Head and Neck Surgery

Marc Reinald G Santiago M.D., DPBO-HNS

Selected Readings
Anatomy pp 12-16,19-22 Introduction to Head and Neck Surgery pp196197 Thyroid Masses pp 290-298 Cancer of the Head and Neck pp 305-313

 Management of neoplasms Most challenging and exciting

Senses in the region Crucial functions and appearance Survival, preservation and/or reconstruction Multidisciplinary approach

THYROID

ORAL CAVITY
Oral cavity vermilion border of the lip posterosuperiorly - hard palate-soft palate junction inferiorly - circumvallate papillae (linea terminalis) laterally - anterior tonsillar pillars

 7 subsites:
Lips Dentoalveolar ridges Oral tongue Retromolar trigone Floor of the mouth Buccal mucosa Hard palate

Oral Tongue
Muscular structure with overlying nonkeratinizing squamous epithelium Ventral portion contiguous with anterior floor of the mouth Posterior limit circumvallate papillae Subsites: lateral tongue, anterior tip, ventral tongue, dorsal oral tongue

 Superior-inferior Longitudinal Transverse Vertical The intrinsic musculature of the tongue provides a minimal barrier to tumor growth

Genioglossus Styloglossus Palatoglossus Hyoglossus

 Lingual A.

 All muscles of the tongue innervated by Hypoglossal N. Except Palatoglossus Pharyngeal branch of Vagus N

 Sensory Innervation Anterior 2/3 lingual N.

Special sensory for taste
Chorda tympani n

Base of the tongue:

Glossopharyngeal

Lymph Drainage Tip submental nodes Lateral tongue level 1 & ll Lack of anastomoses between anterior tongue ipsilateral drainage Skip metastasis to level lV 20-33% Base of tongue upper cervical (crossover)

Anatomy of the Pharynx

Pharynx
Common aerodigestive tract Divided into :
Nasopharynx Oropharynx Laryngopharynx

Musculoskeletal framework of the Pharynx

Muscles
1. Superior pharyngeal constrictor 2. Middle pharyngeal constrictor 3. Inferior pharyngeal constrictor

Nasopharynx
Opening of eustachian tube Salpingopharygeal fold Rosenmuellers fossa Guerlachs tonsil Roof of NP:
Sphenoid bone Floor of Sphenoid sinus Pharyngeal tonsil or adenoids

Oropharynx
Borders
Sup: soft palate Inf: epiglottis, tonsillar crypts and palatine tonsil Ant: post 3rd of tongue Post: midline wall of superior constrictors

Oropharynx
Sulcus
Ant 2/3 & Post 1/3 Circumvallate papillae Divides somatic & visceral innervations of tongue

Oropharynx
Base of Posterior tongue
2 small fossae Bounded by median glossoepiglottic fold and paired lateral glossoepiglottic folds

 Lateral Pharyngeal Wall

Bed of tonsillar crypt Palatoglossal and palatopharyngeal folds

Hypopharynx
Posterior pharynx Post cricoid Pyriform sinus

Triangles of the Neck

2 major triangles of the neck:
1. Anterior Cervical Triangle 2. Posterior Cervical Triangle

Anterior Cervical Triangle

1. Digastric triangle
Superior: Anterior: Posterior: mandible anterior belly of digastric posterior belly of digastric

Anterior Cervical Triangle

2. Carotid triangle
Superior: Anterior: Posterior: posterior belly of digastric superior belly of omohyoid sternocleidomastoid

Anterior Cervical Triangle

3. Muscular triangle
Superior: Anterior: Posterior: superior belly of omohyoid midline sternocleidomastoid

Anterior Cervical Triangle

4. Submental triangle
Superior: Inferior: Lateral: symphysis of mandible hyoid bone anterior belly of digastric

Posterior Cervical Triangle

1. Occipital triangle
Anterior: Posterior: Inferior: sternocleidomastoid trapezius omohyoid

Posterior Cervical Triangle

2. Subclavian triangle
Superior: Inferior: Anterior: omohyoid clavicle sternocleidomastoid

Cervical Fascia
2 major divisions: 1. Superficial Cervical Fascia 2. Deep Cervical Fascia
a. Superficial layer b. Middle layer c. Deep layer

Cervical lymph node groups

Submental (level IA)
Contained within the submental triangle Harboring metastases from cancers arising from the floor of the

mouth, anterior oral tongue, anterior mandibular alveolar ridge, and lower lip

Cervical lymph node groups

Submandibular (level IB)
Within the submandibular triangle Harboring metastases from cancers arising from the oral cavity,

anterior nasal cavity, soft-tissue structures of the midface, and submandibular gland

Cervical lymph node groups

Upper Jugular (level IIA and IIB)
Located around the upper third of the IJV Extending from the level of the skull base above o the level of the

(clinical landmark) Surgical landmark:

inferior border of the hyoid bone below level of carotid bifurcation

Cervical lymph node groups

Upper Jugular (level IIA and IIB)
Divided into IIA (anterior) and IIB (posterior) by the

spinal accessory nerve

Harboring metastases from cancers arising from the

oral cavity, nasal cavity, nasopharynx, oropharynx, hypopharynx, larynx, and parotid gland

Cervical lymph node groups

Middle Jugular (level III)
Located around the middle third of the IJV Extending from the inferior border of the hyoid bone above to the inferior

border of the cricoid cartilage below (clinical

landmark) Surgical landmark:

junction of the omohyoid with IJV

Cervical lymph node groups

Middle Jugular (level III)
Harboring metastases from cancers arising from the oral cavity,

nasopharynx, oropharynx, hypopharynx, and larynx

Cervical lymph node groups

Lower Jugular (level IV)
Located around the lower third of the IJV Extending from the inferior border of the cricoid cartilage above to the clavicle below Harboring metastases from cancers arising from the hypopharynx,

thyroid, cervical esophagus, and larynx

Cervical lymph node groups

Posterior triangle (level VA and VB)
Encompasses all LN contained within the posterior triangle 3 predominant pathways:
1. 2. Nodes located along the SAN Nodes along the tansverse cervical artery Supraclavicular nodes
VIRCHOWs node (sentinel node)

3.

Cervical lymph node groups

Posterior triangle (level VA and VB)
Level VA (superior) and VB (inferior) is separated by a horizontal plane marking the inferior

border of the anterior cricoid arch

Harboring metastases from cancer arising from the

nasopharynx, oropharynx, cutaneous structures of the posterior scalp and neck

Cervical lymph node groups

Anterior compartment (level VI)
Encompasses LN of the anterior compartment of the neck

Perithyroidal LN Pre and Paratracheal LN LN along the RLN Precricoid LN (Delphian node)

Harboring metastases from cancer arising from the

thyroid, larynx, piriform sinus, and cervical esophagus

REVIEW OF THYROID NEOPLASMS

Thyroid Adenoma
Is a true benign neoplasm derived from follicular cells Occasionally multiple and may arise in the setting of a normal thyroid, nodular goiter, toxic goiter, or thyroiditis Occur most commonly in women older than 30 years

Thyroid Cyst
Presence of a cyst does not signify a benign lesion because papillary carcinomas and parathyroid tumors may present with cystic masses Differentiated by ultrasound FNA: thyroid cyst should be drained completely may prove curative in majority of simple cysts If a cyst persist after 3 drainage attempts or reaccumulates quickly, the suspicion for carcinoma should increase

Papillary Carcinoma
Most common form of thyroid malignancy 60-70% of all thyroid cancer 30-40 years of age Female:male ratio of 2:1 Predominant thyroid malignancy in children (75%): presnt more commonly with advanced disease, including cervical and distant metastases, prognosis remains quite favorable

Follicular Carcinoma
10% of thyroid malignancy Female/male ratio of 3:1 Occurs more frequently in iodine deficient areas, esp in areas of endemic goiter A definitive preoperative diagnosis is usually not possible with FNAC Spread through local extension and hematogenous spread

Hurthle Cell Tumor

Diagnosed by FNAC Subtype of follicular cell neoplasm 20% of these lesions are malignant Represent approximately 3% of all thyroid malignancies More aggressive than follicular CA Often multifocal and bilateral at presentation More likely to metastasize to cervical nodes and distant sites

Medullary Carcinoma
5% of all thyroid carcinomas Arise from parafollicular C cells and may secrete calcitonin, carcinoembryonic antigen, histaminadases, prostaglandins, and serotonin associated with MEN 2 Total thyroidectomy should be performed by patient age of 2-3 years or before C cell hyperplasia occurs

Anaplastic carcinoma
One of the most aggressive malignancies, with few patients surviving 6 months beyond initial presentation Represent fewer than 5% of all thyroid carcinomas Long standing neck mass that enlarges rapidly Most will succumb to superior vena cava syndrome, asphyxiation, or exsanguination

The PCS-PSGS-PAHNSI Evidence-Based Clinical Practice Guidelines on Thyroid Nodules

Recommendations for Diagnostic Workups

What is the role of thyroid function tests (TSH, T3, T4 and FT4)?

In the initial evaluation of a patient with a thyroid nodule, serum TSH and/or thyroid hormones are measured.

Recommendations for Diagnostic Workups

Ultrasound evaluation is recommended for the following:
High-risk patients (patients with history of familial thyroid cancer, previous diagnosis of MEN2, childhood cervical irradiation) Patients with suspicious nodule for cancer in the background of MNG Those with adenopathy suggestive of a malignant lesion Evaluation of the patient with nodular goiter

Recommendations for Diagnostic Workups

What is the role of fine needle biopsy in the diagnosis of thyroid nodule?

FNAC is recommended for the diagnosis of benign and malignant thyroid lesions.

Recommendations for Diagnostic Workups

the over all diagnostic accuracy of FNAC ranges from a low of 85% to a high of 96%
Table 1. Summary Characteristics for Thyroid Fine-Needle Aspiration: Results of Local Literature Survey. Author Specificity Sensitivity Diagnostic Likelihood Accuracy Ratio+ (n) % % % %
de los Santos, ET 96.2 PGH 1985 (61) Gomez, JA MMC 92.3 1995 (30) Guiang, J P UST 85 1999 (57) Kintanar, H R 97.1 QMMC 2002 (49) 66.7 91.8 17.5

94.4

93.5

12.25

100

96.5

6.7

57.1

85.7

19.7

 Sensitivity
Likelihood that patient with disease has positive test results

Specificity
Likelihood that patient without disease has negative test results

Positive Predictive value

Fraction of patients with positive test results who have disease

False-negative rate
Fine-needle aspiration negative; histology positive for cancer

False-positive rate
Fine-needle aspiration positive; histology negative for cancer

Recommendations for Diagnostic Workups

What is the role of other imaging modalities such as CT scan, MRI and PET scan?
PET scan with 18F-FDG is an accurate diagnostic tool in the detection of thyroid cancer in inconclusive cytologic diagnosis of thyroid nodules. Magnetic Resonance Imaging and Computed Tomography should NOT be used routinely because they are rarely diagnostic for malignant lesions in nodular thyroid disease.

Recommendations for Medical Treatment

What is the role of TSH suppression for benign thyroid nodule/s?
TSH suppression may be considered in young patients with small (< 3 cm) cytologically benign thyroid nodules.

Recommendations for Medical Treatment

TSH Suppression
result in at least a 50 percent reduction in the size of the thyroid nodule prevented the development of additional nodules

Recommendations for Medical Treatment

What is the role of radioactive iodine (RAI) therapy for benign thyroid nodule/s?
Radioactive iodine is not the primary management for benign thyroid nodule/s. However, it may be given to cases of benign non-toxic goiter patients who have cosmetic complaints or compression symptoms but who refuse surgery or who are at high risk for surgery.

Recommendations for Surgical Treatment

Solitary benign thyroid nodule lobectomy with isthmusectomy is sufficient.

Recommendations for Surgical Treatment What is the role of frozen section in the diagnosis of thyroid CA?

Frozen section has limited utility in diagnosing thyroid malignancies if the fine needle aspiration biopsy result shows follicular neoplasm, inadequate or suspicious aspirate.

Recommendations for Surgical Treatment

Well-differentiated thyroid carcinoma

What is the recommended surgical procedure for the treatment of WDTC?

The recommended surgical procedure for the treatment of WDTC is near-total or total thyroidectomy.

Recommendations for Surgical Treatment

What is the role of completion thyroidectomy in the treatment of WDTC?

Completion thyroidectomy should be offered to those patients for whom a near-total or total thyroidectomy would have been recommended had the diagnosis been available before the initial surgery. This includes all patients with thyroid cancer except those with small (<1.5 cm), intrathyroidal, node-negative, low-risk tumors.

Head and Neck Cancer

Near total glossectomy

Skin incisions

Visor Flap with pull through technique

Marginal mandibulectomy

Inferior maxillectomy via lateral rhinotomy incision

Neck Dissection Classification

1. Radical Neck Dissection
Removal of all ipsilateral cervical lymph node groups, spinal accessory nerve, internal jugular vein, and sternocleidomastoid Indicated for patients with extensive LN metastases or extension beyond the capsule or involvement of SAN and IJV

Neck Dissection Classification

2. Modified Radical Neck Dissection
En bloc removal of lymph node bearing tissue from one side of the neck (I-V) There is preservation of one or more of the ff structures:
SAN IJV SCM

Neck Dissection Classification

3. Selective Neck Dissection
En bloc removal of one or more LN groups that are at risk for harboring metastatic caner Assessment based on the location of the primary tumor Performed for patients who are at risk for early LN metastases

Neck Dissection Classification

4. Extended Neck Dissection
Neck dissection extended to other adjacent structures (parotid) May also remove the hypoglossal nerve, levator scapulae muscle, or carotid artery

And a lot more.

Thank you