ﺁﺷﻨﺎ ﻣﻲﺷﻮﻳﻢ ﻭ ﺑﺪﻳﻦ ﻃﺮﻳﻖ ﺍﺯ ﻣﻴﺰﺍﻥ ‪ Over diagnosis‬ﻛﻪ ﻣﻤﻜﻦ ﺍﺳﺖ ﺩﺭ ﺟﺮﻳﺎﻥ ﮔﺰﺍﺭﺷﺎﺕ ﺭﺍﺩﻳﻮﻟﻮﮊﻳﻚ ﺍﺗﻔﺎﻕ ﺑﻴﺎﻓﺘﺪ‪ ،‬ﻛﺎﺳـﺘﻪ ﺧﻮﺍﻫـﺪ‬
‫ﺷﺪ‪.‬‬
‫ﺍﻳﻦ ﻛﺘﺎﺏ ﺷﺎﻣﻞ ﺩﻭ ﺑﺨﺶ ﺍﺻﻠﻲ ﻣﻲﺑﺎﺷﺪ‪ .‬ﺑﺨﺶ ﺍﻭﻝ ﻣﺮﺑﻮﻁ ﺑﻪ ﻭﺍﺭﻳﺎﺳﻴﻨﻮﺱﻫﺎﻱ ﻧﺮﻣﺎﻝ ﺭﺍﺩﻳﻮﮔﺮﺍﻓﻴﻚ ﺍﺳﺘﺨﻮﺍﻥﻫﺎ ﻭ ﺑﺨﺶ ﺩﻭﻡ ﻣﺮﺑﻮﻁ ﺑﻪ ﻭﺍﺭﻳﺎﺳﻴﻨﻮﺱﻫﺎﻱ ﻧﺮﻣﺎﻝ ﺭﺍﺩﻳﻮﮔﺮﺍﻓﻴﻚ ﺑﺎﻓﺖﻫﺎﻱ ﻧﺮﻡ ﻣﻲﺑﺎﺷﺪ‪ .‬ﺑﺨـﺶ ﺍﻭﻝ ﻭ ﺩﻭﻡ ﺷـﺎﻣﻞ ﻓﺼـﻮﻝ ﺫﻳـﻞ‬
‫ﻣﻲﺑﺎﺷﻨﺪ‪:‬‬

‫ﺑﺨﺶ ﺩﻭﻡ‬ ‫ﺑﺨﺶ ﺍﻭﻝ‬

‫ﻓﺼﻞ ‪ -١١‬ﺑﺎﻓﺖﻫﺎﻱ ﻧﺮﻡ ﺷﻜﻢ‬ ‫ﻓﺼﻞ ‪ -٨‬ﺑﺎﻓﺖﻫﺎﻱ ﻧﺮﻡ ﮔﺮﺩﻥ‬ ‫ﻓﺼﻞ ‪ -٥‬ﻛﻤﺮﺑﻨﺪ ﺷﺎﻧﻪﺍﻱ ﻭ ﻗﻔﺴﺔ ﺻﺪﺭﻱ‬ ‫ﻓﺼﻞ ‪ -١‬ﺟﻤﺠﻤﻪ‬
‫ﻓﺼﻞ ‪ -١٢‬ﺑﺎﻓﺖﻫﺎﻱ ﻧﺮﻡ ﻟﮕﻦ‬ ‫ﻓﺼﻞ ‪ -٩‬ﺑﺎﻓﺖﻫﺎﻱ ﻧﺮﻡ ﻗﻔﺴﺔ ﺳﻴﻨﻪ‬ ‫ﻓﺼﻞ ‪ -٦‬ﺍﻧﺪﺍﻡ ﻓﻮﻗﺎﻧﻲ‬ ‫ﻓﺼﻞ ‪ -٢‬ﺍﺳﺘﺨﻮﺍﻥﻫﺎﻱ ﺻﻮﺭﺕ‬
‫ﻓﺼﻞ ‪ -١٣‬ﺳﻴﺴﺘﻢ ﺍﺩﺭﺍﺭﻱ ﺗﻨﺎﺳﻠﻲ‬ ‫ﻓﺼﻞ ‪ -١٠‬ﺩﻳﺎﻓﺮﺍﮔﻢ‬ ‫ﻓﺼﻞ ‪ -٧‬ﺍﻧﺪﺍﻡ ﺗﺤﺘﺎﻧﻲ‬ ‫ﻓﺼﻞ ‪ -٣‬ﺳﺘﻮﻥ ﻓﻘﺮﺍﺕ‬
‫ﻓﺼﻞ ‪ -٤‬ﻛﻤﺮﺑﻨﺪ ﻟﮕﻨﻲ‬

‫‪Magnetic Resonance Angiography‬‬ ‫)‪(Springer) (2003‬‬ ‫‪478‬‬ ‫ﺗﻌﺪﺍﺩ ﺻﻔﺤﺎﺕ‪:‬‬ ‫ﻗﻴﻤﺖ‪ 500,000 :‬ﺭﻳﺎﻝ‬
‫‪ , Guy Marchal, PhD, M.D.‬ﭘﺮﻭﻓﺴﻮﺭ ﺭﺍﺩﻳﻮﻟﻮﮊﻱ ﺩﺍﻧﺸﮕﺎﻩ ﺍﺷﺘﺮﺕ ﮔﺎﺭﺩ ﺁﻟﻤﺎﻥ ‪(Ingolf P. Arlart, Phd, M.D.‬‬ ‫)ﭘﺮﻭﻓﺴﻮﺭ ﺭﺍﺩﻳﻮﻟﻮﮊﻱ ﺩﺍﻧﺸﮕﺎﻩ ‪ Leuven‬ﺑﻠﮋﻳﻚ‬

‫ﺑﺎ ﺗﻮﺟﻪ ﺑﻪ ﮔﺮﺍﻳﺶ ﺭﻭﺯﺍﻓﺰﻭﻥ ﺑﻪ ﻏﻴﺮﺗﻬﺎﺟﻤﻲﺷﺪﻥ ﺭﻭﺵﻫﺎﻱ ﺗﺸﺨﻴﺼﻲ ﭘﺰﺷﻜﻲ ﻧﻴﺎﺯ ﺑﻪ ﺩﺍﻧﺴﺘﻦ ﺗﻜﻨﻴﻚﻫﺎ ﻭ ﻫﻤﭽﻨﻴﻦ ﻣﻮﺍﺭﺩ ﺍﺳﺘﻔﺎﺩﻩ ﺁﻧﮋﻳﻮﮔﺮﺍﻓﻲ ﺑﺎ ﻛﻤﻚ ﺭﺯﻭﻧﺎﻧﺲ ﻣﻐﻨﺎﻃﻴﺴﻲ )‪ (MRA‬ﺑﻴﺶ ﺍﺯ ﭘﻴﺶ ﺍﺣﺴﺎﺱ ﻣﻲﺷﻮﺩ ﻭ ﻫﺪﻑ ﺍﺻﻠﻲ ﺍﻳﻦ ﻛﺘـﺎﺏ ﻧﻴـﺰ‬
‫ﺁﺷﻨﺎﻳﻲ ﺑﺎ ﺍﺻﻮﻝ ﻭ ﻣﻼﺣﻈﺎﺕ ﺗﻜﻨﻴﻜﻲ ‪ MRA‬ﻭ ﻫﻤﭽﻨﻴﻦ ﻛﺎﺭﺑﺮﺩﻫﺎﻱ ﺑﺎﻟﻴﻨﻲ ﺍﻳﻦ ﺭﻭﺵ ﺗﺼﻮﻳﺮﺑﺮﺩﺍﺭﻱ ﺗﺸﺨﻴﺼﻲ ﻣﻲﺑﺎﺷﺪ‪ .‬ﻓﺼﻮﻝ ﻋﻤﺪﺓ ﺍﻳﻦ ﻛﺘﺎﺏ ﻋﺒﺎﺭﺗﻨﺪ ﺍﺯ‪:‬‬

‫‪ -١٧‬ﻋﺮﻭﻕ ﺭﻳﻮﻱ‬
‫‪ -١٨‬ﺁﺋﻮﺭﺕ ﺷﻜﻤﻲ ﻭ ﺷﺎﺧﻪﻫﺎﻱ ﺁﻥ‬
‫‪ -١٩‬ﺷﺮﻳﺎﻥﻫﺎﻱ ﺍﻧﺪﺍﻡﻫﺎ‬
‫‪ -٢٠‬ﻭﺭﻳﺪﻫﺎﻱ ﺑﺰﺭﮒ ﺑﺪﻥ ﻭ ﺍﻧﺪﺍﻡﻫﺎ‬
‫‪ -٢١‬ﺳﻴﺴﺘﻢ ﻭﺭﻳﺪﻱ ﺍﺳﭙﻠﻨﻮﭘﻮﺭﺗﺎﻝ‬
‫‪ -٢٢‬ﺍﺭﺍﺋﺔ ﺭﺍﻫﻨﻤﺎ )‪ (Guide‬ﺟﻬﺖ ﺭﻭﺵﻫﺎﻱ ﺩﺭﻣﺎﻧﻲ ﺩﺍﺧﻞ ﻋﺮﻭﻗﻲ‬
‫‪Implant -٢٣‬ﻫﺎﻱ ﺩﺍﺧﻞ ﻋﺮﻭﻗﻲ‪ :‬ﺍﻳﻤﻨﻲ ﻭ ﺁﺭﺗﻴﻔﻜﺖﻫﺎ‬
‫‪ -٩‬ﺗﻜﻨﻴﻚﻫﺎﻱ ﻧﻤﺎﻳﺶ ﺗﺼﻮﻳﺮ‬
‫‪ -١٠‬ﻛﻤﻴﺖ ﺟﺮﻳﺎﻥ ﺧﻮﻥ‬
‫‪ -١١‬ﺗﺸﺮﻳﺢ ﻧﻤﺎﻳﺸﻲ ﺳﺨﺖﺍﻓﺰﺍﺭ‬
‫‪ -١٢‬ﺁﺭﺗﻴﻔﻜﺖﻫﺎ ﻭ ﻣﺤﺪﻭﺩﻳﺖﻫﺎ‬
‫‪ -١٣‬ﻋﺮﻭﻕ ﺩﺍﺧﻞ ﺟﻤﺠﻤﻪ‬
‫‪ -١٤‬ﺷﺮﻳﺎﻥﻫﺎﻱ ﻛﺎﺭﻭﺗﻴﺪ ﻭ ﻭﺭﺗﺒﺮﺍﻝ‬
‫‪ -١٥‬ﺁﺋﻮﺭﺕ ﺷﻜﻤﻲ ﻭ ﺷﺎﺧﻪﻫﺎﻱ ﺁﻥ‬
‫‪ -١٦‬ﺷﺮﻳﺎﻥﻫﺎﻱ ﻛﻮﺭﻭﻧﺎﺭﻱ‬
‫‪ -١‬ﺳﻴﺴﺘﻢ ﻋﺮﻭﻗﻲ‪ :‬ﺁﻧﺎﺗﻮﻣﻲ ﻧﺮﻣﺎﻝ ﻭ ﭘﺎﺗﻮﻟﻮﮊﻱﻫﺎﻱ ﻋﺮﻭﻗﻲ ﻭ ﺍﺻﻮﻝ ﻫﻤﻮﺩﻳﻨﺎﻣﻴﻚ‬
‫‪ -٢‬ﺗﻌﺮﻳﻒ ﺁﻧﮋﻳﻮﮔﺮﺍﻓﻲ ﺑﺎ ﺍﺳﺘﻔﺎﺩﻩ ﺍﺯ ﺭﺯﻭﻧﺎﻧﺲ ﻣﻐﻨﺎﻃﻴﺴﻲ )‪(MRA‬‬
‫‪ -٣‬ﺍﺻﻮﻝ ﭘﺎﻳﻪ ﺭﺯﻭﻧﺎﻧﺲ ﻣﻐﻨﺎﻃﻴﺴﻲ ﻫﺴﺘﻪﺍﻱ )‪ (NMR‬ﺟﻬﺖ ﺗﺼﻮﻳﺮﺑﺮﺩﺍﺭﻱ ﭘﺰﺷﻜﻲ‬
‫‪ -٤‬ﻓﻀﺎﻱ ‪ K‬ﻭ ‪Resolution‬‬
‫‪ -٥‬ﺗﻜﻨﻴﻚﻫﺎﻱ ‪ Acquistion‬ﻭﺍﺑﺴﺘﻪ ﺑﻪ ﺟﺮﻳﺎﻥ‬
‫‪ -٦‬ﺗﻜﻨﻴﻚﻫﺎﻱ ‪ Acquistion‬ﻣﺴﺘﻘﻞ ﺍﺯ ﺟﺮﻳﺎﻥ‬
‫‪ Resolution -٧‬ﻓﻀﺎﻳﻲ ﺩﺭ ﻣﻘﺎﺑﻞ ‪ Resolution‬ﺯﻣﺎﻧﻲ ﺩﺭ ‪ MRA‬ﺑﺎ ﺗﺸﺪﻳﺪ ﻛﻨﺘﺮﺍﺳﺖ‬
‫‪ -٨‬ﻣﺎﺩﻩ ﺣﺎﺟﺐ ﺩﺭ ‪MRA‬‬

‫ﺗﻠﻔﻦ‪٠٩١٢١٣٧٢٣٦١-٦٦٩٣٦٦٩٦ :‬‬ ‫ﻧﺸﺎﻧﻲ‪ :‬ﺗﻬﺮﺍﻥ‪ ،‬ﻡ ﺍﻧﻘﻼﺏ‪ ،‬ﺥ ﻛﺎﺭﮔﺮ ﺟﻨﻮﺑﻲ‪ ،‬ﺥ ﻟﺒﺎﻓﻲﻧﮋﺍﺩ‪ ،‬ﺑﻴﻦ ﻛﺎﺭﮔﺮ ﻭ ﺟﻤﺎﻟﺰﺍﺩﻩ‪ ،‬ﺑﻦﺑﺴﺖ ﺳﻴﻤﻴﻦ‪ ،‬ﭘﻼﻙ ‪٢٣٩‬‬ ‫ﻣﺮﻛﺰ ﺧﺪﻣﺎﺕ ﻓﺮﻫﻨﮕﻲ ﺳﺎﻟﻜﺎﻥ ‪ :‬ﺍﺭﺍﺋﻪ ﻛﻨﻨﺪﺓ ﻛﺘﺎﺏ ﻭ ﺳﻲﺩﻱﻫﺎﻱ ﺗﺨﺼﺼﻲ ﭘﺰﺷﻜﻲ‬
 ‫‪85‬‬
‫)‪CT and MR Imaging of the Whole Body (Mosby) (2003‬‬ ‫)ﺗﻌﺪﺍﺩ ﺻﻔﺤﺎﺕ‪] 2272 :‬ﺩﻭﺟﻠﺪﻱ[ (‬
‫ﺭﻳﺎﺳﺖ ﺩﭘﺎﺭﺗﻤﺎﻥ ﺭﺍﺩﻳﻮﻟﻮﮊﻱ ﺩﺍﻧﺸﮕﺎﻩ ‪ Cleveland‬ﺍﻭﻫﺎﻳﻮ )‪(John R. Haaga, MD , FACR‬‬ ‫ﭘﺮﻭﻓﺴﻮﺭ ﺭﺍﺩﻳﻮﻟﻮﮊﻱ ﻭ ﺟﺮﺍﺣﻲ ﺍﻋﺼﺎﺏ ﺩﺍﻧﺸﮕﺎﻩ ‪ Cleveland‬ﺍﻭﻫﺎﻳﻮ )‪(Charles F. Lanzieri, MD, FACR‬‬
‫ﺍﺳﺘﺎﺩ ﺑﺨﺶﻫﺎﻱ ﺭﺍﺩﻳﻮﻟﻮﮊﻱ ‪ Thoracic , Head‬ﺩﺍﻧﺸﮕﺎﻩ ‪ Case Western Reserve‬ﺷﻬﺮ ‪ Cleveland‬ﺍﻭﻫﺎﻳﻮ )‪(Robert C. Gilkeson, MD‬‬ ‫ﻗﻴﻤﺖ‪ 1000,000 :‬ﺭﻳﺎﻝ‬

‫ﺍﻳﻦ ﻛﺘﺎﺏ ﻳﻜﻲ ﺍﺯ ﻛﺎﻣﻠﺘﺮﻳﻦ ﻣﺮﺍﺟﻊ ﺩﺭ ﺍﺭﺗﺒﺎﻁ ﺑﺎ ‪ MRI ,CT Scan‬ﺑﻮﺩﻩ ﻭ ﺩﺭ ﺁﻥ ﺿﻤﻦ ﺑﺤﺚ ﻛﺎﻣﻞ ﻭ ﺩﻗﻴﻖ ﺩﺭ ﻣﻮﺭﺩ ﭘﺎﺗﻮﻟﻮﮊﻱ ﻭ ﻫﻤﭽﻨﻴﻦ ﻳﺎﻓﺘﻪﻫﺎﻱ ‪ Imaging‬ﻣﺮﺑﻮﻁ ﺑﻪ ﺑﻴﻤﺎﺭﻳﻬﺎﻱ ﻣﺨﺘﻠﻒ‪ ،‬ﺍﺯ ﺗﺼﺎﻭﻳﺮ ﮔﻮﻳﺎ ﻭ ﺗﻴﭙﻴﻚ ﻣﺘﻌﺪﺩ ﻫﻤـﺮﺍﻩ ﺑـﺎ ﺗﻮﺿـﻴﺤﺎﺕ ﻛـﺎﻓﻲ ﺑـﺮﺍﻱ ﻓﻬـﻢ‬
‫ﻣﻄﺎﻟﺐ ﺍﺳﺘﻔﺎﺩﻩ ﮔﺮﺩﻳﺪﻩ ﺍﺳﺖ ﻭ ﺍﺯ ﺗﻜﻨﻴﻜﻬﺎ ﻭ ﺟﺪﻳﺪﺗﺮﻳﻦ ﺭﻭﺷﻬﺎﻱ ‪ MRI, CT Scan‬ﺑﻘﺪﺭ ﻛﻔﺎﻳﺖ ﺻﺤﺒﺖ ﺻﺤﺒﺖ ﺷﺪﻩ ﺍﺳﺖ‪ .‬ﺍﻳﻦ ﻛﺘﺎﺏ ﺩﺭ ﺩﻭ ﺟﻠﺪ ﺗﺪﻭﻳﻦ ﮔﺮﺩﻳﺪﻩ ﺍﺳﺖ‪ .‬ﺟﻠﺪ ﺍﻭﻝ ﺍﻳﻦ ﻛﺘﺎﺏ ﺷﺎﻣﻞ ﭘﻨﺞ ﺑﺨﺶ ﻋﻤﺪﻩ ﻣﻲﺑﺎﺷﺪ ﻭ ﻓﻬﺮﺳﺖ ﻓﺼﻮﻝ ﺁﻥ ﺩﺭ ﺫﻳﻞ ﺁﻭﺭﺩﻩ ﺷﺪﻩﺍﻧﺪ‪:‬‬

‫ﺑﺨﺶ ﺳﻮﻡ‪ -‬ﺗﺼﻮﻳﺮ ﺑﺮﺩﺍﺭﻱ ﺳﺮ ﻭ ﮔﺮﺩﻥ‬
‫ﻓﺼﻞ ‪ -١٤‬ﺍﻭﺭﺑﻴﺖ‬
‫ﻓﺼﻞ ‪ -١٥‬ﺍﺳﺘﺨﻮﺍﻥ ﺗﻤﭙﻮﺭﺍﻝ‬
‫ﻓﺼﻞ ‪ -١٦‬ﻛﺎﻭﻳﺘﻲ ﺳﻴﻨﻮﻧﺎﺯﺍﻝ‬
‫ﻓﺼﻞ ‪ -١٧‬ﺗﻮﺩﻩﻫﺎﻱ ﻣﺮﺑﻮﻁ ﺑﻪ ﮔﺮﺩﻥ ﻭ ﺁﺩﻧﻮﭘﺎﺗﻲ ﮔﺮﺩﻧﻲ‬
‫ﻓﺼﻞ ‪ -١٨‬ﺣﻨﺠﺮﻩ‬
‫ﻓﺼﻞ ‪ -١٩‬ﻧﺎﺯﻭﻓﺎﺭﻧﻜﺲ ﻭ ﺍﻭﺭﻓﺎﺭﻧﻜﺲ‬
‫ﻓﺼﻞ ‪ -٢٠‬ﻏﺪﺩ ﺗﻴﺮﻭﺋﻴﺪ ﻭ ﭘﺎﺭﺍﺗﻴﺮﻭﺋﻴﺪ‬
‫ﻓﺼﻞ ‪ -٢١‬ﺗﺼﻮﻳﺮﺑﺮﺩﺍﺭﻱ ﺳﺮ ﻭ ﮔﺮﺩﻥ ﺍﻃﻔﺎﻝ‬
‫ﻓﺼﻞ ‪ -٣٠‬ﺟﻨﺐ )ﭘﻠﻮﺭ( ﻭ ﺩﻳﻮﺍﺭﺓ ﻓﻘﺴﺔ ﺻﺪﺭﻱ‬
‫ﻓﺼﻞ ‪ MRI -٣٣‬ﻗﻠﺐ‬
‫ﺑﺨﺶ ﺩﻭﻡ‪ -‬ﻣﻐﺰ ﻭ ﻣﻨﻨﮋﻫﺎ‬ ‫ﺑﺨﺶ ﺍﻭﻝ‪ -‬ﺍﺻﻮﻝ ‪MRI, CT Scan‬‬
‫ﻓﺼﻞ ‪ -٤‬ﺁﻧﺎﺗﻮﻣﻲ ﻧﺮﻣﺎﻝ ‪ MRI, CT Scan‬ﻣﻐﺰ ﻭ ﺳﺘﻮﻥ ﻓﻘﺮﺍﺕ‬ ‫ﺍﺻﻮﻝ ﺗﺼﻮﻳﺮ ﺑﺮﺩﺍﺭﻱ ﺩﺭ ‪CT Scan‬‬ ‫ﻓﺼﻞ ‪-١‬‬
‫ﻓﺼﻞ ‪ -٥‬ﻧﺌﻮﭘﻼﺳﻢﻫﺎﻱ ﺍﻳﻨﺘﺮﺍﻛﺮﺍﻧﻴﺎﻝ‬ ‫ﻓﻴﺰﻳﻚ ‪MRI‬‬ ‫ﻓﺼﻞ ‪-٢‬‬
‫ﻓﺼﻞ ‪ -٦‬ﻋﻔﻮﻧﺘﻬﺎ ﻭ ﺍﻟﺘﻬﺎﺑﺎﺕ ﻣﻐﺰ‬ ‫ﻓﺼﻞ ‪ -٣‬ﺁﻧﮋﻳﻮﮔﺮﺍﻓﻲ ﺑﺎ ﺍﺳﺘﻔﺎﺩﻩ ﺍﺯ ﺭﺯﻭﻧﺎﻧﺲ ﻣﻐﻨﺎﻃﻴﺲ‬
‫ﻓﺼﻞ ‪ -٧‬ﺳﻜﺘﻪ ﻣﻐﺰﻱ‬ ‫)‪ :(MRI‬ﺍﺻﻮﻝ ﻭ ﺗﻜﻨﻴﻜﻬﺎ‬
‫ﻓﺼﻞ ‪ -٨‬ﻣﺎﻟﻔﻮﺭﻣﺎﺳﻴﻮﻧﻬﺎﻱ ﻋﺮﻭﻗﻲ ﻭ ﺁﻧﻮﺭﻳﺴﻤﻬﺎﻱ ﻣﻐﺰﻱ‬
‫ﻓﺼﻞ ‪ -٩‬ﺗﺮﻭﻣﺎﻱ ﺳﻴﺴﺘﻢ ﺍﻋﺼﺎﺏ ﻣﺮﻛﺰﻱ‬
‫ﻓﺼﻞ ‪ -١٠‬ﺍﺧﺘﻼﻻﺕ ﻧﻮﺭﻭﺩﮊﻧﺮﺍﺗﻴﻮ‬
‫ﻓﺼﻞ ‪ Magnetic Resonance Spectroscopy -١١‬ﻣﻐﺰ‬
‫ﻓﺼﻞ ‪ -١٢‬ﻓﺮﺁﻳﻨﺪﻫﺎﻱ ﻣﻨﻨﮋﻳﺎﻝ‬
‫ﻓﺼﻞ ‪ -١٣‬ﻟﻮﻛﻮﺍﻧﺴﻔﺎﻟﻮﭘﺎﺗﻲﻫﺎ ﻭ ﺑﻴﻤﺎﺭﻳﻬﺎﻱ ﺩﻣﻴﻠﻴﻨﻴﺰﺍﻥ‬
‫ﺑﺨﺶ ﭘﻨﺠﻢ‪ -‬ﺗﺼﻮﻳﺮﺑﺮﺩﺍﺭﻱ ﻗﻔﺴﺔ ﺳﻴﻨﻪ‬
‫ﻓﺼﻞ ‪ -٢٩‬ﻣﺪﻳﺎﺳﺘﻦ‬ ‫ﻓﺼﻞ ‪ -٢٨‬ﻧﺌﻮﭘﻼﺳﻢﻫﺎﻱ ﺍﻭﻟﻴﺔ ﺭﻳﻮﻱ‬ ‫ﻓﺼﻞ ‪ -٢٧‬ﺑﻴﻤﺎﺭﻳﻬﺎﻱ ﻏﻴﺮ ﻧﺌﻮﭘﻼﺳﺘﻴﻚ ﭘﺎﺭﺍﻧﺸﻴﻤﺎﻝ ﺭﻳﻪ‬
‫ﻓﺼﻞ ‪ CT Scan -٣٢‬ﻗﻠﺐ ﻭ ﭘﺮﻳﻜﺎﺭﺩ‬ ‫ﻓﺼﻞ ‪ MRI, CT Scan -٣١‬ﺁﺋﻮﺭﺕ ﺗﻮﺭﺍﺳﻴﻚ‬

‫ﺟﻠﺪ ﺩﻭﻡ ﻛﺘﺎﺏ ﻫﺎﮔﺎ ﺷﺎﻣﻞ ‪ ٤‬ﺑﺨﺶ ﻋﻤﺪﻩ ﺑﻮﺩﻩ ﻭ ﻓﻬﺮﺳﺖ ﻓﺼﻮﻝ ﺁﻥ ﺑﻪ ﺗﺮﺗﻴﺐ ﺫﻳﻞ ﻣﻲﺑﺎﺷﺪ‪:‬‬

‫ﺑﺨﺶ ﻫﺸﺘﻢ‪ -‬ﺭﺍﺩﻳﻮﻟﻮﮊﻱ ﺍﻃﻔﺎﻝ‬
‫ﻓﺼﻞ ‪ MRI, CT Scan -٥١‬ﺩﺭ ﻛﻮﺩﻛﺎﻥ‪ :‬ﻣﻼﺣﻈﺎﺕ ﻭﻳﮋﻩ‬
‫ﻓﺼﻞ ‪ -٥٢‬ﻗﻠﺐ ﻭ ﻋﺮﻭﻕ ﺑﺰﺭﮒ‬
‫ﻓﺼﻞ ‪ -٥٣‬ﻗﻔﺴﻪ ﺳﻴﻨﻪ‬
‫ﻓﺼﻞ ‪ -٥٤‬ﺳﻴﺴﺘﻢ ﻛﺒﺪﻱ ﺻﻔﺮﺍﻭﻱ‬
‫ﻓﺼﻞ ‪ -٥٥‬ﻃﺤﺎﻝ ﺍﻃﻔﺎﻝ‬
‫ﻓﺼﻞ ‪ -٥٦‬ﭘﺎﻧﻜﺮﺍﺱ‬
‫ﻓﺼﻞ ‪ -٥٧‬ﻛﻠﻴﻪﻫﺎ ﻭ ﻏﺪﺩ ﻓﻮﻕ ﻛﻠﻴﻮﻱ‬
‫ﻓﺼﻞ ‪ -٥٨‬ﺩﺳﺘﮕﺎﻩ ﮔﻮﺍﺭﺵ‪ ،‬ﺣﻔﺮﺓ ﭘﺮﻳﺘﻮﺋﻦ ﻭ ﻣﺰﺍﻧﺘﺮ‬
‫ﻓﺼﻞ ‪ -٥٩‬ﻟﮕﻦ ﻛﻮﺩﻛﺎﻥ ﻭ ﻧﻮﺟﻮﺍﻧﺎﻥ‬
‫ﻓﺼﻞ ‪ -٦٠‬ﺳﻴﺴﺘﻢ ﻋﻀﻼﻧﻲ ﻭ ﺍﺳﻜﻠﺘﻲ‬
‫ﺑﺨﺶ ﻫﻔﺘﻢ‪ -‬ﺗﺼﻮﻳﺮﺑﺮﺩﺍﺭﻱ ﺳﻴﺴﺘﻢ ﻋﻀﻼﻧﻲ ﻭ ﺍﺳﻜﻠﺘﻲ‬
‫ﻓﺼﻞ ‪ -٤٦‬ﺗﻮﻣﻮﺭﻫﺎﻱ ﻣﻮﺳﻜﻮﻟﻮﺍﺳﻜﻠﺘﺎﻝ‬
‫ﻓﺼﻞ ‪ MRI, CT Scan -٤٧‬ﭘﺎ ﻭ ﻣﭻ ﭘﺎ‬
‫ﻓﺼﻞ ‪ -٤٨‬ﺯﺍﻧﻮ‬
‫ﻓﺼﻞ ‪ -٤٩‬ﻣﻔﺼﻞ ﺭﺍﻥ )‪(Hip‬‬
‫ﻓﺼﻞ ‪ -٥٠‬ﺷﺎﻧﻪ‬
‫ﺑﺨﺶ ﺷﺸﻢ‪ -‬ﺗﺼﻮﻳﺮﺑﺮﺩﺍﺭﻱ ﺷﻜﻢ ﻭ ﻟﮕﻦ‬
‫ﻓﺼﻞ ‪ -٣٤‬ﺩﺳﺘﮕﺎﻩ ﮔﻮﺍﺭﺵ‬
‫ﻓﺼﻞ ‪ -٣٥‬ﺿﺎﻳﻌﺎﺕ ﺗﻮﺩﻩﺍﻱ ﻛﺒﺪ‬
‫ﻓﺼﻞ ‪ -٣٦‬ﻛﺒﺪ‪ :‬ﺁﻧﺎﺗﻮﻣﻲ ﻧﺮﻣﺎﻝ‪ ،‬ﺗﻜﻨﻴﻚﻫﺎﻱ ﺗﺼﻮﻳﺮﺑﺮﺩﺍﺭﻱ ﻭ ﺑﻴﻤﺎﺭﻳﻬﺎﻱ ﻣﻨﺘﺸﺮ‬
‫ﻓﺼﻞ ‪ -٣٧‬ﻛﻴﺴﻪ ﺻﻔﺮﺍ ﻭ ﺳﻴﺴﺘﻢ ﺻﻔﺮﺍﻭﻱ‬
‫ﻓﺼﻞ ‪ -٣٨‬ﭘﺎﻧﻜﺮﺍﺱ‬
‫ﻓﺼﻞ ‪ -٣٩‬ﻃﺤﺎﻝ‬
‫ﻓﺼﻞ ‪ -٤٠‬ﻏﺪﺩ ﻓﻮﻕ ﻛﻠﻴﻮﻱ‬
‫ﻓﺼﻞ ‪ -٤١‬ﻛﻠﻴﻪ‬
‫ﻓﺼﻞ ‪ -٤٢‬ﭘﺮﻳﺘﻮﺋﻦ ﻭ ﻣﺰﺍﻧﺘﺮ‬
‫ﻓﺼﻞ ‪ -٤٣‬ﺭﺗﺮﻭﭘﺮﻳﺘﻮﺋﻦ )ﺧﻠﻒ ﺻﻔﺎﻕ(‬
‫ﻓﺼﻞ ‪ CT Scan -٤٤‬ﻟﮕﻦ‬
‫ﻓﺼﻞ ‪ MRI -٤٥‬ﻟﮕﻦ‬

‫ﺗﻠﻔﻦ‪٠٩١٢١٣٧٢٣٦١-٦٦٩٣٦٦٩٦ :‬‬ ‫ﻧﺸﺎﻧﻲ‪ :‬ﺗﻬﺮﺍﻥ‪ ،‬ﻡ ﺍﻧﻘﻼﺏ‪ ،‬ﺥ ﻛﺎﺭﮔﺮ ﺟﻨﻮﺑﻲ‪ ،‬ﺥ ﻟﺒﺎﻓﻲﻧﮋﺍﺩ‪ ،‬ﺑﻴﻦ ﻛﺎﺭﮔﺮ ﻭ ﺟﻤﺎﻟﺰﺍﺩﻩ‪ ،‬ﺑﻦﺑﺴﺖ ﺳﻴﻤﻴﻦ‪ ،‬ﭘﻼﻙ ‪٢٣٩‬‬ ‫ﻣﺮﻛﺰ ﺧﺪﻣﺎﺕ ﻓﺮﻫﻨﮕﻲ ﺳﺎﻟﻜﺎﻥ ‪ :‬ﺍﺭﺍﺋﻪ ﻛﻨﻨﺪﺓ ﻛﺘﺎﺏ ﻭ ﺳﻲﺩﻱﻫﺎﻱ ﺗﺨﺼﺼﻲ ﭘﺰﺷﻜﻲ‬
 86
Looking for the number key to the diagrams? Just fold out this page…
A didactically brilliant and unprecedented approach to understanding CT imaging

(Matthias Hofer, MD) Institute fo Diagnostic Radiology, MNR Clinic, Duesseldorf, Germany
Ideal for radiology residents, students and technicians, this concise manual is the perfect introduction to the practice and interpretation of computed
tomography.
Designed as a systematic learning tool, it introduces the use of CT scanners for all organs. Finally, self-assessment quizzes –including answers-ath the
end of each chapter help the reader monitor progress and evaluate knowledge gained.
Special Feature
Includes detachable, pocket-sized cards containing checklists and tables of normal
measurements –perfect for study or quick reference when on rounds.
Contents: -Technical Aspects -Basic Rules of CT Reading -Preparing the patient
-Administration of Contrast Media -Atlas of Normal and Common Pathological Findings in:the Cranium, Neck, Thorax, Abdomen, Retroperitoneum, Bones, and Lower
Extremity -Interventional CT -CT-Angiography -Dose reduction -New protocols for 1-, 4-, and 16-row multislice scanners

MRI and CT Scan of Head and Spine ‫ ﺭﻳﺎﻝ‬500,000 :‫ﻗﻴﻤﺖ‬

(Williams & Wilkins) (C. Barrie Grossman, M.D. Indiana ‫)ﻓﻮﺭﻭﺭﺍﺩﻳﻮﻟﻮﮊﻳﺴﺖ ﻭ ﻣﺘﺪﻭﻟﻮﮊﻳﺴﺖ ﺩﺍﻧﺸﮕﺎﻩ‬ ( 810 : ‫)ﺗﻌﺪﺍﺩ ﺻﻔﺤﺎﺕ‬

:‫ ﺑﺨﺶ ﺍﺻﻠﻲ ﺍﺳﺖ‬٤ ‫ ﺩﺭ ﺯﻣﻴﻨﺔ ﻧﻮﺭﻭﺭﺍﺩﻳﻮﻟﻮﮊﻱ ﺑﻪ ﺑﺤﺚ ﻭ ﺑﺮﺭﺳﻲ ﻣﻲﭘﺮﺩﺍﺯﺩ ﻭ ﺷﺎﻣﻞ‬MRI ‫ ﻭ‬CT Scan ‫ﻛﺘﺎﺏ ﻓﻮﻕﺍﻟﺬﻛﺮ ﺩﺭ ﻣﻮﺭﺩ‬
‫ ﻣﻐﺰ‬: ‫ﺑﺨﺶ ﺩﻭﻡ‬
‫ ﻋﻔﻮﻧﺖﻫﺎ ﻭ ﺑﻴﻤﺎﺭﻱﻫﺎﻱ ﺍﻟﺘﻬﺎﺑﻲ‬-٨ ‫ ﻓﺼﻞ‬MRI ‫ ﻭ‬CT Scan ‫ ﺁﻧﺎﺗﻮﻣﻲ ﻧﺮﻣﺎﻝ ﻣﻐﺰ ﺩﺭ‬-٤ ‫ﻓﺼﻞ‬
‫ ﻣﺎﻟﻔﻮﺭﻣﺎﺳﻴﻮﻥﻫﺎﻱ ﻣﺎﺩﺭﺯﺍﺩﻱ ﻣﻐﺰ ﻭ ﺍﺧﺘﻼﻻﺕ ﻧﻮﺯﺍﺩﻱ‬-٩ ‫ﻓﺼﻞ‬ ‫ ﻧﺌﻮﭘﻼﺳﻢﻫﺎ ﻭ ﻛﻴﺴﺖﻫﺎﻱ ﺍﻳﻨﺘﺮﺍﻛﺮﺍﻧﻴﺎﻝ‬-٥ ‫ﻓﺼﻞ‬
‫ ﻫﻴﺪﺭﻭﺳﻔﺎﻟﻲ ﻭ ﺍﺧﺘﻼﻻﺕ ﺩﮊﻧﺮﺍﺗﻴﻮ ﻭ ﺁﺗﺮﻭﻓﻴﻚ ﻣﻐﺰ‬-١٠ ‫ﻓﺼﻞ‬ ‫ ﺍﺧﺘﻼﻻﺕ ﻋﺮﻭﻗﻲ ﻣﻐﺰ‬-٦ ‫ﻓﺼﻞ‬
‫ ﺁﺳﻴﺐﻫﺎ ﻛﺮﺍﻧﻴﺎﻝ ﻭ ﺍﻳﻨﺘﺮﺍﻛﺮﺍﻧﻴﺎﻝ‬-٧ ‫ﻓﺼﻞ‬
‫ ﺳﺘﻮﻥ ﻓﻘﺮﺍﺕ‬: ‫ﺑﺨﺶ ﭼﻬﺎﺭﻡ‬
‫ ﺗﻜﻨﻴﮓﻫﺎﻱ ﺗﺼﻮﻳﺮ‬،‫ ﺳﺘﻮﻥ ﻓﻘﺮﺍﺕ ﻧﺮﻣﺎﻝ‬-١٥ ‫ﻓﺼﻞ‬
‫ ﻭﺿﻌﻴﺖﻫﺎﻱ ﺩﮊﻧﺮﺍﺗﻴﻮ ﻭ ﺗﺮﻭﻣﺎﺗﻴﻚ ﺳﺘﻮﻥ ﻓﻘﺮﺍﺕ‬-١٦ ‫ﻓﺼﻞ‬
‫ ﺳﺎﻳﺮ ﭘﺎﺗﻮﻟﻮﮊﻱﻫﺎﻱ ﺳﺘﻮﻥ ﻓﻘﺮﺍﺕ‬-١٧ ‫ﻓﺼﻞ‬
‫ ﻣﻼﺣﻈﺎﺕ ﺗﻜﻨﻴﻜﻲ ﭘﺎﻳﻪ‬: ‫ﺑﺨﺶ ﺍﻭﻝ‬
MRI ‫ ﻭ‬CT Scan ‫ ﺍﺻﻮﻝ ﻓﻴﺰﻳﻜﻲ ﻣﺮﺑﻮﻁ ﺑﻪ‬-١ ‫ﻓﺼﻞ‬
CT Scan ‫ ﻣﻮﺍﺭﺩ ﺍﺳﺘﻔﺎﺩﻩ ﺑﺎﻟﻴﻨﻲ‬-٢ ‫ﻓﺼﻞ‬
MRI ‫ ﻣﻮﺍﺭﺩ ﺍﺳﺘﻔﺎﺩﻩ ﺑﺎﻟﻴﻨﻲ‬-٣ ‫ﻓﺼﻞ‬
‫ ﺟﻤﺠﻤﻪ ﻭ ﺻﻮﺭﺕ‬،‫ ﻛﻒ ﺟﻤﺠﻤﻪ‬: ‫ﺑﺨﺶ ﺳﻮﻡ‬
(Sella) ‫ ﻧﺎﺣﻴﺔ ﺯﻳﻦ‬-١١ ‫ﻓﺼﻞ‬
‫ ﻧﺎﺣﻴﻪ ﺗﻤﭙﻮﺭﺍﻝ‬-١٢ ‫ﻓﺼﻞ‬
‫ ﺳﻴﻨﻮﺱﻫﺎﻱ ﭘﺎﺭﺍﻧﺎﺯﺍﻝ ﻭ ﻧﺎﺯﻭﻓﺎﺭﻧﻜﺲ‬،‫ ﺻﻮﺭﺕ‬،‫ ﺟﻤﺠﻤﻪ‬-١٣ ‫ﻓﺼﻞ‬
‫ ﺍﻭﺭﺑﻴﺖ‬-١٤ ‫ﻓﺼﻞ‬

.‫ ﺑﺮﺍﻱ ﻓﻬﻢ ﺑﻬﺘﺮ ﻣﻄﺎﻟﺐ ﺍﺯ ﺗﺼﺎﻭﻳﺮ ﮔﻮﻳﺎ ﻫﻤﺮﺍﻩ ﺑﺎ ﺗﻮﺿﻴﺤﺎﺕ ﻛﺎﻓﻲ ﺍﺳﺘﻔﺎﺩﻩ ﮔﺮﺩﻳﺪﻩ ﻭ ﺑﺮﺍﻱ ﻃﺒﻘﻪﺑﻨﺪﻱ ﻧﻜﺎﺕ ﺍﺳﺎﺳﻲ ﺍﺯ ﺟﺪﺍﻭﻝ ﻣﺘﻌﺪﺩ ﺑﻬﺮﻩﮔﻴﺮﻱ ﺷﺪﻩ ﺍﺳﺖ‬،‫ﻻﺯﻡ ﺑﻪ ﺫﻛﺮ ﺍﺳﺖ ﻛﻪ ﺩﺭ ﻛﺘﺎﺏ ﻓﻮﻕ‬

٠٩١٢١٣٧٢٣٦١-٦٦٩٣٦٦٩٦ :‫ﺗﻠﻔﻦ‬ ٢٣٩ ‫ ﭘﻼﻙ‬،‫ ﺑﻦﺑﺴﺖ ﺳﻴﻤﻴﻦ‬،‫ ﺑﻴﻦ ﻛﺎﺭﮔﺮ ﻭ ﺟﻤﺎﻟﺰﺍﺩﻩ‬،‫ ﺥ ﻟﺒﺎﻓﻲﻧﮋﺍﺩ‬،‫ ﺥ ﻛﺎﺭﮔﺮ ﺟﻨﻮﺑﻲ‬،‫ ﻡ ﺍﻧﻘﻼﺏ‬،‫ ﺗﻬﺮﺍﻥ‬:‫ﻧﺸﺎﻧﻲ‬ ‫ ﺍﺭﺍﺋﻪ ﻛﻨﻨﺪﺓ ﻛﺘﺎﺏ ﻭ ﺳﻲﺩﻱﻫﺎﻱ ﺗﺨﺼﺼﻲ ﭘﺰﺷﻜﻲ‬: ‫ﻣﺮﻛﺰ ﺧﺪﻣﺎﺕ ﻓﺮﻫﻨﮕﻲ ﺳﺎﻟﻜﺎﻥ‬
 87

HIGHLIGHTS OF OPHTHALMOLOGY INTERNATIONAL

WAVEFRONT ANALYSIS, ABERROMETERS and CORNEAL TOPOGRAPHY

B. BYOD, A. AGARWAL (2003) 1100,000R

‫ ﻣﻮﺭﮔــﺎﻧﻲ ﻧــﺎﻡ ﻣــﻲﮔﻴﺮﻧــﺪ‬،‫ ﻋﺪﺳــﻲﻫــﺎﻱ ﺯﻳــﺎﺩﻱ ﺑــﻪ ﭘــﺎﺱ ﺧــﺪﻣﺎﺕ ﺩﺍﻧﺸــﻤﻨﺪ ﺑــﺰﺭﮒ‬،‫ﮔﺮﭼــﻪ ﻫﻨــﻮﺯ ﻫــﻢ ﺩﺭ ﺑﺴــﻴﺎﺭﻱ ﺍﺯ ﻧﻘــﺎﻁ ﻛﺸــﻮﺭﻣﺎﻥ ﺍﻣﻜــﺎﻥ ﻋﻤــﻞ ﺟﺮﺍﺣــﻲ ﻛﺎﺗﺎﺭﺍﻛــﺖ ﺣﺘــﻲ ﺑــﻪ ﺭﻭﺵﻫــﺎﻱ ﻧﺴــﺒﺘﹰﺎ ﻗــﺪﻳﻤﻲ ﻧﻴــﺰ ﻭﺟــﻮﺩ ﻧﺪﺍﺷــﺘﻪ‬
.‫ ﻛﻴﻔﻴﺖ ﺑﻴﻨﺎﻳﻲ ﺑﺎ ﻫﻤﻪ ﺍﺑﻌﺎﺩ ﮔﺴﺘﺮﺩﻩﺍﺵ ﻣﺪ ﻧﻈﺮ ﻗﺮﺍﺭ ﮔﺮﻓﺘﻪ ﺍﺳﺖ‬،‫ ﻫﺪﻑ ﻧﻬﺎﻳﻲ ﭘﺰﺷﻚ ﻭ ﺑﻴﻤﺎﺭ ﻧﺒﻮﺩﻩ‬٢٠/٢٠ ‫( ﻟﻴﻜﻦ ﭘﻴﺸﺮﻓﺖ ﻋﻠﻢ ﻭ ﻓﻨﺎﻭﺭﻱ ﺧﺼﻮﺻﹰﺎ ﺩﺭ ﺩﻭ ﺩﻫﻪ ﺍﺧﻴﺮ ﭼﻨﺎﻥ ﺑﻮﺩﻩ ﻛﻪ ﺩﻳﮕﺮ ﺣﺪﺕ ﺑﻴﻨﺎﻳﻲ‬Morgagnian Cataract)
‫ ﺳـﻴﺮ ﺑﺴـﻴﺎﺭ ﺳـﺮﻳﻊ ﺍﻳـﻦ‬.‫" ﺩﺭ ﺑﺮﺍﺑﺮ ﺩﻳﺪﮔﺎﻥ ﺟﻬﺎﻧﻴﺎﻥ ﭘﺪﻳﺪﺍﺭ ﮔﺸـﺘﻪ ﺍﺳـﺖ‬Super Vision" ‫ ﺍﻓﻖ ﺗﺎﺯﻩﺍﻱ ﺑﻪ ﻧﺎﻡ‬، Customized LASIK ‫ ﺍﺯ ﻋﺮﺻﻪ ﻋﻠﻢ ﻧﺠﻮﻡ ﺑﻪ ﺣﻴﻄﻪ ﺟﺮﺍﺣﻲ ﻛﺮﺍﺗﻮﺭﻓﺮﺍﻛﺘﻴﻮ ﻭ ﻣﻄﺮﺡﺷﺪﻥ‬Wavefront Analysis ‫ﺩﺭ ﺳﺎﻝﻫﺎﻱ ﺍﺧﻴﺮ ﺑﺎ ﻭﺭﻭﺩ ﺗﻜﻨﻴﻚ‬
.‫ ﻭ ﻳﺎ ﻣﺤﺪﻭﺩ ﺑﻪ ﺍﻃﻼﻋﺎﺕ ﭘﺮﺍﻛﻨﺪﻩ ﺑﻪ ﺩﺳﺖ ﺁﻣﺪﻩ ﺍﺯ ﻣﻘﺎﻻﺕ ﺑﺎﺷﺪ‬،‫ ﻣﻮﺟﻮﺩ ﻭ ﻗﺎﺑﻞ ﺩﺳﺘﺮﺳﻲ ﺩﺭ ﻛﺸﻮﺭ ﺍﺯ ﺁﻥ ﺟﺎ ﺑﻤﺎﻧﻨﺪ ﻭ ﻻﺟﺮﻡ ﺩﺍﻧﺴﺘﻪﻫﺎﻱ ﺑﺴﻴﺎﺭﻱ ﺍﺯ ﭼﺸﻢﭘﺰﺷﻜﺎﻥ ﻋﺰﻳﺰ ﻫﻢ ﺑﻪ ﺭﻭﺯ ﻧﺒﻮﺩﻩ‬Text ‫ﭘﻴﺸﺮﻓﺖ ﺑﺎﻋﺚ ﺷﺪﻩ ﻛﻪ ﻛﺘﺐ‬
‫ ﭘﺎﺳـﺨﻲ ﺍﺳـﺖ ﺩﺭ‬،‫ﻛﺘﺎﺏ ﺣﺎﺿﺮ ﻛﻪ ﺑﻪ ﻫﻤﺖ ﻣﺮﻛﺰ ﺧﺪﻣﺎﺕ ﻓﺮﻫﻨﮕﻲ ﺳﺎﻟﻜﺎﻥ ﺩﺭ ﻛﻮﺗﺎﻫﺘﺮﻳﻦ ﺯﻣﺎﻥ ﻣﻤﻜﻦ ﺍﺯ ﺍﻧﺘﺸﺎﺭ ﺁﻥ ﺩﺭ ﺧﺎﺭﺝ ﺍﺯ ﻛﺸﻮﺭ ﺗﻬﻴﻪ ﺑﻪ ﺻﻮﺭﺕ ﺗﻤﺎﻡ ﺭﻧﮕﻲ ﺑﺮ ﺭﻭﻱ ﻛﺎﻏﺬ ﮔﻼﺳﺔ ﻣﺎﺕ ﻭ ﺑﺎ ﻛﻴﻔﻴﺘﻲ ﻛﻢ ﻧﻈﻴﺮ ﺑﻪ ﺯﻳﻮﺭ ﭼـﺎﭖ ﺁﺭﺍﺳـﺘﻪ ﮔﺮﺩﻳـﺪﻩ‬
‫ ﺍﺯ ﻣﻌﺪﻭﺩ ﻛﺘﺐ ﺗﻜﺴﺖ ﻣﻨﺘﺸـﺮ‬، Highlights Of Ophthalmology ‫ ﺍﺯ ﺳﺮﻱ ﻛﺘﺎﺏﻫﺎﻱ‬WAVEFRONT ANALYSIS, ABERROMETERS and CORNEAL TOPOGRAPHY ‫ ﺍﻳﻦ ﻛﺘﺎﺏ ﺑﺎ ﻋﻨﻮﺍﻥ‬.‫ﺟﻬﺖ ﻓﺮﻭﻧﺸﺎﻧﺪﻥ ﻋﻄﺶ ﻋﻠﻤﻲ ﻣﻮﺟﻮﺩ ﺩﺭ ﺍﻳﻦ ﺯﻣﻴﻨﻪ‬
.‫ ﭘﺮﺩﺍﺧﺘﻪ ﺍﺳﺖ‬Cataract Surgery, Customized LASIK, Standard LASIK ‫ ﻭ ﺍﺯ ﻫﻤﻪ ﻣﻬﻤﺘﺮ ﻛﺎﺭﺑﺮﺩ ﺁﻧﻬﺎ ﺩﺭ‬Wavefront Analysis, Orbscan, Topography ‫ﺷﺪﻩ ﻣﻲﺑﺎﺷﺪ ﻛﻪ ﺗﻤﺎﻣﹰﺎ ﺑﻪ ﻣﻘﻮﻟﻪ‬
‫ﻼ ﻣﻮﺟﺰ ﻭ ﻗﺎﺑﻞ ﺩﺭﻙ ﻭ ﻛﺎﺭﺑﺮﺩﻱ ﺑﻪ ﺟﺎﻣﻌﺔ ﺟﻬﺎﻧﻲ ﭼﺸﻢﭘﺰﺷﻜﺎﻥ ﺍﺭﺍﺋﻪ ﻛﺮﺩﻩﺍﻧﺪ‬‫ ﺍﻳﻦ ﻛﺘﺎﺏ ﺭﺍ ﺑﻪ ﺻﻮﺭﺗﻲ ﻛﺎﻣ ﹰ‬Benjamin F. Boyd, M.D., FACS ‫ ﮊﺍﭘﻦ ﻭ ﻫﻨﺪ ﻣﻲﺑﺎﺷﻨﺪ ﻛﻪ ﺑﻪ ﺳﺮﭘﺮﺳﺘﻲ‬،‫ ﺍﺳﭙﺎﻧﻴﺎ‬،‫ﻧﻮﻳﺴﻨﺪﮔﺎﻥ ﺍﻳﻦ ﻛﺘﺎﺏ ﺍﺳﺘﺎﺩﺍﻥ ﺑﺮﺟﺴﺘﻪﺍﻱ ﺍﺯ ﻛﺸﻮﺭﻫﺎﻱ ﺁﻣﺮﻳﻜﺎ‬

‫ﻋﻨﻮﺍﻥ ﻛﺘﺎﺏ‬ ‫ﺳﺎﻝ ﻧﺸﺮ‬ (‫ﻗﻴﻤﺖ )ﺭﻳﺎﻝ‬

1 Section 1: Update on General Medicine 2002-2003 215,000
BASIC AND CLINICAL SCIENCE COURSE

2 Section 2: Fundamentals and Principles of Ophthalmology 2002-2003 270,000

3 Section 3: Optics, Refraction, and Contact Lenses 2002-2003 215,000
AMERICAN ACADEMY OF

4 Section 4: Ophthalmic Pathology and Intraocular Tumors 2002-2003 210,000

OPHTHALMOLOGY

5 Section 5: Neuro-Ophthalmolog 2002-2003 230,000

6 Section 6: Pediatric Ophthalmology and Strabismus 2002-2003 250,000
7 Section 7: Orbit, Eyelids, and Lacrimal System 2002-2003 190,000
8 Section 8: External Disease and Cornea 2002-2003 280,000
9 Section 9: Intraocular Inflammation and Uveitis 2002-2003 185,000
10 Section 10: Glaucoma 2002-2003 160,000
11 Section 11: Lens and Cataract 2002-2003 180,000
12 Section 12: Retina and Vitreous 2002-2003 230,000
13 Section 13: International Ophthalmology 2002-2003 235,000
14 WAVEFRONT ANALYSIS, ABERROMETERS and CORNEAL TOPOGRAPHY 2003 1100,000
15 OPHTHALMOLOGY MONOGRAPHS Cataract Surgery and Intraocular Lenses 2001 200,000
16 COSMETIC OCULOPLASTIC SURGERY Eyelid, Forehead, and Facial Techniques 1999 300,000
17 Glaucoma THE REQUISITES IN OPHTHALMOLOGY 2000 200,000
18 LASIK Principles and Techniques 1998 250,000
19 THE GLAUCOMAS 2000 180,000
20 THE WILLS EYE MANUAL Office and emergency Room Deagnosis and Treatment of Eye Disease 1999 220,000
21 Complications in Phacoemulsification (Avoidance, Recognition, and Management) 2002 400,000
22 Retina and Optic Nerve Imaging (Thomas A. Ciulla, Carl D. Regillo, Alon Harris)

٠٩١٢١٣٧٢٣٦١-٦٦٩٣٦٦٩٦ :‫ﺗﻠﻔﻦ‬ ٢٣٩ ‫ ﭘﻼﻙ‬،‫ ﺑﻦﺑﺴﺖ ﺳﻴﻤﻴﻦ‬،‫ ﺑﻴﻦ ﻛﺎﺭﮔﺮ ﻭ ﺟﻤﺎﻟﺰﺍﺩﻩ‬،‫ ﺥ ﻟﺒﺎﻓﻲﻧﮋﺍﺩ‬،‫ ﺥ ﻛﺎﺭﮔﺮ ﺟﻨﻮﺑﻲ‬،‫ ﻡ ﺍﻧﻘﻼﺏ‬،‫ ﺗﻬﺮﺍﻥ‬:‫ﻧﺸﺎﻧﻲ‬ ‫ ﺍﺭﺍﺋﻪ ﻛﻨﻨﺪﺓ ﻛﺘﺎﺏ ﻭ ﺳﻲﺩﻱﻫﺎﻱ ﺗﺨﺼﺼﻲ ﭘﺰﺷﻜﻲ‬: ‫ﻣﺮﻛﺰ ﺧﺪﻣﺎﺕ ﻓﺮﻫﻨﮕﻲ ﺳﺎﻟﻜﺎﻥ‬