...

I*

m
 The Founders of
Operative Surgery

i
;

Charles Granville Rob MC, MChir, M D , FRCS, FACS
Professor of Surgery, Department of Surgery, Uniformed
j. Services University of the Health Sciences, F. Edward Hebert
School of Medicine, Bethesda, Maryland
Quondam: Professor of Surgery, St Mary's Hospital Medical
School, London 1950-1960;
Professor and Chairman, Department of Surgery, University of
Rochester, New York, 1960-1978;
• Professor oi Surgery, East Carolina University, 1978-1983
Lord Smith of Marlow KBE, MS, FRCS, HonDSc
(Exeter and Leeds), Hon M D (Zurich), Hon FRACS,
HonFRCS(Ed.), Hon FACS, HonFRCSfCan.}, HonFRCSI,
HonFCS(SA), HdnFDS
Honorary Consulting Surgeon, St George's Hospital, London
Quondam: Surgeon, St George's Hospital, London,
1946-1978;
President of the Roval College of Surgeons of England,
1973-1977

j
Rob & Smith's

Operative Surgery

Nose and Throat

Fourth Edition
Rob & Smith's

Operative Surgery

General Editors - .r-

Hugh Dudley C h M , FRCStEd.), FRACS, FRCS

Professor of Surgery, St Mary's Hospital, London, UK

David O Carter M D , FRCS(Ed.),'FRCS{Clas.)

St Mungo Professor of Surgery, University of Glasgow;
Honorary Consultant Surgeon, Royal Infirmary, Glasgow, UK .
. 1
Rob & Smith's

Operative Surgery

Nose and Throat

Fourth Edition

Edited by

John C . BaNantyneCBE, FRCS, HonFResi, DLO

Consultant Ear, Nose and Throat Surgeon,
Royal Free and King Edward VII Hospital for Officers, London, U K

and

D. F. N. Harrison M D , MS, PhD, FRCS, FRACS

Director of the Professorial Unit, Institute of Laryngology and Otology
and Royal National Throat, Nose and Ear Hospital, London, U K

Butterworths
London Boston Durban Singapore Sydney Toronto Wellington
All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means,
including photocopying and recording, without the written permission of the copyright holder, application for
which should be addressed to the Publishers. Such written permission must also be obtained before any part of
this publication is stored in a retrieval system of any nature.

This book is sold subject to the Standard Conditions of Sale of Net Books and may not be re-so!d in the UK
below the net price given by the Publishers in their current price list.

©Butterworths1986

First edition published in eight volumes 1956—1958

Second edition published in fourteen volumes 1968-1971
Third edition published in nineteen volumes 1976-1981
Fourth edition published 1983-

British Library Cataloguing in Publication Data

Rob, Charles
Rob & Smith's operative surgery. - 4th ed.
Nose and throat _
1. Surgery
I. Title 11. Smith, Rodney Smith, Baron
III. Rob, Charles IV. Dudley, Hugh
V. Carter, David C.
617 RD31
ISBN 0-407-00663-X

Library of Congress Cataloging in Publication Data

Includes bibliographies and index.
Contents; HI Alimentary tract and abdominal wall.
1. General principles, oesophagus, stomach, duodenum,
small intestine, abdominal wall, hernia/edited by
Hugh Dudley -12) Urology/edited by W. Scott
McDougal - |etc.| - [4] Nose and throat/edited by
John C. Ballantyne and D. F. N. Harrison.
1. Surgery, Operative. I. Rob, Charles.
U. Smith of Marlow, Rodney Smith, Baron, 1914-
III. Dudley, Hugh Arnold Freeman. IV. Pories,
Walter J. V. Carter, David C. (David Craig)
VI. Operative surgery. IDNLM: 1. Surgery, Operative.
WO 500 061 19821
RD32.06 1983 6T7'.91 ' 83-14465
ISBN 0-407-00663-X [v. 4)

Photoset by Butterworths Lttho Preparation Department

Printed by Blantyre Printing Ltd, London & Glasgow
Bound by Robert Hartnoll Ltd, Bodmin, Cornwall
Volumes and Editors
Alimentary Tract and Abdominal
Wall
1 General Principles * Oesophagus •
Stomach * Duodenum * Small Intestine •
Abdominal Wall • Hernia
2 Liver • Portal Hypertension • Spleen *
Biliary Tract • Pancreas
3 Colon, Rectum and Anus
Cardiac Surgery
The Ear
General Principles, Breast and
Extracranial Endocrines
Gynaecology and Obstetrics
Hugh Dudley ChM, FRCS(Ed.), FRACS, FRCS
Professor of Surgery, St Mary's Hospital, London, UK
Hugh Dudley ChM, FRCS(Ed.), FRACS, FRCS
Professor of Surgery, St Mary's Hospital, London, UK
Ian P. Todd MS, MD(Tor), FRCS, DCH
Consulting Surgeon, St Bartholomew's Hospital, London;
Consultant Surgeon, St Mark's-Hospital and
King Edward VII Hospital for Officers, London, UK
L. P. Fielding MB, FRCS
Chief of Surgery, St Mary's Hospital, Waterbury, Connecticut, USA;
Associate Professor of Surgery, Yale University, Connecticut, USA
Stuart W. Jamteson MB, BS, FRCS
Assistant Professor of Cardiovascular Surgery,
Stanford University School of Medicine, California, USA
Norman F_. Shumway MD, PhD, FRCS
Professor and Chairman, Department of Cardiovascular Surgery,
Stanford University School of Medicine, California, U5A
John C Baliantyne CBE, FRCS, HonFRCSI, DLO
Consultant Ear, Nose and Throat Surgeon,
Royal Freeand King Edward VII HospitalforOfficers, London, UK
Andrew Morrison FRCS, DLO
Senior Consultant Otolaryngologist, The London Hospital, UK
Hugh Dudley ChM, FRCS(Ed-), FRACS, FRCS
Professor of Surgery, St Mary's Hospital, London, UK
Walter I.PoriesMD, FACS
Professor and Chairman, Department of Surgery, School of Medicine,
East Carolina University, Greenville, North Carolina, USA
J. M. Monaghan MB, FRCS(Ed.), MRCOG
Consultant Surgeon, Regional Department of Gynaecological Oncology,
Queen Elizabeth'Hospital, Gateshead, UK
The Hand Rolfe Birch FRCS
Consultant Orthopaedic Surgeon, PN1 Unit and Hand Clinic,
Royal National Orthopaedic Hospital, London and
St Mary's Hospital, London, UK
Donal Brooks MA, MB, FRCS, FRSCI
Consulting Orthopaedic Surgeon, University College Hospital
and Royal National Orthopaedic Hospital, London, UK;
Civilian Consultant in Hand Surgery to the Royal Navy and
Royal Air Force

Neurosurgery Lindsay Symon TD, FRCS, FRCS(Ed-)

Professor of Neurological Surgery, Institute of Neurology,
The National Hospital, Queen Square, London, UK
David G. T. Thomas MRCP, FRCSE
Senior Lecturer and Consultant Neurosurgeon,
Institute of Neurology, The National Hospital,
Queen Square, London, UK
Kemp Clarke MD
Professor and Chairman, Division of Neurological Surgery,
Southwestern Medical School, Dallas, Texas, USA

NoSe and Throat John C. Ballantyne CBE, FRCS, HonFRCSl, DLO

Consultant Ear, Nose and Throat Surgeon,
Royal Free and King Edward VII Hospital for Officers, London, UK
D. F. N. Harrison MD, MS, PhD, FRCS, FRACS
Professor of Laryngology and Otology,
Royal National Throat, Nose and Ear Hospital, London, UK

Ophthalmic Surgery Thomas A. Rice MD

Assistant Clinical Professor of Ophthalmology,
Case Western Reserve University School of Medicine,
Cleveland, Ohio, USA;
formerly of the Wilmer Ophthalmologicat Institute
Ronald C.MichelsMD
Professor of Ophthalmology, The Wilmer Ophthalmological Institute,
The Johns Hopkins University School of Medicine,
Maryland, USA
Walter W.J.Stark MD
Professor of Ophthalmology, The Wilmer Ophthalmol ogical Institute,
The Johns Hopkins University School of Medicine,
Maryland, USA

Orthopaedics (in 2 volumes) George Bentley ChM, FRCS

Professor of Orthopaedic Surgery, Institute of Orthopaedics,
Royal National Orthopaedic Hospital, London, UK

Paediatric Surgery L. Spitz PhD, FRCS

Nuffield Professor of Paediatric Surgery and Honorary
Consultant Paediatric Surgeon, The Hospital for Sick Children,
Great Ormond Street, London, UK
H. Homewood Nixon MA, MB, BChir, FRCS, HonFAAP
Consultant Paediatric Surgeon, The Hospital for Sick Children,
Great Ormond Street, London and Paddington Green Children's
Hospital, St Mary's Hospital Group, London, UK
V
PlaStiC Surgery T. L. Barclay ChM, FRCS
Consultant Plastic Surgeon, St Luke's Hospital,
Bradford, West Yorkshire, UK
Desmond A. Kernahan, MD
Chief, Division of Plastic Surgery,
The Children's Memorial Hospital, Chicago, Illinois, USA

Thoracic Surgery J. W. Jackson MCh, FRCS

Formerly Consultant Thoracic Surgeon, Harefield Hospital, Middlesex, UK
D. K. C Cooper MD, PhD, FRCS
Department of Cardiac Surgery, University of Cape Town
Medical School, Cape Town, South Africa

Trauma John V. Robbs FRCS

Associate Professor of Surgery,
Department of Surgery, University of Natal, South Africa
Howard R. Champion FRCS
Chief, Trauma Service;
Director, Surgery Critical Care Services,
The Washington Hospital Center, Washington DC, USA
Donald Trunkey MD
San Francisco Genera! Hospital, San Francisco, California, USA

Urology W. Scott McDougal MD

Professor and Chairman, Department of Urology, Vanderbilt
University, Nashville, Tennessee, USA

Vascular Surgery James A. DeWeese MD

Professor and Chairman, Division of Cardiothoracic Surgery,
University of Rochester Medical Center, Rochester, New York, USA
Contributors
John Ballantyne CBE, FRCS, HonFRCSI, DLO
Consultant Ear, Nose and Throat Surgeon, Royal Free and King Edward
VII Hospital for Officers, London, UK
Robert W. Bastian MD
Department of Otolaryngology, Washington University School of
Medicine, St Louis, Missouri, USA
Hugh F. Biller MD
Chairman and Professor, Department of Otolaryngology, Mount Sinai
School of Medicine; Otolaryngologist-!n-Chief, Mount Sinai Hospital,
New York, USA
D.J. Brain FRCS
Consultant Ear, Nose and Throat Surgeon, Birmingham and District
Ear, Nose and Throat Hospital, Birmingham, West Midlands, UK
Nicholas M. Breach FRCS, FDS, RCS
Consultant Surgeon, Head and Neck Unit, The Royal Marsden
Hospital, London, UK
Douglas P. Bryce 'FRCS(C), PRCS (Ed.) (Hon), FACS
Professor Emeritus, Department of Otolaryngology, University of
Toronto, Toronto, Canada
G. Buchanan FRCS(Glas.), FRCS(Ed.)
Consultant Ear, Nose and Throat, Southend Hospital, Essex, UK
T. R. Bull FRCS
Consultant Surgeon, Royal National Throat, Nose and Ear Hospital
and Metropolitan Ear, Nose and Throat Hospital, London, UK
A. Cheesman FRCS
Consultant Ear, Nose and Throat Surgeon, Royal National Throat,
Nose and Ear Hospital; Consultant Head and Neck Surgeon, Charing
Cross Hospital, London, UK
C. Croft FRCS,FRCS(Ed.)
Consultant Surgeon, The Royal National Throat, Nose and Ear
Hospital, London, UK
David Downton FDS, RCS
Consultant Oral Surgeon, The Royal Free Hospital, Pond Street,
London, UK
John N. G. Evans DLO, FRCS
Consultant Ear, Nose and Throat Surgeon, The Hospital for Sick
Children, Great Ormond Street and St Thomas' Hospital, London, UK
John M. Frederickson MD, FRCS(C), MD(Hon)
Lmdburg Professor and Head, Department of Otolaryngology,
Washington University, St Louis, Missouri, USA
Philip H. Golding-Wood BSc, FRCS, DLO
Formerly Consultant Ear, Nose arid Throat Surgeon, Kent County
Ophthalmic and Aural Hospital, Maidstone, Kent, UK
Roger Gray FRCS
Consultant Ear, Nose and Throat Surgeon, Addenbrookes Hospital,
Cambridge, UK
John Groves FRCS
Consultant Otolaryngologist, Royal Free Hospital, London, UK
Malcolm Harris M D , FDS, RCS, FFDRCS(i)
Professor, Oral and Maxillofacial Surgery, Eastman Dental Hospital
and University College Hospital, London, UK
D. F. N. Harrison MD, MS, PhD, FRCS, FRACS
Director of the Professorial Unit, Institute of Laryngology and Otology
and Royal National Throat, Nose and Ear Hospital, London, UK
John Hibbert ChM, FRCS
Consultant Ear, Nose and Throat Surgeon, Guy's Hospital, London,
UK
Robert G. Hughes FRCSfEd.)
Honorary Consultant, Wolverhampton District Hospitals,
Wolverhampton, UK
H. Bernard Juby FRCS, DLO
Consultant Ear, Nose and Throat Surgeon to the Ipswich Hospitals,
Ipswich, Suffolk, UK
Ian Mackay FRCS
Consultant Ear, Nose and Throat Surgeon, Harley Street, London, UK
Peter McKelvie M D , ChM, F R C S , DLO
Consultant Ear, Nose and Throat Surgeon, Royal National Throat,
Nose and Ear Hospital, London; London Hospital, London; Dean,
Institute of Laryngology and Otology, University of London, London,
UK
Robin F. McNab Jones FRCS H.J.Shaw VRD,FRCS
Senior Surgeon, Ear, Nose and Throat Department, St Bartholomew's consultant Surgeon, Royal Marsden Hospital, Royal National Throat,
Hospital, London, U K Nose and Ear Hospitals, London, U K

P.M.Steli ChM, FRCS

D.O.Maisels FRCS Professor of Otolaryngology, Head of Department of Otolaryngology,
Consultant Plastic Surgeon, Liverpool Regional Hospital Board, University of Liverpool, Royal Liverpool Hospital, Liverpool, UK
Liverpool, UK

James YeeSuen MD,FACS

Professor and Chairman, Department of Otolaryngology and
A. G. D. Maran MD, FRCS, FACS Maxillofacial Surgery, University of Arkansas for Medical Sciences,
Head of Department of Otolaryngology, University of Edinburgh, Little Rock, Arkansas, U S A
Edinburgh, UK

Stanley E. Thawley M D
A. Richard Maw FRCS Department of Otolaryngology, Washington University School of
Consultant Ear, Nose and Throat Surgeon, Bristol Royal Infirmary, Medicine, St Louis, Missouri, U S A
Bristol, UK

John S. P. Wilson FRCS(Eng), FRCS(Ed.)

Consultant Plastic Surgeon, St George's Hospital, and Westminster
Timothy M. Milward M A , FRCS Hospital, London; Queen Mary's Hospital, Roehampton, London; St
• Consultant Plastic Surgeon, Leicester Royal Infirmary, Leicester and Helier's Hospital, Carshalton, U K
Lincoln County Hospital, Lincoln, UK

R. A. Williams MA, FRCS, FRCStEd.), DLO

Douglas Ranger KBE, M B , BS, FRCS
Consultant Ear, Nose and Throat Surgeon, Middlesex Hospital,
Formerly Dean and Director of the Ferens Institute of Otolaryngology, London and Queen Elizabeth II Hospital, Welwyn Garden City; King
The Middlesex Hospital Medical School, London, UK Edward VII Hospital for Officers, London and Honorary Civilian
Consultant in Otolaryngology to the Army, UK

O. H.Shaheen MS, FRCS David Wright FRCS

Consultant Ear, Nose and Throat Surgeon; Director, Head and Neck Consultant Ear, Nose and Throat 5urgeon, The Royal Surrey County
Oncology Clinic, Guy's Hospital, London, UK Hospital, Guildford, UK

Contributing Medical Artists

Patricia M. A. Archer Slade Dip A T D , F M A A , M A M I , AIMBI Gary M.James MMAA

Rangemore, 30 Park Avenue, Caterham, Surrey CR3 6AH Medical Artist, Department of Medical Illustration, Bristol Royal
Infirmary, Bristol BS2 8HW

Mohd-Noor Awang BDS.MSC

Lecturer in Oral Surgery, University of Malaysia Dental School, Kuala
Lumpur, Malaysia
Robert N. Lane
Medical Illustrator, Studio 19a, Edith Grove, London SW10

Angela Christie MMAA

11 West End Avenue, Pinner, Middlesex HA5 1B) Mrs Gillian Lee FMAA, AIMBI
15 Little Plucketts Way, Buckhurst Hill, Essex |G9 5QU
Jack Diner B A , BCO, M A M I
Medical Artist and Sculptor; Instructor, Department of Otolaryngology
and Maxillofacial Surgery, University of Arkansas for Medical Heinz Loth
Sciences, Little Rock, Arkansas, USA Medical Sciences Building, University of Toronto, Canada

B. Hough Abby Maclnnes

Medical Sciences Building, University of Toronto, Canada Medical Sciences Building, University of Toronto, Canada
Mrs Gillian Oliver M M A A , A I M B I Ros Pritchard
71 Crawford Road, Hatfield, Hertfordshire ALIO OPF

R. Skudra
Miss Margaret Palmer
Medical Sciences Building, University of Toronto, Canada
Robins Oak, Chinthurst Lodge, Wowersh, N'r Cuildford, Surrey

Frank Price (tate) Philip Wilson M M A A

Medical Illustrator 2 3 Normanhurst Road, St Paul's Cray, Orpington, Kent BR5 3 A L
Contents

Preface
John Ballantyne

Nose and Paranasal Sinuses Removal of foreign bodies from the nose
Nose R. A. Williams

Treatment of fractures of the zygomatic bone and arch

Malcolm Harris

Treatment of fractures of the mandible

Malcolm Harris

Treatment of fractures of the maxilla

Malcolm Harris

Treatment of blow out fractures of the orbit

Malcolm Harris

Submucous resection of the nasal septum

R. A. Williams

Septodermo plasty
O. F . N . Harrison

Septoplasty
A. G . D. Maran

Rhinoplasty
T. R. Bill
lanS. Mackay

Turbinectomy
R.A.Williams

Coagulation diathermy treatment of nasal obstruction

John Groves

Lateral rhinotomy
D. F. N. Harrison

Surgery of tumours of the external nose and nasal cavity

John S . P . W i l s o n
Timothy M. Milward
Paranasal sinuses Lavage of the sinuses 110
Robin F. McNab Jones

Intranasal antrostomy 113

John Ballantyne

The Caldwell-Luc and allied operations 116

Robin F. McNab Jones

Maxillary artery ligation 122

P. H.Golding-Wood

Transantral vidian neurectomy 126

Philip H.Golding-Wood

Transantral ethmoidal decompression in malignant (endocrine)

exophthalmos 139
Philip H.Golding-Wood

Radical maxiilectomy 144

D. F. N. Harrison

Oroantral fistula 149

D. Down ton

Pernasal removal of nasal polypi 152

John Ballantyne

Ligation of ethmoidal vessels 155

Robert G . Hughes

Trephine of the frontal sinus 157

Robert G . Hughes

External operations on the frontal, ethmoidal and sphenoidal

sinuses 160
Robert G . Hughes

Osteoplastic frontal flap operation 165

A. G . D. Maran

Transsphenoidal hypophysectomy 170

R. A. Williams

Pharynx and oesophagus Adenoidectomy 178

John Ballantyne
Nasopharynx
Transpalatal approach to the postnasal space 181
Douglas Ranger

Choanal atresia 185

John N. G . Evans
Oropharynx Tonsillectomy by dissection 189
John Ballantyne

Division of a long styloid process in the tonsillar fossa 195

Douglas Ranger

Division of the glossopharyngeal nerve in the tonsillar fossa 198

Douglas Ranger - -

Surgery of quinsy or peritonsillar abscess 201

John Ballantyne

Surgical treatment of parapharyngeal and retropharyngeal

abscesses 203 ,
John Ballantyne

Tumours of the oropharynx and soft palate 206

P. M. Stell

Laryngopharynx and oesophagus Oesophagoscopy 211

A. Richard Maw

Pharyngolaryngectomy 216
H.J.Shaw
Nicholas Breach

Pharyngolaryngo-oesophagectomy 231
H. j . Shaw

Cricopharyngeal sphincterotomy
George Buchanan

Excision of pharyngeal pouch

H. Bernard Juby

Diathermy treatment of pharyngeal pouch

H . Bernard Juby

Larynx and tracheobronchial tree Laryngoscopy and microlaryngoscopy 252

Roger Gray

Bronchoscopy (including fibreoptic bronchoscopy and anatomy

of tracheobronchial tree) 260
C- B. Croft

Tracheostomy and laryngotomy 269

David Wright

Surgery of laryngeal and tracheal stenosis En adults 277

Douglas P. Bryce

Surgery of laryngeal and tracheal stenosis in children 300

John N. G . Evans
 Removal of an internal laryngocele \315 ?
Peter McKelvie

,^ Total laryngectomy 317

David Wright

Surgical approaches to voice restoration after total

laryngectomy 326
Robert W . Baslian
John M. Frederickson
Stanley E. Thawley

Vertical partial laryngectomy 335

Hugh F. Biller

Horizontal partial laryngectomy 341

Hugh F. Biller -

Surgery of laryngeal paralysis 347

P. McKelvie

Epiglottopexy ' 353

Peter McKelvie

Other operations on the head Tumours of the oral cavity 356

and neck A. G . D. Maran

Radical neck dissection 367

P. M. Stell

Functional neck dissection . 382

James Yee Suen

Ligature of the external carotid artery 397

David Wright

Cervical cysts, sinuses and fistulae 400

J. Hibbert

Partial and complete parotidectomy ' ($09)

O.H.Shaheen

Removal of the submandibular salivary gland 425

O.H.Shaheen

Removal of calculus from the submandibular duct - 432

O . H.Shaheen

Approaches for tumours of the infratemporal fossa

O.H.Shaheen

Closure of pharyngocutaneous fistulae 448

P. M. Steil
D. O . Maisels

Craniofacial approach for ethmoidal tumours 459

A. Cheesman

Index 467
Illustration by Gillian Lee

Removal of foreign bodies from the

nose
R. A. Williams M A , FRCS, FRCS(Ed), DLO
Consultant Ear, Nose and Throat Surgeon, Middlesex Hospital, L o n d o n ;
Q u e e n Elizabeth II Hospital, Welwyn Garden City, Herts;
King Edward VU Hospital for Officers, London and Honorary Civilian Consultant in Otolaryngology to the A r m y , U K

Foreign bodies in the nose are more common in children. Adults

In adults, foreign bodies may have been present for

Signs and symptoms
Unilateral nasal discharge, which may be foul, and nasal
obstruction are the usual signs. O n examination the
foreign body may be seen easily but often there will be so
much swelling of the mucosa and discharge that it cannot
be identified. This is more likely if the foreign body is a
vegetable material, such as paper. X-rays should be taken;
occipitofrontal and lateral views will show radiopaque
bodies in the nose.
months, or years. They cause nasal discharge and
obstruction and the foreign body may b e c o m e sur-
rounded by a rhinolith. A general anaesthetic is often
required to deal with this. If the rhinolith and foreign body
are behind a deviated septum a submucous resection may
be necessary for access. The rhinolith is often partly
embedded in an inflammatory mass of granulations,
w h i c h bleed profusely. However, after removal, the nose
usually returns to normal within a few days.
A foreign body in the nose may cause sinusitis and if
X-rays show that the maxillary antra are involved they
should be washed out at the same time.

1
Treatment

If the child is cooperative the nose can first be sprayed

with a vasoconstrictor and local anaesthetic. It may then
be possible to grasp the foreign body with nasal forceps,
to pass a wax hook round to the back of it (illustrated), or
to remove it with a sucker.
However, usually the child is too young for this to be
performed with a local anaesthetic and it is better for the
child to be admitted to hospital for a general anaesthetic
than to be held still by force.
W i t h a general anaesthetic, removal of the foreign body
is usually easy. If it has been present for more than a few
hours there may "be some bleeding, from granulations,
and the nose may have to be packed to stop this.
Illustrations by Philip Wilson
Reduction of fractures of the nasal
bones
David Brain FRCS
Consultant Ear, Nose and Throat Surgeon, Birmingham and Midland Ear, Nose and Throat Hospital, Birmingham;
Senior Clinical Lecturer, Department of Otolaryngology, Birmingham University, Birmingham, UK
Introduction
Nasal fractures have provided a challenge to surgeons for
at least the past-5000 years, as shown by the following
quotation:
'If thou examihest a man having a break in the column
of his nose, his nose being disfigured, and a depression
being in it, while the swelling that is on it protrudes, and
he has discharged blood from both his nostrils. Thou
shouldst say concerning h i m : O n e having a break in the
column of his nose. A n ailment w h i c h i will treat.'
3000 BC Ancient Egypt. Edwin Smith Surgical Papyrus . 1
Although much progress has been made over the
centuries, any nasal surgeon soon realizes that many of
the more difficult septorhinoplasties which he performs
w o u l d not have been required if the majority of patients
with recent nasa! fractures had received adequate,
efficient primary treatment.
Preoperative
indications
Nasal fractures associated with some deformity of the
external nasal pyramid due to displacement of the bony
fragments.
2
Contraindications
1. Simple linear fractures without any osseous displace-
ment.
2 . T h e patient may be unfit for the operation. This '
problem usually occurs when there are several multiple
injuries due to a severe road traffic accident, and here
there may well be other lesions such as a severe head
or ocular injury which require priority in treatment.
Assessment: the time of the injury
O n e ot the most important factors is the delay between
the injury and the surgical reduction of the fracture-
Ideally, this reduction is best performed within a few
hours of the injury by a simple closed manipulative
technique. During the first day, post-traumatic oedema
obscures the nasal skeleton to such an extent that
accurate reduction is very difficult. T h e swelling can be
reduced by local injection of hyaluronidase, but it is
usually best to allow it to subside spontaneously, and this
normally occurs after about 5-7 days. Simple closed
manipulative reduction of the fracture can then be
performed up to a period of 14-21 days after the injury.
After 21 days, simple closed manipulation is impossible
because of the firm fibrous union w h i c h has occurred at
the fracture line. In these cases, an open reduction of the
fracture is required. After 3 months, bony union occurs
and the deformity must then usually be corrected by
formal conventional rhinoplastic techniques. This type of
operation should, however, be delayed for a period of
preferably 12 months, and certainly not less than 6 months
after the original injury, to allow stable union to become
established.
 Reduction oi fractures of ihe nas.il bones .1

Assessment: associated injuries

The nasal septum:

1
The cartilaginous nasal pyramid is the most prominent and
exposed part of the nose and is involved in the majority of
nasal fractures. T h e upper lateral and alar cartilages
usually escape major damage owing to their elasticity and
resilience. The nasal septum Is, however, more often
fractured, and the fracture line usually starts just above
the anterior nasal spine, passing upwards and backwards
through the quadrilateral cartilage, then curving upwards
into the perpendicular plate of the ethmoid, and finally
forwards towards the nasal bones.

2
T h e anterior segment of the septum then usually rotates
a r o u n d a roughly vertical axis, with the deviations of its
anterior and posterior borders in opposite directions
w h e r e they do cause some degree of nasal obstruction.
Failure to diagnose and effectively treat this associated
septal fracture and dislocation almost always leads to a
poor therapeutic result. An important dictum of nasal
surgery is: 'As the septum goes - so goes the nose'.
T h e manipulative replacement of the nasal septum
usually temporarily corrects the anterior deviation, but
n o t the posterior one. In consequence, the cartilage
gradually resumes its original deformed and deviated
position, and this becomes firmly established by fibrosis.
W h e n the septal deviation recurs, it usually pulls the
healing nasal bones with it, causing a recurrence of the
displacement and deformity of the external bony pyramid.
It is therefore of vital importance to diagnose and actively
treat these associated septal fractures and dislocations.
Many studies have shown that, if this is neglected, the
results of simple manipulative reduction of nasal fractures
will be poor in up to 70 per cent of cases -" .
2,3 1

Septal haematomas are much less common than

deviations, but it is extremely important for them to be
2 drained as soon as possible, otherwise necrosis of
cartilage will result in a subsequent saddling deformity of
the nasal dorsum in the supra-tip area.
4 Reduction of fractures of the nasal bones

Fracture of the ethmoids

3
In very severe nasal injuries, the fractured nasal bones are
telescoped backwards on to the underlying ethmoid
labyrinth which crumbles and widens, producing tele-
canthus.
There is also often damage to the medial canthal
ligament, the lacrimal apparatus and cerebrospinal rhinor-
rhoea. This type of injury is almost invariably compound.
T h e normal intercanthal distance in Caucasian races is
24-39 mm. It is extremely important to reduce these
fractures as soon as possible, otherwise the fragments
rapidly organize into a solid, irreducible mass, leading to a
permanent loss of nasal contour and an unsightly
pseudohypertelorism, for which there is no very satisfac-
tory treatment. Once again the early diagnosis of this type
/

of injury is of vital importance, and the intercanthal

distance should be measured. In these patients it is
frequently about 5 c m . However, 4 cm or above is certainly
abnormal . 3

Cerebrospinal rhinorrhoea

This is not normally found in fractures confined to the
nasal bone, but indicates that the fracture line extends
into the anterior cranial fossa. It is associated with a watery
nasal discharge and the flow can be increased by getting
the patient to bend his head forward and gently
compressing the jugular vein. O w i n g to the absence of
mucus, this discharge does not stain handkerchiefs. The
fluid, if sufficient, should be collected and examined for
the presence of glucose. ,
X-rays
X-rays should always be performed because;
1. w h e n positive; they will establish a conclusive diagno-
sis of a nasal fracture and often demonstrate the
anatomy of the bony displacement which is of
importance in planning the operative reduction.
2. they may reveal fractures in adjacent bones which also
require treatment.
3. they may be of medicolegal importance.
An occipitomental view will show the outline of the
piriform fossa and the other important view is obtained by
placing a dental occlusal film parallel to the nose and
directing the rays at right angles so that the bony profile
can be seen in fine detail.
Not every nasal fracture is confirmed by X-ray examina-
tion. This is particularly true of the greenstick fracture
which is most commonly found in children. This is very
unfortunate because slight deformities produced by this
type of fracture invariably get worse with subsequent
growth. A negative X-ray cannot therefore be regarded as
conclusive proof that the nasal bones have not been
fractured a n d , for this reason, it will be necessary at times
to decide to operate solely on indications provided by the
clinical examination.
 Reduction of trat.tures of the nasal bones 3

Anaesthesia Infratrochlear
"nerve
In children, a general anaesthetic is invariably required,
but in adults, it is often possible to reduce a nasal fracture
under a local anaesthetic if this method is preferred. T h e
duration of the operation is extremely variable and this
factor is often difficult to predict. It is therefore necessary
to use a general anaesthetic technique which will give the
surgeon as much time as he needs to obtain a-good result
and this will entail endotracheal intubation and the
insertion of full throat pack to prevent aspiration of b l o o d .
The nose should always be sprayed and packed about 15
minutes preoperative^ with adrenaline (up to 1:80000 is
adequate to reduce bleeding).

4
If local anaesthesia is preferred, the nose should be
sprayed and packed preoperatively with ribbon gauze
soaked in 10 per cent cocaine solution. A local nerve-type
block can be established by injecting 2 per cent lignocaine
with adrenaline.

The operation
Position of patient
The patient should be in the supine position with about a
15° upward head tilt. Towelling should be applied to leave
most of the face from the forehead to the mouth exposed
and any effective aqueous skin preparation can be applied
to the exposed face. The surgeon normally stands for most
of the operation on the right side of the patient.
4
REDUCTION BY CLOSED MANIPULATION
Examination under anaesthesia
T h e full clinical assessment of the injury can often only be
made when the patient has been anaesthetized and the
nasal mucosa suitably prepared with adequate vasocon-
striction. T h e site of the fracture and the mobility of the
fragments can now be established and it will also be
possible to distinguish between recent damage and the
mature fibrotic lesions which are caused by other older
injuries.

Displacement of both nasofrontal processes

5
Waisham's forceps are used for this task. These instru-
ments are designed so that a gap remains between the
blades after closure, thus preventing crushing damage to
the enclosed nasal tissues. The inner blade is narrow and
is shaped to fit the inside of the nose, whereas the outer
broader blade is further insulated from the outside skin by
being enclosed in rubber tubing. T h e r e are two instru-
ments available, one for each side of the nose. It is
important that the forceps are not placed so high in the
n o s e that they extend above the fracture line. This can
5 usually be easily located by careful palpation.
6 Reduction of fractures of the nasal bones

6a-d
In the most common type of fracture, the method
described by Gillies and Kilner is usually effective. In this
6

technique, the first step is to displace both the nasal

processes of the maxilla outwards with Walsham's forceps
using controlled and guarded force and avoiding sudden
jerky movements.
 Reduction of fractures of the nasal bones 7

7
Disimpaction of the nasal bones

Asch's forceps are applied to the septum just behind the

nasal dorsum. These forceps are designed on similar
principles to those of Walsham, but each blade is quite flat
and is separated from the main handle below by a
w i d e n e d , curved shank which thus avoids compression
and damage to the rather broader columella. Forward
traction is exerted to disimpact the nasal bones.

Manipulation of the septum

The last step will usually straighten the anterior part of the
septum, but Asch's forceps are reinserted more posterior-
ly. Forward and upward traction is then exerted to deal
with this part of the septum.

7
Moulding the nasal pyramid

The nasofrontal processes are then pushed inwards and
the nasal bones are moulded with the fingers. T h e
surgeon should not be satisfied with the manipulation
unless the nose can now be pushed into an over-corrected
position and stay in that position without support. Failure
to achieve this would indicate that the disimpaction and
mobilization are incomplete and must be repeated.
T h e surgeon should then move to the top of the table
and carefully inspect the external nasal pyramid by
looking down the nasal dorsum from above. Final
adjustments may be required and these can be effected by
moulding the external pyramid with medial pressure from
the fingers.

Possible final septal corrections

8
Anterior rhinoscopy is now performed to check on the
position of the nasal septum. If there' is still a residual
posterior septal dislocation, a Cottle septal elevator is
placed submucosally below the displaced edge of the
s e p t u m , which is levered back into the midline.
This may not, however, be entirely effective and should
there be any doubts on this score, the surgeon should
proceed to some form of more radical septal operation
such as a septoplasty or limited submucous resection as
the success of this step in the operation is of critical
importance. T h e details of these techniques are given
elsewhere in this volume.
8 Reduction of fractures of the nasal bones
The suture of cutaneous lacerations
Lacerations of the overlying skin may occur in compound
fractures a n d , if present, these now have to be closed. It is
extremely important to open the w o u n d and to explore it
for small foreign bodies such as fragments of glass, dirt or
gravel. A small toothbrush is very useful for removing all
dirt, and this is vital if an unsightly pigmented scar is to be
avoided. The excellent blood supply in this region allows
the surgeon to perform a primary closure on almost any
wound seen within 36 hours, and little or no debridement
is required. Sutures are best inserted about 3-4 mm apart
and very small superficial wounds can sometimes be
closed with sterile adhesive tape (Steristrips).
Fixation
In the case of the nasal bones, there are no muscular
forces at work which are likely to cause re-displacement of
the deformity and this simplifies the fixation required. T h e
only major problems occur where" there has been
extensive comminution of the bony fragments, and this
type of injury will require the use of special techniques.
9
In the average case, fixation starts with the use of
cutaneous splinting in the form of strips of micropore
tape. It probably helps to apply benzoin tincture to the
skin of the nose to enable the tape to adhere better. 1 use
a 16inch (13 mm) micropore strapping which is sold under
the name of Blenderm. The strips should overlap,
otherwise herniation of skin and subcutaneous tissue can
occur through any gaps left between the strips, and this
has sometimes led to skin necrosis and ugly scarring. A
vertical loop is used to support the lobule, but this should
not cross the nostrils.
10
External fixation
For external fixation, I use a plaster of Paris cast over the
nose. The operating theatre nurse keeps a pattern of the
splint and usually cuts out about 6-8 thicknesses of a
quick-drying plaster of Paris. T h e cast is then dipped in
warm water, which accelerates the setting time, and the
excess water is squeezed out. Lubricant should be applied
to the eyebrows, and the eyes should be closed and
covered with protective gauze before the cast is placed on
the nose, as a painful conjunctivitis can occur if particles
of plaster of Paris get into the eyes. It may be necessary to
trim the cast, should it irritate the inner canthus. W h e n
the cast is dried, it should be sprayed with Nobecutane,
this improves its adhesion to the strapping which is used
to hold it in place.
 Reduction of fractures of (he nasal bones 9

11
Alternative fixation I

The depressed type of nasal fracture associated with

extensive comminution is unstable and needs additional
fixation. Further lateral compression is required in the
form of lead-plates, held in place with stainless steel
sutures passing through the fractured lines in the base of
the bony pyramid. It may be possible to insert these
sutures with a straight Keith needle, but more often it is
necessary to use a trocar and cannula first and then to
thread the w i r e through the cannula. The lead plates are
padded medially with soft felt to minimize the risk of skin
necrosis.

Alternative fixation 11

12
T h e problem of fixation is greater w h e n there is very
severe comminution, and in this case, the intranasal
splints designed by Sear are usually satisfactory. These
7

provide rigid internal support to the nasal dorsum. They

are constructed from oval sections of Vb inch (3.175 mm) X
Vie inch (1.5875 mm) soft stainless steel, which is bent in
the shape of a f i g u r e ' T , the wider diameter being flat. T h e
e n d of the short arm is rounded and polished; the end of
the long arm is bevelled to a sharp point and a hole is
drilled through it. Traction wire of 0.35 mm soft stainless
steel wire is then threaded through this hole and tied in
place.
12
10 Reduction of fractures of the nasal bones

13
A Cottle or Killian nasal expanding speculum and a pair of
Henckel's forceps are used to insert the splints. T h e
longer limb is inserted backwards until the short limb is at
the level of the nostrils; the splint can then be rotated
upwards until the short limb lies under the nasal bone and
the upper lateral cartilage. The rounded end of the shorter
limb should be just above the level of the internal nares.

14
The traction wire is then pulled forward until the sharp
end of the longer limb becomes firmly lodged in the floor
of the nose. T h e second splint is inserted in a similar
fashion on the other side. A n assistant now maintains
tension on the traction wires while the surgeon elevates
the upper lip and passes a sharp mandibular awl through
the mucosa in the midline of the upper glngivolabial
sulcus upwards into the nasal cavity passing as close as
possible to the outer wall of the anterior nasal spine. T h e
traction wire is threaded through the awl and drawn back
into the mouth without kinking. T h e awl is then reinserted
through the same mucosal puncture upwards into the
opposite nasal cavity, again passing as close as possible to
the anterior nasal spine. T h e second traction wire is
threaded and the awl once again withdrawn into the
mouth. T h e two traction wires are tied together tightly
under the anterior nasal spine. T h e knot is then buried
beneath the mucosa.

14

OPERATION BY OPEN METHOD
Indications
1. W h e n there has been a delay of over 3 weeks and less
than 3 months in .reducing the fracture.
2. Cases in which a previously performed closed mani-
pulative operation has been unsuccessful.
3. Very severe compound nasal fractures which extend
backwards to involve the ethmoids.
Anaesthesia
Same as the closed technique.
Reduction of fractures of the nasal bones 11
Position of patient
Same as the closed technique.
The incision
In some cases of compound fracture, and this particularly
applies to the fractured ethmoid type of injury, it is
possible to explore the nasal bones through the overlying
cutaneous laceration.
15
M o r e often, the intercartilaginous and t r a n s l a t i o n
incisions are u s e d . First, the nostril is opened up by the
use of a two-pronged Kilner retractor and pressure from
the middle finger is exerted on the external skin at the
alar-nasal groove thus displacing the internal nares
downwards into the centre of the operative field. An
incision is made at the level of the internal nares with a
N o . 15 blade Bard-Parker knife. It is deepened to pass
between the upper lateral cartilage and the lateral crus of
the alar cartilage. In addition to direct inspection, the
depth reached by the knife can be readily felt by the tip of
the supporting finger at the alar-nasal groove, and this
eliminates any risk of producing a through-and-through
incision to the outer skin.
T h e caudal border of the septal cartilage is then clearly
exposed and identified by the use of a Cottle columella
clamp which is used to displace the columella over the
opposite nostril. A transfixation incision is then made at
the lower border of the septal cartilage. It is particularly
important to avoid making this incision too low through
the membranous septum - as this can lead to the
complication of columellar retraction. Transfixation and
intercartilaginous incisions unite at the level of the septal
angle. These incisions are then repeated on the opposite
side and the two septal components are united, thus
separating the cartilaginous septum from the membra-
nous septum.
16
Exposure of the nasal framework
T h e next step consists of uncovering the skeletal
framework of the nasal dorsum through the intercartilagi-
: nous incision. This incision is opened up with a pair of
Knapp scissors a n d , by means of a combination of
spreading and cutting movements, the skin and sub-
cutaneous tissues are dissected off the outer surface of
the upper lateral cartilages. T h e plane of the dissection
should be as close as possible to the cartilaginous
framework because most of the blood vessels lie more
superficially and can thus be avoided. After the early stage
.of the dissection has been completed, the use of an
Aufricht's speculum facilitates reasonable visual control
over this stage of the operation. The elevation is
continued upwards over the nasal bones and the adjacent
frontal processes of the maxilla to just beyond the level of
the nasi on.
12 Reduction ot tractures oi the nasal bones

Reduction of the fracture

T h e soft tissues have been elevated off the nasal bones

a n d the position of the fracture and the displacement of
the fragments can now be directly s e e n . A Joseph
subperiosteal elevator can be used to determine the
mobility of the bony fragments. If this is restricted by firm
fibrous healing, it may be necessary to reopen the fracture
line either with scissors or a guarded osteotome.

17a, b&C
T h e reduction is now performed using Walsham's forceps
in a similar manner to that used in the closed technique,
only the outer blade without its rubber tubing is placed
under the skin and subcutaneous tissues. T h e upper
lateral cartilages are firmly attached to the lower border of
the nasal bones and they usually return to their original
position once the nasal fracture has been completely
r e d u c e d . If, however, they have been partially separated
from the nasal bones or buckled by fibrosis, it would be
necessary to re-align them at this stage.

17b

Septal surgery
The septum is now carefully inspected. It is usually found
to be deviated a n ' , must be straightened either by a
septoplasty or an _xtreme!y limited submucous resection
technique, the details of which are given elsewhere in this
volume.
18
Reduction of fractures of the nasai bones 13
Closure
Careful inspection is made of the nose to check the result
of the reduction a n d , if no minor re-adjustments are
required, the intercartilaginous incision is closed with one
or two 3/0 chromic catgut sutures.
Fixation
Same as for the closed technique.
THE REDUCTION OF OLD FRACTURES BY
OSTEOTOMIES
18
W h e n treatment is delayed until after complete healing of
the fracture has occurred, it is necessary to refracture the
nose by means of osteotomies and then reduce the
surgical fracture so that the deformity is corrected.
In this operation, the preliminary stages of the incision
and uncovering of the external skeleton are much the
same as for the open reduction technique except that the
uncovering of the frontal process of the maxilla is
restricted because the splinting support of the soft tissues
o n the lateral bony wall is needed after the osteotomies
have been performed. If there are any very sharp or
prominent projections on the bony nasal pyramid, these
are rasped down before proceeding to the osteotomies.
Septal surgery
T h e importance of the septal surgery cannot be over-
estimated and it is impossible to straighten the bony
pyramid without first restoring the septum to the midline
by a septoplasty technique.
The Osteotomies

19
The bony lateral walls of the nose are completely
mobilized by the establishment of medial, transverse,
lateral a n d , in my hands, also paramedian osteotomies. It
is most important that the main osteotomies (medial,
transverse and lateral) are performed in a complete and
radical fashion. T h e membrane bone, which forms the
bony pyramid, does not produce much callus and, w h e n
fractured, it heals mainly by fibrous union. Mobilization
and reduction by incomplete osteotomies usually correct
the deviation'initially, but the subsequent contraction of
the fibrous tissue will- result in a recurrence of the
deformity within 6 w e e k s .

20
T h e medial osteotomies are first performed using a
guarded osteotome which is slipped submucosally along-
side the septum and pushed upwards to engage at the
lower border of the nasal bones. An assistant now delivers
two blows with a mallet on the lower end of the
osteotome and then the surgeon checks the position of
the instrument up the nose by palpating the guard under
the s k i n . This sequence is repeated until the thicker bone
at the root of the nose is reached - at that level the sound
of the mallet striking the chisel becomes duller.

21
A more symmetrical nose follows the use of additional
paramedian osteotomies. These can be made with a
Quisling shatter hammer. The instrument is placed above
the prominent nasal bone and then below the depressed
side.
 Reduction of fractures of the nasal bones 15

22a & b
Finally, the lateral and transverse osteotomies are cut with
a curved guarded osteotome. T h e incision is first made
inside the nasal vestibule just in front of the anterior end
of the inferior turbinates. T h e incision is extended down
to the bony rim of the piriform aperture. It is "neither
necessary nor desirable to elevate the periosteum over the
proposed site 0' the osteotomy. T h e osteotome is placed
just above t h e levef of the anterior turbinate and the
osteotomy is fashioned by directing the instrument first
backwards to the base of the bony lateral nasal wall and
then upwards and finally medially to reach the upper end
of the medial osteotomy. This curved osteotomy was
described by Richard Webster and gives a good correc-
8

tion without narrowing the nasal airway at the valve area.

After the osteotomies have been performed, the
segments of the bony nasal pyramid should all be freely-
mobile. Should this not be the case, it is evident that a
greenstick type of osteotomy has been made. T h e
reintroduction of an osteotome in such a case always
produces very severe postoperative bruising and swelling,
often with enormous black eyes. This can be avoided by
carefully inserting the Quisling shatter hammer along the
line of the incomplete osteotomy and giving a sharp tap.
This is normally followed by the total mobilization of the
lateral bony segments.
Finally, the bony pyramid is carefully examined for any
irregularities w h i c h can be trimmed with bone scissors or
very carefully lowered w i t h a pusher rasp. A puller rasp
should not be used at this stage of the operation because
it is possible to avulse the mobilized nasal bone
completely.

23
Trimming of the upper lateral cartilages
In these deviated noses, one upper lateral cartilage is
invariably found to be wider than the other. The upper
lateral cartilages should be detached from the cartilagi-
nous septum, preferably submucosally, with a pair of
scissors. A medial strip is then usually excised from the
w i d e r upper lateral cartilage.

23
16 Reduction of fractures of the nasal bones
Fixation
The bony pyramid has now been completely mobilized
and the different segments can be placed in a slightly
over-corrected position before fixation and splinting.
An additional procedure
This operation can be combined with a number of
different procedures, such as:
1. turbinate reduction;
2. correction of nasal tip deformities;
3. lowering of a nasal hump;
4. augmentation of the nasal d o r s u m .
Postoperative care
Morphine 10 mg is given postoperatively to allay restless-
ness. T h e patient is nursed, after recovery from the
anaesthetic, with the head well raised. Ice bags are
applied to each eye. If the nasal cavities have been packed
to maintain septal alignment and prevent haematoma
formation, the packs should be removed in 2 days. No
plugging is used in cases with cerebrospinal rhinorrhoea,
and only external crusts are removed from the nostrils.
The cutaneous taping is removed after 7 days and the
plaster splint after 14 days. Lateral lead nasal splints are
usually removed after 21 days unless severe nasal sepsis
occurs. It is necessary to give a short general anaesthetic
to remove the Sear splints, and this is normally performed
after 4-6 weeks. When there is evidence of cerebrospinal
rhinorrhoea, penicillin and sulphadiazine must be given
for 10 days postoperatively.
Complications
Severe haemorrhage is rare. Anterior nasal packs of
ribbon gauze soaked in 1:1000 adrenaline or postnasal
sponges should be used. Electrocoagulation of the septal
vessels may be necessary. Very occasionally the anterior
ethmoidal artery may need to be ligated through an
external approach.
Sepsis is also rare. A septal haematoma, unless
evacuated, may become infected, with resultant chondri-
tis, loss of septum and 'saddle nose'. Synechiae may
occur, especially after lateral compression with lead
plates. T h e adhesion should be divided and Silastic N o . 7
splints should be inserted for 7 days to prevent recurrence
during the healing phase.
References
1. Classic reprint. Treatment of fractured noses in Ancient Egypt.
From: Breasted, J. H. Edwin Smith Surgical Papyrus.
Commentary by F. McDowell. Plastic and Reconstructive
Surgery1969; 43:402-411
2. Mayell, M. J . Nasal fractures: their occurence, management
and some late results. Journal of the Royal College of Surgeons
of Edinburgh.1973; 18: 31-3&
3. Harrison, D. H. Nasal Injuries: their pathogenesis and
treatment. British Journal of Plastic Surgery 1979; 32: 57-64
4. Murray, J . A. M., Maran, A. G. D. The treatment of nasal
injuries by manipulation. Journal of Laryngology and Otology
1980; 94:1405-1410
5. Stranc, M. F. Primary treatment of naso-ethmoid injuries with
increased intercanthal distance. British Journal of Plastic
Surgery1970;23:8-25
6. Gillies, H. D., Kilner, T . P. The treatment of the broken nose.
Lancet 1929; 1:147-149
7. Sear, A. J. A method of internal splinting for unstable nasal
fractures. British Journal of Oral Surgery 1977; 14: 203-209
8. Webster, R., Davidson, T. M., Smith, R. C. Curved lateral
osteotomy for airway protection in rhinoplasty. Archives of
Otolaryngologyl977; 103: 454-458
Illustrations by Mohd-Noor Awang
Treatment of fractures of the
zygomatic bone and arch
Malcolm Harri:- MD,FDS,RCS,FFD, RCSI
Professor of Maxillc -Facia! Surgery, The Institute of Dental Surgery and University College Hospital, London, U K
Lateral trauma may depress the arch only, whereas
anterior injuries will displace the zygomatic bone (malar)
with or without the arch.
Preoperative
Clinical indications for operation
1. Flattening of the zygomatic area which may be obvious
or anticipated from palpable bony defects - especially a
step defect of the infraorbital margin.
2. Trapping of mandibular coronoid process with impair-
ment of opening.
3. Disruption of orbital suspension with lowering of the
pupillary level.
4. Prior to reduction of a fractured maxilla, as part of a Le
Fort III injury.
5. Entrapment of the orbital fascia with restricted upward
gaze (see chapter on 'Treatment of blow out fractures
of the orbit', p p . 50-54).
Contraind i cations
1. O l d or fragile patients without disturbance of orbital
function.
2. Contralateral blindness - there is a rare possibility that
elevation of the zygoma will produce a retro-orbital
haematoma with spasm of the ophthalmic artery a n d
retinal infarction. With positive indications to treat a
zygomatic fracture in a patient with contralateral
blindness, the procedure should be carried out with an
ophthalmic surgeon monitoring the retina. An eyebrow
incision with retro-orbital drainage would be recom-
mended.
3. Proptosis due to gross orbital haematoma should be
allowed to subside before elevation.
investigations
Eye movements and reflexes are examined and recorded.
The visual field and retina should be examined w h e r e
appropriate, i . e . severe orbital injuries.
Radiographs
T h e standard occipitomental ( O M ) view provides a
complete picture of the zygomatic bones and arches, and
also shows any narrowing of the maxillary sinus outline.
T h e lower orbital margins and the zygomatic arches are
seen better with tilted views, i.e. 15° Or 30° O M .
T h e arches may also be outlined o n a submentovertical
radiograph w h i c h may be used to examine the base of
s k u l l . Computerized tomography (if not available, plain
tomography) may be necessary to exclude orbital floor
defects and will also show the relationship of impacted
bone fragments to the orbital nerve and rectus muscles.
Preoperative preparation
Gross orbital oedema should be allowed to subside.
W h e r e the temporal (Gillies) approach is being used, a
• 5 x 5 cm square patch is shaved anterosuperior to the ear,
preferably on the ward.
Anaesthesia
Maxillofacial injuries are best managed by nasoendot-
racheal anaesthesia with a cuffed tube-and throat pack.
This enables the dental occlusion to be examined
intraoperatively and prevents aspiration of blood from
oral or antral wounds. The face and ears are carefully
cleaned with 1 per cent cetrimide solution or aqueous
cetrimide and chlorhexidine gluconate (Savlodil).
T w o linen towels and a waterproof paper towel are
placed beneath the head and the upper towel is tightly
folded over the head, exposing the ears. T h e nasal
anaesthetic tube and eyes may then be protected with a
small adhesive drape. A large sheet covers the trunk and
neck and is tightly clipped to the head towels at the neck.
Dexamethasone 10 mg with the anaesthetic induction
agent and repeated i . m . 12-hourly followed by 5 m g
12-hourly x 2 helps to reduce postoperative oedema.
18 Treatment of fractures of the zygomatic bone and arch

The operation

1
Percutaneous facial elevation
Th'e simplest technique uses a zygomatic hook which is
passed through the skin below the estimated mid point of
the lower border of the zygoma. The depressed bone is
then elevated upwards and outwards. This can be carried
out under a short intravenous anaesthetic as an outpatient
procedure.
If on review 3 days later the reduction is unsatisfactory
or the fracture is comminuted the following procedures
are employed.

Temporal elevation

2
This may be used for both zygomatic arch and bone.
Adrenaline 1:80 000 is infiltrated into the subcutaneous
tissue. A 3 cm oblique incision is made with a No. 15 blade
in the shaved area, where possible between any visible
vessels. The incision is carried down through the scalp
layers until the temporal muscle is reached.

3
The correct level is confirmed by passing a Howarth
periosteal elevator freely below the arch and anteroinfer-
iorly below the zygomatic bone. Occasionally attempts are
made to use the false plane between the split layers of the
temporalis fascia.
 Treatment of fractures of the zygomatic bone and arch 19

4
The fascial margins are retracted with miniature Langen-
beck's retractor and then either a Kilner, Rowe or Bristow
elevator is inserted. The first two instruments are
designed to indicate the depth of the w o r k i n g end and
also allow direct unsupported elevation. T h e assistant
must hold the head firmly during elevation - audible
crepitus will often indicate reduction w h i c h may be
confirmed by inspection and gentle palpation. Commi-
nuted arches should be over-reduced. T h e w o u n d may be
loosely closed with 3/0 black silk sutures after marginal
vessels have been diathermied.

Open reduction

Unstable and comminuted zygomatic bones

These require open reduction and internal wiring; T h e

former may be anticipated w h e n radiographs show
marked displacement and w h e r e a greater part of the
inferior orbital rim is depressed.

5
As the principal means of suspension is an interosseous
wire at the zygomaticofrontal fracture site, elevation may
be carried out through an eyebrow incision. It is
unnecessary to shave the eyebrow, particularly as poor
skin closure may occasionally produce distortion of the
eyebrow. A curved 2-3 cm incision is made down to bone
through the lateral third of the eyebrow as far as the
midlateral orbital margin. Haemostasis is facilitated by
prior subcutaneous infiltration with 1:80 000 adrenaline.

6
The margins are retracted with 'catspaws' or skin hooks
and the periosteum carefully elevated with a Howarth
periosteal elevator. T h e bony exposure is extended onto
the orbital surface.
22 Treatment of fractures ot the zygomatic Done and ^rui

Prolapsed orbital floor

T h e orbital floor may be prolapsed, occasionally with the

origin of the inferior oblique muscle producing diplopia
on upwards and outwards gaze.
If this cannot be manipulated into a stable position
through the infraorbital incision, a Caldwell-Luc antros-
tomy is required and can also be used for providing
support with an antral pack.

14
A n intraoral semilunar incision down to the bone is made
above the premolar gingival margins from the apex of the
canine to the first molar region. This is reflected upwards
w i t h a finger and dry swab until the infraorbital neuro-
vascular bundle is seen. Further reflection is carried out
w i t h a Howarth's periosteal elevator. Usually the antral
w a l l is fractured and the antrostomy merely requires
adequate removal of loose fragments with rongeurs.

15
The antrum may be packed using a substantial roll of 2
inch Raytec ribbon gauze, soaked in Whitehead's Varnish
(compound iodoform ether paint) or bismuth and
iodoform paste (BIPP) and squeezed dry. Before inserting
the pack an intranasal antrostomy is created at the level of
the nasal floor by passing a pair of heavy curved Spencer
Wells forceps into the antrum from the nose. The e n d of
the gauze is grasped by the forceps and pulled out
through the nose. Sawing it backwards and forwards will
ensure a smooth margined patency in the nasal-antral
wall. The pack is then fed in layers superolaterally to
support the orbital floor and zygomatic bone. Displace-
ment of bone spicules supero medially may damage the
ophthalmic artery or veins. It is therefore important to
examine the orbital floor directly after packing to ensure
there is no intraorbital herniation of the gauze.
The oral incision may be closed w i t h a 3/0 resorbable
suture. T h e protruding nasal end of the pack is sutured to
the alar margin to prevent posterior displacement. The
pack is removed 3 weeks later using intravenous analgesia
and sedation.
 Treatment of fractures of the zygomatic bone and arch 23

Combination of defective orbital floorand orbital

herniation of orbital contents

Obturation is required. This can be done with 1 mm

silicone elastomer (Silastic) sheeting or bone from the
contralateral antral wall. Either should be carefully
contoured so as to lie comfortably behind the repaired
orbital r i m .

pin fixation

16
As an alternative to an antral pack, unstable zygomas may
be supported by bone screws, such as the Toller or Moule
self-tapping pin screw. The thickened frontal bone at the
junction of the temporal and supraorbital ridges is used
for the suspensory pin. This is inserted by screwing the
p i n , in its T-shaped chuck, through a stab wound into a
drill hole which has been prepared with a tapering fissure
burr.

17.
Another pin is similarly inserted into the fractured zygoma
and fixed with connected rods and two universal joints
after elevation. Half-inch ribbon gauze soaked in White-
head's Varnish may be tied round the base of the pin as a
dressing. The pins are removed after 3 w e e k s .
24 Treatment of fractures ot the zygomatic bone and arch
Postoperative care
The facial w o u n d requires dry gauze dressings for 48
hours followed by an adhesive spray. Sutures should be
removed in 5 days. A large cross painted in Bonney's Blue
on the operated site is a simple means of alerting the
nursing staff to prevent the patient from resting on the
elevated bone.
T h e conjunctiva should be irrigated with saline and
lubricated with chloramphenicol 1 per cent eye ointment.
This may be repeated 6-hourly for 48 hours if there is gross
chemosis.
Metronidazole 1 g rectal suppository 8-hourIy or 400 mg
orally 12-hourly as appropriate is used as a prophylactic
antibiotic for 5 days.
Complications
Gross retro-orbital haematoma following elevation may
produce proptosis and spasm of the ophthalmic artery -
with retinal infarction. Rapid decompression through the
lateral orbital wall may be achieved by a superolateral
margin incision. If the examination of the fundus shows
retinal arteriolar shutdown, or if the light reflex is lost and
the pupil dilated, retrograde infusion via the supraorbital
artery with papaverine and heparinization should be tried.
If the antrum has been packed this must be removed.
Patients should be warned of prolonged infraorbital and
maxillary anaesthesia due to neuropraxia and late intermit-
tent epistaxis from decomposed antral haematoma.
Delayed treatment
After 15 days simple elevation may not be stable due to
restored masseteric tone and resorption at the fractured
surfaces. If s o , transosseous wiring will be essential.
Malunion requires open reduction following refractur-
ing with fine osteotomes.
Occasionally a bone graft has to be inserted intraorally
at the zygomatic buttress to support a downward
displaced untreated malunited zygoma.
Ophthalmoplegias and epiphora require early ophthal-
mic surgical management.
Further reading
Banks, P. Killey's fractures of the middle third of the facial
skeleton. A Dental Practitioner Handbook No. 3.4th ed. Bristol:
Wright P.S.G.,1983
Rowe, N. L, Williams, J. H. eds. Maxillofacial injuries. Edinburgh:
Churchill Livingstone, 198^
Illustrations by Mohd-Noor Awang
Treatment of fractures of the mandible
Malcolm Harris M D , FDS RCS, FFD RCSI
professor of Maxillo-Facial Surgery, T h e Institute of Dental Surgery and University College Hospital, London, UK
General principles
As with all trauma cases it is essential first to establish an
airway and if necessary ventilate the patient; and second,
to arrest haemorrhage and maintain the circulation. The
former is more relevant to facial injuries, especially those
involving the mid face region. T h e latter may not apply
unless a major vessel is damaged locally or there are
multiple injuries elsewhere. Therefore the minimum
action will be to set up an intravenous infusion of
Hartmann's solution and take blood for grouping and
crossmatching.
Finally, reassessment, w h e r e appropriate, must be
carried out to eliminate intracranial, thoracic and abdo-
minal injuries; careful exclusion of eye injuries is also
necessary.
Priorities in the management of the multiple injured
patient are: (7) cranial, thoracic, abdominal; (2) maxillofa-
cial, orthopaedic and ophthalmic. W h e r e possible good
liaison will enable these to be treated together or
sequentially, using the minimum number of anaesthetics.
Preoperative
Assessment
Extra- and intraoral examination are essential in determin-
ing the site of the bone injuries, which may be indicated
by:
1. tenderness on pressure, e.g. at the condylar neck or
angle of mandible;
2. a step defect or separation within the dental arch with
abnormal mobility;
3. disturbance in occlusion, e.g. premature contact
between the molar teeth;
4. impaired labial sensation due to damage to the inferior
dental neurovascular bundle.
Bilateral fractures of the anterior mandible were
formerly considered to be a threat to the airway as a result
of the unsupported tongue falling backwards. This danger
only exists in the deeply unconscious or unsupervised
anaesthetized patient.
25
26 Treatment of fractures.of the mandible
Investigations
Teeth should be indivi dually palpated for mobility to avoid
accidental luxation by the anaesthetist. Missing teeth and
dentures should be ca refully noted and a good radiograph
of the chest taken to eliminate the possibility of foreign
body aspiration. N.B. Plastic dentures are usually radiolu-
cent and may remain undetected in the respiratory tract
until they give rise to irritation or infection.
Radiographs
If possible, a panoramic tomogram or orthopantomogram
should be obtained as this gives a complete view of the
whole mandible. Failing this the following radiographs of
the mandible are required.
1. Right and left lateral obliques to show the premolar,
molar, angle and ascending ramus regions.
2. Posteroanterior view to show the anterior body and
angles and most of the ascending ramus.
3. T h e condylar regiori will often be obscured and will
require Townes or reversed (posteroanterior) T o w n e s
view.
4. A n intraoral dental occlusal film provides the best view
of fractures of the symphyseal region.
5. Periapical dental films are required for teeth in a
fracture line to determine their integrity.
Treatment
There is rarely an indication for emergency treatment of
simple mandibular fractures. However, in cases of
multiple injury, debridement, reduction and fixation will
facilitate management of the airway and nursing.
Head
towel
nsparent
adhesive drape
The aim of treatment is reduction of the displaced
component and restoration of normal dental occlusion.
Therefore, undisplaced fractures without malocclusion
may not require operative treatment. This applies in
particular to fractures of the condyle, ascending ramus
and angle of mandible. Treatment here will be analgesics
and antibiotics for 5 days, and a soft diet for 3 weeks.
Antibiotics
Preoperatively amoxycillin 500 mg can be given intramus-
cularly or intravenously. Postoperatively the dose is
repeated 8-hourty until oral medication with a syrup is
acceptable - 500 mg phenoxymethylpenicillin, 6-hourly.
Alternative therapy can be metronidazole: a l g supposi-
tory preoperatively followed by 1 g suppository, 8-hourly
postoperatively until an oral suspension of 400 mg
12-hourly can be given.
Oedema
Dexamethasone 10 mg by intramuscular or intravenous
injection preoperatively, repeated 12 hours later, with
5 m g , 12-hourly the following day will reduce postopera-
tive oedema.
Local anaesthesia
Fractures requiring only closed reduction with intermaxil-
lary fixation can often be treated with bilateral inferior
dental local analgesic blocks with additional infiltration of
the lingual and long buccal nerves. The maxillary gingivae
will also require buccal and palatal infiltration. This is
facilitated by a small dose of intravenous sedation, e . g . of
diazepam l O m g . Higher doses make the patient difficult
to manage.
1
Genera! anaesthesia
T h e patient should be given atropine and relaxed. T h e
anaesthetic is delivered by a nasoendotracheal tube which
does not protrude beyond the nose so that the catheter
mount and connecting hose lie close to the surface of the
face and do not interfere with the surgery. A cuffed tube
and lubricated throat pack will both prevent aspiration of
blood or foreign particles.
T h e head is positioned with the neck extended on a
rubber ring, and the face is thoroughly cleaned with an
aqueous detergent such as 1 per cent cetrimide or
aqueous cetrimide and chlorhexidine gluconate (Sav-
lodil).
T w o cotton towels and a non-absorbent paper towel are
placed beneath the head, the top one being folded over
the scalp to leave the operative area exposed. If this
includes the maxtlla, the orbital area and nose are left
uncovered. In these cases the eyes and anaesthetic tube
may be covered with a small adhesive transparent drape.
A large sheet covered the rest of the body up to the
neck.
 Treatment of fractures of the mandible 27

Methods of fixation
The choice is usually determined by the experience of the
surgeon and the availability of a maxillofacial technician.
Techniques which do hot require a technician include:
eyelet wiring; arch bar w i r i n g ; use of modified dentures;
bone plates. A maxillofacial technician is required for:
custom-made Gunning splints; cast silver alloy cap splints.

2a & b
Good access is essential and is provided by a dental prop
or adjustable gag and a Kilner cheek retractor on the
buccal side to protect the angle of the mouth (which
should be generously and repeatedly lubricated with 1 per
cent hydrocortisone cream or petroleum jelly). The
tongue is retracted with a Lack's retractor or a self-
retaining large, modified soup spoon. Suction with a
fine-bore sucker and good light are also mandatory.

retractor

Eyelet wiring

3
Eyelets are prepared from 0.5 mm soft stainless steel wire
that has been stretched 10 per cent. A 3 mm loop is
prepared in the middle of a 15 cm length of wire by
grasping the ends of the wire between wire-holding
forceps and making two twists around a vertical axis such
as a heavy nail from which the head'has been cut off.
28 Treatment of fractures'of the'mandible

4a, b & c
Starting at the back of the mouth the eyelet wires are
passed between pairs of teeth from buccal to lingual. O n e
w i r e is then passed distally around the tooth, grasped on
the buccal side and pulled through until it can be threaded
through the 'eye'. The other w i r e is passed anteriorly
around and between the teeth. Both wires are then pulled
tight and twisted with heavy Spencer Wells forceps. T h e
assistant should push the wire loops on the lingual side
into the gingival sulcus with a narrow instrument so that
they grip the necks of the teeth as they are tightened. T h e
twisted wire coil is then cut 1 cm long and twisted between
the teeth to avoid irritating the oral tissues.
Treatment of fractures of the mandible 29
30 Treatment of fractures of the mandible

6
Four to five eyelets are required in both.upper and lower
dental arches to provide sufficient attachments for a
s e c u r e cross bracing by the tie wires. These are 15m
lengths w h i c h are passed diagonally between pairs of
eyelets.
Before the tie wires are drawn tight by twisting into a
coil the mouth and pharynx are sucked dry with a
large-bore sucker and the throat pack removed.
If all wires are twisted clockwise, by convention, it is
easier to undo them. Always twist, then p u l l , then twist to
tighten a w i r e . Twisting and pulling simultaneously will
break the w i r e .

Arch bars
Arch bars can be fabricated from a 3 mm half-round
German silver bar but are usually obtained prefabricated,
e.g. Erich or Jelenko forms. They are particularly useful
where the patient has lost many teeth, as eyelets are less
effective on lone-standing teeth.

7
A length is cut to extend to the distal aspects of the last
tooth in each side. It is bent at each end so as not to
abrade the soft tissues.
Ligation is done with 10 mm lengths of stretched 0.5 m m
soft stainless steel w i r e , again ensuring that on the lingual
palatal aspect of the tooth the loop is held against the neck
of the tooth while being tightened.
Treatmenl of fractures of the mandible 31
32 Treatment ol irnctures of t n t manuiuie

9a, b & c
If this produces poor retention, e . g . around a straight,
narrow lower incisor or canine, one wire is carried back
over the bar as an additional loop. This provides a better
attachment but is tedious and time-consuming for every
tooth. Wire loops or elastic bands may be used for
intermaxillary fixation.

9c

Dentures
Dentures may be converted into splints for the fixation of
fractures in the edentulous mandible. Ideally they should
be lined with a layer of black gutta percha to prevent
ulceration of the mucosa. T h e denture fitting surface may
be hollowed out with an acrylic burr. The sheet of gutta
percha is softened in hot water, moulded to the
undersurface of the denture and trimmed to size. It is then
removed, made adherent by heating it over the flame of a
spirit lamp and then compressed once more against the
surface of the denture. The margins of the gutta percha
are trimmed with a hot blade and then sealed again v.
the lamp. The anterior teeth are grpund off to facilh
suction from the mouth and feeding. Intermaxil'
fixation may be achieved by hooks which can be attacl
with quick-curing acrylic or more easily by passing w
through horizontal drill holes in the dentures. The ho
or drill holes are prepared preoperatively and
modified denture splint is then decontaminated
soaking in an aqueous disinfectant such as chiorxhexic
or glutaraldehyde prior to fixation.
 Treatment oi fractures or the mandible

Cunning splints Denture

The alternative to converting the patient's denture is a

custom-made G u n n i n g splint made by a technician, either
from impressions of the patient's upper and lower alveolar
ridges or from models prepared from his or her dentures.
This technique requires the appropriate expertise and
equipment.

10a-e
The splints are anchored to the jaws with 15cm lengths of
0.5 mm stretched soft stainless steel wire using a Kelsey-
Frey or Obwegeser a w l . For the mandible, the awl is
passed up through the submandibular skin close to the
inner bony surface to appear in the floor of the mouth
opposite the space between the second premolar and first
molar. A wire is passed through the eye and half twisted
around itself. T h e awl is retracted carefully, avoiding
withdrawing it through the skin, and then passed around
the lower border and upwards on the buccal side of the
jaw. It is detached from the awl, which is removed, and
then with a sawing motion, pulled tight against the lower
border of the mandible. This work-hardened section is
drawn upwards and the wire tightened and twisted over
the lateral surface of the splint. Three circumferential
wires will be required, two posterior and one in the
midline anteriorly. Avoid passing wires near vertical
fracture lines in case they pass between the interfaces.

T h e upper splint may be attached by a variety of wiring

techniques: (7) peralveolar; (2) circumpalatal; (3) circum-
zygomatic (see chapter on 'Treatment of fractures of the
maxilla', pp. 41-49).
34 Treatment of fractures or the mandible

Peralveolar

Peralveolar wires are relatively easy to pass in a soft elderly

maxilla. A short straight awl is pushed and twisted through
the maxilla f r o m the mid buccal surface towards a point
1 cm lateral t o the midline of the palate. A generous hole
will have been made in the palate of the splint at this
point. W h e n the awl emerges a 0.5 m m wire is passed
t h r o u g h , the eye and pulled back t o the sulcus. This
palatobuccal loop is then twisted and tightened around
the splint. This is repeated on the opposite side.
 Treatment ot fractures ot the mandible i5

Circum palatal

Using the nasal floor to suspend an acrylic splint was

described by M a d a n .
1

Holes should be drilled through the anterior buccal

flange of the splint and also just anterior to the palatal
edge, lateral to the midline on the suspension side.
A long Kelsey-Fry awl is passed intraorally through the ft
mucosa at the level of the nasal floor and distally to
emerge through the soft palate at its junction w i t h the
hard palate. Upward compression w i t h a finger will
facilitate this. A long wire (20 cm) is attached to the
posterior margin of the denture by a single loop t h r o u g h
the prepared hole. The two ends are passed through the
eye of the awi (bent for security) and then pulled
anteriorly along the floor of the nose. W h e n they emerge
into the mouth one end is passed through the deep aspect
of the hole in the anterior flange. The ends are then
twisted together and tightened.

Cast silver alioy cap splints

These may be prepared from impressions of the teeth by a

maxillofacial technician. They are cemented into place
w i t h fluoride containing phosphate cement.
36 Treatment of fractures of the mandible

CLOSED VERSUS OPEN REDUCTION

Where the fracture is undisplaced or if on reduction there

is no tendency to displacement, intermaxillary fixation by
any appropriate technique will be satisfactory. However, if
the fracture line is unfavourable, i.e. irreducible, or with a
tendency to displacement, then open reduction with
internal fixation is required, using an upper or lower
border wire, or bone plate.

13a &b
With a vertically unfavourable fracture (i.e. when viewed
in the vertical plane) the pterygomasseteric muscle sling
can be seen to displace the proximal fragment lingually
(a). The undisplaced vertically favourable fracture does
not usually require interosseous wiring (b).
V

13a

14a &b
With a horizontally favourable fracture (i.e. when viewed
in the horizontal plane) the proximal fragment is secured
by the fracture interface despite the muscle pull (a). With
an unfavourable fracture line an interosseous wire is
necessary for stability (b).
 Treatment of fractures of the mandible 37

Upper border wiring

15a &b
T h e incision is made intraoraliy along the gingival margin
around standing teeth or along the ridge in the edentu-
lous mandible. The mucosa is reflected bucally and

Holes are drilled with a No. 6 rosehead or a tapering

fissure burr. They can pass through to the lingual cortex or
diagonally into the fracture line so that a square or
triangular loop will secure the fracture.
38 Treatment of fractures of the mandible

Lower border wiring

16a, b &c
This is most useful in the dentate mandible w h e r e no
tooth requires removal, in the midline anteriorly, and in
the unstable atrophic edentulous mandible.
T h e facial nerve crosses the midpoint of the lower
border and travels on the undersurface of the deep
cervical fascia. T o avoid damaging this nerve a subman-
dibular incision must be two finger's breadth from the
lower border and must pass first through platysma, then
through the thick fascial layer into the plane w h i c h
contains the superficial veins and the submandibular
gland. Dissection proceeds upwards over the surface of
the salivary gland and, if necessary, the facial artery and
anterior facial vein are found, divided and t i e d . A s the
mandibular branch (VII) passes superficial to these vessels
at this point, upward retraction of the tied vessels and
incision of the periosteum at the site of their division will
avoid any nerve damage.
O n c e the periosteum is incised and elevated, the bony
fragments can be reduced with bone-holding or Kocher
forceps. Holes are drilled so that a horizontal w i r e
mattress suture may be passed. An additional figure-of-
eight wire through the same holes reduces the l o w e r
border and strengthens the fixation. T h e w i r e is passed
from buccal to lingual, then under the lower border and
through the other hole from buccal to lingual before
twisting tight. T h e ends should be bent into a drill hole or
in such a way that they will not be palpable.
T h e wound is closed in layers, leaving in a vacuum drain
to reduce haematoma formation.
 Treatment ul Ir-icture;. ot (tie mandible

17a &b
Bone plating

O p e n reduction with bone plating can provide a suffi-

ciently rigid means of fixation so that immobilization to
the maxilla is not required. This has obvious advantages,
particularly in uncooperative or elderly patients. Champy
has devised a miniature plating set. The plates are easily
adapted to any site of fracture*. Compression plates are
also available which provide greater rigidity and theoreti-
cally prevent opening of the upper border and occlusal
defects. Alternatively, small orthopaedic, i.e. metacarpal
or Sherman plates, may be used.
Unfortunately the plates need to. be fixed with care to
avoid opening the fracture line at the upper border. This
may be prevented by first applying a temporary lower
border transosseous wire together with an intraoral
circumdental wire ligature; single rooted teeth alone on
either side of the fracture should never be used as they
may be subluxed. The plate can then be'screwed to the
under surface of the lower border. With unstable fractures
an additional buccal plate may be added.
• These techniques have the disadvantage of possible
infection around the plate, necessitating its removal.

* Champy. Maxillofacial osteosynthesis small plates. Manufac-

tured by GebrQder Martin, Tuttlingen, West Germany.
FRACTURES OF THE MANDIBLE IN CHILDREN Alternatively 5 per cent s v > „ ~ perborate or weak
sodium bicarbonate or soc^rr, --ioride solutions (a
These are uncommon and heal quickly. Eyelet wires may teaspoon in a tumbler of w a r n v.;,-; rj a v be used.
: m

be used unless the deciduous teeth are loose and about to

be shed. However, the simplest management is with a
loose-fitting overall acrylic splint, made on a model of a
child of similar jaw size. This is fixed with a periodontal
pack material and secured with Circumferential wires for
Duration of fixation for the mandible
2-3 w e e k s . Intermaxillary fixation is not necessary.
Fixation is retained for the following periods or until t h e
fracture sites are non-tender on firm palpation.
Children 2 weeks
Postoperative care Adults 3 weeks
Elderly patients 4 - 5 weeks
N.B. Fractures of the condyle and ascending ramus do not
A nasopharyngeal airway, supervised and sucked out
need fixation unless the occlusion is deranged in w h i c h
hourly, is essential during the first postoperative 24 hours.
case simple intermaxillary fixation for 1-2 weeks is
All jaw fracture patients with intermaxillary fixation
satisfactory. Bilateral condylar fractures with a deranged
require individual nursing care in a high dependency area.
occlusion may prove difficult to correct. If after 2 w e e k s '
A size 12 nasogastric tube is desirable after any major
fixation normal occlusion is not restored, open reduction
intraoral surgery, especially maxillary fractures, to aspirate
is required, although some surgeons will persevere w i t h
from the stomach accumulated blood w h i c h may have
simple fixation for further periods of 2 weeks until a
leaked around the throat pack or been swallowed. T h i s ,
successful correction is achieved.
together with an antiemetic such as metoclopramide
10 mg intravenously, will reduce the incidence of vomiting.
Vomit should be sucked out via the nasopharyngeal
airway and mouth. Intermaxillary fixation does not need to
be released. References
Small intramuscular or intravenous injections of an
analgesic such as papaveretum (Omnopon) 5-10 mg given 1. Madan, D. K. Circum-palatal wiring. Oral Surgery, Oral
2-3 hourly if required will control pain. Medicine, Oral Pathology1973; 36: 2-5
Fluid balance should be maintained intravenously for 24
hours but the infusion set is retained until the patient is
drinking comfortably either by feeding cup or straw.
A homogenized and liquid diet containing 75 g of
protein and approximately 10500 kj (2500 KCal), will be Further reading
required daily. If early oral feeding is not possible a
Banks, P. Killey's fractures of the mandible. Dental Practitioner
fine-bore nasogastric tube will be required. . Handbook No. 5.3rd ed. Bristol: Wright PSC, 1983
T h e mouth should b e cleansed with 0.2 per cent
chlorhexidine gluconate mouthwash or gel on a child's Rowe, N. L , Williams, J . H. eds. Maxillofacial injuries. Edinburgh:
soft toothbrush. Churchill Livingstone, 1984
Illustration by Mohd-Noor Awang

Treatment of fractures of the maxilla

Malcolm Harris MD,FDS,RCS,FFD,RCS[
professor of Maxilto-Facial Surgery, The Institute of Dental Surgery and University College Hospital, London, U K

Introduction
Aims of Surgery
The object of surgery is to reduce and immobilize the and fixation is principally to eliminate the discomfort of a
middle third facial bones in order t o : eliminate facial mobile maxilla. With no displacement or a minimally
deformity; correct the dental occlusion; and establish a displaced edentulous maxilla no ^intervention may be
normal nasal airway w i t h patent nasolacrimal ducts'. In appropriate.
many cases the disturbance may be minimal and reduction

41
42 Treatment of iractures 0 1 the maxilla
1
Classification of maxillary fractures
1. Le Fort l - separation of the hard palate and
dentoalveolar complex usually with the lower end of
the pterygoid plates.
2 . At a higher level the injury produces a Le Fort II - a
pyramidal fracture including the maxillary walls and
nasal bones.
3. Severe midfacial injuries. Le Fort III - craniofacial
separation in w h i c h the zygomatic bones are added to
the above.
In practice a patient may present with a combination of
injuries.
Preoperative
Preoperative assessment
A nasopharyngeal tube is passed to ensure that there is a
patent airway. Occasionally- the maxilla is impacted
downwards and backwards and will need to be digitally
elevated to facilitate this. Clots, mucus, tooth and denture
fragments are sucked out.
The patient is best supervised:
1. when conscious, sitting up at 45°.
2. with impaired consciousness in the semiprone posi-
tion.
3. Deeply unconscious patients will need an endotracheal
tube and ventilation.
4. If an endotracheal tube cannot be passed and
respiration is obstructed or impaired by a chest injury
then a tracheostomy is required.
It should be established whether there was an associ-
ated head injury and a neurological record commenced
where appropriate. With unconscious patients, half-
hourly observations must be carefully made and recorded
to detect the incipient effects of a latent intracranial
haemorrhage. Surgery must be delayed 24-48 hours until
the neurological observations are satisfactory and stable.
Not only might an anaesthetic mask any adverse changes,
but inadvertent anoxia will create increased cerebral
oedema and brain damage.
O n e should note whether there is (1) any cerebrospinal
rhinorrhoea due to a cribiform plate fracture with dural
tear; (2) cerebrospinal otorrhoea due to a fractured skull
base.
Cleansing and basic closure of facial lacerations may be
possible under local anaesthetic. Where a general
anaesthetic is anticipated this should be restricted to
subcutaneous suturing and the use of adhesive strips for
the skin surface.
Lef""
Radiographs
T h e most useful radiographs are the occipitomental * {('Z i/t r
particularly the standard and a 25" tilted projection- ^ 1
latter helps to reveal displacement of t h e inferior on*
margin. ^
Indistinct fracture lines may be confirmed with #
facial bone radiograph. f
N.B. Head injury cases will require p o 5 t e r o » r * ' T ? ^ , /
lateral skull and Townes views to detect fracture*
calvarium and occasionally a submentovertical ^ A i
fa
r f
base of skull which may be difficult to take ' Af
therefore of little value. A CT scan is now t h e i d e a l ^ ^ - y /
detecting fractures of the skull base a n d i n t r * * - ^ y.
haemorrhage.
Preoperative preparation
W i t h frank or anticipated cerebrospinal r h i n o r r f v ^ - '
a Le Fort III fracture, chemotherapy s h o u l d fc»* f,4a'0-
menced in adequate concentrations to cross t h e ^^/k&g
the 'blood-brain barrier*, e.g. co-trimoxazote i^tfiv
(sulphamethoxazole 800mg and trimethoprim,'*7%*jffi
orally, intramuscularly or intravenously e v e r y 1 2 \^j7^ r
For allergic patients use amoxycillin 500 m g ^^^JjgUS
erythromycin stearate 500 mg, 6-hourly or erfi**^'' j?
lactobionate 600mg i.v., 8-hourly. p$
If cap metal splints or acrylic C u n n i n g * ^
required, impressions must be taken as early a * ^
to allow the technician to prepare them ( s e e dr&s
'Treatment of fractures of the mandible', p p - 2 5 — . ^ftf
If a zygomatic fracture also requires e l e v * ^ ' *
anterior temporal region should b e s h a v e d .

The operation
Anaesthesia is delivered via a nasoendotracheal tube with
an absorbent throat pack.
The choice of fixation will be determined by the practice
of the surgeon and to some extent by the nature of the
fracture. The .principle is that, following reduction, the
maxilla is attached to and sandwiched between the
mandible below and the nearest stable structures above.
The order of the treatment is as follows.
Treatment of fractures of the maxiila 43
Wiring or splinting
If splints have not been used and cemented preoperative-
ly, arch bars or eyelets are attached to the teeth or
Gunning splints are used if the patient is edentulous (see
chapter on 'Treatment of fractures of the mandible',
pp. 25-40).
Mandibular reduction
Any mandibular fracture is reduced to provide a base for
reducing and fixing the maxilla.
Elevation of zygomatic fracture
Any zygomatic fracture is elevated and, if necessary, fixed
with transosseous wire at the frontozygomatic separation.
2
Disimpaction and reduction of the maxilla
This may be done manually or with Rowe's disimpaction
forceps. The blade on the straight arm is inserted onto the
nasal floor and the one on the curved arm onto the hard
palate. By gripping both right and left forceps the maxilla
may be rocked upwards and forwards into its normal
position where it will occlude with the mandible. During
this manouvre the head is gripped by the assistant and
care is taken not to displace the anaesthetic tube.
44 i reatment oi iraaures 01 m^nu;

3
Reconstruction of the orbital margin
If the margin is comminuted, it will be necessary 'to
explore and reconstruct it with 0.35 mm w i r e loops,
through a subciliary (blepharoplasty) incision (see chapter
on 'Treatment of blow-out fractures of the orbit, pp.50¬
54). T h e orbital floor may be explored at the same time.

4
Fixation of unstable split hard palate
A split hard palate may complicate the described patterns
of injury. In many cases the halves are satisfactorily drawn
together by the occlusal interdigitation after intermaxillary
fixation. If they are very unstable a single 0.5 m m
transosseous wire may be passed through drill holes
adjacent to the fracture margins, after reflecting the
palatal mucoperiosteum.

Fixation of jaws
The temporary intermaxillary wire loops are used to fix the
jaws in occlusion.
 Treatment of fractures of the maxilla 45

Suspension of maxilla

The maxilla is then suspended either internally or

externally.

5a, b & G
Internal suspension

Circumzygomatic wires provide a useful posterosuperior

suspension when both zygomatic arches are intact. They
are used for Fort 1 and Fort II injuries. The long awl is
inserted at a point behind the superolateral orbital rim.
This is located by palpation prior to passing the awl
downwards and forwards until it emerges in the buccal
sulcus. A 15 c m , 0.5 mm wire is attached to the eye of the
awl which is then carefully pulled back and upwards, but
not out through the skin. With care it may be manoeuvred
over the edge of the zygomatic bone and passed down on
its facial aspect to re-emerge in the sulcus where the end
of the wire is released and the awl removed.
The wire is pulled tight by a sawing motion and can then
be passed through rings or around cleats on the upper
splint. Some surgeons prefer an intermediary ring which
can be readily made from a sterile safety pin with wire
cutters. This enables a short wire loop to be used for the
final suspension to the mandible which can be cut to
release the intermaxillary fixation, leaving suspensory wire
in situ.
46 Treatment of fractures of the maxilia

6a, b & c
Perfrontal wiring is used for Fort 111 injuries. An eyebrow
incision is made at the superolateral corner of the orbital
margin down to bone. (The eyebrow is not shaved.)
T h e periosteum is reflected on both surfaces of the
margin and a 0.5 mm (some prefer 0.4 mm) wire loop is
passed through drill holes. This may be facilitated by
passing a fine (0.35 mm) wire loop from the outer to inner
aspect of the frontal process of the zygoma to pull the
transosseous wire.through the lower drill hole. This acts
both as anchorage for the perfrontal suspensory wire and
as transosseous fixation. The suspensory wire itself is
drawn up from the buccal sulcus with a long awl which has
been passed down through the incision and behind the
zygomatic bone. To save an extra journey, as with
circumzygomatic wiring, the doubled wire can be drawn ;

up attached to the awl by a simple fine wire loop w h i c h is

removed. T h e perfrontal transosseous w i r e is passed
through the suspensory wire and then tied. This is
repeated on both sides. Before the wound is closed a 0.35
w i r e twisted loop is attached to the suspensory w i r e and
left protruding through the skin where it is protected w i t h
tape. This enables the end of the long loop to be pulled
out through the skin and cut, prior to removal through the
mouth as attempts to pull it through its transosseous
suspension may lead to breakage.

6c
 Treatment of fractures of the maxilla 47

7
External suspension
External suspension employs cast silver splints for which
impressions are required. The splints are cemented on to
the teeth with cold cure acrylic or a polyphosphate dental
cement preoperatively. The maxillary splint incorporates a
locking plate to which a connecting rod is attached by
miniature s c r e w s .

8
This rod may in turn be attached to a form of halo frame
(Crewe or Royal Berkshire).

9
Alternatively, the rod is attached to self-tapping bone
screw pins (Moule or Toller) which have been screwed
into drill holes in the thickening of the superior temporal
line 1 cm above the supraorbital ridge.
48 Treatment of fractures of the maxilla

10
With the skin held immobile between two fingers, a stab
w o u n d is made through which a tapering fissure burr is
used to drill a narrow 5 mm deep hole directed in an
imaginary line towards the centre of the globe of the e y e .
Without releasing the skin, the screw-pin is carefully
screwed firm using the T-handle.
In both cases connecting rods and universal joints are
used.

10
11
A modification of the latter system is the box frame in
which screw pins are also inserted in the mandible behind
and below the mental foramen. T h e four pins are joined
up to form a square. This avoids the need for cast splints
and a locking plate system, allowing the use of eyelets or
arch bars.
Once maxillary reduction and suspension have been
achieved, fractured nasal bones should be treated. T h e
temporary intermaxillary wire loops are then divided, and
all intraoral and facial incisions and wounds closed. For
intraoral wounds use a 3/0 black silk or polyglycolate
suture, but a 5/0 monofilament for the skin. The pharynx is
carefully sucked dry and the throat pack removed, prior to
definitive intermaxillary fixation with 0.5 mm wire loops
(some surgeons prefer elastics during the first 24 hours). A
nasopharyngeal airway is left in situ and will require
hourly suction to maintain patency and clear any postnasal
ooze.
Jaw fracture patients with intermaxillary fixation require
individual postoperative nursing care in high dependency
areasJ
 Treatment of fractures of the maxilla 49

Postoperative care Complications

Serious infection is now rare with routine antibiotic
prophylaxis.
Care of the airway and administration of analgesics and
Dental problems which will require attention include
antiemetics are as described for mandibular fractures (see
fractured teeth, which can be root,filled and c r o w n e d or
p. 000). Antibiotics for dural tears are maintained for 10
extracted; missing teeth, which will require dentures or
days. If the cerebrospinal rhinorrhoea persists after
bridgework; and minor malocclusion, which can be
reduction or with a severe head injury a neurosurgical
corrected by spot grinding.
opinion is required.
Persistent diplopia or epiphora will require ophthalmic
T h e mouth is cleansed with 2 per cent chlorhexidine or
attention.
5 per cent sodium perborate or a weak solution of sodium
Anosmia is rare and recovery is unpredictable.
bicarbonate or sodium chloride. All wires and connecting
Post-traumatic meningitis is also rare, but the possibility
joints must be checked daily.
should always be considered.
Nasal crusting is prevented and the drainage of antral
Disturbances in personality and depression can also
blood clot is facilitated by steam inhalations (pine,
occur after severe facial and head injuries.
tinct.benz.co. or Karvol).
Intermaxillary fixation is maintained for 3 weeks and
mobility is tested before the suspension is removed. This Further reading
is of course not possible with the box frame w h i c h can
only be completely taken d o w n . Banks, P. Killey's fractures of the middle third of the facial
skeleton. Dental Practitioner Handbook No. 3,4th ed. Bristol:
Removal of wires is best done with relative analgesia or Wright, P. S. G.,1981
intravenous sedation and analgesia, i.e. diazepam 10 mg
and pentazocine 60 mg, although some surgeons take Rowe, N. L , Williams,). H. eds. Maxillofacial injuries. Edinburgh:
pride in removing them 'cold'! Churchill Livingstone, 1984
Illustrations by Mohd-Noor Awang

Treatment of blow out fractures of t h e

orbit
Malcolm Harris MD,FDS,RCS,FFD,RCSI
Professor of Maxillo-Facial Surgery, Institute of Dental Surgery and University College Hospital, L o n d o n , U K .

Introductiori
A true blow out fracture implies the loss of orbital floor or
wall with an intact orbital rim. The orbital fascia may also
be ruptured with extrusion of connective tissue and fat
into the air sinuses.
T h e possible complications which may arise and require
treatment are diplopia and enophthalmos.
There are two aetological theories, the classic being that
a sudden rise in intraorbital, hydraulic pressure due to a
blunt blow o n the eye with a tennis ball, elbow, e t c . ,
ruptures any thin section of the bony wall of the orbit,
usually the floor or medial w a l l .
1
T h e second theory is that a b l o w o n t h e oraza
which does not fracture, is transmitted as a bx:c:<;fr-'.5:Tt^c'-
along the orbital floor. This may p r o d u c e a H - - - - -rscr^r*-
or frank defect . In this situation t h e orbital
2
T T S * b<
trapped in the linear fracture o r ruptured c ^ i i e s -may
herniate through a defect as the result of a s e c c c c s r v riv-
in orbital hydraulic pressure d u e t o o e d e m a s a i rrscsna-
toma.
It is probable that both m e c h a n i s m s c=a# -x&J-
separately or together.

50

ORBITAL FLOOR BLOW
OUT FRACTURES
Assessment
O e d e m a , ecchymosis and surgical emphysema often mask
the eye and conceal the restriction of upward ocular
movement with diplopia. This is usually due to trapping of
the orbital connective tissue and hot the inferior oblique
and inferior rectus muscles . With a significant loss of
3
orbital fat there will be enophthalmos which will later
become apparent with retroplacement of the eye and
deepening of the supratarsal sulcus giving a pseudoptosis
of the upper lid.
With inferior entrapment there is globe retraction on
attempted upward gaze and an increase in applanation
tension within the globe.
Pupillary size, symmetry and reaction to light and
accommodation must be noted.
T h e eye should also be examined by an ophthalmic
surgeon t o :
1. establish visual acuity;
2. exclude corneal, anterior chamber and retinal damage;
3. make orthoptic recordings of the field of binocular
fixation and of the ocular movements with the Lee/Hess
screen.
Treatment of blow out fractures of the orbit 51
Investigations
Standard (Waters) and 30° (Caldwell) occipitomental films
may s h o w a cloudy antrum or prolapse of the mucosa of
the antral roof, the 'hanging drop' sign, with an intact
bony r i m . Hypocycloidal polytornography will provide
more information, but axial and coronal computerized
tomography give most detailed information especially of
the connective tissues and muscles.
Indication for operation
There is rarely any urgent need to operate except w h e r e
there is gross herniation of orbital contents into the
a n t r u m . W h e r e possible, oedema and haematoma should
be allowed to diminish. The patient is given a course of
amoxycillin or erythromycin for 5 days and instructed not
to blow his or her nose or rub the eye.
Surgery is indicated if between 10 and 14 days after
trauma there i s :
1. enophthalmos of 3 mm or more;
2. connective tissue entrapment with restricted move-
ment and globe retraction on upward gaze; and <
3 . unchanging diplopia on upward gaze.
The operation
T h e c o r n e a is protected with chloramphenicol ointment
prior to surgery and access is improved by trimming the
eyelashes. •
1
A subciliary blepharoplasty incision should be placed in a
skin crease with a No. 15 blade a few millimetres below
the lid margin, extended to the lateral canthus and then
d o w n w a r d s and laterally for 1 c m . This is first marked with
a pen and then infiltrated with a local anaesthetic-
vasoconstrictor solution. The assistant should firmly
stretch and hold the skin whilst the incision is made d o w n
to muscle layer. T h e lower margin is elevated with a skin
hook and separated from the orbicularis muscle with
sharp dissection. The dissection is then continued down
through the muscle to the orbital margin taking care not to
breach the orbital septum, which is the extension of the
orbital fascia into the lid. Should this occur fat will
herniate through and is best ignored.
 UUI niii-HjIWWI UlCUi'l/ll

2
The periosteum is incised at the orbital rim as widely as
possible and then carefully elevated with a sharp
instrument such as the Mitchell's trimmer. T h e orbital
contents are gently elevated with a narrow copper strip
whilst the bony defect is explored.
Entrapment by a linear fracture due to a 'buckling injury'
may have to be released by gently prising the margins
apart.
Small loose specules of bone should be removed.

3
Loss of bony continuity can be restored with 1 or 2 mm
silicone elastomer sheeting or bone from the ipsilateral
intact maxillary w a l l . T h e maxillary wall is exposed through
a long intraoral semilunar incision in the buccal sulcus.
T h e periosteum is reflected to the level, of the infraorbital
foramen and bone is removed from between the canine
root and zygomatic prominences. This can be done with a
fine fissure burr or carefully with a 3 mm osteotome. This
leaves a large antrostomy through which the orbital floor
may be palpated.

4
The minimum amount of material is placed compatible
with the provision of support to the orbital contents. Care
must b e taken to avoid encroaching on the optic nerve
and its blood supply at the orbital apex.
Before closure, ocular mobility should be checked by
forced duction, that Is passively rotating the globe away
from the defect either with plain dissecting forceps or a
suture through inferior rectus tendon near its insertion.
T h e periosteum is carefully closed with 3/0 polyglycolate
and t h e skin with a 5/0 monofilament suture.

Postoperative care
The eye is irrigated with normal saline to remove blood
and 1 per cent chloramphenicol eye ointment is applied."
The eye may be covered with a light pad, but visual acuity
must b e carefully monitored 6-hourly postoperatively for
24. hours. Sudden decrease in visual acuity suggests an
4
orbital haemorrhage with haematoma formation. This
must be immediately decompressed by opening the
w o u n d and removing the implant.
The patient should receive antibiotics during and after Complications
the operative procedure for 5 days.
O e d e m a may be reduced by giving dexamethasone Extrusion of silicone elastomer sheeting has b e e n r e -
10 mg with the anaesthetic induction agent, repeating this ported and is'probably due to too large a piece i n s e r t e d
12 hours later then giving 5 mg 12-hourly x 2. over minimal defects. Persistent diplopia due to d e n e r v a -
Orthoptic eye muscle exercises may be introduced from tion of the inferior oblique and rectus muscles may b e
the fourth day after the operation and continued for confirmed by electro myogram examination a n d w i l l
several weeks. require muscle surgery to restore visual axis p a r a l l e l i s m .

MEDIAL BLOW OUT
FRACTURES
A medial blow out fracture is a fracture of the thin (average
0.5 mm) medial wall of the orbit, the lamina papyracea,
with an intact orbital rim. Indications for treatment are
diplopia and enophthalmos due to trapping of the medial
rectus muscle and herniation of the orbital tissues into the
ethmoidal air cells. Improved diagnostic techniques
suggest that such fractures are not uncommon but that
enophthalmos and trapping are rare.
Assessment
O e d e m a and ecchymosis of the eyelids may conceal
subcutaneous emphysema, horizontal diplopia, retraction
of the globe on attempted abduction, and enophthalmos.
A positive forced duction test (i.e. detection of tethering
of the medial rectus with plain dissecting forceps) helps to
distinguish entrapment from restricted movements due to
nerve damage, muscle oedema and haematoma.
Treatment of blow out fractures of the orbit 53
As with all injuries involving the orbit an ophthalmic
surgeon is required to examine:
1. the c o r n e a , anterior chamber and fundus;
2. pupillary size symmetry and .reaction to light and
accommodation;
3. visual acuity and fields;
4. e y e ' movements including Hess screen and forced
duction.
O n c e recorded these observations provide a baseline for
further assessment.
Investigations
Plain radiographs using a standard (Waters) and 30°
(Caldwell) occipitomental views will show clouding of the
ethmoidal air sinus. A break in the vertical radiopaque
lamina papyracea and orbital emphysema may not be
detectable. Hypocycloidal polytomography is superior to
linear tomography for further investigation, but both are
inferior to axial and coronal computerized tomography
(CT) which, can detect medial rectus entrapment. N.B. As
medial blow out fractures are commonly associated with
orbital floor injuries, coronal sections are desirable."
The operation
W h e r e there is positive C T scan evidence of medial rectus
entrapment or w h e r e abduction continues to be limited
after 10 days, especially with globe retraction, the medial
orbital wall should be explored.
5
Access is limited through an infraorbital incision w h i c h
may be necessary for an orbital floor injury. T h e medial
approach is made through a semilunar incision 1 c m
anterior to the medial angle (inner canthus) of the eye on
the lateral surface of the bridge of the nose. It is therefore
commences at the level of the upper edge of the anterior
lacrimal crest and the medial palpebral ligament and
passes upwards to the superomedial angle of the bony
orbit.
D4 Treatment 01 oiow out iractures ot tne oroit

6
The dissection is made subperiosteal^ with a small sharp
elevator such as a Mitchell's trimmer. T h e lacrimal sac
should be carefully mobilized from between the anterior ,
and posterior lacrimal crests. This should enable the
medial wall to be carefully explored towards the apex of
the orbit and any connective tissue and muscle mass to be
freed from the fractured margins of the lacrimal air cells. If
the defect is extensive an inferior subciliary approach may
also be required.
Compression of the orbital contents should be avoided
by the careful use of narrow flexible copper strips.

7
The bony defect can be closed with 1 mm silicone
elastomer sheeting (e.g. Silastic) or cortical bone from an
intact antral w a l l . Once trimmed this can be wedged into
place.
Mobility of the globe should be confirmed by forced
duction prior to closure. T h e periosteum is sutured with
3/0 polyglycolate and the skin with a 5/0 monofilament.
T h e eye is irrigated with normal saline, and 1 per cent
Chloramphenicol eye ointment is applied to the corneal
and conjunctival surface before covering with a light eye
pad.
Antibiotics and dexamethasone are administered as
described for orbital floor blow out factors and the eye
examined 6-hourly.

References
1. Smith, B., Regan, W. F., Jr. Blowout fractures of the orbit.
Mechanism and correction of internal orbital fracture.
American Journal of Ophthalmology 1957; 44 : 733-739

2. Fujino, T., Makino, K. Entrapment mechanism and ocular

injury in orbital blow out fracture. Plastic and Reconstructive
Surgery1960; 65:S71-576

3. Fells, P. Acute enophthalmos. Transactions of the

Ophthalmologic^ Societies of the United Kingdom 1982; 102
(Pt.1): 88-89

.',7.
Illustrations by Frank Price

Submucous resection of the nasal

septum
R. A. Williams M A , FRCS, FRCS(Ed), DLO
Consultant Ear, Nose and Throat Surgeon, Middlesex Hospital, London and
Q u e e n Elizabeth II Hospital, Welwyn Garden City, Herts;
King Edward VII Hospital for Officers, London and Honorary Civilian Consultant to the Army, UK

Preoperative
. Indications
The most common indication is nasal obstruction due to a
deviated nasal septum. T h e obstruction may be a cause of
recurrent sinus infections. Straightening the septum is
sometimes required to gain access to the"nose and sinuses
w h e n dealing with polypi, enlarged turbinates, tumours,
rhinoliths, or epistaxis when it comes from the posterior
part of the nose.
Contraindications/
: — — - —
f the nasal obstruction is only partly due to the deviated
s e p t u m , and partly d u e to an allergic rhinitis, straightening
the septum may well have n o lasting effect and s h o u l d "
not, therefore, be undertakemKAn acute upper respiratory
infection, even a c o l d , within 2 w e e k s , can make the
operation more difficult, because of bleeding,' and
postoperative complications more likely and so it is best to .
postpone operation in these circumstances.
Preoperative preparation
L^c^l__apipJication of vasoconstrictors is helpful, both to
make it easier to see and to reduce bleeding. The nose
may be sprayed with adrenaline 1:10000, or one of a
variety of proprietary constricting agents having the same
effect, i l l s advisable to apply the vasoconstrictor only a
few minutes before operation. If a local anaesthetic is to
be used it is combined with the vasoconstrictor; for
example, lignocaine 4 p e r c e n t with adrenaline 1:10000 is
suitable. A^ejieraJLjuiae^theJic i s , however, preferable
and a cuffed endotracheal tube should be used with a
pharyngeal pack.

55
;>o ^uomutous resection oi the nasal septum

The operation

Position of patient
T h e patient lies supine on the operating table, which is
tilted about 15° head-up. The surgeon faces the patient,
standing on the right-hand-side of the table

1
The incision
T h e incision is made on one side of the septum, about
5 mm from the anterior edge of the septum.
It is carried through the mucosa and perichondrium.
T h e incision should be made on the side of maximum
deviation.

2
The dissection
A plane of cleavage is found between the cartilage and
perichondrium and this is opened by dissection.

3
3&4
The cartilage is incised in the same line as the original
incision and a cut is then taken through the cartilage to
open another plane of cleavage on the other side, again
between the cartilage and perichondrium. If the deviated
septum was caused by trauma then these p l a n e s of
cleavage may come to an end where the cartilage w a s
cracked.
 Submucous resection of the nasal septum 57

5
^je_«rti]a^eL4s_j^eTrj^ by punch forceps or by a
Ballenger's swivel knife as far as the dissection has
proceeded, and then further separation of the flaps is
continued back onto the perpendicular plate of the
ethmoid and vomer.

There is no set amount of cartilage or bone to remove;

as much is removed as is necessary to straighten the
septum. A strip of cartilage should be left anteriorly, in
front of I r i e i n d s i o n T about 5 mm w i d e , and another
-

similar strip along the dorsum of the nose. These are to

maintain the shape of the nose and prevent collapse of the
nasal tip or retraction of the columella.

ANTERIOR DISLOCATION

An anterior dislocation of the cartilage into one nostril can

sometimes be corrected, but it may be necessary to
remove some cartilage right to the front. In this event the
first incision is right on the end of the dislocated cartilage.
The supporting strip is, if possible, left a little farther back
and a second incision is made on one or other side,
behind this strip.

7
The bony crest

The cartilage is surrounded by perichondrium and the

layers on each side join under the cartilage. The lower
edge of the cartilage therefore comes away, leaving a
groove of perichondrium lying on the crest of the maxilla
and vomer. Usually this crest is deviated or widened and
has to be removed. Another plane of cleavage is f o u n d
between the bone and periosteum on both sides, so that
the crest of the bone is completely freed of soft tissue. It
may be helpful to make a tunnel from the front, under the
periosteum, and then to fracture the crest into the
midline, to prevent tearing of the flaps at the apex of the
deviation. The bone is removed with a hammer and gouge
or bone forceps.
It is important not to leave any deviated ridge of bone
below, or the whole septum will be held to one side.

The flaps

Tearing a flap ori one side is of no consequence unless
there is another tear in the other flap exactly opposite. If
this happens, a permanent perforation will probably
result. If both sides are torn they can be sewn u p ;
otherwise no suturing is necessary or desirable. The nose
can be left unpacked after operation, but packing gently
on both sides does hold the flaps together and helps to
prevent bleeding and haematoma formation. T h e packs
should be left in for a few hours. Chemotherapy is not
required.
 ji-j.iui.ou.i resection oi me nasai septum
Postoperative care
The patient should be on his side, to prevent inhalation of
blood, a n d , as the nose may be blocked, the airway has to
be maintained during recovery from the anaesthetic.
After 24 hours, warm normal saline is sniffed through
the nose twice a day and this will help to clear blood and
secretions. O n the third postoperative day the nose
should be examined and any blood clot or coagulated
exudate removed, if it comes away easily. If adhesions
start forming between the turbinates and septum, they
should be separated every day or two for as long as
necessary, sometimes up to 2 or 3 w e e k s .
Reduction of the turbinate on the side opposite to
the deviation
After a deviated septum is straightened the nose will be
clearer on the side previously blocked by the deviation
but may become more blocked on the other side. This is
because the inferior turbinate usually enlarges on the side
opposite to the deviation and so this turbinate will need to
be reduced when the septum is centralized (see chapter
on 'Turbinectomy', pp. 80-82).
illustrations by Robert N. Lane

Septodermoplasty
D. F. N. Harrison M D , MS, PhD, FRCS, FRACS
Director of the Professorial Unit, Institute of Laryngology and Otology and Royal National Throat, Nose and Ear Hospital,
London, U K

Introduction
Control of epistaxis by cauterization of the lesions in
familial haemorrhagic telangiectasia (Osler-Rendu-Weber
disease) is rarely effective. Removal of the vascular lesions
from the nasal septum and accessible parts of the nasal
m u c o s a , with replacement by a thin skin graft, provides
relief from bleeding although revasularization eventually
occurs with development of new lesions.
foU Septociermopiasty

The operation

Anaesthesia may be general or by local infiltration with 1

per cent lignocaine and 1:200 000 adrenaline.

1
In the narrow nares a small alar incision may expedite
access; the anterior incision is simitar to that made for
submucous resection of the nasal septum, being carried
through mucosa and perichondrium. A plane of cleavage
is found between cartilage and perichondrium although
previous cauterization frequently makes separation diffi-
cult. The flap is separated as far posteriorly as there are
telangiectasis. Mucosa on the floor of the nose is then
separated from underlying periosteum up to the inferior
meatus on the lateral nasal wall.
Separation of involved mucosa from the inferior
turbinate is often impossible and this bone can be
removed along with its covering of telangiectasis.

Placement of skin graft

2
A suitably sized split-skin graft is sewn with catgut to the
edge of the vestibular skin and coated on its inner surface
with 'tissue glue'. This allows the graft to be firmly
attached to underlying perichondrium or periosteum by
firm pressure with a Hill's elevator or other suitably
shaped instrument.

3
This technique enables the septum and nasal floor to be
covered as far posteriorly as desired without the need for
nasal packing.
Extension of skin graft coverage to the inferior meatus
presents no difficulty but good attachment to the
denuded inferior turbinate is less satisfactory. Adhesion
occurs within 30-40 seconds depending on the glue
utilized and no nasal packing is necessary or desirable.

3
 Illustrations by.Gillian Lee
Septoplasty
A . G . D. Maran MD,FRCS
Consultant Otolaryngologist, Royal Infirmary, Edinburgh, UK
• Q
Preoperative
Indications
Septoplasty is an operation designed to replace a deviated
nasal septum in the midposition by dividing almost all its
attachments and leaving the quadrilateral cartilage
attached to a flap of mucosa to preserve its viability. •
T h e procedure is of particular use under the following
circumstances.
1. W h e n septal deformities have to be dealt with as part of
a rhinoplasty. T h e scarring caused by a submucous
resection militates against a good rhinoplasty result a n d
also prevents use of a one-stage procedure.
2. W h e n there is a dislocation of the caudal end of the
quadrilateral cartilage. Removal of this by submucous
resection would cause immediate collapse of the nose.
3. W h e n deviation of the cartilaginous part of the nose is
external and cosmetically unacceptable.
T h e operation may be done in children but it is advisable
to become very experienced in the procedure before
performing it in patients under 18 years of age.
Anaesthesia
T h e operation may be performed under either local or
general anaesthesia.
If the latter is used, some degree of hypotension is
advisable since a clear operative field is essential for
accurate repositioning. This may be achieved with the use
o f j j a j o t h a n e and" posture; if this is to be done, the
anaesthetist must also allow the surgeon to infiltrate 6 ml 2
per cent lignocaine with noradrenaline.
If local anaesthesia is preferred the premedication
should consist of chlorpromazine, pethidine and scopola-
m i n e in a dosage according to the patient's weight and
age.
Jn^LriiejMnstance the nasal septum, dorsum and tip are
infiltratedwTth local anaesthesia as described above.
T w e n t y minutes prior to surgery the nasal cavity is lightly
packed with cotton wool soaked in lignocaine and
adrenaline.
Preoperative preparation
T h e packs are removed from the nose and the vibrissae
are trimmed with scissors. The surgeon cleans the whole
face w i t h aqueous Hibitane and the towels are applied so
that both eyes may be seen; this allows the nose to be
straightened more accurately. It is also important to check
that the endotracheal tube is in the midline so that the tip
of the nose is not distorted. *
61
 jtJpHJplilSl)'

The operation

The incision
A hemitransfixation incision is performed with a N o . 15
blade from the side of the caudal dislocation. There is no
need to elevate skin from the dorsum of the nose if only a
septoplasty is to be performed. If a complete transfixion
incision is performed, it is likely that the tip will d r o p .

Creation of mucoperichondrial flaps

Dissection begins at the caudal end of quadrilateral
cartilage using straight iris scissors and making sure the
correct plane is entered.

A Freer elevator is inserted and a plane developed back to

the bony septum in the upper half of the septum.

A long Killian speculum is inserted and opened. This

distracts the cartilage from the mucoperichondrial flap
and makes dissection easy in the, lower half. A similar
procedure is followed on the other side.
 Septoplasty to

Dissection of inferior part of the septum

4
The cartilaginous 'spur' which is equivalent to the inferior
fractured edge of the septum, is identified. Dissection
from this side is simpler because there is less scar tissue,
and it is easier to follow the cartilage. This allows entry to
the contralateral flap. T h e dissection proceeds from the
maxillary space to the ethmoid plate.

Repositioning of the cartilage

5,6&7
If there are any large bony deviations, these are removed,
but in every case about 0.5-1 cm of vomer and ethmoid is
removed to allow the cartilage to be repositioned without
catching on the bony margin.
T h e cartilage is trimmed along the floor, using tur-
binectomy scissors, in order to let it lie in the vomerine
crest. The cartilage should not require any stitches or
packs to hold it in position.
oa & D
Sharp vertical angles

In vertical fractures of the septum it is impossible to

Crosshatch so that the cartilage unfurls. This is because the
cartilage is traumatized and not normal. It must therefore
be excised in a strip and held over with reverse stitches.

9
Closure of incision

The hemitransfixion incision is closed with two polyglyco-

hc acid sutures which pull the quadrilateral cartilage back
into the columella.
 Septoplasty 65

10 & 11
Dressing
The skin is sprayed with an adhesive and tape is applied
from above downwards, each tape overlapping the
previous one. They are then held with a sling of tape
applied around the tip.
Finally a 10-thickness plaster of Paris dressing is applied.

Postoperative care

T h e patient is given one megaunit of penicillin at the end
of the operation and the next day goes on to oral penicillin
for one w e e k .
Care is taken that no plaster of Paris enters the eyes. If it
d o e s , the eyes are carefully irrigated with saline and the
patient uses Gantrisin eye drops for 5days.
T h e plaster, tape and packs are removed at one week
and the patient uses decongestant nose drops f o r a further
2 w e e k s . He or she is advised to wear the plaster cast in
bed for 2'inonths to prevent distortion of the nose during
sleep and "is~"iTso given instructions on how to avoid
trauma to the nose in the course of dressing and washing.
Ill filial . J '-" J ! • • • • • -
Rhinoplasty
T. R. Bull FRCS
Consultant Surgeon, Royal National Throat, Nose and Ear Hospital,
and Metropolitan Ear, Nose and Throat Hospital, L o n d o n , UK
lan S. Mackay FRCS
Consultant S u r g e o n , Metropolitan Ear, Nose and Throat Hospital,
Westminster Hospital and Brompton Hospital, L o n d o n , U K
History
In India during the eighteenth and nineteenth centuries,
amputation of the hose for adultery and other crimes w a s
a c o m m o n punishment and reconstruction of the total
nose with a forehead flap has been described, whilst
reference has been made to pressure dressings applied to
the nose in ancient Indian and Egyptian hieroglyphics.
Jacques Joseph, the famous German Surgeon, is
generally recognized as the father of modern rhinoplasty,
having first given a detailed account of reduction
rhinoplasty in 1898 and later in 1931 in his comprehensive
book entitled Nasenplastik und Sonst'tge Gesichtsplastik
Nebst Mammaplastik.
In this chapter, the basic technique for reduction
rhinoplasty is described.
Preoperative
Before agreeing to undertake a rhinoplasty to improve t h e
shape o r function of the nose, it is essential to assess t h e
patient from the general standpoint as well as the nasal
deformity. It is important to understand clearly the
anatomical factors involved in the deformity and to define
the steps to correct it. It is also important to explain to the
patient what can - and perhaps even more importantly -
what cannot be accomplished. Some are unable to accept
the limitations of surgery and, should the surgeon be in
doubt about the patient's mental attitude to the operation,
a psychiatric opinion should be sought.
66
In all cases, good preoperative photographs are
essential: not only is this necessary as a medicolegal
record but it also enables the patient and surgeon to
discuss what changes are planned, giving the patient a
realistic idea of what can be achieved. An unmounted
black and white print can be turned face down to an X-ray
viewing box and the planned changes pencilled over.
Preoperative preparation
In most cases, the authors prefer to undertake surgery
under general anaesthesia, the airway being protected by
a cuffed endotracheal tube and bleeding controlled with
local vasoconstrictors both by injection and topically to
the nasal mucosa. A full examination and routine
preoperative investigations are therefore required to
ensure that there are no contraindications to general
anaesthesia. A controlled hypotensive anaesthetic gives
excellent operating conditions for the surgeon, with
minimal bleeding, but has the limitation or risks over and
above a standard anaesthetic.
Anaesthesia
The patient is premedicated for general anaesthesia in the
usual way. As the nose is to be infiltrated with 1:8D0O0
adrenaline, the anaesthetist may w i s h to avoid halothane
and use a ^-blocking agent, provided there is no medical
contraindication, e.g. asthma.
T h e patient should also be monitored with an E C G
recorder throughout. After intubation with a cuffed
endotracheal tube, the cuff is inflated and the pharynx
packed with moist ribbon gauze.
The operation
REDUCTION OF OSTEOCARTILAGINOUS HUMP

1
Position of patient

The patient is placed on the operating table in the supine

position and tilted, head u p , to about 15° with the head
raised on a head-ring. The operating lights should be
arranged with one light from above and one from the foot
of the table. It is necessary in addition to use either a
headlight or fibreoptically illuminated instruments, parti-
cularly if the rhinoplasty is associated with work to the
nasal septum. The skin of the face should be prepared
with an aqueous solution of Hibitane and the nasal
mucosa prepared with 0.5 inch ribbon gauze, soaked in
aqueous Hibitane solution and packed lightly into t h e
nasal vestibule for a few minutes.

It is important that the endotracheal tube be placed and

fixed with strapping in the midline to avoid asymmetry of
the face. Similarly, the head towels should be crossed and
firmly secured with a towel clip in the midline, care being
taken to avoid piercing the skin. It is also useful to place
two towel clips from the head towels onto the head-ring in
such a w a y as to prevent the towel slipping forwards. The
eyelids are closed with 0.5 inch Steristrips.
2a-f
Anaesthesia

The nose is infiltrated with local anaesthesia (Lignocaine 1

per cent) and a Vasoconstricting agent {adrenaline
1:80000). The following sites are infiltrated.
(a) Between the upper lateral and lower lateral" nasal
cartilages.
(b) Along the dorsum of the nose. (It is sometimes
helpful, particularly with a large hump also to inject
percutaneously the root of the nose.)
(c) Into the region of the infraorbital nerve. This should
be carried out in a 'fanning' motion.
id) Along the site of the lateral osteotomy, under the skin
but external to the nasal bones. It is also helpful to
inject a little under the mucous membranes, medial to
the nasal bones.
(e) Along the columella.
if) • Along the lower margin of the lower lateral cartilage.
It can take 10-15 minutes for vasoconstriction to have
'maximum effect.
It is useful to apply a little cocaine and adrenaline paste
to the nasal mucous membranes.
 Rhinoplasty 69

3
Trimming vibrissae

The vibrissae are trimmed, using a pair of blunt-ended

straight scissors, smeared with a little vaseline. As the
hairs are cut, they tend to adhere to the blades.

The incisions

4a &b
W h e n the alar, retractor is used to elevate the rim of the
nose and gentle pressure is applied with the index finger
over the upper lateral cartilage, a clearly defined line
presents between the upper and lower lateral nasal
cartilages. A n incision is made along this line using a No.
15 blade scalpel. T h e intercartilaginous incision is con-
tinued medially to become continuous with the transfi-
x i o n incision w h i c h separates the columella flush with the
caudal border of the nasal septum.
70 Rhinoplasty

5a &b
In some cases, it may be helpful for this incision to be
placed in such a way as to include a small sliver of septal
cartilage in the columella (high transfixion incision) to
prevent contracture of the scar pulling the tip of the nose
downwards resulting in a 'pollybeak'. These incisions are
extended with c u r v e d , pointed scissors. •

6a &b
Skin elevation

T h e skin overlying the upper lateral cartilages is n o w

elevated using either curved, blunt-ended scissors or a
scalpel with No. 15 blade. The skin should be elevated up
to the nasal bones and a little beyOnd the osteocartilagi-
nous junction of the nasal bones and upper lateral nasal
cartilages to the glabella. Elevation onto the forehead is
unnecessary and leads to postoperative oedema w h i c h is
slow to settle.

7
Elevation of periosteum
T h e periosteum overlying the nasal bones is then elevated
using a periosteal elevator but care must be taken to avoid
disarticulation of the upper lateral nasal cartilage from the
nasal bone as this can lead to an unsightly depression
later.
 Rhinoplasty 71

If Division of upper lateral cartilages

'The upper lateral nasal cartilages should now be divided

from the nasal septum using a straight pointed (No. 11)
m blade. The Aufrecht's retractor not only provides expo-
H sure but also serves to protect the overlying nasal skin. It
m is most important that the upper lateral nasal cartilages are
ll'divided
a s c o s e
' a s
'y possible to the nasal septum, to
| ) prevent the formation of a T-shaped structure which may
i f i be difficult to lower using either Foman scissors or scalpel.
^ O c c a s i o n a l l y , patients may have a V-shaped deformity
where the upper lateral nasal cartilages and nasal septum
t j l p / j o i n . This can be baffling and confusing until the deformity
? | | ? has been recognized. This deformity may be the under-
W lying cause of a wide nose.

9a &b
T h e upper lateral nasal cartilages and cartilaginous nasal
septum are now lowered, one at a time, with Foman
scissors up to the bony nasal hump, resulting in a
'step-shaped' deformity.
72 Rhinoplasty

Removal of bony hump

10a&b
The bony hump can be removed using a Robin chisel. This
is a T-shaped chisel: the bar of the T ensures that one is
using the chisel in the correct plane and not lowering one
side more than the other. The bony hump can then be
grasped with a large pair of artery forceps (Spencer Wills)
but should be pushed further into the nose prior to
withdrawal to detach any adhesion between the mucous
membrane, periosteum and bone.

1la&b
Alternatively, the osteocartilaginous nasal hump can be
removed in one manoeuvre, using a Bull's nasal saw. This
saw has a single fine blade which allows the operator to
remove even a small hump and a rounded blunt end to
prevent damage to the overlying s k i n .

t'

11b
 Rhinoplasty 73

12
Whichever method is used to remove the nasal h „ „ m

rasp should now be used to smooth down and

I T fHi ° S S e o u s n a s a l s e
Pt™ t ° t h e ^ J s i ed

12
VPS**"

13
74 Rhinoplasty

Medial osteotomies

14
T h e medial osteotomies are the next step and a wide
osteotome (10-13 mm) is used. A narrow osteotome
carries the risk of slipping under the nasal bones and
damaging the cribriform plate. The media! osteotomies
are made in a slightly curved direction, curving laterally as
the osteotome ascends. This leaves a more natural root to
the nose, and on infracture the nasal bones will come to
lie under this remaining bony spine.

15
In some cases, it may not be possible to infracture the
nasal bones without removing further bone from the root
of the nose. This can be likened to attempting to push
books together on a bookshelf: no amount of pressure
can bring these books together but if a few books are
removed, those remaining can slide together easily.
Thickened bone can be removed from this area using a
fine but strong bony rongeur. In other cases, intermediate
osteotomies may be necessary.
 Rhinoplasty
r
7 5

f-
4
i
i' ' ! Lateral osteotomies

I 16
• Lateral osteotomies are undertaken with a saw or with an
osteotome introduced intranasally at the lateral aspect of
the pyriform aperture; a 2 mm osteotome may also be
used via external, stab incision. T h e use of a saw
necessitates elevating' a periosteal tunnel which usually
leads to marked' swelling postoperatively. It is also
laborious, requires considerable exertion and may cause
bone dust w h i c h can become infected. This is less likely to
occur with an osteotome.

17
It is not necessary to make an endonasal incision w h e n
using a Parkes osteotome. The osteotomy s h o u l d be
performed in a curved direction towards the medial
o s t e o t o m y , avoiding the necessity for a s u p e r i o r
osteotomy.
18
Whichever method is used to undertake the lateral
osteotomy, it is very important that this should be mmm
accomplished as close to the face as possible to prevent a
'step' deformity- which can often be seen and felt
postoperatively.
T h e nasal bones are then infractured.

18

19
It is important at this stage to recheck that the levels of the
septum and upper lateral nasal cartilages have been
lowered to the desired profile line. Ideally, the upper
laterals and septum should be lowered equally. It is
preferable to remove a little too much cartilage from the
supratip region rather than'too little as the latter may well
lead to a secondary hump or 'pollybeak' deformity.

19

20
Pressure with the thumb in the nasolabial a n e l « w i l l
depress the tip of the nose and make any excess c a r t i l a s e
in the supratip region appear more prominent; t h i s c a n
then be excised.
 Rhinoplasly 77

MODIFICATION OF THE TIP

Although the technique described here is a 'basic

technique', it will provide a satisfactory method for
correcting many of the more common deformities. Care
should be taken when modifying the tip cartilages,
particularly with thin skin, as mistakes here can lead to
conspicuous deformities which are difficult to revise.

21
The aim of this technique is to excise the upper border of
the lower lateral cartilage, shown here as a shaded area.
Note that the lower border of the lower lateral cartilage is
not parallel to the margin of the nasal vestibule but
ascends as it sweeps laterally. In some cases, it may
ascend very steeply and it is always important to palpate
carefully the lower margin of the lower lateral cartilage
prior to making any incision. This margin is often
delineated by the junction between the hair-bearing and
the non-hair-bearing vestibular skin.

22
The incision

This cartilage-splitting incision should be made in such a

way as to leave intact a rim of cartilage 2-3 mm wide.
Curved sharp-pointed plastic scissors are then inserted
into this incision and the blades spread. In this manner,
the skin overlying the upper part of the lower lateral
cartilage is undermined.

The lower border of the upper segment of the lower

lateral cartilage is then held with a pair of Adson's forceps
and pulled downwards; a periosteal elevatory can then be
passed under the skin and cartilage. The cartilage will thus
be uppermost with vestibular skin beneath.

23
Excision of cartilage

24
The segment of cartilage can now be e x c i s e d , taking care
to preserve the underlying vestibular s k i n . Loss of
vestibular skin in this region can lead to scarring and
contracture and a 'pinched-in' nasal appearance w i t h
airway obstruction at the valve area.
O n c e the upper segment of the lower lateral cartilage
has been removed, it is possible to rotate the tip
containing the caudal rim of the alar cartilages upwards in
a bucket-handle motion to shorten the nose. By removing
or leaving cartilage medial to the dome, it is also possible
to increase or decrease tip projection by this method. In
addition, removal of this upper segment of the lower
lateral cartilage will remove bulkiness and refine the tip.

25
At this stage - and it is best left to the very end - the
inferior border of'the septum can be excised. It is often
not necessary to remove more than a small sliver of
cartilage: excising too much may lead to columellar
retraction. Ideally, the columella should be clearly visible
w h e n the patient is viewed on profile.

Closure
T h e cartilage-splitting incision should be closed on each
side using two or three 4/0 catgut sutures on a small,
curved atraumatic needle. The intercartilaginous incision
need not be sutured, although it may sometimes be
necessary to remove a small triangle of upper lateral
cartilage including mucosa if this is protruding into the
nose and obstructing the airway. T h e transfixion incision
is closed, using 3/0 plain catgut on a straight atraumatic
needle. The nasal vestibule is packed lightly with a
dressing for 12-24 hours for haemostasis.
 Rhinoplasty 7')

A small piece of Cel-Foam.is placed over the bridge of the

nose which is then strapped with 0.5 in (13 mm) Steristrips
across the bridge and around the tip of the nose.

.licircle of plaster of Paris bandage, 8 layers thick, is

. cut to a suitable size for the nose. This is then soaked
,i w a r m water for a few seconds, then pressed between
w a d s of gauze and moulded over the bridge of the nose.
T h i s is strapped with more 0.5 inch (13 mm) Steristrips and
finally, a piece of 1 inch (2.5 cm) waterproof Elastoplast
dressing.

Routine postoperative care is usually all that is required

for the first night. The following morning, the packing is
27
r e m o v e d . There is often a slight epistaxis for about 10
minutes following removal of the pack, although this is
seldom troublesome. T h e patient is usually fit for
discharge about 4 hours after removal of the pack on the
following day. Postoperative pain is not expected and
analgesics should not be required. Complications
T h e plaster of Paris is removed at1 w e e k . Postoperative
photographs are taken for both medicolegal reasons and Immediate postoperative complications of rhinoplasty are
for teaching purposes and critical self-analysis o n the part very uncommon and epistaxis in the absence of associated
of the surgeon. The postoperative photographs are best septal surgery is rare. The lateral osteotomy causes
taken at about 4 weeks postoperation, by w h i c h time most periorbital oedema and haematoma which varies in
of the swelling has subsided. There will be further change severity. The oedema settles within 3-4 days but the
over the next 6 months and some slight change a year or bruising, occasionally associated with a subconjunctival
more after operation. haemorrhage, may take 2 weeks to subside.
11: u cUiO! ! s Oy <^_i 111311 L S 6

R. A. Williams MA, FRCS, FRCSfEd), DLO

Consultant Ear, Nose and Throat Surgeon, Middlesex Hospital, London and
Q u e e n Elizabeth i I Hospital, Welwyn Garden City, H e r t s ;
King Edward VII Hospital for Officers, London, and Honorary Civilian Consultant in Otolaryngology to the Army, U K

Indications 4. Removal of the anterior end of the middle turbinate

m a y b e required to assist drainage of an infected frontal
1. In hypertrophic or vasomotor rhinitis, partial tur- sinus.
binectomy may be indicated to improve the nasal 5. A neoplasm involving a turbinate. * t
airway. \
2. After a submucous resection it may be necessary to
reduce one inferior turbinate (see chapter on 'Sub- Contraindications •
mucous resection of the nasal septum', pp. 55-58. An allergic rhinitis is often best treated medically and
3. For access to the inferior meatus, a small part of the partial turbinectomy is not normally an effective treat-
anterior end of the inferior turbinate can be removed ment. In children, surgical reduction of the turbinates is
as a preliminary to an intranasal antrostomy. very rarely indicated.

80
 TurbineUomy tf'l

The operation

T h e position of the patient and surgeon is the same as for

submucous resection (see chapter on 'Submucous resec-
tion of the nasal septum', pp. 55-58}. Preoperative
application of vasoconstrictors is necessary. A general
anaesthetic is preferable.

INFERIOR TURBINATE

Anterior end

A cut is made with a turbinate scissors for 13 mm OA inch)

back from the anterior e n d . A snare is used to remove the
p i e c e , and the wire should cut obliquely so that the new
anterior end slopes backwards. The cut bone may have to
be t r i m m e d .

Posterior end

A nasal cutting snare is used, with the wire slightly angled.

It is usually possible to place the snare round the
ballooned posterior end of an inferior turbinate. If the
snare cannot be used, the posterior end may be gripped
with a Luc's forceps and removed by pushing backwards
into the nasopharynx. If the forceps are pulled forwards a
m u c h larger piece of turbinate may come away than was
planned.
82 Turbinectomy

Middle turbinate
A cut is made with turbinate scissors back for about 18 mm
{ A inch) from the anterior e n d , and the partially freed
3

piece of turbinate is fractured downwards. It is then

possible to snare off the appropriate amount to open up
the middle meatus. *

Bleeding Atrophic rhinitis

The turbinates are very vascular and postoperative Atrophic rhinitis can result from too radical turbinectomy.
bleeding may occur. It is, therefore, usually necessary for If the nose is made too wide it ceases to function normally
patients to remain in hospital for a few days, depending and becomes dry and crusty. The nasopharynx and throat
on the extent of the surgery. may also be too dry.

•
Illustrations by Gillian Lee
John Groves M B , BS, FRCS
Consultant Ear, Nose and Throat S u r g e o n ,
Royal Free Hospital, London, UK
SUBMUCOSAL DIATHERMY
OFTHENOSE
Preoperative
Indications
Submucosal diathermy is indicated in nasal obstruction
due to persistent engorgement of the inferior turbinates,
as may occur in vasomotor rhinitis and rhinitis medi-
camentosa. Every effort should be made first to treat
causative allergies or chronic sinus infections. Paroxysmal
sneezing and rhinorrhoea are not m u c h , if at a l l , relieved
by submucosal diathermy. Classical hypertrophic rhinitis,
with 'mulberry' pedunculated masses, requires surgical
excision of redundant tissue, for w h i c h submucosal
diathermy is no substitute.
T h e technique may be combined usefully with other
intranasal procedures such as submucous resection of the
s e p t u m , and even with tonsillectomy if the operator
adapts his technique to the 'upside-down' position.
Anaesthesia and preparation
Although it can be carried out under topical anaesthesia,
the operation is unpleasant for the patient and therefore
likely to be inadequately performed. General anaesthesia
is recommended, with cuffed tracheal tube and pharyn-
geal pack. T h e nasal mucosa is then painted with 1:1000
adrenaline or cocaine paste to induce vasoconstriction.
Equipment
A pointed electrode, insulated except for 3-5 mm at its tip,
is connected to a standard surgical coagulation diathermy
source, the earth electrode being placed on the thigh or
buttock. It must permit good manual control and a clear
view of the intranasal insertion [see Illustration "/).
83
ir4 Coagulation diathermy treatment ot nasal obstruction

The operation

Insertion

1
An insulated nasal speculum is not necessary because the
anterior end of the swollen inferior turbinate is well clear
of the blade-tip of a standard Thudicum's s p e c u l u m .
T h e electrode point is pressed against the intended
point of entry and activated to produce blanching of the
mucosa.

2
The electrode is then advanced through this 'devascuia-
rized' spot, parallel to the floor of the nose and hugging
the medial surface of the turbinal bone until, at between 5
and 7 cm depth, the posterior end of the turbinate is
reached.
Art and judgement are required to follow the bone
closely in its irregularities and to avoid 'buttonholing' the
mucosa inadvertently.

Coagulation
The diathermy circuit is closed while the electrode is
gradually withdrawn so that a submucosal linear burn
results, with minimal injury to the mucosal surface. At the
point of exit, artful electrode technique will usually seal
off any tendency to bleeding. In more severe cases a
second or even third ' r u n ' may be m a d e , parallel to the
first, if a greater degree of shrinkage is required.
oil uoaguiation diathermy treatment of nasal obstruction

5
With the left thumb the soft tissues of the cheek are pulled
upwards and outwards to drag the nostril open. The
coagulating current is then applied for 2 or 3 seconds, so
that the soft tissues are 'anchored' and inhibited from
rolling inwards around the bony rim of the nose. A second
spot-weld about 1 cm below the first can easily be made
through the same mucosal puncture. It is wiser to make
two 'spot-welds', rather than to coagulate a continuous
swage of tissue, so as to avoid the risk of sensory
denervation of the nasal tip.
Most cases are bilateral, and both sides are similarly
treated.

This is minimal. Slight swelling alongside the nose, and a

feeling of stuffiness and stiffness, subside within a week
or two.

Problems are unusual. Bleeding is occasionally a nuisance
and unless the nose is absolutely 'dry' at (he end of the
procedure a pack or inflatable rubber bag for 8-12 hours is
a wise precaution.
T h e patient may leave hospital within a day or two. T h e
nose should be inspected after 4 or 5 days for removal of
any crusts. Provided that accidental abrasion of the
septum has been avoided, adhesions will not occur.
For 7-10 days the patient must expect no improvement.
His nasal obstruction may indeed be worse. Thereafter the
mucosal shrinkage begins to be apparent. T h e end result
may fairly be assessed at about 4 - 6 weeks.
Repeated diathermy
If the result is inadequate or, after a good response,
relapse occurs, the procedure may be repeated -
judiciously, with greater 'dosage'.
4 aperture.
Coagulation dialhermy (reatment oi na^al obstruction JS5
ALAR COLLAPSE — 'SPOT
WELDING'OFTHEALAE
NASI
Preoperative
Indications
This procedure is indicated for inspiratory valvular
collapse of the alae nasi, causing nasal obstruction.
Diagnosis is by simple observation, reinforced by the
obvious relief afforded by pulling the alae laterally.
-Qfiyjated septum, often a contributory factor, should be
recognized and surgically rectified. Spot-welding is not
always successful, but deserves to be tried in most cases
before resorting to plastic surgery which may alter the
appearance of the face. The method affords marginal
improvement, but will not overcome the forced, obses-
sional compression of the nostrils persistently complained
of by the neurotic subject.
Preparation
Naseptin cream should be applied to the nostrils two or
three times daily for 2 days, and systemic antibiotics (e.g.
erythromycin) should be given to cover the operative
period. These precautions are necessary to eliminate the
risk of postoperative facial cellulitis.
Anaesthesia
As for submucosal diathermy.
The operation
4
T h e electrode with insulated shaft recommended for
diathermy of the inferior turbinates should be used. Its tip
is placed within the nostril and pressed laterally against
the lower edge of the nasal bone. It is drawn downwards
until it slips off the bone. The point is then pressed
through the mucosa to lie just lateral to the bone
subcutaneously, 1 or 2 mm above the edge of the pyriform
([lustrations by Robert N. Lane

D. F. N. Harrison M D , MS, PhD, FRCS, FRACS

Director of the Professorial Unit, Institute of Laryngology and Otology and Royal National Throat, Nose and Ear Hospital,
London, U K

There has been a failure to appreciate the value of the procedure is suitable for both benign and malignant
lateral rhinotomy approach to the nasal passages and the intranasal tumours, affording means whereby the whole
ease with which both ethmoid and maxillary sinuses may lateral nasal wall and nasal septum may be removed
be visualized via a relatively short skin incision. T h e completely.
 Lateral i ninutomy

The operation

1
Skin incision
The upper limit of the incision need be no higher than a
point halfway between the medial canthus and dorsum of
the nose. To avoid an unsightly depressed scar it should
run just medial to the nasomaxillary groove but follow the
ala to finish within the nasal cavity. All layers are divided,
including the nasal mucosa, retraction of the alar region
away from the incision then allowing a clear view of the
vestibule and front of the nasal cavity.

2
Additional exposure
Elevation and retraction of the skin and periosteum over
the nasal bone and frontonasal process of the maxilla
allow removal of part of these bones to be carried out with
nibblers. Bone removal can be extended to include both
lacrimal bone and the lamina papyracea of the ethmoid.
By this means the ethmoidal labyrinth can be removed
' completely, together with all the turbinals.
Retraction of the cheek laterally enables the anterior
face of the maxilla to be removed as far as the level of the
infraorbital foramen.
Bleeding is minimal unless the nasal passage contains an
unusually vascular or malignant tumour. T h e excellent
visualization obtained by this approach enables the
surgeon to control even the most troublesome haemor-
rhage. Complete 'sleeving' of the nasal mucosa is
possible, with the exception of the region of the
cribriform plate, and this is particularly useful when
dealing with tumours such as malignant melanoma. Skin
grafting of bare septal cartilage or bony nasal floor is
unnecessary since re-epithelializatioh occurs rapidly.
Preliminary suturing of the eyelid is usually recom-
mended to avoid contamination from blood or infected
material.
Closure of skin incision
Preliminary closure with 4/0 chromic catgut is essential to
avoid undue tension on the fine 5/0 silk sutures used for
the s k i n . This enhances the excellent cosmetic appearance
of the skin. Contracture of the anterior nares does not
usually occur.
Illustrations by Angela Christie

John S. P. Wilson FRCS (Eng), FRCS (Ed) .

Consultant Plastic S u r g e o n , St George's Hospital and Westminster Hospital, London;
Royal Marsden Hospital, L o n d o n ; Queen Mary's Hospital, Roehampton, London; 1

St Helier's Hospital, Carshalton, Surrey, UK

Timothy M. Miiward M A , FRCS

Consultant Plastic S u r g e o n , Leicester Royal infirmary, Leicester and Lincoln County Hospital, Lincoln, U K

Incidence T h e depth of excision is critical: it is a salutary warning

Carcinoma of the nose constitutes 26 per cent of all skin
carcinomas. Approximately 90 per cent of nasal neoplasms
are basal cell carcinomas, 9 per cent squamous cell
carcinomas and the remaining 1 per cent a mixture of
rarities, including m e l a n o m a ^ . Lesions involving nasal
1
vestibules and septum are rare, the majority being
squamous cell carcinomas, with a few melanomas . 3
that incomplete clearance is more common in depth than
at the periphery of the specimen. Infiltration of the area
w i t h 1:200000 adrenaline serves the dual purpose of
reducing bleeding and accentuating deep attachments,
and the level of excision should be through the anatomical
layer below the deepest one involved. If clearance is in
doubt, a negative biopsy from the wound bed is more
informative than examination of the specimen itself.

Anaesthesia
Local anaesthesia using 1:200000 adrenaline with 1 per
cent lignocaine is used for smaller lesions. In patients in
w h o m more extensive excision is necessary, a general
Principles of excision
anaesthetic via an endotracheal tube is preferable. W h e r e
the viability of reconstructive flaps may be in doubt, the
T h e margin of excision, balancing unnecessary mutilation
blanching due to vasoconstrictors can be misleading, so
against adequate tumour clearance, is a matter for
they are better avoided.
individual decision. A s a general rule, 5~"l0mm of normai
skin should be excised for most well- and moderately
differentiated carcinomas. Clearance by frozen section
monitoring i s , however, essential. Conventional margins
Position of.patient
of excision for melanomas are not feasible on the face and
T h e patient is placed in the supine position using a head
a compromise is necessary. Fortunately, many of the facial
ring. An oral endotracheal tube is led caudally. Standard
melanomas arise in areas of lentigo. This is a relatively
head towels are applied, exposing the whole face. Care
benign variation of the disease and the prognosis is good.
should be taken to protect the cornea from damage. A n y
For many lesions an excision biopsy, as opposed to an effective aqueous skin preparation may be used. Some
incision biopsy, can serve for both diagnosis and degree of head-up tilt is helpful to reduce venous
treatment. All lesions should be examined by the bleeding.
pathologist to confirm complete clearance if the recur-
rence rate is to be reduced, and this is vital where primary
reconstruction is planned. Sutures
Basal cell carcinomas of the nose which are situated in
the alar groove are particularly prone to recurrence. They Stitches tied too tightly produce transverse scars, a n d
should be widely excised to include the underlying sutures maintained for too long result in unsightly pits d u e
muscle. If complete clearance is in any doubt, reconstruc- to epithelialization of the stitch holes. Interrupted 6/0
tion should be deferred for a year, as recurrence under a nylon is indicated for small incisions, whereas 4/0 or SO
flap travels widely in a subcutaneous plane before silk is more suitable for the larger reconstruction. Sutures
presenting on the surface. are removed after 5-7 days.

89
%• Surgery or tumours of the external nose and nasal cavity

If in any instance the surgeon is uncertain about the

advisability of a flap repair, a split-skin graft or skin-to-
mucosa suture is quite acceptable as a temporary solution
and in no way compromises future flap reconstruction.

1
The skin of the face may be divided into a number of
aesthetic units, determined by the natural crease lines
bounding areas of similar skin thickness. It is important to
honour these areas when reconstructing the nose and to
consider the advantages of replacing a whole unit rather
than a random area, even to the extent of carrying out
total resurfacing of the nose for a subtotal resection.

2
Small localized lesions can be excised and closed directly.
Scars should be placed in the natural crease lines, which
can be determined by pinching up the skin to see the
direction of the natural folds. A fish-tailed excision can
ease closure and diminish the dog ears.

FULL THICKNESS SKIN CRAFT

3
If the defect cannot be closed directly and there is an
adequate vascular b e d , a skin graft can be used. T h e
thicker skin of the nasal tip is best replaced with a local
flap, but a graft is ideal for the thin skin of the bridge and
inner canthus.
 Surgery of tumours of the external nose and nasal cavity 91

Full thickness skin gives a superior cosmetic result to split

skin, and a donor area with skin of suitable colour and
texture lies behind the ear, where the excision is
concealed. A pattern of the defect is m a d e j r o m the foil of
a suture pack, and the proposed graft is outlined over the
postauricular skin crease, adding two triangles to elimin-
ate dog ears when closing, the defect. T h e graft is
dissected with a scalpel from the cartilage and uneven
pieces of fat are smoothed off with scissors. Unlike full
thickness grafts from other areas, the fat is not deleterious
to graft-take, and can be retained to restore contour. A
graft of 2 cm x 3 cm can be obtained with primary closure.
For large grafts, split skin from the arm may be required
for the postauricular defect.

Full thickness grafts are sutured edge to edge and should

be immobilized by a 'tie-over' pack of proflavine or damp
cotton wool. Some of the sutures are left long and tied
over the wool to immobilize the graft. The pack and ear
suture are carefully removed after 1 week.
•j-i Surgery of tumours of the external nose and nasal cavity

C O M P O S I T E S K I N GRAFT

7
When the lesion infiltrates the columella or alar margin,
full thickness excision is required. If the defect is less than
1 c m in depth a composite graft of skin and cartilage from
the ear is the method of choice.

The lesion is excised using a No. 11 blade angled obliquely

to provide an increased raw area for vascularization of the
graft (see inset, Illustration 10).
 Surgery of tumours of the external nose and nasal cavity 93

A three-dimensional mould of the defect is made with

Stent's Dental Compound. This is transferred to the ear
and a suitable section of helix rim is marked out to match
the defect. On thejggriphery of the graft a wedge is drawn
to facilitate closure"of the ear defect. T h e wedge is
stepped at the helix rim to avoid notching of the ear by
scar contracture. It is important to carry the apex of the
w e d g e , including cartilage, down into the conchal hollow.
Up to 1.5 cm of helix rim can be excised without creating a
deformity.

In contrast to a full thickness graft, the composite graft

obtains all its blood supply from the wound margins.
Consequently suturing with interrupted 6/0 nylon must be
atraumatic and precise, and handling 'of the graft
throughout must be extremely gentle. No dressings
should be applied, it is common for the graft to be
cyanosed for 48 hours.

10
94 Surgery of tumours of the external nose and nasal cavity

NASOLABIAL FLAP

For the larger alar defects a nasolabial flap is indicated,

especially in older patients where there is lax skin in this
region. In males care should be taken to avoid transferring
hair-bearing skin to the nose.

In a full thickness defect the flap is infolded in o.Hsr to

provide lining, cover and adequate support for the nostril.

T h e tip of the flap is first sutured to the nasal lining with

catgut. Fine silk is used for the nasal skin and the cheek
defect is then closed directly. As the flap obliterates the
alar groove, the cosmetic appearance can be improved by
incising around the base of the flap at 3 months. At the
same time thinning of the flap can be performed.
 Surgery of tumours of the external nose and nasal cavity 95

G L A B E L L A R FLAP

In the upper third of the nose, if periosteum has been

removed, a skin graft will not take and a flap is required. A
glabellar flap transfers skin from the forehead where it can
be spared to the nasal bridge where skin is short.

The flap is lifted, pivoting on the medial end of the

opposite eyebrow, and transposed into the defect. The
internal angular vein may cause troublesome bleeding and
require ligation.

15

•v

16
Limited undermining allows closure of the forehead
defect. Dog ears on the nasal bridge and forehead can be
trimmed at this time.

16
96 Surgery of tumours of the external nose and nasal cavity

LATERAL NASAL FLAP

Free grafts will not restore contour at the nasal tip, but for
a small defect the lateral nasal flap provides skin of a
suitable thickness. The triangular defect at the nose tip is
transferred to the forehead where lax skin permits direct
closure in a natural skin crease.

18
The flap is lifted and carefully undermined at its base to
allow transposition to the nose tip.

Suturing commences at the nasal tip w h e r e tension is

greatest and proceeds to the glabella. The forehead defect
is sutured in two layers.
 Surgery of tumours of the external nose and nasal cavity 97

ALA REPLACEMENT WITH A FOREHEAD FLAP

A. pattern of the nasal defect is drawn on the forehead,

allowing sufficient pedicle length to reach the wound.
This is best checked with a piece of nylon tape. The flap,
which is based on the contralateral supratrochlear artery,
can be marked obliquely across the forehead to gain extra
length. If lining to the nose is required, a longer flap
should be planned to produce a two-layer repair.
98 Surgery of tumours of the external nose and nasal cavity

The forehead defect can be closed directly in most cases,

although considerable undermining deep to the frontalis
muscle may be necessary. With larger defects a split-skin
graft should be employed. This is held in place with a
'tie-over' dressing (see Illustrations 5 and 6).

23
After 3 weeks the pedicle is divided and returned to the
forehead, removing as much skin graft as possible. If the
remaining split-skin graft is cosmetically unacceptable, it
can b e replaced by postauricular skin. Should the
forehead have been closed directly, a section of the
pedicle should be returned to separate the eyebrows.
 Surgery of tumours of the external nose and nasal cavity 99

Large superficial tumours not involving the deeper tissues

may be excised and the defect covered by an immediate
forehead flap (see Illustrations 30-33). However, in the
case of an infiltrating tumour it is safer to defer
reconstruction and only amputate the nose, carefully _ , v

monitoring the margins with frozen section biopsy. - "~^'**%.-. '

100 Surgery o! tumours ol the external nose and nasal cavity

Closure by skin grafting

If the excision extends on to the cheeks and direct closure
is not possible, a split-skin graft is required. The skin
margins are sutured to the subcutaneous tissues and the
suture ends left long. A piece of Stent's Dental Compound
is heated in boiling water and squeezed into the piriform
opening so as to mould to its shape. It is then hardened by
cooling in iced water, and a split-skin graft is draped over
its surface. The mould is then applied to the defect and
maintained in position by multiple tie-over sutures. The
mould is removed and the graft exposed in 7 days.
 Surgery of tumours of the external nose and nasal cavity 1 0 1
TOTAL NASAL RECONSTRUCTION WITH
FOREHEAD FLAP
General principles
A total nasal reconstruction requires skin, skeletal support
and lining. Reconstruction is best carried out as a
secondary procedure (see Illustrations 24 and 25). Without
any doubt, the best nose is made from forehead s k i n ,
w h i c h is superior in thickness, texture and colour to other
donor areas, i.e. the arm or abdomen. It has an additional
advantage in that it can be brought to the nose in a single
stage. Contraindications are a badly scarred forehead or
an objection to its use by the patient,
29
Nasal lining
If complete lining is not provided during reconstruction,
the raw areas will contract, leading to gross distortion of
the skin covering. T h e end of the forehead flap can be
turned in to line the lower third of the nose, but the upper
defects require local flaps which can only be safely raised
some months after the nose has been amputated. A skin
graft may be employed for lining but has a marked
tendency.to contract.
Nasal cover
Having sutured the lining flap and incised the piriform
margins and columellar base, the skin required for nasal
cover is outlined on the forehead, allowing approximately
7.5 cm from alar base to alar base in the average adult
male. A three-dimensional foil pattern of the nose can be
helpful. In w o m e n and children where the hairline is low,
the pattern will need to be set obliquely.
T o improve the final cosmetic appearance, any skin left
between the eyebrow and the flap should be discarded so
that the lower edge of the forehead skin graft is partly
hidden by the eyebrow.
Vol Surgery oi tumours of the external nose and nasal cavity

To limit forehead scarring a Converse scalping flap is

4

used. The incision runs from the lateral side of the pattern
to the mid-vertex and thence to the opposite temple. That
area destined to cover the lower one third of the nose is
raised superficial to the frontalis muscle to preserve its
function and avoid the unsightly appearance of an
immobile forehead. The rest of the flap is elevated deep to
the muscle and aponeurosis. The end of the flap is
infolded to make a central columella and two alae. This
form is maintained with a catgut suture (see inset).

Suturing commences at the nasal tip, advancing down-

wards as much skin as possible to provide bulk in this
region. A split-skin graft is applied to the forehead and
scalp defects and immobilised by a 'tie-over' dressing of
plastic foam or damp cotton w o o l .

After 3 weeks the flap may be divided and the pedicle

returned to the scalp. The skin graft is excised with the
exception of that required to cover the remaining
forehead defect, although this can also be excised and
replaced by a full thickness supraclavicular skin graft if
improved colour match is required.
 Surgery of tumours of ihe external nose and nasal cavity 103

Thinning the reconstructed nose

Of necessity a reconstructed nose is more bulky and less
well defined than normal, it is not justifiable to perform
primary thinning, as this prejudices the flap's blood
supply. W h e n the flap has had 6-8 weeks to consolidate,
thinning should be undertaken. Wedges are excised from
the alar rim and columella to improve the nasal airways
and thin the tip. Some weeks later the lateral sides of the
nose d o w n to the alar region are undermined with a N o .
15 blade at a subdermal level, leaving a strip of
undisturbed skin in the midline. The skin is elevated from
the fat and underlying adipose tissue is then excised as a
soiid rectangle and the flap resutured. These manoeuvres
improve the shape of the reconstructed nose.

34

35
104 Surgery of tumours of the external nose and nasal cavity

Skeletal support

39
Autogenous bone is the most satisfactory material and the
iliac crest is a commonly used donor site, providing
compact bone for strength with a cancellous lower surface
for rapid bony union. At least 2 months after the nasal
thinning a suitably-shaped piece of bone is fashioned by a
combination of chisel cuts and bone nibbling. This is
inserted as a cantilever strut via an interiorly based
turn-down flap. A pocket is then made by blunt dissection
to the tip of the nose to receive the graft.

39

Using a chisel, a wedge-shaped cut is now made In th

lower edges of the remains of the nasal bones to create
socket for morticing the graft.

The graft is stabilised using fine stainless steel w i r e and the

skin flap is then replaced and sutured in two layers.
 Surgery of tumours of the external nose and nasal cavity M)s

EXTERNAL NASAL PROSTHESIS

in elderly or infirm patients, or in the case of a biologically

aggressive tumour, reconstruction is undesirable. A
spectacle frame nasal prosthesis provides an alternative
method of rehabilitation. Excellent prostheses can be
manufactured, and It is helpful if the technician can see
the patient preoperatively so that he may take an
impression of the nose.
Unnecessary delay in acquiring the spectacle frame and
lenses can be avoided by refracting the patient's eyes at
the same time.

43

RESECTION OF SEPTAL TUMOURS

Septal tumours are rare and the majority are squamous

cell carcinomas, with the occasional melanoma. Sub-
44 mucosal spread is common.

Tumours confined to the septum

Surgical approach
Adequate, controlled excision necessitates good exposure
and this can be achieved, with minimal external scarring by
a nasal tip approach. The incision runs from alar groove to
alar groove, passing just inside the nostril margins and
crossing the columella at its junction with the lip. In the
case of posterior lesions the incision is extended upwards
to improve the exposure by allowing the lower two thirds
of the nose to be retracted superiorly.

45
106 Surgery of tumours of the external nose and nasal cavity

The septum having been exposed, full thickness excision 46

of the lesion is performed. The cartilage is trimmed back
to allow mucosal healing over the septal edges. As long as
there is no proximal obstruction to the nasal airways, a
septal fistula causes little embarrassment.

The nose tip is accurately resutured with fine stitches and

the nostrils are packed with paraffin gauze for 48 hours.
 A * 4t

Surgery of tumours of the external nose and nasal caviiy 107

Tumours involving the nasal floor

Surgical approach 49
W i d e r exposure is needed for septal tumours invading the
nasal floor and upper alveolus. The previously discussed
septal approach (see Illustrations 44-48) is combined with
a central lip split.

50

The anterior septum and central portion of the upper

alveolus containing the tumour are isolated by chisel cuts.
The specimen is then removed and an impression of the
cavity is taken with Stent's Dental C o m p o u n d .

51
108 Surgery of tumours or the external nose and nasal cavity

A split-skin graft is draped over the Stent mould and can

be held in place by a metal tray attached to a previously
cast cap splint (see inset).

52

53
T h e nose is reset in position and sutured in two layers,
great care being taken to position the alar bases at the
same level. The lip is closed in three layers, particular
attention being paid to the alignment of the vermilion
border.
Fitting the prosthesis
The contour of the face is maintained at first by the Stent
mould. This is replaced after 10 days by an acrylic form.
W h e n healing is complete and oedema has settled, an
obturator attached to an upper denture provides perma-
nent nasal support.

54

References
1 . Conley, J . Cancer of the skin of the nose. Archives of 3 . Lyons, G. D. Squamous cell carcinoma of the nasal septum.
Otolaryngology 1 9 6 6 ; 8 4 : 5 5 - 6 0 Archives of Otolaryngology 1 9 6 9 ; 8 9 : 5 8 5 - 5 8 8

2 . Bennett, J. E„ Moore, T. S., Vellios, F., Hugo, N. E. Surgical 4 . Converse, J. M. Clinical applications of the scalping flap in
treatment of skin cancer of the nose. American Journal of reconstruction of the nose. Plastic and Reconstructive Surgery
Surgery 1 9 6 9 ; 1 1 7 : 3 8 2 - 3 8 7 1969; 43: 247-259
Illustrated by Ros Pritchard
Robin F. McNab jones FRCS
Senior Surgeon, Ear, Nose and Throat Department, St. Bartholomew's Hospital, London, UK
The maxillary a n t r u m
Lavage of this sinus is a common procedure. Von Aleya
and others have recommended lavage through the natural
ostium using a blunt cannula. T h e most widely practised
technique employs a straight Tilley-Licbwitz trochar and
cannula which is inserted through the inferior meatus and
this method will be described.
indications
1. As a diagnostic procedure to elucidate X-ray findings,
i.e. proof puncture.
2. As a means of assisting resolution of an acute or
sub-acute antral infection. Lavage may be repeated at
weekly intervals.
Contraindications
In children under 3 years of age the sinus may be so small
as to make lavage unjustifiably hazardous.
Occasionally an adult will have a very small antrum with
thick bony walls and lavage is impractical in these cases.
110
Anaesthesia
Local
The nasal passage is sprayed with 10 per cent cocaine and
1:1000 adrenaline solution and left for 3 minutes. This
shrinks down the inferior turbinate and 'opens up' the
inferior meatus. It also 'opens up' the middle meatus and
may ease the passage of washings through the ostium.
Consequent insertion of a cotton wooltipped probe into
the inferior meatus is made easier for the surgeon and
more comfortable for the patient. The wool is best carried
on aTumarkin wire. If this is not available a thin silver w i r e
wool carrier should be used. T h e wool should be dipped
into cocaine paste or soaked in a 20 per cent solution of
cocaine with a mucilin base. The probe is left in situ for 4
minutes.
General
Lavage under general anaesthesia is usually incidental to
other procedures, such as adenoidectomy or the removal
of polypi. If an endotracheal tube is used it should be
passed through the mouth. Lavage alone may require
general anaesthesia in children under 12 years of age and
in nervous adults.
 Lavage of the sinuses 111

Technique of puncture
T h e Tilley-Lichwitz trochar and cannula are inspected as is
the Higginson's syringe that wiil be used for lavage. T h e
trochar must be sharp and the tip should project 3 mm
beyond the cannula. It should slide easily in and out of the
cannula. The distal end of the cannula should be bent
slightly inwards so that it engages the neck of the trochar
and presents a smooth surface for piercing the antral wall.
All instruments, syringes, jug and receiver should be
sterilized.

1
The wire wool carrier is removed from the inferior meatus
a n d , visualizing the area with a Thudichum's speculum,
the trochar and cannula are inserted under the inferior
turbinate. The tip of the instrument is passed gently along
the lateral wail of the inferior meatus, nearer the roof than
the floor. Initially the wall of the meatus bulges laterally
away from the tip. It then bends medially and the tip will
naturally tend to be arrested at this point. Now the tip is
withdrawn 3 mm and pointed in the direction of the tragus
of the homolateral ear. Moderate pressure, sometimes
assisted by a gentle boring movement, causes the trochar
to pierce the bony wall of the meatus and enter the
antrum. In the adult the ideal point of entry is 3.5 cm into the antrum alongside the first. Washout then
posterior to the lateral edge of the vestibule. It lies behind proceeds through one cannula and out of the other.
the opening of the nasolacrimal duct and pierces the Air must never be passed through the cannula as this
thinnest area of the bony wall of the meatus. T h e trochar is has caused fatal air embolus.
removed and the cannula advanced until its distal end is Following lavage, the cannula is withdrawn and the
judged to be in the centre of the antrum. If necessary it patient w a r n e d that the antrum will continue to drain for
can be pushed against the lateral wall and then withdrawn the next hour or so.
1 cm.

Lavage
Clean tap water or sterile normal saline at 37°C should be
used. T h e Higginson's syringe is filled and connected to
the cannula. T h e patient is asked to lean forward and flex
the head over the receiver. He must then breathe through
his open mouth while the washout proceeds. The fluid
usually passes easily through the natural ostium and out of
the anterior nares. Any pathological contents in the
washings should be sent for bacteriological and cytologic!
al examination.
W h e n lavage is performed under general anaesthesia
the patient is often in the tonsil position with a
Boyle-Davis type gag in place. In these circumstances it is
best to introduce 5-10 ml of fluid with a Luer syringe and
then attempt to aspirate it rather than allowing fluid to
overflow into the nasopharynx.
For in-patients where frequent washout is desirable, a
thin polythene tube can be introduced through the
cannula and its proximal end taped to the forehead.
U n d u e pressure mqst never be used. If necessary the tip
Compiications
Slight haemorrhage occurs from the site of puncture,
especially in very acute infections. It usually ceases
spontaneously but very rarely it may be necessary to insert
a small bismuth, iodoform paraffin paste .(BIPP) 0.5 inch
ribbon gauze pack into the inferior meatus for 24 hours.
T h e end of the.pack should be taped to the cheek and the
patient kept in hospital until it is removed.
T h e cannula may be wrongly positioned so that attempts
at lavage are accompanied by acute pain and sometimes
by swelling outside the antra! walls. The washout should
be abandoned and antibiotics given. The cannula may be
superficial to the anterior wall of the antrum or, more
dangerously, it can enter the orbit. Neither of these
misplacements will happen if the above instructions for
puncture are followed carefully.
If the antral wall is thicker than usual and undue
pressure is exerted to puncture it, the force applied may
carry the trochar through the antral lumen and it can then
pierce either the lateral or posterolateral wall. This can be
avoided by using boring mnvfmpnt" m h r r t h n r - ' T n ' g
t h f

of the cannula is moved into different positions until an -ptesswe and by holding the trochar with the index finger
easy washout is achieved. If the natural ostium is closed by protruded so that it presses into the check as soon as the
oedema it may be necessary to insert a second cannula medial antral wall is pierced.
112 Lavage 01 the sinuses

The ethmoid sinuses The sphenoid sinus

Lavage of these sinuses is impractical owing to their Lavage of this sinus is occasionally necessary. It should not
number, small sizes and anatomical variations. be performed without previous X-ray studies, and poor
pneumatization of the sinus is a contraindication.
Although it is possible to introduce a cannula into the
normal ostium the usual method is puncture and lavage
through the anterior w a l l . This can be performed under
local or general anaesthesia. In either case good shrinkage
of the nasal mucosa with suitable vasoconstrictors is
Lavage of the sinuses through the frontonasal duct has essential.
been performed and was a relatively common procedure
at one time. It was sometimes preceded by forcible
dilatation of the duct with special curved dilators. Both
procedures run the risk of causing orbital trauma and are
not recommended.
Current preference is for lavage through a t h i n ,
in-dwelling, polythene tube introduced via a trephine
opening in the floor of the sinus.

2
A Watson-Williams graduated blunt trochar and cannula is
used to puncture the thin anterior bony wall of the sinus.
The instrument is introduced under vision using a
long-bladed Killian speculum to open the nasal passage as
widely as possible. Only in a few cases will the anterior
wall of the sphenoid be seen.
The correct point of puncture lies 7 cm from the anterior
nasal spine at an angle of 45° with the line of the floor of
the nasal passage. The tip of the trochar should be in the
same vertical plane as the posterior end of the middle
turbinate rather than near the midline where the bone is
thicker.
After the trochar is withdrawn, 2-3 ml of fluid is
introduced with a 5 ml Luer syringe and the washings are
aspirated and inspected. Any pathological contents
should be sent for laboratory investigation.
illustrations by Gillian Lee

John Ballantyne CBE, FRCS, HOHFRCSI

Consultant Ear, Nose and Throat Surgeon,
Royal Free Hospital and King Edward V I I Hospital for Officers, London, U K

indications
Intranasal antrostomy gives very satisfactory results in
cases of simple subacute or chronic empyema of the
maxillary sinus in which the diagnosis has been confirmed
but the condition has not been cured by o n e or two proof
punctures with lavage.
Anaesthesia
The operation can be performed under topical anaesthe-
sia, but general anaesthesia with a cuffed peroral
endotracheal tube and pharyngeal pack i s , generally, to be
preferred. Immediately before the operative procedure,
but after the induction of anaesthesia, the .nose is
prepared by painting the mucosa, both medial and lateral
to the inferior turbinate, with cocaine-adrenaline paste
applied on a cotton-wool-tipped jobson-Horne Cor similar)
probe. The paste is prepared by dipping the w o o l , barely
moistened in-a 1:1000 solution of topical adrenaline, in
crystals of pure cocaine hydrochloride.

113
VI4 Intranasal antrostomy

Tilr* r\T*>cs'
\ \ I f

Exposure of the antronasal wall

The inferior meatus is exposed by inserting, a long-

bladded Killian's nasal speculum lateral to the inferior
turbinate and displacing the turbinate medially by
opening the blade of the speculum.

Making the opening in the antronasal wall

The initial opening in the bony antronasal wall can usually

be made with a Hill's elevator or a similar perforating
instrument.
W h e n the bone is very thick, it may be necessary to use
a mallet and gouge.
 Intranasal antrostomy 115

Enlargement of the antrostomy

T h e opening is enlarged posteriorly with Luc's forceps and

anteriorly with Ostrum's forward-biting forceps. Each
piece of bone is removed cleanly, together with its
attached mucosa on both medial and lateral surfaces, in
order to avoid rolling up of the mucosal edges which may
encourage subsequent closure.

T h e antrostomy should be extended down to the level of

the nasal floor, and as far forward as possible to facilitate
cannulation for suction or lavage.
If the opening is made too far back, there is a risk of
damage to the descending branch of the sphenopalatine
artery, with severe haemorrhage; if it is too h i g h , the
lower opening of the nasolacrimal duct may be d a m a g e d ,
with subsequent stenosis and epiphora.

Postoperative care

T h e antrum should be sucked out through the antros-

tomy, or washed out with a sterile solution of physiologic-
al saline, 2 or 3 days and again about 2 weeks after the
operation, to prevent closure by organizing blood clot.
Illustrated by Ros Pritchard

Robin F. M c N a b Jones FRCS

Senior S u r g e o n , Ear, Nose and Throat Department, St Bartholomew's Hospital, London, UK

O u t l i n e description of the
operations
CALDWELL-LUC 2. Partial removal of this bony pyramid to provide a
common opening into the antrum and nasal passage.
1. Sublabia) approach to the anterior wall of the maxillary 3. Closure of sublabial incision leaving anterior antros-
antrum. tomy.
2. O p e n i n g of t h e anterior wall and intra-antral inspection
and manipulation.
3. T h e fashioning of an antrostomy in the inferior meatus.
JANSEN-HORGAN
4. Closure of the sublabial incision.
1. Caldwell-Luc operation.
2. Opening and extenteration of posterior and middle
DENKER'S ethmoidal cells via the antrum.
3. Intranasal exenteration of the anterior and agger
1. Sublabial approach to the anterior angle between the ethmoidal cells.
bony nasal and antral walls. 4. Closure of sublabia! incision.

116
 The Cafdweil-Luc and allied operations 117

Antehorethmoidalforam

ic
This illustration shows the lateral view of the medial wall foramen
of the orbit and antrum.

mg into
posterior
ethmoidal cell

Anterior ethmoidal foramen

Optic foramen

o?thi tf /
, U 0 n h O W S t h e a n t e r i o r v i e w o f t h e m
e d i a l wall
ot the orbit and antrum.
Opening into posterior
ethmoidal cell from antrum

Point of entry for

antrum puncture

Anteriorethmoidal foramen

Posterior ethmoidal
cell opened from antrum

Sphenoidal
sinus
This illustration shows the lateral wall of the nasal cavity
and related sinuses. 1

Opening of
nasolacrimal
duct
118 The Caldweli-Lucand allied operations

CALDWELL-LUC
OPERATION
Indications
This operation is indicated whenever a good view is
required of the interior of the maxillary antrum. It permits
removal or manipulation of the antral contents. It is the
operation of choice in the following conditions.
1. Radical cure of chronic sinusitis with removal of part or
the whole of the lining membrane.
2. Removal of foreign bodies, usually the root of a molar
or premolar tooth, from the sinus lumen.
3. Inspection and biopsy of suspected neoplasm.
4. Surgery for closure of an oroantral fistula.
5. Surgery for dental cysts involving the antrum.
6. As part of the manoeuvres necessary for adequate
removal of an antrochoanal polypus.
In addition the operation may be used to elevate a
fractured orbital floor with stabilization of the bony
fragments by an intra-antral pack. It is often necessary to
perform the operation when reducing a 'blow out'
fracture of the orbit.
The operation cart be used as a method of approach to
adjacent areas, e . g . : (7) removal of the posterior bony wall
of the antrum allows access to the pterygomaxiliary fissure
and the sphenopalatine fossa. Ligation of the maxillary
artery and vidian neurectomy are two procedures utilizing
this approach; (2) the ethmoidal labyrinth can be
approached through the antrum, allowing exenteration of
most ethmoidal cells and exploration of the sphenoidal
sinus and pituitary fossa.
Contraindications
It should not be performed until after the teeth of the
secondary dentition have erupted so as to avoid unneces-
sary damage to t h e m .
Preoperative preparation
The nasal passage on the affected <;ide r-h--^!d be ueated
with vasuconMficiurs.
Anaesthesia
Adequate local anaesthesia is achieved by infiltration of
the soft tissues under the upper lip and the inferior
meatus.
General anaesthesia is achieved via endotracheal i n -
tubation, either through the mouth, or the nasal passage
on the non-affected side. Adequate pharyngeal packing is
essential.
 The Caldwell-Luc and allied operations ng

Position of patient
The patient should be semi-sitting with head and neck
flexed on trunk.

The incision
The-vUp.pfir^ lip is retracted and the tissues just above the
•gingiybiabiai' reflection infiltrated with 1 m l 1:200 000
solution of adrenaline. T h e incision is placed 3 mm above
the line of reflection and starting at the canine ridge runs
laterally for 3.5~4cm parallel to the teeth.

Opening the antrum

T h e soft tissues are incised down to bone. Using a
periosteal elevator, the bony anterior wall of the antrum is
exposed by elevating the soft tissues upwards. This
elevation should stop 5 mm short of the intraorbital
f o r a m e n . Using a 5 mm Jenkins gouge, a sliver of the
anterior wall is elevated and removed with forceps. This
exposes the mucosa! lining which may be preserved while
enlarging the bony opening with Hajek's sphenoidal
punch forceps. The eventual size of the bony opening
should be approximately circular and 1.5 cm in diameter.
O n e should avoid removing bone too far in a lateral
direction or troublesome bleeding may occur. This can
usually be stopped by inserting a coagulation diathermy
needle into the vessel orifice or by squeezing the bone
with punch* forceps. Removal of bone to antral floor level
increases the risk of denervating the teeth or damaging
their apices.
"120 The Caiciwell-Luc and allied operations

/
Removal of antral lining

The antral mucosa should be incised and its contents

examined - the opening is enlarged as necessary to obtain
a satisfactory view. If it is decided to remove the whole
mucosal lining it should be elevated carefully with straight
and curved elevators, and if possible removed in toto, as
this reduces the amount of bleeding, which can be
considerable at this point. The bleeding is best controlled
by suction using a pharyngeal end, or by swabbing with
gauze tonsil swabs.

The antrostomy opening

The lateral bulge of the ipfprior meatus into the ar-uu!

lumen is usually obvious. The Jenkins gouge is applied to
the area of maximum convexity and a sliver of bone is
removed. This exposes the nasal mucosa lining the
inferior meatus. The bony opening is enlarged with
Hajek's forceps in all directions, in particular lowering it to
the level of the nasal floor and enlarging it in an anterior
direction almost up to the anterior end of the inferior
turbinate. Enlargement posteriorly beyond the 'bulge'
may cause bleeding from a branch of the greater palatine
artery. The eventual size of the opening should be
approximately 1 c m wide by 1.5 cm long. If the mucosa
lining the meatus is stili intact, it should be incised with a
scape! and an area exactly corresponding to the bony
opening must be excised. Some surgeons recommend
turning down a flap of mucosa hinged interiorly to line the
floor of the opening.

Closure

If bleeding is troublesome the cavity may need packing

with 1 inch ribbon gauze impregnated with bismuth
iodoform paraffin paste (B1PP) or bismuth carbonate in
glycerine. The end of the pack should be brought out via
the antrostomy opening and taped to the cheek. It should
be rejnoved after 24 hours. T h e buccal wound must be
carefully sutured with 3/0 plain catgut on an 8 mm
atraumatic needle. Good approximation of the wound
edges preserves the labioalveoiar sulcus. If this is
obliterated, fitting satisfactory artificial dentures may be
difficult or impossible.
 The Caldwell-Luc and allied operations 121

indications
This operation is an alternative to the Cafdwell-Luc
operation. It might be particularly indicated in exploration
0f suspected neoplasms.

9
PROCEDURE

This requires a sublabial incision similar to that for the Nasal cavity
Caldwell-Luc operation, and extended medially to the
fraenum.
Elevation of the soft tissues off the bone reveals the
anterior bony pyramid of the maxilla. Using gouges and
punch forceps the triangular piece of bone between the

')
lateral wall of the nose and the front of the antrum is
removed. The antral and nasal mucosae are then incised. JANSEN-HORGAN
This produces an adequate w i n d o w for inspection of the
antrum and an anteriorly-placed antrostomy. At "the OPERATION
conclusion of the operation the sublabial incision is
sutured as in the Caldwell-Luc procedure. Indication

C h r o n i c infection and polyposis of the ethmoid and antral

sinuses.

10
PROCEDURE

After performing a Caldwell-Luc operation the posterior

ethmoid cells are opened through the antrum. This is
achieved by pushing a closed Tilley-Henckel forceps in an
u p w a r d , media! and posterior direction at the upper and
inner angle of the antrum - the forceps should be pointing
in the direction of the opposite parietal e m i n e n c e .
Examination of the surgical anatomy {see Illustrations 1
and 3) shows that there is commonly a large posterior
ethmoid cell present at this point which often extends
backwards to the front wall of the sphenoid s i n u s . The
initial opening should be enlarged with suitable punch
forceps to allow adequate exenteration of the posterior
a n d middle ethmoid cells. G r e j u _ c a j ^
^ t l i j u ^ j m ^ j h e ^ p ^ T u j g iniLipj^yJirT^^
order to avoid damage^fothe cribriform plate and optic
nerve respectively. T^gce-js_c^nsjdeiable variation in the
size and distribution of the posterior ethmoid cells and
10 their relationship to the optic foramen. T h e anterior wall
of the sphenoid sinus is exposed and should be opened if
necessary.
T h e best results are obtained by using both the antral
and intranasal routes for exenteration of the ethmoid
cells. The nasal route gives access to the anterior and
agger ethmoid cells.
Cadaver practice and skilled instruction are wise
precautions before a solo effort at this operation.
illustrations by Philip Wilson
P h i l i p H . Golding-Wood BSc, F R C S , D L O
Formerly Consultant Ear, Nose and Throat Surgeon,
Kent County Ophthalmic and Aural Hospital, Maidstone, Kent, UK
Indications
ACUTE MASSIVE EPISTAXIS
Although serious nasal bleeding can nearly always be
controlled by appropriate packing, the patient is highly
uncomfortable and miserable at best. Moreover, such
packing leads to decreased oxygen tension and increased
carbon dioxide tension within the pulmonary alveoli,
these changes being aggravated by any obstructive lung
disease. This induced hypoxia and hypercarbia accounts
for some of the sudden deaths reported in patients with
indwelling nasal packs.
Arterial ligation is necessary in only about 2 per cent of
cases. W h e n bleeding continues after 3 days' packing it
will reduce the patient's suffering, hospital time and
expense while sharply reducing the complication rates.
T h e approximate site of bleeding must be determined
for the appropriate artery to be selected. Bleeding from
the anterior ethmoidal artery (internal carotid system) is
uncommon since this vessel supplies only about 7 per
cent of the nasal mucosa, all above the middle turbinate
on the lateral wall of the nose. Ethmoidal bleeding is
usually traumatic in origin and evidence of ethmoidal
fracture is frequent; once recognized, diathermy and
division of ethmoidal vessels is simple and the end of the
matter.
In the vast majority of severe cases bleeding arises from
the area of maxillary supply (external carotid system).
Here transantral maxillary ligation is usually ideal,
although in elderly, enfeebled patients exhausted by
repeated packing and blood loss there is a case for
external carotid ligation. Such ligation, simple enough
under local anaesthesia, will stop the bleeding; neverthe-
less, it carries a risk of blindness should the ophthalmic
artery arise from the external carotid system via its middle
meningeal branch, as it rarely may. Maxillary ligation
avoids this risk of possible ocular disaster and observes
surgical first principles. With other indications external
carotid ligation is inappropriate and any vascular ligation
must be maxillary.
• The term ligation hctc refers always lo ligation-division of the artery, for simple ligation in continuity is seldom adequate.
122
RECURRENT NON-SPECIFIC EPISTAXIS
Here the problem is not control of bleeding but
elimination of frequent recurrence. Such patients are
often hypertensive but neither suitable for, nor amenable
t o , antihypertensive therapy. Alternatively, the haemor-
rhage may be one in a frequent series that is all too often a
terminal event in an elderly arteriosclerotic subject.
In either case external carotid ligation is useless because
the anastomotic area will open up within a week. Maxillary
ligation, however, is highly effective in preventing further
epistaxis, although after 2-3 years further ligation of
intranasal vessels may be required to control anastomotic
circulation.
HEREDITARY TELANGIECTASIS
The control of severe frequent recurrent epistaxis from
this cause is proverbially difficult. Even after successful
septal dermatoplasty revascularization of the graft occurs
in about 2 years and haemorrhages are apt to recur.
Maxillary ligation alone will seldom suffice and even
when combined with ligation of all intranasal vessels it all
too often fails to do more than limit the frequency and
severity of the epistaxis. Sometimes, however, it is fairly
effective in this. Even so, after some 2 years recurrences
are apt to arise from new vessels forming afresh from
ophthalmic or other branches of the internal carotid. A
similar tendency has also been noted after embolization.
NASOPHARYNGEAL ANGIOFIBROMA
Extirpation of these vascular tumours, which may extend
into the medial part of the pterygopalatine fossa, is usually
attended by copious bleeding, difficult to control.
However, their principal vascular supply, generally the
sphenopalatine artery of either side, can be identified by
angiography. Preliminary transantral ligation of the feed-
ing vessels will often then allow almost bloodless
resection of the tumour forthwith. With increasing size
the tumour may acquire more feeders; but only those
from the internal carotid siphon cannot be ligated.
 Maxillary artery ligation 123

Preliminary steps

Under general endotracheal, preferably hypotensive,

anaesthesia the patient is positioned as for a Caldwell-Luc
procedure {see chapter on 'The Caldwell-Luc and allied
operations', pp. 116-121). T h e preliminary opening of the
maxillary antrum is again as in a Caldwell-Luc operation,
the anterior wall being widely removed. Those unfamiliar
with the anatomy of the pterygopalatine fossa should
consult the chapter on 'Transantral vidian neurectomy'
(pp. 126-138).

Outlining the posterior antral window

T h e antral mucosa is removed over the posterior wall of
the antrum. An elliptical window is outlined on the thin
posterior wall of the antrum by small chisel cuts. This
posterior antral window does not encroach on the thick
medial buttress, nor. should the window extend upwards
on the posterior part of the roof. Only the bone is cut
through, care being taken to avoid penetrating the
periosteal layer behind it. '

Completion of posterior antral window

A Zeiss microscope with 300 mm lens and 6 x or 1 0 X
magnification is then swung into position and focussed.
T h e bone covering the window area is now lifted from the
periosteum with a small curved elevator and removed.
Any prominent vein running across the window i n the
periosteum is lightly coagulated.
124 Maxillary artery ligation

Exposing the maxillary artery

Scissors (curved on the flat with rounded ends) are thrust

backwards through the periosteum and opened widely in
both vertical and horizontal planes to give wide cruciate
opening of the periosteum.
Some part of the maxillary artery is now detectable by its
pulsation and can be defined by further light touches with
scissor dissection.

Cleaning the maxillary artery

A curved hook is slipped under the artery and withdrawn

slightly to hold the vessel under slight tension. This
manoeuvre not only facilitates subsequent steps but
should also control any bleeding inadvertently caused.
Whilst the artery Is thus held on the hook it is cleaned of
surrounding fat by scissor dissection. This cleaning
proceeds until the arterial pattern is clear and the main
branches are fully exposed.
As the transverse part of the maxillary artery tends to
loop forward its lateral infraorbital branch may be
mistaken for the proximal trunk. In fact, this trunk of the
artery lies on a deeper plane and runs vertically upwards
through the surrounding fat.

5
Application of occluding clips

Whilst the artery is held under slight tension on the hook

tantalum clips are applied separately to occlude both the
proximal trunk and the infraorbital branch. They must be
firmly closed by two-handed pressure on the applicator.
For safety, two clips are placed well proximal to the
proposed line of section of the artery.
 Maxillary artery ligation \2S

The arterial resection

Experience has shown that if the maxillary artery is merely

divided between clips bleeding will continue in 10 per
cent of cases because flow up the descending palatine
artery can maintain sphenopalatine bleeding. Thus it is
imperative to display the terminal bifurcation of the
maxillary artery before resecting any part of the vessel.
The maxillary artery is divided distal to the occluding clips
and this arterial resection must extend medially to include
the separate origins of the sphenopalatine and descend-
ing palatine arteries to eliminate the possibility of
anastomotic backflow. The severed ends of the sphenopa-
latine and descending palatine arteries are sealed by
diathermy.

An anomalous pharyngeal artery

It is also necessary to divide any anomalous pharyngeal
artery coursing medially and deeply over the sphenoid
bone. Such will be found by dissecting down through the
fat to the sphenoid bone, sweeping in an arc from the
lower edge of the foramen rotundum downwards and
medially below the level of the pterygoid canal. Any such
artery is coagulated by diathermy and divided.

This arterial resection completes the operation. No nasal

antrostomy is usually required. Leaving the buccal incision
unsutured-ensures a smoother postoperative course with
minimal facial swelling.

Special instruments

A suitable hook is required for retraction of the artery as

are tantalum clips of appropriate size and a clip applicator.
T h e author's designs (available from Down Bros) have
proved eminently satisfactory and the clips are easy to
apply. T h e well-known Cushing clips are inadequate in
this situation.
illustrations by Phiiip Wilson
Philip H. Golding-Wood BSC, F R C S , D L O
Formerly Consultant Ear, Nose and Throat Surgeon, Kent County Ophthalmic and Aural Hospital, Maidstone, Kent, UK
T h e vidian nerve passing through the pterygoid canal
combines cholinergic and adrenergic fibres separately
derived from the greater superficial petrosal nerve and the
sympathetic plexus about the internal carotid artery.
These fibres form the autonomic root of the sphenopala-
tine ganglion, w h e n c e they are distributed mostly to the
nasal mucosa. Here the glands are entirely surrounded by
cholinergic endings, whereas the blood vessels receive
essentially an adrenergic innervation.
126
Thus the vidian nerve is essentially s-cretomotor to the
nasal mucosa and lacrimal giand. It can be reached within
the mouth of the pterygoid canal and this is best
approached across the maxillary antrum and pterygo-
palatine fossa.
T h e relevant anatomy must first be clarified before the
technical procedures are discussed. This approach is
flexible, serving equally well for ligation of the maxillary
artery, or for resection of maxillary nerve, vidian nerve or
sphenopalatine ganglion.
 Transantral vidian neurectomy 127

T h e pterygopalatine fossa is a small pyramidal cul-de-sac that projects medially through the ptery go maxillary fissure from
the infratemporal fossa. It forms a space between the posterior wall of the maxillary antrum in front and the pterygoid
extension of the great w i n g of the sphenoid behind. This fossa serves as a distribution channel for the nerves and vessels to
the face, nose and palate. Thus it contains the third part of the maxillary artery and its terminal branches; the maxillary
nerve; the sphenopalatine ganglion and its branches.

Rostrum of sphenoid
Superior orbital fissure Lesser wing of sphenoid

Orbital plate of great

wing of sphenoid

Maxillary nerve
Position of
Sphenopalatine 'bundle' pterygopalatine fossa

Maxillary artery
Lateral pterygoid plate
Pyramidal process
of palatine
Medial pterygoid plate

2
Superiorly the fossa opens into the apex of the orbit via the inferior orbital fissure. Interiorly it is closed by the pyramidal
process of the palatine bone which projects laterally, fusing with the maxilla in front and the diverging pterygoid plates of
the sphenoid b e h i n d .

Lateral pterygoid plate

Hamular process 2
128 Transantral vidian neurectomy

Orbital process of palatine

J
The palatine bone and sphenopalatine foramen

Medially the pterygopalatine fossa extends to the lateral

wall of the nose, here formed by the vertical plate of the
palatine bone, as it bridges the gap between maxilla and
medial pterygoid lamina. Superiorly the vertical plate of
the palatine bifurcates into a short sphenoidal process
posteriorly and a larger orbital process anteriorly that,
fusing with the maxilla, forms a strong bony buttress.
The deeply rounded notch between these processes,
being roofed by the body of sphenoid bone, forms the
sphenopalatine foramen that transmits arteries and nerves
from the fossa into the nose just behind the posterior end
of the middle turbinate.
Pyramidal process
of palatine Nerves and vessels in
descending palatine canal

4
The transantral approach to the pterygopalatine
fossa

Many of the salient relationships that govern this

approach can be deduced from the dry s k u l l .
Approaching the pterygopalatine fossa across the
maxillary antrum, an elliptical area of the posterior wall of
the antrum is removed. Ordinarily, the bone is very t h i n ,
but at the posteromedial corner its fusion with the
palatine bone results in a strong vertical bony buttress.
Superiorly this buttress turns somewhat laterally due to
lateral inclination of the orbital process of the palatine
bone. Superomedial to this laterally inclining buttress, the
bone thins again owing to the presence of an encroaching
posterior ethmoid cell.
Through this antral window the posterior (sphenoidal)
wall of the fossa can be visualized. Two foramina in this
sphenoidal wall, i.e. the foramen rotundum and the
pterygoid canal, provide fundamental landmarks. T h e
view obtained varies with the breadth of the posterior
antral window, itself dependent on the shape of the
maxillary antrum. In a narrow antrum it is better to accept
restricted confines than risk difficulty from encroachment
of Bichat's fat.
 Fransanlral vidian neurectomy \2')

The foramina in the sphenoidal wall of the fossa

The foramen rotundum which transmits the maxillary

nerve lies just below the upper limit of the fossa and the Optic foramina
superior orbital fissure. Hence surgical procedures must
not extend above the foramen rotundum lest they
endanger structures in the orbital apex.
Superior orbital fissure
T h e pterygoid canal which transmits the vidian nerve is
1 c m long and is ordinarily narrow. Anteriorly this canal
widens to a funnel-like mouth similar in size to the
foramen rotundum. T h e mouth of the pterygoid canal lies
8-9 mm below and medial to the foramen rotundum. it is
also recessed on a posterior plane, and between these two
foramina there is often a distinct vertical bony ridge. T h e
medial face of this ridge passes backwards to form the
lateral aspect of the mouth of the pterygoid canal.
Ordinarily the pterygoid canal runs along the infero-
lateral aspect of the sphenoidal sinus. In this position the
canal can be opened via the transpalatal approach by
burring into the junction of the body of sphenoid and the
origin of the medial pterygoid process. It must be Foramen
realized, however, that this approach may be complicated rotundum
by a lateral encroachment of the sphenoid sinus w h i c h
may completely engulf the pterygoid canal.
Pterygoid canal
T h e sphenopalatine ganglion lies directly in front of the
anterior funnelled mouth of the pterygoid canal. O n
entering the pterygopalatine fossa, the maxillary nerve
gives a stout branch to the sphenopalatine ganglion. This
branch forms a guideline to the sphenopalatine ganglion
and pterygoid canal. Depicted in various textbooks as
separate nerve filaments, this branch is, in fact, a stout
bundle of fibres, here referred to as the sphenopalatine
bundle. Necessarily this bundle passes medially and
downward at approximately 4 5 ° from the maxillary nerve.
Lying fairly close to the sphenoid, this bundle may appear The pterygopalatine canal
stretched across the bony ridge separating the foramen
rotundum and pterygoid canal. Vertically below the mouth of the pterygoid canal but
slightly anterior is the pterygopalatine canal between
palatine bone and maxilla. This carries the descending
Maxillary antrum under orbital floor palatine nerves and artery to emerge on the palate via the
greater palatine foramen.

Posterior
ethmoid cells
Infraorbital
Sphenopalatine groove
foramen

Pterygopalatine Foramen rotundum and infraorbital canal

fossa
Foramen rotundum A transverse section of the pterygopalatine fossa at the
level of the foramen rotundum shows that the line of the
Body and greater
wing of sphenoid infraorbital canal lies well lateral to the foramen rotun-
d u m . Hence the maxillary nerve on entering the pterygo-
Carotid groove-;ife'ff"* yjs palatine fossa runs laterally and slightly upwards before
turning forward through the inferior orbital fissure to
Foramen ovale continue as the infraorbital nerve within its canal.
Foramen spinosum

Schematic transverse section through foramen

6 rotundum (arrow shows course of maxillary nerve}
130 Transantral vidian neurectomy

7
Maxillary antrum
T h e pterygoid canal and sphenopalatine foramen

The pterygoid canal lies almost in the anteroposterior

plane of the medial wall of the antrum. Its transantral
exposure is thus dependent upon a medial extension of
the posterior antral window by appropriate lowering of its
medial buttress.
A. transverse section of the pterygopalatine fossa at the
level of the pterygoid canal shows that the sphenopalatine
foramen (arrow) lies medial and slightly anterior to the
mouth of the pterygoid canal. Owing to the angulation
between orbital and sphenoidal processes of the palatine
b o n e , the sphenopalatine foramen is set obliquely to the
pterygoid canal. This relationship allows a probe passed
through the nose and through the sphenopalatine
foramen to enter the pterygoid canal.
If this route is chosen for vidian neurectomy, however,
it must be recognized that only a very narrow diathermy
probe can be so passed. In about 2 per cent of cases the
pterygoid canal will admit a 2 mm probe throughout its
length. In practical surgery the employment of this route 7
may entail unacceptable risk of ophthalmoplegia due to
Schematic transverse section through pterygoid canal
over-penetration of the diathermy probe.

8
The sphenopalatine ganglion

Turbinates This ganglion, lying immediately in front of the funnelled

mouth of the pterygoid canal, is laterally compressed.
Thus it will not normally be seen as a distinct fusiform
structure by the surgeon approaching from across the
maxillary antrum.
The sensory and autonomic supply to the nasal cavity
leaves the ganglion in a series of nerves that enter the
nose through the sphenopalatine foramen.
From the foregoing it will be appreciated that, within
the pterygopalatine fossa, the maxillary nerve, spheno-
palatine bundle and ganglion together with its nasal and
descending palatine branches all lie essentially in a single
transverse plane. As the flattened sphenopalatine gang-
lion is seen edgewise on via a transantral approach, the
surgeon does not see an obvious ganglion. As the
sphenopalatine bundle is traced medially towards the
pterygoid canal it seems merely to bifurcate into a
descending palatine nerve and a leash of branches that
nerve enter the sphenopalatine foramen.
The neural junction is tethered behind by the vidian
nerve emerging from the pterygoid canal. It is only after
8 , the vidian n e r v e , often bound up with the vidian artery in
a fibrous envelope, has been severed that the neural
junction can be manipulated to disclose the entire mouth
of the pterygoid canal.

The sphenopalatine ganglion is a distribution centre for
sensory fibres from the maxillary nerve reaching it via the
sphenopalatine bundle, and autonomic fibres from the
vidian nerve. T h e sensory fibres pass through the ganglion
and are distributed via its so-called branches. T h e nasal
branches enter the nose via the sphenopalatine foramen.
Some break up on the lateral wall of the nose, supplying
the mucous membrane over the larger posterior part of
superior and middle turbinates, others cross the sphe-
noidal roof of the nose to reach the septum. The largest of
these (the nasopalatine branch) runs downwards and
forwards on the septum to reach the incisive canal.
Maxillary division of V
Descending palatine nerve
9 tor impulses mentioned above.
Transantral vidian neurectomy 13-5
The descending palatine nerve leaves the spheno-
palatine ganglior^and passes downwards in the pterygopa-
latine canal. Within this canal the nerve divides into two or
three branches. The largest of these, emerging at the
greater palatine foramen, turns forward to supply the
anterior part of the hard palate. T h e smaller palatine
nerves emerge on the palate through a lesser palatine
foramen and turn backwards to supply the soft palate.
Also within the pterygopalatine canal, small nasal
branches arise and pass through the vertical plate of the
palatine bone to supply the mucous membrane over the
posterior part of the inferior turbinate and adjacent
middle and inferior meati of the nose.
The vidian nerve
The vidian nerve supplying the autonomic root of the
sphenopalatine ganglion derives from the junction within
the foramen lacerum of parasympathetic fibres from the
greater superficial petrosal nerve and sympathetic fibres
from the plexus surrounding the adjacent internal carotid
artery. These autonomic fibres are distributed with the
sensory branches of the sphenopalatine ganglion. T h e
secretomotor fibres of the lacrimal gland join the maxillary
nerve via the sphenopalatine bundle and pass with the
zygomatic branch to join the lacrimal nerve.
The vidian pathway also contains a number of afferent
fibres from the nose that pass backwards with the greater
superficial petrosal nerve. T h e distribution and functions
of these fibres are not clearly understood but it is
probable that they may subserve pain.
Vidian neurectomy alone removes secretomotor im-
pulses from glands of the nasal mucosa and from the
lacrimal gland. Sensation within the nose or on the palate
is not disturbed. Sphenopalatine ganglionectomy per-
manently removes sensory innervation of the ipsilateral
side of the nose and palate, together with the secretomo-
132 Transantral vidian neurectomy

Maxillary nerve
l

The maxillary artery

T h e maxillary artery, that has run forward through the

infratemporal fossa on the outer surface of the lateral
pterygoid muscle, finally dips between the two heads of
this muscle to enter the pterygopalatine fossa via the
pterygomaxillary fissure. Within the pterygopalatine fossa,
this artery runs a characteristically tortuous and variable
course, but it always lies anterior to the transverse plane
of the nerves within the fossa. The basic plan, however, is
simple. Arching upwards and forwards as it passes
medially across the fossa, it terminates by bifurcation into
sphenopalatine and descending palatine arteries, just
within the fossa it gives off a small posterior superior
alveolar branch that runs downwards and outwards, and
then a very large lateral branch that is the infraorbital. This
infraorbital branch runs laterally and upwards to enter the
infraorbital canal through the inferior orbital fissure.
T h e sphenopalatine artery continues medially and
upwards across the sphenopalatine bundle to pass
through the sphenopalatine foramen above and in front of
the superior nasal branches of the sphenopalatine 10
ganglion. Within the nose it passes across the sphenoidal
roof of the nose to reach the septum whence it runs
forwards and downwards with the nasopalatine nerve, just
before leaving the fossa it gives off a posterior nasal
branch that passes through the sphenopalatine foramen
to break up to supply the lateral wall of the nose. This
point of origin of the posterior nasal artery is variable.
Generally it occurs only at the sphenopalatine foramen
and thus it is not readily seen in the transantral approach
to sphenopalatine ganglion or pterygoid canal. Frequent- Veins
ly, however, it arises independently from the termination
of the maxillary artery; the sphenopalatine artery is thus Within the pterygopalatine fossa there is no trace of the
apparently double. venous plexus so evident about the lateral pterygoid
T h e descending palatine artery turns downwards to join muscle in the infratemporal fossa. Within the periosteum
the descending palatine nerve and leaves the fossa in the over the posterior wall of the antrum there is often a fairly
pterygopalatine canal. At a variable point it divides into prominent vein running transversely over the fossa.
two. Again, the maxillary artery may seem to give rise to Within the fat surrounding the maxillary artery there is a
two descending palatine branches. small thin-walled vena comitans. O n the antero-inferior
aspect of the laterally directed maxillary nerve there is a
further minute vena comitans.

The pharyngeal artery

Posteriorly directed vidian and pharyngeal arteries enter Fat

the pterygoid and palatinovaginal canals respectively.
Either or both arise variably, often from sphenopalatine or
posterior nasal arteries in the region of the sphenopala-
tine foramen.
A frequent anomaly in the origin of either the
pharyngeal or vidian artery is of practical importance.
Either may arise directly from the posterior aspect of the
maxillary artery at or shortly after its entry into the
pterygopalatine fossa. In this event, either or both vessels
run medially over the face of the sphenoid and reach their
destination by passing deep to the transverse plane of the
nerves.
Dissection within the pterygopalatine fossa is often
hampered by the loosely textured fat that is commonly
present. This fat, however, can be readily pulled away to
expose the vessels and nerves. In sharp distinction is the
coarsely lobulated yellow pad of fat (the fat pad of Bichat}
that is closely applied to the posterolateral wall of the
maxillary antrum (see Illustration 4 ) . This fat may encroach
if the posterior antral window is extended too far laterally.
This cannot be pulled away and any such attempt merely
drags it into the pterygopalatine "fossa to the surgeon's
subsequent difficulty.
 Transantral vidian neurectomy 133

Indications Position of patient

Vidian neurectomy may be indicated i n : As for a Caldwell-Luc procedure, with whatever head-up
tilt the anaesthetist may require - the head then being
1. Severe intractable secretomotor rhinopathy of cholin-
suitably extended. The closed eyelids are covered with
ergic (nonatopic) type.
adhesive tape.
1. Similar apparently atopic cases when other measures
have failed.
3. Crocodile tears (where tympanic neurectomy is imprac-
tical or has failed). Special instruments
4. Severe senile nasal drip.
5. Severe recurrent nasal polyposis (together with A special hook, arterial clips and applicator, rugines,
thorough polypectomy and ethmoidectomy). sickle knives and shouldered diathermy' probes, are
required. Those devised by the author are available from
D o w n Bros. The smaller half-hook is invaluable where
space is inadequate to employ the ordinary h o o k . This is
particularly likely when following the sphenopalatine
Precautions bundle.
The author's small rugines are used w h e n w o r k i n g over
It is essential that the maxillary antra are adequately
the sphenoid face. Their edges are slightly serrated to grip
developed and are clear of infection. Appropriate X-rays
soft tissue, so they serve also in cleaning arteries and
with a submentovertical view will determine the size and
nerves within the fossa. A single straight rugine ordinarily
shape of the antrum and suggest the thickness of its walls.
suffices but occasionally up-swept or down-swept rugines
are helpful. The author's shouldered probes for diathermy
within the canal are deemed essential to safety.
Anaesthesia
General endotracheal anaesthesia with hypotension. A
systolic blood pressure of about 60 mm/Hg is often critical
in giving an adequately bloodless field.

Preliminary steps
T h e antrum is opened as for a Caldwell-Luc procedure,
care being taken to ensure as wide an anterior opening
into the antrum as practicable. The infraorbital foramen is
carefully preserved and direct pressure on the infraorbital
nerve must be avoided as the cheek is retracted.

Outlining the posterior antral window

T h e antral mucosa is removed over the posterior wall of
the antrum. An elliptical window is outlined in the thin
posterior wail of the antrum by small chisel cuts. This
posterior antral window must not extend upwards on the
posterior part of the roof, nor at this stage should it
encroach on the thick medial buttress. Only the bone is
cut through, care being taken to avoid penetrating the
periosteal layer behind it.
134 Transantral vidian neurectomy

Completion of the posterior antral window

A Zeiss microscope with 300 mm iens and 6 x or 1 0 x

magnification is swung into position and focused. The
bone covering the window area is now lifted from the
periosteum with a small curved elevator and removed.
Any prominent vein running on the periosteum and across
the window is lightly coagulated.

Exposing maxillary artery

Scissors (curved on the flat with rounded ends) are thrust

backwards through the periosteum and opened widely in
both vertical and horizontal planes to give a wide cruciate
opening of the periosteum. Some part of the maxillary
artery will quickly be found and is further defined by light
touches of scissor dissection.

Cleaning the maxillary artery

A fully curved hook is slipped under the vessel and

withdrawn slightly, to hold the artery under slight tension.
Thus held the -artery is cleaned of surrounding fat by
scissor dissection, until the arterial pattern is clear and the
main branches are fully exposed. As the maxillary artery
tends to loop forward, its main trunk must be sought on a
deeper plane, running vertically upwards through the
surrounding fat.
 Transantral vidian neurectomy 135

A r:

Application of occluding clips

yVhilst the artery is held under slight tension on the hook,

tantalum clips are separately applied to occlude the
proximal trunk and infraorbital branch. They must be
firmly closed by two-handed pressure on the applicator,
for safety, two clips are placed well proximal to any
proposed point of section of the artery. The bifurcation of
the maxillary artery into the ascending sphenopalatine and
descending palatine arteries is displayed. Later, to
facilitate the neural exposure, the sphenopalatine artery
will be resected.
W h e n maxillary ligation - division is used to arrest
severe epistaxis, resection of this terminal bifurcation of
the maxillary artery is necessary to prevent anastomotic
backflow leading to continued bleeding.

Exposure of the foramen rotundum

The maxillary artery is displaced downwards and the
maxillary nerve is sought by scissor dissection in the fat
above the artery. O n c e found in the upper lateral
quadrant through the posterior antral window, the
maxillary nerve is traced backward to its emergence from
the foramen rotundum. A small rugine is used to sweep
away the fat to expose the sphenoid and the lower edge
of the foramen rotundum. This point establishes the
superior limit of safe dissection.

Locating the sphenopalatine bundle

T h e sphenopalatine bundle, arising from the media)
aspect of the maxillary nerve immediately after it has left
the foramen rotundum, is now defined. If necessary the
loose fat surrounding it is seized in small Tilley-Henckel
forceps and pulled away. As it is traced downwards and
medially this bundle is crossed anteriorly by the spheno-
palatine artery. This and the overlying buttressed medial
part of the posterior antral wall temporarily impede
further dissection of the sphenopalatine bundle.
136 Transantral vidian neurectomy

Lowering the medial buttress

The mouth of the pterygoid canal is stiii under cover of the

medial buttress of the posterior antral window. Its
approximate position, however, is revealed by the
direction of the sphenopalatine bundle, and also by the
sphenopalatine artery that passes above it to reach the
sphenopalatine foramen. This buttress is now lowered
flush with the medial wall of the antrum by appropriate
chisel cuts.

Resection of the sphenopalatine artery

The terminal part of the maxillary artery is lifted on a hook

and the sphenopalatine artery is divided by scissors. T h e
long distal stump of the sphenopalatine artery is short-
ened and the remaining stump diathermized as it is held in
crocodile forceps.

Cutting the vidian nerve

W h e n the sphenopalatine artery has been resected, the

sphenopalatine bundle can be traced further medially,
working over the adjacent sphenoid bone with a rugine.
Some 8 mm medial and inferior to the foramen rotundum
the sphenopalatine ganglion is reached. Its position is
indicated by the divergence of its descending palatine and
nasal branches.
A small hook is slipped under the terminal divergence
of the sphenopalatine bundle and a sickle knife is swept
beneath it to cut the vidian nerve emerging from the
pterygoid canal.
 Transantral vidian neurectomy 137

Exposure of the pterygoid canal

O n c e the vidian nerve is divided, the sphenopalatine
bundle and its postganglionic branches can be moved
upwards or downwards to expose fully the mouth of the
pterygoid canal.
If the sphenopalatine bundle is now swung superiorly
and medially, the mouth of the pterygoid canal will be
seen lateral to the displaced descending palatine nerve.
With experience, however, the mouth of the pterygoid
canal is best displayed by swinging the sphenopalatine
bundle inferolaterally. The canal mouth is then exposed
just below the nasal branches of the sphenopalatine
ganglion, medial to the descending palatine nerve.

Diathermy of the pterygoid canal

O n c e the mouth of the pterygoid canal has been properly
e x p o s e d , one of the blunt-headed and shouldered probes
of the author's design is inserted to fit snugly into the
mouth of the c a n a l . O n occasion the pterygoid canal will
admit a 2 mm probe throughout its length and diathermy
applied to such a penetrating probe will cause serious
ophthalmoplegia.
The author's shouldered probe, used so that the
shoulders fit against the mouth of the canal, will eliminate
such risk. A 3 mm probe is generally u s e d ; occasionally a
larger one is u s e d . O n c e properly sited, diathermy
coagulation is safely applied to ensure destruction of the
vidian fibres over a distance sufficient to ensure lack of
regeneration and haemostasis from the severed vidian
artery. This coagulation is intermittently applied for a total
of some 5 s e c o n d s .

Completion
Haemostasis s e c u r e d , the operation is complete. No nasal
antrostomy is made unless a grossly thickened mucosa has
21 been stripped o u t . Leaving the buccal incision unsutured
ensures a smoother postoperative course with minimal
facial swelling.
135 Transantral vidian neurectomy

Postoperative care and

Absence of lacrimation Ophthalmoplegia

The relatively dry eye may give some discomfort for a few This results from over-penetration of the pterygoid canal
w e e k s , but is relieved by artificial tear drops. Local goblet by a narrow probe for diathermy. With such it is a 2-3 per
and mucus cells suffice to give adequate moisture to cent risk. Proper use of the author's shouldered probes
protect cornea and conjunctiva. eliminates this risk.

Facia! analgesia Infection of antrum

Some loss of sensation over the upper lip and cheeks is Responds normally to appropriate antibiotics-and antral
usual, but clears in about 2 months. washouts.
Illustrations by Philip Wilson
Philip H. Golding-Wood BSc, F R C S , D L O
Formerly Consultant Ear, Nose and Throat Surgeon, Kent County Ophthalmic and Aural Hospital, Maidstone, Kent, U K
This type of hormonal but progressive exophthalmos
characteristically follows the arrest of thyrotoxicosis,
weeks or even months after a euthyroid state has been
achieved.
It is normally bilateral and marked lid retraction is
typical. The proptosis is .due essentially to the vast
increase in size of the extraocular muscles from increasing
oedema and lymphocytic infiltration.
With increasing proptosis the conjunctiva becomes
oedematous, cor%ested and chemotic. Eye movement is
progressively restricted and may be lost. Vision may be
threatened by ulceration of the cornea deprived of lid
cover, or through the development of p a p i l l e d e m a or
visual field defect.
Although malignant (endocrine) exophthalmos is gener-
ally a self-limiting disorder, spontaneous improvement
can occur at any point short of extremes. As proptosis
recedes, ocular movement improves, although one or
more of the extraocular muscles may remain fibrotic and
w e a k , giving diplopia.
Most cases can be controlled by medical m e a n s ,
especially steroids, until the condition has gradually
subsided. Dexamethasone 4 m g four times a day or
prednisolone 20-30 mg four times a day are suitable.
Despite such treatment, a few cases progress to the point
of endangering the eye and decompression of the orbit
may become imperative to avert strangulation within it-
Such decompression is not curative, merely an episode in
management, but it can play a vital role in the preservation
of sight.
139
140 Transantral ethmoidal decompression in malignant (endocrine) exophthalmos

Indications for decompression Anaesthesia

1. evidence ot corneal ulceration. General endotracheal anaesthesia with hypotension, is
2. Increasing visual loss or progressive field defect. employed.
3. Appearance of p a p i l l e d e m a .
4. Increasing loss of extraocular movement.

Position of patient

Methods of orbital decompression The patient lies supine, with a head-up tilt to avoid venous
congestion. The head is then extended so that the
The orbit can be decompressed from any aspect and in the ethmoidal region is easily visualized after the maxillary
occasional extreme case more than one may become antrum is opened. Illumination by headlight is required
necessary. and a magnifying loupe of relatively long focal length is an
Neurosurgeons employ a transfrontal craniotomy or a advantage.
lateral approach to remove the orbital roof, outer part of
the sphenoidal ridge, pterion and posterolateral wall of
the orbit.
Rhinologists employ an extended ethmoidectomy.
Ordinary external ethmoidectomy may succeed but it
involves unacceptable temporary increase in pressure on
orbital contents already near strangulation. A transantral
route avoids this whilst permitting further removal of the
orbital floor up to the line of the infraorbital nerve. Total
removal of the orbital floor is generally unnecessary and
may invite some descent of the globe.

Whilst orbital exploration demands a transcranial

approach, the transantral route is widely accepted as
preferable for simple decompression. Its simplicity and
speed (35 minutes for bilateral operation) favour decom-
pression at an earlier and more effective stage. Providing
the entire ethmoid space for unopposed expansion, it
gives greater orbital recession than the transcranial
operation. Also it is free of postoperative eye pulsation,
need for tarsorrhaphy, shaven scalp or external incision.
Any possible antroethmoida! sepsis must, of course, be
eliminated beforehand.

V
 Transantral ethmoidal decompression in n u l l u m .endocrine) exophthalmos 141

Opening the maxiilary antrum

The antrum is opened as for a Caldwell-Luc operation (see

page 118). The bony window is made as large as possible,
particularly at its superomedial angle. It is essential,
however, to preserve the orbital rim and also the inferior
orbital foramen.

Clearing the ethmoid cells

Pressure is applied with the point of Tilley-Henckel

forceps in the superomedial corner of the antrum, aiming
at the parietal eminence of the opposite side. The ethmoid
is thus easily entered and its contained cells are
systematically removed under visual control. This clear-
ance must proceed upward to meet the smooth firm
resistance of the ethmoid roof. These ethmoid cells are
removed from as far forwards as can be reached and back
to the sphenoid sinus. During this preliminary exentera-
tion the lamina papyracea is preserved. Similarly the
middle turbinate is left intact and protects the cribriform
plate.

Removal of medial orbilal floor

, , f i „ . , J M ' I medial wall of the orbit is thus
r

The convex bony floor ^

ake^dy^been' identiHed- The. infraorbital canal extends,
backwards in the orbital floor .n the same anteropostenor

p
, i
' ti
a n
iq used uontly u
e
ie the orbital floor
A small ch.se , <•' K £ |,
l n f r a o r b i t a l c a n a c a r e

jnteropostenorly jus^m • periorbitum intact.

S ! m e d l a l U S a l floor is levered
downward and r e m o v a l im^emeal.
142 Transantral ethmoidal decompression in malignant (endocrine) exophthalmos

5
Removal of lamina papyracea

The lamina papyracea forms an upward continuation of

the medial orbital floor. It is easily removed with biting
forceps, up to the stout roof of the ethmoid, over as wide
an anteroposterior extent as possible. It is essential that
the periorbitum is still preserved intact to prevent
premature prolapse of orbital fat. Irrespective of the high
intraorbital pressure it remains seemingly slack.

Opening the periorbitum

The periorbitum is now to be incised anteroposterioriy

over most of its exposed extent, a small sickle knife being
used. This incision is placed horizontally just below the
lower edge of the enlarged medial rectus muscle. T h e
periorbitum must also be divided vertically at both ends of
this horizontal incision to allow adequate decompression.
As orbital fat rapidly and progressively prolapses through
this periorbital incision, the incision must be made in
definite sequence if vision is not to be hampered: first,
the vertical posterior limb then the horizontal connecting
limb from behind forwards, and finally the anterior
vertical limb.
 Transantral ethmoidal decompression in malignant (endocrine) exophthalmos 143

•f p effect of decompression
n This recession is immediate and associated with
k-. u - . J J J i -J I b u W 1 . 1 1 u . ,, lliUIK^U W J I I l>^UI_ !UI(JI>JVCllieiK
and rapid subsidence of chemosis. Any p a p i l l e d e m a or
The periorbital incision'completed, orbital fat can be seen visual field defect previously evident clears within days.
rapidly protruding through it to fill most of the ethmoidal Impaired vision improves. Rapid improvement in ocular
space. Traction is not required and must not be applied to movement occurs but some diplopia may remain.
the prolapsing orbital tissue lest oculomotor nerve palsy
be provoked. T h e formerly protruding eyeball recedes
quite dramatically.
Some judgement is required in making the incision in
the periorbitum. If too small, it will be inadequate; if too
large, it may invite trapping of the medial rectus muscle.
Occasionally, in a very small antrum, it may be desirable
to remove the portion of the orbital floor that lies lateral to
the inferior orbital canal. Diplopia
O c c u r r i n g within weeks of operation, this may be of any
type and is due to inherent muscle defect. As such it
Completion o c c u r s as frequently after spontaneous recession as after
any type of decompression. Occasionally, however, and
A small nasal antrostomy is made as in a Caldwell-Luc after excellent early recovery diplopia may occur from
operation before the buccal incision is closed with trapping of the medial rectus muscle. Later muscle-
interrupted catgut sutures. balance surgery is feasible and corrective.
As the eyeball recedes, proper lid cover is generally
assured. No tarsorrhaphy is required unless cornea!
ulceration is already present.
Later Sinusitis
This has been s e e n , but responds to the usual treatment
Bilateral operation without further incident.

Progressive exophthalmos is typically symmetrical and

bilateral operation is ordinarily required. It confers every
advantage if such bilateral operation is completed in the
same session.
Results
The greater the degree of preoperative proptosis, the
greater the degree of recession, an average of 5 mm of
recession being attained.
Further reading
Golding-Wood, P. H. Trans-antra! ethmoid decompression in
malignant exophthalmos. Journal of Laryngology and Otology,
1969;83:683-694
Naffziger, H. C. Progressive exophthalmos: Hunterian lecture.
Annals of the Royal College of Surgeons, 1 9 5 4 ; 1 5 : 1 - 2 4
Walsh, T. E., Ogura, j . H.Transantral orbital decompression for
malignant exphthalmos. Laryngoscope 1957; 67: 544
illustrations by Robert N. Lane

D. F. N. Harrison M D , M S , PhD, F R C S , F R A C S
Director of the Professorial Unit, Institute of Laryngology and Otology and Royal National Throat, Nose and Ear Hospital,
London, UK

For total maxillectomy to be an effective oncoiogical
operation the disease must of necessity be confined
within the bony walls of the maxillary sinus o r , in the case
of primary bony tumours, to the maxilla itself.
Unfortunately, this is rarely the case and most opera-
tions for carcinoma of the maxillary sinus will require not
only a total maxillectomy, but orbital clearance together
with exenteration of the ethmoidal labyrinth. Permission
to remove the eye must be obtained pre-operatively in any
patient undergoing total maxillectomy for in many
patients a final decision regarding involvement of the
orbital periosteum can only be made during the opera-
tion.
In view of the frequent need to remove the orbital
contents, it is this procedure that will be described
together with any pertinent observations related to the
lesser operation.

144
 Radical maxillectomy 145

Although there is no valid reason why this operation

should not be performed with minimal blood loss there is
no doubt that hypotensive anaesthesia facilitates not only
the duration of the procedure but also the effectiveness,
since a really dry field enables the surgeon to visualize the
anatomical limits of his excision. However, such facilities
cannot be expected if they carry a significant increase in
what should be an insignificant operative morbidity or
mortality rate.

1
Incision

If the orbital contents are to be preserved, then the

eyelids are sewn together and the horizontal part of the
incision will pass approximately 2 mm below the lash
margins along the lower lid. This allows the skin of the
lower lid to be detached from the underlying orbicularis
ocull and minimize postoperative oedema. W h e n the
orbit is to be cleared then a circumferential incision is
made through the conjunctiva, thus preserving both
eyelids; this facilitates the fitting of an ocular prosthesis
without jeopardizing survival.
T h e incision begins over the dorsum of the nose medial
to the inner canthus. Extension to the inner canthus
enables the subconjunctival incision to be carried out and
this is assisted by traction sutures through both eyelids. In
maxillectomy alone the junction of the horizontal incision
and the vertical nasal incision inevitably produces an acute
angle w h e r e , in postirradiated patients, skin loss from
avascular necrosis is c o m m o n . Consequently, this angle
must be made as obtuse as possible.
T h e nasal incision extends first medial to the nasal
crease, then around the ala to the midline of the
columella. The upper lip is divided with scissors,
haemostasis being obtained by pressure on each side of
the incision.

2
The remainder of the incision is intraoral and follows the
alveolar buccal sulcus, around the maxillary tuberosity
and across the palate at the junction of the soft palate with
the posterior end of the hard palate.
T h e final incision is slightly lateral to the midline to join
the original incision in the region of the upper first incisor
tooth. If present this tooth will have to be removed.
Diathermy may be used for the intraoral incision to
minimize bleeding.
146 Radical maxillectomy
Elevation of the facial ^Mn
After division of the nasal mucosa around the pyriform
o p e n i n g , traction on the skin edge enables the facial skin
and buccinator to be elevated from the anterior wall of the
maxilla back to the zygomatic arch and the lateral margin
of the malar bone.
T h e skin of the lower eyelid will be carried with the
upper part of this flap leaving the orbicularis oculi muscle
in situ.
There is no particular merit in attempting an incontinuity
resection of orbital contents and maxilla. In those
circumstances where removal of the eye is in doubt it is
also necessary to identity the orbital rim and detach the
orbital periosteum.
3
An incision just below the rim allows this to be carried out
without incising the periosteum and releasing orbital fat.
Orbital periosteum is only attached at the rim and
elevation of the periosteum may be carried out around the
whole orbit after division of the medial and lateral
suspensory ligaments. Transection of the optic nerve and
vessels allows removal of the orbital contents.
4
If the orbital contents have been left in situ they can be
elevated to allow identification of the inferior orbital
fissure and a curved forceps may be introduced under the
malar bone and passed into the orbit to allow division of
the bone with a Gigli saw. O n many occasions where the
maxilla has been weakened by neoplasia, this is best
carried out with a Stryker saw to avoid fragmentation.
Prior removal of the eye naturally facilitates this step in the
operation.
Zygomatic arch
Following division of the masseter at its attachment, the
zygomatic arch is transected.
Clearance of the ethmoid
There is no reason for preserving the ethmoirjal labyrinth,
whether involved in disease or not, and this should be
carried out prior to separating the nasal bone from the
frontal process of the maxilla. Care must be taken to avoid
damage to the cribriform plate for, under hypotension
particularly, the position of the anterior and posterior
ethmoidal arteries may be of little use as anatomical
landmarks. The bony orbital floor lying between the
inferior orbital fissure and the defect now left in the
medial orbital wall is divided with an osteotome. The
upper part of the maxilla is now free.

Division of h a r d naiafe
It \$ usual to leave the separation of the hard palate and
rem o v a l of the pterygoid process to the end of the
operation since they are frequently associated with
troublesome bleeding. Although a Gigli saw may be
passed through the nasal cavity and out between hard and
soft palate, the most effective method is to use a wide
osteotome for the alveolar margin, placed at the site of the
6
Radical maxillectomy 147
upper centra! incisor, and a chisel for the hard palate. The
straight edge of the latter must be sited just lateral to the
midline to avoid splitting the nasal septum superiorly.
Division of soft from hard palate requires only a knife
though bleeding from the greater palatine artery may be
severe until the bony walls of its foramen have been
opened.
5
Separation of the pterygoid process
Although it is desirable to remove the medial and lateral
pterygoid plates, to facilitate the fitting of a comfortable
prosthesis and to minimize postoperative trismus, this
may conveniently be carried out after removal of the
maxilla. A n osteotome inserted behind the tuberosity in
the groove between it and the pterygoid process may
need only pressure to separate both plates from the
posterior wall of the maxilla. If the attachment is broad
and firm then a sharp blow is effective.
Bleeding from the maxillary artery is rarely a problem
and its importance has been over-emphasized.
6
Removal of the maxilla
Despite the freeing of the bone from its attachment, it is
always necessary to divide mucosal fibres a n d , posteriorly,
muscle fibres, to allow removal of the specimen.
Occasionally the internal maxillary artery may require
ligation but more frequently bleeding is minimal. The
remaining bony walls of the ethmoid, anterior wall of
sphenoid sinus a n d , where the eye has been removed,
orbital floor are removed together with the pterygoid
plates.
148 Radical ma\iilectomy

7
closure of skin

Prior to skin closure the inner raw surface of facial skin

may be grafted with split-skin although this is not always
essential. 3/0 Chromic catgut sutures are used sub-
cutaneously to hold skin edges in position prior to
insertion of silk skin sutures.
W h e r e the eye has been removed, the lash margins and
tarsal plates are cut off from the eyelids which are then
approximated with fine silk sutures.
It is always desirable to introduce a prosthesis into the
palatal defect at the end of the operation since this
prevents contracture, maintains facial contour and en-
ables the patient to eat a soft diet immediately. The cavity
is lightly packed with 2 inch ribbon gauze impregnated
with Whitehead's Varnish, this being removed 1 week
later when the prosthesis is changed.
illustrations by Ciilian Oliver

D. Downton FDS, RCS

Consultant in Oral and Dental Surgery, Royal Free Hospital Teaching G r o u p , London, UK

Preoperative Preoperative preparation

Oroantral fistula is not uncommonly created during the

extraction of the maxillary molar or premolar teeth,
especially in those cases where the apices of these teeth
are very closely related to the antral floor. W h e n a break
occurs in the antral floor during an extraction, immediate
treatment can often lead to spontaneous healing, but
once a fistula has been established surgical closure is
necessary.
T h e mouth should be cleaned and free from infected teeth
Anaesthesia
Endotracheal anaesthesia together with a local anaesthetic
containing a vasoconstrictor, infiltrated around the site to
reduce bleeding, or a local anaesthetic alone.

149
150 Oroantral fistula

Surgical closure
B u c c a l flap operation

1
A circular incision is made around the opening of the
fistula about 1 mm from its edge, and the fistulous tract is
excised together- with any granulations or polypi. Two
divergent incisions are made, 0.5 cm each side of the
defect, into the mucoperiosteum and then extending into
the mucosa of the buccal sulcus. The alveolar ends of the
incisions are then extended into the excised edge of the
fistula. The base of the flap must be as broad as possible to
ensure an adequate blood supply.

2
The mucoperiosteal flap is raised and a horizontal incision
is made just through the periosteum on the undersurface.
This mobilizes the cheek mucosa. Before suturing, the
mucoperiosteum adjacent to the fistula must be cut back
to expose a shelf of bone about 3 mm w i d e . The free end
of the flap can then be trimmed to cover the fistula and fit
accurately.

Finally, it is sutured in position without tension and the

suture line is over healthy bone.
If polyps or chronic granulations are present, these
must be removed before suturing and it may be necessary
to enlarge the fistula on the buccal aspect for adequate
access.
A plate can be constructed preoperatively to cover the
operation site; this helps to hold the flap in position and
prevent irritation by food, etc.
 Oroantral fistula 15!

PALATAL FLAP O P E R A T I O N

4
First the fistula is excised as in the buccal flap operation.
Two longitudinal incisions are made on either side of the
greater palatine vessels and joined anteriorly. A palatal
mucoperiosteal flap is then raised to provide a pedicle flap
which is nourished by the palatine vessels.

T h e flap is then rotated to cover the defect and sutured

down to sound bone on the buccal aspect. Before
suturing, the portion of mucosa between the fistula and
the flap bed must be excised.
This procedure is more difficult to carry out and it leaves
a bare bony defect anteriorly. The defect must be covered
with a ' p a c k (e.g. gauze strips soaked in Whitehead's
Varnish), w h i c h must be sutured in place or held by a
plate. Also the flap is thick and not easy to manipulate,
and this makes its adaption difficult.
Intranasal antrostomy is not indicated in either opera-
tion.

A broad-spectrum antibiotic should be prescribed for 5

days, and a 10 day course of decongestant nose drops and
inhalations. Sutures (black silk) should be removed on the
tenth day postoperatively.
illustrations by Gillian Lee
John Ballantyne C B E , F R C S , HonFResi
Consultant Ear, Nose and Throat Surgeon,
Royal Free Hospital and King Edward VII Hospital for Officers, London, UK
Indications
Simple nasal polypi arise most commonly from the
ethmoidal sinuses, usually lateral to the middle turbinate
but not infrequently from its medial" aspect also; much
less commonly they arise from the maxillary sinuses
(antrochoanal polypi). In either event they can nearly
always be removed satisfactorily through the nose.
152
Anaesthesia
Simple polypi, especially when single and pedunculated,
may often be removed satisfactorily under topical anaes-
thesia. T h e nose is first sprayed with a 10 per cent solution
of cocaine, and this is followed by careful painting of
every accessible part of the nose, especially around the
base of the polypus, with the cocaine-adrenaline paste
described on p. 69.
W h e n they are multiple and sessile, they are better
removed under a general anaesthetic delivered through a
cuffed peroral endotracheal tube, with a pharyngeal pack.
 Pernasal removal of nasal polypi 15 5

1
«_ a un vi

REMOVAL OF POLYPI WITH A SNARE

Under topical or general anaesthesia, the wire loop of a

snare is insinuated around the fundus of each polypus and
advanced to its base. Closure of the snare is followed by
gentle avulsion.

REMOVAL OF MULTIPLE ETHMOIDAL POLYPI AND

ANTROCHOANAL POLYPI; PERNASAL
ETHMOIDECTOMY

Under general anaesthesia, and after careful preparation

of the nose w i t h cocaine-adrenaline paste, the polypus-
bearir -ea of the nose is exposed with the help of a
Killian _ w i g - b l a d e d speculum and the main polypoid
masses are removed with Henckel's forceps.

The remaining pieces of polypoid mucosa are removed

with Citelli's upturned forceps, which are also used for
uncapping the ethmoidal bulla and for removing every
visible trace of oedematous mucosa from the air cells. This
requires meticulous care under direct visual c o n t r o l , and
particular attention must be paid to the cells of the agger
nasi. It can be helpful to remove the final pieces of
polypoid mucosa through the binocular operating micro-
scope, using x300 objective.
154 Perncjsal removal of nasal polypi

Complications and special

precautions

4
The roof of the ethmoidal labyrinth is above the level of
the cribriform plate; its lateral wall (the lamina papyracea)
separates it from the orbit.
If instruments are advanced too high, they may
penetrate the cribriform plate, with the danger of possible
meningitis or other intracranial complications; if they
penetrate the lamina papyracea, they may perforate the
orbital periosteum, with a subsequent risk of orbital
haematoma or abscess.

T h e posterior extremity of the lamina papyracea extends

almost to the level of the optic foramen, just behind the
exit of the posterior ethmoidal artery (arrow). If instru-
ments are allowed to penetrate too far back through this
orbital wall of the labyrinth, they may injure the optic
nerve, with consequent blindness. W h e n the surgeon is
working in the ethmoidaj labyrinth, his instruments must
therefore be kept: below the cribriform plate; medial to
the orbital periosteum and also to the lamina papyracea;
and in front of the optic foramen.

{Photograph taken by D. Connolly from a specimen prepared by

Professor C. Nicof)

5 Any 'fleshy' nasal polypi, especially w h e n they are

unilateral, should be submitted to histopathological
scrutiny.
Most 'simple' nasal polypi result from instability of the
nose's vasomotor mechanism, and energetic postopera-
tive treatment of the underlying vasomotor disturbance is
essential to the prevention of recurrence. This can usually
be achieved by the long-term use of antihistamines but
occasionally one may be justified in prescribing a systemic
steroid, in a short course of diminishing dosage,
especially w h e n the polypi are multiple and/or recurrent.
Illustrations by Philip Wilson

Robert G . Hughes F R C S (Ed.)

Consultant, Wolverhampton District Hospitals, Wolverhampton, UK

Preoperative Special equipment

1. Ferris-Smith orbital retractor or, alternatively, angled

The anterior and posterior ethmoidal arteries arise as orbital retractors as used in the Patterson external
branches of the ophthalmic artery within the orbit. ethmoidal sinus operation.
Perforating the medial orbital periosteum, they traverse 2. Metal haemostatic clips.
the anterior and posterior ethmoidal canals respectively to
supply the sinuses and thence enter the cranium,
returning to the nose via the cribriform plate.
Preoperative preparation

1. Routine skin preparation with an agent that is non-

Indications
1. To minimize haemorrhage during extensive ethmoidal
sinus surgery.
2. To control epistaxis of apparent ethmoidal origin.
injurious to the cornea and conjunctiva, such as an
aqueous solution of acriflavine.
2. Maintenance of eye closure by suturing the upper and
lower lids together to safeguard against accidental
corneal abrasion.

Anaesthesia

Orotracheal general anaesthesia with oropharyngeal pack-

ing with moist gauze.

155
156 Ligation ot ethmoidal vessels

A curved incision 1-1.5cm long is made medial to the

inner canthus.

The incision Is continued through the periosteum which is

separated progressively from the bone. Stripping pro-
ceeds posteriorly into the orbit, displacing the lacrimal sac
and orbital periosteum laterally.
W h e n a depth of 1.5-2 cm posterior to the lacrimal
groove is reached one must proceed with caution owing
to the variable disposition of the ethmoidal vessels and
the danger of tearing through the vessel w a l l . Retraction
of the torn- artery might result in their disappearance into
the orbit, with resulting orbital haemorrhage, or into the
sinuses with retrograde bleeding. Once located, the artery
is occluded by a ligature or metal artery clip. Further
gentle orbital retraction and progressive periosteal separa-
tion locate the posterior ethmoidal artery, which is dealt
with similarly.
Illustrations by Gillian Lee
Robert G . Hughes FRCS(Ed.)
Consultant Surgeon, Sub-regional Ear, Nose and Throat Departments, Wolverhampton and Dudley, UK
Indication
Trephining is indicated for acute obstructed frontal
sinusitis, which is diagnosed w h e n frontal sinus pain and
extreme tenderness on palpation persist despite conserva-
tive treatment with antibiotics and decongestants. W h e n
the pressure of pus within the sinus reaches capillary
blood pressure, mucosal necrosis and later bone necrosis
lead to the spread of infection beyond the sinus.
As a rough clinical guide, failure to relieve the severity
of symptoms after 24-43 hours' intensive therapy is a
reliable signal for surgery.
Preoperative preparation
A routine skin preparation of the forehead and upper face
is undertaken using a preparation harmless to the eyes,
such as an aqueous solution of acriflavine. Suturing the
eyelids together is a sensible means of avoiding accidental
cornea! abrasion.
Position of patient
T h e patient lies in a supine position with the head flexed
and the table in the reversed Trendelenberg position to
minimize bleeding.
157
158 Trephine of the frontal sinus

The incision

A n incision about 1 cm in length is made beneath the

medial end of the eyebrow, cutting through skin,
subcutaneous tissue and periosteum. Haemorrhage is
often brisk and haemostasis is established.
The periosteum is then stripped off an area of the floor
of the frontal sinus underlying the incision and the thin
bone of the frontal sinus is perforated using either a burr
or a small gouge and hammer - the latter is usually
quicker and neater.

The mucosa of the frontal sinus is thus exposed and

perforated (if this does not occur spontaneously) to
release a gush of pus under pressure. A swab is taken for
bacteriological culture. O n occasion one may be surprised
by the absence of pus and it is most important to realize
that almost invariably this is because a frontoethmoidal
cell has been opened. A careful removal of the roof of this
cell will lead to the true frontal sinus, resulting in
drainage.
Radiography may warn of the above possibility but it is
not always reliable.
In the clinically ill patient the sinus roof should be
inspected by extension of the original opening of the
sinus floor.
Not infrequently in these cases the removal of a portion
of the roof of the sinus will reveal an extradural abscess
(see chapter on 'Cortical Mastoidectomy' p. 54 (paragraph
5) in the 3rd edition when exposure of the lateral sinus and
middle fossa is imperative).

Postoperative care
It is imperative to persist with measures to restore health
and normality of frontonasal function.
1. Antibiotic therapy is continued, and may have to be
modified when the results of bacteriological culture are .
known.
2. Nasal decongestant therapy is continued.
3. Lavage of the sinuses. The frontal sinus is washed out
through the in-dwelling tube until the washout is freely
returned through the nose over a period of not less
than 48 hours.
It is common to find infection of the ipsilateral antrum
which should be washed out until c u r e d , alternatively
surgery for drainage may be required.
Trephine of the frontal sinus 159
It is important to consider the state of the contralateral
maxillary sinus as infection here is the most common
cause of frontal sinusitis with complications. Any infection
in this sinus must be appropriately eradicated.
Complications
Complications due to surgery are most unusual but
complications of the disease have to be constantly looked
for, e . g . spreading osteomyelitis of the skull, spreading
intracranial venous thrombophlebitis, extradural absces-
s e s , brain abscesses and meningitis.
Illustrations by Gillian Lee

Robert G . Hughes F R C S (Ed.)

Consultant, Wolverhampton District Hospitals, Wolverhampton, UK

A n external approach to the paranasal sinuses is indicated Special equipment

for extensive disease. The intranasal route does not
provide adequate access to, or visualization of, the Hammer and gouge.
anterior ethmoid and the sphenoid area nor does it Self-retaining wound retractor (e.g. Ferris-Smith).
provide sufficiently reliable landmarks to ensure that the Forward and side-biting punch forceps; Citelli and
intraorbital and intracranial contents are not at risk. Tilley-Henckel forceps.
T w o approaches are available. O n e approach, com- Portex tube.
monly attributed to Howarth, uses a near-vertical para-
nasal skin incision; the other, attributed to Patterson, uses
a near-horizontal infraorbital incision.
Preoperative preparation

For the forehead and upper face, a preparation that is

HOWARTH'S OPERATION non-irritant to the eye and conjunctiva is used. No shaving

of the hair or eyebrows is indicated. The eyelids are
sutured together to avoid accidental damage to the
cornea.
A topical vasoconstrictor such as cocaine 5 per cent or
Moffett's solution is applied to the nasal mucosa. An
antibiotic umbrella may be desirable. /
Indications
1. Extensive chronic irreversible mucosa! changes in the
sinuses. Anaesthesia
2. Chronic obstruction to the drainage of infection from
the sinuses. A general anaesthetic is administered through an oro-
3. As a method of approach to the pituitary fossa. tracheal tube and the pharynx is packed with moist gauze
4. Drainage of acute ethmoidal abscesses with complica- to protect the airway from blood and pus. Induced
tions. hypotension is often desirable.

If.O
 External operations on the frontal, ethmoidal and sphenoidal siau

position of patient
The patient lies supine. The reversed Trendelenburg
position is desirable to minimize oozing of blood- The
head is further flexed if necessary so that a line between
the medial canthus and the external auditory meatus is in
line with the surgeon's gaze. This serves as a rough guide
to the plane of the base of the cranium.

1
The incision

A slightly curved incision, medial to, and concave

towards, the medial canthus of the eye is made.
The periosteum is raised to reveal the nasal process of
both the maxilla and the frontal bone and the medial
orbital wall. Deformity is minimal if the periosteum is
raised at the same level or medial to the skin incision.
The lacrimal sac is _£le_yjite^jronx its groove and
displaced laterally. Periosteal elevation is continued
posteriorly to reveal the ethmoidal vessels as they
penetrate into the nasal cavity.
It may be necessary to extend the incision upwards and
laterally if extensive exposure of the frontal sinus is
indicated, in which case C £ j ^ _ j m t £ L J 3 e J a J i g i L j £ ^
dariiageJp_tjTe^^ superior oblique ocularis
muscle.

Ligation of ethmoidal vessels

The insertion of a Ferris-Smith retractor facilitates isolation
of the ethmoidal vessels, which are then secured with
sutures or metal clips.

2
Exposure of ethmoidal sinuses
T h e thin ethmoidal bone medial to the orbit is penetrated,
thus exposing the ethmoidal cells. Thjg^c_ejjs are progres¬
sively exenterated to expose the insertions of the middle
and^supe_rior turbinates. The cribriform plate is defined
sijperioriy and the ostium of the sphenoidal sinus is
jdj^tjfieck.
T h e anterior wall of the sphenoidal sinus is then
removed. It is safer to commence its removal by w o r k i n g
downwards and medially from the ostium. T h e size of the
sinus is then more easily defined and further removal of
the anterior wall can be carried out with safety.
162 External operations on the frontal, ethmoidal and sphenoidal sinuses

Exposure of frontal sinus

Exenteration of the anterior ethmoidal ceils is completed

by working upwards until the floor of the frontal sinus is
exposed. The bony wall of the floor is sufficiently removed
to expose the interior of the sinus.
T h e diseased contents of the sinus are evacuated, and
removal of the anterior wall of the frontonasal duct is then
completed.

3
Maintenance of frontal sinus drainage

Following the extensive removal of bone in the anterior

ethmoid region there is a risk that postoperative collapse
in the frontonasal area may occur, thus isolating the
frontal sinus from the nose.
A w i d e j ^ p r b & r - e f o x e inserted, extending from
the frontal sinus to the nasal cavity. This is retained for
months - until the surrounding tissue is firm.
T h e practice of lining the tube with a Thiersch skin graft
introduces keratinizing epithelium into the nose and is
therefore not recommended.
Polythene tubes have the disadvantage of being so inert
as to permit the regrowth of epithelium along their outer
wall and ultimately over the lumen, thus risking further
frontal sinus obstruction.
Portex tubing is less inert and its use avoids this
complication.

The maxillary sinus

It is likely that disease in this sinus will have been

previously dealt with. If not, the antrum is cleared via the
Caldwell-Luc route (see chapter on 'The Caldwell-Luc and
allied operations', pp. 116-121).
Closure
The periosteal and skin layers are carefully sutured. The
sutures may be removed in 3-5 days.
Orbital infections may possibly ensue but should be rare,
especially if care is taken not to damage the orbital
periosteum.
Diplopia and epiphora are usually transient. Frontonasal
obstruction may lead to fistula formation. Late closure of
the new frontonasal duct may occur following the removal
of the indwelling tube.
 External operations on the frontal, ethmoidal and sphenoidal sinuses 163

DATTFRSON'S OPFRATION

indications
1. Extensive chronic mucosal changes in the sinuses.
2. Chronic-obstruction to the drainage of infection from
the sinuses
3. As an approach to the pituitary fossa.
4. T h e repair of blow-out fractures of the orbit.
5. T h e reduction of malignant exophthalmos.
6. T h e excision of tumours such as 'Ringertz' tumour
involving the ethmoids.

4
Special instruments

As for the Howarth's operation except that the Ferris-

Smith retractor is not used, orbital and frontonasal duct
retraction being effected by the retractor illustrated.

4
Preoperative preparation
Routine skin preparation is carried out, followed by
suturing of the eyelid to protect the cornea and
application of a local vasoconstrictor such as Moffett's
solution to the nasal mucosa.

The incision
A n incision up to 1-2 cm long is made in the natural
crease-line about a finger's breadth below the infraorbital
margin after injection of 1-2 ml of 1:400000 aqueous
adrenaline solution into the area to aid haemostasis.
T h e orbicularis muscle is thus exposed and is split in the
line of its fibres, revealing the periosteum which is then
incised.
The periosteum is elevated off the bone superiorly until
the orbital margin is reached. Elevation of the periosteum
is continued on to the medial third of the floor of the orbit
and its medial wall for a distance of 1-2 c m .
Creat care is exercised when elevating the periosteum
off the actual rim of the orbit, which often presents as a
sharp crest. Tearing the periosteum risks the herniation of
orbital fat with subsequent enophthalmos and a greater
risk of orbital infection.
T h e superior part of the nasolacrimal duct is now
visible.. A 1 cm segment of the anterior face of the maxilla
is removed by hammer and gouge from a point 0.5 cm
lateral to the duct medially to the nasal bone. This opens a
w i n d o w into the maxillary sinus and exposes the
nasolacrimal duct.
164 External operations on the frontal, ethmoidal and sphenoidal sinuses

7
The bony orbital floor posterior to the duct and the medial
orbital wall adjacent to it are removed to a depth of
1-2 c m . The media! orbital wall defines the lateral limit of
surgery as all the important structures are just lateral to
this line.
All cells medial to this line are now exenterated using
Tiliey-Henckel or Ferris-Smith punch forceps.
The sphenoidal ostium is identified and the sinus
opened by removing its anterior wall to the extent dictated
by disease.

The maxillary sinus

The contents of the maxillary sinus can be removed

through the 'window' in its superomedial angle.
Drainage from the sinus should be adequate following
the ethmoidectomy. Should the disease demand a more
thorough inspection of the antrum a Caldwell-Luc
exposure should be performed. Both sutures and nasal packing may be removed on the
third postoperative day. Nasal crusting may occur for the
first few weeks postoperatively and may need to be
removed once or twice a week.
The frontal sinus

Exenteration of the anterior ethmoidal cells is continued

until the ring opening of the frontal sinus is defined. A
frontal sinus cannula is then inserted to explore the sinus.
This is usually sufficient to provide excellent drainage
but if locutation within the frontal sinus is suspected the
floor is exposed via a separate incision and partly removed
so that the contents of the frontal sinus can be evacuated.
T h e w o u n d is closed in layers, the split fibres of the
orbicularis being approximated by a layer of catgut
sutures. This provides a firm bed for the skin layer and
leads to a very good cosmetic result. The nasal cavity may
need packing with BIPP gauze to minimize postoperative
oozing.
Com pi icpti on s
If care is taken not to damage the orbital periosteum,
orbital infection is avoided and diplopia and epiphora are
transient.
The retention of an intact bony ring in the floor of the
frontal sinus and the retention of the superior section of
the orbital wall ensures the continued patency of the
frontonasal area, with adequate ventilation and drainage
of the frontal sinus.
Recurrence of anterior ethmoidal polyposis is very rare
following this technique.
Illustrations by Gillian Lee

A, G. D. Maran M D , FRCS, FACS

Consultant Otolaryngologist, Royal Infirmary, Edinburgh, UK

Indications

This approach to the frontal sinus is usually indicated for:

1. removal of osteoma;
2. removal of muco- or pyocele;
3. exploration of the frontal sinus posterior wall after
trauma;
4 . removal of chronically infected mucosa.

Anatomy of frontal sinus

T h e frontal sinus is a cavity with vertical and horizontal

projections. The anterior wall is joined to the posterior
wall by up to eight septa whose degree of completeness
varies. The posterior wall and floor are thinner than the
anterior wall. The supraorbital ridge is much thicker in
males than in females. The bulge of the roof of the orbit
often disguises the horizontal projection and may extend
as far posteriorly as the clinoid. The frontonasal duct is
surrounded by anterior ethmoid cells. By opening the
mouth of the duct the ethmoid labyrinth is opened and
the sphenoid may be reached easily.

165
jf,f> Osteoplastic frontal flap operation

Surface marking of frontal sinus

2
Immediately before the operation a radiograph is taken in
the occipitomental position. The patient has two crossed
wires strapped to the forehead with transparent tape (for
visibility). The radiograph accompanies the patient to the
theatre and the frontal sinus section is cut out with
scissors to form a template.

W h e n the patient is anaesthetized the template is

superimposed on the wires strapped to the forehead,
making sure that the magnification factor has been
equalized. The outline of the sinus is then tattooed on the
skin with methylene blue. It is best to inject the dye to
make certain that it reaches the periosteum.

1 *
 Osteoplastic frontal flap operation 157

The operation
The incisions

4&5
Bitemporal coronal incision

This can be done as far posteriorly as the interaural line.

There is no need to shave the hair since the cranium is not
entered. The patient, however, should wash the hair with
chlorhexldine daily for 3 days before the operation. T h e
skin incision is taken down through the aponeurosis and
the flap is elevated forward to the supraorbital ridges.

Eyebrow incision
O n a male w h o is bald or who has a strong family history
of baldness the eyebrow incision leaves a more acceptable
scar. This goes through the eyebrows (which are not
shaved); it does not need to be so extensive as the
bitemporal coronal incision since the elevation is smaller.
163 Osteoplastic frontal flap operation

7
Creation of bone flap

Clips over towels are applied to the edges of the incision.

The periosteum is incised 2.5cm beyond the tattoo
marks and elevated to just beyond these marks. A Stryker
saw is used at an oblique angle to incise the bone through
the supraorbital ridge, taking care not to damage the
supraorbital and supratrochlear nerves. It is also helpful to
make a bony incision at the nasion.

The anterior wall is now held to the posterior wall by

several septa. These are incised by inserting a 10mm
osteotome into the sinus. Three such osteotomes can
then be used as levers to create the flap and open the
sinus.

Clearance of sinus

If an osteoma is to be removed it can be drilled out or, if

on a narrow base, removed by osteotomes.
Diseased mucosa is elevated from both walls and
recesses with a Freer elevator. The bone is then drilled
with a cutting burr until smooth. W h e n the horizontal
recess is found, it is opened as widely as the roof of the
orbit will permit.
 Osteoplastic frontal flap operation 169

prainage or obliteration
the frontonasal duct has to be either opened very wide or
obliterated. For discussion of the relative merits of each
method see other texts.

Fat from the abdominal wall is used for obliteration.

The largest Portex tube obtainable should sit in the

opened duct/ethmoid if obliteration has not been per-
formed.

The bone flap is replaced and the periosteum is sutured

with 3/0 chromic catgut. A rubber dam drain is placed in
each side of the incision and the skin is closed with a
running suture of 3/0 silk. If there has been no
obliteration, the Portex tube is sutured to the columella. A
pressure dressing is applied on the second day.
Illustrations byCiilian Lee
R. A. W i l l i a m s M A , F R C S , FRCS{£d), O L O
Consultant Ear, Nose and Throat Surgeon, Middlesex Hospital, London and
Q u e e n Elizabeth II Hospital, Welwyn Garden City, Herts;
King Edward VII Hospital for Officers, London, and Honorary Civilian Consultant in Otolaryngology to the A r m y , UK
Indications for removal of normal pituitary
The indications for total removal of a normal pituitary
gland have lessened in the last 10 years. Now the
operation is occasionally performed to relieve bone pain
from secondary deposits in carcinomatosis of the breast
and prostate. If the indications are right, this is a very
effective treatment, but there are other methods which do
not involve surgery. An experienced oncologist ought to
be consulted before hypophysectomy is performed for
hormone-dependent secondary carcinomatosis. '
Indications for removal of pituitary tumours
Transphenoidal pituitary surgery is often the treatment for
various types of primary tumour. T h e indications may be
surgical and/or medical.
Surgical indications for removal of pituitary tumours
The local tumour may expand upwards and cause
headache, p a p i l l e d e m a and bitemporal visual field
defects leading to blindness, If it erodes sideways into the
cavernous sinuses, base of skull and orbits, there may be
multiple cranial nerve palsies. Downward expansion can
be large without symptoms or signs, but cerebrospinal
fluid rhinorrhoea and meningitis can occur
170
Medical indications for removal of pituitary tumours
The endocrinologist often asks the surgeon to remove a
pituitary tumour to treat the diseases that result from
overproduction of various hormones. T h e following
conditions indicate removal.
1. Acromegaly and gigantism.
2. Cushing's disease of pituitary origin.
3. Nelson's syndrome.
4. Prolactinomas.
5. Rare tumours producing a mixture of hormone
abnormalities.
Transphenoidal hypophysectomy is usually a satisfac-
tory and effective treatment for acromegaly. T h e growth
hormone level can be lowered to normal in about 70 per
cent of cases by operation alone.
Cushing's disease is not so easy to treat surgically. The
adenoma may cause enlargement of the fossa and be
locally invasive. However, the abnormality is often a
microadenoma, which does not show on plain X-rays.
Identification and microdissection of these tumours
requires considerable experience, with medical and
histological backup. The same applies to Nelson's
syndrome, when Cushing's disease has been treated by
adrenalectomy and a pituitary tumour then grows with
high A C T H levels and pigmentation.
Prolactinomas may be large tumours or microadeno-
mas. The indications for surgical treatment to lower
prolactin levels have changed since the introduction of
bromocriptine and similar drugs. However, if medical
treatment is not tolerated or is not effective, removal of
the adenoma can lower the prolactin level to normal,
provided the tumour is not too large.

Contraindications
sis of the breast or prostate is contraindicated if the time
between the diagnosis of the primary lesion and the
appearance of secondary deposits is less than about 3
years. T h e liver may contain secondary deposits; if there is
evidence of this clinically (by jaundice, or an enlarged
liver) or biochemically, patients are not helped by
hypophysectomy. The platelet count may be reduced by
bone deposits, radiotherapy or chemotherapy a n d , if it is
below 30000 per m m , troublesome bleeding can be
3
expected. Although this may be overcome by platelet
transfusions, it usually means that there will not be any
worthwhile recovery. It is not safe to proceed in the
presence of nasal or sinus infection, and this should be
cleared up first.
Local factors
Normal anatomy
The floor of the pituitary fossa bulges to a variable extent
from the roof of the sphenoidal sinus. Full pneumatization
occurs in 86 per cent. In 11 per cent the pneumatization
does not extend posterior to the front of the fossa, and in
3 per cent the sphenoid is not pneumatized enough to
expose the pituitary fossa. These variations do not
contraindicate transphenoidal surgery but can make
surgery more difficult.
The extent of the tumour
T h e limits of the tumour can be demonstrated in various
ways.
1. Signs and symptoms, such as visual field defects or
crania! nerve palsies.
2. Imaging techniques.
(a) Plain X-rays and tomography are essential to show
the normal anatomy and the expansion of the fossa
b a c k w a r d s , downwards and forwards. Break-
through of tumour into the sphenoidal sinus can
also be s e e n .
(b) C T scans. A modern scanner can s h o w the upper
edge of a tumour with contrast. Microadenomas,
cysts or empty fossas can be seen as areas of low
density. T h e facility for simulating sagittal views by
computerization is helpful.
(c) If such scans are not available, air encephalography
or the use of water-soluble radiopaque solutions
will show the upper part of the tumour w e l l , but this
investigation is invasive and should not now have to
be performed.
T r a n s s p h e n o i d a l hypophyseciomv 17 i
(d) Arteriography is sometimes advisable if there are
indications, in the other X-ravs or scans, that the
(e) Cavernous sinus venography is useful to show
lateral extensions of tumours, but this investigation
is not often required.
W h e n the tumour is outlined, it is possible to decide
whether trans-sphenoidal operation is appropriate.
Upward extensions of about 10 mm posteriorly''and
3 mm anteriorly can be removed from below. Large
upward extensions, especially with visual field defects, are
best removed transcranially. Dumb-bell tumours may
require surgery from below first and then from a b o v e , and
so full consultation with a neurosurgeon is essential.
Lateral extensions cannot be removed under direct
vision, but need blind curetting. Even if there "are palsies
of 111, IV and VI nerves, surgery can be worthwhile.
Downward extensions do not usually present difficulties
w h e n the bone of the basisphenoid and basiocciput is
invaded.
Preoperative preparation
Prophylactic antibiotics starting with the premedication
are advisable, and a mixture of soluble penicillin by
injection, and sulphonamides by mouth, except for the
first dose w h i c h is given by injection, has proved to be
effective. Steroid cover should be with complete physiolo-
gical replacement doses. - If the patient has been on
steroids already, or has Cushing's disease, the dose will
need to be increased considerably. This should start
during surgery. It is convenient and safer to give the
steroids intravenously for the first 24 hours, as the dose
can be adjusted quickly if necessary.
Anaesthesia
Generally it is helpful to have controlled ventilation with
some negative phase to keep the venous pressure l o w . Air
embolism does not seem to be a problem w i t h the
cavernous sinuses, but if air is seen to enter the sinuses,
the ventilation pressure can be adjusted accordingly.
Hypotension makes the dissection of the pituitary much
easier and safer, and is generally indicated for that stage of
the operation.
Especially in acromegaly, there can occasionally be
serious difficulty with intubation, owing to the shape of
the lower jaw and enlargement of the tongue. T h e
anaesthetist should be prepared for this in all cases of
acromegaly.
172 Transsphenoidal hypophysectomy

The approach

The sphenoid may be approached by:

(a) Transethmoidal operation, with an external incision.

(6) Trans-septal operation, with a sublabial incision
' (Cushing's approach).

T h e external ethmoidal approach gives a wider access

and there are two openings: the ethmoid for vision and
the nose for instrumentation (7c). This makes the
operation easier, especially if there are any anatomical
difficulties, or if a tumour extends downwards and
backwards. The disadvantages are an external scar, and
that in some acromegalics with large frontal sinuses, the
frontonasal duct may become obstructed postoperatively
by scar tissue. Special care has to be taken at operation to
try and avoid this.
A n advantage of the sublabial approach is that there is
no external scar. T h e approach makes it easier to deal with
upward extensions, but vision and instrumentation are
through one smaller opening and this is technically more
difficult. Occasionally the incisor teeth may be dener-
vated. However, for normal sized pituitaries, this
approach has more advantages than disadvantages.

Instruments
For both approaches a routine nasal set of instruments is
required, including sphenoidal punches and a Zeiss
operating microscope with a 300 mm objective lens.

For the externa! ethmoidal approach

1. A Luongo retractor, with an extra long blade for
acromegalics.
2. A set of Angell-James' dissectors.
3. Angell-James' forceps, diathermy ends and small
punches.
4 . A Williams' curette.
5. A set of Hardy curettes.
6. A long straight nasal sucker.
7. A dental drill with a straight handpiece and long-shank
cutting burrs.

For the sublabia} approach

1. A set of Hardy retractors instead of the Luoneo
retractor.
2. An angled handpiece for the dental drill, with lone-
shank burrs.
 Transsphenoidal hypophysectomy 17'j

position of patient External ethmoidal approach

f r tne eAiei iiai euimuiuai appfuacn tne operating taole is
0 It may be necessary to perform a submucous resection of
tipped about 25° head-up, the neck slightly flexed and the the nasal septum for access to the right side of the nose.
head turned to the right to face the surgeon. For the An external incision is made, curved round the medial
sublabial approach the neck is not flexed and the head side of the right orbit, for right handed surgeons. T h e
:

tipped back a little. incision is deepened towards the nose rather than
laterally, so that the nasolacrimal sac is avoided. Superior-
ly the supratrochlear nerve is avoided by straightening the
upper 1 cm of the Incision. A piece of muscle can be taken
from the frontalis region if the pituitary fossa is s m a l l ;
otherwise the muscle will have to be taken from
elsewhere, usually the lateral thigh.

2
T h e incision is deepened to the bone by dividing the
periosteum. T h e orbital periosteum is separated from the
bone using a periosteal elevator anteriorly, but o n c e the
dissection is back past the orbital rim the separation is
easier. T h e anterior ethmoidal artery is identified in the
frontoethmoidal suture. This artery is diathermied with a
touch above and below. It can then be separated by firm
dissection against the bone; there is usually no bieeding
or extravasation of fat. The dissection continues to the
posterior ethmoidal artery which is left as a landmark. T h e
lacrimal sac is lifted out of its groove and mobilized to
avoid tension w h e n the retractor is inserted.

3
The Luongo retractor is inserted and if necessary the
medial end held down by a stay suture.

T h e bone of the orbital rim is then removed w i t h a drill

or gouge.- Care must be taken not to lay o p e n the
frontonasal duct too much. The bone of the paper plate of
the ethmoid is nibbled away, using the level of the
anterior ethmoidal artery as an upper limited of the
ethmoids. A complete external ethmoidectomy is per-
f o r m e d . If the middle turbinate limits access it can be
removed, but this is not often necessary. The sphenoidal
sinus is entered through the posterior ethmoidal c e l l . T h e
bone of the anterior wall of the sphenoidal sinus is
removed with punch forceps or a drill as widely as
possible. T h e rostrum of the vomer may also have to be
drilled away to gain full access to the left side of the
sphenoidal sinus. Any intersphenoidal septa are removed
to identify the bulge of the pituitary fossa completely.
3
174 Transsphenoidal hypophysectomy

A gingival incision is made. T h e periosteum is elevated

w i t h the mucosa to expose the mucosa of the pyriform
opening and floor of the nose. The dissection is carried up
onto the front of the nasal septum. Firm retraction is
needed to elevate the upper lip and tip of the nose, using
small right-angled retractors. The mucosa is separated
from the floor of the nose, to both sides and from the
nasal septal cartilage. The bony opening of the front of the
nose is thus fully exposed, and can then be enlarged
laterally with a bone p u n c h . This is not always necessary,
and may cause temporary or occasionally permanent
denervation of the incisor teeth.

A submucous resection of the nasal septum is then

performed, holding the flaps apart with a large Killian
speculum. A Hardy bivalve speculum is inserted. T h e
anterior wall of the sphenoidal sinus is opened with a
gouge or drill and removed laterally as far as possible. It is
not always easy to identify the pituitary from this angle, as
it is from the ethmoids, especially if the pneumatization is
only partial. If there is any difficulty an X-ray can confirm
the position.

From this point the operation is the same whichever

approach has been used, except that angled instruments
are used sublabially and straight instruments trans-
ethmoidaliy.
T h e Zeiss operating microscope is now brought i n ,
5 Vfi using 300 mm objective lens and about x 6 magnification.
 Transsphenoidal hypophysectomy 175

Exposing the dura

The dura covering the pituitary is exposed by drilling away

the bone using a cutting burr which does not damage the
dura. A layer of bone is removed, extending above to the
top of the sphenoidal sinus, sideways until the bone
thickens and the full width of the fossa is reached and
downwards to the floor. The floor is not removed, as this
is needed to support the muscle plug, targe tumours
often erode through the bone and sometimes also
through the dura, presenting in the sphenoidal sinus.

Opening the dura

7
W i t h normal-sized pituitaries the cavernous and inter-
cavernous sinuses can usually be seen through the dura,
and the incision can be made to avoid t h e m , ff possible a
cruciate incision is made but if there is insufficient space
between the superior and inferior intercavernous sinuses,
a transverse incision is adequate. A diathermy point cuts
through the two layers of dura and helps seal them
together.

At this stage the C T scan should be inspected to see the

position of the diaphragm. If there is a partially empty sella
the incision should be made appropriately low to avoid
entering the subarachnoid space.

Dissection

T h e gland tends to bulge out of the incision straight away.

T u m o u r tissue may be extruded but normal pituitary is
more solid, and just presents itself.
176 Transsphenoidal hypophysectomy

With norma! glands there is a plane of cleavage around the

gland and Angell-James' dissectors are shaped to separate
the floor, sides and then right round to the stalk.

T h e gland is held with forceps and the stalk cut with

microscissors. It may be possible to remove the entire
gland in o n e , but often pieces are left behind and these
can-be found with a right-angled curette. For total removal
the diaphragm must be cleaned until it is transparently
t h i n , and the walls and floor inspected carefully.
W h e n removing large tumours, curetting may have to
be blind into the cavernous sinuses and into the
suprasellar area. If a tumour erodes cancellous bone of
the basisphenoid, it can be drilled out under direct vision
without difficulty.

Microdissection
This involves removing the tumour and leaving the normal
functioning pituitary tissue. Experience is required to be
able to identify norma! and abnormal gland by inspection.
Microadenomas associated with prolactinomas tend to
occur posterolateral^; basophil adenomas posteriorly
and acidophil adenomas anterolaterally. O n c e identified,
the microadenoma is curetted and sucked away. A frozen
section of the adjacent normal gland is helpful as long as
there is sufficient gland remaining for the biopsy not to be
functionally significant. Normal gland is firm and slightly
yellow; tumours are softer and vary from creamy-white to
haemorrhagic, solid or cystic.

Bleeding Muscle packing

Hypotension during the pituitary dissection is helpful.
Venous bleeding is lessened by the head-up tilt and by
controlled ventilation with some negative phase. If the
cavernous sinus or intercavernous sinus is o p e n e d , a little
pressure with a small swab or the sucker controls the
bleeding and the operation can continue.
Cerebrospinal fluid escape
This occurs when the diaphragm is breached. The
cerebrospinal fluid can be sucked away until the pressure
is lowered, w h e n the flow will stop and the operation can
proceed.
Insertion of a piece of muscle into the fossa stops
bleeding and escape of cerebrospinal fluid. It also holds
the diaphragm up and prevents postoperative headache
due to stretching of the diaphragm. The muscle should be
placed in the fossa rather than packed tightly. Too large a
plug is more likely to be extruded. The muscle is covered
with Sterispon to prevent the pack sticking and then a
16 inch (12.7 mm) ribbon gauze pack is inserted into the
sphenoidal sinus. More packing is placed in the nose to
hold the sphenoidal pack in position. Sphenoidal packs
stay in for 9 days. Nasal packs can be removed sooner,
especially with a Cushing approach, but this depends on
the stability of the sphenoidal pack. With the trans-
ethmoidal operation the pack should fill the ethmoidal
sinuses but not bulge into the orbit. Only the skin is
sutured. With the sublabial approach, the mucosa is
sutured.

Diabetes insipidus occurs if the posterior pituitary or stalk
has been damaged. It is temporary in nearly every case.
Treatment consists in injecting 1 to 3/xu of DDAVP if the
urinary output exceeds 1500 ml in 3 hours, or 5 litres in 24
hours. This is only a guide and if there is doubt it is always
safer not to give D D A V P . .
The temperature may rise for the first 24 hours, but
nearly always drop to subnormal for about 8 days
postoperatively. This is a hypothalmic effect. After the
nasal packing is removed on the 9th postoperative day,
the nose should be treated as after any other intranasal
operation. Normal saline nose sniffs clear blood and
secretions, and after a week the nose should be
Transsphenoidal hypophysectomy 177
inspected. Any crusts remaining in the ethmoids can be
removed but the sphenoid should be left alone for 2
w e e k s . By then it is often clean, Hut, if necessary, residual
crusts should be removed. The site of entry into the
pituitary fossa can be seen to be pulsating for up to a
month postoperatively.
Patients leave hospital about 10 days postoperatively
and are seen weekly until the nose is clean.
After removal of pituitary tumours, assessment of
normal pituitary function and previously abnormal hor-
mones will be required about 3 weeks after discharge
from hospital. The endocrinologist can then see if any
long-term replacement therapy is necessary.
illustrations by Gillian Lee
John Ballantyne C B E , F R C S , HonFRCSi
Consultant Ear, Nose and Throat Surgeon, Royal Free Hospital and King Edward VII Hospital for Officers, London, U K
Preoperative
Indications
Anteroposterior enlargement of the adenoids produces
nasal obstruction, with the possible secondary effects of
sinusitis; when of long standing the 'adenoid fades' may
result, with a high-arched 'Gothic' palate and spongy
gums. Lateral enlargement predisposes to otitis media,
serous or suppurative. When any of these symptoms
persists or recurs regularly, the adenoids should be
removed.
Anaesthesia and position of patient
The main principle in anaesthetizing a child for ade-
noidectomy alone is to induce a fairly deep level of
anaesthesia and to operate during, the recovery phase.
Ideal conditions may be achieved by the use of halothane
with nitrous oxide and oxygen, the depth of anaesthesia
being controlled by varying the quantity of haiothsne.
When combined with tonsillectomy, the anaesthesia is as
for that operation. 1
The child lies supine on the table and a Boyle-Davis gag
is inserted. A position is adopted w h i c h is similar to that
for tonsillectomy but with less extension.
 Adenoidectomy i tl

palpation of nasopharynx and insertion of curette

An index finger is introduced behind the soft palate to

assess the width of the nasopharynx and the size of the
adenoids. Adenoidectomy is a blind procedure and great
care must therefore be taken to ensure that the curette
engages the upper edge of the mass. This is more readily
done with an unguarded sharp curette, and failure to do it
with precision may result in leaving a tag of lymphoid
tissue in the curve between the roof and posterior wall of
the nasopharynx. The surgeon should select the broadest
curette that will span the width of the postnasal space
without encroaching upon the Eustachian tube orifices.

2
Curettage of adenoids

Exerting a steady pressure 0*1 the currette, the adenoids

are shaved away with a firm sweeping movement of f h , (

wrist until the curette emerges from behind the \o(i

palate. If the instrument follows too deep a plane it ni.iy
injure vessels which pass submucosally from side to sific
of the nasopharynx, at the junction of its roof and
posterior w a l l . This central mass of .the adenoids jt>
removed with Luc's forceps after delivering it into the
oropharynx. Smaller lateral masses are removed in the
same way with a smaller curette, controlled by careful
palpation.
180 Adenoidectomy

r-i , • '

Complications

This is as for Tonsillectomy (see p. 194).
If bleeding is obviously excessive on completion of the
operation, a postnasal pack should be inserted (as
described below) at the primary operation, before the
child is allowed to recover from the anaesthetic.
Haemorrhage
Troublesome haemorrhage after adenoidectomy is rela-
tively uncommon but may be extremely dangerous.
Continued bleeding from the nose is of course diagnostic,
but this is not always evident and the first sign of
haemorrhage may be an extensive .vomit of blood. T h e
child should be returned to the theatre without delay,
when the loss is severe, for the insertion of a postnasal
pack.

3a, b & c
This is done by passing a small soft rubber or plastic
catheter through each nostril, via the nasopharynx, into
the oropharynx (a). The catheters are drawn out through
the mouth and one piece of stout thread attached to each
side of the pack is tied to the distal end of each catheter
(6). The catheters and attached threads are then with-
drawn through the anterior nares and the pack firmly
settled into the postnasal space (c). The threads are tied
across the columella. A third piece of thread, which has
been previously sutured to the lower edge of the pack at
its centre, is secured loosely on the cheek with adhesive
tape; 24 hours later, the pack is removed through the
open mouth, after cutting the columellar knot, by pulling
on the lower central thread, at first downwards and then
forwards.
3a

3b
Illustrations by Gillian Oliver
Douglas Ranger KBE, M B , BS, FRCS
Dean and Director of the Ferens Institute of Otolaryngology,
The Middlesex Hospital Medical School, London, U K
Indications
Access to the postnasal space via an opening in the palate
is indicated when it is necessary to remove tumours or
cysts such as nasopharyngeal angiofibromas or develop-
mental or retention cysts.
[t is^ajsj) jrjdicated.when it is necessary to take a biopsy
under direct v i s i o n . Some growths presenting with
neurological symptoms and signs may infiltrate deeply
without any abnormality being evident on the surface. In
such patients it may not be possible to obtain an adequate
biopsy via the nasal passages or by retracting the soft
palate forwards, and it may be necessary to take a wedge
biopsy with a knife under direct vision through a palatal
opening.
Anaesthesia
The operation is best performed under general anaes-
thesia administered through a cuffed flexometallic tube
passed through the mouth. As an additional precaution a
gauze pack is inserted into the pharynx.
Position of patient and preoperative preparation
Although the operation can be performed with the
surgeon sitting at the head of the table, haemorrhage is
usually troublesome because of the venous congestion
which occurs with the patient in this position. For this
reason it is best for the head of the table to be inclined
upwards and the patient's head extended over a small
sandbag placed under the shoulders, although care must
be taken not to extend the patient's neck unduly. T h e
surgeon stands at the side of the patient opposite the
shoulders and is able to obtain an excellent view.
Although reasonable illumination may be obtained
from a properly focused overhead light, a head-lamp
has considerable advantages, especially w h e n the
nasopharynx has been o p e n e d , a n d it is strongly
recommended. A Boyle-Davis or similar gag is inserted to
keep the tongue depressed but care must be taken to
ensure that the blade of the instrument does not occlude
the anaesthetic tube or damage the posterior pharyngeal
wall by pressure. It is best to ensure that there is a gauze
pack between the tip of the tongue blade and the
posterior wall of the pharynx.
Bleeding is reduced if the soft tissues of the palate
between the tuberosities are infiltrated with a solution of
1:100 000 adrenaline.
181
182 Transpalatai approach to the postnasal space

The incision

A curved incision bowed forwards is made with a sharp

knife between the tuberosities, keeping internal to the
greater palatine foramina. The degree of forward curving
of the incision will depend on the extent of the exposure
required. Adequate access to the postnasal space alone
can be obtained through an incision which extends just in
front of the posterior margin of the hard palate, but if the
operation is being performed for the removal of a tumour
which extends forwards into the nasal passage the incision
should be carried well anteriorly. Alternatively a midline
incision can be made forwards from the centre of the
incision if it is found necessary to obtain an exposure
more anteriorly.

2
Elevation of flaps

The original incision is made through mucosa and

periosteum down to bone. In order to simplify subse-
quent suture it is easiest to start by elevating, for a short
distance, the edge of the mucoperiosteal flap on the
anterior s'de of the incision. The posterior flap is then
separated completely from the undersurface of the hard
palate. A small right-angled dissector is used to separate
the flap from the posterior margin of the-bone but a knife
may be needed to free the attachment to the posterior
spine of the hard palate. If necessary, further access may
be obtained by removing the posterior spine and the
adjacent bone.
 Transpalatal approach to the postnasal space 183

Separation of soft palate

The mucosa on the upper surface of the palate is divided
transversely and the postnasal space examined. The
incision is then extended as necessary to allow adequate
access for dealing with the condition w h i c h is present.
Anteriorly, further exposure m a y ' b e obtained by a
midline incision through the mucoperiosteum and remov-
al of as much bone of the hard palate as is necessary.
Posteriorly, the incision may be extended posterolateral!-/
just medial to the pterygomandibular raphe and the
pterygoid hamulus. At this point the tensor palati muscle
is seen as it fans out from the tendon passing round the
hamulus and if necessary it is divided just medial to the
hamulus. The posterior limit of the incision will depend
on the exposure required in each patient a n d , in unilateral
lesions, will usually be different on the two sides.

4
Exposure of postnasal space
Depression of the soft palate with a retractor will give
adequate exposure of the postnasal space with a view of
the posterior edge of the nasal septum, the posterior ends
of the turbinates, the roof and lateral walls of the
postnasal space, and the Eustachian orifices.

4
184 Transpalata! approach to the postnasal space

Closure

After dealing with the lesion in the postnasal space and

sealing any bleeding points with diathermy, the palatal
incision is sutured. It is not necessary to close the mucosa
on the superior surface separately. The flaps are sutured
in the midline and then a further two or three sutures are
inserted o n each side, depending on the extent of the
incision. Dexon is the suture material of choice in most
patients.

Postoperative care and

Eating can. be allowed soon after operation. Healing

usually occurs rapidly and there isJiitle^-risk j j j fistula,
formation although this may occur occasionally, especially
in patients who have, had large doses of radiation. If a
fistula develops the edges should be resutured after any
infection has been controlled by antibiotics and any
oedema has subsided.
Illustrations by Philip Wilson

john N. G . Evans D L O , F R C S
Consultant Ear, Nose and Throat Surgeon, T h e Hospital for Sick C h i l d r e n , Great O r m o n d Street
and St Thomas's Hospital, London, UK

Preoperative

Choanal atresia occurs as a result of failure of canalization

of the bucconasal membrane. Bilateral atresia causes totai
nasal obstruction and unless immediate treatment is
initiated asphyxia will occur. The diagnosis is confirmed
w h e n a catheter fails to pass from the nose into the
nasopharynx.

Investigation

After aspirating mucus from the nasal cavity, Gastrografin

is instilled and a lateral radiograph will demonstrate the
thickness of the atretic septum.
In 60 per cent of cases with a bilateral atresia another
major congenital abnormality may be present.
Unilateral atresia may also cause respiratory difficulty in
the neonatal period in which case immediate operation is
advised. If nasal obstruction is not gross then surgical
correction may be delayed until the age of 4-5 years.

First-aid treatment
An oral airway must be established and this is achieved by
inserting a size 270 Gueel airway into the mouth and taping
it to the mandibular region with adhesive strapping.
Preoperative preparation
Dehydration should be corrected by orogastric tube
feeding but if immediate operation is performed then
dehydration is not a problem. Blood transfusion is not
usually required.

135
186 Choanal atresia

Position of patient

A sandbag is placed behind the shoulders and a

Boyle-Davis gag inserted. A 6 cm slotted tongue plate is
used. The operator sits at the head of the patient. A
headlight is used for illumination.

T h e choanal septum is then perforated using a straight

handpiece and electric drill. A 2 mm cutting burr effects
the initial penetration of the septum. Great care must be
taken to ensure that the drill is directed parallel with the
floor of the nose. If this precaution is not observed the
drill may penetrate the basisphenoid. The operator's
forefinger is placed in the nasopharynx and as the burr
penetrates the dorsal septum the burr may be felt with the
pulp of the finger.

In order to avoid damage to the nostril margin, the shaft of

the burr is covered with 12 Fg Portex tubing.
 Choanal atresia 187

After the initial penetration of the choanal septum the

hole is enlarged using a 5 mm diamond burr. Illustration 5
shows a view"-of the choanal septa from behind. The
choanal septumjis drilled away superiorly, laterally and
interiorly and_ar least 7 mm of the posterior edge of the
nasal septum is removed.

7
o

After the choanal partition has been removed tubes must

be inserted through the choana to prevent subsequent
stenosis. The nasal tubes are made from 12 Fg Portex
tubing (nasogastric). A bridge of tubing is cut as s h o w n ;
this holds the tubes apart and prevents damage to the
columella.

In order to prevent displacement of the nasal tubes a

continuous nylon thread must be passed through the
tubes and tied anteriorly. This is achieved by passing two
fine catheters through the nasal tubes. T h e distal ends are
delivered through the mouth and the nylon thread
attached. T h e catheters are then withdrawn and the nylon
thread tied in front.
Blockage of the tubes is prevented by instillation of
0.5 mi of normal saline into each tube and then suction is
applied by means of a fine catheter w h i c h must be long
enough to pass through the tubes into the nasopharynx.
The tubes are retained in position in the nose for 6 w e e k s .

11

10
illustrations by Gillian Lee
John Ballantyne CBE, FRCS, HonFRcsi
Consultant Ear, Nose and Throat Surgeon, Royal Free Hospital and King Edward VII Hospital for Officers, L o n d o n , U K
Indications
The commonest and best indication for tonsillectomy is
the frequent recurrence of acute tonsillitis. Tonsillectomy
must also be performed after one quinsy, preferably 4-6
weeks after the acute infection has subsided; and it
should be considered in patients w h o have recurrent
attacks of acute rheumatism or nephritis and in those w h o
are stubborn carriers of streptococci or diphtheria bacilli.
Less commonly the operation is performed in children
who have recurrent otitis media associated with sore
throats, or whose tonsils are so large that they interfere
with swallowing or breathing. Tonsillectomy is'sometimes
necessary in adults when enlargement of one tonsil
without ulceration demands the exclusion of malignancy.
Rarely the tonsils may have to be removed to allow access
to an elongated styloid process or the pharyngeal branch
of the glossopharyngeal nerve.
Contraindications
Tonsillectomy should never be undertaken without very
good reason in those with a known bleeding diathesis,
such as haemophilia; nor in allergic patients, in whom a
simple nasal allergy may be replaced by asthma. It is
probably unwise to perform tonsillectomy during a local
or national epidemic of poliomyelitis.'
Premedication
ldeally, the patient about to undergo tonsillectomy should
arrive.tn. the'anaesthetic room drowsy or asleep. This
applies particularly to children. In adults, premedication is
usually given by a single intramuscular injection 1 hour
before the operation, and in the average adult this
contains either pethidine 75 mg with promethazine
(Phenergan) 25 mg or papaveretum (Omnopon) 20 mg
with scopolamine 0.4 mg. In children between 6 and 10
years of age papaveretum 15 mg and scopolamine 0.8 mg
can b e given intramuscularly 1 hour preoperatively; but in
younger children, especially when they are unusually
apprehensive, preoperative medication should be given
by mouth 2 hours before the surgery. Quinalbarbitone
(Seconal) 6mg/kg body weight, or trimeprazine (Vallergan
Forte Syrup) 4 - 5 mg/kg is generally well tolerated. In order
to achieve good sedation and early recovery; diazepam is
used in large doses, i.e. 0.1 mg)kg orally three times
during t h e previous day,"and 0.5 mg/kg VA hours before
the operation.
Anaesthesia
There are today f e w , if any, contraindications to the use of
general anaesthesia for patients in whom tonsillectomy is
recommended. After induction with thiopentone (Pento-
thal) i h e anaesthetic is continued with nitrous'"oxide,
oxygen and halothane. In adults these gases are delivered
by pernasal endotracheal intubation, in younger children
^through the tongue blade of a Boyle-Davis gag. In otder
children, especially w h e n the operation is to be combined
with adenoidectomy and/or myringotomy, tt is preferable
to intubate peroraliy and to use a split tongue blade •
Position of patient

The patient is placed supine, with the head slightly

extended. Excessive extension is to be avoided. The
Boyle-Davis gag is introduced and opened, with the
tongue blade in the midline. It is important to see that the
lips are not caught in the gag. The gag is secured in the
optimum position with Draffin's bipods.

The incision

The tonsil is grasped with Luc's or similar forceps and

drawn firmly in a medial direction, thus exposing an area
of mucosa medial to the free edge of the anterior faucial
pillar. The incision is started halfway between the upper
and lower 'poles' of the tonsil, the scissors or other sharp
instrument being inserted to the depth of the surgical
'capsule' of the tonsil. Taking care to preserve as much as
possible of the mucosa, the surgeon carries the incision
downwards to the base of the tongue and upwards to the
upper pole.
 Tonsillectomy by dissection ig-|

3
Beginning of blunt dissection

W h e n the capsule has been identified, a Howarth's nasal

raspatory or similar blunt dissector is used to separate the
tonsil and its capsule from the surrounding peritonsillar
tissues.

Mobilization of upper pole

The upper pole must first be mobilized, care being taken

to keep the dissector as close as possible to the capsule
throughout the dissection. 'Digging' into the fossa causes
more bleeding and more postoperative scarring.
192 Tonsillectomy bv dissection

J V

5
Continuing the dissection
Gripping the tonsil by its upper pole, the surgeon
continues to draw the tonsil towards the midline, and
extends the dissection by separating the peritonsillar
tissues from the capsule, until the lower pole is
approached.

Mobilization of lower pole

Towards the lower pole of the tonsil there is a firm fibrous
triangular fold which tends to hold up the dissection at
this point. The triangular fold should be cut with scissors
and the dissection carried on to the base of the tongue.

6
 Tonsillectomy by dissection 193

Removal of tonsil
There is nearly always a flat 'tongue' of lymphoid tissue
which passes from the lower pole of the tonsil proper to
the tonsillolingual sulcus, where this small extension joins
the base of the tongue. A cold-wire snare is threaded over
the tonsil, which is finally removed by closing the snare at
the level of the tonsillolingual sulcus. This ensures that the
lingual 'tongue' of lymphoid tissue is removed with the
tonsil proper. Failure to do so may result in 'recurrence'.

Control of haemorrhage
Most of the primary bleeding from tonsillectomy is
v e n o u s , either from the paratonsillar vein of Denis
B r o w n e , which is rarely visualized throughout its entire
length, or from smaller tributaries. Minor bleeding is
usually controlled naturally by the contraction and
retraction of the smaller vessels; and this will usually
occur spontaneously if a gauze swab is placed gently but
firmly in the fossa for 2 or 3 minutes. However, the main
paratonsillar vein may be 'holed' or sectioned, w h e n it
should be Mgated with silk thread (right fossa). M i n o r
persistent bleeding from smaller vessels may beacon-
trolled quickly and effectively with insulated diathermy
• forceps (left fossa).
194 Tonsillectomy by dissection
Postoperative care
The most important single factor in the postoperative
management of the patient after tonsillectomy is his/her
position. He/she should be turned on his/her side with the
mouth directed slightly downwards, and with the head
end of the table, trolley or bed lowered slightly below the
foot e n d . This prevents blood and mucus from entering
the lower respiratory tract and at the same time allows
bleeding to be detected more readily.
Adequate postoperative sedation can do much to
relieve the intense immediate postoperative pain after
tonsillectomy. Intramuscular pethidine is analgesic with-
out being depressant, and in children 3-8 years of age the
injection should be given as soon as they are turned on
their sides on completion of the operation, in a dosage of
1.0-1.5 mg/kg. In older children and adults an injection of
papaveretum 20mg should be given as soon as the patient
begins to recover from the anaesthesia.
The patient should be kept under close observation
until a fair level of consciousness has been restored, and a
quarter-hourly pulse chart is essential for the first hour.
Thereafter a half-hourly, and later an hourly, record
should be kept until it is certain that the pulse rate is
steadily diminishing.
Soluble aspirin half an hour before meals is very useful
in reducing the postoperative pain and the patient should
be encouraged to eat and drink as much as possible, and
to talk as little as possible.
Antibiotics are indicated if the temperature is per-
sistently raised, or the granulating area appears to be
infected.
Complications
Haemorrhage
Primary haemorrhage should be controlled on the
operating table but the most serious complication is
reactionary haemorrhage, a form of haemorrhage which
occurs, sometimes very insidiously, within a few hours of
the operation. The blood may be seen to be coming from
the m o u t h , but not uncommonly it is 'internal' and not
seen. This means that it is being swallowed and care
should be taken to look for excessive swallowing. A rising
pulse or one which fails to come down steadily suggests a
continuing haemorrhage, which may sometimes be vprv
or continued bleeding may be the sudden and frightening
vomiting of a large quantity of stale blood, or the grey and
sweaty ashen pallor of surgical shock.
Secondary haemorrhage occurs, usually between the
fifth and the tenth postoperative days, when the pro-
tective slough separates from the granulating fossa. It is
sometimes associated with local infection and should be
anticipated whenever there is a persistent postoperative
pyrexia without physical signs in the chest. It is usually
minor but may occasionally be serious.
Treatment Postoperative haemorrhage after tonsillectomy
can be one of the most alarming conditions in surgical
practice.
If there is a very minor ooze, without signs of shock, it
may suffice to remove the clot from the fossa and
sometimes to hold against it a small cottonwool swab
wrung out with hydrogen peroxide or topical adrenaline.
However, in anything but the most minor loss, especially
if it has continued for more than half an hour, it is safer to
return the patient to the theatre without delay, to give a
second anaesthetic, to identify any bleeding points and to
control the bleeding by diathermy, ligature or suture. A
blood transfusion should be given if the bleeding is
severe. The control of haemorrhage after tonsillectomy
requires the services of a skilled surgeon and a skilled
anaesthetist.
Lower respiratory complications
These include bronchitis, pneumonia and lung abscess.
They are due to the inhalation of blood and mucus, and
they usually respond quickly to systemic antibiotics.
Upper respiratory complications
These include sinusitis and otitis media, especially after
pernasal intubation. Earache after tonsillectomy is com-
monly due to referred otalgia but the ears should always
be examined.
Dental injuries
Loosened or extracted permanent teeth may sometimes
be re-implanted if the services of a dental surgeon are
immediately available.
Illustrations by Gillian Oliver
Douglas Ranger K B E , M B , BS, F R C S
Formerly Dean and Director of the Ferens Institute of Otolaryngology, The Middlesex Hospital Medical S c h o o l , L o n d o n , U K
indications
Troublesome "pain, often intermittent in character, may
arise as a consequence,of calcification in the stylohyoid
l i g a m e n t - c o m m o n l y referred to as a long styloid process.
In some patients this pain may result from neuritis in the
closely associated glossopharyngeal nerve but even if this
is so the pain will usually be relieved by excision of the
bone without division of the nerve as well.
T h e diagnosis can often be made by palpation of the
tonsillar fossa, w h e r e the bony projection may be felt. In
some patients this may not be possible, either because of
tenderness or because of the size of the tonsil. T h e
diagnosis is readily confirmed radiologically once it is
suspected.
In a few patients spontaneous fracture may occur, w i t h
the development of a pseudarthrosis, and this may relieve
the pain. Therapeutic fracture may be considered as a
method of treatment but is applicable only in those
patients with a thin process and even then the results of
such a procedure are unpredictable because it is difficult
to ensure that the fracture occurs sufficiently near the
base of the process to relieve the symptoms. If the bone is
so thin and fragile that it may be fractured by pressure
exerted on the tonsillar fossa in a conscious patient then
this is a procedure which is well worth trial because of its
simplicity. However, this is not usually possible and if a
general anaesthetic is required then it is wiser to proceed
direct to excision of a portion of the process.
Preoperative preparation
T h e operation is best performed under general anaesthe-
sia with an endotracheal tube passed through the nostril
on the opposite side. The patient is placed in the
tonsillectomy position and the surgeon sits at the head of
the table.
195
196 Division of a long styloid process in the tonsillar fossa

Insertion of gag

In order to obtain the best view of the tonsillar fossa it is

best to insert the Boyle-Davis gag with the tongue plate
not in the midline but somewhat to the side of the
operation.

Tonsillectomy

The tonsil and plica triangularis are removed in the usual

way. At this stage the elongated styloid process can be
palpated through the musculature of the tonsil bed and it
often produces a prominence which can be seen.

Exposure

The elongated styloid is exposed by dividing the muscle

fibres over the tip of the process and extending the
incision vertically.
 Division of a long styloid process in the tonsillar fossa 19;

\l Ml

Division

The muscles are retracted and the process is divided with

bone-cutting forceps.

Postoperative care and

Because of the division of the superior constrictor muscle

and the opening of deep tissue planes it is advisable to
administer an antibiotic postoperatively and to keep the
patient in hospital for 9 days.
Illustrations by Gillian Lee

Douglas Ranger KBE, M B , BS, FRCS

Formerly Dean and Director of the Ferens Institute of Otolaryngology, T h e Middlesex Hospital Medical S c h o o l , L o n d o n , UK

Indications

Severe pain mediated via the glossopharyngeal nerve may
be associated with carcinoma in the posterior part of the
tongue, in the tonsillar area or in the vallecula; this pain
may be intermittent and radiate to the ear. Carcinoma in
these areas may be submucosal, with no abnormality of
the surface. A l s o , it may be impossible to distinguish
between pain arising in areas supplied by the superior
laryngeal nerve and pain arising in the glossopharyngeal
region. Accordingly, it is always essential to examine the
pharynx and larynx carefully under an anaesthetic before
making a diagnosis of primary idiopathic glossopharyn-
geal neuralgia.
To relieve severe pain, either primary or secondary,
division of the nerve may be required. This can be
accomplished by approaching the nerve in the posterior
cranial fossa, in the neck or in the tonsillar fossa. Unless
there is clear evidence that the nerve is involved above the
tonsillar fossa the approach to the nerve in that region is
so much simpler and safer than either of the other routes
that it is the operation of choice.
Preoperative preparation
The operation is best performed under general anaesthe-
sia with an endotracheal tube passed through the nostril
on the opposite side. The patient is placed in the
tonsillectomy position and the surgeon sits at the head of
the table.

198
 Division of (be glossopharyngeal nerve in the tonsillar rossa l>y
l

Insertion of gag

T h e best view of the tonsillar fossa is obtained by inserting

the Boyle-Davis gag with the tongue plate not in the
midline but somewhat to the side of the operation.

Tonsiilectomy
i

T h e tonsil and plica triangularis are removed in the usual

w a y . At this stage in most patients the fascia and muscle of
the tonsillar bed hide the nerve which is lying externally.
H o w e v e r , in some patients the superior constrictor
muscle does not have an origin from the side of the
tongue and in such patients the lower part of the nerve
may be seen through the fascia after the tonsil has been
removed.

Division of constrictor muscle

To expose the nerve outside the constrictor muscle it is

easiest to divide the muscle fibres across the.line of the
nerve by an incision made parallel with the posterior pillar
of the fauces and about 1 cm anterior to it.

3
Exposure of nerve

T h e edges of the muscle are separated with forceps and

the nerve will be seen crossing the incision obliquely from
a point nearer the base of the skull posteriorly rather than
anteriorly.
200 Division ot the glossopharyngeal nerve in the tonsillar fossa

4
Identification of nerve branches

After the main trunk of the nerve has been'identified it

should be lifted from its bed with forceps and branches
sought so that these can be divided.

Division of nerve

The nerve is held in artery forceps and exposed as far as is

accessible up towards the base of the skull. It is then
divided with scissors. The wound is left open and there is
no need to suture the divided muscle fibres.

Postoperative care and

complications
Because of the division of the superior constrictor muscle
and the opening of deep tissue planes it is advisable to
administer an antibiotic postoperatively and to keep the
patient in hospital for 9 days.
Illustrations by Gillian Lee
john Ballantyne C B E , F R C S , HonFResi
Consultant Ear, Nose and Throat Surgeon, Royal Free Hospital and King Edward VII Hospital for Officers, London, U K
A quinsy is an abscess between the 'surgical capsule' of
the tonsil and the superior constrictor muscle and fascia of
the adjacent lateral pharyngeal wall. W h e n an acute
infection of the tonsil spreads beyond its capsule, usually
on one side only, there is at first a peritonsillitis (or
peritonsillar phlegmon). W h e n frank pus forms, an
abscess (or quinsy) has developed.
Indications
A n early peritonsillar phlegmon will usually respond to
vigorous treatment with adequate doses of an appropriate
antibiotic; but this may 'suppress' a quinsy and should be
discontinued if the phlegmon is not settling after 48 hours.
W h e n frank pus is suspected it should be evacuated
surgically. The presence of pus is suggested w h e n the
anterior faucial pttiar is red and oedematous and obscures
the tonsil (see Illustration 7), when a yellow spot is visible,
or when trismus is marked.
Anaesthesia
Most quinsies occur in adults, and general anaesthesia or
the spraying of a local anaesthetic agent may diminish the
cough and swallowing reflexes, and hence lead to the
danger of inhaling pus or blood. The injection of a local
anaesthetic may spread the infection. It is therefore wiser
to use no anaesthetic in the adult; the relief is so marked
and so rapid w h e n the pus is released that the momentary
pain of incision is usually acceptable. In those relatively
rare instances w h e n a quinsy occurs in childhood, general
anaesthesia is both permissible and advisable, provided
that the tonsillectomy position is adopted and suction is
readily available.
201
202 Surgery of quinsy of peritonsillar abscess

i lie o p e i dUOH

INCISION OF A QUINSY

Site of incision

The incision is made either at the thinnest part of the

faucial mucosa or, if such is not visible or palpable, at the
classical site of election.
The classical site for the incision of a peritonsillar
abscess is to be found at the point w h e r e an imaginary
horizontal line through the base of the uvula is intersected
by a perpendicular line from the junction of the anterior
faucial pillar with the base of the tongue.

2
The incision

The best instrument to use is the sharp-pointed quinsy

forceps. After penetrating the surface mucosa with the
pointed ends, the forceps are advanced backwards for
13 mm or so and opened widely. The 'capsule' of the
abscess may be felt as a distinct resistance.

ABSCESS-TONSILLECTOMY

{See chapter on Tonsillectomy by dissection', pp.

189-194).
Immediate tonsillectomy has been advocated by some
surgeons but there is always a risk of severe haemorrhage,
and ideally the operation for enucleation of the tonsils
should be postponed until 4-9 weeks after the acute
illness has subsided.
Antibiotics should be continued or re-commenced after
the abscess has been evacuated. Hot gargles and
mouthwashes of salt and bicarbonate of soda (one 5 ml
spoonful of each to one pint of hot water) help to relieve
the discomfort. Aspirin or one of its compound prepara-
tions should be given before meals.

Complications

These include parapharyngeal abscess, oedema of the

glottis, haemorrhage and septicaemia.
[[lustrations by Gillian Lee
The parapharyngeal space (see Illustration 3) lies outside
the pharynx and Is triangular in cross-section. It extends
from .the base of the skull above to the superior
mediastinum below.
T h e reSrg^ar^ngeaj_s^ace_oi Gilette (see Illustration 3)
lies behindth^^h^ryrix7°b^tvveen the buccopharyngeal
fascia and the prevertebral fascia. The space contains the
paired retropharyngeal lymph nodes, which are separated
from o n e another by a tough median partition. These
glands usually disappear spontaneously in the third or
fourth year of life.
Abscesses may occur in either of these spaces.
Parapharyngeal abscess
Infection reaches the parapharyngeal space from the
tonsils or the pharynx, or from a lower wisdom tooth and
its surrounding bone and gum. -~—-
Retropharyngeal abscess
There are two distinct types of retropharyngeal abscess:
acute and chronic.
Th_e aca£e_abjcje^j_s__c^used by suppuration in the
retropharyngeal lymph nodes, which may become in-
fected from the nasopharynx or the oropharynx; or very
rarely from an acute mastoiditis, along the tissues
surrounding the eustachian tube. Most cases occur in
infants, in the first year of life.
T h e chronicjabscess is alwaysjuberculous and may be
due either to tuberculous infection in the retropharyngeal
n o d e s , w h e n the abscess lies laterally in the space of
Gijette, or to_ tuberculous c a r i e s _ o L i h e cervical spine,
w h e n the abscess !ies~centfally behind the prevertebral
fascia.
A c u t e pyogenic infection of the parapharyngeal and
retropharyngeal spaces must be treated by systemic
disinfection. In tuberculous cases of chronic retrophary-
ngeal abscess various combinations of streptomycin, PAS
and I N A H are u s e d .
; Indicationsj
Surgery is ^indicated when therejs any embarrassment to
respiration or deglutitionTwhen fluctuation is present; or
w h e n the general condition suggests the threat or the
presence of complications.
(Anaesthesia)
J h ^ j e x a a j a t L o x L o L a parapharyngeal or a retropharyngeal
abscess always demands the use of a general anaesthetic.
203
204 Surgical treatment of parapharyngeal and retropharyngeal abscesses

OPERATION THROUGH THE MOUTH

This Is sometimes possible in acute parapharyngeal

abscess and mandatory in acute retropharyngeal abscess.

Position of patient ^ '

The patient is placed in the supine position, with the head

lowered sufficiently to prevent the inhalation of blood or
pus. Suction must be to hand.
 Surgical treatment of parapharyngeal and retropharyngeal abscesses 205

OPERATION THROUGH THE NECK

A parapharyngeal abscess is often surprisingly deep and it

is usually preferable to approach such an abscess through
the neck. This_approach becomes absolutely essential if
difficulty is encoTjnHfed"ih localizing the pus through the
mouth, and it is also essential in all cases of chronic
retropharyngeal abscess oHuberculcms origin.

3
The incision .

In most instances _the incision is made in front of the

sterhomastoid muscle (A), in the plane between the
carotid sheath and the visceral compartment of the neck.
If the^abscess, is high inthe neck it is better approached
frdm'Tiehind the carotid sheath (B), through an incision
behind the sternomastoid muscle.

Treatment with appropriate antibiotics must be continued
vigorously, for at least^10 days, after the abscess has been
evacuated. Anajgesics are given for pain, and spinal caries
may require immobTfization in a plaster bed. ~ t
Complications
These include oedema of the glottis, mediastinitis and
septicaemia. Sudden rupture of such an abscess may
cause sudden death from aspiration.

— • y y
Illustrations by Robert N, Lane
P. M. Stell C h M , FRCS
Professor of Otorhinolaryngology, University of Liverpool, UK
TUMOURS OFTHE
OROPHARYNX
The oropharynx extends from the soft palate above, to the
hyoid bone below and has anterior, posterior and lateral
walls. T h e chief sites from which tumours arise are the
tonsil and the base of the tongue, although tumours can
sometimes occur on the soft palate and in the vallecula;
the latter are better' thought of, and treated as, laryngeal
tumours.
T h r e e types of malignant tumour occur in the
oropharynx: squamous carcinoma, the reticuloses and
salivary tumours. The reticuloses are of course treated
exclusively by radiotherapy; furthermore it is usual to
treat squamous carcinoma at this site primarily by radical
radiotherapy, but surgery may be needed for recurrence
after radiotherapy. Salivary tumours at this site are often
adenoid cystic carcinomas, which are usually radioresis-
tant and must be treated surgically. Finally, about 70 per
cent of squamous carcinomas at this site metastasize to
the lymph nodes of the neck, so that even if the primary
tumour is sterilized by radiotherapy, a radical neck
dissection will often be needed.
Access can be gained by splitting the mandible, but
since it is difficult to close the soft tissues in the presence
of an intact mandible, a segment of bone in the region of
206
the angle of the mandible is usually removed - a
hemimandibulectomy; removal of bone may also be
indicated of course, because of involvement by, or
proximity to; the tumour.
Since the mandible is divided at or behind the mental
foramen, leaving the anterior arch of the mandible and its
attached muscles intact, the cosmetic and functional
disability after this operation are acceptable, and no
attempt is made to reconstruct the mandible.
Preoperative preparation
As in hemiglossectomy, careful consideration must be
given to the teeth before operation and all carious teeth
must be removed.
The o p e r a t i c . Ucgir.s -..iih a tracheotomy, and the
anaesthetic is continued through this.
To facilitate excision it is useful to tattoo the excision
line with methylene blue, since it is possible to comprom-
ise adequate tumour clearance once the mandible is cut.
This is done after the tracheotomy using a needle dipped
in the dye.
The skin is prepared in the usual fashion, and the mouth
cleaned with Cetavion. The towels are put on with the
mouth exposed, and a loose towel is placed over the
mouth until the radical neck dissection, i.e. with the neck
turned to the opposite side and extended.
 Tumours of the oropharynx and soft palate 207

The incision

An upper incision is marked out which starts in the

midline of the lower lip, curves downwards to the hyoid
bone, and up to the mastoid process.
If a radical neck dissection is being done a lower
incision is used, frequently a horizontal one above the
clavicle, since the operation is usually performed only for
failed radiotherapy. A radical neck dissection is done if the
patient has ah enlarged lymph node in the neck. Attention
is paid to two points: first, the pre- and postvascular
nodes around the facial artery, where it crosses the
mandible, must be removed; second, the neck dissection
remains attached in the region of the angle of the jaw.
Only that part of the upper incision which lies in the neck
is made at the start of the neck dissection and the lip is not
divided until the neck dissection is finished. After the
neck dissection, the head is rotated into the centra! 1
position and the towel removed from the mouth.
T h e incision through the lower lip Is completed making
it in the form of an S to conform to the lines of election for
scars; the cheek is then elevated off the mandible, as far
as the angle of the jaw, dividing the buccal mucosa in the
2
buccal sulcus, well away from the tumour. Excision

Using a knife the periosteum is elevated off the mandible

at the anterior point of division of the latter, clear of
tumour, usually about the mental foramen. T h e masseter
is elevated from the ascending ramus of the mandible with
a periosteal elevator, up to the coronoid process, the
sigmoid notch and the neck of the mandible. A Gigli saw is
passed round the neck of the ascending ramus w i t h a
Gray's forceps and the mandible is divided. T h e coronoid
process is freed from the temporalis muscle with a straight
scissors. Next, the mandible is divided a.t the mental
foramen with a S t r y k e r saw or fissure burr. (It is simpler to
do the superior division first before the mandible
becomes mobile.)

T h e tongue is pulled out of the mouth with a towe! clip

and the primary tumour of the tonsil or the base of the
tongue removed using cutting diathermy, following the
tattoo marks. T h e margin of excision of the primary
tumour should be w i d e , and on the base of the tongue
should be at least 3 c m . A portion of the soft palate must
also often be removed, and on occasion part of the
posterior end of the upper alveolus.
T h e segment of the mandible and the neck dissection
are* kept in continuity with the primary tumour.
T h e w o u n d is washed and gowns, gloves and towels
changed in the usual manner.
208 Tumours of the oropharynx and soft palate

Repair

It is possible to sew the tongue remnant to the cheek

remnant and close the skin, without repairing soft tissues,
but this produces a physiological d e f o r m i t y - t h e tongue is
partially tethered, thus interfering with speech and
swallowing. It is, therefore, preferable to repair the soft
tissues by a skin flap. The cosmetic deformity after a
hemimandibulectomy is not unsightly, however, since the
defect is not in the midline; for this reason there is no
need to attempt to reconstruct half a mandible.
T h e oral defect must usually be closed. Axial flaps, such
as the deltopectoral and temporal, have now largely
passed into history. The two alternatives now in use are
musculocutaneous and free flaps. Of the various musculo-
cutaneous flaps the pectoralis major is much to be
preferred. The use of free flaps is beyond the scope of this
book, and in any case free flaps, such as the forearm flap,
are only rarely indicated for this defect because the
pectoralis major flap is technically easier, and its end
result is at least as good as that of a free flap.

A pectoralis major flap is elevated. A tunnel is created into

the lower neck and the flap is brought upwards into the
neck so that its muscle pedicle lies over the carotid
sheath, and the skin island comes to lie in the pharynx.
This operation can be rather cumbersome if the patient
has not had a radical neck dissection because of the bulk
of the flap, but if the patient has had a radical neck
dissection this flap is very useful because the muscle
serves to protect the carotid sheath.
T h e skin island is sewn into the defect in two layers all
around the edges of the defect which is thus closed
completely. The great advantage of this particular tech-
nique is that the defect is closed completely at the first
operation and the patient is not left with a fistula.
Furthermore the bulk of the muscle fills out the defect
resulting from the removal of part of the mandible, thus
improving the cosmetic result.
The skin incision is now closed in two layers with
continuous suction drainage in the usual way. Great care
must be taken to ensure that the incision in the lower lip is
closed properly and the vermilion border is apposed
correctly to prevent an unsightly scar of the lower lip.
If it is intended to close the defect with a deltopectoral
flap the skin of the neck and chest are sterilized down to
the level of the xiphisternum. A deltopectoral flap is
elevated and its distal end passed into the defect. At this
stage it is usually possible only to close part of the defect
in the pharynx with the flap, the remainder being closed
when the flap is later divided. The distal end of the flap is
stitched in two layers to the divided edge of the base of
the tongue, with the skin surface placed into the mouth.
The remainder of the flap is tubed, skin surface outwards,
3nd the neck incision closed.
 T u m o u r s of the oropharynx and soft palate 209

Postoperative care
1. General.
2. Routine tracheostomy care. The tube is left in place for
at least 3 w e e k s , until the Hap is divided and returned.
3. Antibiotic cover for 1 week.
4. Tube feeding.

5
Return of a deltopectoral flap
This is quite a lengthy operation which must be done
under general anaesthesia - therefore, the tracheostomy
tube is left in place so that the anaesthetist has access
without disturbing the mouth.
T h e flap is divided flush with the skin of the neck. T h e
proximal end is detubed, its edges freshened, the edges
of the donor site freshened, and the flap remnant sewn
back in place. T h e distal part of the flap which now is
attached to, and gets its blood supply from, the base of
the tongue is moved to fill the remaining part of the defect
in the tonsillar area. T h e edges of the remaining part of the
defect are f r e s h e n e d , and the free, recently divided end of
the flap, moved into the area. The flap is sewn in place
with non-absorbable sutures.
T h e edges of the defect in the neck are also freshened,
and closed in two layers in the usual way.
The patient must be tube fed for at least 7-10 days after
this stage, before feeding begins, but the tracheostomy
tube can usually be removed after this stage.
210 Tumours of the oropharynx and soft palate

Tl ! M O l IRS O F T H F SOFT
PALATE
T u m o u r s arising primarily in the centre of the soft palate Preoperative preparation
are fortunately rare, and because of the functional
disability after complete resection of the soft palate, Free access to the mouth is needed for this operation so a
should be treated primarily by radiotherapy, so that temporary tracheostomy is done and the general anaes-
surgery wiil only be needed for recurrence. thetic continued through this.

Excision

The whole of this operation can be done through the

mouth, and it is not necessary to divide the mandible for
access.
The mouth is held open with a gag, such as that of
Boyle-Davis, and the soft palate excised with a healthy
margin, using cutting diathermy.
The tonsil and faucial pillars can be removed on one or
both sides if necessary. A few bleeding points, particularly
the greater palatine artery will need to be caught and tied
or stitched.
This part of the operation is simple but the problem is
that of repair.

6
Repair of the soft palate

If the soft palate is removed the patient usually cannot

speak properly, and regurgitates his food down his nose.
Although a few patients do not suffer this, the defect
should always be repaired. This can be done with a
backward extension on a dental plate, but permanent soft
tissue repair is preferable. This can be done by using a flap
of mucosa from the posterior pharyngeal wall based
superiorly and turned up into the defect or with a lined
forehead flap or a deltopectoral flap.
These techniques are beyond the scope of this book,
however, and will not be described here.
Illustrations by G . James
A. Richard Maw FRCS
Consultant Ear, Nose and Throat Surgeon, Bristol Royal Infirmary, Bristol, U K
Indications
Diagnostic oesophagoscopy is indicated in the presence
of certain specific symptoms. Difficulty in swallowing or
obstructive dysphagia may be acute, e.g. from ingestion of
a foreign body, or chronic. The latter may represent local
oesophageal disease such as stenosis, c a r c i n o m a ,
hypopharyngeal pouch or achalasia of the cardia; o r
general disease such as scleroderma, neuropathy or
brain-stem pathology. Occasionally acute-on-chronic dys-
phagia results from lodgement of a foreign body on
underlying pathology such as a carcinoma. T h e procedure
is indicated in cases of painful swallowing w h i c h may b e
caused by high lesions in the hypopharynx and oesopha-
gus, e.g. post-cricoid carcinoma which frequently follows
Paterson-Brown-Kelly (Plummer-Vinson) Syndrome; or
lower lesions such as oesophagitis, frequently associated
with hiatus hernia and often accompanied by other
symptoms of indigestion, heartburn or flatulence. Some-
times high dysphagia with local discomfort is complained
of with chronic pharyngitis and in these cases the throat is
usually said to be 'dry'. Dysphagia and complaint of a
'lump' in the throat are sometimes the presenting
symptoms of lower rather than upper oesophageal
lesions, e . g . hiatus hernia with reflux oesophagitis.
Oesophagoscopy should be an integral part of the
panendoscopic investigation of a cervical node mass
clinically thought to contain metastatic tumour. T h e
procedure may be therapeutic when combined with
dilatation by bougies, e.g. for strictures or for placement
of indwelling oesophageal tubes ( O w e n , Souttar, Celestin
or Mousseau-Barbin). Dohlman's upper oesophagoscopy
with a bivalved oesophageal speculum may be used for
the treatment of a hypopharyngeal pouch.
Contraindications
T h e general.condition.of the patient may contraindicate
oesophagoscopy, particularly under general anaesthesia,
e . g . in severe heart disease or extreme old age. Gross
spinal abnormalities, e.g. kyphoscoliosis o r spinal rigidity
due to ankylosing spondylitis, may preclude examination.
Oesophagoscopy may be particularly difficult in patients
w i t h a short, thick neck and in the presence of gross
trismus or dental mal-occlusion, particularly w h e r e the
upper teeth are prominent. Care must be taken in the
presence of an aortic aneurysm. In some cases of acute
corrosive oesophageal burns, further trauma to the
mucous membrane may result if oesophagoscopy is
performed.
Anaesthesia
Premedication should include atropine and scopolamine
1 hour preoperatively to produce drying of the mucous
membrane so that, if used, local anaesthesia (lignocaine
2 per cent) can penetrate the mucous membrane and will
control the vagal reflex. An endotracheal general anaes-
thetic appropriate for age and weight is administered
either by relaxant or spontaneous respiration technique.
T h e endotracheal tube cuff may need to be deflated to
allow the oesophagoscope to pass through the crico-
pharyngeus. Postoperatively the patient is nursed initially
in the routine post-tonsillectomy position. Usually little
analgesia is required and oral sterile water is given for 24
hours.
T h e procedure may be performed under local anaesthe-
s i a . A 2 per cent lignocaine spray is used for the pharynx,
the pyriform fossae are anaesthetized using a Jackson
applicator, and 2 ml of anaesthetic are sprayed between
the vocal cords with a laryngeal cannula. Alternatively the
superior laryngeal nerve may be infiltrated externally, and
likewise the larynx via the cricothyroid membrane.
211
212 Oesophagoscopy
Instruments
Round or oval, rigid oesophagoscopes with distal or
proximal fibreoptic lighting are available in adult and
children's sizes. These are appropriate for removal of
foreign bodies and for the management of some distal
stenoses, particularly where oesophageal dilatation is
present with intraluminal food or fluid. However, in
general they are more effective than flexible instruments
for the management of upper compared with lower
oesophageal lesions. The procedure is more difficult with
spinal and dental abnormalities and under local rather
than general anaesthesia as usually only a collapsed
oesophageal lumen is examined.
Flexible fibreoptic oesophagoscopes are technically
easier to use than rigid oesophagoscopes for routine
diagnostic oesophagoscopy, particularly under local
anaesthesia, and especially for examination of the mid and
lower oesophagus. The lumen can be dilated and
photography can be performed.
1
 Oesophagoscopy 213

2&3
Introduction

The dorsal recumbent position is usually adopted and

a Negus endoscopy frame may prove helpful. The
oesophagoscope is held in the fingers and thumb of the
right hand (right-handed surgeon), the left fingers and
thumb retracting the lips and protecting the teeth. A lead
or plastic splint or a gauze swab protects the upper teeth.
With the patient's head and neck flexed upon the chest,
the tip of the oesophagoscope is introduced into the right
side of the mouth under the upper surface of the right
side of the tongue until the right side of the larynx or
endotracheal tube is visualized

Passage through cricopharyngeus

The head is then extended at the atlanto-occipital joint.

T h e tip of the oesophagoscope is passed from the right
pyriform fossa towards the midline a n d , when behind the
larynx, it is advanced downwards applying a forward tilt of
the tip using the left thumb. The cuff of the endotracheal
tube may need to be released and undue force should not
be used at this point. With continued gentle advancement
and forward tilting of the tip the instrument will pass
through the cricopharyngeal sphincter.
 Oesophagoscopy

r o c

Passage through oesophagus

The oesophagoscope is then advanced down and to the

left, maintaining the lumen of the oesophagus in the
centre of the field of view. Secretions and debris should
be aspirated to maintain this view throughout the
procedure. Gradually the neck is extended as the
instrument descends and it may be helpful to tilt the head
of the operating table upwards until the transition from
oesophageal to gastric mucosa is observed.

Removal of foreign bodies

These usually lodge at the anatomical and physiological

constrictions of the oesophagus, namely the crico-
pharyngeus (15 cm from the incisor teeth), the aortic arch
(22.5 c m ) , the left main bronchus (27.5 cm) and the
diaphragm (40 cm).
A foreign body may be removed with grasping forceps
either whole or piecemeal. The object may be introduced
into the lumen of the oesophagoscope with the forceps,
w h i c h are then gradually withdrawn, together with the
oesophagoscope. Shears may be required to reduce
certain foreign bodies to an appropriate size for removal,
and forceps are available for closing safety pins.

Dilatation . ^

Biopsies Oesophageal bougies made of gum elastic in a full range

These should be taken with punch forceps. Twisting
and pulling actions which may lacerate the adjacent
mucous membrane must be avoided. Brush biopsies via
flexible oesophagoscopes can be used for cytological
examination.
of sizes are available. Gradual dilatation using increasing
sizes of bougie will dilate most strictures and this may
facilitate placement of an intra-oesophageal tube. Occa-
sionally these tubes must be 'rail-roaded' into position,
using a small bougie as a guide line. Undue force must not
be used during dilatation.

The patient is initially transferred to the Recovery
Unit, semiprone. Little analgesia is required. Following
oesophagoscopy under general anaesthesia, it is advisable
for the patient to take only sterile water until the day
following operation. After the procedure under local
anaesthesia a soft diet may be resumed after several hours
and a normal diet the following day. Postoperative pain,
particularly w h e n radiating to the back between the
scapulae, may indicate that perforation of the oesophagus
has occurred during the operation. This may be further
indicated by more marked dysphagia, particularly if
Oesophagoscopy 215
r ^ . « i n u dJoo uy pyrexia, ^uocutaneous surgical
emphysema in the neck or supraclavicular regions may be
the first sign of perforation and the neck should be
examined for its presence routinely one hour postopera-
tively and thereafter if indicated. Perforation most
frequently occurs at the cricopharyngeus or at the cardiac
sphmcter. The former may require external drainage, the
latter thoracotomy.
Damage may occur to the lips and teeth and if the latter
are removed during the operation, dental advice should
be sought immediately, for in certain cases teeth can
be replaced in a viable state. Trauma to the posterior
pharyngeal wall during passage of the oesophagoscope
may produce submucosal haemorrhage or mucosal
laceration, particularly if cervical osteophytes are present.
illustrations by Philip Wilson
H.J.Shaw V R D , F R C S
Consultant S u r g e o n , Royal Marsden Hospital and Royal National Throat, Nose and Ear Hospitals, London, UK
Nicholas Breach M B , B S , F R C S , F D S , R C S
Consultant S u r g e o n , Head and Neck Unit, The Royal Marsden Hospital, London, UK
As a result of persistent dysphagia many patients are often
in a serious state of malnutrition before operation and a
week or two is well spent improving their genera!
condition by parenteral or nasogastric tube feeding and by
measures to reduce local infection in the m o u t h , throat
and neck tissues.
Partial pharyngectomy with partial laryngectomy a n d
partial pharyngectomy with total laryngectomy and partial
thyroidectomy will be discussed in this section.
Indications
These operations are normally required for limited
malignant tumours involving the vallecuiae, epiglottis with
its attachments and the apex of the pyriform fossa. Such
tumours can additionally involve parts of the oropharynx,
larynx and tongue base.
In some cases the disease is confined to unilateral
involvement of these areas, notably in the lateral wall of
the oropharynx and the pyriform fossa. In others,
especially with postcricoid and upper oesophageal le-
sions, the disease is more often circumferential. Different
surgical techniques will therefore be required in each
situation .
216
Contraindications
General considerations of fitness for surgery must apply.
Locally, tumours spreading widely across the midline of
the posterior pharyngeal wall or showing circumferential
involvement of more than 50 per cent usually rule out
partial resection with preservation of mucosal continuity
and will require total pharyngolaryngectomy (see below).
T u m o u r s involving the cervical oesophagus and extending
below the thoracic inlet cannot be dealt with by these
o p e r a t i o n s and will require pharyngolaryngo-
oesophagectomy.
Anaesthesia
Premedication is usually by meperidine hydrochloride and
promethazine hydrochloride with atropine sulphate.
Induction of general anaesthesia is by thiopental sodium
and succinylcholine chloride. Maintenance is then with
combinations of nitrous oxide, oxygen and halothane via
an endotracheal tube, transferred to a soft cuffed plastic
tracheostomy tube at an early stage in surgery. If the
lesion is causing any appreciable airway obstruction, it | S
safer to carry out the tracheostomy under local anaesthe-
sia before general induction.
 Pharyngolaryngectomy 217

RESECTION W l f H PRESERVATION O F M U C O S A L
CONTINUITY

Since precise assessment of the extent of the lesion is

mandatory, a preliminary direct pharyngoscopy and
laryngoscopy must be done. The procedures can best be
r i e d out from the involved side through an extended
c a r

lateral pharyngotomy approach preceded by an ipsilatera!

radical neck dissection.

In the heavily irradiated neck, even if primary closure may

be technically possible, it is wiser to plan the exposure as
shown, using curved McFee incisions, the lower being
placed to cross the midline if required. The intervening
skin bridge of not less than 4 c m at its waist is raised with
the underlying platysma as on the upper and lower flaps.

2
After dissecting the skin flaps, the preliminary neck
dissection is p e r f o r m e d , if possible in continuity with the
main specimen a n d working beneath the skin bridge. This
can be moved as needed with a gauze loop or cotton tape.
T h e strap muscles are then divided superiorly and
inferiorly. Half the hyoid bone and the posterior two-
thirds of the upper half of the thyroid alar cartilage are
now removed. If not already performed, a temporary
tracheostomy is now carried out for continued anaesthc
sia and the peroral anaesthetic tube withdrawn.
 •t&--.' ^—w^f
.
-
* '
"—-
~ "

218 Pharyngolaryngectomy

3
The lateral pharyngeal wall is exposed and the mucosa
incised well away from the tumour margin. A direct view is
obtained and a further assessment made. If necessary the
supraglottic larynx in whole or in part may also be
resected with the pharyngeal specimen, the vocal cords
being preserved {partial pharyngectomy with partial
laryngectomy). Closure of the defect in three layers using
2/0 chromic catgut and careful drainage is then carried
out.

If the decision is made to resect the whole larynx with only

part of the pharyngeal wall, the dissection is carried across
the midline, the larynx being rotated into the w o u n d and
skeletonized by further division of the strap muscles,
internal laryngeal vessels and nerves and the constrictor
muscles on each side.
The larynx and involved portion of the pharyngeal wall
are then excised in continuity with the neck dissection
specimen and the ipsilateral thyroid lobe. Resection of
part of the valleculae or tongue base may also be needed
for completion.
Frozen section confirmation of clearance of margins
should be obtained in all cases.
T h e divided end of the trachea is now bevelled
anteriorly and a large oval stoma created in the midline of
the lower skin flap at a point marked out at the start of the
operation. Interrupted 1/0 silk sutures are inserted to
secure the junction.
 Pharyngolaryngectomy 210

REPAIR

5
in the non-irradiated or moderately irradiated neck,
provided about half the mucosal circumference remains,
primary closure of the mucosa! defect may be carried out
after passage of a nasogastric feeding t u b e , using a
composite continuous 2/0 atraumatic inverting stitch of
chromic catgut. This should be extramucosal as far as
possible and incorporate the cut edge of the divided
constrictor muscles with each stitch as back-up to the
suture line. A second layer of interrupted 2/0 chromic
catgut sutures is then inserted in the muscle coats.

A large calibre suction-drainage catheter is placed on

either side of the neck through separate stab incisions and
the w o u n d closed by layers in routine fashion. Interrupted
atraumatic 3/0 silk is used for skin closure. "An alternative
giving excellent cosmetic results is to use continuous
subcuticular 3/0 Prolene sutures.

If the neck has been heavily irradiated, primary closure

may be unwise and a plastic closure will be n e e d e d , using
a pedicle or free flap.
220 Pharyngolaryngectomy

M y o c u t a n e o u s flaps

7
Pectoralis flap
The skin overlying the pectoralis major muscle receives its
blood supply from perforating arteries and terminal
arteries coursing around the free inferolateral border of
the muscle. The supplying artery lies on the deep surface
of the muscle; this is the pectoral branch of the
acromiothoracic artery. A skin paddle is marked on the
pectoralis major to incorporate the arterial supply as
outlined above. T h e length of the flap should correspond
to the length of the pharyngeal defect to be recon-
structed.
T h e skin and muscle are elevated - the sternal origin of
the muscle needs division. At this point the pectoral artery
should be identified. O n c e the position of the artery is
known the lateral part of the muscle can be divided,
allowing an adequate fringe of muscle on either side of
the axial artery. In this way the whole muscle is divided
and the nerve to pectoralis major is taken with the vascuiar
pedicle.

The myocutaneous paddle is used as a patch to make good

the pharyngeal defect; or it may be tubed and used to
bridge a gap between pharynx and oesophagus as an
alternative to a deltopectoral flap after total pharyngolary-
ngectomy. An advantage of the myocutaneous flap is a
layer of muscle which supports the cutaneous element.
Three layers of absorbable sutures can then be used to
achieve an adequate closure.
 Pharyngoiaryngectomy

A skin tunnel is made over the clavicle to allow the paddle

patch or skin tube to be introduced into the neck, using
the lower incision of the McFee approach to guide it. To
avoid kinking of the vascular pedifle to the flap it is
advisable not to separate the c l a j t u l a r origin of the
muscle immediately overlying the vfscular axis.

T h e pharyngeal suturing of the patch or the upper and

lower anastomosis of a skin tube can be completed at this
initial operation, thus providing a one-stage pharyngeal
repair. A two-layer closure using absorbable and non-
absorbable sutures provides an adequate seal.
222 Pharvngolaryngectomy

A nasogastric tube should be introduced into the stomach

before the anastomoses are completed. The neck is then'
drained and closed in the usual way.

Latissimus dorsi flap

Using the principle of the pectoralis major flap, a similar
myocutaneous paddle flap can be raised on the latissimus
dorsi muscle; the major blood supply to this muscle is the
lateral thoracic artery. The origin of the muscle is divided
beyond the measured skin paddle; both the upper free"
border and the anterior/lateral free border should be
included with the paddle. The muscle, as it is inserted into
the bicipital groove, is divided just beyond the entry of the
vascular pedicle. A tunnel Is made deep to the anterior
axillary wall through the clavico-pectoral fascia, then
superficial to the clavicle and into the neck w o u n d .

As with the pectoralis flap a one-stage operation is

possible for pharyngeal patch repair; if tubed, the upper
and lower anastomoses are closed primarily. T h e donor
defect is also closed primarily and it is advisable not to use
a free skin graft on the back as healing will be delayed.
Primary closure is usually possible as when pectoralis
major flaps are used.
 Pharyngolaryngectomy 22J

Free cutaneous flaps

Radial forearm flap

The ventral forearm skin receives its arterial blood mainly from the radial artery. Recently the Chinese have shown that
large forearm flaps can be raised which are dependent upon the radial artery. The venous drainage can either be via the
superficial veins, i.e. the cephalic v e i n , or the communicating veins running with the artery.

Care must be taken w h e n raising the skin flap, from medial to lateral (ulnar-radius), not to transgress the mesentery
conducting the arteries. T h e distal vessels are divided. Proximally the vessels are exposed almost to the antecubital fossa to
provide a length of pedicle for the microvascular anastomoses.

W h e n the proximal vessels are divided no clamps should be placed on the vessels to be anastomosed; the flap should be
flushed through with a heparin-saline solution. This is best done with a syringe and blunt needle^The skin paddle may be
used as a patch for pharyngeal repair or tubed, if required, using a double-layer closure. T h e proximal forearm donor site
can be closed primarily. T h e more distal part, however, requires a split skin graft. This latter can most readily be acquired
from the upper part of the arm, a tie-over dressing supporting the graft.
 Pharyngolaryngectomy

the pharyngeal anastomoses should be completed. This is

done as a one-stage procedure in a similar manner to that
described for the myocutaneous flaps. The fixation of the
pharyngeal reconstruction is important as tension must
not be placed later on the vascular anastomoses.

Experience has shown that the most efficient vascular

anastomosis is end-to-side, i.e. donor end to side
recipient. If possible, the external carotid artery is c h o s e n ,
although the presence of atheroma is a definite contrain-
dication. When the external carotid itself cannot be u s e d ,
the facial or superior thyroid arteries are c h o s e n ; but if
there is any tension an interposed vein graft should be
u s e d . Ideally the internal jugular vein is most suitable for
the venous anastomosis, but frequently this has been
sacrificed in the block dissection. W h e n this is the case
the external or anterior jugular vein is used in the
end-to-end fashion, although there may be some discrep-
ancy in vessel size.
This particular form of repair has much to recommend it
as the forearm skin is thin, easily tubed and the bulk of the
flap is minimal. Good preoperative perfusion is mandatory
if microvascular techniques are to be employed. T h e
anastomoses are done using the operating microscope
and atraumatic 8/0 or 9/0 nylon or Prolene.
16

If the radial artery is to be sacrificed, a preoperative
Allen test should always be done to confirm that the ulnar
artery supply to the whole hand is adequate.
T h e latissimus dorsi flap already described can be used
as a free flap as the vascular pedicle is sufficiently long.
The major disadvantage, when compared to the radial
forearm flap, is its bulk and the difficulty of stabilization
and subsequent torsion of the vascular anastomoses.
Once the vascular flow is well established, these free flaps
may be secured in place as patches or tubes to fit the
previously measured defect.
 Pharyngolaryngectomy 225

TOTAL PHARYNGO- the cervical oesophagus which a k n extend d ^ ' ^ w r ^

LARYNGECTOMY
u i - .iio.av.ii. i n l n UitiC H C A I ^iltljjief J.

WITH TOTAL
THYROIDECTOMY Anaesthesia

T h e same technique is used as for the previously

described operation.
Preoperative

indications

This type of procedure is normally required for:

1. extensive tumours of the pyriform fossa spreading
across the midline of the posterior pharyngeal w a l l ;
2. the more common postcricoid tumours spreading
circumferentially into the oesophageal junction; or
3. tumours involving the cervical oesophagus but clear of
the thoracic inlet.
Contraindications
Genera! considerations apply. Locally, this procedure is
ruled out for less extensive lesions which can be dealt with
by the techniques already described and for tumours of
The operation
RESECTION OF A COMPLETE SEGMENT OF
PHARYNGEAL MUCOSA
In line with modern concepts it is not usually considered
desirable to use large cervical skin flaps to provide lining
for major soft tissue defects. This is due to anatomical
disturbance of and proximity to suspect lymphatics,
should neck dissection become necessary later. In many
cases these tissues also have reduced viability as a result of
previous heavy irradiation. In some instances it may be
undesirable to use any heavily irradiated neck skin for
cover in the repair. All lining and cover are better obtained
from pectoral or latissimus dorsi pedicle flaps or revas-
cularized free flaps.

Skin incisions may be slightly varied, but for the single

deltopectoral flap operation the simplest is an adaptation
of the McFee double transverse pattern. In this case the
lower incision is placed across the midline.
At this time the position for the permanent tracheos-
tome should be marked. These incisions are placed on the
side of main tumour involvement to facilitate combined
neck dissection.
226 Pharyngoiarvngectomv
T h e flaps are elevated and dissected to contain the
platvsma muscle as before. Especial care is taken with
handling of the central skin bridge beneath which the
main dissection must proceed. At this stage an in-
continuity neck dissection should be carried out w h i c h
greatly facilitates later placement of the skin flap.
Strap muscles are then divided low down and the
parapharyngeal and paratracheal gutters palpated for
metastatic tumour spread. The larynx is rotated to free the
constrictor muscles on either side from the prevertebral
fascia and to ligate and divide the main thyroid gland
vessels and internal laryngeal neurovascular bundle. T h e
hyoid bone is detached from its suprahyoid attachments,
and the dissection is carried down to the mucosa of the
valleculae which is swept upwards off the anterior surface
of the epiglottis and preserved. At this point the pharynx is
entered and a direct view obtained of the upper limits of
the tumour.
Attention is now turned to the lower incision line. T h e
18
thyroid isthmus is divided, a tracheostome created and a
cuffed plastic tracheostomy tube inserted for continued
anaesthesia, enabling the peroral tube to be withdrawn.
Starting at the pharyngeal opening, this incision is
continued circumferentially around the whole lower
pharynx to give the upper end of the tumour at least 3 cm
clearance. The larynx and laryngopharynx are now
dissected forwards and downwards off the prevertebral
fascia and drawn through the lower incision line until it is
considered that a suitable level has been reached to give
at least 3 cm clearance also at the lower end of the tumour.
This can be assessed more accurately by splitting the
lower pharynx and upper oesophagus down the posterior
midline. At the same time adequate precautions must be
taken against spillage of tumour cells. Frozen section
confirmation of clearance is again mandatory.
After placing stay sutures in the oesophagus and
trachea, the large specimen, including the whole thyroid
gland, is amputated.
REPAIR
Deltopectoral technique
A deltopectoral skin flap is carefully measured, marked
out and raised to include the deep pectoral fascia and axial
branches of the first four internal mammary perforating
vessels. Usually it need not be extended beyond the
mid-deltoid line . It is important to raise the deep pectoral
2
fascia with the cutaneous flap. The acromiothoracic axis
should be ligated rather than diathermied.
This flap is swung up into'position through the lower
neck incision to the side of the tracheal stoma and under
the central skin flap bridge.
 Pharyngolaryngectomy 227

The deltopectoral flap at its distal end is sutured

end-to-end to the divided pharynx with a continuous
inverting 270 chromic catgut stitch on an atraumatic
needle. This layer is then backed up with well-spaced',
interrupted 2/0 non-absorbable sutures.
In this way the transposed flap becomes tubed on itself,
raw surface outward, and buried beneath the central skin
flap. A suitable nasogastric feeding tube is passed and
tubing of the flap is continued downwards, using the same
suture technique, until the oesophageal stump is reached.

19

This is vertically split on one side for about 3 c m . The

widened oval opening is then carefully sutured end-to-
20a side at a convenient point into the deltopectoral tube,
using continuous 2/0 chromic catgut backed up with
another layer of silk sutures. .

T h e cut end of the trachea is now bevelled anteriorly. A

large oval stoma is created in the lower skin flap or
incision line using 1/0 interrupted silk sutures to secure
the junction. - •
228 Pharyngolaryngectomy

While this repair is being carried out, the assistant should

take an adequate split-skin graft from the thigh, to be
stored for 24-48 hours and then applied as a delayed
primary graft to the raw pectoral region. During the delay
period, the exposed pectoral muscle is firmly covered
with sterile saline gauze on paraffin mesh packs.

It will be noted that a small fistula now leads out onto the
chest wall to the side of the tracheostoma. This can be
closed primarily by de-epithelializing the circumference of
the deltopectoral flap at this point and obliterating the
lumen by direct suture in one stage. For greater safety the
fistula should be left open and the lumen of the tube
decompressed by inserting a suction catheter in retro-
grade fashion up the tube as far as .the pharyngeal
junction. Large-calibre suction catheters are then placed
independently through the flaps into each side of the neck
and the wound closed in layers using 2/0 chromic catgut
and 3/0 interrupted silk sutures for the-skin.

O n e month later, in a short final operative stage, the

proximal end of the deltopectoral tube is divided and the
flap residue returned to the chest wall. At the same time
the lower end of the skin tube is closed by simple
inverting 2/0 chromic catgut sutures and buried beneath
the lower neck incision.
It should be noted that the myocutaneous pedicle flaps
or cutaneous and myocutaneous free flaps may also be
used as tubes to bridge the loss of a complete segment of
mucous membrane.
 Pharyngolaryngectomy 2

Reconstruction usins a free jejunal ^e^ment

Ideally, after a complete pharyngolaryngectomy, a tubed

organ should be used to replace the cervical oesophagus,
in the same way that mucosa should be used to replace
mucosa whenever possible. However, this type of repair is
only possible when tumour does not extend into the
thoracic oesophagus.

A segment of j e j u n u m , adjacent to the duodenojejunal

junction, can be taken with its arcade of vessels and with
an adequate pedicle length; the vessel size is of the order
of 1.5 mm. It is important that the length of the pharyngeal
defect to be replaced should be measured and the jejunal
segment tailored accurately. Excess should be avoided.
As with the previously described skin tube (see pp.
223-224), the proximal and distal pharyngo-oesophageal
anastomoses must be completed before the microvascular
surgery is attempted. This will ensure stability of the
reconstructed pharynx and reduce the tension on its
vascular connections. T h e distal anastomosis is most
conveniently completed first; a bowel stapling device is
ideal. T h e proximal anastomosis requires a three-layered
closure. Everting 3/0 silk sutures are used for the mucosal
layer.
Ideally the vascular anastomoses are end-to-side, as
described in the previous section on free tissue transfer. It
may also be necessary to take the vascular pedicle to t h e
contralateral side of the neck if the major vessels on the
ipsilateral side have been sacrificed.

Postoperatively there is frequently a copious secretion

of mucus from the jejunal segment. This readily settles,
but nasogastric feeding is necessary for 8-10 days.
230 Pharyngolaryngectomy
Wound drainage will usually be via large-calibre suction
catheters placed one on each side of the neck through
separate stab incisions and left in place until drainage is
minimal, over a period of 24 hours. In most cases,
therefore, dressings will be tight using gauze and adhesive
tape. But occasionally, when large doses of irradiation
have been given it is an advantage to use, in addition, a
bulky gauze wool and crepe bandage dressing - mainly for
immobilization and support of the neck tissues.
The separate suction catheter placed within the Bakam-
jian fistula should remain at least until firm healing is
established and closure completed, in addition, all
fistulous openings will require careful cleansing and
painting with zinc peroxide cream or other anti-infective
agent at least twice daily.
Feeding is by nasogastric tube until fistulae are closed
and complete healing is established. As soon as feeding by
mouth is satisfactory, active speech therapy is begun.
Reasonable though weak oesophageal speech may be
expected in some patients. In others the use of an electric
speech aid will be necessary,
Apart from general hazards such as stroke, cardiovascu-
lar accidents, pneumothorax and pulmonary infections,
the most worrying local problems are haematoma,
infection or haemorrhage with subsequent wound break-
d o w n . The latter is most likely to develop after disruption
of a primarily ciosed pharynx with resulting exposure and
infection of jugular or carotid vessels.
For these reasons the after-care with drainage and
dressings must be meticulous, and broad-spectrum
systemic antibiotics must be used liberally until healing is
complete.
References
1. Conley, j . Concepts in head and neck surgery. New York:
Grune and Stratton, 1970
2. Bakamjian, V. Y. A two-stage method for pharyngoesophageai
reconstruction with a primary pectoral skin flap. Plastic and
Reconstructive Surgery!965; 36:173-184
Further reading
McFee, W. F. Transverse incisions for neck dissection. Annals of
Surgery 1960; 151: 279-284
Olivari, N. The latissmus flap. British Journal of Plastic Surgery
1976; 29:126-128
Reid, C. D. and Taylor, C. 1. The vascular territory of the
acromiothoracic axis. British Journal of Plastic Surgery 1984; 37:
194-212
Song, R-, Gao, Y., Song, Y.. Yu, Y., Song, Y. The forearm flap.
Clinics in Plastic Surgery 1982; 9: 21-26
Illustrations by Phiiip Wilson
H. ] . Shaw VRD, FRCS
Consultant Ear, Nose and Throat Surgeon, Royal Marsden and Royal National Throat, Nose and Ear Hospitals, L o n d o n , UK
Many growths of this region are advanced w h e n di-
agnosed and grossly involve the whole cervical oesopha-
g u s , often with extension beyond the thoracic inlet.
Furthermore, there is the strong possibility of bilateral
involvement of paratracheal and superior mediastinal
lymphatics in addition to those in the lower jugular chains.
In s u c h situations, if a cure is to be achieved, it is essential
to carry out an ultraradical resection comprising the lower
pharynx, larynx and whole oesophagus, often with radical
dissections of the neck and even of the superior
mediastinal lymphatics.
Although the operation of total oesophagectomy for
cancer has been performed sporadically for many years.
usually as a transthoracic procedure, it is only in the last 20
years that publications have demonstrated the value of a
c o m b i n e d c e r v i c o a b d o m i n a l o p e r a t i o n for upper
oesophageal cancer, with immediate visceral replacement
using a segment of colon or the whole stomach as a
vascular pedicled transplant. Good results, in terms of
early restoration of function, with a moderate chance of
cure can be obtained by either m e t h o d , although
operative mortality is high. Choice of viscus for restora-
tion of continuity is often determined by the surgical
experience or skill of the abdominal team, governed by
the particular circumstances of each c a s e . 1-6
231
232 Pharyngotaryngo-oesophagectomy
Indications
This operation is indicated for removal of:
1. tumours of the pharyngo-oesophageal region or cer-
vical oesophagus which directly involve the upper
thoracic oesophagus;
2. similar tumours not precisely extending into the
thoracic oesophagus but whose lower margin pre-
cludes adequate resection and repair through the neck
alone.
Contraindications
The procedure is contraindicated i n :
1. many patients over 70 years of age and/or those whose
- general condition is judged unsuitable for ultraradical
surgery;
2. metastatic disease or local extensions which render the
tumour incurable. Such evidence of spread of disease
may only be discovered at exploration of the neck or at
laparotomy.
Radiotherapy
Radiotherapy is not necessarily a contraindication and may
be considered as an elective adjunct in the new case.
Judicious irradiation to a modified dose of about 4 0 G y
(4000 rad) over a 4-week period may reduce the bulky
tumour and effectively discourage local recurrence fol-
lowing radical surgery carried out 4-6 weeks after the
completion of irradiation. The use of radical ablative
surgery with visceral replacement for tumours which have
recurred after high-dose radical radiotherapy is certainly
associated with an increased morbidity and mortality.
Nutrition
Nutrition is often a problem in patients with carcinoma of
the oesophagus at any level. This is particularly true
during and after prolonged radiotherapy, and it is one
factor to be considered in the selection of patients for
elective preoperative therapy. Care taken in-the preopera-
tive period, attending to the patient's intake of calories,
protein and vitamins, will often be rewarded by a
reduction in postoperative complications.
The degree of obstruction will determine the practicali-
ties but, whenever possible, all patients should have a
low-residue, high-calorie diet with high vitamin supple-
ments. Many are now commercially available but it is
nnp^i IJI.I V.I.OI.IC Llllil 11 I C pUUCiU U t 1UVT • i>L<11 1U_- i n e
rationale of preoperative feeding which must be made as
palatable as possible.
In cases of near-complete or complete obstruction,
preliminary parenteral feeding with intravenous amino-
acid solutions is essential. These should be accompanied
by sources of calories in the form of sorbitol or lipid
emulsions. Control of a sub-acute or chronic catabolic
state by parenteral means may be difficult; it can also be
helped by judicious blood transfusion.
Creation of a gastrostomy or jejunostomy for feeding
should be avoided in the preoperative phase because of
contamination of the abdominal field. But a jejunostomy
constructed during operation by the abdominal team may
facilitate postoperative feeding, especially in those cases
where delayed healing in the neck may be anticipated.
Bowel preparation
For operation with repair by colon transplant, beginning at
least 7 days before the operation, a low-residue, high-
calorie, high-vitamin diet is given, with non-residue fluids
only for the last 2 days. Five days before the operation
10 ml of a suspension of 8.5 per cent magnesium
hydroxide is given four times a day. Phthalysuiphathiazole
is also given each night with colonic washout each
morning. O n the last 3 nights before the operation a
retention enema of neomycin sulphate 1 g in 500 ml H2O is
given. Administration of oral ampiciilin anhydrous (Pen-
britin) in a dosage of 500mg four times a day is started 2
days before the operation.
For operation with repair by pharyngogastric anastomo-
sis bowel sterilization and purgation may not be necessary
in theory, but in practice a clean and empty colon allows
the abdominal team the choice of viscus at laparotomy
a n d , when stomach is used, the recovery of intestinal
function will not be delayed by colonic stasis.
Anaesthesia
For premedication, either meperidine hydrochloride and
promethazine hydrochloride with atropine sulphate is
administered or droperidol and fentanyl (Thalamonal) also
with atropine. Induction is by thiopental sodium and
succinylcholine chloride (Scoline). Anaesthesia is then
maintained with combinations of nitrous oxide, oxygen
and halothane via an endotracheal tube but transferred to
a cuffed tracheostomy tube (Bradfield) at an early stage in
surgery.
 Pharyngolaryngo-oesophagectomy 233

Pharyngolaryngo- I

oesopnagectomy

Where nodes are not clinically palpable or are not

suspected, a shallow S0rensen U-shaped incision is most
suitable. If necessary, this can easily be extended for neck
dissection. Where neck nodes are palpable or are
suspected, a modified Gluck type of incision pattern
comprising upper and lower horizontal components
joined by a midline incision at an angle of about 60° may
be u s e d , or a McFee incision pattern as modified on page
217. Elective neck dissection is not usually advocated.

The exploration of the deeper neck tissue is quickly

performed in order to determine the approximate limits of
the primary lesion and confirm resectability. Any suspi-
cious lymph nodes should be removed carefully and sent
for frozen section review.
If all is well, the abdominal team then goes ahead w i t h
exploratory laparotomy and preparation of the colonic
segment for transplant.

The resection of the cervical viscera proceeds routinely as

described in the previous chapter, to include a total
thyroidectomy in every patient with as much paratrachea!
and paraoesophageal areolar and lymphatic tissue as is
possible and a radical neck dissection on one or both
sides if ordinarily indicated. Usually in those cases w h e r e
there is doubt about obtaining clearance at the lower limit
of the cervical oesophagus, and in all tumours extending
well into the thoracic oesophagus, the neck specimen is
left attached to the oesophagus, which is later removed
completely by division at its lower end. T h e trachea is also
transected below the larynx and secured with insertion of
a cuffed tracheostomy tube toward the end of the
dissection and before the whole specimen is removed.
234 Pharyngolaryngo-oesophagectomy

Preparation of the colon segment

Laparotomy is performed through a long right paramedian

incision. The presence or absence of secondary metastasis
in the liver is first established. The whole of the colon is
then mobilized, starting on the right side and bringing the
ascending colon forward on its vascular pedicles by
making an incision in the paracolic gutter up to the
hepatic flexure. The omentum is detached from the
transverse colon and the splenic flexure is mobilized. T h e
upper half of the descending colon is similarly mobilized
by making an incision down the left paracolic gutter. T h e
vascular anatomy of the colon is identified and the
ileocolic branches to the caecum are divided close to their
origin. The middle colic artery is then divided as it goes
under the pancreas. This leaves the transverse and
ascending colon supplied by the left colic artery.
Occasionally the local vascular anatomy requires that the
middle colic artery be used to supply the colonic segment
with division of the left colic vessel.
Following this mobilization, the colon is transected
between clamps about 5-10cm below the splenic flexure
at the site marked in the diagram. The marginal artery is
4
also divided, thus freeing the transverse and ascending
colon supplied by the left colic branch of the inferior
mesenteric artery. T h e terminal ileum is then divided
Excision of the oesophagus
following mobilization and division of the ileal branches in
this region. A small enterotome (Zachary Cope) is next At this point it is convenient to perform a pyloroplasty,
placed about 5 cm from the caecum across the ascending necessary after the vagotomy w h i c h accompanies the
colon and the bowel is divided. The caecum and terminal major resection. Mobilization of the lower part of the
ileum are now discarded. An injection of streptomycin 1 g oesophagus is next carried out by finger dissection
in norma! saline solution is given into the isolated colonic through the diaphragmatic hiatus as high as possible from
segment. below, a n d , similarly, freeing the oesophagus from above
by gentle finger dissection through the cervical incision.
In this way, the whole of the oesophagus is mobilized.. T h e
oesophagus is then divided at the gastro-oesophageal
junction. T h e oesophagus is closed by a mass ligature and
the cardia closed with two layers of continuous 2/0
chromic catgut sutures.

5
After making sure that the oesophagus has been fully
mobilized by finger dissection from the neck in the upper
mediastinum, it is removed by gently pulling the
specimen, which includes, the larynx and pharynx,
upwards.
Care must be taken to recognize at once any bleeding or
pneumothorax. It is also important to divide carefully the
fibrous band which often attaches the oesophagus to the
posterior tracheal wall at its bifurcation; otherwise tearing
of the posterior tracheal wall may result. Temporary
deflation of the cuff on the endotracheal tube is also
advised during this manoeuvre' . 1

Transplant of colon
At the time of upward removal of the oesophagus it may
be convenient to replace it immediately by the colon in
the posterior mediastinal position. This is achieved by
division of the right crus and enlargement of the hiatus
before stay sutures are inserted between the muscularis of
the oesophagus and ascending colon. This should be
6
Pharyngolaryngo-oesophagectomy 235
done in such a way that, when it lies in the mediastinum,
the colon will lie on the right of its vascular pedicle. Use of
the oesophageal bed in the posterior mediastinum has the
advantage that the colon acts as a pack which discourages
any venous oozing.
6
The preferred retrosternal route is shorter and is made by
an incision in the diaphragm in the region of the anterior
mediastinum and directly under the xiphisternum. T w o
fingers are worked upward to create a retrosternal tunnel.
A similar procedure is begun in the neck, where a finger
is passed down just deep to the manubrium sterni a n d , by
a process of blunt dissection with the fingers from above
and below, an adequate tunnel is made through which the
ascending colon is passed up into the neck. During this
procedure pleura may also be torn, especially on the right
side. This has been found to be of no great disadvantage if
it is recognized at the time and intercostal watersealed
drainage is established. O n occasions, the thoracic inlet to
the right of the trachea may be quite small. This will
necessitate excision of the right sternoclavicular joint if
the division of the trachea has not already been
accompanied by a resection of the upper part of the
manubrium.
236 Pharyngolaryngo-oesophagectomy

Anastomoses
T h e upper end of the colon is then anastomosed to the
pharynx by a one-layer technique using interrupted
stainless steel wire sutures. Care must be taken to ensure
that the pedicle and the marginal artery are not twisted or
under any pressure, particularly in their passage through
the mediastinal tunnel.

>

The lower end of thp rplon is then ? n . ^ n r p n ' ; M tr,
antciiui -.unuk-c ut uic siuntcn.il as nign on tne lesser
curvature as is convenient; this is a two-layer anastomosis
with continuous mucosal 2/0 chromic catgut and inter-
rupted seromuscular silk or linen sutures. The ileum is
anastomosed to the descending colon by end-to-end
anastomosis in two layers in a similar manner.
At the end of the operation and before closure of the
abdomen, a jejunostomy is also constructed to enable the
patient to be fed as soon as possible after surgery. The
abdomen is closed in routine fashion and soft drains are
placed in the left paracolic gutter and the right sub-hepatic
pouch. T h e neck w o u n d is closed with bilateral suction-
drainage and an additional mediastinal drain. A perma-
nent tracheostome is established in the usual way.
Cervicoabdominal procedure and
repair by pharyngogastric
anastomosis
Anaesthesia
The same methods are employed as in the colon repair
procedure.
T h e same incisions and technique for resection of the
neck specimen are used as in the previously described
surgical resection.
Mobiiization of the stomach
The abdomen is opened by a long, upper midline or
paramedian incision, extended if necessary by excision of
the xiphoid cartilage. An exploratory laparotomy is
performed and the liver is at once examined for evidence
of metastases. Para-aortic lymph nodes are much less
frequently involved than is the case in carcinoma of the
thoracic oesophagus but any suspicious node should be
examined by frozen section. The left triangular ligament is
divided, allowing the left lobe of the liver to be retracted
to the right and giving access to the hiatus, the fundus and
lower oesophagus. Except for the fact that gastric
mobilization needs to be more extensive, the procedure is
the same as for operations for carcinoma of the thoracic
oesophagus, with retention of the right gastric and right
gastroepiploic vessels.
T h e dissection starts at about the midpoint of the
greater curvature, working then towards the pylorus, just
below and to the right of the pylorus the gastroepiploic
vessels must be exposed accurately. Both vessels are freed
sufficiently to allow the gastroduodenai angle to be
straightened out, particular attention being paid to the
v e i n . This vein provides the main venous drainage of the
mobilized stomach, and if it is damaged the circulation in
the stomach may be impaired fatally.
The hepatic flexure of the colon is reflected downwards
and the duodenum and head of the pancreas mobilized by
Kocher's manoeuvre. Freeing of the pyloroduodenal
region Is then completed by exposure of the bile duct and
right gastric artery above the first part of the duodenum.
For complete mobilization of the greater curve, the
vessels in the gastrosplenic omentum are divided, Above
Pharyngolaryngo-oesophagectomy 237
the spleen the dissection is continued up to the
oesophagus, w h i c h is itself freed up through the hiatus.
Mobilization of the stomach is completed by division of
the gastrohepatic omentum and the left gastric vessels. In
view of the fact that both vagi will later be divided", the
abdominal part of the operation is completed by
performing a pyloromyotomy or pyloroplasty.
Mobilization of the oesophagus and transposition
of the stomach
This is carried out when the cervical dissection is
completed. W i t h gentle traction on the stomach the
oesophagus is freed as far up as possible, under direct
v i s i o n . T h e right crus is then divided, to provide easier
access to the mediastinum and to straighten out, and so
slightly s h o r t e n , the new bed for the stomach. By blind,
finger dissection the thoracic oesophagus is now freed,
keeping as close to the oesophagus as possible and paying
careful attention to the fibrous band previously men-
tioned attaching the posterior tracheal wall at its bifurca-
tion to the oesophagus.
As before, this blind mobilization of the thoracic
oesophagus makes it necessary for'the abdominal surgeon
to insert his w h o l e hand through the hiatus and into the
chest. During this procedure the cervical operator
continues to free the upper thoracic oesophagus by digital
dissection from above, taking great care in separating the
posterior tracheal wall. If massive haemorrhage occurs,
the right chest must be opened for effective control.
O n c e the oesophagus is free, the stomach is drawn up
into the neck by gentle traction, while the abdominal
operator guides the duodenum and pancreas up towards
the hiatus. O w i n g to the rotation of the stomach, the
fundus reaches a distinctly higher level in the neck and
should always reach sufficiently high above the level of
the hyoid to allow its suture to the pharynx without undue
tension. With completion of this part of the procedure,
the laparotomy incision is closed routinely in layers with
insertion of suitable drainage.
233 Pharyngolaryngo-oesophagectomy

Anastomosis of stomach to pharynx

The oesophagus is divided flush with the stomach, which

is closed in two or three layers with continuous 2/0
chromic catgut, this suture line lying above the upper
border of the manubrium. The fundus of the stomach is
opened at its highest point and anastomosed to the
pharynx. The control of a few bleeding points on the cut
edge of the stomach is often necessary.
 Pharyngolaryngo-oesophagectomy 239

There is no difficulty in adapting the size of the gastric

opening to the width of the pharynx, and in all cases the
junction is sutured with two or three layers of 2/0 chromic
catgut. A nasogastric tube is passed through the anasto-
mosis with its tip lying well down into the body of the
stomach.

Before closure of the neck incision two wide-calibre

suction drains are inserted, one on either side of the
anastomosis, and a third is passed down into the upper
mediastinum. All three tubes are brought out through stab
wounds away from the main incision. T h e neck incision is
closed in two layers, the divided trachea being secured to
a surrounding skin stoma with interrupted 1/0 silk sutures.

VARIATIONS

A number of options are available when using the colon

replacement technique. The transverse colon with splenic
flexure and part of the descending colon has been used by
some authors, though it carries the disadvantage of using
an antiperistaltic segment w h e n swung into position. In
addition, a choice of route to the neck will include the
posterior mediastinum through the space previously
occupied by the oesophagus, or an extrathoracic sub-
cutaneous route in front of the sternum. The posterior
route is longer and has the disadvantage of increased risks
13 to the delicate blood supply of the transplant. The anterior
subcutaneous route has an advantage for the poor-risk
patient in producing less intrathoracic trauma and is
therefore theoretically safer. However, it is also a long
route with a bend at either end of the thoracic cage, giving
an added risk of vascular compression and often a slow
swallow as a functionalresult.
240 Pharyngolaryngo-oesophagectomy
Complications
, ' After colon transplant
The cervical wound and associated tracheostome require
similar attention for drains, dressings and suction as given
previously. Active chest and general physiotherapy with
regular chest films is essential. Any pneumothorax is
tapped to an underwater sealed drainage bottle in the
usual way until the lung is fully expanded. T h e neck and
abdominal drains are left until no further drainage
appears, usually 4-5 days. Abdominal tension sutures
remain for 2 weeks.
Particular care must be given to maintenance of
parenteral nutrition for the first 2-3 postoperative days.
Solutions based on protein hydrolysate, sorbitol and
intralipid must be used with balanced electrolytes to give
approximately 16.8 kj (4000 calories) daily. Jejunostomy
feeding can be started slowly on about the third day.
Thyroxine and calcium replacement with regular bioche- frj After gastric transplant
mical monitoring should start at once. Oral feeding can
usually start 7-10 days after operation, with liquids and
very soft diet checked by barium swallow films. Discharge
from hospital can be planned about 3-4 weeks after
surgery and a suitable convalescence must be arranged.
Some patients may require postoperative radiotherapy
during this period.
Normal swallow often takes longer to become estab-
lished using a colon transplant than in the gastric repair.
But, when natural peristalsis returns to the segment, rapid
improvement occurs without the regurgitation which can
be troublesome when the stomach is used.
Development of 'oesophageal' voice is unpredictable. A
number of patients do develop a serviceable voice of this
type with speech therapy. In others an electric speech aid
or the insertion of a surgical speech prosthesis is required.
Serious problems seldom arise in relation to the intra-
abdominal anastomoses and suture lines providing the
technique is meticulous. Also, using the short anterior
and retrosternal route, any failure of the transplant
vasculature is highly unlikely providing the dissection and
manipulations are well planned and carried out. The most
frequent sources of trouble are likely to be variable
breakdown and fistula formation at the pharyngocolic
anastomosis, with cervical and occasionally mediastinal
infection. Chest physiotherapy is essential to combat the
constant risk of pulmonary infection following all major
surgery of this type.
There are fewer anastomoses and the abdominal field
seldom gives trouble, but the pharyngogastric junction
may also leak into the neck, giving rise to infection and
fistula.
A pneumothorax must not be missed a n d , in view of the
longer posterior mediastinal route, the likelihood of
mediastinal haemorrhage, haematoma or infection is not
infrequent. This requires urgent treatment and may lead
to haemothorax or empyema, requiring aspiration and
drainage. General complications such as cardiac infarc-
tion, pulmonary embolism and cerebral thrombosis are
natural hazards of this age group and especially so in this
type of surgery.
References
1. Ong, C . R., Lee,T. C. Pharyngogastric anastomosis after
oesophago-pharyngectomy for carcinoma of the hypopharynx
and Cervical oesophagus. British journal of Surgery 1960-61;
48:193-200
2. Lequesne, L. P., Ranger, D. Pharyngolaryngectomy with
immediate phary'ngastric anastomosis. British Journal of
Surgery 1966; 53:105-109
3. Fairman, H. D., John, H. T. Treatment of cancer of the pharynx
and cervical oesophagus, journal of Laryngology and Otology
1966; 80:1091-1101
4. Harrison, D. F. N. Surgical management of cancer of the
hypopharynx and cervical oesophagus. British Journal of
Surgery1969; 56: 95-103
5. Stell, P. M. Esophageal replacement by transposed stomach;
following pharyngolaryngo-esophagectomy for carcinoma of
the cervical esophagus. Archives of Otolaryngology 1970; 91:
166-170
6. Griffiths, J. D., Shaw, H. J. Cancer of the laryngopharynx and
cervical esophagus: radical resection with repair by colon
transplant. Archives of Otolaryngology 1973; 97: 340-346
Illustrations by Gillian Lee
George Buchanan r-RCS(Glas.), FRCS(Ed.)
Consultant Ear, Nose and Throat Surgeon, Southend Hospital, Essex, UK
Indications
This is a relatively simple procedure which should be
included in the repertoire of all Ear, Nose and Throat
Surgeons. H]s^cn1ca!]y_^icopharyngeai sphincterotomy
was first used in the treatment of severe dysphagia -
resulting from bulbar poliomyelitis.
It should be considered in motor neurone disease with
the onset of progressive swallowing difficulties. Early
surgery is advisable as soon as a patient begins to
complain of spill-over into the larynx. The operation is
most effective w h e n there is still a moderate degree of
tongue movement and when respiratory involvement is
limited. ~ 400 mg intramuscularly, given 2-4 hours preoperatively.
Sphincterotomy may be of considerable benefit in
pharyngeaTToafalysis following brain-stem infarction or
due to lesions high in the vagus nerve i t s e l f . / ^
T h e procedure has been successfully used for the relief
of dysphagia in the rare oculopharyngeal form of muscular
dystrophy.
It remains a safe and effective technique for the
treatment of small pharyngeal pouches where excision of
the pouch is not required. An additional indication for
operation is muscular incoordination of the upper
oesophageal sphincter (achalasia).
It is also needed in supraglottic laryngectomy and
occasionally as an adjunct to improve swallowing in
extensive oropharyngeal resections.
Contraindications
Patients with severe gastro-oesophageal reflux may be
worse after cricopharyngeal sphincterotomy.
5<
u h'c. jJi' < 1 ^ i z
3 " \
Preoperative preparation
To minimize pulmonary complications time is well spent
on a period of breathing exercises. -' v - —
Premedication
A suitable dose of intramuscular opiate with an antisialo-
gogue is satisfactory. Oral premedicants are not indicated.
T h e risks of postoperative pulmonary aspiration may be
reduced by using the H receptor antagonist cimetidine
2
Anaesthesia
^Positive pressure ventilation or spontaneous breathing
"anaesthesia via an endotracheal tube is used. Suxametho-
nium is best avoided in rapidly progressive motor neurone
disease and there is evidence to suggest an increased
sensitivity to non-depolarizing relaxants.
T h e patient" is most safely extubated in the lateral
position w h e n full consciousness has returned. Patients
with severe_neuromuscular problems may exper?elToir~a~
delay in regaining an adequate tidal volume postoper-
atively and if so should be reintubated and ventilated,
usually until the following morning.
241
242 Cricophnryngeal sphincterotomy
Position of patient
The patient is placed supine with the occiput supported
on a head ring. An oesophagoscopy is usually performed
to exclude the presence of a neoplasm, The_sphinctero-
tomy will be facilitated by the insertion of a small Foley
catheter in'tolhe cervical oesophagus. T h i s J s _ p a r t i a l l y
inflated w i t h ^ l O mt_of water and will be used to put the
cricopharyngeu5 muscie on the stretch. Alternatively this
can be accomplished by the passage of a size 36 French
gauge mercury-filled flexible bougie. The patient's neck is
slightly extended with the chin turned away from the side
of the operation. The.oper£dvefieldis then prepared and
draped for surgery.
infiltration of the neck
A dilute solution of noradrenaline, 1:400000 in normal
'saline," is TfTfTItrated into the wound area to produce
vasoconstriction.
The incision
A transverse incision is made at the level of the cricoid
cartilage between the midline and the external jugular
v e i n . An. approach through the left side of the neck is
; preferred except when the right vocal cord is paralysed.
' 'Superior and inferior skin flaps are elevated in the
subplatysmal plane, widely exposing the anterior border
of the sternomastoid muscle.
2
Division of the omohyoid
T h e investing layer of the deep fascia along the anterior
border of the sternomastoid muscle is incised and the
muscle is fully mobilized. This exposes the underlying
omohyoid which is routinetytransected where it crosses
the carotid sheath. A Q - g i i g r t ^ ^ a c l e to preserve the
branches of the 'ansaicervicaTts which innervate the strap
muscles..
 O r o p h a r y n g e a l sphincterotomy 24 j

3
Ligature of the inferior thyroid artery

pissection is carried between the carotid..sheath and the

taryngo-oesophageal complex dividing the middle thyroid
vein. IJLllbfi. r e j r o p h j ^ above the
inferior t h y r o l c f n o r n t h e r e is no risk to the recurrent
laryngeal nerve. The assislajit^hQM.|d retract the posterior
border of the thyroid cartilage, thereby rotating the larynx
so that the posterior aspect of the pharynx and oesopha-
gus is exposed. T h e inferior thyroid artery will need to be
divided between ligatures well away from the thyroid
gland and well clear of the recurrent laryngeal nerve.

This phase of the operation is best carried out using the

operating microscope. The cricopharyngeus is readily
identified by its transverseffbres wifficTOTef midline raphe.
It helps to define the muscle clearly with a dissoctihg'
s w a b : small vessels are always present and need to be
carefully coagulated. At this point the anaesthetist is asked
to withdraw the Foley catheter slowly until the fibres of
the cricopharyngeus are stretched out. T h e retractors
should then be adjusted to provide a good view of the
deeper structures. A spj^jncterpj^y.iaf^^ScmJs made as
^ close to the midline as possible to avoid damage 4©-the
, j~l recurrent laryngeaLnejyg^The incision in the cricophary-
- ngeus is begun by stroking the knife through the circular
muscle fibres until the mucosa is s e e n . T h e incision is
carried caudally into the upper muscle fibres of the
oesophagus and craniaIly_Jrvto_jh^ pharyngeal
constrictor until t h j T n u i a ^ the length
of the myotomy. Aj^ojtiojTjj^ji^ be submitted
for histological examination. The mucosa is inspected for
tears and if it has been inadvertently damaged it is
carefully repaired.
244 Cricopharyngeal sphincterotomy
T h e mouth and pharynx should be kept clear by suction to
prevent aspiration of secretions. Physiotherapy is re-
sumed postoperatively and a broad-spectrum antibiotic is
given to minimize chest infection.
Care of wound
The suction drain is normally removed on the morning of
the second postoperative day. Alternate sutures are
removed on the fifth day and the remaining sutures the
following day.
Feeding
Intravertojjs fluids _are_jgiven until tube feeding is
established. The nasogastric tube is left in position for 2 or
3 days, or longer if mucosal damage has occurred. A
purged diet is introduced once the feeding tube has been
removed and is increased gradually as the patient's
tolerance increases. The patient can usually return home
within a week t a k i n g ^ ne^icTrmaT^iet.
Compjlcations
Atelectasis in the basal segments may give rise to infection
and pyrexia.
VooaL cord^paralysii^due to injury to the recurrent
laryngeal nerve occasionally occurs even after every
possible care and precaution.
Haematoma jormat}onJs unusual if adequate suction
drai nagelTrnai ntai ned.
Salivary fistula following mucosal damage seldom lasts
more tharTTbTei days.
Mediastinit/s very rarely occurs but is a much more
serous matter.
Massive tracheobronchial aspiration has been described
following cricopharyngeal sphincterotomy.
Incomplete section of the cricopharyngeus inevitably
leads to failure of the operation to improve swallowing.
Further reading
Kaplan, S. Paralysis of deglutition, a post-poliomyelitis
complication treated by section of the cricopharyngeus muscle.
Annals of Surgery 1951; 133: 572-573
Lund, W. S. The cricopharyngeal sphincter: its relationship to the
relief of pharyngeal paralysis and the surgical treatment of the
early pharyngeal pouch. Journal of Laryngology and Otology
1968;82:353-367
Mills, C. P. Dysphagia in pharyngeal paralysis treated by
cricopharyngeal sphincterotomy. Lancet 1973; 1: 455-457
Mladick, R. A., Horton, C. E., Adamson, J. E. Immediate
cricopharyngeal myotomy. An adjunctive technique for major
oral-pharyngeal resections. Plasiic and Reconstructive Surgery
1971;47:6-11
Illustrations by Gillian Lee
H. Bernard Juby FRCS, DLO
Consultant Ear, Nose and Throat Surgeon to the Ipswich Hospitals, Suffolk, UK
A small pharyngeal pouch causing minima! symptoms may
require no treatment, particularly in an elderly patient. In
the majority of cases symptoms of dysphagia, regurgita-
t i o n , cough and chest infection due to overspill will be
indications for treatment. One-stage excision of the
pouch is the treatment of choice, but if the patient is
considered unsuitable for excision for any reason then
diathermy treatment will relieve the symptoms in most
cases.
Preoperative preparation
If the patient Is wasted or dehydrated this should be
corrected by a period of feeding through a nasogastric
tube. A preliminary direct examination of the pouch a n d
oesophagus will enable the state of the mucosa lining the
pouch to be assessed and will exclude the presence of
carcinoma which may develop within a long-standing
p o u c h . At the examination it is much easier to locate the
pouch than the oesophagus since all instruments tend to
pass into the posterior pouch and it may be difficult to
locate the entrance to the oesophagus, which is anteriorly
situated. Unless the pouch is very large it is not necessary
to wash it out before operation.
Anaesthesia
A general anaesthetic is given through a cuffed endo-
tracheal tube. After the patient has been anaesthetized the
pouch is sucked out through a pharyngoscope and packed
with flavine ribbon gauze, the end of which is brought out
through the mouth. At the same time a nasogastric tube is
passed through the nose and guided into the oesophagus
under direct vision through the pharyngoscope.
Position of patient
T h e patient lies supine with a pillow or sandbag under the
shoulders to extend the neck. T h e chin is turned to the
right.
245
246 Excision of pharyngeal pouch

The incision

A transverse skin crease incision at the level of the cricoid

cartilage on the left side may be satisfactory. For the
occasional operator, and if the pouch is large, a vertical
incision along the anterior margin of the left sterno-
mastoid muscle is preferable as it can be extended as
required. The scar after this incision is usually satisfactory.

2
Exposure of infrahyoid muscles

The skin flaps are dissected and retracted. The attachment

of the cervical fascia to the anterior border of the
sternomastoid is divided and the muscle retracted laterally
to expose the sternohyroid, sternothyroid and omohyoid
muscles.

Division of infrahyoid muscles

The omohyoid muscle is always divided. Occasionally it is

necessary to divide the sternohyoid and underlying
sternothyroid muscles to gain adequate exposure of the
gap between the sternomastoid muscle and great vessels
laterally, and the larynx, trachea and thyroid gland
medially.
H

Mobilization of thyroid giand

The middle thyroid vein, or veins, are defined and divided

so that the thyroid gland can be retracted medially and
forwards.

5
Location and dissection of pouch

T h e pouch is found lying in front of the cervical spine and

associated muscles, and behind the thyroid gland, trachea
a n d oesophagus - which is identified by palpation of the
nasogastric tube. The pouch is grasped with norf-toothed
forceps and cleared by blunt dissection to expose the
neck w h e r e it is attached to the pharynx. The neck may be
w i d e , particularly when the pouch is large. The ribbon
gauze packing is removed by the anaesthetist at this point.

Removal of pouch

Two pairs of forceps are applied across the neck of the

p o u c h . These may be curved artery forceps or the Satinsky
clamp, used in vascular surgery. The neck of the pouch is
divided between the forceps and removed. A continuous
2/0 catgut suture is applied over the remaining forceps and
tightened as the forceps are withdrawn.
24S Excision of pharyngeal pouch

8
Cricopharyngeal myotomy

The fibres of the cricopharyngeus muscle are located

below the repaired site of the neck of the pouch and
divided down to the mucosa with Mclndoe type scissors.
This procedure is not essential but is said to lessen the
chance of recurrence.

Closure

T h e infrahyoid muscles are sutured with catgut. The

platysma and subcutaneous tissues are sutured with
catgut. Suction drainage is preferred, brought out through
a separate stab incision. The skin is closed with clips or by
interrupted sutures of silk or nylon.

Antibiotic cover with penicillin, unless the patient is
known to be sensitive to it, should start on the day of
operation and be continued for 7 days. The suction drain
is removed after 48 hours unless there is copious drainage
through it. The nasogastric tube and the skin sutures are
removed after 5 days.
Excision of pharyngeal pouch 249
1. Surgical emphysema - no treatment required.
2. Fistula with salivary leak - will heal spontaneously after
a period of feeding through the. nasogastric tube.
3. Vocal cord paralysis due to damage to the left recurrent
laryngeal nerve. It may be temporary or permanent
according to whether the nerve was stretched or
bruised, or actually divided.
4 . Local or pulmonary or mediastinal infection is usually
prevented by antibiotic cover.
5. Recurrence does occur, but less offer! if the crico-
pharyngeus muscle is divided at operation.
6. Stenosis may occur, but again is less common after
cricopharyngeal myotomy.
Illustrations bv Frank Price and Gillian Lee

An alternative to excision for the relief of the symptoms of a patient with a pharyngeal pouch is to divide the party wall
between the pouch and oesophagus by diathermy. T h e tissue divided includes the circular fibres of the cricopharyngeus
muscle.

The instruments devised by Dohimann are essential for this treatment. These consist of (a) a special endoscope split
distally to provide an anterior lip which passes into the oesophagus and a posterior lip which passes into the p o u c h ; (b)
insulated forceps; (c) diathermy knife; and (d) protector.

250
t Diathermy treatment of pharyngeal pouch 251

Anaesthesia

General anaesthesia through a cuffed endotracheal tube

preoperative preparation using non-explosive anaesthetic agents.

^ wasted or dehydrated patient should be treated by a

period of feeding through a nasogastric tube. This could
be passed at the time of a preliminary examination under Position of patient
general anaesthesia which is essential to exclude the
presence of a carcinoma before embarking on diathermy T h e patient lies supine with the neck flexed and the head
MM treatment. extended.

The special endoscope is passed so that its anterior lip

passes into the oesophagus and its posterior Sip passes
into the pouch.

The party wall between pouch and oesophagus then

presents as a transverse ridge. This ridge is grasped with
the special insulated forceps and a coagulating current is
passed for 1-2 minutes according to the thickness of the
tissue involved. T h e coagulated area is then divided with
the diathermy knife, cutting backwards onto the protector
w h i c h has been passed into the p o u c h . At the conclusion
of the diathermy division a nasogastric tube is passed
d o w n the oesophagus.

Postoperative care

Antibiotic cover is maintained for 7 days. T h e nasogastric

tube is left in position for 5 days and the patient should be
fit to leave hospital 7 days after treatment.

Complications

Local infection should be controlled by antibiotic therapy.

Incomplete relief of symptoms or recurrence of symp-
toms is an'indication for repetition of the diathermy
treatment or excision of the pouch.
Stenosis after one o r m o r e diathermy treatments may be
treated by dilatation or excision.
Development of carcinoma in the p o u c h , w h i c h is not
removed by the diathermy treatment, has been reported.
 Illustrations by Philip Wilson

Roger Gray FRCS

Consultant Ear, Nose & Throat S u r g e o n , Addenbrookes Hospital, Cambridge C B 2 2 Q Q , UK

DIRECT LARYNGOSCOPY
An abnormality of the larynx which cannot be seen or
dealt with by indirect or fibroscopic laryngoscopy requires
a H°S "o
p^VtL^rtf™!™*? " ", A ° * " «a * d
P e a d 5 h 0 r t r ri d

direct examination under general anaesthesia. Biopsies

may be taken for histological examination; foreign bodies avoided if
and benign lesions may be removed. The mobility of the dangerously loose teeth) Y P e x t r a c t l o n
°<
arytenoid cartilages may be tested with a probe and at the
end of the procedure active movements of the cords and
sphincters of the larynx observed. A microscope is heipfui
for delicate work within the laryngeal cavity {see 'Micro-

"
la ryngoscopy')
a ^a^r? x r«x L e sis,er wi
P 0

252
H I
'Local anaesthesia may be achieved by holding cocaine
i- jwabs in the pyriform fossae but this technique is rarely
; needed.
h A general anaesthetic with a small bore endotracheal
'"'tube provides the conditions required for an unhurried
'examination of the larynx. Many methods are possible
^ using cuffed tubes, uncuffed tubes and catheters entrain-
ing air by the Venturi principle. It is best to ask the
:
anaesthetist which he or she prefers, encouraging the use
; of the most unobtrusive device. The three tubes favoured
in our department are shown in Illustrations 1-3.
Laryngoscopy and micro!aryngoscop\
Atropine 0.4mg by intramuscular injection will dry the
pharynx and intravenous suxamethonium paralyses the
larynx for examination. The patient must be ventilated
artificially.
Occasionally an obstruction such as a tumour in the
larynx makes intubation difficult and use of suxametho-
nium potentially fatal. In such cases the surgeon must be
guided by the anaesthetist. A tracheostomy after gas
induction or local anaesthetic may be an essential
preliminary to laryngoscopy.
Coplans tube - for direct laryngoscopy
1
This is a long thin tube with a stiffish wall. It'must be
displaced into the posterior or anterior commissure by the
beak of the laryngoscope to see all of the larynx.
Coplans tube seals the tracheal lumen to the Boyle's
apparatus, allowing common anaesthetic gases to be
used. It is sometimes too long and narrow for the
respiratory requirements of a large patient.
Carden tube - for microlaryngoscopy
2
T h e tube is short and is passed well below the glottis
where it is retained by an inflatable cuff. The tracheal
lumen is held in free communication with room air while
the patient is kept paralysed and asleep with intravenous
drugs. Intermittent jets of oxygen are delivered through a
pilot tube; these inflate the lungs, entraining air by the
Venturi effect.
Both the cuff inflation and oxygen delivery pipes lead
through the glottis, giving an excellent v i e w , as they are
slim and unobtrusive. The Carden tube tends to ride up
into the field of view and the Rusch tube obviates this
problem.
Rusch tube - for microlaryngoscopy
3
T h e Rusch tube is similar to the Carden tube and is used in
the same way. A malleable wire introducer is bonded
between the two thin tubes which must lie between the
cords. The introducer simplifies placement of the device
and prevents it riding up into the field of view.
254 Laryngoscopy and microlaryngoscopy

Instruments

The Negus laryngoscope (right) and smaller anterior

commissure scope (left) are illustrated. T h e former has a
beak with a long cutaway and a removable section. This
facility is needed only if a bronchoscope is passed via the
instrument.

5
Fitting the lighting cable

Two fibreoptic light channels provide illumination from a

single cable. Note the 'stand-by lamp'.

Positioning the patient and inserting the tooth

guard

The head should be well extended on the atlas and the

neck flexed. This position is easily remembered as the
posture adopted w h e n 'sniffing the morning air'. It may be
achieved very simply with a pillow placed partly under the
shoulders and partly under the head of a supine patient.
Plumping the pillow beneath the occiput further flexes the
neck and the head extends oyer the upper pillow edge.
Final adjustments may be made by lifting the head piece of
the table.
As the gum or tooth guard is inserted the surgeon
stretches the jaws and extends the atianto-occipital joint.
 Laryngoscopy and microlaryngoscopv 255

7
Passing the laryngoscope

The laryngoscope is lubricated and the sucker turned o n .

The surgeon stands, and pushing down on the lower jaw
with a free hand looks for the uvula, the first landmark.
The pharynx is often full of saliva and this is aspirated.
Sitting down at this point changes the line of sight. T h e
anaesthetist's tube may be followed to the epiglottis
which is the second landmark. A second injection of a
paralysing agent may now be needed.

Finding the larynx

T h e beak of the laryngoscope is eased beneath the

epiglottis and the instrument is lifted. Anaesthetic tubes
should lie in the posterior part of the glottis between the
arytenoid cartilages.
256 Laryngoscopy and microlaryngoscopy

The grip

T h e instrument is introduced holding the inner handle.

O n c e the organ is in view the grip is changed so that
considerable thrust may be exerted on the base of the
tongue and mandible without leverage on the upper
teeth.

Viewing the larynx

If a lesion is present, the surgeon should look everywhere

else first before giving attention to it. Bleeding from
contact or a biopsy will cloud the view. Four areas of the
larynx are regarded as 'hidden' and often require the
smaller anterior commissure scope. T h e subglottis,
laryngeal ventricles, laryngeal surface of the epiglottis and
the anterior commissure are the places which should
receive special attention.

Postoperative care

Bleeding from a biopsy site is rarely significant but the

anaesthetist will appreciate the surgeon's help in placing
the patient head down in the coma position. This is the
moment to assess the airway and wheel the stridulous
patient back into theatre for a tracheostomy.
Silence is advised fqr a few days w h e r e the operation
has been performed to improve the voice.
1ft
' j ^ V i e extra light and magnification of a binocular operating
^ **'microscope facilitate examination and performance of
..fcJLlicate procedures within the laryngeal cavity.
*|Jafcpreparation and position of the patient are as for direct
%MFJ^vngoscopy with the addition of a Mayo table or
**3&rpose-buitt platform placed over the chest. A 400 mm
-jjujjjjective j n s is required.
e
^Teaching and recording
beam splitter is needed in the optical system. Tutor
epieces or cameras may then be fitted. Diverting 70 per
*• Kent of the light to a video camera via a 70/30 beam splitter
• Igives an excellent image on a closed circuit television
.iwhich may then be captured on video tape. To keep a
- bright image for the surgeon the microscope should be
fitted with a 100 watt quartz halogen bulb and a cooling
fan instead of the standard Zeiss 30 watt item.
11
Laryngoscopy and microlaryngoscopy 257
Instruments
A specially designed set of scopes and instruments for
microlaryngoscopy has been produced by Kleinsasser 4
w h o pioneered this technique. There are several sizes and
shapes of scope, w h i c h are matt black to minimize
reflection, and these are held by a clamp attached by a
ratchet to a chest piece. This releases the surgeon's hands
for dissection.
Angled and straight forceps of cup and alligator pattern,
two types of scissors, a sickle knife and an insulated
diathermy probe are available for use in a variety of
situations. Each set should have two suckers of appropri-
ate length. Some instruments can be seen on the tray in
Illustration 73.
2d8 Laryngoscopy and microlaryngoscopy

Suspending the laryngoscope

W h e n the glottis is in view an assistant secures the holder

to the laryngoscope handle and guides the long lever bar
to the platform over the patient's chest. With his eyes on
the glottis the surgeon turns the handle until, braced
against the platform, the assembly becomes stable.
Sometimes external pressure on the cricoid cartilage by an
assistant is needed to bring the anterior larynx into view.

The microscope

The 400 mm objective lens is needed to permit working

space for long instruments. A magnification of 1 0 x is
usually adequate. Note that the surgeon has both eyes and
both hands in use. Sterile rubber caps cover the
microscope control knobs. This optical assembly carries
both a tutor eyepiece and a camera.

Excision biopsy

If this granuloma of the cord was too large to remove with

the cup forceps s h o w n , it could be held by the cups and
cut away from the cord with microscissors. Microdiather-
my or 1:1000 topical adrenaline-soaked swabs will stop
bleeding.

The surgical laser (not illustrated)

A carbon dioxide laser may be married to the operating

microscope . Its principal use is vaporization of papil-
5

lomas.
 Laryngoscopy and microlaryngoscopy 259

FIBROPTSC
LARYNGOSCOPY
15
Steady improvements in fibroptic instruments over the
iast 15 years have been made. A fibroptic laryngoscope
passed through the nose or mouth (even from below if a
tracheostomy is present) produces an image of the larynx
where all the parts are in sharp'focus. This is a useful
alternative method of laryngeal endoscopy both in and
out of the operating theatre. The paediatric laryngologist
may use the 3 m m narrow fibroscope in place of direct
laryngoscopy under general anaesthesia. In this case the
infant will not need a general anaesthetic for the diagnosis
of congenital stridor. T h e nasogastric tube seen in the
illustration does not hinder the view.

15

References
1. Coplans, M. P. A cuffed nasotracheal tube for microlaryngeal
surgery. Anaesthesia 1976; 31: 43CM32
2. Carden, E., Ferguson, C . B., Crutch field, W. M. A new Silicone
Elastomer tube for use during microsurgery on the larynx.
Annais of Otology Rhinology and Laryngology 1974; 83: 360
4. Kleinsasser, O. Microlaryngoscopy and endolaryngeal .
microsurgery. Ruckblick auf 2500 Faiie H. N. 0.1974; 22:
69-83. German with English abstract
5. Strong, M. S., Vaughan, C. W., Cooperband, S. R., Clemente,
M. A. C. P. Recurrent respiratory papillomatosis -
management with the C 0 laser. Annals of Otology, Rhinology
2

3. Eisele, G., Binner, W. H., Dick, W. Direct laryngoscopy with and Laryngology 1976; 85: 508-516
injection technique through a modified Carden Tube.
Anaesthesist 1978; 27: 87-89. German with English abstract
Illustrations by Gillian Lee

including fibreoptic bronchoscopy and anatomy of

tracheobronchial tree . ,
C. B. Croft F R C S , FRCS(Ed.)
Consultant S u r g e o n , T h e Royal National Throat, Nose and Ear Hospital, London, UK

Anatomy of the tracheobronchial

tree

1
It is vitally important that an understanding of norma!
bronchial anatomy is gained before insertion of either a
conventional rigid or a flexible fibreoptic bronchoscope.
Use of the flexible instrument relies particularly o n . this
and the illustration demonstrates the main segmental
branches of the bronchial tree, inverted to show the
sequence of branching as found in a supine patient. It
should be noted that a wide range of normality exists,
particularly in the division of the left main stem bronchus
and the divisions of the segmental bronchi in the right
lower lobe. Practice using a lung model is highly
recommended.

260
 Bronchoscopy (including fibreoptic bronchoscopy and anatomy of tracheobronchial tree) 261

mm-
LILLT- I:

1
Rigid bronchoscopy allows inspection of the orifices of ^ £
the third bronchial division whereas use of the fibreoptic
flexible bronchoscope allows routine inspection of the
fourth and sometimes fifth bronchial divisions. T h e
illustration shows the range of the flexible fibrescope.

The bronchoscopist is interested in viewing the walls of

the tracheobronchial tree to discern distortion (such as
carinal blunting) or reduced mobility; abnormalities of the
mucosa with infiltration or ulceration; and the presence of
exudate or blood within the lumen. For an excellent
photographic record of endobronchial pathology the
reader is referred to Stradling, P. Diagnostic Bronchos-
copy. Edinburgh, London: Churchill Livingstone, 1976.

Contraindications
Rigid
Indications 1. Aneurysm.
2. Marked kyphosis
Rigid bronchoscopy
Flexible
1. Removal of obstructing lesion such as foreign body or
1. Vascular tumour - use rigid scope with balloon and
mucus plug.
packing ready.
2. Diagnostic evaluation of the walls and mucosa of the
2. Foreign body removal.
tracheobronchial tree.
3. Biopsy of a suspected tumour.
4. To secure an airway in upper respiratory tract obstruc-
Preoperative preparation
tion, where intubation is difficult or impossible.
Recent posteroanterior and lateral chest films should be
available. .
For rigid bronchoscopy standard premedication is
given.
Flexible bronchoscopy
For fibreoptic flexible bronchoscopy, premedication
consists of: atropine 0.6 mg and i.v. diazepam (Valium)
1. Diagnostic evaluation of trachea and bronchi third and
5-10 mg (titration). :
fourth divisions.
A n appropriate bronchoscope size is selected. The
2. Evaluation of haemoptysis, as in post-tracheostomy
following diameter sizes are appropriate:
bleeding.
3. Suction clearance of obstructing mucus plugs in a Paediatric: Neonate 3 mm
postoperative or intensive care unit setting. 9-24 months 3.5 m m
4. Peripheral lesion diagnosis via transbronchial lung Adult: Female 6 mm
biopsy with radiographic control. Male 8 mm
262 Bronchoscopy (including fibreoptic bronchoscopy and anatomy of tracheobronchial tree)

RIGID BRONCHOSCOPY

Anaesthesia

General anaesthesia with i.v, scoline and pentothal is

preferred. Ventilation is maintained by the oxygen Venturi
system using oxygen at 50-60 lb/in (345-414kPa) (use air at
2

50-60lb/in if the system is used with the Laser).

2

For children, a reducing valve should be fitted as the

smaller bronchoscope sheaths require less pressure for
satisfactory ventilation and high pressures can be
dangerous.

Position of patient

T h e patient's cervical spine is flexed and the head is

e x t e n d e d . The eyes are protected. The surgeon's left hand
steadies, protects and controls the upper jaw.

3 \

Insertion of bronchoscope

T h e bronchoscope is inserted through the right side of the

m o u t h , lifting and following the tongue to the epiglottis.
Gentle lateral movements will help identify this, if it is not
readily visible.
 Bronchoscopy (including fibreoptic bronchoscopy and anatomy of tracheobronchial tree) -763

Identification of the glottis

The tip of the epiglottis is elevated and using the left

; thumb as a fulcrum the bronchoscope is brought to a
more horizontal position revealing the posterior aspect of
the glottis.

Passing the glottis

The bronchoscope is passed forward to the glottis and

rotated 90° with the tip to the right. The v i e w is centred on
the left vocal cord and the instrument is advanced towards
this until the beak passes through the vertical axis of the
glottis. A gentle twisting movement and further advance-
ment-of the bronchoscope allow passage past the larynx.
2&4 Bronchoscopy (including fibreoptic bronchoscopy and anatomy of tracheobronchial tree!

Inspection of the trachea and carina

Alignment of the bronchoscope and trachea is sought,

which may require further extension of the head. The
bronchoscope is advanced gently, viewing the tracheal
walls until the sharp outline of the normal carina is seen.

Entry to left main bronchus

This requires particular care as on the left the main

bronchus is longer and curved at an oblique angle to the
trachea. The bronchoscope is positioned in the right angle
of the mouth and the head rotated to the right, bringing
the long axis of the instrument and the left main bronchus
into alignment and allowing a view of the secondary
carina.
 Bronchoscopy (including fibreoptic bronchoscopy and anatomy of tracheobronchial tree) 265

Entry to the right main bronchus -10

The right main bronchus is shorter and more vertical and
easier to examine. The head and bronchoscope are Posterior basal branch
rotated to the left and the instrument advanced into the
Medial basal Lateral basal branch
bronchus intermedius. The right upper bronchus requires
a lateral viewing telescope for adequate inspection. branch
Anterior basal branch
2bb Bron, hoy.apv (including fibreoptic bronchoscopy and anatomy of tracheobronchial tree:

Taking a b i o p s y

Aspirated material should be collected for (trap) cytology

and culture. All suction and manipulation should be
performed with the utmost gentleness to reduce the risk
of haemorrhage. Endobronchial biopsy should ideally be
performed with the scope close to and giving good access
to the lesion. The use of integral telescope and biopsy
forceps is highly recommended, allowing delicate and
accurate biopsies to be taken.

Removing foreign bodies

Inert

These should be removed after careful inspection, and

withdrawn into a scope of suitable size, if the foreign body
is too large it is removed together with the bronchoscope.
Aspirated bones and broken pieces of denture are the
most frequently encountered. T h e tracheobronchial tree
should be re-examined and cleaned after the foreign body
has been extracted.

Irritants

Vegetable foreign bodies such as peanuts rapidly produce

mucosal reaction with swelling of the mucosa, partially
obscuring the foreign body and making extraction
difficult. Telescopic forceps are available and recom-
mended for precise removal in these difficult cases.

Fibreoptic bronchoscopy
Anaesthesia

The local nasal route is preferred, using an oxygen

catheter if the patient has obstructive airway disease. The
nose, pharynx and larynx are sprayed with topical 4 per
cent lignocaine.

Position of patient

The patient is semirecumbent. The operator stands to the

right facing the patient, allowing eye contact and
reassurance The right hand controls the instrument
housing and the left inserts the fibre bundle through the
wider nasal chamber.
 Bronchoscopy (including fibreoptic ronchoscopy and anatomy of tracheobronchial tree) 2b7
mmmt

Identification of the larynx

The instrument is passed above the inferior turbinate and

beneath the middle turbinate to the nasopharynx. The
patient breathes through his nose, and the tip is deflected
*> down into the oropharynx, allowing a good view of the
larynx. The instrument is advanced just proximal to the
cords and the two syringes containing 2 ml of 4 per cent
[ignocatne are injected into the cords and into the glottis.
After waiting 2-3 minutes the tip is advanced through the
glottis and into the upper trachea. A further 2 m! of 2 per
cent lignocaine is injected down the trachea. T h e patient
may cough briefly but is encouraged and asked to breathe
gently until the spasm settles. Further use of 2 per cent
lignocaine is required as the major bronchi are entered.
The tree is examined, keeping in mind the route taken, as
the position of the scope peripherally can only be
ascertained through reference to landmarks already
negotiated.

Biopsies

The aspirate can be used for cytolbgical examination.

Biopsies and brushings taken through the biopsy channel
are most useful, even though the specimen is small.
It is important to remember that if the tip is deflected,
the biopsy forceps may not pass. In this case the
instrument should be withdrawn and tip deflection
reduced before biopsy proceeds. The cups should be just
in front of the viewing objective for precise manipulation.
268 Bronchoscopy (including fibreoptic bronchoscopy and anatomy of tracheobronchial tree)

Complications Flexible bronchoscopy

As general anaesthesia is avoided, the complication rale

Rigid bronchoscopy should be very low (mortality: 0.01 per cent).

Haemorrhage Any vascular lesion or friable tumour Haemorrhage Avoidable if gentle use of the biopsy
may bleed briskly. The head should be tilted down and forceps is achieved. Impacting the instrument tip into a
pressure applied with a peanut swab soaked in 1:1000 segmental bronchus should be tried if bleeding con-
adrenaline. If ineffective, a larger pack should be inserted tinues.
or a Fogarty balloon catheter used to tamponade the
bronchus. The pack should be left in place for 5 minutes.
Pneumothorax Pneumothorax occurs in 5 per cent of
transbronchial lung biopsies, but is rare in routine flexible
bronchoscopy. Postoperative chest X-ray is required.
Laryngeal oedema Use of too large a diameter
instrument and prolonged examination, particularly in
children, may cause laryngeal oedema and stridor. The
use of humidity and steroids is helpful in these cases but
Local anaesthetic reaction Adherence to recom-
mended doses and lignocaine is the best safeguard.
avoidance is the best course.

Oxygen desaturation A l O m m H g f a l l in arterial oxygen

Teeth Protection of the teeth with a gum shield and tension may occur, and chronic obstructive airway cases
using the thumb as a fulcrum for the bronchoscope should receive oxygen through a nasal catheter during the
should prevent damage to the teeth. procedure.
Illustrations by Margaret Palmer
David Wright FRCS
Consultant Ear, Nose and Throat S u r g e o n ,
Royal Surrey County Hospital, Guildford, Surrey, U K
TRACHEOSTOMY
The operation of tracheostomy is best performed,
whatever the indication, as an elective procedure under
endotracheal anaesthesia in an adequately equipped
operating theatre. If correctly anticipated, an emergency
tracheotomy will be avoided in most cases. Intubation
with an endotracheal tube may provide an alternative
interim procedure.
Indications
Respiratory obstruction
1. Trauma: mandibular fractures complicated by oedema
and haematoma. External or internal injury to larynx or
cervical trachea.
2. Foreign body: commonest in children.
3. irritants, corrosives and burns: causing damage to the
mucous membrane of the mouth, larynx and trachea.
4. Infections: acute laryngotracheobronchitis, acute epi-
glottitis.
5 . Angioneurotic oedema or drug sensitivity.
' 6. Bilateral recurrent laryngeal paralysis or cricoartytenoid
arthritis.
7. Malignant lesions, benign tumours and cysts of the
respiratory tract.
Tracheostomy may be required as a preliminary procedure
to operations on the larynx and pharynx.
Secretory retention
Inadequate clearance of secretions from the tracheo-
bronchial tree, producing hypoxia and hypercarbia.
Respiratory insufficiency
Respiratory insufficiency caused by pulmonary, cardio-
vascular or muscular disease may need tracheostomy to
enable intermittent positive pressure respiration which
will reduce the air-flow resistance and the volume of the
dead space. In some conditions it is desirable to produce
respiratory paralysis by the use of drugs to provide
controlled respiration.
Prevention of inhalation of fluids into the trachea
A cuffed tracheostomy tube may be required to prevent
the inhalation of blood or the overspill of oral secretions
and food w h e n there is paralysis of the protective
sphincter mechanism of the larynx.
Anaesthesia
An elective operation is best carried out under endo-
tracheal anaesthesia. Drugs that might depress the
respiratory system should not be given in the preoperative
period. Tracheostomy may be satisfactorily performed
under local anaesthesia and this may be indicated in a
patient with an obstructive lesion when general anaesthe-
sia or intubation w o u l d prove difficult. Local anaesthesia is
obtained by injection of the skin and subcutaneous tissues
with 1 per cent procaine and 1:200 000 adrenaline. Before
the trachea is opened 0.5 ml of 4 per cent cocaine should
be injected into the tracheal lumen.
The patient should be warned that he may not be able to
use his voice immediately following the operation.
Position of patient
A sandbag ts placed under the patient's shoulders to give
extension of t h e h e a d and prominence to the trachea and
larynx, if t h e patient has severe dyspnoea and the
operation is to be carried out under local anaesthesia then
a compromise position of extension will have to be found.
269
1
The incision

A transverse incision approximately 5 cm in length is made

2 cm below the lower border of the cricoid cartilage
through s k i n , subcutaneous fat and deep cervical fascia.
Flaps are raised by undermining with blunt dissection for a
short distance to expose the anterior jugular veins and
infrahyoid muscles.

2
Separation of infrahyoid muscles

The fibrous median raphe in the interval between the right

and left sternohyoid muscles is defined and separated
with blunt dissection. The sternothyroid muscles on a
deeper plane are identified and retracted laterally.

3
Identification of the thyroid isthmus

T h e thyroid gland and part of the trachea will then be

visible. Anatomical variations in the size and position of
the thyroid isthmus are to be expected. The thyroid
isthmus may be small and not interfere with the approach
to the trachea but in most patients it is of sufficient size to
need dividing. A small horizontal incision is made through
the pretracheal fascia over the lower border of the cricoid
cartilage so that a.small haemostat can be inserted into the
incision and directed interiorly behind the thyroid isthmus
and its fibrous attachment to the anterior wall of the
trachea. After determining the place of cieavage the
thyroid isthmus can be completely separated from the
trachea by blunt dissection.
 Tracheostomy and iaryngotomv

Division of the thyroid isthmus

A large haemostat is placed on each side of the thyroid

isthmus, which is divided with a knife or diathermy. T h e
cut surfaces of the thyroid are oversewn or simply ligated
on each side.

5
Opening of the trachea

Before the trachea is opened complete haemostasis must

be obtained. A sucker with a catheter attached should be
ready for aspiration of the trachea. At this stage sutures
may be inserted into the skin edges in anticipation of
closure of the lateral parts of the w o u n d after the tube has
been inserted. The trachea is retracted in an antero-
superior direction by inserting a tracheal hook below the
cricoid cartilage. A transverse incision is made into the
intercartilaginous membrane below the second or third
ring and then converted into a circular opening by holding
the upper and lower margins in turn with strong forceps
and removing the cartilage with a knife. Alternatively a
ring punch can be used. T h e first tracheal ring must on no
account be disturbed.

6
Insertion of the tracheostomy tube

T h e type of tracheostomy tube which will be required in

the immediate postoperative period should be selected. A
soft cuffed tube will be needed if anaesthesia is to be
continued and positive pressure ventilation required, or if
the accumulation of secretions, in the trachea from-
laryngeal overspill is to be prevented. If the operation is
for simple airway obstruction a silver tracheostomy tube
or a softer synthetic tube can be used. The latter tubes are
provided w i t h an obturator to help insertion through the
fenestra in the anterior tracheal wall. The obturator is then
removed and replaced by the inner tube.
272 Tracheostomy and laryngotomy

Fixation of the tube

W h e n in position the tube is retained by tapes passed

around the neck and secured by a reef knot on one side of
the neck. It is important that the patient's head is well
flexed when the ties are knotted otherwise the ties may
become slack w h e n the patient sits up in bed with the
head forward, resulting in the possible displacement of
the tube from the trachea! lumen when the patient
coughs. A preformed sterile sponge tracheostomy dres-
sing or Vaseline gauze with impregnated antibiotic is
packed around the tube and the lateral margins of the
w o u n d loosely approximated with the skin sutures. There
should be sufficient space remaining around the tube to
minimize the danger of subcutaneous emphysema.

If there is a lack of experienced nursing care available

immediately after tracheostomy, a flap of trachea based
interiorly and sutured to the skin margin of the incision
will retain an airway in the advent of the tracheostomy
tube being accidently displaced. It also makes reintroduc-
tion of the tube easier, but there is more likelihood of
tethering of the skin to the trachea during healing.
8a 8b

Humidification and prevention of crusting

Postoperative care
Prevention of tube displacement
Attention is required in maintaining the correct position of
the tube within the trachea. The tension in the securing
tapes must be regularly checked. If the tube has a
tendency to displacement then the suitability of that tube
must be suspected and a more satisfactorily shaped tube
substituted. A soft tissue lateral X-ray of the neck will show
the position of the tube within the tracheal lumen.
Crusting may occur in the trachea unless the inspired air is
adequately humidified. A constant room temperature of
approximately 70°F should be maintained and humidifica-
tion provided by a continuous thermostatically-controlled
humidifier. Secretions should be removed from the
trachea and bronchi with a soft sterile catheter. Suction
should be applied only on withdrawal of the catheter.
Prolonged or too frequent suction should be avoided.
Change of tube

T h e tube may be changed on the fourth day postopera-

Care of the inner tube
The inner tube should be removed and cleaned every 2 or
3 hours during the first few days. The inner tube should be
2 or 3 mm longer than the outer tube so that secretions
remain within the inner tube. If a cuffed tube is to be
retained then a tube with a long cuff should be selected
and inflated to produce an adequate air-tight seal. A short
cuff or high pressure within the cuff should be avoided. If
the pressure within the tube is correctly maintained
periodic deflation o f t h e cuff should not be required.
tively. Changing the tube before that time may give rise to
difficulty in reinsertion. Tracheal dilators and adequate
illumination should always be available.
Voice
If after a few days it seems unlikely that surgical
emphysema will occur due to resistance following
expiration or coughing, an inner tube with an inspiratory
valve may be used to allow the patient to speak.

Apnoea and hypertension
An abrupt decrease in the carbon dioxide content of the
blood may result in a loss of stimulus for breathing in
patients with chronic laryngeal insufficiency, thus produc-
ing apnoea. The administration of 5 per cent carbon
dioxide in oxygen may be necessary for some hours
afterwards. The sudden decrease in carbon dioxide level
may also lead to hypertension.
Displacement of the tube
Displacement of the tube may be prevented by the correct
siting of the tracheostomy opening, the use of a correctly
fitting tracheostomy tube and well adjusted and secured
tapes-around the neck. If these requirements are not
fulfilled the tube may be displaced into the pretracheal
space and this may not be quickly recognized.
Tube obstruction
The tube may become blocked by tenacious secretions.
The risk of a blocked tube will be minimized by frequent
changing of the inner tube, if present, adequate humidi-
fication and regular suction. If the tube cannot be cleaned
adequately then it should be replaced by a new one.
Subcutaneous emphysema and pneumothorax
These complications are more likely to occur in children,
especially if there is obstruction of the trachea or
tracheostomy tube. Unnecessary dissection of tissue
planes during the operation must be avoided and a clear
airway maintained both before and after the operation.
If the pleura is inadvertently incised, producing a
pneumothorax during the operation, the incision should
be closed.
Tracheal stenosis
Fibrous stricture in the subglottic region or around the
tracheostome will be avoided by making the correct size
of opening into the trachea below the level of the second
tracheal ring and by avoiding an ill-fitting tube.
Tracheosto-"\ and laryngotomy 273
Difficult decannulation
L/tmuiuy may occur in remowng tne tracheostomy tube in
infants and smali children due to the necessity to readjust
the redirection of air through the larynx. The dependence
on the tracheostomy may be decreased by gradually
reducing the size of the tracheostomy tube in adults or
partially corking the tube in c h i l d r e n .
Failure of closure of the fistula after
decannulation
If the edges of the fistula have become epithelialized in a
patient w h o has maintained a tube for a long period the
fistula should be allowed to contract for some weeks after
the decannulation. T h e epithelialized tract can then be
excised and the w o u n d closed in layers. Keloid formation
may follow an infected tracheostomy w o u n d .
Pulmonary infection
Profuse broncial secretions may occur due to irritation
from the tracheostomy tube or to endotracheal aspiration
and overspill. Atelectasis of the opposite lung may occur if
the tip of the tracheostomy tube is too long and" reaches
the main stem b r o n c h u s . Pneumonia may be avoided by
strict use of a sterile suction catheter.
Tracheitis siccus and crusting
Crusting may be reduced by adequate humidification and
the careful removal of crusts until such a time as the upper
part of the trachea has become adapted to directly
receiving the inspired air.
Haemorrhage
Haemorrhage during the operation may be troublesome
from the anterior jugular system, from the thyroid isthmus
or from the tracheal w a l l . Haemostasis must be obtained
before the trachea is opened. If secondary haemorrhage
occurs blood may enter the trachea around the tracheos-
tomy tube. A cuffed tube should be inserted as an
immediate measure and the wound reopened and the
bleeding controlled. Fatal erosion of a large artery can
occur from ulceration of the anterior wall of the trachea by
the pressure of the tip of an incorrectly fitting tracheos-
tomy tube. This underlines the importance of the careful
selection of the size and shape of the tube for each
individual patient.
274 Tracheostomy and laryngotomy

An emergency tracheotomy is indicated when a patient's

condition is rapidly deteriorating due to increasing
hypoxia not affording the time for an elective tracheos-
tomy and when the facilities of endotracheal intubation or Laryngotomy is used for acute complete airway obstruc-
the insertion of a bronchoscope are not available. The tion w h e n endotracheal intubation is not possible. The
operation is not easy to perform on an infant whose opening into the airway is made through the cricothyroid
trachea is soft and not easily palpable or in the short membrane. T h e operation can be accomplished within
thick-necked adult, especially if there is disease at the site 15-30 seconds.
of the operation. The technique differs from the elective
operation in the following ways.
1. A vertical incision is made in the midline from the level Position of patient
of the cricothyroid membrane to the suprasternal
notch. The patient's neck- is placed in extension by a roll of
2. T h e index finger of the left hand identifies the cricoid clothing or towelling under the shoulders so that the
cartilage a n d , with the help of finger dissection, the thyroid notch becomes prominent. The forefinger should
thyroid isthmus is pushed interiorly to expose the identify the carina of the thyroid in the mid-line and follow
upper three tracheal rings. downwards to the prominence of the cricoid cartilage.
3. A mid-line vertical incision is made through the second The depression of the cricothyroid membrane is then
and third tracheal rings. A tracheostomy dilator or identified and marked in the midline with the finger nail.
haemostat is introduced into the incision while a
suitable tube is inserted into the lumen. Once the
airway is established the procedure is followed by an
elective tracheostomy.

Incision
A vertical incision is made in the mid-line over the thyroid
and cricoid cartilages. T h e subcutaneous tissues are
retracted from the mid-line with the thumb and index
finger. T h e w o u n d is spread apart by finger dissection
until the cricothyroid membrane is identified.
 1 ra< hcoslorm and laryngotomy 273

Incision of the cricothyroid membrane

The cricothyroid membrane is incised horizontally as

close as possible to the cricoid cartilage tro avoid the
cricothyroid arteries, w h i c h run at a higher levei across the
membrane.

Establishment of an airway

T h e opening into the cricothyroid membrane is widened

by insertion of the handle of the knife into the horizontal
incision and rotating through 90 . A tracheostomy tube or
5

similar tube if available can then be inserted. O n c e the

airway is established, the procedure is followed as soon as
is practicable by an elective tracheostomy.

Complications

Perichondritis, subglottic oedema and cicatricial stenosis

may follow a prolonged thyrotomy.
Illustrations by B. Hough, R. Skudra, Ataby Macinnes and Heinz Loth

Douglas P. Bryce F R C S ( C ) , FRCS{Ed.)(Hon), F A C S

Professor Emeritus, Department of Oto-Laryngology, University of Toronto, Canada

T h e relative frequency of the types of stenoses has
changed In recent years. Very few tracheal stenoses are
n o w e n c o u n t e r e d , damage from intubation and assisted
positive ventilation being seen almost exclusively in the
posterior larynx and in the immediate subglottis.
The relative incidence of laryngeal fractures has in-
creased. In particular, supraglottic laryngeal fractures
resulting in varying degrees of stenosis are seen and
require correction.
278 Surgery of laryngeal and tracheal stenosis in adults
Indications
The indications for the repair of stenosis of the larynx and
trachea are usually apparent. These are airway obstruction
and aphonia. Obstruction to the airway that necessitates a
permanent tracheotomy is a serious disability, especially
for the young.'Such stenosis of the larynx may also affect
the voice to a severe degree so that communication may
be possible only by a hoarse whisper.
A relatively small percentage of laryngeal webs and
tracheal stenosis may be managed by repeated dilatations.
Occasionally such conservative measures may be success-
f u l , but in most cases, if the scarring is circumferential or
severe, dilatations must be carried on idefinitely.
Significant limitations in airway and voice are the
indications for specific surgical procedures designed to
alleviate the condition permanently.
Contraindications
T h e major contraindication to surgical correction of
laryngotracheal injuries is a poor pulmonary and cardiac
reserve in the patient. Operations of this magnitude in the
airway inevitably make great demands upon the patient.
During the anaesthetic and in the postoperative course,
limitation of air exchange for short periods may occur. T h e
patient must be able to clear effectively his lower
respiratory system of secretions and blood. Excessive
coughing, repeated pulmonary infections and the need
for excessive suctioning of secretions will reduce the
success of the operative procedure.
Repair of the laryngotracheal injury is also contraindi-
cated if the extent of damage or collapse is too great.
Reconstruction and repair of more than half of the trachea
is rarely successful. Complete destruction of the larynx to
the extent that it cannot act as a phonating organ without
constant laryngeal aspiration and repeated pulmonary
infections is a contraindication to its repair.
Premedication and anaesthesia
There is no area of surgical endeavour in which the
smooth sympathetic cooperation between the surgeon
and the anaesthetist is more important than in operative
procedures to relieve stenosis of the larynx and trachea.
Many patients requiring such surgery exhibit mild or
moderately severe stridor. The benefits of a tracheotomy
to relieve this respiratory distress must be weighed against
the technical disadvantages of such a procedure.
A tracheotomy may, in cases of tracheal stenosis,
destroy the only section of normal trachea remaining
which is essential for a proper repair. Moreover a
tracheotomy introduces an inevitable amount of infection
which will complicate and prolong the healing process
following the subsequent definitive surgery and may even
threaten its success.
A tracheotomy for postoperative care is almost always
necessary, and the .level at which the tube is inserted into
the trachea depends upon the site of the stricture. A
laryngeal stricture will allow the insertion of the tube at
the level of the 2nd or 3rd tracheal ring. A tracheal
stricture may require a tracheotomy distal or proximal to
the stricture or, in order not to damage normal tracheal
w a l l , through the stricture itself.
At operation, in order to establish a non-collapsible
airway and allow maximum flexibility, a cuffed armoured
tube is inserted into the trachea at the site of choice.
Anaesthesia for patients with airway obstruction is fraught
with danger in that the patient may rapidly abandon
efforts at voluntary respiration when anaesthesia is
accomplished. Unless expert facilities are available to
establish an airway in such circumstances, a tragedy may
ensue. There may also "be a disturbance of blood gases
caused by the slow build-up of C 0 which will require
3
immediate treatment.
In addition to these considerations, a continuing
sympathetic partnership is required by the surgeon and
anaesthetist during the operative procedure. The airway
must be constantly maintained. O n the other hand, it
must also be made available for short periods to the
surgeon for suturing and without the obstruction of the
anaesthetic tube.
The special anaesthetic problems will be referred to in
context as the surgical procedures are described. Such
procedures will be successful, however, only if harmony is
established between all members of the operating team.
 Surgery ot laryngeal and tracheal stenosis in adults i?c

The operations
LARYNGEAL FRACTURE INVOLVING THE
SUPRAGLOTTIS

1 &2
A supraglottic laryngeal fracture displaces the supraglottic
structures posteriorly and may obstruct the airway. Under
local anaesthesia, a curved incision is made at the level of
the cricoid and is deepened to expose the fractured
thyroid cartilages and the anterior trachea to the level of
the fourth or fifth rings, to allow the insertion of an
armoured tube for ventilation and administration of the
anaesthetic.

When the patient is anaesthetized, further dissection to

expose the extent of supraglottic fracture is carried out.
The fractured alar cartilages can be identified and the
degree of tearing of the aryepiglottic folds demonstrated.
Displacement may be slight or the total supraglottis may
be tilted back in the pharynx so that the full extent of the
vocal cords is exposed. ;

Very limited debridement is carried out and the lines of

cartilaginous fracture and mucous membrane tears are
delineated. The :disp|aced.-soft tissues and cartilaginous
attachments of the supraglottis are pulled upwards and
forwards and sutured .tothe glottic and subglottic
fragments of the thyroid alae, thus restoring the normal
relationship of these structures.
280 Surgery of laryngeal and tracheal stenosis in adults

5,6&7
In order to strengthen and stabilize the fracture reduction,
a moulded laryngeal stent is sewn in place with wire
sutures which are placed proximal and distal to the
fracture line, passing through the thyroid alae and the
body of the stent, and tied together to support the
laryngeal reconstruction. A tracheotomy is done emerging
through a separate incision in the lower skin flap. After 3
weeks the wire is cut and the stent removed endoscopical-
ly through the same incision. Closure of the tracheotomy
may be allowed if the airway is adequate in the next 2-3
days.
 Surgery of laryngeal and tracheal stenosis in adults 281

of digastric muse
When delayed scarring is allowed to result in a supraglot-
tic stricture, a modified supraglottic laryngectomy is
necessary.
In order to expose the larynx from above, it is necessary
to enter the pharynx or pyriform sinus. The hyoid bone
and its attachments are exposed. T h e superior thyroid Hypoglossa
artery and vein are identified and this sheath of vessels is nerve
ligated. The carotid sheath is exposed and retracted
laterally. The sternohyoid and thyrohyoid muscles are
freed from the inferior surface of the hyoid bone and the Superior
attachments of the digastric and stylohyoid muscles are thyroid
freed from the superior border. The digastric attachments artery
with the stylohyoid muscle are retracted superiorly along
with the hypoglossal nerve.

Epiglottis

In this way, the lateral pharyngeal wall is e x p o s e d , entry to

the pharynx can be achieved and the epiglottis visualized.
T o enter the pharynx at a lower level through the pyriform
Pharyngeal sinus, the inferior constrictors must be freed from the
wa
Thyrohyoid posterior border of the thyroid alae.
membrane
282 Surgery of laryngeal and tracheal stenosis in adults

Repair is achieved by the freeing up of the mucosa in the

valleculae and the pyriform sinus. This mucosa is then
advanced over the denuded areas of the supraglottis and
sewn to the laryngeal mucosa. The postoperative care may
require tube feeding for a few days and tracheotomy-
suctioning until aspiration ceases to be a problem. Such a
relatively local excision will not cause significant swallow-
ing disability.
 Surgery of laryngeal and tracheal stenosis in adults 2H3

LARYNGEAL FRACTURES I N V O L V I N G THE GLOTTIS

13
Sufficient force applied laterally against the laryngeal
cartilages will cause a vertical fracture of the thyroid ala on
the involved side. As a result, the cartilage is displaced
medially and tears the vocal cord and may displace the
arytenoid. The subsequent stenosis results in anterior-
posterior shortening of the vocal cord and its fixation. T h e
degree of scarring varies but may be sufficient to require a
tracheotomy for relief of respiratory obstruction.

T h e larynx is approached by laryngofissure and the

scarred shortened vocal cord is exposed and excised.

Repair is achieved by the freeing up of the postcricoid and

pyriform sinus mucosa which is then sutured over the
defect. A stent is inserted into the larynx and left in place
for 3 w e e k s .
284 Surgery of laryngeal and tracheal stenosis in adults

LARYNGEAL FRACTURES INVOLVING THE GLOTTIS

AND SUPRAGLOTTIS

Extensive laryngeal fractures involving the cricoid will

result in comminution of the cartilaginous fragments and
wide-spread scarring.

^ 1 6

If the damage to the cricoid cartilage is not too great and

there is some mucosal continuity of the l u m e n , meticu-
lous replacement of the displaced fragments about a stent
may be possible.

17
 Surgery of laryngeal and tracheal stenosis in adults 285

Some laryngeal fractures will not result in comminution

but will combine tearing of the glottis and the supraglottis
with a combined subsequent stricture involving both
areas.

Repair is best achieved by anterior thyrotomy to expose

the extent of the stricture. The scar involving the vocal
cord extending to the supraglottis is excised and repair is
effected by mucosal advancement from the hypopharynx.
Such scarring also will involve the posterior commissure
and should be managed as shown in Illustration 38.

Repair
286 Surgery of laryngeal and tracheal stenosis in adults

( A u y v j r . p A t f p \c~n ! P W I T H r n i r n T r * » n - i r \ i
C

jcr-MKrttiUiN

In this fracture the trachea is pulled away from the cricoid

cartilage, which is usually fractured. A gap in the air way
results. T h e recurrent laryngeal nerves are always injured
and no effort to find or repair them should be made. If
seen in the first 2 weeks before scarring and stricture have
occurred, simple replacement and suturing of the trachea
back to the larynx is the treatment of choice.

20

As a result of cricotrachea! separation, injury to the

oesophagus may occur and a tracheo-oesophagea! fistula
ensue.

Such a defect should be closed.

 Surgery of laryngeal and tracheal stenosis in adults 287

The suture line is reinforced by a muscular layer obtained

by freeing the sternothyroid muscles from the oblique line
of the thyroid alae and crossing and suturing them in front
of the oesophagus. Direct anastomosis of the trachea to
the larynx can then be accomplished anterior to the
repaired oesophagus.

Following the laryngeal drop and dissection of the

mediastinal trachea, the patient's head is flexed and
anastomosis of the trachea to the thyroid alae anteriorly
and the cricoid plate posteriorly can be accomplished.

If repair is delayed a concentric tracheal and laryngeal s Limit of

subglottis results. T h e same clinical picture may result resection
from the pressure of indwelling tubes with or without an
Cricothyroid
inflated cuff. Resection of the subglottic stenosis with
joint
direct anastomosis is necessary.
Several special anatomical features must be considered
in this type of resection. The recurrent laryngeal nerves
and the cricothyroid joint form essential landmarks. The
Recurrent
recurrent nerve enters the larynx as an immediate laryngeal
posterior relation to the cricothyroid joint so that the level nerve
of the joint limits the proximal extent of resection of the
posterior plate of the cricoid cartilage. Anteriorly, the
cricoid may be completely resected as may the thyroid 25
cartilages up to the level of the vocal cords.
288 Surgery of laryngeal and tracheal stenosis in adults

If the subglottic scarring extends proximally beyond the

level of the cricothyroid joints, excision of the scar up to
the level of the subglottic mucosa is carried out. The
posterior plate of the cricoid cartilage is preserved but
thinned by shaving its anterior surface.

T h e trachea is then pulled upwards and its posterior wail

sutured to the immediate subglottic mucosa. The anterior
tracheal wall is sutured to the inferior borders of the
thyroid alae.

The distal extent of the subglottic stenosis is determined

by repeated incisions into the anterior tracheal wall which
are continued distally until normal trachea is reached.
If the vocal cords have been mobile preoperatively the
recurrent laryngeal nerves are identified at the level of the
inferior thyroid artery and traced proximally to the thyroid
cartilage at the level of the cricothyroid joint
290 Surgery of laryngeal and tracheal stenosis in adults

Closure of the gap created by the resection is accom-

plished in three ways: by dropping the larynx, freeing up
the trachea and the mediastinum a n d , finally, by flexing
the patient's head. T h e larynx is dropped from the hyoid
bone w h i c h allows a closure of about 2 c m . The
thryohyoid muscles are incised at the level of the superior
border of the thyroid alae which exposes the thyrohyoid
membrane. This is incised as closely as possible to the
superior border of the thyroid aiae to prevent damage to
the superior laryngeal nerve. The drop is completed by
incision of the superior cornu of the thyroid cartilage and
resection of the fibres of the inferior constrictor as the>
t

attach to the superior third of the lateral border of t h e f

thyroid alae. Such a laryngeal drop not only provides an

additional length of 2 cm but also rotates the larynx
forward and makes suturing it to the trachea much easier.
 S u r - f r v o i laryngeal and tracheal ^te-n.,^ m adults ^'j 1

Anteriorly, this is the same plane used in mediastinoscopy

and posteriorly it is the plane between the oesophagus
and the trachea. W h e n the trachea is freed up in this
manner, it can be sutured to the larynx as in Illustration 24,
292 Surgery of laryngeal and tracheal stenosis in adults

. ^ -7-"' ' ^v\!r,n\!_ ADHESIONS AND

:

STENOSES DUE TO I N I O D ^ U ^ . ,

The common intubation injury to the laryngotracheal

complex, is posterior commissure stenosis, with adhe-
sions which tether the movements of the arytenoids and
give the clinical picture of a bilateral abductor paralysis.

Horizontal laryngeal
section at cord level

The posterior laryngeal scar is viewed through the ant eric

thyrotomy approach and is excised. Freeing the aryteno
cartilage is also attempted.

Repair is then obtained by advancing mucosal flaps from

the posterior pharynx. This is supported for 2 weeks by
the positioning of an individual laryngeal mold.
 Surgery of laryngeal and tracheal stenosis in adults 2<)3

Sometimes the posterior commissure scar is in the form of

an interarytenoid band which is readily incised and results
in immediate airway improvement and motility of the
arytenoids provided the scarring does not affect the
cricoarytenoid joints.

Resection of tracheotomy stoma stenosis

T h e commonest site of tracheal stenosis occurs at the

tracheotomy stoma in patients receiving IPP ventilation
assistance in respiratory units. Movement of the
tracheotomy tube because of attachment to the respirator
and infection are the causes of such a stenosis. The stomal
stenosis is characteristically triangular with the apex
anteriorly. A few minor stenoses at this site may be
satisfactorily dilated but most must be resected.

Anaesthesia may be instituted by an endotracheal tube

which passes through the stricture or if the stenosis does
not allow this a tracheotomy under local anaesthesia is the
first step. T h e site of stenosis is exposed and by filleting
the trachea the extent of stenosis is defined, and resected.
Anaesthesia is continued by a tube inserted into the distal
trachea.
294 Surgery or laryngeal and tracheal stenosis in adults

The peroral anaesthetic tube is then advanced across the

suture line which is completed anteriorly..

6*

The stenosis at this level may spare the posterior tracheal

wall and be very limited in extent. In such cases, a simple
wedge resection of the anterior and lateral walls of the
trachea may be adequate. .
 Surgerv ot laryngeal and tracheal stenosis in adulb

Excision of stenosis at cuff site

Stenosis caused by the inflated cuff on a tracheotomy tube

occurs at about the mid-point of the trachea. Such a
resection is still feasible through a cervical approach.

45

Cuff stenoses are characteristically circumferential and

very resistant to treatment other than resection.

Anaesthesia is difficult at this site of resection because a

tracheotomy cannot be placed distal to the site of
stenosis. The primary anaesthesia must be by means of a
peroral endotracheal tube or by means of a pre-existing
tracheotomy whose tube passes through the stenosed
site.
T h e trachea is exposed and the site of stenosis
identified. The cuff stenosis must be differentiated from
the depressed site of the previous tracheotomy. T h e distal
extent of the stenosis is identified by tracheal filleting.
2% Surgery or laryngeal and tracheal steno^k in adulk

The armoured anaesthetic tube is passed distally into the

normal trachea as the peroral anaesthetic tube is partially
withdrawn.

49
Tracheal drop and tracheal freeing is accomplished. T h e
distal trachea is pulled up into the neck with trachea on
the stenosed lateral walls which remain attached.

50
T h e posterior suture line is completed and the peroral
anaesthetic tube is advanced to allow insertion of the
anterior and lateral sutures.
A proximal tracheotomy is done and a No. 4 tube
inserted to pass through the line of anastomosis.
 5un^.'i v u\ ijrynqeai and tracheal stenosis in adults 297

passive combined laryngotracheal fracture

51
If there is complete loss of mucosal continuity through the
fractured or damaged area of the laryngotracheal complex
or if the extent of the damage is too great for excision of
the scarred area and direct anastomosis, then reconstruc-
tion of the larynx and/or trachea will be necessary.

In these cases, the stenosed area is exposed and all scar

and grossly displaced cartilage is removed. Mucosa is
usually found in some areas of the posterior wall and this
is retained. Cartilage which may help to build up the
lateral walls of the trough of the larynx and trachea is
maintained as this depth is essential and will otherwise
have to be constructed by autogenous grafts of bone or
cartilage. It is essential that the debridement of the area
extends distally to a viable cartilaginous ring or subse-
quently the trough will continue to collapse at this site.

Rotation skin flaps are then outlined on each side of the

neck, so that full-thickness skin can be advanced into the
trough to line the lateral walls and sewn to any posterior
mucosa w h i c h may have been saved.
29S Surgery of laryngeal and tracheal stenosis in adults

If possible, a tracheotomy should be carried out through

distal normal trachea. There may not be enough trachea
for this, in w h i c h case the tracheotomy tube is inserted
into the trachea at the distal end of the trough. A
specially-constructed prosthesis is inserted into the
trough to maintain a smooth posterior wall, and to avoid
maintenance ties or straps which would embarrass the
blood supply of the rotation flaps.

COUlp'iCULiUltJ
Surgical procedures to correct stenosis of the larynx and
trachea have many postoperative problems in common.
Supportive therapy
The nutritior of all these patients requires careful
consideration. In many of the procedures, aspiration of
saliva and food may be a problem and will require careful
airway toilet and duodenal or gastrostomy feeding.
Patients required to survive prolonged periods of
convalescence often with airway obstruction, loss of voice
and feeding problems almost always pass through a
period of severe depression. Constant encouragement by
the surgeon is essential, and at each step of the way, the
purposes of the procedures must be adequately ex-
plained. Good occupational therapy is most helpful.
Airway maintenance
Patients undergoing this type of surgery almost always
require prolonged care of the airway, either because of an
indwelling orotracheal tube or a tracheotomy tube. Expert
nursing and all the facilities of a respiratory unit are
essential to avoid sudden tragedy because of airway
obstruction. Constant humidification is necessary.
In the 'immediate postoperative period following
tracheal resection and anastomosis, some type of airway
assistance is necessary until the patient can demonstrate
independence from this aid. T h u s , it is wise to use a small
tracheotomy either distal or proximal to the suture line in
the trachea to allow for suction and to prevent the
build-up of pressure in the trachea during coughing which
may cause separation of the repair.
Mir^ury of laryngeal and tracheal stenosis in adults 2.W
When a laryngeal drop has been carried out, aspiration
is unavoidable for some days and a safety-valve
patient. Such a small tracheotomy tube does not further
weaken the tracheal wall and does not harm the sutured
area.
Haemorrhage
Acute postoperative haemorrhage or subcutaneous
emphysema may elevate the skin of the neck and cause
considerable trouble. This is best avoided by adequate
drainage and snug dressing. Closed suction-drainage is
not desirable because of the frequent openings into the
glottic or tracheal airways.
Secondary haemorrhage may be most destructive to the
operative procedure. It must be managed by opening the
incisions to evacuate the clots. If the infection is gross the
incision may be packed open until this is controlled and
then closed secondarily.
Voice problems
If the voice has been lost for some time, the patient may
require encouragement and the instruction of a speech
therapist before a good useful voice is restored. For
example, false cord phonation can occur in patients who
have had large cervical fistula for a considerable period of
time.
Prolonged f oliow-up
Late scarring of the trachea and laryngeal structures may
result in delayed vocal cord paralysis, or the recurrence of
tracheal strictures. This may be unrecognized unless the
patient is followed by an experienced surgeon for a long
period of post surgery.
Illustrations by Philip Wilson

John N. G . Evans D L O , FRCS

Consultant Ear, Nose and Throat S u r g e o n , The Hospital for Sick Children, Great O r m o n d Street
and St. Thomas's Hospital, London, UK

Introduction

Stenosis of the larynx and trachea in children may be
congenital or acquired. Congenital w e b s and stenosis of
the subglottic larynx are the most common and are easier
to deal with than the stenosis caused by intubation. This is
often associated with perichondritis of the cricoid a n d , as
a consequence, free cartilage grafts have to be used to
r e p l a c e lost t i s s u e . S t e n o s i s may also f o l l o w a
tracheotomy. These stenoses occur at the site of the
tracheostome and at the tip of the tracheotomy tube.

300
 Surgery of laryngeal and tracheal stenosis in children 301

N O L I Ni J r \ L

LARYNGEAL WEB

1
Small anterior webs cause some dysphonia. They should
be dealt with surgically only after careful discussion with
the parents as it is impossible to guarantee that the child's
voice will return to normal postoperatively, and this is the
reason for operating. If the web occupies more than the
anterior third of the glottis operation is desirable.

A preliminary tracheotomy is required, preferably 1 w e e k

before the open operation on the larynx.

Anaesthesia

2
T h e operation is performed under general anaesthesia.
T h e patient is positioned as for tracheotomy with the neck
hyperextended. The patient is tipped head up and a
diathermy pad is applied.

2
302 Surgery of laryngeal and tracheal stenosis in children

A horizontal incision i | made in the neck after preliminary

infiltration with w p e r cent lignocaine (Xylocaine) with
adrenaline 1:200000 in the skin over the thyroid cartilage.

Laryngofissure

The skin incision is deepened in a horizontal direction

until the strap muscles are identified.

T h e sternohyoid muscles are distracted laterally and the

thyroid cartilage is identified.

Erratum

Operative Surgery 4th edition

Nose and Throat
'Surgery of laryngeal and tracheal stenosis
in children'.

The dosage of lignocaine stated on p302

 Surgery of laryngeal and tracheal stenosis in children 303

6
Using a No. 11 blade the thyroid cartilage is incised in the
midline. Care should be taken not to enter the laryngeal
lumen at this stage.

Opening the larynx

7
Skin hooks are used to distract the thyroid laminae
laterally. T h e mucosa of the'supraglottic larynx is opened
using a fine pair of sharp pointed scissors.
A probe is passed through the glottis and the web is
incised under direct vision using a No. 11 blade.

A piece of Silastic approximately 2 c m x 2cm is cut and

inserted between the laminae of the thyroid cartilage.
304 Surgery of laryngeal and tracheal stenosis in children

T h e Silastic is removed endoscopically 6 weeks later.

Gentle traction on the Silastic will tear it loose from the
stay sutures, making an open operation unnecessary.

CONGENITAL
b U B L i L O ! iiCSltNOSIS
The stenosis lies within the lumen of the cricoid cartilage,
which is often thickened. The predominant symptom of
this condition is stridor. The diagnosis is confirmed by
endoscopy a n d , if the stridor is severe, a tracheotomy is
necessary. It is often performed during the first few weeks
Surgery ot laryngeal and tracheal stenosis in children 305
of life. T h e patient is kept under review and repeat
endoscopies are performed at 3-monthly intervals. If there
is no sign of spontaneous improvement a laryngotracheo-
plasty will be necessary. Operation is usually deferred
until the infant is over one year of age.
A preliminary tracheotomy will have been performed. The
operation is performed under general anaesthesia using a
cuffed flexometallic tube through the tracheostome.
The patient must be postitioned so that the neck is
hyperextended. A sandbag is placed under the shoulders.
T h e occiput is supported by a ring. T h e patient is tipped in
the head-up position and a diathermy pad is applied.
Laryngeotracheoplasty
Incision
T h e skin over the cricoid cartilage is infiltrated using 1 per
cent lignocaine with adrenaline 1:200000 to aid haemo-
stasis and a horizontal incision is made approximately
3.5cm in length. T h e investing layer of the deep cervical
fascia is exposed. Branches of the anterior jugular vein will
need to be coagulated.
306 Surgery of laryngeal and tracheal stenosis in children

W h e n the strap muscles have been identified the

condensation of deep cervical fascia between them is
divided in a vertical plane.

The sternohyoid and sternothyroid muscles are distracted

and the larynx and upper three tracheal rings are
displayed.
T h e cricothyroid muscle is dissected away from the
upper border of the cricoid cartilage on both sides.
 Surgery of laryngeal and tracheal stenosis in children 3or

Incision in the Larynx and Trachea

A vertical incision is made between the thyroid laminae

and through the cricothyroid ligament. Great care must be
taken not to injure the upper border of the cricoid
cartilage.
T h e incision now passes horizontally, separating the
cricothyroid membrane from the upper border of the
cricoid cartilage. The incision passes inferiorly through
one half of the thickness of the cricoid arch, and then
passes horizontally across the midline. The cricoid is
narrow at this point and care must be taken to ensure that
the slips of the arch of the cricoid are of approximately
equal height. T h e incision is continued into the tracheal
rings in a 'castellated' fashion. This incision is made
through the full thickness of the cricoid arch into the
lumen of the larynx and continued into the tracheal lumen
below.

Coring out the Cricoid

17
If the cricoid is abnormally thick its lumen may be
increased by removing part of its internal surface. As
much mucosa as possible is preserved over the lamina of
the cricoid. Any fibrous scar tissue present is excised and
the overlying mucosa is preserved. This dissection is
facilitated by using the operating microscope and 'aural
scissors'.
308 Surgery of laryngeal and tracheal stenosis in children

A stent of Silastic sheeting size 5005 for infants is cut with

two flanges on its upper surface. They project between
the vocal cords and help prevent adhesions forming at the
anterior commissure. T h e length of each flange corres-
ponds to the anteroposterior length of the vo'cal cord of
the patient (in a child aged 18 months it is approximately
1 c m ) . T h e vertical height corresponds to the length of the
trachea w h i c h has been incised.

The Silastic is w o u n d up like a 'Swiss roll'

19
Surgery of laryngeal and tracheal stenosis in children 309
310 Surgery of laryngeal and trachea! stenosis in children

The 'Swiss roll' is inserted into the lumen of the opened

larynx and trachea.

This variety of stent is self-adjusting and adapts easily to

the complex shape of the conus elasticus. This illustration
shows a coronal section through the larynx and trachea
with a Silastic stent in situ.

Seen through the laryngoscope, the flanges on the upper

aspect of the Silastic stent project between the vocal
cords and prevent adhesions forming at the anterior
commissure.
 Surgery of laryngeal and tracheal stenosis in children 31!

Expansion of the cricoid cartilage and the tracheal lumen

is achieved by suturing the interdigitating pegs in their
new distracted position, using 5/0 Prolene sutures.

24

The stent is secured with a transfixion stitch which passes

through the trachea and prevents the stent from moving
up or down. Care must be taken to ensure that the flanges
on the upper edge are positioned accurately just at the
free margin of the false cords.
312 Surgery of laryngeal and trachea! stenosis in children

IV

The suture is placed superficial to the strap muscles, fed

through a piece of polythene tubing and tied. T h e
purpose of the polythene tubing is to make it easier to find
the transfixion stitch w h e n it is due for removal.
T h e w o u n d is drained and a pressure dressing applied.
T h e patient is placed on a broad spectrum antibiotic for
10 days.

Postoperative management

T h e stent is removed after 6 w e e k s . The transfixion stitch

is divided at open operation; the stent is removed
endoscopicatly.
A further direct laryngoscopy is performed 2 weeks later
to check the patency of the laryngeal lumen. Any
granulomata present may be removed at this time. If the
laryngeal lumen looks satisfactory the patient is prepared
for decannulation.

Complications
Spill-over on swallowing may occur for the first few days
postoperatively. In this c a s e t u b e feeding is necessary. If
spill-over persists, a microlaryngoscopy must be per-
formed to check the position of the Silastic roll. If the
flanges are found to be above the false cords they can be
trimmed using microlaryngoscopy right-angled scissors.
 Surgery of laryngeal and tracheal stenosis in children 313

ACQUIRED
SUBGLOTTIC STENOSIS
This type of subglottic stenosis is often associated with
perichondritis of the cricoid. A laryngotracheoplasty is
impossible. A laryngotracheal reconstruction using a free
graft of costal cartilage will be required.

The larynx and trachea are opened in the midline.

A free graft of costal cartilage is taken from the costal

margin. The size of cartilage graft is measured v e r y
carefully so that it fits exactly the defect created in the
airway. The cartilage graft is sutured in place using 5/0
Prolene sutures. The perichondrial surface of the graft is
placed facing the lumen of the airway. The larynx does not
require stenting.

29
314 Surgery of laryngeal and tracheal stenosis in children

A L I ^ U I K t U S U b U L U I 1 iC
STENOSIS AND WEBBING
OFTHE POSTERIOR
COMMISSURE

This endoscopic view of the larynx shows a subglottic

stenosis with webbing of the posterior commissure. T h e
scar tissue posteriorly fixes the vocal processes of the
arytenoid cartilages, which are therefore unable to abduct
on inspiration. This is an extremely important cause of
failure of decannulation.

The larynx is opened In the midline, together with the

involved tracheal cartilage.

T h e scar tissue in the posterior commissure is divided

vertically and the lamina of the cricoid is exposed. T h e
cricoid lamina is divided in the midline. T h e cricoid ring is
separated by an anterior and posterior vertical incision. A
free graft of costal cartilage is prepared whose dimensions
fit exactly the defect in the cricoid lamina. T h e cartilage
graft is sutured in place using 6/0 Vicryl sutures. Stenting
of the larynx is not required.
T h e defect in the anterior wall of the larynx and trachea
is closed if necessary as shown in Illustration 29 by a
s e c o n d , larger piece of costal cartilage.
T h e w o u n d is drained and a pressure dressing applied.
T h e patient is placed on a broad spectrum antibiotic for
10 days.
[lustrations by Angela Christie

Peter McKelvie M D , ChM, F R C S , D U O

ENT Consultant Royal National Throat, Nose and Ear Hospital, and the London Hospital, London;
D e a n , Institute of Laryngology and Otology, University of London, L o n d o n , UK

A large cystic ballooning of the false vocal cord coupled

with gross dysphonia and threatened airway obstruction
are the hallmarks of this condition.

The incision

A n internal laryngoceie is best removed through a

1 aryngo-fissure approach. A transverse incision 7.5 cm (3
inches) long is made over the pomum adami and
dissection is carried out down to the thyroid cartilage.
316 Removal of an interna! laryngoceie

3
A temporary tracheostomy is then established via a
separate stab incision below the operation site.

The laryngoceie is opened from the anterior e n d , i.e. from

the laryngeal ventricle, with the false vocal cord retracted
upwards. The mucosa lining the ventricle is dissected
from the large cystic lumen thus revealed. A large dead
space with a raw interior is then established. Haemostasis
in this cavity is essential and is usually achieved with
diathermy. The false vocal cord can then be sutured with
chromic catgut to obliterate this dead space, pulling the
false vocal cord laterally, re-establishing the airway in the
supraglottis and fastening the false cord against the inside
of the thyroid cartilage. A naso-oesophageal tube is
passed and the larynx is reconstituted by chromic catgut
sutures passed through the receding angle cartilage, tying
the alae together. T h e w o u n d is closed without drainage.

Postoperative care

The tracheostomy, corked after 2 days, can generally be

withdrawn after 4 days, and the naso-oesophageal tube is
withdrawn w h e n continent swallowing of fluids is estab-
lished.

Persistent dysphonia, mild in nature, is common.

 Illustrations by Robert N. Lane
David Wright FRCS
Consultant, Ear, Nose and Throat Surgeon,
The Royal Surrey County Hospital, Guildford, Surrey, UK
Indications
Laryngectomy is i n d i c a t e d j o r the curative treatment of
carcinoma of the larynx or combined with partial or total
pharyngectomy in the treatment of carcinoma of the
hypopharynx when previous radiation has not been
successful o r j s considered unsuitable. It may also be
indicated as a^-palliative treatment if the patient's terminal
suffering is thought to be minimized by the operation.
Preoperative care
T h e operation and rehabilitation should be discussed with
the patient and his family,^offering a sympathetic and
encouraging approach. The s p e e c h j he rapist should meet
the patient. Consideration should be given at this stage as
: to whether it is to the advantage of the patient to meet a
- laryngectomized patient., w h o can demonstrate an
oesophageal voice. The'"physiotherapist should start
preoperative breathing exercises. Unhealthy gums, ca-
rious teeth and nasal sepsis must receive attention.
Anaesthesia
A general anaesthetic is preferable and a suitable
premedication can safely be given as any depressive effect
of the drug on the respiratory system will have worn off by
the end of the operation. The anaesthetic can be
administered through an endotracheal tube if the natural
airway is adequate for intubation. T h e tube is withdrawn
later in the operation, when the larynx has been removed,
a n d the anaesthetic continued through an angled tube
inserted through an opening made into the trachea prior
to the construction of the tracheostome. If the airway is
substantially restricted by tumour, making intubation with
an endotracheal tube difficult, a preliminary tracheostomy
under local anaesthesia will be required, after w h i c h a
general anaesthetic may be given through a cuffed portex
tracheostomy tube.
Hypotension may be helpful, particularly if the opera-
tion is combined with a neck dissection.
Laryngectomy can be carried out under local anaesthe-
sia obtained with 1 per cent lignocaine (Xylocaine) and
1:200000 adrenaline solution. Following infiltration of the
incision, the region of the superior laryngeal nerves
between the superior cornu of the thyroid cartilage and
the greater cornu of the hyoid bone should be infiltrated.
Cotton pledgets soaked in a 5 per cent cocaine solution
can be applied locally or further injections of lignocaine
given as required.
Position of patient
T h e head is extended by placing a sandbag under the
shoulders to make the laryngeal structures more prom-
inent, A
- ' .>*"'
317
318 Total laryngectomy
mm

The operation 111

The incisions H

U-shaped flap
Each limb of the U-shaped incision commences at the
anteriojjagrder of the sternonxasjoid muscle at the level of
the tip of the greater horn of the hyoid bone and follows
the anterior border of the muscle with a gradual curve to
join the opposite incision 1_cm below the lower border of
the cricoid cartilage. ~ ~~
The incision is carried through to the deep cervical
fascia to i n c l u d e j h e ptatysma in. the apron flap. This flap
gives gooc!__expbsure and facilitates the making of the
tracheostome. Adequate cover is given to the pharyngeal
reconstruction in the midline and lateral drainage can be
provided away from the tracheostome.
If a rad]cajjie_ck_diss£ction is to be included the incision
is extended_on.the_ipsilateral side to the tip_oX£h£,mastoid
and a further limb added f r ^ m J b e j r ^ p ^ ] n j : j o t h e _ c e n t r e
of^hj^c]ayide.
The apron flap is retracted superiorly on a plane
between the platysma muscle and the deep fascia
covering the strap muscles. T h j t ^ n t e j ^ c ^ u g j J a j i y e ^
ligated and included in the J.lap. The dissection is
continued "until the body of the jryoid bone can be
palpated and the suprahyoid musculature exposed. The
flap is anchored by a subcutaneous suture to the face
towels. T h e deep fascia is divided a l o j T g J h e j r i e j ^ J ^ ^
° * th§_Jtejmqmastoid muscles and the carotid sheath
identified by.palpation on each side.

Vertical incision t 4 A
The vertical incision can have advantages if the l i ' y * 1

tomy is not tojse coimbined with a radical neck $ . - - * ^

£

T h e incision includes both"deepTascia and p l a t y ^ - 1 8

the skin. T h e incision will he^[jTioj^„quickly t " * * 1

U-shaped flap with less induration and

fibrosis, especiallyin the radiated neck. In the ' * * ! ] < ? £ j
u n , r

advent of fistula formation due to breakdov/fl

breakdown vs
w o u n d , there will be less loss or retraction of a $

the apron flap.

2
 Total laryngectomy 319

3
Division of the infrahyoid muscles

T h e fibrous raphe between the two sternohyoid muscles

at the level of the thyroid isthmus is identified and the
sternohyoid muscles are divided close to their inferior
attachments. T h e omjahyoid m u s c l e T T r e ' divided'"where'
they crqss_the carotid sheath. The broader sternothyroid
muscles are carefully separated from the vascular capsule
of the thyroid gland and divided close to their attachments
to the manubrium and first rib. The sternothyroid muscle
may be left attached to the thyroid gland if the
homolateral lobe is to be removed with the larynx.

v.

Mobilization of the hyoid bone: suprahyoid

dissection

The body of the hyoid bone is identified and as far as

possible t h e m u s d e s of the tongue (genioglossus,
:

hyoglossus and mylohyoid) are separated by subperiosteal

dissection. The sty 1 ohyoid ligameTTHTdetaebed from the
:

lesser cornu of the hyoid bone. Retraction of the tubercle

of the hyoid with tissue forceps will facilitate separation of
the middle constrictor, stylohyoid and digastric tendon
from the upper margins of the greater c o r n u . The lingual
artery must be avoided where it lies close to. the" de~ep
surface o j j h e great c o r n u .
After separating the muscles the submucosal layer of
the vallecular mucous membrane will be visible.
320 Total laryngectomy

5
Division of the isthmus of the thyroid gland

The isthmus of the thyroid gland is divided where it

usually covers the second and third tracheal rings. The
anastomotic vessels of the superior thyroid arteries lie at
its superior border and numerous inferior thyroid veins at
its inferior border.
The fibrous attachment of the isthmus to the tracheal
wall is separated by blunt dissection. T h e isthmus is
divided between haemostats and retracted to ^expose the ^
lateral surfaces of the trachea. The cut ends are oveFsewn
or simply ligated. If the homolateral lobe of the thyroid is
to be removed in continuity* with t h e "larynx "because of
subglottic spread of tumour, the superioj;Jhyroid pedicle ->
with its artery and nerve, the middlejhyrpid veins and the '
inferior thyroid .artery should be diyjded and ligated. In [ •
this way the homolateral lobe of trie thyroid With the j
parairacheal lymphatics are not separated from the larynx.

Division of the superior laryngeal vessels and

nerve

The laterj^ligamentoyspart of the thyroJiyojdjT^ejmbrane

is divided to allow retract]cm^fJjie_greajte,r.cornu of the
hyoid bone to display the internal laryngeal nerve where it
pierces the thyrohyoid membrane. The superior laryngeal
vessels will be found passjngjthrough the membrane at a
lower level. The nerve and vessels are divided.
 Total laryngectomy 321

7
Division of the inferior constrictor muscle

T h e transverse fibres of the inferior constrictor muscle are

separated on each side from the posterior part of the
thyroid ala and preserved fojjiejpjnj^ccmsjru^c^
pharynx and in the~p7od action ofjan_aesophageal voice.
T h e external "laryngeal" nerve which winds around the
inferior thyroid tubercle should be preserved if possible.
T h e inferior constrictor fibres are separated by sharp
dissection "from the~Thyroid ala and then completely
separated from the posterior border by s u b pe: ri ch o n d r i a I
dissection* Exposure is facilitated by rotating the larynx
lateralty~by a hook placed under the posterior border of
the thyroid ala.
This method of dissection will retain the integrity of the
stylopharyngeus muscle in association with the inferior
constrictor muscle. Further retraction will allow separa-
tion^ the mucous membrane of the pyriform fossa from
the deep surface of tfieTcartffageT"™ '

8
Opening of trachea

The anaesthetic at this stage is conveniently transferred

from the peroral endotracheal tube, to a sterile right-
angled tube inserted through an opening made into the
trachea. The opening is made by cutting across the trachea
b e t w e e a J h e second and third or third a n d i o u r t h rings
depending on the site and spread of the tumour. The
anterior edge of the trachea is secured to the skin incision
by a silk traction suture.
Tracheal secretions are removed by catheter suction. A
cuffed right-angled tube is inserted and connected to the
anaesthetic circuit. The peroral tube is then removed.
Ribbon gauze is placed in the trachea above the tube and
fresh towels are placed in position. T h e tube is stabilized
by suturing to the skin on each side.
Delivery of epiglottis

To ensure clearance of the pre-epiglottic space the hyoid

bone is removed with the larynx. "
The hypopharynx is opened by retracting interiorly on
the__hyoid_bone until the tip of the epiglottis can be
palpated. T h e opening is made by division of the.mucous
membrane around the tip. and . lateral borders of the
epiglottis and so preserving most of the mucous mem-
brane of the vallecula. O n c e the epiglottis is visible it can
be delivered through the opening and retraction main-
tained by holding with tissue forceps. If the tumour
involves the suprahyoid part of the epiglottis or en-
croaches into the vallecula the dissection must be
modified and taken at a higher level through the tongue.
The larynx is now inspected to assess the size and extent
of the tumour so that the incisions into the mucous
membrane of the pharynx can be planned.
The incisions will normally pass_medially through_the
mucousTrTembrane, which has previously been separated
from the thyroid ala in the upper part of each pyriform
fossa, to each aryepiglottic fold, to meet the incision of
the opposite side on;the posterior surface of the cricoid
cartilage. "* * """"

10
Separation of larynx from hypopharynx and
cervical oesophagus

T h e mucous membrane of the hypopharynx is dissected

from the posterior surface of the cricoid cartilage and
upper membranous part of the trachea. The separation
between_th^Jxach,ea-and-the-oesophagus should~o"e"no
more than is required to allow division of the trachea at
the desired level.
T h e trachea is divided far enough above the tracheal
ring to allow sufficient mucous membrane to make good
healing with the skin edge when the tracheostome is
formed.
Fashioning of a p o s t e n o r ^ n g u e of the membranous
part of the trachea * w f f T make construction of the
tracheostome easier.
T h e larynx, with its hyoid bone and muscle attachments,
are then removed for photography and histological
examination."l^fteT removal of the larynx further strong
silk sutures are used to close the anterior edge of the
trachea to the skin margin. The sutures should pass below
a tracheal ring to give adequate support. Ribbon gauze is
packed into the trachea around the cuffed anaesthetic
tube to prevent blood from entering the trachea while the
vascular pharynx is repaired.
 Total laryngectomy 323

Repair of hypopharynx and cervical oesophagus

T h e V-shaped defect in the anterior wall of the

hypopharynx is closed in three layers into a T-shaped
repair. T h e most lateral margins of the 'V, formed by the
mucc^s^ membrane^of ..the..vallecula, are marked with
traction sutures.and the horizontal limb closed with a
continuougjp^dtijjg suture of 4/0 chromic catgut on an
atraumaTTcneedle inserted extramucosally. The vertical
section is similarly closed. A secojidJgy_er of closure is
obtained by placing intexrjjpte^s^tures through the fascia
immediately lateral to and burying the primary suture line.

Approximation of inferior constrictor muscles

If prior to operation, it is planned that secondary

rehabilitation of the voice w i t h rehabilitation by
tracheoesophageal puncture and silicone voice prosth-
esis, a P-segment should be created In the hypopharynx
using a two layer closure with a pharyngeal constrictor
myotomy otherwise the third layer is formed by approx-
imating the inferior constrictor muscles to give support
around the reconstructed membranous tube. At this stage
a sterile nasogastric feeding tube is passed through the
nose by the~^na^striet'fst into the stomach and spigotted.
The thyroid lobes, if both are retained, can also be
approximated in the midline.
Meticulous care must be taken with the closure of the
pharynx to reduce the incidence of fistula formation.
 i oia! laryngectomy

Creation of tracheostome

l.f the blood pressure has been lowered it should be

sufficiently elevated to make sure that all bleeding points
have been controlled. T h e nec_kj5_flexed and the apron
skin flap is returned to its original position. T h e
tracheostome can now be completed by placing further
sutures below the upper tracheal ring to give accurate
approximation of the mucosal edge of the trachea with the
skin, suturing the intercartilaginous part of the trachea to
the apex of the flap. The anaesthetic tube can be removed
for a short period while the final sutures are placed
around the tracheostome. Blood clots or mucus in the
trachea and bronchi should be removed by catheter
suction.
13

Skin closure and drainage

T h e skin is closed with intemjgted fine silk, ensuring that

the edges of the platysma ..muscles are included in the
suture to support the wound margins.
The w o u n d must be adequately drained during the
following 7 2 h o u r s . Continuous suction rlfainage has the
advantage of collapsing the skin flap and eliminating dead
space. The tube should be sited laterally through separate
incisions well away from the tracheostome. The tubing is
attached to l o w pressure suction when the subcutaneous
closure is airtight. If blood is retained under the flap,
saline solution can be instilled and evacuated through the
tubing.
After a firm dressing has been applied, a lightweight
silicone laryogectojrryJujDe is inserted into the tracheos-
tome and secured by tapes around the neck.
W h e n the blood pressure is satisfactory the patient is
placed in a semirecumbent position with three or four
14 pillows.

The patient should, for the first 24 hours, be highly
dependent on nursing care.
Dressings
T h e dressings should be chanjjed^on the secpjidjJay. T h e
continuous low pressure suction drainage should be
maintained for a minimum of 48 hours to eliminate the
dead space under the flap and prevent the accumulation
of blood and exudate.
Care of the tracheostome and laryngectomy tube
T h e silicone laryngectomy tube should be removed and
cleaned every 2 or 3_ hours during the first few days. If, as
an ^Tf^nativeTa^olleTdge^Wpe silver laryngectomy tube
has been used, the inner tube should be removed for
cleaning without disturbing the outer tube.
Suction apparatus should be available at the bedside so
that tKe^ttryngectomy tube and trachea can be aspirated as
required with a soft catheter, iStfftion isjDrjiyjippjjeaLpn
withdrawal oj_jbe_cat_heter, w h i c h should have either a
side-fToTe~or a Y'-connection so that pressure can be
;
regulated with the finger.
Wound healing
It is advisable that the operation be covered with a suitable
broad spectrum antibiotic. The use of a local antibiotic
spray in the vvounH before closure of the w o u n d , can help
reduce wound infection. Primary healing usually occurs
within 7-10 days but will be influenced by the effect of any
p^e^perftfve radiation. If a fistula is to occur, the leak of
saliva from the w o u n d will usually become evident by the
seventh to tenth day.
Total !ar\ngeciotTV.
Feeding
A soft nasogastric feed tube is passed at the time f 0
operation so that with the discontinuation of intravenous
fluids after the first 48hours, the patient can be fed on a
fortified iiquidized diet. The tube should be secured in the
nose by a stitch or strapping. The tube can be removed
when the neck skin has healed and then feeding
commenced with fluids, gradually progressing within a
few days to a soft diet. A return to a ' n o r m a l ' swallow with
very little more voluntary effort can be expected in time.
Speech
After removal of the nasogastric feeding tube, the speech
therap]st_can within a few days continue instruction on the
production of oesophageal speech.
Evaluation, either pre- or postoperatively, will indicate
whether restoration of the voice after total laryngectomy
using a 'duck-bill' style valved prosthesis in a surgical
fistula created between the oesophagus and the posterior
wall of the trachea is to be considered as an alternative to
either oesophageal speech or the use of an 'electronic
larynx'.
Complications
1. Reactionary haemorrhage. If necessary the w o u n d must
be reopened immediately and the bleeding vessel
ligated.
2. Wound infection
3. Pharyngeal fistula. If a fistula o c c u r s , feeding must be
continued through the nasogastric tube until the fistula
closes spontaneously. If the fistula is large, further
reconstruction will be required at a later date.
4. Trachea! crusting. If humidification and tracheal toilet
are inadequate, crusting may form in the upper part of
the trachea restricting the airway. T h e crusts should be
moistened with sodium bicarbonate solution and
carefully removed.
Illustrations by Gillian Oliver
Robert W . Bastian M D
John M. Fredrickson M D , FRCS(C)
Stanley E. Thawley M D
Department of Otolaryngology, Washington University School of Medicine, St Louis, Missouri, U S A
The reason for sustained interest in voice restoration after
laryngectomy reflected in the literature of laryngology is
obvious. The human need to voice ideas, emotions and
desires is very basic. Beyond the profound importance of
the human voice for communication is its importance to
convey personality. Finally, the use of the human voice as
a musical instrument is universal in all cultures.
T h u s the impact of permanent loss of voice is
tremendous. Great adjustments must be made not only by
the patient following laryngectomy, but also by every
person with w h o m he or she comes in contact. The patient
must grieve for a lost body part and for the loss of a
portion of his or her identity. He must struggle at times to
communicate even the simplest wish to family and
friends, not to mention with their reciprocal frustration in
32&
trying to understand. Even with early rehabilitation with
the best methods available, a time of adjustment and
acceptance is required, for no existing method restores
fully the human v o i c e .
This discussion of surgical restoration of voice after total
laryngectomy is divided into three main parts: first,
although this chapter centres on surgical methods, a brief
review of major surgical and non-surgical methods to
rehabilitate the laryngectomy patient is given; the second
part contains a technical description of what seems to be
the most widely useful present technique, the tracheo-
oesophageal fistula/prosthesis method; and the final
section deals w i t h continuing work on a relatively new
idea, that of implanting an electromagnetic sound source
for voice restoration.
 Surgical a roachf-s to voice restoration j ; t e r total laryngectomy 327

it is no surprise that methods tried for voice restoration,

dating from the first successful laryngectomy, done by
Billroth in 1874, have been varied. Rather than dividing
these attempts into surgical vs non-surgical, historical vs
current, prosthetic vs non-prosthetic, etc., w e will base
our organizational scheme on the sound source devised
or reconstructed. W e can thus divide these approaches
into three main groups, each with a surgical and
non-surgical part. W e will call them the 'reed' group, the
'vibrating tissue segment' group and the 'electromagnetic
device' group.

THE REED GROUP

1
Non-surgical

In this method a prosthetic device containing a reed is

attached to the tracheostome and a tubing'system is run
into the pharynx through either mouth or nose. W h e n the
patient exhales through the device, the reed is excited and
the resulting sound is piped into the pharynx to be acted
upon by normal speech articulators.

Surgical

Into this group goes the very earliest attempt at voice

restoration. In 1874 Gussenbauer, while training under
Billroth, designed a reed bypass device .for use in the
patient w h o underwent Bill roth's first successful
laryngectomy . In this early laryngectomy, the pharynx
1

was left open and this provided a fistula into which sound
from his device could be directed. O n e more recent
example of a very similar idea is that described by Shedd
et a l .
2
328 Surgical approaches to voice restoration after total laryngectomy

THE VIBRATING TISSUE SEGMENT GROUP

3
Non-surgical

Main types are 'pseudowhisper', buccal, pharyngeal and

oesophageal s p e e c h . Only the last of these has practical
value, but the underlying idea is the same for all four:
non-pulmonary air is first trapped and then released
slowly to set either the cheek, the palate and base of
tongue, or the pbaryngo-oesophageal-walls into vibration.

Surgical

This group has received the most time and attention, both
historically and currently. All of these procedures are
designed to divert exhaled pulmonary air through
variously constructed fistulae in order to cause fistula tract
and/or pharyngo-oesophageal (POE) segment vibration.

The idea is to drive what is essentially oesophageal voice

with pulmonary, rather than swallowed, air. Although
surgical technique may vary, different tissues may be
used, a prosthesis may or may not be required, and results
and complications may differ, these procedures are
related in that the attempt is made to reconstruct a
vibrating tissue segment powered by pulmonary air
entering the POE lumen through a fistula of some sort. In
this manner such diverse procedures as Pearson's
near-total laryngectomy (which is actually an extreme form
of conservation s u r g e r y ) ' (Illustration
3 4
4) Staffieri's
technique - (Illustration 5 ) , the Asai p r o c e d u r e - (Illustra-
5 6 7 8

tion 6) Taub's present technique {Illustration 7) and the

9

Singer-Blom and Panje {Illustrations B and 73) techni-

10 11

ques may be classed, though somewhat artificially,

together.
Surgical approaches to voice restoration after total laryngectorn /
330 Surgical approaches to voice restoration cfi=:r total laryngectomy

THE ELECTROMAGNETIC DEVICE G R O U P

Non-surgical

T h i s concept is familiar as represented by any one of the

electrolarynx variations. A vibrating device is held against
the external surface of the neck to transmit sound through
soft tissue into the patient's articulatory tract ( A ) . This
basic idea has also been adopted in t h e attachment of a
sound-making device to a modified denture ( B ) . 12

Surgical

Under this heading fits the implantable voice source as

described by Griffiths, Fredrickson and B r y c e and then
13

by Bailey, Griffiths and Everett. W o r k in progress on this

14

idea at Washington University' is described and illustrated

in the final section of this chapter.

ANALYSIS OF METHODS

T h e great number of different procedures w h i c h have What, tnen, o. the surgia^j methods for creation of a
been tried a n d w h i c h are presently being u s e d testify to vibrating tissue segment? 1 - h s - m a j o r c r i t e r i a u s s d t 0

t h e fact that, perhaps until recently, n o o n e procedure compare these procedures a r simplicity f execution,
e 0

clearly superior to the others .had been d e v i s e d . H o w , rate of success in restoring v . .o i c e complication ( r a t e o f

t h e n , does o n e decide the best approach to take in (aspiration, fistula stenosis) a r , l d i j g quality of
t h e r s s u t n

rehabilitation? This is a highly complex question w h i c h 'voice'. \

can only b e dealt with briefly. First of a l l , this decision A review of the literature has; yielded reports generally
should b e t h e result of collaboration between t h e favourable to a number of t h e s . techniques, notably the
s u r g e o n , speech pathologist and patient. Most people
e

Asai, Staffieri,Taub, Singer-Blorr.,, . t it is

w o r k i n g in this area agree that perhaps t h e best
a n d P a n j e t y p e s Y e

probably fair to say that many c techniques have

postlaryngectomy method of communication, if the
3 f t h e s e

not become widely used because, | jp|

patient can master it/is good oesophageal s p e e c h . ' G o o d '
o f t h e n e e d f o r m u t e

stagings and revisions, high rat> f duce

should b e emphasized because as many as 40-60 per cent
e o f a i ! u r e t 0 p r o

voice, or aspiration of saliva and f d !

of patients w i l l not find this a truly satisfactory method.

0 0

Given these criteria, w e b e l i e f t h e Singer-Blom

A n d , as Snidecor points "out, even t h e best speak with t h a t

and Panje techniques are today's p r o c e d u r e s of choice in

limitations of fluency, loudness and rate of speech that the
those patients w h o do not qualify , f conservation surgery
norma} speaker does not e x p e r i e n c e .
15 o r

and in those w h o fail to learn go<-, oesophageal speech. d

A n o t h e r popular method of communication is that of W e base this o n the observation, compared to the t h a t f

t h e electrolarynx device. Depending on the patient's neck other restorative approaches, the* s s rate has been s u c c e

topography, dexterity and acceptance of the device's high high and the complication rate I c J f i i description of w A u

noise-to-signal ratio and mechanical s o u n d , this may or the Singer-Blom t r a c h e o - o e s - puncture/ o p n a o e a l

may not b e a useful method (Illustration 9). Certainly, prosthesis techmquefollows. Panje > (illustration 8) is si d e a

e v e n w h e n used skilfully, it can be generally only similar and therefore not described ^ \)y h e r e . u

r e c o m m e n d e d for its utility.

 Surgical approaches to voice restoration after total laryngectomy
In 1980 Singer and B i o m described a tracheoesophageal
10
puncture technique in which a small opening is created
between the trachea and oesophagus and kept patent by a
prosthesis. A similar procedure, but using a slightly
different prosthesis, was introduced by Panje in 1981.
11
Both prostheses have one-way valves which allow air to
pass from the trachea into the hypopharynx but prevent
food and saliva in the hypopharynx from entering the
trachea. T h e newest generation of both prostheses have
internal and external flanges to hold them in proper
position.
T o date, over a thousand of these procedures have been
done throughout the world. The initial success rate is
about 90 per cent, but during the first year this drops to
about 70 per cent mostly for reasons detailed b e l o w . T h e
procedure is very simple, complications are f e w , normally
minor, and usually easily resolved. Our results compare
favourably with other large series.
Timing of the procedure has been a matter of debate.
10
331
Some surgeons have performed 'the voice restoration
surgery at the time of total laryngectomy; others
recommend waiting between 2 and 12 months following
surgery. Our recommendation is to wait at least 6 months
following the laryngectomy to allow the patient time to
learn oesophageal speech. This is because w e consider
that, given all of the choices, 'good' oesophageal speech
is still a desirable method of postlaryngectomy com-
munication.
W h e n the patient fails to learn oesphageal speech and
surgery is agreed upon by surgeon, speech therapist and
patient, the patient undergoes extensive preoperative
teaching and counselling to prepare him or her for surgery
and the later care of the prosthesis. T h e stoma is examined
to be sure that it is large enough and that there is no
tracheitis. A small catheter is passed through the nose into
the oesophagus to perform the insufflation test to rule out
oesophageal spasm which can cause failure of a technical-
ly successful procedure to produce voice.
Technique
Surgery is done under a general anaesthetic in the
operating room. (Panje's has been described as an office
procedure.)
A modified bronchoscope with a hole cut on the midline
dorsal surface close to the distal end is u s e d . This is
positioned within the oesophagus parallel to the midline
of the posterior tracheal wall so that the hole is
approximately 5 mm inside the upper mucocutaneous
junction of the tracheostome. Proper positioning of the
bronchoscope prior to puncture is confirmed by palpation
of the special hole through the posterior tracheal w a l l . A
puncture is made through the posterior wall of the trachea
with the needle which then passes through the hole in the
bronchoscope and into its interior. W e use a 14 gauge
needle which is used normally for starting large in-
travenous lines. A No. 5 silk or a plastic IV cannula and
guide-wire can be passed through this needle once it is
correctly positioned as viewed through the modified
bronchoscope.
332 Surgical approaches to voice restoration after total laryngectomy

i S

The silk or cannula is grasped and brought out through

the proximal end of the bronchoscope, the needle is
removed, and only the silk is left trailing through the
puncture site. Now a curved needle is threaded onto the
stoma end of the silk to allow suturing of this end to the
distal (narrow) end of a 14 Fr red rubber catheter. While
the assistant pulls on the end of the silk coming through
the m o u t h , the surgeon pushes the catheter through the
puncture site to follow the silk. The catheter is pulled up
through the mouth in order to detach the silk.

Finally, the direction of the catheter is reversed under

direct vision so that it goes down the oesophagus toward
the stomach rather than upwards out the mouth.

The external portion of the catheter is sutured to the neck

or attached to a tracheotomy tape tied around the neck, 12
and left in position for between 2 and 4 days. At the end of
this time the catheter is removed in the office and the
prosthesis is fitted and secured.

RESULTS A N D D I S C U S S I O N "

In most cases speech is immediate or develops within the

first 24-49 hours of prosthesis fitting. To speak, the patient
must either simply 'exhale' while covering the tracheo-
stome or be fitted with a valved stoma cover. In either way
pulmonary air enters the pharyngo-oesophageal segment
t h r o u g h t h e p r o s t h e s i s . This c a u s e s p h a r y n g o -
oesophageal segment vibration, creating oesophageal
speech using pulmonary rather than swallowed air.
As previously stated, this has been a very satisfying Sound source
procedure in our hands with a long-term success rate of is pharyngo-
about 70 per cent for good voice production. Most of the oesophageal
segment
complications in our patients and in those from other walls
centres have resulted from improper fitting of the
prosthesis or improper care of the prosthesis by the
patient.
Problems with fitting may be avoided by making sure
that the prosthesis is not so long as to touch the posterior
oesophageal wall (causing pain) nor too short (failing to
keep the fistula l u m e n patent). Singer-Blom prostheses
13
will also fit poorly if the puncture site is placed too deeply
within the_ trachea. Poor patient motivation is also
responsible for some failures. Some simply will not Generally, patients have been very satisfied with the
perform the necessary daily cleansing and replacement quality of sound they produce. Pulmonary air-powered
procedure. Some will cough and leave out the prosthesis oesophageal speech is approximately the same in quality
or leave it out during cleaning long enough (as little as a as standard (swallowed air) oesophageal speech. Howev-
few hours) for the puncture site to close. In these cases, er, patients with the tracheo-oesophageal prosthesis can
repuncture is possible if indicated. phonate continuously for a longer time.
 Surgical approaches to voice restoration alter total larvngix tomv
Progress in medicine has been cioseiy tied to the
development of new technologies. Having thus far
reviewed the list of major ideas in use for the restoration
14
l)i
of voice after laryngectomy, and having described our
uescnoe a current project at wasnington University w h i c h
may, for a select group of patients, lesuit In another
practical approach to voice restoration after ablative
surgery.
T h e project involves implanting an electromagnetic
voice source into the patient's tissues using the technique
described below. This is investigational; w h e t h e r or not it
will ultimately prove to be a useful approach depends on
tissue acceptance of the implant, device reliability a n d the
quality of sound produced in comparison to present
methods.
Illustration 14 shows the overall scheme for the implant-
able voice source. The main features include an implant-
able voice source in the retropharyngeal soft tissue, a
shielded wire leading to a subcutaneous power and signai
input terminal on the chest, and a belt-worn power supply
and variable signal source. When a button in the pocket is
p u s h e d , the sound source is activated.
Given encouraging results from animal research, a pilot
study was done in two human volunteers. T h e r e were no
significant problems with placing the implant, either in
terms of the operative procedure or in terms of long-term
tolerance of prevertebral tissue, even in the face of
radiation. The voice achieved was felt to be significantly
superior to the hand-held electrolarynx, but still of
mechanical quality. Both patients were very pleased with
the device and used it freely for one year e a c h . At this time
one device failed and had to be removed, and the other
was removed because of swallowing difficulty, despite the
patient's objections to its removal. This latter patient had a
compromised pharyngeal lumen as a result of a total
laryngectomy combined with partial pharyngectomy.
W e feel that with technology presently available and our
experience thus far, no insoluble problems with device
reliability or tissue compatability will be encountered. The
major determinant of eventual clinical usefulness may be
the quality of sound possible with this approach.
33-5 Surgic.il approaches to voice restoration aiter total laryngectomy
References
1 OuviPnbatiPr, C, Uebpr die prste durchTh. Billroth am
Menschen ausgefuhrte Kehlkopf-Exstirpation, und die
Anwendung eines kunstlichen Kehlkoptes. Vernandlungen
DeutschenGesellschaft fur Chirurgie 1874; 3:76-39
2. Shedd, D., Bakamjian, V., Saka, K., Hann, M., Barba, S.,
Schaff, N. Reed-fistula method of speech rehabilitations after
laryngectomy. The American Journal of Surgery 1972; 124:
510-514
3. Pearson, B. W . , Woods, R. D., Hartmann, D. £. Extended
hemilaryngectomy for T3 glottic carcinoma with preservation
of speech and swallowing. Laryngoscope 1980; 90:1950-1961
4. Pearson, B.W. Subtotal laryngectomy.The Laryngoscope
1981; 91: 1904-1912 -
5. Staffieri, M. New surgical approaches for speech
rehabilitation after total laryngectomy. In: Shedd, D. P.,
Weinberg, B. (eds). Surgical and prosthetic approaches to
speech rehabilitation, pp. 77-117 Boston: C. K. Hall & Co.,
1980
6. Griffiths, C. M., Love, ]. T. Neoglottic reconstruction after
total laryngectomy. A preliminary report. Annals of Otology,
Rhinology and laryngology 1978; 87:180-184
7. Asai, R. Laryngoplasty after total laryngectomy. Archives of
Otolaryngology1972; 95:114-119
R Miller A. H . Four vears' ° x o - r i p n r p with the As^i technique
Journal of Laryngology and Otology 1971; 85: 567-576
9. Taub, S., Spiro, R. H. vocal rehabilitation of laryngectomees.
Preliminary report of a new technique. American Journal of
Surgery 1972; 124: 87-90
10. Singer, M. I., Blom, E. D. An endoscopic technique for
restoration of voice after laryngectomy. Annals of Otology,
Rhinology and Laryngology 1980; 89: 529-533
11. Panje, W. R. Prosthetic vocal rehabilitation following
laryngectomy. The voice button. Annals of Otology,
Rhinology and Laryngology 1981; 90:116-120
12. Goode, R. L. Artificial laryngeal devices in post-laryngectomy
rehabilitation. The Laryngoscope 1974; 85: 677-689
13. Griffiths, M. V., Fredrickson, J . M., Bryce, D. P. An
implantable electromagnetic sound source for speech
production. Archives of Otolaryngology1976; 102: 676-682
14. Bailey, B . ] . , Griffiths, C. M., Everett, R. An implanted
electronic laryngeal prosthesis. Transactions of the American
Laryngology Association 1977; 97: 71-82
15. Snidecor, J. C. Some scientific foundations for voice
restoration. The Laryngoscope 1975; 85: 640-648
1 i 1 ustrations by Robert N. Lane
Hugh P. Biller M D
Professor and Chairman, Department of Otolaryngology, The Mount Sinai Medical Center, New Y o r k , U S A
Preoperative
indications
T h e procedure of vertical partial laryngectomy is utilized
to resect vocal cord cancers which extend to involve one
or more of the following sites: anterior commissure and
opposite cord; subglottic extension p J ^ c m o M l e s s ;
posterior extension to involve the vocaT^process or
anterior face of the arytenoid. T h e procedure is also
utilized for tumours limited to the membranous vocal
cord in young patients where irradiation may be consi-
dered contraindicated. The procedure is also used in
select cases of recurrent tumour following treatment with
radiotherapy. In these cases it is important that the
following criteria be considered. (1) T h e original lesion,
prior to treatment with radiotherapy, is amenable to a
vertical partial laryngectomy. (2) The recurrence is in the
same area as the original tumour. (3) Subglottic involve-
ment is less than 0.5 c m .
Contraindications to hemilaryngectomy
Cartilage invasion
Cartilage invasion is always a contraindication to vertical
partial laryngectomy.
Vocal cord fixation
Vocal cord fixation secondary to subglottic involvement or
cricoarytenoid joint involvement is a contraindication to
partial laryngectomy. Vocal cord fixation from vocalis
muscle invasion or tumour bulk is not necessarily a
contraindication. Transglottic tumours should not be
treated by a vertical partial laryngectomy because of the
significant incidence of recurrence which is most probably
a result of tumour in the pre-epiglottic space.
Preoperative assessment
in order to perform vertical partial laryngectomy and to be
able to remove the tumour with adequate margins, it is
essential that the exact extent of the lesion is recognized
preoperatively. This may be determined by indirect
laryngoscopy and direct laryngoscopy. In lesions which
extend subglottically, it is necessary to be able to assess
the exact distance from the free margin of the vocal c o r d .
This can be assessed by a laryngogram o r with a C T scan.
335
336 Vertical partial laryngectomy
Anaesthesia and position of patient
The operation may be initiated with the patient under
local or general anaesthesia. If local anaesthesia is decided
upon then a tracheotomy is performed under local
anaesthesia through a transverse incision two finger's
breadth above the sternal notch. The trachea is opened
and an endotracheal tube is inserted into the trachea. T h e
opposite end of the tube is slipped under the drapes for
the anaesthetist to connect to.the anaesthetic machine.
T h e patient is then anaesthetized. This procedure is
performed under sterile conditions so there is no need to
reprepare and drape the patient.
If general anaesthesia is utilized the patient is induced
and anaesthesia maintained through a 7.5 mm oral
endotracheal tube. The patient is then positioned. A smal!
roll is placed under the shoulders to allow maximum
extension of the neck. T h e patient is prepared and draped
in the routine manner. The endotracheal tube is brought
superiorly from the oral cavity and taped to the forehead
over four or five sponges. The draping should be such that
the anaesthetist can extract the endotracheal tube without
contaminating the field. This will occur when the
tracheotomy is completed and the endotracheal tube is
inserted into the tracheotomy site. The distal end of this
tube is then passed under the drapes for the anaesthetist
to connect to the anaesthetic machine. T h e drapes are
sutured in place.
The incision
Following completion of the tracheotomy and institution
of the anaesthetic through the tracheotomy site the
transverse incision from the tracheotomy is extended
bilaterally from the midline to the external jugularveTh'
This flap is elevated deep to platysma muscle and superior
to the level of the hyoid bone. T h e flap is then sutured to
the upper drapes. -
2
The sternohyoid and sternothyroid muscles are separated
in the midline. T h e anterior aspect of the thyroid cartilage,
cricoid cartilage and first two tracheal rings are exposed.
This may or may not require dividing the isthmus of the
thyroid gland. A n incision is made~Tn~"fhe thyroid
perichondrium in the midline extending from the thyroid
notch to the lower border of the thyroid cartilage. The
perichondrium is elevated. T h e elevation is first per-
formed with a 'peanut' and then completed with an
elevator. T h e perichondrium on the side of the lesion is
elevated posteriorly to approximately 1 cm from the
posterior border of the thyroid cartilage.
3
O n the contralateral side the perichondrium is elevated
only a centimetre or two. T J i e ^ i o s t e j i o j i c j j i i Q ^ e thyroid
cartilage is placed 1.5 cm anterior to the posterior border
of the thyroid cartilage. This cut runs in an inferosuperior
direction. T h e anterior cut varies depending upon the
anterior extent of the tumour.

If the tumour of the vocal cord does not extend to the

anterior commissure then the anterior cartilage cut is in
the midline and extends from the base of the thyroid
notch to the lower border of the thyroid cartilage.
338 Vertical partial laryngectomy

5
If, on the other h a n d , the tumour involves the anterior
commissure the anterior cut is placed approximately
1-1.5 cm from the midline on the side of lesser involve-
ment and extends from the superior aspect of the thyroid
cartilage to the inferior aspect.

Following completion of the thyroid cartilage cuts, the

cricothyroid membrane is incised transversely just above
the cricoid cartilage. This transverse cut begins in the
midline and extends to the side of lesser involvement
along the upper border of the cricoid cartilage.
 Vertical partial laryngectomy 339

Through this incision, by the use of a hook, the subglottic

mucosa is visualized on the side of greater involvement of
the tumour. If the area is clear an incision is made
following the upper border of the cricoid cartilage from
the anterior midline laterally and posteriorly. This will
allow sufficient exposure of the undersurface of the cords,
but it will be difficult to see the undersurface of the
anterior commissure.

In order to visualize this area it is necessary to place the

patient in the Trendelenberg position and to retract the
cricothyroid membrane superiorly. A n elevator is then
introduced from below, between the vocal cords, and the
normal vocal cord is abducted. T h e margin of the involved
cord and the anterior commissure are then visualized. In
order to perform this the patient must be paralyzed. Only
after the anterior commissure is visualized is the thyr-
otomy completed. It is decided whether to perform the
thyrotomy through the anterior commissure or whether 1,
2 or 3 mm of the opposite Cord is to be included in the
resection. Depending on this decision a scape! is utilized
to continue the superior extent of the thyrotomy either at
the commissure or through a portion of the opposite vocal
cord. The thyrotomy continues to the superior border of
the thyroid cartilage. The two thyroid alae are then
retracted with hooks.

T h e tumour is visualized. Normal vocal cord is retracted

using a right-angle retractor and a tenaculum is placed at
the false cord level of the hemilarynx to be resected.
Scissors are then used to cut the soft tissue above the false
cord at the level of the superior border of the thyroid ala
w h i c h is being resected. As this incision progresses
branches of the superior laryngeal artery will be encoun-
tered. These should be clamped and suture-ligated.
Following mobilization of the superior aspect of the
hemilarynx the inferior or subglottic area is incised along
the superior border of the cricoid cartilage. This incision
continues posteriorly to the area of the cricoarytenoid
joint. T h e posterior cut may either be through the vocal
process, through the body of the arytenoid or posteriorly
so the entire arytenoid is removed w i t h the specimen,
depending upon the extent of the lesion. Following
removal of the hemilarynx, bleeding vessels are caute-
rized. T h e cut margin of the opposite true vocal cord is
sutured anteriorly to the perichondrium with interrupted
4/0 chromic sutures
340 Vertical partial laryngectomy

in
The epiglottis is fixed anteriorly with a mattress suture of 0
chromic which extends from the perihyoid tissue through
the petiole of the epiglottis and then through the
perihyoid tissue w h e r e it is tied.
The reconstruction of the resected hemilarynx depends
upon whether or not the arytenoid has been removed. If
the arytenoid has not been removed then no reconstruc-
tion is performed and the laryngostome is closed by
approximating the perichondrium on each side with
interrupted absorbable sutures. The strap muscles are
then reapproximated as the second layer. If, on the other
hand, the arytenoid has been removed then it is essential
to replace the arytenoid to avoid a deficient posterior
glottic chink, which results in significant aspiration. T h e
closure of this posterior defect may be accomplished by
the use of muscle fat, fascia, tendon or cartilage'. T h e
author prefers the use of free or pedicled cartilage. A
piece of cartilage from the posterior border of the thyroid
ala, tailored to measure approximately 1 cm x 5 m m , is
wired to the arytenoid facet of the cricoid. The cartilage
may be pedicled on the inferior constrictor muscle or may
be utilized as a free graft. The mucosa from the
postarytenoid, postcricoid and medial wall of the piriform
sinus is mobilized, thinned and utilized to resurface the days. If the tracheotomy tube can be corked for 48 hours,
cartilage reconstruction as well as the area of the resected it is then removed along with the nasogastric tube. T h e
true and false cord. This mucosa! flap therefore is sutured tracheotomy opening is taped and the patient is started on
with interrupted 4/0 chromic sutures along the subglottic oral feeds. In general, aspiration is minimal or does not
area. Closure of the laryngostome is accomplished by occur. The patient usually is discharged 2 or 3 days
approximating the perichondrium from one side to the following removal of the tracheotomy tube. In those
other with interrupted absorbable sutures. The strap patients with a keel in place, the tracheotomy tube is not
muscles are approximated as a second layer. If in the removed. The nasogastric tube is removed at 7 days and
resection the opposite vocal cord has been resected to the patient is discharged to be readmitted in 6 weeks for a
such a degree that the anterior margin cannot be sutured laryngoscopy and removal of the keel. T h e tracheotomy
to the anterior cartilage cut, then postoperative webbing tube is removed the next day.
of the anterior larynx may occur leading to a decrease in
the anteroposterior diameter and possibly stenosis. In
Complications
view of this, a Silastic keel is inserted anteriorly within the
larynx in an attempt to avoid the webbing. There are only two significant complications: inadequate
airway resulting in inability to decannulate the patient;
Closure is the same except that the keel extends
and persistent aspiration.
anterior to the approximated strap muscles. This portion
of the Silastic is pierced with a 2/0 nylon suture w h i c h is The first is unusual but may occur in those patients w h o ,
then fixed on either side of the neck with a button. T h e following arytenoid removal and reconstruction, have a
skin flap is reapproximated in layers. A Penrose drain is flap which becomes bulky and oedematous. This bulky
inserted and the endotracheal tube is replaced with a N o . flap may prevent decannulation because of an inadequate
7 or N o . 8 tracheostomy tube with a cuff. A nasogastric airway. In this case, a laryngoscopy is performed at 8
tube is inserted and a light dressing is applied. w e e k s and the flap is removed with a biting cup forceps or
with the laser. Decannulation can usually be accom-
plished 1-2 weeks later.
Late stenosis from scarring may occur thereby produc-
ing an inadequate airway requiring a tracheotomy. This
complication usually requires corrective surgery of the
larynx using a thyrotomy and skin grafting with a stent.
Routine tracheotomy care is performed: humidified air via Occasionally, the stenosis may be corrected by using the
a collar mask, frequent tracheal suction, and adequate laser perorally through the laryngoscope.
hydration. Prophylactic antibiotics are used routinely In patients with persistent aspiration the specific
beginning preoperatively and continuing until 12 houring causative factor or factors must be determined. The larynx
postoperatively. Naso-gastric tube feeding is instituted at is visualized to assess whether there is glottic closure or
approximately 48 hours after demonstration of adequate incompetence. If glottic closure is adequate then it is
bowel sounds. Ambulation is begun the morning follow- necessary to evaluate whether there is oesophageal or
ing surgery. T h e laryngeal airway is usually adequate for crtcophrayngeal obstruction. If glottic closure is inadequ-
corking of the tracheotomy tube at approximately 6-7 ate then correction is necessary. This may require Teflon
days, except in patients who have had arytenoid removal injection or reoperation to correct the incompetence by
and replacement, w h e n corking can usually be done at 14 muscle or cartilage implants.
illustrations by Robert N. Lane

H u g h F. Biller M D
Professor and C h a i r m a n , Department of Otolaryngology, The Mount Sinai Medical Center, New York, U S A

Preoperative Contraindications

1. T u m o u r w h i c h crosses the ventricle to involve the true

indications
This procedure is utilized to treat tumours which involve
the epiglottis and/or false cords. In select cases it may be
utilized to resect tumours involving the medial or anterior
wall of the piriform sinus.
vocal c o r d .
2. involvement of the interarytenoid space.
3. -'Significant involvement of the arytenoid which' would
prevent an adequate margin with disarticulation of the
cricoarytenoid joint.
4. Limitation or fixation of the vocal cord.
5. C A T scan evidence of paragiottic involvement.
6. -A 2 mm margin at the inferior extent of all supraglottic
tumours.

341
342 Horizontal partial laryngectomy

Positioning of patient

T h e patient is placed supine with a pillow under the

shoulders and the neck extended.

Anaesthesia

Anaesthesia is initiated and maintained by endotracheal

i n t u b a t i o n . F o l l o w i n g preparation and draping a
tracheotomy is performed through a vertical incision and
anaesthesia is then maintained through the tracheotomy
site. This procedure is performed under sterile conditions
and repeat preparation and draping is not necessary. A n
alternative method is to perform the tracheotomy under
local anaesthesia following preparation and draping.

The incision

A transverse incision is made at the level of the cricoid

cartilage if a neck dissection is not performed. If a neck
dissection is being performed with the primary section, a
modified H-type of incision is utilized. .The neck dissec-
tion is completed before the primary tumour is resected
and the block of tissue is left attached at the thyrohyroid
membrane.

2
 Horizontal partial l a r v n g e a o n n J4i

The strap muscles are cut at the superior border of the

thyroid cartilage. O n the side of the lesion these muscles
are severed from the thyroid notch to the posterior border
of the thyroid cartilage. O n the side of lesser involvement
they are sectioned only approximately midway to the
posterior border. Perichondrium along the superior
border of the thyroid cartilage is then incised and
reflected inferiorly to the lower border of the thyroid
cartilage. The superior cornu of the thyroid cartilage on
the side of the lesion is mobilized.

T h e cartilage is then marked prior to sectioning with a

saw.

T h e anterior cut is at the junction of the lower two-thirds

w i t h the upper one-third of the thyroid ala. From this
p o i n t , on the side of the lesion, the cut extends
posteriorly to the mid-portion of the posterior border of
the thyroid ala. O n the contralateral side the cut extends
superiorly to the mid-portion of the superior aspect of the
thyroid ala. The hyoid bone is mobilized and the
suprahyoid muscles are sectioned from the hyoid bone.
T h e hyoid bone is cut at the lesser cornu on the side of
least involvement. T h e pharynx is opened through the
vallecula and epiglottis is grasped with a tenaculum.
344 Horizontal partial laryngectomy

///.

6a, b & c
The resection begins on the side of least involvement by
incising the margin of the epiglottis. The aryepiglottic fold
is sectioned just above the arytenoid cartilage. All cuts are
made after the tumour is adequately visualized. T h e
ventricle and true vocal cord are observed. In order to
improve visibility the patient is paralysed and the severed
aryepiglottic fold is retracted laterally with a hook. J_he_
^iiKisjoiijxQiSj^sjh^^ aspect of the false cord to
the ventricle and extends anteriorly to the anterior
commissure. T h e entire supraglottis is then rotated to the
side of greater involvement.
Horizontal partial laryngectomy
346 Horizontal partial laryngectomy

RECONSTRUCTION

8
A cricopharyngeal myotomy is performed posterior to the
recurrent laryngeal nerve by incising the cricopharyngeal
muscle over a finger placed in the upper oesophagus. The
recurrent laryngeal nerve is not identified.
If the arytenoid has been resected it must be recon-
structed in order to prevent a postoperative posterior
glottic defect, w h i c h will result in aspiration. A free piece
of cartilage is taken from the superior aspect of the thyroid
ala and wired into place at the cricoarytenoid joint. T h e
vocal process is then wired to the graft or the cricoid. The
entire reconstructive area is covered by a flap from the
aryepiglottis.

9
T h e pharyngostome is closed by approximating the
perichondrium and~cuT; margin ot tfTe strap muscles to the
base of tongue. This is a single-layer closure; the suture
material used is 0 silk. A\\ sutures.are inserted and then
they are tied, beginning at the site of least resection. T h e
suture in front of the one to be tied is crossed so that the
tension is removed from the suture being tied. The head is
also flexed to relieve tension on the suture line. Closure
on the side w h e r e the pharyngostome is largest is
performed by a specially placed suture. En route from
base of tongue to perichondrium this suture passes from
outside-to-in and tnside-to-out at one or more areas of the
cut margin of the lateral pharyngeal w a l l . This inverts the
cut margin, thereby strengthening the c l o s u r e . T ^ l o w i n g .
^ o s j j r e ^ o f . j l T e , pharyngostome the flaps are reapproxi-
mated by suturing the platysma muscle and then the skin.
If a neck dissection has been performed Hemovac
drainage is utilized. If a neck dissection has not been
performed two Penrose drains are utilized.

Postoperative care
T h e patient is f e d by nasogastric t u b e . Routine
tracheotomy care is instituted. Ambulation is begun the
day^following surgery. At 7 days the sutures are removed.
At 14 days the tracheotomy tube is occluded for 24 hours
a n d if the airway is adequate the tracheotomy tube is Carotid artery
removed. T h e tracheotomy site is allowed to close.
Feedings are not begun until the tracheotomy site is 9
closed. T h e nasogastric tube is removed at 18-21 days and
peroral feedings are begun which initially consist of only
solid foods, with intravenous supplementation given as
required for the first 3 - 4 days. After feeding with solids is
accomplished liquids in the form of cold carbonated
beverages can then be'introduced.
 lustrations by Angela Christie and Frank Price

P. McKelvie M D , ChM, F R C S , D L O
Consultant Ear, Nose and Throat Surgeon, T h e London Hospital and
Royal National Throat, Nose and Ear Hospital, London, UK

Paralysis of the vocal cord{s) may warrant two quite separate types of surgical intervention.

1
T h e first is directed at unilateral palsy, w h e n there is a weak voice, with 'air wastage'. T h e functioning vocal cord is unable
to reach across to, and phonate against, the flaccid-palsied or abducted c o r d . Operations are to give bulk to; to splint or to
adduct the palsied c o r d .
The second type of operation is to separate bilaterally-fixed, palsied or otherwise damaged vocal cords w h i c h are
obstructing the laryngeal airway.

347
348 Surgervot laryngeal paralysis

PALSY The operation is performed by microlaryngoscopy under

(treated by intracordai injection of
Teflon paste)
indications
1. A weak voice in a unilateral vocal cord palsy of at least
six months' duration, or of shorter duration if the palsy
is caused by malignant disease.
2. More rarely, vocal cord palsy accompanied by aspira-
tion of pharyngeal contents into the trachea.
general anaesthesia.
Intravenous induction followed by intubation with a
fine polythene catheter through which nitrous oxide,
oxygen and halothane (Fluothane) are delivered, affords a
safe, manageable regimen. Local anaesthetic and non-
intubation general anaesthesia have obvious advantages,
but are less generally applicable.
The palsied vocal cord is viewed with an operating
microscope, fitted with a 300 mm objective' thr^ogh a
microlaryngoscope. T h e endotracheal catheter is adjusted
to occupy the interarytenoid region. A Brunings syringe
primed with 2 ml of Teflon paste is used to inject the vocal
cord at two points. (Loading the syringe needs practice.
The Teflon paste tube may be stored in sterilizing solution
to allow a sterile loading technique to be used.)

Contraindications

Impaired airway, in which reduction, however slight;

might be an embarrassment.
2
The first point is in the middle third of the vocal c o r d ,
2.5 mm clear of (lateral to) the cord margin and 2.5 mm
anterior to the tip of the vocal process. Paste is injected
until the cord assumes a fusiform shape, usually needing
three to six clicks of the syringe. The bulge on the cord
should reach the midline.

3
A second injection is made further forward at the junction
of the anterior and middle thirds of the vocal cord, the
margin being 'straightened' by the injection. Rarely, if a
defect is visible further anteriorly, there is need for a third
injection in the anterior third of the cord, usually of a very
small v o l u m e .
Paste flows from the syringe after piston pressure has
been discontinued and surplus paste has to be sucked
carefully from the injection sites. Oedema follows within
10 minutes and is rarely of consequence.

Rarely a hemilaryngitis warrants heavy antibiotic and

steroid cover.
A careful postoperative watch for airway obstruction is
mandatory, although obstruction warranting tracheos-
tomy is extremely rare, and for the most part confined to
those with bilateral vocal cord weakness, respiratory
infection and laryngeal/pharyngeal incapacity due to gross
neurological disease.
 Surgery of laryngeal paralvsis l-Y)

low transverse incision is used. O n completion, the

O H A T C D A I \/or&! r o p n

PALSY
(treated by arytenoidectomy)
Airway obstruction due to bilateral vocal cord paralysis in
adduction and to midline fixation of the vocal cords may
be relieved by arytenoidectomy to separate the cords.
Excellence of voice has to be exchanged for this
improvement in the airway.
Evisceration of the vocal cord bulk, and endoscopic,
external lateral and external frontal routes for arytenoid-
ectomy have all been devised.
The operations
THE FRONTAL APPROACH
If no tracheostomy is already present, this is done under
general anaesthesia with an endotracheal tube in place. A
cuffed tracheostomy tube, the anaesthetic tubing coming
up over the chest, under new towelling, leaving a clear
operation field.
A second transverse incision is made immediately below
the pomum adami, extending as far as the anterior border
of the sternomastoid muscles. T h e thyroid cartilage is
skeletonized in the midline by division of the platysma
and separation of the sternohyoid muscles.
More clearance of soft tissues is effected on the left side
since a suture is to be inserted later, close to the midpoint
of the thyroid ala, near to its posterior border.
The wound is opened to a diamond shape, revealing the
full height of the thyroid cartilage and a part of both
cricothyroid and thyrohyoid membranes; a mastoid
retractor under skin and platysma reveals the area.
Laryngofissure shears or thyrotomy scissors are used to
split the thyroid cartilage in the midline, starting from a
small stab incision in the cricothyroid membrane and
extending up to divide the lower half of the thyrohyoid
membrane and the adjacent part of the infrahyoid
epiglottis. Care is taken to avoid an off-centre division of
the anterior commissure of the vocal cords, by dissecting
the intralaryngeal soft tissues clear of the cartilage before
introducing the deep blade of the shears.

4
A laryngofissure retractor is inserted and is- carefully
opened; further horizontal division of the cricothyroid
membrane, may be required to gain access without
disrupting the thyroid alae with the retractor.
An operating microscope with a 300 mm objective is
used to view the arytenoid to be removed; this is usually
the left one in a symmetrically palsied larynx, and the
operator sits to the patient's right.
The vocal process of the arytenoid is identified by
moving the vocal cord with a probe w h e n the junction of
the rigid process and the soft membranous cord becomes
evident.
Fine scissors are used to make a vertical incision
through the vocal cord margin at the tip of the vocal
process. T h e incision is carried u p , obliquely and
posteriorly along the upper surface of the vocal process
4 and on to the upper surface of the arytenoid at the level of
the false vocal cord.
350 Surgery of laryngeal paralysis

By spreading the scissors in a vertical plane, the vocal

process is dissected free and the body of the arytenoid
cartilage revealed. Non-toothed forceps or a skin hook are
used to control the easily-fragmented, very mobile
cartilage. T h e scissors are spread horizontally in the
crico-arytenoid joint and the cartilage is rotated upwards,
thus revealing the posterior aspect. T h e substantial
insertions of the interarytenoid and - crico-arytenoid
musculature are divided hard against the cartilage keeping
intact the pharyngeal mucosal surfaces beyond.
T h e cartilage is then freed and removed, leaving a
substantial space.

The slightly tortuous incision is closed with 5/0 atraumatic

catgut.
A braided stainless steel suture, with an atraumatic
needle at each e n d , is used to fix the operated cord in
abduction.
T h e posterior end of the membranous cord is trans-
fixed, close to its margin, with one needle, w h i c h is then
passed from the lumen of the larynx above the cord and
through the thyroid lamina in the depths of the laryngeal
ventricle. T h e other needle is passed through the lamina
in the subglottis so that the suture appears above the
inferior cornu of the thyroid cartilage. T h e suture is placed
so as to pull the vocal cord against the inner surface of the
thyroid cartilage and also move the posterior end of the
cord bulk interiorly, since its posterior end has already
lost the height of the arytenoid cartilage. T h e free
needle-bearing ends are knotted externally, i.e. on the
outer surface of the thyroid ala.
This manoeuvre offsets the positions of the vocal cords,
yieldirrg-a more generous though tortuous airway.
T h e thyroid laminae are affixed anteriorly with through-
6 and-through catgut sutures and the wound drained for 2
days under firm dressings.
O n the fourth day attempts are made to cork the
tracheostomy tube; if the laryngeal airway appears to be
adequate, decannulation is done after 2 nights spent with
the tracheostomy tube corked.
Balanced views on these procedures are given by Dedo
and Montgomery . 2
 Surgery ot laryngeal paralysis 35!

I fit. w - ' - ' '

^ number of lateral approaches have been described "" . 5 7

In Woodman's popular technique an arytenoidectomy

6

is performed from a lateral approach, though most of the

thyroid cartilage is retained and the vocal cord, with
perhaps the tip of the vocal process of the arytenoid, is
fixed to the lower border of the thyroid ala with a retaining
suture.
This procedure is as follows:

7
A preliminary, temporary tracheostomy is carried out. A n
incision is made in the neck along the anterior border of
the sternomastoid muscle to retract that muscle posterior-
ly and the strap muscles anteriorly. T h e thyroid ala is
exposed anterior to,the carotid sheath, and the inferior
constrictor dissected to its posterior margin. T h e
perichondrium is then incised and carried over on to its 7
medial margin by blunt dissection.

8
T h e cricothyroid joint may be dislocated at this point. T h e
mucosa of the pyriform fossa is then deep to the
dissection, which is carried. forward to the cricoid
cartilage. A finger detects the anatomy through this
mucosa and dissection is carried out along the cricoid
cartilage, extramucosally, until the muscular process of
the arytenoid is reached. Two dissections are then made.
In o n e , the mucosa is elevated over the upper surface of
the arytenoid cartilage. In the other the crico-arytenoid
joint is separated by spreading fine scissors in the joint
space.

The arytenoid cartilage is removed by traction and

dissection, the tip of the vocal process being left. At this
point, a suture is placed either around the inferior cornu
of the thyroid cartilage or through its substance, fixing the
vocal process or the adjacent part of the vocal cord to the
wall of the larynx in far abduction. It is worthwhile viewing
this procedure endoscopically: 6 mm separation should
be achieved at the posterior ends of the vocal cords.
Chromic catgut 3/0 or braided steel suture is used. It is
beneficial to suture the vocal cord laterally at a different
level to its original, in that the airway is improved by
offsetting the height of the vocal cord against its fellow.
352 Surgery of laryngeal paraKsis

Closure Is done by covering the thyroid cartilage with its

perichondrium, fixing the strap muscles to the anterior
border of the sternomastoid and closing the skin with
subcutaneous catgut and then silk, without any drainage.

Postoperatively some intralaryngeal, intratracheal spill-

over is to be expected, and soft foods, jellies or mince are
given in the first few days. The better the airway, the
poorer the voice to be expected; indeed the patient
exchanges excellence of voice for airway. T h e speech
therapist nonetheless can advise how to minimize the air
waste.

References
1. Dedo, H. H., Urrea, R. D., Lawson I . Intracordal injection of 5. Woodman, De G. A modification of the extralaryngeal
Teflon in the treatment of 135 patients with dysphonia. Annals approach to arytenoidectomy for bilateral abductor paralysis.
of Otology1973; 82: 661-667 Archives of Otolaryngology1946; 43: 63-65

2. Montgomery, W. W. Surgery of the upper respiratory system,
Vol. 2. Philadelphia: Lea and Febiger,1973: 445
3. King, B. T. A new and function-restoring operation for bilateral
cord paralysis: Preliminary report. Journal of the American
Medical Association 1939; 112: 814-823
4. Kelly, J . D. Surgical treatment of bilateral paralysis of the
abductor muscles of the larynx. Transactions of the American
Academy of Ophthalmology and Otolaryngology 1940; 45:
133-145
6. Woodman, De C. The open approach to arytenoidectomy for
bilateral abductor paralysis witj/a report of 23 cases. Annals of
Otology, Rhinology and Laryngology 1948; 57: 695-704
7. Woodman, De C. Rehabilitation of the larynx in cases of
bilateral abductor paralysis. Open approach to
arytenoidectomy, with report of the last4 years' experience.
Archives of Otolaryngology 1949; 50: 91-96
Illustrations by Angela Christie

Peter McKelvie M D , C h M , F R C S , D L O
Royal National Throat, Nose and Ear Hospital, London, UK

Introduction

Epiglottopexy is a surgical technique to prevent intractable between the arytenoids are the major features of the
aspiration in laryngopharyngeal palsies. A permanent procedure. T h e epiglottis is fixed like a lid on the top of
tracheostomy and a small laryngopharyngeal fistula the larynx.
35-4 Epiglottopexy

A right lateral approach along the anterior margin of the

right sternomastoid muscle is used after the establishment
of a permanent tracheostomy through a separate trans-
verse incision. T h e dissection proceeds medial to the
sternomastoid muscle and carotid sheath.

The pharynx is opened posterior to the ala of the thyroid

cartilage, revealing the piriform fossa. Retractors are
applied to draw the larynx forward and to the left,
revealing the posterior surface of the epiglottis from
which mucosa Is resected with scissors. Attachments of
mucosa and perichondrium to cartilage are firm and the
dissection may be done better with a Treer's dissector.
The mucosa of the aryepiglottic fold is removed and a
sequence of silk sutures is inserted, first on the left, then
on the right side and left long for tying at the end of the
operation.
 Epiglottopexy .i^n

C\.

3a, b & c
The epiglottis is sutured onto the upper surface of the
laryngeal inlet in the manner of a hinged lid. A
cricopharyngeal myotomy is performed with a finger
inserted Into the upper oesophagus and a fine-bore
nasogastric tube is left in place.

T h e mucosa is closed with chromic catgut in the

pharyngeal w a l l . Suction drainage is inserted and main-
tained for 3 days.

T h e fine-bore nasogastric tube is only withdrawn w h e n

continent swallowing is established. It may be appropriate
to close the whole of the laryngeal inlet with the epiglottis
since the tiny interarytenoid area is closed with difficulty
and can be reopened endoscopically. This method
ensures a continent laryngeal closure. A valved tracheos-
tomy tube for speech purposes cannot be w o r n since the
fistula left is so tiny. The tracheostomy, therefore, has to
be a permanent feature.
Illustrations by G i l l i a n Lee
A. G . D. Maran M D , FRCS, FACS
Consultant Otolaryngologist, Royal Infirmary, Edinburgh, U K
With the advent of n e w , reliable methods of reconstruc-
tion and a more critical appraisal of functional results, the
treatment of tumours of the oral cavity has undergone
great change in the last 5 years. It is impossible in a
chapter of this length to encompass all the methods of
reconstruction available. 5ome standard general prin-
ciples will be outlined here and some well-tried methods
of treatment at different sites will be described.
ore.
Neck dissection policy
There is no doubt that if ipsilateral nodes are palpable, a
standard radical neck dissection should be performed. If
contralateral or bilateral nodes are palpable, serious
consideration should be given to the possibility that the
patient may not be curable. Bilateral neck dissection in
oral cancer is not totally contraindicated but the patient
survival figures are low. If no nodes are palpable, the
choice lies between performing a functional neck dissec-
tion or a bilateral suprahyoid dissection with node
sampling followed by a full neck dissection if any samples
are positive.

Radiation therapy
ji tne iiidiiuiuie tid* oeen irrauiateu, a oone gran win not
usually be successful if salvage surgery is performed later.
For this reason radiation should not be used in the
anterior part of the oral cavity: loss of the anterior arch of
the mandible is a terrible defect both functionally and
cosmetically. Loss of the lateral part of the mandible does
not present such great problems.
if teeth are irradiated, the patient must be motivated to
attend regularly for periodontal attention because debris
collecting in the gingival pockets is potentially of much
greater significance in the irradiated than in the non-
irradiated mouth. Caries at the neck of a tooth can lead to
later osteoradionecrosis of the mandible. Since people
have a greater awareness of dental health than formerly,
full dental extraction is no longer an acceptable prere-
quisite of radiation treatment of the oral cavity. If the teeth
are in poor condition, however, they should be removed
prior to treatment.
T h e place of external irradiation of the tongue and floor
of the mouth is still debatable but implants are a well-tried
method in the treatment of T 1 and T 2 lesions.
Perhaps the main drawback to irradiation of the oral
cavity is the problem of detecting a recurrence. It is very
rare for a recurrence to manifest itself on the surface
mucosa. Often only a hard area is felt in the tongue, or the
patient develops trismus as the tumour spreads into the
pterygoid region. Either way it is usually impossible to
obtain a biopsy in time to perform salvage surgery.
The tongue
In order to be usefully mobile the tongue needs a
gingivolingual sulcus. It also needs at least one hypoglos-
sal nerve and the bulk of geniogiossus and the lateral
interdigitations of the hyoglossus. For good articulation
the tongue also needs a tip which functions and can be
protruded against teeth or a lower alveolus.
Tumours ot the oral cavity 357
Because the horizontal distance between the frenulum
T n d the or°eoi'3'o 't!'~ ^ P . I I " . v"—
- r- ••
,
,
mvoive tne aeeper part or the geniogiossus muscle
demand not only a total glossectomy but also either a
concomitant laryngectomy or at least removal of the entire
pre-epiglottic space. Total glosseotomy on its o w n tor
malignant disease is an illogical procedure.
The mandible
Removal of an entire segment of the mandible is required
w h e r e there is gross involvement by tumour or if there is
evidence of invasion of the inferior dental canal. If the
lateral segment of the mandible is removed, the cosmetic
defect is often acceptable as the myocutaneous flaps fill in
the defect and there are few problems with articulation. If
it is decided to replace the missing mandible, however,
use can be made of osseomyocutaneous flaps. Probably
the easiest one to use is the pectoralis major flap together
with the sixth rib. A n alternative is to use the trapezius flap
together with the spine of the scapula. Free flaps may also
be used for this purpose: the best one is probably the
forearm flap incorporating the radius (the Chinese flap).
If the whole of the anterior arch of the mandible is to be
removed, use of one of the above flaps is mandatory;
otherwise the defect will be unacceptable. If the entire
segment of mandible is not to be removed, marginal
mandibulectomy may be considered. However, it should
be remembered that the vertical height of the mandible
decreases with age. It may not be possible to perform a
marginal mandibulectomy in an older person w h o has
been edentulous for a long time without rendering the
mandible so unstable that a stress fracture may occur.
A little-used alternative to all of the above is to remove a
segment of mandible, freeze it and then wire it back into
position.
35fi Tumours oi the oral ca\ i;\

The operations
' \ 1A *
h
'fy

i
1

MARGINAL MANDIBULECTOMY i
i
The Stryker saw is the instrument of choice to cut the
mandible as it comes with blades of many different sizes i f
., 7
and shapes. Either the upper half or the lingual plate of the
mandible may be removed, but if both are removed there
is a high risk of stress fracture of the mandible.

Mandibular fixation

A free or osseomyocutaneous graft inserted into the

mandible is held with a Kirchner wire as shown.

Although external fixation is not strictly necessary, it aids

healing by immobilizing the mandible. External fixation
may be by means of an arch bar or by Halo fixation. The
external fixation should be left for at least a month. A
temporary tracheostomy is preferable during this period,
and the patient is fed by nasogastric tube.

SOFT TISSUE REPLACEMENT
it is in this uetd that the greatest advances have taken
piace. The following general principles should be remem-
bered.
Unless the removal of tissue is minimal, primary closure
cripples the oral cavity. An initial primary closure can be
resolved a few weeks later by inserting a split-thickness
skin graft. This is kept in place with a modified denture
which must be w o r n at all times to prevent the skin graft
contracting. The advantage of a split-thickness skin graft is
Tumours or the ora! cavisv 35
that it is thin, allowing the dentist to C ^ T Y O'J* hi- -•-"•*
, — ^ i c d i e r ease man ir he
were dealing with a buiky graft. A skin graft also makes the
creation of a gingivolingual sulcus easier, It should b e
remembered that a sulcus is necessary if the tongue is to
function normally.
The standard method of replacing soft tissue in the oral
cavity is by myocutaneous flaps. These do not contract but
are so bulky that they often require thinning at a later
stage. The first choice of myocutaneous flap is the
pectoralis major and the second is the trapezius flap, as
the blood supply for the trapezius flap is often comprom-
ised during radical neck dissection.
The locally available nasolabial flap still has its uses in
the reconstruction of the anterior part of the ora! cavity,
but it is stiff and bulky. The forehead flap which for so
long was favoured for reconstruction of the oral cavity is
now seldom used for primary reconstruction. It still has its
uses in the repair of breakdowns because its take is so
reliable.
Free, revascularized flaps do not pose the problem of
bulk, and their take is excellent. As an initial procedure
they are very time-consuming to perform, but the patient
is later saved multiple small revision procedures. Most
widely used is the Chinese flap, taken from the forearm;
the radial vessels are anastomosed to branches of the
external carotid. The dorsalis pedis flap with or without
the second metatarsal as the osseous component pro-
duces less morbidity at the donor site. Free, revascular-
ized jejunum makes excellent lining for the floor of the
mouth but the smell is sometimes a problem.
Pectoralis major myocutaneous flap
The flap is marked by drawing a line from the acromion to
the xiphisternum. From the halfway point of the clavicle a
perpendicular is dropped to meet the original line. This
marks the line of the acromiothoracic artery. T h e lower
border of the pectoralis major muscle is palpated. Using
this as the lower limit of the flap, the desired area of skin is
marked out.
5
The first incision is made at the lower border of the flap to
verify that the surface palpation of the pectoralis muscle
has been correct. In order not to distract the skin from the
muscle (so rupturing the perforating vessels), the skin is
stitched to the muscle. This is continued throughout the
elevation of the skin paddle.
A hand is passed under the pectoralis muscle and the
vessels are easily seen.
360 Tumours of the ora! cavity

If a deltopectoral skin flap is raised now it makes further

dissection of the muscle and flap easier, and it has the
advantage of providing a well delayed deltopectoral flap if

illy
needed to repair any breakdown in the w o u n d or
anastomosis. If the deltopectoral flap has not been raised,
the strip of muscle overlying the vessels must be cut while
w o r k i n g under the skin bridge. Alternatively, the chest
skin may be cut through in a linear manner, but this
incision precludes the chest skin from being made into a
further flap.
T h e dissection continues up to the clavipectoral fascia
w h e r e the vessel arises from the second part of the axillary
artery.

T h e paddle of skin is stitched to underlying muscle and is

attached.to a strip of muscle overlying the acromiothor-
acic vessels. It can now be swung over the clavicle, under
the neck skin and into any desired site in the oral cavity.
W h e n passing the flap through the neck, care should be
taken not to twist the pedicle. The donor site on the chest
wall can be closed primarily by undercutting the sur-
rounding skin widely and bringing it together. A drain
should always be inserted.
 T u m o u r s or she oral cavity 36i

y
LOCAL REMOVAL OF A TONGUE TUMOUR AND
QUILTED GRAFTING

If a tongue tumour is less than 2cm at its greatest

diameter, it can be removed safely peroraliy with cutting
diathermy. The resulting defect can be closed primarily
but this may distort the tongue. It is therefore preferable
to graft the area with a split-thickness skin graft obtained
from the thigh and cut to a thickness of 3/*.m. Accuracy
can be achieved using a dermatome.
In order to take, a skin graft must be immobilized for at
least one week. Sewing bolsters into the oral cavity is not a
rewarding task because the bolster subsequently becomes
wet and foetid. Quilting is the method preferred for
fixation. Sutures of 4/0 Vicryl are placed around the edges
of the graft and at 1 cm intervals on the surface of the graft,
taking good bites of underlying tongue muscle.

REMOVAL OF FLOOR OF MOUTH AND PARTIAL

GLOSSECTOMY

Preparation

A preliminary tracheostomy should be performed and

general anaesthesia continued by this route, with the
anaesthetic equipment clear of the field. A nasogastric
tube should be passed before the operation is started.
The desired excision margins should be tattooed
peroraliy since tissue tends to become distorted later. The
tumour should be fulgurated with coagulating diathermy
in order to reduce the possibility of implantation when it is
manipulated during excision.

The incision

If a full radical neck dissection is to be carried out, a

double horizontal incision (as shown) is used. Many other
incisions are acceptable h o w e v e r , especially in the
non-irradiated patient. If an upper neck dissection is to be
performed, only the upper limb of the incision needs to
be used. For the operation described here a lip-splitting
incision is not required- G o o d access to the mouth m a y b e
gained by elevating the skin from the mandible. If the
facial nodes are enlarged, the ramus mandibulare nerve
should be sacrificed.
3f>2 Tumours of the oral cavitv

Access to the ora) cavity

In order to avoid the pull-through operation, mandibulo-

tomy used to be advised. If the tumour is fulgurated,
however, the incidence of implantation is negligible. T h e
contents of the oral cavity are delivered into the neck by
dividing the mylohyoid muscles and the small anterior
tongue muscles. If the tumour is close to the mandible,
the lingual plate should be divided, and this, too, allows
delivery of the tongue into the neck.
Excision along the previously tattooed margins is best
carried out with cutting diathermy. It is of utmost
importance to keep the lines of the excision as vertical as
possible so that deeper extensions of the tumour are not
left behind.

Closure

It is possible to perform a primary closure with an

epithelial inlay a few weeks later, but a pectoralis
myocutaneous flap is preferable. A few 3/0 chromic catgut
sutures should be placed between the pectoralis and the
geniogiossus, and 3/0 Vicryl is used to join the skin to the
tongue epithelium.
Closure of the lateral border presents more difficulty
because of the flat mandibular surface and the impossibil-
ity of getting a good deep layer for closure. It is often
helpful to attach the pectoralis muscle pedicle to the outer
skin over one or two buttons. If a fistula is going to form, it
will be in this area. It is prudent to test the closure with a
finger from the inside and the outside prior to closing the
skin layers with suction drainage.
 Tumours ot the oral cavity 36)

Postoperative care
it the initial closure has not been watertight, the drains
will draw air or saliva within a few days. In this case an
attempt should be made to revise the closure while the
tissues are still reasonably fresh. If the myocutaneous flap
fails to survive, it will become apparent around the 10th
day. If there is tissue necrosis, wide debridement should
be performed and closure of the fistula with a forehead,
deltopectoral or free flap planned at a time w h e n the
w o u n d is quite clean. This is usually after about 3 w e e k s .
T h e tracheostomy should be removed after a few days,
but the nasogastric tube should be left for 7-10 days. By
this time the patient should be eating an adequate diet.
Depending on the amount of tissue removed the flap
may require thinning before dental rehabilitation can
begin. The flap should not be thinned for at least 6 w e e k s .

TOTAL GLOSSECTOMY

The incision
Although a total glossectomy can be performed using the
previously described approach, there is an alternative
w h i c h involves splitting the lip. In this case, the incision
must run around the prominence of the chin to avoid an
unsightly scar. The lip should be marked to that the
vermilion border can be identified at closure, and the
incision is carried into the lip in the midline. It is joined to
a neck incision which may be single or double but is
always horizontal.

Mandibulotomy •

W h e n the skin is elevated from the mandible a ' V Is

marked on the mandible and drill holes are made with a
fissure burr. It is advisable to drill the holes before
dividing the mandible. The mandibular division is best
carried out using a 5tryker saw.
364 Tumours of the ora! cavity
 Tumours of the oral cavity 365

A large pectoralis myocutaneous flap is raised and swung

up through the neck under the skin to reach the oral
cavity. It is difficult to stitch it in place in more than one
layer. The posterior stitches should be placed first of all
and closure completed by coming along each sulcus.

In the anterior part of the closure the skin should be

sutured to the mucosa of the lower lip. Before this can be
completed the mandible must be repositioned and wired
in place using the previously made drill holes.

The mandible does not require further fixation. O n c e it

has been wired then the skin incisions are closed in two
layers and suction drainage inserted into the neck.
illustrations by Robert N. Lane
P. M. SteN C h M , FRCS
Professor of Otorhinolaryngology, University of Liverpool, UK
introduction
The lymphatic drainage from almost all the sites in the
head and neck where carcinomas may arise is into the
lymph nodes of the neck, which form an interconnecting
system with virtually only one outlet, at the inferior end of
the internal jugular chain. The lymph nodes of the neck
thus form an efficient barrier to the spread of cancer of the
head and neck, and even if the tumour has metastasized
to these nodes, distant metastasis does not occur for many
months, so that treatment is still worthwhile at this stage.
Although the primary tumour often responds to
radiotherapy, lymph nodes invaded by squamous carcino-
ma seldom do so and must be treated surgically.
Operation may therefore be needed on the nodes alone
or for removal of the nodes in continuity with the primary
tumour. In this chapter the operation for removal of the
nodes alone will be described.
Types of neck dissection
Several operations have been described for removing the
lymph nodes of the neck and they must be described
briefly first. A radical neck dissection is the classic
operation, first described by Crile in 1906, in w h i c h the
entire lymph-bearing area between the clavicle and the
mandible, the midline and the trapezius is removed; with
rare exceptions, this is the operation which should be
adhered to. A block dissection consists of removal of the
primary tumour in continuity with an enlarged mass of
n o d e s ; this operation will often leave behind smaller
involved nodes and should not be done. A n elective or
prophylactic neck dissection has in the past been
recommended when there are no palpable nodes but the
primary tumour is k n o w n to metastasize frequently. It is
thus hoped that nodes w h i c h may be involved histologi-
caliy will be removed before they become palpable. There
is no evidence that this procedure improves the cure rate
compared with a policy of 'wait and see', and it is in
general unjustifiable to carry out this operation, w i t h its
attendant increase in morbidity and mortality, until
acceptable evidence is produced that it confers benefit on
the patient.
Several partial neck dissections have been d e s c r i b e d /
among them a functional neck dissection, preserving the
sternomastoid muscle and the accessory nerve, and
suprahyoid dissection in which only the tissues above the
hyoid are cleared. Neither of these appear to be safe
procedures and are not recommended. Indeed the only
place for a local removal of palpable nodes appears to be
in the treatment of papillary carcinoma of the thyroid, a
tumour with a long natural history, which never breaks
out of the capsule of the thyroid gland and does not follow
the usual lymphatic channels taken by other head and
neck carcinomas.
The patient is shaved between the level of the angle of the
mouth and the nipple, including the hair over the mastoid
process.
A general endotracheal anaesthetic is used. If a bilateral
neck dissection is being performed a tracheostomy should
be made to protect the patient from oedema of the airway,
and the anaesthetic can be delivered through this.
T h e towels should be applied as for any other head and
neck operation, and should be stitched in place to prevent
them slipping.
T h e patient's neck is extended, and the head turned
towards the opposite side by a pillow under the shoulder
on the same side as the operation.
3&7
368 Radical neck dissection

The incisions

1a, b & c
T w o basic types of incision are in use for a radical neck
dissection: the Y-type (a) and the double horizontal
incision (b).
If the patient has not been irradiated, a Y incision is
used. If the patient has been irradiated, a double
horizontal incision protects against the danger of w o u n d
breakdown and is preferred. In either case the upper
incision extends from the point of the chin down to the
hyoid bone and ends over the mastoid process.
If a Y incision is used, the vertical limb starts about the
middle of and at a right angle to the horizontal limb. The
limb then continues down in an S-shape; when the scar
contracts this becomes a straight line, but if a straight line
were used in the first place a w e b might result. This
incision must not cross the clavicle as this would
compromise any future chest flaps.
In a double horizontal incision the second incision lies
about 2 cm above the clavicle, starting laterally at the
anterior border of the trapezius and ending medially at the
midline. The lateral end of this lower incision can be
turned up if necessary to improve access.
A bridge flap is lifted between the two incisions. T h e
entire lower part of the dissection must be done first and
the specimen passed under-this flap to allow completion
of the upper part of the dissection.
A further incision which can be used for either
irradiated or unirradiated patients, and which can easily
be modified for all major operations on the neck, is the
half-H incision (c). This incision respects the two areas of
vascular territory in the neck: the one supplied in-
feromedially from branches of the subclavian system and
the other superolateratly from branches of the external
carotid system.

Raising the flaps

Applied anatomy

During dissection of the upper flap, two branches of the

facial nerve must be preserved, the cervical and man-
dibular.
 Radical neck dissection 3 ,

2
The cervical branch supplies the part of the platysma
which crosses the mandible and is inserted into the corner
of the mouth, and the mandibular branch supplies the
muscles around the mouth. Division of either nerve,
therefore, leads to drooping of the lower lip. Both nerves
curve downwards, below and in front of the angle of the
mandible, across the facial vessels about one finger's
breadth below the mandible. The mandibular branch then
runs immediately superior to the submandibular gland,
while the cervical branch runs lateral to this gland. Both
nerves then curve upwards again to reach their destina-
tion.

5\

The incision is marked out with methylene blue using

either a mapping pen or a sharpened orange stick. T h e
skin should not be scratched with a needle t o indicate
suture m a r k s ; it is better to dip the tip of an intramuscular
needle in methylene blue and make dots o h the skin in
three or four places for critical sutures.

T h e skin is incised in one movement down to and through

platysma muscle. In the posterior part of the neck the
platysma is very thin and the fibres of the sternomastoid
are inserted directly into the skin, resulting in a little
bleeding in this area. The platysma should be kept on the
skin flaps as it increases the strength of the wound and
increases the blood supply to the skin flaps.
T h e skin is retracted by double skin hooks placed
underneath the platysma. These are pulled directly
• upwards while applying counter-traction to the specimen
to expose the subplatysmal plane. Dissection here causes
no bleeding provided the branches of the externa! and
anterior jugular veins are tied. Bleeding usually signifies
that a new and wrong plane has been entered.

4
370 Radical neck dissection

In a double horizontal incision the lower flap and the

lower half of the middle flap are raised from below and the
upper flap and the upper half of the middle flap from
above. Access is gained by retracting the middle bridging
flap with tapes.
W h e n raising the upper flap the branches of the facial
nerve must be preserved. The usual method of protecting
these nerves, by ligating and dividing the facial vessels on
the submandibular gland and lifting them over the
mandible, is dangerous when the nerve's course is lower
than usual; this manoeuvre also compromises removal of
the pre- and postfaciaLoodes which are often affected in
oral tumours. It^s also difficult to preserve these branches
if the platysma'is left on the specimen.
T h e easiest sway to preserve the branches of the facial
nerve Is to cut. right through the fascia at the level of the
hyoid b o n e , down to the capsule of the submandibular
gland, and elevate the resulting flap in continuity with the
skin flap.
W h e n the flaps" have been elevated they are stitched
back to the toweis, care being taken not to pass the needle
through the epidermis. This excludes the skin surface
from the w o u n d .

5b
 Radical neck dissection ir

1 2

• Lower end of the internal jugular vein

Applied anatomy

T h e lower end of the internal jugular vein lies posterior to

the lower e n d of the sternomastoid muscle, within the
carotid sheath. The common carotid artery lies post-
eromediafly, with the vagus nerve between the two
structures, so that the nerve is in danger. A small
unnamed tributary often joins the internal jugular vein
about 2.5 cm above the end of the clavicle and can be the
cause of troublesome bleeding.
Immediately lateral to the lower end of the carotid
sheath lies the scalenus anterior muscle, with the phrenic
nerve running from lateral to medial across it.
O n the left side the thoracic duct ascends medial to the
internal jugular vein, passes laterally, posterior to the
v e i n , and then descends to enter the junction of the
internal jugular and subclavian veins. Its size, position,
tributaries and ending are very variable, and it should be
looked for carefully in the root of the neck on the left side.
Posterolateral to the lower end of the common carotid
artery, next to the medial border of the scalenus anterior,
lies the thyrocervical trunk, which is short and immediate-
ly divides into the inferior thyroid, suprascapular and
transverse cervical arteries. The latter two pass across the
field of dissection. At the point where the inferior thyroid
artery turns medially, there arises the ascending cervical
artery, which is closely applied to the posterior wall of the
carotid sheath, so that traction on this vessel can tear the 15 14 13
thyrocervical trunk and indeed the subclavian artery.

7 = Common carotid artery; 2 = internal jugular vein; 3 = vagus

nerve; 4 = ascending cervical artery; 5 = scalenus medius
muscle;6 = phrenic nerve; 7 = inferior thyroid artery; 8 = C5
nerve; 9 = thyrocervical trunk; 10 = brachial plexus;
11 = subclavian artery;-12 = scalenus anterior muscle;
13 - subclavian vein; 14 - internal thoracic artery; 15 = thoracic
duct
372 Radical neck dissection

Technique

It is a basic principle of cancer surgery that the main vein

draining the area being operated upon must be divided
first, to reduce the number of systemic metastases caused
by t u m o u r emboli released by manipulating the tumour.
T h e lower end of the interna] jugular vein must, therefore,
be divided first " after exposirig ~rr~by—dividing the
_

sternomastoid muscle, the assistant applying traction to

the lower end while the surgeon~~9oes t h e same to the
upper e n d . T h e muscle is then divided with a knife until
the blueness of the vein is seen. Usually one vessel needs
to be tied in the lower part of the sternomastoid. T h e
l o w e r , divided end of the sternomastoid muscle should
not be transfixed. This produces a large mass of necrotic
muscle w h i c h will almost certainly form an abscess leading
to breakdown of the w o u n d .
7

T h e carotid sheath is opened right down to the vein wall

and the vein is freed using right-angled forceps at right
angles to the vein. W h e n the vein is free, it is retracted
laterally with a small vein retractor. Only when the vagus
nerve has been identified on the wall of the common
carotid artery should ligatures of 2/0 silk be passed round
the vein w a l l ; three ligatures, two at the lower end and
one at the upper e n d , are used. Each end is then
transfixed with 3/0 silk. The vein is then held up by the
long ends of the suture and divided with a knife between
the transfixion stitches.

Supraclavicular dissection
Applied anatomy
T h e posterior triangle of the neck is divided by the
omohyoid muscle into the occipital triangle and the
supraclavicular triangle; the latter will be considered in
this section, the former in the next. The supraclavicular
triangle is filled by fat, and its floor is formed by the
prevertebral fascia overlying the phrenic nerve and
brachial plexus. Its important contents are the omohyoid
muscle which forms its upper boundary, the subclavian
vein in the very lowest part of the triangfe behind the
clavicle, the external jugular vein crossing its roof, and the
transverse cervical artery passing laterally over the fascia
of its floor.
Radical nock dissection J7'i
Technique
The omohyoid muscle occasionally overlies the internal
jugular vein but it is usually found immediately lateral to
it; it can be divided without clamping as it will not bleed if
cut through its tendon. The fascia over the fat pad lateral
to the internal, jugular vein is incised and this fat pad is
elevated to identify the phrenic nerve passing over the
scalenus anterior muscle from lateral to medial. T h e nerve
lies behind the prevertebral fascia, w h i c h must not be
incised as it protects the phrenic nerve and also the
brachial plexus, which is encountered next. Diathermy
must not be used over the fascia as this can also damage
these nerves.
7 = Phrenic nerve; 2 = sternomastoid muscle; 3 = vagus nerve;
4 = common carotid artery; 5 = scalenus anterior muscle;
6 = internal jugular vein; 7 = subclavian artery and vein;
8 - posterior cord of brachial plexus; 9 ~ pectoralis major
muscle; 70 = deltoid muscle; 11 = pectoralis minor muscle;
12 = lateral cord; 13 ~ suprascapular artery; 14 ~ descending
scapular artery; 75 = lowertrunk; 16 = external jugularvein;
17 — upper trunk of the brachial plexus
3/4 Radical neck dissection

Dissection of this area can be greatly facilitated by using

the plane between the fat pad and the prevertebral fascia.
A finger is passed laterally, anterior to the prevertebral
fascia, as far as the anterior border of the trapezius; the
transverse cervical artery and vein in this area are ligated
and divided if necessary. The external jugular vein is also
divided and tied. T h e fat in the supraclavicular fossa can
now be divided without bleeding by cutting down onto
the finger, taking care not to cut the subclavian vein as it is
pulled out of the thorax by the upward finger retraction.

Now turning to the anterior part of the specimen, the

internal jugular vein is elevated out of the carotid sheath.
Great care is needed so as not to tear a high thoracic
duct on the left side, and a plane is established on the wall
of the c o m m o n carotid artery. The specimen must not be
pulled up too hard at this point as it is possible to tear off
the thyrocervical trunk because of traction on Its inferior
thyroid branch.

11
 KaHkal nock d i c t i o n J"3

Cervical plexus
The occipital triangle

Applied anatomy
T h e other haif of the posterior triangle is the occipital
triangle, formed by the sternomastoid, the trapezius and
the omohyoid muscles. Its floor is formed by the levator
scapulae, which will be seen later to be of importance.
T h e triangle is filied by fat, and contains only two items of
interest to the surgeon: the accessory nerve coursing
laterally to end in the trapezius muscle, 5 cm above the
clavicle, and the branches of the transverse cervical artery.
T h e latter artery divides at the anterior margin of the
levator scapulae into a superficial and a deep branch; the
superficial branch ascends deep to the anterior edge of
the trapezius muscle and is accompanied by a vein.
T h e third and fourth cervical nerves give off a number of
small branches, usually three or four, that pass posteriorly
across the floor of the posterior triangle. The branches
from the third cervical nerve may joint the accessory nerve
just proximal to its insertion into the trapezius, or may
enter the muscle directly. The branches from the fourth
cervical nerve pass directly to the deep surface of the
trapezius. O n the deep surface of the trapezius muscle the
spinal accessory and the cervical nerves branches form a Ascending branches of the transverse cervical artery run
plexus to supply the muscle. Contrary to previous along the anterior border of the trapezius m u s c l e , making
o p i n i o n s , these branches from the cervical plexus are dissection along this part of the muscle bloody and
motor nerves to the trapezius muscle. tedious.

Technique

13
T h e easiest method is to develop a tunnel with, the finger
over the prevertebral fascia immediately anterior to the
border of trapezius. The fat is divided between two large
artery forceps until the sternomastoid is reached. During
this part of the dissection the accessory nerve is cut,
causing the shoulder to jump.
37b Radical neck dissection

With the specimen n o w free inferiorly and posteriorly, it is

pulled medially and the fat pad is elevated off the
prevertebral fascia. This is best accomplished by the
assistant taking the specimen in a swab and pulling it
upwards very hard. T h e specimen is freed by sharp
dissection with a k n i f e , together with countertraction. It is
tacked down in three places, however, by the three
cutaneous branches of the cervical plexus; these neuro-
vascular bundles consist of a vein, an artery and a nerve
and should be c l a m p e d , divided and tied high on the
specimen to avoid damage to the phrenic nerve and to the
branches arising from C3 and C4 which course across the
floor of the posterior triangle to supply the trapezius
muscle. It is important to preserve these nerves, as this
step preserves movement of the shoulder girdle in about
80 per cent of cases.
Dissection is continued along the common carotid
artery on the adventitial plane up to the bifurcation, taking
care to preserve the vagus nerve.

2 1 21

14

The upper end of the internal jugular vein

Applied anatomy

It is customary to divide the upper end of the internal

jugular vein at the level of the easily palpable transverse
process of the first cervical vertebra. At this point the vein -
is covered by the posterior belly of the digastric muscle,
w h i c h is the key to dissection in this area. This muscle has
few superficial relations except for the tail of the parotid
gland and the common facial vein. Once the upper end of
the sternomastoid muscle, with the overlying external
jugular vein, has been divided, it is easy and safe to
expose the posterior belly of-the digastric. The internal
jugular vein will be found issuing from beneath the
muscle, with the accessory nerve lying over the vein..The
internal and externa! carotid arteries are posteromedial to
it at this point, and the hypoglossal nerve emerges
between the vein and the interna! carotid artery, lying
7 = internal carotid artery; 2 = superior laryngeal nerve; medially in the carotid sheath. The occipital artery runs
3 = external carotid anery; 4 - posterior auricular artery;
laterally along the inferior border of the digastric muscle
5 = facial artery; 6 = hypoglossal nerve; 7 = lingual artery;
8 = internal laryngeal nerve; 9 = superior thyroid artery;
and can be a troublesome source of haemorrhage. At the
10 - external laryngeal nerve; 77 = common carotid artery; level of the transverse process of the atlas ( C I ) , the
72 - descendant hypoglossal nerve; 13 = hypoglossal nerve; internal jugular vein is often joined by the occipital v e i n .
14 = vagus nerve; 75 « descendens cervicalis nerve;
76 = internal jugular vein; 17 m lower sternomastoid branch of
occipital artery; IB facial vein; 19 » accessory nerve;
2 0 = upper sternomastoid branch of occipital artery;
21 = digastric muscle (posteriorbelly)
 Radical ned- uii^i.'i . i o n

Technique

The sternomastoid muscle is divided from the mastoid

process and the internal jugular vein is followed upwards
to the transverse process of the first cervical vertebra from
b e l o w , dividing the fascia of the carotid sheath with
scissors. This frees the jugular vein on three sides and by
keeping close to the wall it is an easy matter to pass
right-angled forceps round it anteriorly and put on the
three 2/0 silk ties - two above and one below the point of
division.

17
An alternative way of identifying the interna! jugular vein
is to cut down onto the posterior belly of the digastric
m u s c l e - t h e r e are no vital structures superficial to it at this
point except the common facial vein. T h e muscle is
retracted upwards, and the vein will be seen emerging
from beneath it with the accessory nerve overlying it.

It is not necessary to remove the posterior belly of the

digastric muscle since it is so helpful in covering closure
lines and for carotid artery protection. However, in order
to remove as much jugular vein as possible the posterior
belly of the digastric is retracted upwards to allow the
ligatures to be slid up as high as possible, but before tying
the ligature the vagus and hypoglossal nerves must be
identified. The occipital artery crosses the posterior part
of the v e i n ; it is ligated and divided, as is the occipital vein
if present, before dividing the main vein. After transfixion
with 3/0 silk, the upper end of the internal jugular vein is
divided.
Dissection then proceeds anteriorly. The posterior
branch of the posterior facial vein is found 13 mm anterior
to the internal jugular vein; it is ligated and divided. The
tail of the parotid gland is then divided in a line between
the mastoid tip and the angle of the jaw. If at this point the
knife is angled upwards the facial nerve may be c u t , so
that the knife must be angled slightly downwards to the
transverse process of the first cervical vertebra, thus
cutting the parotid gland obliquely.
378 Radical neck dissection

The hypoglossal nerve is then identified and traced to the

bifurcation of the common carotid artery. Bleeding may
occur from veins accompanying the hypoglossal nerve -
these veins generally run medial to the nerve but send
three or four anastomotic branches anterior to it. These
anastomotic vessels are freed by dissection along the
hypoglossal nerve on the perineural sheath, clamped,
divided and t i e d ; diathermy must never be used in this
area. If bleeding occurs from these veins it is important to
realize that the bleeding point will retract medial to the
hypoglossal nerve. T h e only way to stop this bleeding
without damaging the hypoglossal nerve is to lift the
nerve, either up or d o w n , with a blunt hook, find the
bleeding point, apply a small artery forceps and tie the
bleeding point.
Finally the hypoglossal nerve is traced forwards into the
submandibular triangle.

The submandibular triangle

Applied anatomy
The important anatomical feature of the submandibular
area is its floor, from w h i c h the gland must be separated
safely. The floor is formed by the mylohyoid and
hyoglossus muscles, with the lingual and hypoglossal
nerves passing laterally across them. The hypoglossal-
nerve is seldom in danger, however, since it is protected
by the anterior belly of the digastric muscle. The lingual
nerve describes a curve, U-shaped downwards, being
tethered by its branch to the submandibular ganglion.
Anteriorly the nerve disappears medial to the mylohyoid
muscles accompanied by the submandibular duct, around
w h i c h it does its well-known swerve, medial to the
mylohyoid muscle, and not in the area of dissection. T h e
facial artery enters the triangle between the submandibu-
lar gland and the posterior belly of the digastric muscle.

Submandibular salivary gland Inferior dental nerve

Lingua! nerve
Nerve to mylohyoid

Medial pterygoid muscle

 Radical neck dissection 379

Technique

The upper border o? the submandiOular gland is freed by

dividing and tying the vessels, including the facial artery,
which cross the lower border of the mandible.
T h e fat in the submental area is separated from the chin
and the anterior belly of the digastric muscle displayed.
T h e anterior part of the submandibular giand is then
identified and freed in a posterior direction to the
posterior border of the mylohyoid.

T h e mylohyoid muscle can now be pulled forwards to

s h o w the submandibular duct and the lingual nerve pulled
down in a curve. The latter is freed by dividing the fascia
around the submandibular ganglion with a knife, where-
upon the lingual nerve springs upwards behind the body
of the mandible. The submandibular duct is tied and
divided. Protection of the carotid artery
The neck specimen is removed after transfixion and
division of the facia! artery at the posteroinferior border of The carotid artery must be protected in any patient,whose
the gland, and division of the fascia over the strap muscles skin w o u n d is likely to break d o w n , or who is likely to
in the region of the hyoid bone. develop a fistula; this includes patients who have been
irradiated, poorly nourished patients and diabetics.
Several methods of carotid artery protection have been
described, but the only absolutely reliable method is that
of using the levator scapulae muscle.

The levator scapulae is identified and its posterior border

freed. The lower border is also freed as near to the scapula
as is possible and divided. It is then easy to swing the
muscle forwards, pedicled on its anterior border like a
page of a book; this preserves its blood supply entering
from its anterior border. T h e brachial plexus must not be
injured during division of the lower e n d .

T h e muscle is stitched over the carotid arteries using

interrupted 3/0 chromic catgut sutures, usually to the
sternohyoid muscle anteriorly, to the posterior belly of
the digastric superiorly, and to the stump of the
sternomastoid inferioriy.
350 Radical neck dissection

Closure R a d i c a l n e c k d i s s e c t i o n as p a r t of a c o m b i n e d
pi o»_edU('c
T h e w o u n d is w a s h e d , dirtyinstruments are discarded and
the entire operating team change their gowns and gloves. W h e n a primary tumour is removed in continuity with a
Haemostasis is completed with coagulation diathermy. neck dissection, it is important to keep a band of
Blood always pools at the insertion of the trapezius muscle continuity between the neck dissection and the primary
to the clavicle because any bleeding that occurs in the growth.
neck will run down to this point. Continuous suction-
drainage should be used, preferably of the Haemovac
type.
Laryngeal cancer
T w o Haemovac drains are introduced, from the under-
surface of the lower flap to the outside. It is safer to put In a total laryngectomy, the neck dissection should be left
them in from within out since, if they are inserted in the attached along the w h o l e length of the larynx to include
opposite direction, the sharp introducer may damage the the superior and inferior lymphatic pedicles.
carotid artery if it slips. The drains are held with 3/0
chromic sutures, one along the anterior border of the
trapezius and the other in front of the carotid artery
Pharyngeal cancer
curving upwards into the submandibular region. Drains
should never cross the carotid sheath, and they should be
W h e n a laryngopharyngectomy is performed the pedicle
cut to the correct length so that there are no holes outside
must be as broad as possible and is best left along the
the s k i n , otherwise an airtight closure will not be possible.
whole length of the pharynx.
T h e drains are secured to the skin with a Roman garter
stitch of 3/0 silk. A final check is now made for: bleeding
from the veins accompanying the hypoglossal nerve;
bleeding on the undersurface of the middle flap, if a
Oral cancer
double horizontal incision has been u s e d ; a chylous leak.
These are the three commonest causes of trouble in the Oral cancers drain to the submandibular, submental and
postoperative period. upper deep cervical nodes. Therefore, the specimen
should be left attached along the lower border Of the
Division of the thoracic duct on the left side is often mandible and should include the inner layer of the
necessary and the duct is often injured. This is of no periosteum, to preserve continuity.
importance, but it must be recognized during the
operation. Since the patient is starving, the chyle will be
clear and scanty. It is therefore important to look carefully Oropharyngeal cancer
for it at this stage in the groove posterolateral to the lower
end of the common carotid artery. If there is a slight Tumours of the oropharynx drain by a pedicle to the
collection of chyle, the surrounding fascia should be upper deep cervical nodes. The specimen should be left
oversewn until the area is dry. attached, therefore, near the tail of the parotid gland.
Buried sutures of 3/0 chromic catgut are placed at the
skin marks and further similar interrupted sutures are
placed until the flap is airtight. In order to check for this,
suction is applied to the Haemovac drains. If any air leaks,
further sutures are inserted.
The skin is closed with a blanket stitch of 5/0 Dermalene 1. Continuous suction to the drains.
and air tightness is again checked. 2. _ Intravenous fluids until the next day.
No dressing is needed if all bleeding has been stopped 3. Feeding by mouth can begin the next day.
and the w o u n d closed so that it is airtight. Nobecutane 4. Antibiotics should never be needed unless basic
should not be used on the wound as this sticks to the skin surgical principles have been contravened.
and stitches, so that when the stitches are removed, 5. T h e drains are not removed until drainage is less than
removal of the film of Nobecutane may drag the wound 10ml per day - usually about the fourth day.
edges apart. 6. Stitches are removed on about the fifth day.

Complications
me juguiar v e i n , tne subclavian v e i n , pharyngeal v e i n s ,
superior and inferior thyroid pedicles and the posterior
surface of the bridge flap.
(2) Chyle leak If the thoracic duct has been damaged
and this has not been recognized, when feeding begins,
abundant white milky fluid will issue from the suction
drain. The neck must be re-explored immediately and the
end of the duct found and oversewn.
(3) Nerve lesions It is possible to damage the following
nerves - phrenic, sympathetic trunk, brachial plexus,
vagus, accessory, facial nerve and its lower b r a n c h ,
hypoglossal and lingual.
(4) Facia! oedema
(5) Cerebral oedema This may come on after a
bilateral neck dissection; after a second, staged neck
dissection; or after the first neck dissection, if a large
dominant internal jugular vein has been removed. T h e
symptoms are restlessness and a bursting headache, w i t h
a falling pulse rate and a rising blood pressure; the face is
swollen and cyanosed, whereas the extremities remain
pink and warm. It should be treated by sitting the patient
u p , releasing all constricting dressings round the neck and
giving an intravenous infusion of 200 ml of 25 per cent
mannitol.
(6) Infection and wound breakdown These are
usually d u e , apart from lapses in surgical technique, to the
Radical neck dis^.-cnon ifj |
, . . ..„ ^. u . - i / p c 0 1 niusion in a patient w h o has
been irradiated. If the flaps become non-viable, necrotic
material must be excised if present, and local soaks, such
as eusol, used. A culture of the infected material often
reveals opportunist Gram-negative bacilli, so that antibio-
tics are not often indicated. The pyocyaneus, w h i c h
secretes pyocyanin, a toxin that dissolves s k i n , can often
be eliminated by 1 per cent acetic acid soaks.
(7) Rupture of the carotid arteries This may be a
sequel to w o u n d breakdown in an irradiated patient if the
arteries have not been protected by a levator scapulae
graft. If this complication occurs, the artery must be tied
off, ensuring as far as possible that the cerebral blood flow
is maintained, by replacing lost blood, keeping the head
low and not allowing CO2 retention. At least half the
patients w h o suffer this complication will die, and many of
the survivors suffer a hemiplegia.
(8) Frozen shoulder In the classical procedure all the
innervation of the trapezius muscle is divided. T h e
muscles that abduct the shoulder are still.innervated but
the patient cannot fix his shoulder girdle, w h i c h therefore
falls forwards, making abduction of the arm mechanically
impossible. He is therefore given exercises to brace the
shoulder girdle backwards and to maintain mobility of the
shoulder joint to prevent a frozen shoulder. In the
technique described above of preservation of the bran-
ches from C3 and C4 of the cervical plexus, normal
shoulder movement is retained in 80 per cent of patients.
(9) Recurrence in the skin or glands
illustrations by Jack D i n e r
James YeeSuen MD,FACS
Professor and Chairman, Department of Otolaryngology and Maxillofacial Surgery
University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
History
Although neck dissections have been performed for over
100 years, only in the last three decades have modifica-
tions begun to surface in an effort to decrease the
shoulder dysfunction.
E. Bo'cca of Italy was one of the first surgeons to report
on functional neck dissections and his technique was first
described in'1966 . Alando J . Ballantyne of the M. D.
1
Anderson Hospital and Tumor Institute in Houston, Texas
has been doing functional neck dissections for over 25
years. His technique, which has not been previously
described in detail is performed completely from an
anterior approach, while Bocca's technique uses an
approach both anterior and posterior to the sternocleido-
mastoid muscle. Both techniques are useful with each
having its advantages and disadvantages. The anterior
approach using Ballantyne's technique is not simply an
anterior neck dissection as it also dissects out the majority
of the posterior cervical triangle.
Principles and justification
T h e functional neck dissection can remove essentially all
of the same lymph nodes in the neck that a radical neck
dissection does, but with preservation of the sternomas-
toid muscle, internal jugular v e i n , spinal accessory nerve
and cervical plexus nerves. Several reports " in the past 7
2 5
or 8 years reveal that the control rate for N0-N1 lesions is
no different whether treated with a radical neck dissection
or a functional neck dissection. This is partly due to the
liberal use of irradiation in these advanced cancers where
neck dissections are incorporated. Another reason is that
lymph node metastasis is very predictable. For example,
Skolnick has shown that posterior cervical nodes are
rarely involved w h e n the nodes in the jugular chain are
negative with laryngeal cancers. Therefore, when a lesion
is NO it is not as essential to remove the posterior triangle
nodes. Until further studies are completed, it is critical
that functional neck dissection follows strict indications
and contraindications so.that the oncological treatment is
not compromised.
382
The author feels that the present indications and
contraindications for a functional neck dissection are as
follows.
Indications for anterior approach (Ballantyne
technique)
1. Clinically negative neck but significant (greater than 25
per cent) risk of occult n o d e s ; this is considered an
'elective neck dissection'. Included in this category
would be involvement on both sides of the neck along
with some midline primaries, such as in the base of the
tongue and the supraglottic larynx. T h e modified neck
dissection is usually performed in conjunction with
resection of the primary.
2. Single node ( < 3 c m ) in patients with thin or medium-
size necks w h e n surgery is to be followed by
irradiation, e . g . T3 or T 4 , N1M0 of oral cavity,
oropharynx or hypopharynx.
Indications for anterior-posterior approach
(Bocca technique)
1. N1 neck in patient with short, full neck which is difficult
to assess.
2. N2 neck w h e n functional neck dissection is to be
attempted.
3. N3b neck w h e r e bilateral neck dissections are planned
and a functional neck dissection is to be performed on
the least involved side. Postoperative irradiation should
be given.
4. Papillary carcinoma of the thyroid with neck metastasis.
5. NO neck in melanomas, Level IV or V.
Contraindications
1. Clinically positive nodes when surgery is the only
treatment modality to be used.
2. Clinically positive nodes after irradiation of the neck.
3. Clinically positive nodes after previous modified or
regional neck dissection.
4. Melanoma with clinically positive nodes.
5. Inexperience of the surgeon.
 Functional neck dissection 383

ANTERIOR APPROACH (BALLANTYNE TECHNIQUE)

1
The incision

The type of incision is not critical as long as it is an

acceptable, standard one in which the neck structures are
exposed adequately. If the functional neck dissection is
performed from an anterior approach only, as described C*^c
here, then the incision and flaps do not have to be
elevated behind the posterior border of the sternomastoid
muscle.

1
2
Beginning the surgery

A flap of skin and platysma is elevated until adequate
exposure is obtained. The mandibular branch of the racial
nerve should be identified and preserved as it runs in the
submaxillary gland fascia. The surgical field exposed
should include the ipsilateral strap muscles, submaxillary
triangle contents, the anterior half of the sternocleidomas-
toid (SCM) muscle and the tail of the parotid gland.
Haemostats are used to clamp the thin superficial fascia
of the medial half of the SCM muscle and the fascia is
retracted medially anteriorly. An incision is made into this
superficial fascia along its entire length using a No. 10
scalpel or the Shaw scalpel (hot knife) which works well
for this part of the operation. This incision should be
anterior and parallel to the superior part of the external
jugular vein and then carried interiorly about mid muscle
to the lower SCM muscle attachment. The fascia is then
dissected off the muscle to its anterior border. Retracting
the SCM muscle posteriorly with a gauze pad and hand
will facilitate dissection of the fascia.
On the illustration the dotted line over the fascia of the
strap muscles indicates the anterior or medial extent of
the neck dissection which is performed toward the end of
this operation.

Submaxillary
. triangle contents
384 Functional neck dissection
Dissecting underneath the SCM muscle and
identification of the spinal accessory nerve
T h e fascia is then dissected from the mediai surface of the
S C M muscle (an unwrapping manoeuvre). T h e muscle
must be retracted posteriorly, initially using a hand with a
gauze p a d , then with loop-type retractors. During this
dissection small perforating vessels will be noted to enter
the muscle from the fascia. These can be electrocaute-
rized or ligated as they are encountered. Some of these
muscle branches are very close to the internal jugular vein
and must be grasped with a clamp or forceps before being
cauterized to avoid injury to the jugular vein.
Preservation of the spinal accessory nerve is one of the
primary reasons for the functional neck dissection so
extreme care must be taken to identify and preserve it.
T h e upper third of the nerve is encountered initially as the
3b
fascia is dissected away from the medial side of the S C M at
the junction of the upper and middle third of the muscle.
The nerve usually divides into the sternomastoid and
trapezius branches just before it enters the S C M muscle.
Both branches should be preserved.
After identification of the spinal accessory nerve, the
fascia dissection should continue inferior to the nerve
until the posterior edge of the S C M muscle is noted. T h e
surgeon should palpate the lateral skin of the neck to
judge w h e r e the posterior edge of the S C M muscle is, so
that the dissection will not extend into .the posterior
triangle skin w h i c h is close. The cervical plexus nerves will
also be encountered as they wrap around the posterior
S C M muscle edge. The upper part of the neck dissection
is performed later.
Phrenic nerve N
Cervical plexus
Plane of cross-section indicated in illustration 3a

The posterior cervical triangle
This illustration shows the extent of the posterior and
supraclavicular dissection with the anterior approach. The
inferior limit is at the level of the transverse cervical artery
and omohyoid muscle which may be preserved or
resected. There is no well-defined stopping point in this
area but it is only 2 or 3 cm above the clavicle. The
posterior margin is anterior to the trapezius muscle and
almost parallel to the lower two-thirds of the spinal
1
Functional neck .iissection 3:i5
accessory nerve.
T h e author feels that it is unnecessary to dissect to the
trapezius and clavicle when the neck is clinically negative.
If clinically positive nodes are encountered in the lower
jugular or posterior cervical areas the nodes could be
checked with frozen sections and if pathologically
positive, the .dissection should be converted to a radical
neck dissection.
386 , Functional neck dissection

11.UI I I I U I I f , I C
- - - - -'' ' O
•- r"

care being taken not to injure the spinal accessory,

At the posterior edge of the sternomastoid muscle, the
direction of the dissection is in a ' U ' turn and is carried
down to the fascia overlying the deep cervical muscles
(levator scapulae and scalenus). T h e cervical plexus nerves
should be preserved because the spinal accessory nerve in
the posterior triangle usually intertwines with one or two
of the cervical plexus nerves and can easily be severed
inadvertently. If there is any question as to whether a
nerve is the spinal accessory nerve, a nerve stimulator
should be used to check it. The second and third branches
of the cervical plexus nerves give off branches to the
spinal accessory nerve so that stimulation of these nerves
will also stimulate the trapezius muscle. Therefore, all of
these branches should be preserved.
The fascia, fat and nodes are retracted medially with
haemostats and are dissected over the deep neck muscles,
cervical plexus and phrenic nerves. This part of the
dissection Is performed with a N o . 10 scalpel blade. T h e
best way to dissect between the cervical plexus nerves is
to dissect out the nerves with a haemostat which will
release the fatty tissue between the nerve. The fatty tissue
is then grasped with haemostats, placed on traction and
dissected off the deep muscles in a medial direction
towards the carotid sheath. During sharp dissection it is
very helpful for the operator to use his or her opposite
hand with a gauze pad to push the tissues medially as the
dissection continues.
As this deep layer of fascia is dissected medially, small
vessels with accompanying nerves can be noted entering
the medial side of the levator scapulae muscle. These
neurovascular bundles do not have to be resected and the
dissection should be just above these structures.

'/ / j Spinal
accessory nerve

External
jugular
iin

I
Posterior scalene muscle f
Cervical Deep cervical fascia
plexus nerves
5a
Internal
jugular vein

Vagus
nerve

Carotid
artery

Phren
Cervic;
us nerves
Plane of cross -section indicated in Illustration 5a
 Functional neck dissection .JJJ7

Dissecting the carotid sheath

The phrenic nerve (often two branches) should be
identified and preserved as the neck contents are
dissected over the trunks of the cervical plexus nerves.
The carotid sheath is encountered next. Normally the
jugular vein is lateral to the artery but with traction of the
fascia and its contents in an upward and medial direction,
the jugular vein is almost dorsal to the artery. Therefore,
the carotid artery is encountered first and the dissection
should be directly against this vessel without cutting the
artery. Strong traction is important here so that w h e n the
knife blade touches the vessels, the fascia and adventitia
of the artery a n d vein is dissected off easily and cleanly.
T h e vagus nerve must be identified between the vessels
and preserved. Tributary branches of the interna! jugular
vein should be divided and ligated next to the vein. This
dissection is carried superiorly up to the level of the
carotid bifurcation. It is dangerous to use the electrocaut-
ery or hot knife around the major vessels.

Spinal
accessory nerve

Carotid artery
Phrenic nerve

Interna) jugular vein

Carotid artery —

>':• V
Cervical plexus nerves

Plane of cross-section indicated in illustration 6a

}
388 Functional neck dissection

Dissecting the upper neck contents

T h e tissue and nodes remaining in the upper lateral neck
are shown in Illustrations 7a and 7b. T h e superior extent of
the dissection is at the ieve! of the digastric muscle. A
small amount of the tail of the parotid is included by
cutting through it with a hot knife or electrocautery until
the underlying digastric muscle is encountered. The
posterior facial vein is found in the tail of the parotid and
wili need to be identified and ligated. T h e cervical branch
of the facial nerve is also located in the tail of the parotid
and should be identified. This nerve branch can be
divided but the mandibular branch should be preserved
with the rest of the facial nerve. T h e posterior belly of the
digastric muscle should be exposed and its fascia
dissected off the inferior surface.

Dissecting the proximal spinal accessory nerve

A haemostat is used to follow the spinal accessory nerve
superiorly. T h e tissue overlying the nerve should be
divided to expose the nerve, which is protected by the
haemostat. The hot knife works well here to avoid
troublesome bleeding. At the upper end the nerve goes
below the digastric muscle. The jugular vein can be
identified immediately beneath the proximal portion of
the nerve.

Cross-section indicated {see illustration 7b)

 Functional neck dissection 389

Completing the nerve dissection

The nerve is gently freed with sharp dissection. T h e tissue

to be dissected is then.identified. T h e dotted line on the
illustrations indicates the tissue to be removed.

Cross-section (see Illustration 10b)

10a &b
Completing the upper cervical tissue dissection

Haemostats are used to grasp this tissue and retract it

medially. Retractors are placed on the upper S C M muscle
and on the parotid and digastric muscle for exposure. An
electrocautery or hot knife can be used to cut through the
tissue at the apex until the underlying muscles are noted
in the base of the dissection. T h e spinal accessory nerve
should be protected at all times. T h e tissue is then
dissected medially off the splenius capitus and levator
scapulae muscles and carried to and underneath the
spinal accessory nerve to the jugular vein and internal
carotid artery. T h e posterior occipital artery is in this
triangle and this is divided and ligated or cauterized.
W h e n near the carotid sheath a No. 15 scalpel blade is
used to decrease the chance of injury to the vessels.

Cross-section
390 Functional neck disseclion

Dissecting over the vessels

Using sharp dissection, the nodes, etc. are then dissected

over the internal carotid artery and jugular vein towards
the submaxillary triangle. The posterior belly of the
digastric muscle must be retracted superiorly to expose
any subdigastric nodes which should be dissected out at
this point.
The hypoglossal nerve lies between the artery and vein
and crosses the carotid arteries just above the bifurcation.
The dissected tissue should be carried over the hypoglos-
sal nerve, preserving i t .
• pi I Spinal accessory nerve
Jugular vein — A j

The lateral neck contents are then dissected off the vessels
w i t h sharp dissection. The c o m m o n facial vein and
superior thyroid artery can usually be preserved as the
dissection is carried t o the strap muscles inferiorly and to
the hyoid bone and submaxillary triangle superiorly. The
most medial extent of the dissection is the fascia over the
sternohyoid muscle w h i c h is cut in a vertical direction and
dissected off the muscle up t o the h y o i d . The anterior
jugular vein is usually removed w i t h this part of the
dissection. This will complete the neck dissection except
for the submaxillary triangle. cross-section

The submaxillary triangle

Dissection of this triangle is well illustrated in many

surgical atlases and will not be described here.
392 Functional neck dissection

ANTERIOR-POSTERIOR APPROACH (BOCCA

TECHNIQUE)

15 & 16
The incision

The incision should allow exposure to the same anatomic-

al boundaries as the standard radical neck dissection, i.e.
the inferior border of the mandible, trapezius, clavicle and
the anterior midline of the neck. This will allow dissection
of the posterior cervical triangle separately and carry the
dissection under the S C M muscle.

External jugular vein

SCM I

1/
Beginning the dissection
An incision is made with a No. 10 knife blade or a hot knife
through the lateral superficial fascia of the S C M muscle
near the midline and carried to the posterior border of the
muscle at its inferior and superior attachments. The fascia
is grasped with multiple haemostats along its'edge and
retracted posteriorly while the fascia is dissected off the
SCM
Spinal accessory nerve -
Functional neck dissection 393
m u s c l e . T h e external jugular vein-is divided and ligated
superiorly but the sensory nerve branches off the cervical
plexus nerves are preserved. The fascia is dissected to the
posterior border and slightly medially underneath the
S C M muscle. T h e haemostats are then removed.
External jugular vein
394 Functional neck dissection

Defining the posterior border and identifying the

spinal accessory nerve

T h e posterior border of the neck dissection is the edge of
the trapezius muscle. This part of the-neck dissection is
similar to a radical neck dissection except that the spinal
accessory nerve must be identified and dissected out
carefully. This nerve will run just medial and parallel to the
lower third of the trapezius muscle. It can be identified by
using a haemostat to dissect in this area until the nerve is
f o u n d . O n c e identification of nerve is confirmed by a
nerve stimulator, a haemostat is used to dissect out the
nerve superiorly, and the tissue external to the nerve is
dissected off with sharp dissection. The hot knife is useful
here. T h e nerve should be dissected free from the lower
trapezius area up to the S C M muscle where it exits.

External jugular vein

I
Spinal accessory nerve

1Q
Resecting the posterior cervical triangle contents
With the spinal accessory nerve protected, the posterior
cervical triangle contents can be dissected. Haemostats
are placed on. the posterior neck contents near the
trapezius muscle and are pulled in an anterior and medial
direction. T h e fascia, fat and nodes are dissected d o w n to
the levator scapulae and scalenus muscles, then the fascia
of these muscles is dissected off in a medial direction.
T h i s tissue is carried underneath the spinal accessory
nerve and after the nerve is free enough, the nerve is
retracted posteriorly so that the dissection can continue
medially. In the lower posterior cervical triangle a number
of transverse cervical veins will be encountered, and these
should be divided and ligated.
T h e transverse cervical artery should be identified and
can be preserved or removed. The supraclavicular
branches of the cervical plexus nerves will also be
encountered in these areas and can be preserved by using
a haemostat to dissect them out. The adjacent tissue is
then grasped with haemostats and dissected medially
toward the carotid sheath.
Spinal
accessory nerve
Functional neck dissection 395
T h e supraclavicular tissue is dissected off the clavicle
d o w n to the deep neck muscles (scalenus) and brachial
plexus. The lower external jugular vein should be
identified, divided and ligated near its entrance to the
subclavian vein. The omohyoid muscle can be identified
here and divided. A haemostat is placed on the proximal
end of the muscle and retracted medially with the rest of
the neck contents.
M u c h of the dissection can be made easier during knife
dissection if the operator uses a gauze pad in the opposite
hand to push the tissue medially. This method makes
vessels and nerves much easier to identify and it helps to
preserve them.
Using the anterior-posterior approach of Bocca, more
tissue is resected in the supraclavicular and lower jugular
areas than with the anterior approach. T h e author does
not feel this is necessary most of the time. If nodes are
suspicious or positive in these areas, he would do a radical
neck dissection.
396 Functional neck dissection

Dissecting medial to the SCM muscie

The posterior cervical triangle contents are dissected
medially until it is medial or underneath the S C M muscle.
At this stage the posterior dissection can be discontinued.
T h e rest of the neck dissection is done anteriorly as
discussed in the anterior approach. W h e n the anterior
dissection reaches the posterior part of the S C M muscle,
all of the posterior contents can then be delivered
underneath the S C M muscle and the dissectio 1
pleted.
If the transverse cervical artery was divided later illv
must be divided again just distal to the infenoj t h J r
artery b r a n c h . Large lymphatic ducts at the lower iuLu
vein area must be recognized and preserved'or |i
satisfactorily. ";.}; '

if***

IIHH
External jugular vein
4'X
Posterior cervical
triangle contents

Splenius capitus muscle

-^" ^
v N
Spinal accessory nerve 20

Trapezius muscle

References
4. Mollnari, R., Cantu, C , Chiesa, F., Grandt, C. Retrospective
1. Bocca, E. Supraglottic laryngectomy and functional neck comparison of conservative and radical neck dissection in
dissection. Journal of Laryngology and Otology 1966; 80: laryngeal cancer. Annals of Otology, Rhinology and
831-838 Laryngology 1980; 80: 578-581

2. Bocca, E. Critical analysis of the techniques and value of neck 5. Jesse, R. H., Ballantyne, A . ) . , Larson, D. Radical or modi) "J
dissection. Nuovo Archivio Italiano Otologia, Rinologia, neck dissection: A therapeutic dilemma. American Journal of-
Laringologia 1976; 4; 151-158 5urgery1978; 136:516-519 ,^

3. Lingeman, R. E „ Helmus, C , Stephens, R., Ulm,). Neck 6. Skolnick,E. M., Yee, K.F., Friedman, M., Goldon, T. A. The J,
dissection radical or conservative. Annals of Otology, posterior triangle in radical neck surgery. Archives of
Rhinology and Laryngology 1977; 86: 737-744 Otolaryngology1976; 102:1-4
Illustrations by Robert N. Lane
David Wright FRCS
Consultant Ear, Nose and Throat Surgeon, The Royal Surrey County Hospital, Guildford, Surrey, U K
Indications
Ligation of the external carotid artery is indicated when
normal methods will not control haemorrhage from:
mouth and tongue; tonsils; lower two thirds of nasal
cavity and maxillary sinuses; and hypopharynx and larynx.
Severe haemorrhage can occasionally occur during a
surgical procedure, following erosion of a major vessel by
advanced malignant disease, or after severe trauma to the
face or neck. It may be preferable to ligate'one of the
branches of the external carotid artery close to the site of
the haemorrhage rather than the main artery itself; for
example in epistaxis, the maxillary artery may be ligated in
the pterygopalatine fossa.
After ligature of the external carotid artery the circula-
tion is later re-established by the free communication
between most of the large branches of the artery and the
corresponding arteries of the opposite side and by
anastomosis of its branches with those of the internal
carotid artery.
Position of patient
T h e neck is moderately extended by placing a sandbag
under the shoulders and the head is partially rotated to
the opposite side.
397
393 Ligature of the externa! carotid arterv

The incision
A curved incision following one of the skin folds of the
neck is made centred over the bifurcation of the common
carotid artery at the upper border of the thyroid cartilage.
The incision is carried through platysma muscle to the
deep cervical fascia. The great auricular nerve should be
preserved.

2
Exposure of the carotid sheath
The deep cervical fascia is divided along its attachment'to
the sternomastoid muscle so that the carotid sheath lying
between this muscle and the infrahyoid muscles can be
exposed by blunt dissection. The pulsations of the artery
within the sheath should be easily palpable. The facial vein
is divided and ligated.

Facial Facial
artery nerve
and vein branches Hypoglossal nerve

iin
 Ligature ot the external carotid artery 399

Retracted posterior digastric

antification of the external carotid artery Hypoglossal

nerve
2 carotid sheath is opened to expose the common Cornu of h
•otid artery and the jugular vein with the vagus nerve
i g posteriorly. The bifurcation of the common carotid External carotid artery
ery into the internal and external artery lies at the level
the upper border of the thyroid cartilage. T h e posterior
lly of the digastric muscle and the stylohyoid muscle agus nerve
ould be identified where they cross laterally to the
Internal jugular
:ernal and external carotid arteries and retracted to
Thyroid vein
pose the carotid bulb.
cartilage
The hypoglossal nerve should be carefully identified
lere it crosses lateral to both arteries.
O n c e the bifurcation has been demonstrated it is Thyroid artery
sential to identify the external carotid artery by finding
least o n e of its branches.
T h e level of the greater cornu of the hyoid bone serves Thyroid gland
a useful landmark to the lingual and facial arteries
Vich usually arise at this level from the external carotid
• ery. Variations in the origin and arrangement of all the
anches of the external carotid artery must be expected,
h e n no uncertainty remains to identification the
ternal carotid artery is ligated in continuity with a strong
read or silk ligature at the desired level.
Failure to control bleeding, especially from the
popharynx, can be due to failure to include the Wound closure
-cending pharyngeal branch in the ligation.
It s h o u l d be remembered that the larynx derives much The deep cervical fascia is approximated to the sterno-
:' its blood supply from the inferior thyroid artery and so mastoid muscle. The s k i n , including the platysma muscle,'
Ration of the external carotid artery alone may not is closed with interrupted silk. It is usually wise to insert a
jffice. small drain for 24hours.
illustrations bv G i l l i a n Lee
£

J.Hibbert CHM, FRCS

Consultant Ear, Nose and Throat Surgeon, Guy's Hospital, St Thomas Street, L o n d o n , U K

EXCISION OF
CYSTIC HYGROMA
The most important consideration prior to operation is a n '
assessment of the extent of the lesion. This is diff ...it, but
oral, parotid, axillary and mediastinal extension are the
This lesion almost certainly arises as a congenital
ones to look for. A chest radiograph is essential to exdudejjf
malformation of developing lymphatic tissue in the neck.
or confirm mediastinal involvement. It may be mat * l t h
Excision is the only acceptable treatment, but the most
the more widespread use of computerized ax a! tomo-^
difficult decision is at what age to intervene surgically.
graphy more precise assessment of these lesion: w l l be*
There is some evidence to suggest that a proportion of
possible.
these lesions will regress during the first year or two of
life . O n the other h a n d , some continue to grow and
1

haemorrhage, or infection in the cysts may cause rapid

and dangerous increase in size. Thus some authors advise
a policy of observation whilst others advise immediate
1

surgery . Clearly the former has advantages in that if

2
regression does occur the surgery will be easier and safer.
Very large lesions found at birth, along with tracheal
deviation and airway obstruction, should be dealt with by
immediate surgery. In smaller lesions there is a great deal
to recommend a policy of initial observation to allow for
possible regression and to allow for growth of the c h i l d .
Anaesthesia
Difficulties with anaesthesia are increased by tracheal r"
displacement and therefore endotracheal intuoition h
essential. Spontaneous respiration is satisfactory
allows for the use of a nerve stimulator in identification*
the facial and accessory nerves.

V
400
 Cervical cysts, sinuses and fistulae 40!

Position of patient and incision

T h e patient is supine with a sandbag under the shoulders

to extend the neck. The head is rotated to one side. The
incision depends upon the site of the swelling, but a
single horizontal incision is satisfactory in the vast majority
of instances. In very high lesions and those with a
significant parotid extension a standard parotidectomy
incision may be used, either alone or with a lower cervical
incision. Even in large lesions no skin should be excised
initially. At the end of the procedure redundant skin can
be excised, though this is rarely necessary. In those cysts
with significant mediastinal extension a median sterno-
tomy incision may be necessary.

The skin flaps are elevated to include the platysma, and

the sternomastoid muscle is dissected along its anterior
and posterior borders to free it from the lesion. T h e
greater auricular nerve is preserved where it lies super-
ficial to the sternomastoid and, in addition, it is usually
necessary to divide and ligate the external jugular vein as
the muscle is mobilized. In the posterior triangle the
accessory nerve must be identified where it runs out from
the posterior border of the sternomastoid to the anterior
border of the trapezius. The nerve may be entirely
surrounded by the lesion and its identification is made
easier by the use of a nerve stimulator. T h e deep surface
of the sternomastoid is dissected free of the lesion and it is
useful to retract this muscle by means of a tape sling.
402 Cervical cysts, sinuses and fistulae

3
Attention is next paid to the inferior part of the dissection
and the omohyoid muscle is identified and freed from the
lesion. T h e swelling may be closely adherent to the
subclavian vein inferiorly and extend along the trunks of
the brachial plexus. In the inferomedial part of the neck
the carotid sheath is identified and it is nearly always
necessary to open the sheath, identify the contents and
dissect the lesion free from the internal jugular vein. As
the dissection proceeds superiorly, the sympathetic trunk
lying behind the carotid sheath, but superficial to the
prevertebral fascia, is preserved. More laterally the
phrenic nerve is also identified where it lies behind the
prevertebral fascia.

As the lesion is dissected free from the contents of the

carotid sheath from an inferior to superior direction the
digastric muscle will be identified. It should be dissected
free and preserved. O n a deeper plane and inferior to
the digastric muscle the hypoglossal nerve should be
found and preserved. Extension of the cyst into the sub-
mandibular triangle a n d . f l o o r of the mouth should be
followed, preserving the hypoglossal nerve in this region.
If there is a significant extension of the lesion into the
parotid gland 'it is hazardous to proceed by blind
dissection and further dissection should only follow after
the facial nerve has been identified and its branches
followed forward and preserved, i.e. a superficial paro-
tidectomy is p e r f o r m e d .
After removal of the lesion haemostasis is ensured and
a large Redivac drain inserted. In very large lesions
involving extensive dissection, pharyngeal and laryngeal
oedema are liable to give rise to respiratory obstruction. A
temporary tracheostomy is an essential safeguard against
this.

Complications

The operation for an extensive cystic hygroma is a very
difficult one and the brachial plexus, facial, vagus,
hypoglossal, accessory and phrenic nerves may be
injured. Because some of these lesions are so extensive
and the operation to remove them is a considerable
undertaking, there is something to be said for two teams
of surgeons. Alternatively, although it is not to be,
recommended as routine, the operation can be done in
two stages. Whilst this is not entirely desirable it is
certainly preferable to an inadequate single operation in
which portions of the lesion are left to recur at various
sites.

BRANCHIAL CYSTS
The pathogenesis of branchial cysts is u n k n o w n . The
name implies a developmental origin from the primitive
branchial apparatus, but it is by no means certain that this
is true. An origin from squamous cell rests within
lymphoid tissue seems to fit the available facts in a more
satisfactory w a y .
3
A definite diagnosis is the most important preoperative
consideration, followed by the exclusion of other lesions
w h i c h give rise to a lateral neck mass and may mimic a
branchial cyst. A proportion of branchial cysts are solid
Cervical cysts, sinuses and tistulae 4tJJ
and the differentiation from an enlarged Ivmr.h :-»-..->.-> ^ >
•-- "- " . . ^ 0 1 u r n to exciuae a primary
carcinoma in the head and neck by endoscopy of the
upper respiratory and alimentary tracts. A branchial cyst
may transmit carotid pulsation but a significantly pulsatille
neck swelling should be presumed to be a chemodectoma
and investigated by carotid angiography. A high branchial
cyst may be impossible to distinguish from a tumour in the
tail of the parotid gland, but treatment is identical, namely
excision by superficial parotidectomy.
Some patients with a branchial cyst present w h e n the
cyst is acutely inflamed. Treatment with antibiotics should
be undertaken until the infective episode has subsided
and then the cyst should be excised. Incision and drainage
of an infected branchial cyst is hardly ever necessary and
should be avoided if possible since this makes subsequent
excision of the cyst more difficult.
Anaesthesia
General anaesthesia with orotracheal intubation and
spontaneous respiration is most suitable. The endo-
tracheal tube is led out of the corner of the mouth
opposite to the side of the lesion.
Position of patient and incision
T h e patient is placed in a supine position with the neck
extended using a sandbag under the shoulders. T h e head
is supported in a head ring and the face turned to the side
opposite to the cyst. A transverse incision about 10 cm
long is made at the level of the cyst and it is desirable, and
nearly always possible, to place this incision in a skin
crease. The incision is made through the platysma and the
skin flaps are elevated, and retracted. The upper flap
should only be elevated to a limited extent, just sufficient
to permit access, since excessive elevation of this flap may
result in damage to the mandibular division of the facial
nerve.
6
T h e external jugular vein will be identified lying on the
sternomastoid muscle and on occasions may need to be
d i v i d e d . More posteriorly the greater auricular nerve may
be seen and it should be preserved. T h e investing layer of
deep cervical fascia is incised at the anterior border of the
sternomastoid muscle and the muscle is dissected free
from the cyst. Posterosuperiorly on a deeper plane the
accessory nerve may be related to the cyst as the nerve
enters the sternomastoid. It should not be damaged. It is
usually fairly easy to develop a plane of dissection close to
the cyst wall and the cyst should be retracted with gauze
swabs or malleable retractors and dissected free of
adjacent structures.
404 Cervical cysjs, sinuses and fistulae

7
Anteriorly the cyst is closely related to the posterior facia!
vein w h e r e the latter enters the internal jugular vein. T h e
cyst should be carefully dissected from the facial v e i n , and
then from the carotid sheath and internal jugular vein on
its deep surface.

Superiorly the cyst is dissected from the posterior belly of

the digastric and on a deeper plane the hypoglossal nerve
should be identified and preserved. A number of
pharyngeal veins may be encountered in this area and if
damaged should be carefully picked up and ligated. O n
the very rare occasions that a branchial cyst has a
connection with the pharynx it is identified at this point
and followed to the pharynx between the internal and
external carotid arteries superior to the hypoglossal nerve.
Finally the medial surface of the cyst is separated from the
carotid sheath and removed. Following removal of the cyst
haemostasis is secured, a suction drain inserted through a
posteriorly placed stab incision and the w o u n d closed in
two layers.

Complications

Facial nerve injury will only occur in superiorly placed

cysts and these should be treated by identification of the
facial nerve and superficial parotidectomy. If the cyst is in
the usual position the mandibular division of the facial
nerve may be damaged by over-enthusiastic elevation of
the upper skin flap.

THYROGLOSSALDUCT
This is a cystic lesion which occurs along the line of
development of the primitive thyroglossa! duct, anywhere
between the foramen caecum and the thyroid isthmus -
usually in the midline. The cyst is joined to the foramen
caecum by the persistent thyroglossal duct. Both cyst and
duct must be excised to avoid 'recurrence. The most
essential feature of the operation, the excision of the
central portion of the body, of the hyoid b o n e , is well
k n o w n . This is the most certain way of excising the
thyroglossal duct, and although not an original observa-
tion was well documented by Sistrunk . 4
Cervical cysts. >inus,; a n d i.siul.n..
S
Preoperative
T h e only contraindication to surgery is when the patient
presents with an infected cyst. The infection should first
be controlled with antibiotics, incision and drainage of an
infected cyst is to be avoided as this results in the
formation of a sinus and makes subsequent surgery more
difficult. •
Anaesthesia
General anaesthesia with a nasotracheal tube is most
desirable a n d allows the surgeon easy access to the
mouth.
Position of patient and incision
T h e patient is supine with the neck extended. T h e incision
depends upon the exact site of the cyst, but a single collar
incision is satisfactory. This should be at the level of the
thyroid prominence for a high cyst and slightly lower for
an inferiorly placed cyst. The incision is carried through
the platysma and upper and lower flaps-are elevated. In
patients w h o have a recurrent cyst and a sinus tract after
previous surgery an ellipse of skin must be excised to
include the sinus and previous skin incision.
T h e cyst is dissected free of the underlying strap muscles,
care being taken superiorly to avoid damaging the
persistent thyroglossal duct which must be excised with
the cyst. In inferiorly placed cysts the duct is usually very
obvious and is dissected upwards towards the hyoid bone.
In high cysts the cyst may be adherent to the hyoid bone
and no attempt at separation should be made.
406 Cervical cysts, sinuses and fistulae

The attachments of the sternohyoid muscle and thyro-

hyoid membrane to the central segment of the hyoid bone
are detached and the body of the bone is divided with
bone cutters to remove a segment of about 1-2 cm.

T h e next stage of the operation is facilitated by placing a

finger in the mouth and exerting pressure on the foramen
c a e c u m . A conical-shaped core of muscle Is excised in the
base of the tongue between the hyoid bone and foramen
caecum in order to remove the most superior part of the
persistent duct. The defect in the base of the tongue is
closed by approximating the incised muscle, the wound is
drained by suction and closed in layers.

Complications
T h e major complication of this procedure is a persistent
sinus following surgery and this means that part of the cyst
or thyroglossal duct has been left behind. T h e surgery of a
recurrence is difficult because inevitably there are
infected granulations in the area w h i c h make identifica-
tion of a tract very difficult, if not impossible. In such an
instance the procedure must be a wide excision of the
area, including skin, granulation tissue,-body of the hyoid
bone if it remains, and muscles of the base of the tongue.

Ctv/ u S ^ i u r \ L . J I I N U ^ C D AINU
FISTULAE
T h e implication in the name of these lesions is that they
arise as developmental anomalies of the primitive branc-
hial apparatus and are therefore present at birth. I n j a c t ,
complete fistulae with an external opening and an internal
•pharyngeal opening do occur, but are rare ..Mo re common
are sinuses with an external opening along the~aofeTior
border of the sternomastoid and a tract of variable length.
Although the external opening is more common in the
lower neck it may occur.high u p j u s t below the external
ear. Fistulae_Qj3_-QCCur which have an opening in the
external auditory meatus and in the submandibular
triangle. T h e most common developmental sinuses in the
head and neck are the preauricular sinuses. These are
usually superficial tracts which probaolyTepresent incom-
plete fusion of the tubercles which form the external ear
and are not therefore derived frDjn_the branchial cleft. The
embryology of the lesions, which are thought to arise
from the branchial apparatus, are_discussed in a well-
k n o w n lecture by W i l s o n .
3
Cervical cysts, sinuses and fistulae 407
The surgery of the most common lesion, namely a sinus or
fistula with its opening lower in the neck, will be
described.
F^ti^sinusejL^and jTjrtuJae^ar-e-. present at birth and
p?oduce a mucoid ""discharge because they are lined by
i^E^I^U!^^ mucous glands, and
'even with a true fistula salivary discharge does not occur.
_A preoperative differentiation between a sinus and fistula
cannot normally be made unless the tract is outlined by
injection of radiopaque material but since the surgical
management is the same in each case this procedure is not
necessary. '~~~~~"~~
Anaesthesia
_G_ejieraUanaesthesia with an orotracheal tube is recom-
mended.
Position of patient and incision
TjTe^rjajU3ni.isjn.a-supine position with the neck extended
aTicTthTlace rotated to the side opposite the lesion. A
U3nsvej£e_ejlirjt^ is made around the external
opening of the lesion and the tract identified. This is
relatively easy as these tracts are surrounded by striated
muscle and therefore fairly substantial.
The upper skin flap is elevated to allow identification and
dissection of the tract, p i e tracfjies_]ust deep to the
anterior border of the sternomastoicTl-nuscIe which must
be identified and retracted posteriorly.
410 Partial and complete parotidectomy

Bony meatus

There are a number of pointers to the position of the main

trunk of the facial nerve as it emerges from the
stylomastoid foramen. The most reliable of these is the
groove formed by the anterior face of the mastoid and the
edge of the bony external auditory meatus, namely the
tympanomastoid sulcus. The facial nerve bisects the apex
of this groove at a slightly deeper level than the edge of
the bony meatus, and thence passes forwards, downwards
and slightly outwards. In this position it lies immediately
above the upper border of the posterior belly of the
digastric muscle, and lateral and somewhat posterior to
the root of the styloid process. T h e posterior auricular
artery lies close to the nerve, generally just below it, and
gives off a small branch which enters the fallopian canal.
The arrow-shaped configuration of the cartilaginous
meatus can also be used as a guide to the position of the
facial nerve.
The point at which the facial nerve divides into its two
main divisions is variable, but usually occurs a short
distance within the parotid gland. T h e upper or temporo-
facial division inclines sharply forwards and slightly
upwards becoming more superficial as it approaches the
zygomatic arch, and dividing into several tortuous
branches. The pattern of branching is variable, but there
are temporal and upper zygomatic branches which incline
upwards and forwards over the zygomatic arch. The lower
zygomatic branch passes forwards below the zygomatic T h e use of relaxing agents and intermittent positive
arch and lies above the parotid duct. The numbers and pressure ventilation is unnecessary and probably undesir-
points of origin of the buccal subdivision are variable, able, since a relaxant such as curare might conceivably
being from either main division or even the bifurcation. interfere with the results of direct stimulation of the facial
The lower or cervicofacial division passes downwards, nerve. Induced hypotension with short-acting agents is
forwards and laterally, and rapidly divides into a buccal useful since it reduces blood loss and allows the surgeon
branch (where it originates from the lower division), a to find and dissect out the facial nerve that much more
mandibular branch and a cervical branch. T h e mandibular quickly.
branch inclines downwards and forwards and crosses the
retromandibular vein to lie immediately anterior to it at its
point of emergence from the tail of the parotid gland. This Preoperative preparation and special
relationship of nerve to vein at the tail of the gland is
constant and provides an alternative method of finding
considerations
and dissecting out the facia! nerve and its branches. Although facial weakness is uncommon in the overtly
uncomplicated case, the patient should be warned of its
T h e retromandibular vein traverses the deep lobe of the
possibility w h i l e stressing the likelihood of early recovery
gland from above downwards, lying immediately medial
if it occurs. This also gives the surgeon some latitude for
to the branches of the facial nerve. T h e external carotid
dealing with the occasional unexpected low-grade malig- , <"
artery lies deep to the vein and is not normally seen in a
nancy, w h i c h by virtue of minor involvement of the facial
partial parotidectomy. Both vessels, however, are excised
nerve obliges him to resect one or possibly two branches
in operations for the total removal of the gland.
of the nerve. T h e r e is scope for complete recovery of
facial' function- if only one branch is resected (the
mandibular branch- being an exception), and removal of
Premedication two branches should allow almost complete recovery,
This is usually given 1 hour before operation and is very particularly if the gaps between the divided ends are
much a matter of personal preference. Pethidine 100mg bridged with a graft. Widespread involvement of the facial
and hyoscine 0.2-0.4 mg given by intramuscular injection nerve is a contra-indication to partial operations and
are a suitable combination. A more popular premedica- required the patient's permission for sacrifice of the facial
tion is O m n o p o n 10-20 mg and hyoscine 0.2-0.4 mg given nerve. Sufficient hair should be shaved from the
intramuscularly. preauricular area to allow for an incision which reaches up
to a point level w i t h the pinna.

Anaesthesia Biopsy of the gland should be avoided if a neoplasm is

After induction the larynx and trachea are sprayed with a
topical anaesthetic agent such as lignocaine (lidocaine),
and the trachea intubated. Light general anaesthesia with
spontaneous respiration is maintained with halothane.
considered to be benign, as there is a very real danger of
implanting cells from pleomorphic adenomata into the
biopsy track. A frozen section should be requested at
operation if there is doubt about the pathology of a
tumour and the action to be taken.
 Partial and complete parotidectomy 411

Position of patient

The patient is placed in the supine position with the neck

slightly extended and the head turned away from the
surgeon. T h e table may either be horizontal or inclined in
a head-up position to reduce venous congestion and
lower the arterial pressure. The towels are so arranged
that the homolateral eye and corner of mouth are just
visible.

2
T h e incision commences -inferiorly in a skin crease
approximately two fingers' breadths below the mandible
and well forwards. It runs parallel to the horizontal ramus
of the mandible onto the sternomastoid muscle where it
inclines upwards to the mastoid process. At the lower
border of the mastoid process it curves forwards to the
point at which the lobe of the ear joins the face. It then
follows the preauricular crease upwards almost to the top
of the pinna.

The incision below the mandible is deepened through

superficial fascia and platysma, to include those layers in
the anteriorly based flap. However, some surgeons prefer
to leave the platysma undivided until such time as they are
ready to pursue the dissection of the mandibular branch
of the facial nerve downwards and forwards.

3
412 Partial and complete parotidectomy

T h e anterior flap consisting of skin and subcutaneous

tissue, and possibly platysma inferiorly, is raised using the
knife and retracted forwards. T h e base of the flap is an
imaginary line which joins the upper and lower ends of
the skin incision. The flap is held forward by a silk stay
suture. Haemostasis using plain catgut or the coagulating
diathermy is carried out.

The great auricular nerve is identified lying on the deep

cervical fascia investing the sternomastoid muscle. T h e
anterior border of the sternomastoid muscle is separated
by sharp dissection from the posterior border of the
parotid gland, and the great auricular nerve divided at the
point w h e r e it crosses onto the parotid gland.

Further u p , the gland is separated from the mastoid

process and the cartilaginous external meatus.
 Partial and complete parotidectomy 413

7
The sulcus which now exists between the parotid gland
and the sternomastoid muscle is deepened by sharp
dissection in order to expose the posterior belly of the
digastric, and the muscle is traced upwards and backwards
to the point where it dips beneath the mastoid process.
Great care must be exercised at this stage to avoid
damaging the facial nerve.

A n attempt is now made to find the main trunk of the facial

nerve. The sulcus between the parotid gland on the one
hand and the external meatus and mastoid process on the
other is deepened, so that the edge of the bony meatus
can be identified. T h e fibrous bands bridging the sulcus
are most dense opposite the mastoid process, and contain
one or more veins. Using a mosquito haemostat to splay
out the bands in the sulcus, the facial nerve is sought by
blunt dissection in the groove formed by the bony meatus
;

and mastoid process. The nerve is .distinctive in appear-

ance, but even so one of the fibrofatty trabeculae may be
mistaken for it. If there is any.doubt about the structure in
question, it can be stimulated with a nerve stimulator or
gently tweaked with a haemostat to see if the face
twitches. Electrical stimulators, however, must not be
relied on exclusively as they sometimes fail to excite the
nerve, or alternatively may stimulate it from a distance.

A haemostat is inserted into the gland immediately

superficial to the main trunk of the nerve and opened up
in order to establish a plane. A suitable retractor is
inserted into this plane in order to retract the superficial
lobe of the parotid forwards, and to allow identification of
the bifurcation of the nerve.

9
414 Partial and complete parotidectomy

T h e haemostat is now slid over the upper division and the

blades o p e n e d . Glandular tissue overlying the posterior
blade is incised upwards and backwards with a knife or
scissors in order to divide the posterior border of the
gland.

10

The retractor is readjusted so as to expose the origin of the

first or temporal branch and the haemostat reinserted and
opened to extend the plane of cleavage. O n c e again the
glandular tissue overlying the posterior blade is divided,
the knife or scissors being directed upwards and
backwards, thereby extending and deepening the first cut.
In this way the superficial lobe is mobilized up to the
upper border of the gland. T h e procedure is repeated with
the haemostat straddling the next branch of the upper
division so that the upper border of the superficial lobe
can be separated from the soft tissues overlying the
zygomatic arch.

11

By dividing the lower half of the posterior border and the

inferior border of the gland using the same technique
along the inferior division and consecutive branches, the
superficial lobe is freed sufficiently to allow it to be
pedicled anteriorly.
 Partial and complete parotidectomy 415

T h e buccal branch or branches are traced forwards, and

the pedicle of the superficial lobe eventually severed.
Small bleeding vessels are tied off with plain catgut. It is
usual to see the retromandibular vein lying vertically deep
to the branches of the facia! nerve, and emerging from the
tail of the remaining gland just posterior to the mandibular
branch. In the process of following the mandibular branch
forwards and downwards the platysma will have to be
divided if this step has not already taken place w h e n
raising the skin flap.

The platysma is sutured using inverting interrupted plain

catgut sutures. The wound is drained through a separate
stab incision just below the main incision, using either a
corrugated or a suction drain. Care must be taken w h e n
using a suction drain to ensure that the tip is well away
from the facial nerve. T h e skin is .closed with interrupted
silk or nylon sutures and the w o u n d covered with dry
dressings supported by a generous amount of woo! which
is held in place by a bandage.
416 Partial and complete parotidectomy
Dressings are changed when soaked and w h e n a
corrugated drain has been used, this is shortened as the
bleeding lessens. A suction drain can generally be
removed the next day. Sedation with 100 mg pethidine by
intramuscular injection may be necessary in the first 24
hours but is rarely necessary thereafter. Antibiotics are
generally not required. Stitches are removed- 5-7 days
after operation.
Complications
Haemorrhage
This is not usually a problem but may occur during or just
after w o u n d closure as a complication of hypotensive
anaesthesia if haemostasis is attempted prior to a return of
the blood pressure to normal. The w o u n d must be
reopened and bleeding arrested.
Haematoma
This is not uncommon in view of the dead space w h i c h
exist between the flap and the parotid bed. It may be
prevented by carefully applied pressure dressings or by
the use of a suction drain. Once a haematoma has formed
it is difficult and probably undesirable to try to evacuate it.
Facial weakness
In straightforward uncomplicated cases the incidence is
l o w , being approximately 20 per cent, and the weakness is
generally temporary, rarely lasting longer than 2-3 w e e k s .
Some parts of the face, such as the lower lip and forehead,
are more vulnerable than others.
Anaesthesia
It is not uncommon for patients to experience anaesthesia
in the preauricular region and the outer aspect of the
lower half of the pinna. T h e effect can be lessened by
trying to preserve the posterior ramifications of the
greater auricular nerve. A rare complication of dividing
the nerve is a very unpleasant h y p e r e s t h e s i a resulting
from neuromatous expansion of the distal cut e n d .
Fistula formation
This is very uncommon, and probably results from
excessive saliva production in the remaining deep lope of
the gland. If the flow of saliva does not show any sign of
diminishing, it can be stopped by reintroducing the
suction drain, shortening it gradually, while maintaining
external pressure with a bandage.
Gustatory sweating
Sweating in the preauricular region at meal times is a
frequent complication, commencing two to three months
after operation. If unpleasant or severe it may be arrested
by tympanic neurectomy. However, the effect of this
operation is uncertain and currently desiccating solutions
as prescribed for hyperhidrosis are being tried.
 Partial and complete parotidectomy 417

TOTAL CONSERVATIVE
r A K W ! IDte,! O M Y
Contraindications
Indications
The operation for the removal of the superficial and deep High-grade malignant neoplasms infiltrating the facial
lobes of the parotid gland with preservation of the facial nerve should not be removed by total conservative
nerve is referred to as a total conservative parotidectomy. operation.
This is indicated in cases of benign neoplasms arising in
the deep lope of the parotid, chronic parotitis secondary
to long-standing duct obstruction, and tuberculous Preoperative preparation, premedication and
parotitis. It is performed in cases of recurrent pleomor-
phic adenoma, low-grade malignant tumours, and rarely anaesthesia
for small high-grade malignancies w h i c h do not involve
the facial nerve. As for partial parotidectomy (see pp. 409-410).

A superficial parotidectomy is performed, at*the end of

which the superficial lobe may be left pedicled inferiorly
instead of anteriorly. T h e pedicle ideally should lie
between the cervical and mandibular branches of the
facial nerve. Alternatively the superficial lobe is excised
completely and the deep lobe removed as a separate
specimen.
The branches and the main trunk of the facial nerve are
dissected off the underlying deep lobe using small
scissors to divide the fascial attachments of the nerve to
the underlying gland. This manoeuvre is helped by lifting
and supporting the nerve and its branches with a nerve
hook.
418 Partial and complete parotidectomy

This deep lobe is separated with scissors from the

posterior border of the ascending ramus of the mandible
and from the temporomandibular joint.

17
The deep aspect of the gland is gently separated from its
underlying bed with small scissors which are introduced
above and below the main trunk of the facial nerve. Some
dense fibrous attachments to the styloid process may have
to be divided.

T h e upper and lower ends of the retromandibular v e i n ,

and any anterior branches are divided between ligatures.
T h e more deeply-placed external carotid artery may not
have to be interrupted if, as sometimes occurs, the artery
does not actually penetrate the gland, but lies deep to it.
M o r e often than not, however, it perforates the deep lobe
medial to the retromandibular vein, and that part w h i c h
lies in the gland therefore has to be removed with the
specimen.
 Partial and complete parotidectomy 419

As for partial parotidectomy (see page 000).

Complications
Facial weakness

T h e incidence of temporary facial weakness is almost

certainly higher than after partial parotidectomy, but is by
no means inevitable.
• 420 Partial and complete parotidectomy
RADICAL PAKUi IDtLIUMt
Indications
The most common indication is a high-grade carcinoma of
the parotid gland, the removal of which cannot be
accomplished satisfactorily without sacrificing the facial
nerve. Tumours falling into this category are generally
large and invasive, and often accojnganjejd by facial nerve
involvement. T h e procedure is frequently combined with
a radical neck dissection. It is occasionally performed in
cases of recurrent pleomorphic adenoma when for
technical reasons there is little hope of preserving the
facial nerve. It is also an integral step in the operation of
sub-total petrosectomy for carcinoma of the middle ear
and external auditory meatus.
Contraindications
Benign lymphoepithelia! hyperplasia may mimic a carcino-
ma by enveloping branches of the facial nerve. Tuberculo-
sis and sarcoid may also simulate a carcinoma by causing
facial weakness, but a radical procedure is not necessarily
indicated with either condition.
•T- C o . X I A ' N ' V *j Position of patient
2i
_0
Preoperative preparation
Consent for sacrifice of the facial nerve is essential before
the operation. T h e patient should be shaved as for a
partial parotidectomy (see page 000).
Biopsy
In cases of suspected high-grade cancer, a preliminary
biopsy is necessary to rule out non-neoplastic conditions
causing facial paralysis, and to confirm the diagnosis of
malignancy before sacrificing the facial nerve. If surgery is
the primary method of treatment, the biopsy immediately
precedes the operation, and the diagnosis is made on a
frozen section. W h e n doubts exist as to the adequacy of
the diagnosis, the results of a permanent paraffin section
should be awaited before embarking on the operation.
O n the other h a n d , there are occasions w h e n it is
desirable to treat the patient by irradiation prior to
operation, in w h i c h case the biopsy antecedes the start of
radiotherapy. In either case the biopsy track must be
widely excised in continuity with the specimen.
The o p e r a t i o n
This is as described for patients undergoing partial
parotidectomy (see page 000).
Skin incision
A n incision similar to that described for partial paro-
tidectomy is u s e d , although its superior limit may be
extended upwards and forwards. An extension inferiorly
may also be necessary to accommodate a radical neck
dissection. A flap consisting of skin and subcutaneous
tissue superiorly, and including platysma inferiorly, is
raised and pedicled anteriorly.
 Partial and complete parotide tomv til

The description which follows applies to the parotid gland

alone and does not take into account radical neck
dissection in-continuity, partial mandibulectomy with
exenteration of the infratemporal fossa, and mastoidec-
tomy or petrosectomy. T h e operation would have to be
modified if a block dissection of the cervical lymph nodes
w e r e required. T h e posterior limits of the dissection are
defined in the same way as for partial parotidectomy.
Using a knife, the posterior border of the parotid gland is
therefore dissected free from the sternomastoid muscle to
expose the posterior belly of the digastric. The gland is
freed higher up from the mastoid process and external
auditory meatus.

T h e retromandibular vein is ligated, and divided at the tail

of the parotid. A retractor is inserted deep into the gland
to elevate it, and reveal the posterior belly of digastric and
stylohyoid muscles.

T h e external carotid artery is clamped, divided and ligated

just before It enters the deep aspect of the gland, above
the stylohyoid muscle. T h e soft tissues at the tail of the
gland are further incised in a forward direction until the
angle of the mandible is reached.
All Partial and complete parotidectomy

Starting at the lower border of the mandible and working

upwards along a vertical line which is anterior to the
parotid gland, the soft tissues overlying the ascending
ramus are divided down to bone all the way up to the
zygomatic arch. Structures sectioned during this step
include subcutaneous fat, branches of the facial nerve, the
transverse facial artery and veins, the parotid duct and the
masseter muscle. T h e cut peripheral branches of the facial
nerve may be tagged with silk to help in identifying them
later if a graft is to be inserted.

T h e periosteal elevator is used to push the soft tissues of

the specimen backwards to the posterior border of the
ascending ramus of the mandible.

Next the soft tissues overlying the zygomatic arch are

incised down to the bone, as far back as the p i n n a .
Branches of the upper division of the facial nerve are
sectioned during this step, and may be tagged for
subsequent grafting. T h e superficial temporal artery and
vein are divided at the point w h e r e they cross the arch.
T h e incision is now carried downwards between the
parotid gland, and the cartilage of the external auditory
meatus, to joing the earlier line of separation.
 Partial and complete parotidectomy 423

OQ

By retracting the tail of the specimen superiorly the gland

is dissected away from its bed with scissors, starting from
below and working upwards. It is separated from the
posterior border of the mandible, from the styloid process
w h i c h lies deep to it, and from the anterior face of the
bony external meatus, below which the facial nerve is
divided as it emerges from the stylomastoid foramen. T h e
specimen can now be retracted downwards and outwards
sufficiently to expose the maxillary artery and veins, so
that they can be divided between clamps. Haemostasis of
the deep parotid bed is secured by using the coagulating
diathermy.

A nerve graft consisting of branches of the cervical plexus

derived from a common stem, can now be inserted
between the divided trunk and branches of the facial
nerve and sutured with fine silk under magnification.

Closure

T h e wound is closed in layers and drained with a

corrugated or a suction drain.
424 Partial and complete parotidectomy
ModiTicanons ui uic upcia.u\jit
W h e n cancer has invaded the skin overlying the parotid
gland, this will have to be included with the specimen,
and provision made for resurfacing the defect with a
regional flap or a split-skin graft. T h e ascending ramus of
the mandible, including the temporomandibular joint,
may sometimes have to be divided w i t h the oscillating saw
and the posterior half resected with the specimen. The
zygomatic arch and part of the temporalis muscle are
sometimes included, together with the bony and cartilagi-
nous meatus and mastoid process. T h e anterior part of the
sternomastoid muscle is not infrequently removed, and
deeper still the pterygoid muscles. As previously men-
tioned, a radical neck dissection is often necessary.
At the end of the operation, parolein drops are instilled in
the eyes, and thereafter sulphonamide eye drops used
four times a day for 1 week. Pethidine is administered by
intramuscular injection when necessary. Dressings are
changed if soaked, but otherwise left undisturbed until
they become uncomfortable or slip. Suction drains are
generally removed after 24 hours and corrugated drains
shortened until drainage has subsided at which time they
are removed. Antibiotics are not administered routinely,
except perhaps to irradiated patients, and stitches are
to support the cheek or corner OT the moutn is useiui as a
means of preventing overstretching of the paralysed
muscles, w h e n grafting has taken place. A tarsorrhaphy
may have to be performed to protect the eye on the
paralysed side.
Complications
Complete facial paralysis
The asymmetry resulting from division of the facia! nerve
is more disfiguring in some individuals than others; Its
impact can be lessened considerably by a successful nerve
graft, or alternatively by the subsequent insertion of
fascial slings to support the mouth and eye. Muscle
transposition or transplantation may also help to reduce
the deformity.
Problems relating to healing
Sepsis and w o u n d breakdown are more prone to occur
after radical parotidectomy, particularly if the patient has
been previously irradiated. A swab should be t a k e n , and a
suitable antibiotic administered once the organism and its
sensitivities have been defined. Massive breakdown of the
w o u n d may occasionally have to be repaired by a regional
flap or a split-skin graft once infection has been brought
under control.
Illustrations by Patricia A r c h e r a n d Robert N. Lane
O.H.Shaheen MS,FRCS
Consultant Ear, Nose and Throat S u r g e o n , G u y s Hospital and Royal National Throat, Nose and Ear Hospital, L o n d o n , U K
Indications
T h e most frequent indication is repeated enlargement of
the gland, often at meal times, due to an inaccessible
calculus lodged far back in Wharton's duct. Calculi in the
gland itself and recurrent stones are also best treated by
excision of the submandibular gland. Duct'Stenosis from
previous stones, trauma, or neoplasms in the floor of the
mouth may cause persistent enlargement of the gland
with discomfort thus necessitating its removal. Acute
phlegmonous sialadenitis constitutes a further indication,
once symptoms and signs have completely subsided.
c L^y^.
Although recurrent enlargement with sialectasis is m u c h
less common than in the parotid it may sometimes prove
sufficiently troublesome to justify operation. In young
children with enlargement of unknown aetiology, the
diagnosis of tuberculosis can only be excluded at times by
excision of the gland. Primary neoplasms of the subman-
dibular gland are much less common than in the parotid
and more inclined to be malignant. They should all be
excised, and in the case of high-grade cancers a radical
neck dissection performed at the same time.
425
426 Removal of the submandibular salivary gland

Surgical anatomy

The mandibular branch of the facial nerve is easily

damaged in operations for the removal of the subman-
dibular gland if care is not taken to preserve it. The nerve
leaves the tail of the parotid gland just anterior to the
retromandibular vein and posterior to the angle of the
mandible. It passes forwards and downwards deep to the
platysma about 2 cm below the horizontal ramus of the
mandible, lying on the outer aspect of the deep cervical
fascia to which it is intimately attached. It runs parallel to
the mandible for a short distance before dividing into
several smaller nerves which pass upwards and forwards
in the direction of the lower lip. The trunk which crosses
the facial vessels at their point of contact with the lower
border of the mandible often appears to be the dominant
subdivision of the mandibular nerve. There are three
methods of preserving the mandibular branch of VI 1th
nerve and its branches: the first is to identify it at the tail of
the parotid w h e r e it lies anterior to the retromandibular
vein and to trace it forwards: the second avoids
identifying the nerve altogether by ensuring that the plane
of gland excision is always deeper than the nerve. This is
accomplished by approaching the gland at the level of the
hyoid b o n e , and by keeping the dissection deep to the
gland's fascial covering. The third method relies on
dividing the facial vessels well below the mandible and on
lifting up the upper ligated stumps, so as to retract the
main nerve trunk out of harm's way.
T h e hypoglossal nerve, which lies on the hyoglossus
m u s c l e , is related superficially to the deep part as well as
to t h e junction of the superficial and deep parts of the
submandibular gland. There is rarely any difficulty in
identifying it once the gland is mobilized off the Preoperative preparation
h y o g l o s s u s m u s c l e , although after p h l e g m o n o u s
sialadenitis it may be embedded in dense scar tissue No special preparation is required apart from asking male
w h i c h is adherent to the gland. patients to shave their beards.
T h e lingual nerve appears in the dissection as a
U-shaped loop drawn downwards by traction of the deep
part of the gland to which it is attached. In order to release Premedication
it, t h e ganglionic attachment must be severed. A vein
almost invariabiy-run5 side by side with the ganglion and A suitable combination is pethidine 100 rog given by
can cause troublesome bleeding. The facial artery which is intramuscular injection and hyoscine 0.2-0.4 mg given 1
a large vessel has a variable relationship to the gland. hour before operation. Omnopon 1Smg and hyoscine
C o m i n g off the external carotid artery higher up than is 0.2-0.4 mg are a popular alternative.
often imagined, it loops over the upper border of the
posterior belly of the digastric and the stylohyoid muscle
to descend to the lower edge of the posterior border of
the submandibular gland, it ascends either intimately Anaesthesia
attached to the posterior margin of the gland, or actually
e m b e d d e d in it, giving off branches to the gland before it After intravenous induction, the larynx and trachea are
loops over the inferior border of the mandible. The artery sprayed with a suitable topical anaesthetic, and the
needs to be ligated and divided in two places, namely just trachea intubated. Anaesthesia is maintained with
before it reaches the gland and also below the mandible halothane, no attempt being made to assist respiration.
before it pierces the deep cervical fascia. Induced hypotension is useful but not essential.'
 Removal of the submandibular salivary gland 427

ie n n p r ^ f i o n

Position of the patient

T h e patient is placed in the supine position with a smali

sandbag under the shoulders and the head turned in the
opposite direction. The towels are so arranged that the
homolateral corner of the mouth is visible. Tilting the
table head up helps to lower the arterial and venous
pressures.

A horizontal skin incision is made well below the

mandible preferably in a skin crease just above the hyoid
bone. The incision should overlap the sternomastoid
muscle posteriorly, and extend just beyond the anterior
limit of the gland anteriorly. v 2

3
T h e incision is deepened with the knife through the
subcutaneous fat and platysma down to the level of the
deep cervical fascia, and bleeding vessels coagulated with
the diathermy.
The deep cervical fascia is incised along the anterior
border of the sternomastoid muscle a n d • horizontally
above the hyoid bone to expose the fascial condensation
surrounding the submandibular gland.

T h e fascial capsule surrounding the gland is incised

horizontally at the lower border of the gland.
428 Removal of the submandibular salivary gland

5
The upper flap consisting of skin, subcutaneous fat,
platysma, deep cervical fascia and the fascial capsule
superficial to the gland is now elevated with a knife. The
dissection proceeds from below upwards in the plane
between the gland itself and its fascial covering. A
retractor is inserted deep to the flap and elevated by the
assistant, or a self-retaining retractor may be used as an
alternative.

T h e common facial or anterior facial vein is now divided

between ligatures.

7
The lower border of the gland is grasped by suitable
traction forceps, and lifted up. This reveals the common
tendon of the digastric muscle and the hyoglossus muscle.
Using the knife the gland is separated from the muscular
floor of the submandibular triangle, and the hypoglossal
nerve with its venae comitantes identified on the
hyoglossus muscle. T h e anterior segment of the gland is
released from the mylohyoid muscle.
 Removal of the submandibular salivary gland 429

in

Traction on the gland is now applied forwards and

upwards, and the stylohoid and posterior belly of the
digastric retracted downwards and outwards. T h e facial
artery is identified as it emerges from its position deep to
these muscles and divided proximal to the gland between
strong ligatures. This frees the gland posteriorly.

T h e gland can now be retracted downwards in order to

divide its superior fascial attachments to the mandible and
to expose the facial artery and anterior facial vein just
below the mandible. These vessels should be divided as
close to the gland as possible in order to avoid accidental
damage to the mandibular branch of the facial nerve. If
the dissection has been correctly performed, the nerve
should have been retracted with the soft tissue flap w h i c h
is being elevated by the assistant, and the deep cervical
fascia should intervene between it and the gland. T h e
facial vessels have to penetrate the fascia to reach the
outer aspect of the mandible, at which point the nerve
crosses superficial to them. Twitching of the corner of the
mouth indicates that the nerve is close at hand and being
irritated.

A blunt retractor is now inserted deep to the posterior free

border of the mylohyoid muscle and the muscle retracted
forwards, thus exposing the deep part of the gland. With
traction on the gland still maintained in a downward
direction the lingual nerve is dragged d o w n from its
position deep to the mandible and its attachment to the
gland severed. A vein which runs alongside the ganglionic
attachment is divided at the same time and usually
requires ligation.
430 Removal of the submandibular sali\ar\ gland

Traction is now applied in a downward and lateral

direction and the duct of the gland identified, clamped,
and its distal segment tied.

After securing bleeding vessels, provision is made for

drainage through the lower flap using a suction or
corrugated drain.

The platysma is closed with interrupted inverting plain

catgut sutures and the skin sutured with interrupted silk,
monofilament nylon or a subcuticular nylon stitch.

Dressings

Dry dressings are applied, supported by a generous

amount of cotton wool and stretchable adhesive plaster or
a bandage.

Postooerative care
If a bulky dressing has been applied, steps should be
taken to ensure that the patient's airway does not become
obstructed during recovery of consciousness. The patient
should be adequately sedated with pethidine in the first
24 hours after operation, but later simple analgesics such
as aspirin are generally ail that is required. Early
mobilization is necessary in older subjects, and antibiotics
prescribed in infected cases. Stitches are removed 5-7
days after operation.
Complications
Haemorrhage
This is an uncommon complication and more often
venous than arterial. If the wound is found to be oozing
steadily at the end of the operation, and the oozing
persists after emptying the dead space by pressure, it
should be re-explored in order to find and secure the
bleeding point.
Haematoma /
This is not uncommon, as there is a large area of dead
space which is difficult to obliterate even with suction-
drainage. There may also be dependent bruising of the
s k i n . No action need be taken if the haematoma is not
Removal of the submandibular salivary gland 431
i r , H i ; ! . ' i v " - -i
^ _ (j^.. vji svciiie sinus
iorceps to open the w o u n d , or suction with a sterile tube,
will help reduce the size of a large haematoma.
Paralysis of the depressor anguli oris /
The mandibular branch of the facial nerve is probably the
most vulnerable of all the branches. It is not uncommonly
damaged during excision of the submandibular gland, the
nature of the injury being more often compression or
traction of the nerve than discontinuity. Over-enthusiastic
use of the diathermy too close to the nerve has also been
held responsible for its injury.
T h e deformity which results, namely a failure to depress
the corner of the lower lip, is more often than not
permanent.
Hypoglossal nerve palsy /
This is an uncommon complication of the operation, and
results in deviation of the tongue to the affected side, and
eventually fasciculation and wasting. No action need be
taken in a unilateral palsy.
Damage to the lingua! nerve '
This is very uncommon and results in paraesthesiae or loss
of taste in the homolateral half of the tongue. Should the
paraesthesiae prove troublesome, division of the nerve
relieves the symptom but results in loss of taste instead.
illustrations by Patricia A r c h e r

O . H. Shaheen MS, F R C S
Consultant Ear, Nose and Throat Surgeon, Guy's Hospital and Royal National Throat, Nose and Ear Hospital, L o n d o n , UK

Contraindications
Preoperative
Calculi situated in the deep part of the submandibular
gland are best removed by excising the gland itself.

Indications
T h e operation is indicated when a calculus in Wharton's
duct is accessible for removal through the floor of the
mouth.
Anaesthesia
T h e operation can be performed under local anaesthesia,
but this is much less satisfactory than general anaesthesia.

432
 Removal of calculus from the submandibular duct 433

i t i c O J J C I ctuui*

T h e patient's jaws are separated by dental props, or by a

suitable mouth gag such as Doyen's. The tongue is pushed
to the opposite side by a malleable retractor held by the
assistant, or drawn away from the side of the stone by a
traction suture. The position of the calculus is noted by
palpation and silk sutures are passed deep to the duct,
both proximal and distal to the calculus, and the sutures
tagged. T h e sutures are lifted up by an assistant to prevent
the calculus from slipping back into the gland. A solution
of 1:200 000 adrenaline is injected through the mucous
membrane overlying the calculus and around the duct in
order to minimize bleeding which is otherwise very
troublesome.

Using a No. 15 blade on a long handle the duct is slit open

between the stay sutures to expose the calculus.

3
T h e calculus is grasped by a haemostat and removed from
the duct. No attempt is made to suture the duct.

- Warm antiseptic mouth washes are recommended until

healing occurs. Disprin is prescribed for pain, and
antibiotics if the submandibular gland is infected. Mas-
sage of the gland periodically may be helpful in expressing
stagnant saliva.

Complications
Damaged lingual nerve The lingual nerve may be
damaged during the operation by reason of its close
relationship to the duct, resulting in paraesthesiae or loss
of taste.

Duct stenosis This uncommon complication may result

in enlargement of the gland for a time, but this generally
subsides as the gland undergoes pressure atrophy. If,
however, the gland becomes infected, it may be wiser to
3 excise it once the infection has subsided.
in. -*—,tinns bv R o b e r t N. Lane
:
O.H.Shaheen MS,FRCS
Consultant Ear, Nose and Throat Surgeon, Guy's Hospital and
the Royal National Throat, Nose and Ear Hospital, London, U K
Indications
The infratemporal fossa lies adjacent to the m o u t h ,
antrum, orblC nasopharynx and middle ear, and is
therefore vulnerable to invasion by primary neoplastic
disease ansjng_frjjnilh^ Resection of the contents
and boundaries of this area may therefore be legitimately
incorporated into procedures for the elimination of
disease emanating from the primary sites mentioned and
involving the fossa. Typical examples are cancers of the
roouib_. and maxilla, angiofibroma of the nasopharynx,
ameloblastoma of the mandible and maxilla, carcinoma of
the middle ear, chordoma, and deep lobe tumours of the
parotid gland.
T,be introduction of computerized scanning has enabled
the clinician to improve definition of instances of early,
well-circumscribed invasion of the infratemporal fossa
and hence j o _ recognize their suitability for surgical
resection, white-ejecting cases pt^rpssinvasionas being
beyond the scope of adequate removal.
Primary tumours o f J he,.infratemporal iossa are a rarity.
T h o s e suitable for resection include angiomas, mening-
iomas, fibro- and chondrosarcomata. Jgyes^aJjojis^for
such suspected conditions include conventional radi-
ology, scanning, and needle or open biopsy. Disease
yyJ^icjiJaxgeJyj^glaces the soft tissue contents of the fossa
'and erodesits boTTy boundaries may well be too advanced
for successful removal; and care must therefore be
exercised in the selection of cases for resection. Distant
dissemination of malignant disease constitutes a contra-
indication to surgery.
 Approaches for tumours of the infratemporal fo

SnrHn! .imtnmv
T h e infratemporal fossa is filled with muscles, nerves and
blood vessels and communicates by fissures and openings
with adjacent spaces. I t J i e s J ^ e J p v x U i e i ^ s e _ o £ j i ^ ^
deep to the ascending ramus of the mandible and is
shaped rather like an inverted pyramid, possessing a roof,
anterior, lateral and posteromedial walls, a posterior edge
and inferiorly an apex.

T h e lateral pterygoid plate represents the anterior half of

the medial boundary of the fossa with the tensor palati
muscle and superior constrictor forming the posterior half
of the medial limit.

O n the lateral side, the inner aspect of the zygomatic arch,

the masseter and temporalis muscles, the ascending
ramus of the mandible and the deep lobe of the parotid
constitute the external boundary.

Greater wing of sphenoid

3
Superiorly the roof is formed by the infratemporal surface
of the greater wing of the sphenoid and a small part
posteriorly of the squamous temporal bone.
436 Approaches lor tumours or [he iniraiemporal lossa

6
T h e inferior orbital fissure similarly communicates with
the orbit at the junction of roof and internal wall of the
fossa.
 Approaches for tumours of the infratemporal fossa

8
The muscles which fill the infratemporal fossa are the
media! and lateral pterygoid muscles, and the temporalis.
ThjejTiajdUary-artecy^^ off a number
of branches in its passage towards the inferior orbital and
pterygomaxiliary fissures. T h e fossa abounds with veins
with thin wajls, some of which are grouped together
within and overlying the pterygoid muscles as the
pterygoid venous plexus. T h e mandibular division of the
fifth cranial nerve, its anterior and posterior subdivisions
and their branches also traverse the length of the fossa,
for the most part In a downward and lateral direction
between the pterygoid muscles.

Preoperative preparation

The temporal hair should be shaved for all but the anterior
and submandibular approaches.

Premedication Position of patient

This is very much a matter of personal preference, but
pejhkiine-^Qjmg and hyoscine 0.2-0.4 mg given by
intramuscular injection one hour before operation, seem
to be a suitable combination. O m n o p o n 10-20mg and
hyoscine 0.2-0.4 mg given intramuscularly are a useful
alternative.
All the apoj^ache^jiescjibed require the patient to be in
t h e s u p i n e position with the occiput supported by a
mastoid ring. !ri_frjj^ase^LJhe^lateral,-^xten^ed
anterolateral and subjr^ajbjjiar_approaches a sandbag
b^n^atr71he~shoulder extends the neck and facilitates
exposure.
438 Approaches for tumours of the infratemporal fossa

Access to the infratemporal fossa via this route is

somewhat restricted and it is therefore more suitable for
the removal of well-circumscribed clinically benign mas-
ses. It has been found adequate for the removal of
extracranial meningiomas, fibrosarcomas and recurrent
pleomorphic adenoma invading the fossa.

9
A superficial parotidectomy is performed through an
extended parotidectomy incision (see chapter on 'Partial
and complete parotidectomy', pp. 4 0 9 ^ 2 4 , for descrip-
tion of the operation).

10
The branches of the facial nerve are traced as far distally as
possible, and freed from underlying structures such as the
temporalis fascia, zygomatic arch and masseter m u s c l e .

11
The temporalis fascia is separated j r o m the upper border
of the zygomatic a r c h , taking care not to damage the
branches of the facial nerve which lie superficial to it. T h e
arch is divided anteriorly close to the zygomaticomalar
suture and posteriorly atjts_root. The_strip of bone tTTus
separated, together with the inferiodylrttacKed masseter
muscle, is allowed to drop beneathlhe_ov^rjyJr^^ranches
of the facial nerve in order to expose the ascending ramus
of the mandible, clearance being achieved with a
periosteal elevator.

tjMhe_ released zygomatic arch and masseter are too

bunched up to permit their retraction inferiorly for access
to the ascending ramus, the arch may be detached
completely and replaced at the end of the operation as a
free graft.
 Approaches for tumours of the infratemporal fossa 439

12
The_ascejiding^^ is divided in a
trifurcate manner,, above the level of the lingula.

13
The coronoid segment with attached temporalis muscle is
reflected superiorly, threading it under a branch or two of
the facia! nerve, if necessary, to maximize exposure, or
alternatively the coronoid process may be excised
altogether. The lower fragment ofjthe ascending ramus is
retracted interiorly and the~irTfratemporal~?ossa o p e n e d ,
t h e removal of, encapsulated m a i s ^ s j s j a c [ i j t a i e d by an
assistant inserting a finger in the nasopharynx and
exerting outward P""gssure_ against the lateral nasoph-
aryngeal w a l l . * ' ~~~
More extensive masses may require division or resec-
tion of the pterygoid muscles. Once the tumour has been
removed the mandible and zygomatic arch may be
rewired and the w o u n d closed with drainage.

Dressing

Dry dressings-are supported by a generous amount of

w o q j ^ n d a bandage which is taken horizontally around
the head and forehead and round the neck.

Complications

Creat_caj£jrnujit^^ stretch the branches of
tfie facial nerve7ifli)roTo7^^ muscle weakness is to
be avoided. T J x e J o f e j i o j J i i ^ ^
may be damaged in spite of attempts to preserve t h e m ,
and are more often sacrificed with removal of the tumour
mass. The resulting mental and lingual anaesthesia is less
distressing than the paraesthesiae which result if the
nerves are spared but damaged in the process, l o s s of the
aj^ioujo^mrxjra^ n e j y e j ^ J e a d j i o anaesthesia of the
upper pinna and side of the scalp, and division of the great
auricular nerve ajLa.pjElirrijjTa^ will
result in loss of sensation in the tower pinna and
preauricular area.
440 Approaches Jor tumours of the infratemporal fossa

txam^at i c u e i ai d j j p i o c u . i l

This approach is suitable for cases of carcinoma of the

parotid, eJ^ernaJjneajus, and middle ear cleft in which
facial nerve paralysis is evident.

Re^eiUijoxuof4he-pa£otid-gland including the facial nerve,

zygomatic arch and ascending ramus of the mandible
allows the surgeon to get at the lateral aspect and base of
the skull, and the contents of the infratemporal fossa. A_
formal resection of the external auditory meatus, mastoid
and middle ear may be incorporated into the procedure.
With the horizontal ramus turned forwards, the internal
carotid artery can be traced up to the base olthe^skull and
the pterygoid and l o w e j ^ p j i r £ j ^ t h e ^ ^
excised. If necessary the bone forming the undersurface
of the skull may be drilled away over a wide area; and the
pterygoid plates removed. The cartilaginous Eustachian
tube may be dissected out of its groove and the bony tube
drilled away.
T h e large dead space is obliterated by a suitable muscle
flap, or if skin has been resected by a myocutaneous flap,
both of w h i c h provide cover for the internal carotid artery.
T h e w o u n d should always be drained.

Dressings '
These are as for a radical parotidectomy, with substantial
padding in the form of a large bolus of cotton wool.
Complications
The pre-existing facial paralysis may require a lateral
tarsorrhaphy for short-term protection of the eye, but if a
nerve graft is feasible at the time of formal excision it may
eventually serve to reanimate the muscles of the face and
permit one to dispense with the tarsorrhaphy.
Resection of the ascending ramus of the mandible
causes the horizontal rami to slew over to the side of
operation and throws occlusion of upper and lower jaws
out of alignment, making chewing impossible. T h e patient
must therefore subsist on a soft diet.
Anaesthesia of the chin, tongue, and side of scalp are
inevitable sequelae of the resection. Other complications
may relate to resection of the middle ear cleft when this is
part of the procedure.
 Approaches for tumours of the infratemporal r'os:

i i - -- ' ' •

This approach is designed for the removal of well-

circumscribed masses such as juvenile angiofibroma of
the nasopharynx.

A modified Weber-Ferguson incision is made.

A cheek flap is reflected laterally and the infraorbital nerve

transected with a small protective cuff of soft tissue
around it.

16
442 Approaches for tumours of the infratemporal fossa

The anterior, lateraf, posterior and medial antral wails are

drilled out or removed with rongeurs leaving the oribital
floor and superior alveolus intact. The lateral nasal wall
incorporating the inferior and middle turbinates is
removed.

18

That part of the angiofibroma which extends behind the

antrum into the infratemporal fossa is mobilized by blunt
dissection, working medially and forwards so that the
swelling is displaced into the dead space provided by the
antrum. T h e internal maxillary artery is identified and
divided.
 Approaches for tumours of the infratemporal fossa 443

Removal of the vertical plate of the palatine bone, namely

the most posterior part of the bony lateral w a l l , provides
access to the neck of the dumb-bell swelling lying as it
does in a much enlarged sphenopalatine foramen. This
releases the neck of the bilobed swelling and enables the
surgeon to get at the nasopharyngeal component,-which
is excised together with its mucosal covering.
T h e dead space is filled with ribbon gauze impregnated
in bismuth-iodoform-paraffin paste, and the external
w o u n d closed in layers.

Dressings but if not, the diminished degree of sensation does not

T h e conjunctival fornices are filled with Chloromycetin
ointment, and the eye covered with a pad. T h e incision is
covered by a thin layer of vaseline. If desired a pressure
dressing may be applied to the eye and cheek.
Complications
Anaesthesia of the cheek, upper lip and side of the nose is
inevitable. In younger subjects it may recover completely,
seem to be accompanied by distressing paraesthesia.
Slight downward eversion of the medial end of the
lower lid may occur with resultant epiphora, but this is
usually self-correcting and permanent ectopion is very
uncommon.
Slight rocking of the upper jaw under digital or dental
pressure has occurred in one patient, but eventually
disappeared. A bone graft buried in soft tissue and placed
between the orbital and alveolar shelves would correct
this complication if it were to persist. Crusting of the nose
has only proved to be a nuisance in the first month after
operation, thereafter disappearing completely.
444 Approaches for tumours of the infratemporal fossa

This operation is designed to deal with carcinoma of the

antrum extending into the infratemporal fossa and may be
combined with exenteration of the orbit. It may be
modified to encompass oral cancers, such as retromolar
and tonsillar carcinoma when invasion of the infratempor-
al fossa is judged to have taken place.
T h e incisions will depend to a certain extent on the site
of the primary neoplasm. In the case of the maxilla and
orbit, two major flaps are raised. The upper comprising
soft tissues only is the larger and incorporates the cheek
and homolateral forehead, whereas the lower comprising
lower lip and mandible is in the form of an osteoplastic
flap.

The upper incision resembles the classical Weber-

Ferguson, but is made to surround the eye and is carried
upwards in the midline of the forehead, curving slightly
outwards as it proceeds backwards. To ensure that the
orbicularis oculi muscle is not denervated at the outer
extremity of the eye the muscle is transected in the medial
third of the lids and the lateral two-thirds of the muscle
incorporated in the flap to be mobilized. The lower
incision which splits both lip and mandible is extended
backwards into the submandibular triangle and the
contents of the triangle mobilized and reflected back-
wards.
 Approaches lor tumours of Ihe infratemporal fossa 445

23
T h e mucosa of the floor of the mouth and mylohyoid
muscie are incised close to the inner aspect of the
horizontal mandibular ramus. The medial pterygoid is
identified and Its insertion into the lower inner aspect of
the ascending ramus divided. The cheek, lid and forehead
flap are lifted off the bone of the maxilla, malar b o n e ,
zygomatic arch and side of skull. In order to free this
enormous flap the superior attachment of the temporalis
fascia must be divided. In this way the branches of the
facial nerve are all contained within the substance of the
flap and are consequently not at risk.
T h e oral mucosa is divided along the upper gingivobuc-
cal sulcus, at the posterior end of which the incision is
curved downwards medial to the pterygomandibular
raphe to join up with the floor of mouth incision.
T h e zygomatic arch is divided at its posterior and
anterior ends and the temporalis muscle detached from
the coronoid. process of the mandible. T h e lateral
pterygoid muscle is divided close to its point of insertion
into the condyle of the mandible, the inferior dental nerve
is divided, and the mandible rotated almost 90° from the
sagittal axis. The infratemporal fossa is now fully exposed
and its contents ready for removal in conjunction with a
maxillectomy, which in turn may include resection of the
malar bone and orbital exenteration. The upper head of
the lateral pterygoid is detached with a periosteal elevator
from the undersurface of the greater wing of the
sphenoid, the mandibular nerve divided as it exits from
the foramen ovale, and the pterygoid plates removed at
their base with an osteotome. T h e soft tissues comprising
the contents of the infratemporal fossa are removed
together with the maxilla and orbit, so that the bony
boundaries can be inspected. If necessary the bone of the
greater wing of the sphenoid may be drilled away in part,
and the maxillary nerve removed flush with the foramen
rotundum. Any residual fibrofatty tissue either in the
pterygopalatine fossa or the infratemporal fossa is either
removed or diathermized.
At the conclusion of the operation the mandible is Dressings
r e w i r e d , the soft tissues approximated in two layers and
the lower wound drained. If the eye has been removed Pressure dressings are applied to prevent excessive soft
the lids minus their tarsal plates are sutured together, and tissue swelling.
a medicated pack inserted into the operative cavity to
keep it clean. Whitehead's varnish or bismuth-iodine-
paraffin paste are useful for this purpose. A dental plate
with obturator which is placed in the oral cavity to provide Complications
a seal for the palatal defect is immobilized with circum-
alveolar and suspension wiring. Anaesthesia of the forehead, cheek and c h i n is inevitable.
If the primary neoplasm is in the oral cavity, the During the operation the condyle of the mandible may be
operation is modified to dispense with the incision around inadvertantly dislocated from the temporomandibular
the eye and in the forehead. A laterally reflected cheek joint, and will have to be carefully repositioned. S u c h an
flap w i l l , however, enhance access to the upper part of the eventuality will lead to trismus which may be slow to
infratemporal fossa, particularly if the lower half of the improve. Breakdown of the lids is not u n c o m m o n .
malar bone and the lateral aspect of the maxilla are drilled Rehabilitation of such problems is generally a long
away. drawn-out affair.
446 Approaches for tumours of the infratemporal fossa

This approach allows satisfactory access to the upper

lateral part of the infratemporal fossa but as exposure is
relatively cramped its adaptability to most pathologies is
limited. It might be considered useful for the removal of
osteoblastoma at the skull base, low grade malignancies,
or simply as a safe avenue for biopsy. It has the merit of
allowing dissection to take place beneath the temporalis
muscle and therefore deep to the facial nerve.

T h e incision depicted is taken down to bone and the pinna

reflected downwards and forwards after transecting the
cartilaginous external auditory meatus.

24

25
T h e temporalis muscle is detached from the side of the
skull with a periosteal elevator and the muscle pushed
downwards and forwards. To increase exposure, the
zygomatic arch may be fractured at its anterior and
posterior extremities, and the lateral margin of the w o u n d
displaced outwards by a retractor placed deep to the
temporalis muscle and the flail zygomatic arch. To gain
further exposure of the base of the s k u l l , the infratempor-
al crest is burred away until the dura is exposed and the
bone-work carried medially if necessary along the greater
wing of the sphenoid. This approach may also be made
part of an operation directed at the middle ear and
mastoid.
At the conclusion of the procedure, the divided
temporalis muscle and external meatus are reconstituted
with catgut, a dependent drain inserted, and the skin
sutured. T h e meatus is packed with a medicated w i c k .

Complications

Slight flattening of the side of the head may ensue as a

consequence of dividing the zygomatic arch although this
may be prevented by wiring it back in place.
Meatal stenosis as a result of transection is unlikely to
occur if a medicated wick is left in place for a week to ten
days.
 Approaches tor tumours of the infratemporal fossa 447

This is appropriate for localized benign tumours of the

infratemporal fossa.

A long submandibular incision is necessary to permit

retraction of soft tissues and bone superiorly and laterally.

26

The incision is deepened to expose the submandibular

salivary gland which is either pedicled downwards and
forwards, or removed altogether. T h e upper flap of the
incision is reflected upwards and the periosteum of the
lower border of the mandible divided along its long axis.
.Using a periosteal elevator the horizontal and ascending
rami of the mandible are laid bare and the outer aspect of
the oral mucosa displaced inwards off the bone taking
care not to enter the oral cavity.

The mandible is divided at the junction of horizontal and

ascending rami, the saw cut being inclined downwards
and forwards. T h e ascending ramus of the mandible is
then retracted upwards and laterally, and the insertion of
the medial pterygoid into its inner aspect released to
facilitate outer retraction of the bone. This ensures
adequate access to the lower part of the infratemporal
fossa. At the conclusion of the procedure the mandible is
rewired and the w o u n d closed in layers with drainge.

Dressings
A firm pressure bandage is placed around the head in a
submentovertical axis with several turns around the neck
in a submentosuboccipital axis.

Complications
Trismus will occur for several days after the operation,
gradually improving with the passage of time. Dental
anaesthesia from division of the inferior dental nerve is
permanent. Movement at the fracture line is the consequ-
ence of ineffectual immobilization of the bony fragments.
•Illustrations by Robert N. Lane

P. M. Stell ChM, FRCS

Professor of Otorhinolaryngology,
University of L i v e r p o o l , U K

D. O . Maisels FRCS
Consultant Plastic S u r g e o n ,
Liverpool Regional Hospital Board, UK

Pharyngocutaneous fistulae complicating total laryngec-
tomy almost always occur in the irradiated patient, w h i c h
makes repair difficult. Repair should not be undertaken
during the first 60 days; du.ring this time local infection is
controlled and fistulae occurring in non-irradiated pa-
tients will virtually all heal spontaneously.
T h e tissue lost must be replaced, so as to provide an
epithelial lining to complete the pharyngeal l u m e n , and
aiso an epithelial outer closure. According to the
availability of local healthy tissue, most fistulae can be
divided into three categories.
Type I - in which both epithelial surfaces can be
provided locally.
Type II - in which there is sufficient local healthy tissue
to provide inner lining, but outer cover must be provided
from a distance.
Type II! - in which there is no local healthy tissue and
both surfaces must be provided from a distance.

448
In Type I fistulae, the inner layer is provided by two
ellipses of skin turned inwards. A crescentic flap is marked
out on each side of the fistula, each being the same w i d t h ,
at its widest point, as the fistula. The ends of each ellipse
are close to the margin of the fistula to avoid bunching of
excess tissue.

1
 •bO Closure of pharyngocutaneous fistulae

& Connell inverting sutures are used for the inner layer. It is
preferable to begin suturing from each end of the defect,
tying the knot in the middle, to ensure that the skin at
each end of the defect is inverted into the lumen.
After suturing the flaps, the resultant pressure of the
excess tissue forces the edges of the flaps down into the
l u m e n , producing good apposition of their edges.
A second layer and preferably a third layer of sub-
cutaneous sutures is inserted to strengthen the closure.

The resulting raw surface must be covered by a local flap,

usually a rotation flap, which is fashioned in accordance
with the basic principles of plastic surgery. A n isosceles
triangle is drawn around the defect with pen and ink, the
sides of the triangle adjacent to angle x being e q u a l . A
rotation flap is now marked out in such a way that the
distance between the apex of the triangle and the pivot
point P of the rotation flap is four times the length of the
triangle opposite to angle x.

5
8
452 Closure- of pharyngocutaneous fistulae
For a fistula to be considered as Type II there must be
healthy viable skin on each side of the fistula for a width at
least equal to that of the fistula. If there is not, the inner
lining cannot be provided locally and the fistula is then
considered to be Type 111.
As the flap has to cross intact skin to reach the fistula, it is
t u b e d . The distal end is now sutured to the edges of the
bare area on the neck.
In Type 1! fistulae, the inner lining is provided by turning
in local flaps as in closure of a Type I fistula, but the defect
must be covered by a flap from elsewhere because of lack
of local tissue. For most situations the best distant flap is
the medially based deltopectoral flap.
A deltopectoral flap is raised in the following way.
9
The borders are first marked on the chest with a pen and
ink: the upper border is over the clavicle, the lateral
border at the level of the acromion, and the lower border
just above the nipple, low enough to include the upper
four perforating branches of the internal mammary artery
in the base of the flap. The lower border passes through
the anterior aspect of the axillary fold and the excess
tissue present at this point allows the flap to elongate after
it has been lifted.
Incisions are then made through the skin and deep
fascia, and the flap, with the pectoral fascia attached, is
raised off the underlying muscles, care being taken to
preserve the perforating branches of the internal mam-
mary artery w h e n the base is being dissected. It is
extremely important to preserve the pectoralis fascia on
the flap, as this layer of fascia protects the vascular supply
of the flap. Diathermy should not be used for bleeding
points on the flap and any large veins requiring ligation
should be dissected free and ligated 1 cm away from the
flap, to prevent retrograde thrombosis.
10
 Closure 01 pharyngocutaneous fisi

12a

11 &12
T o prevent the weight of the flap pulling it away from the
edges of the defect it is advisable to imbricate the flap or
to hold its weight by extra non-absorbable sutures held
over buttons.
Finally, the split skin is applied to the raw area over the
shoulder. The rest of the defect is not grafted as the bulk
of the flap will be returned to the chest wall after closure
of the fistula and it is a tedious and difficult procedure to
remove split skin from muscle.
T h r e e weeks later the unwanted, proximal part of the
flap is released, detubed and-returned to the chest w a l l .

12c
454 Closure of pharyngocutaneous fistulae

Closure of Type 111 fistula

These fistulae may be closed using a musculocutaneous
flap or a free forearm flap. The pectoralis major is much
the most useful musculocutaneous flap but has the
disadvantage of bulk due to its muscle content. For the
latter reason a free revascuiarized forearm flap based on
the radial artery is probably to be preferred.

A pectoralis major flap is marked out to include a skin

island large enough to provide complete cover for the
fistula once it has retracted by 10-15 per cent in all
dimensions.

T h e flap is raised in the usual way, with about 2 cm of

muscle beyond the edge of the skin island in all
directions.
 Closure of pharyngocutaneous fistulae 455

The skin island is tacked to the underlying muscle w i t h a

e w 2/0 black silk sutures to prevent shearing of the skin
rom the muscle when the flap is brought through the
u n n e l . T h e sutures are removed once the flap has been
ransf e r r e d .

15

A tunnel is created beneath the skin over the upper part of

the chest and the lower part of the neck over the clavicle
coming out at the fistula. The edges of the fistula are
incised.
4f,-\ •-losure of pharyngocutaneous fistulae

j n f - pectoralis major flap is led through the tunnel to

e n v i the neck with its skin surface inwards.
n

The edges of the flap are sutured to the inside edges of the
fistula in two layers to create a watertight closure.

T h e edges of the skin surrounding the fistula are

undermined for a distance of about 2 c m and the edge of
the pf-ctoralis muscle is tucked into this pocket all around
the fr.tuia.
Non-absorbent sutures are placed at about eight points
around the fistula about 4 c m from the skin edge. T h e
suture pierces the.skin, emerges in the pocket, picks up
the muscle, and then comes back out of the s k i n . It is
finallyt i e d o
button or rubber catheter to prevent
v e r a

ulcer.tiion of the skin. In this way the flap is anchored and

its w e ' l ?
n i
supported during the healing phase.
i s

T h e outer surface of the flap may now be covered with

anolher flap, usually the deltopectoral flap, but a very
satist.i^tory result can be achieved by covering this area
w i t h split ^ ' ' preferably using the primary delayed
s n

technique.
 Closure of pharyngocutaneous fistul

Most fistulae can be closed by application of the above

principles, but two further unusual situations must be
mentioned: the very small fistula (not more than 5 mm
across) which will not heal despite excision of its epithelial
track; and a small mucosal dehiscence (not more than
5 mm) associated with a large area of skin loss.

VERY SMALL FISTULA

It is not usually possible to close a very small fistula by

turning flaps i n , because the hole is too small. Instead a
small flap on one side of the fistula is turned over and
buried in a pocket on the other side.

The skin is incised and a semi-circular flap is raised

stopping short of the edge of the fistula.

A pocket of the same size is then raised o n the other side

of the fistula by undermining.

21
-bfi C l o s u r e of pharyngocutaneous fistulae

The flap is then raised, tucked into the pocket and sutured
in p l a c e , making sure that the ends of the defect are
closed. T h e area on top of the flap can be left bare; since it
is small it will rapidly epithelialize spontaneously.

SMALL MUCOSAL DEHISCENCE

A small mucosal dehiscence is treated in the following

way. T h e edges of the mucosal defect are freshened and
closed with a Connel! suture. The edges of the skin defect
are then freshened and closed using a deltopectoral flap
as described previously (see Illustrations 9-72). A small
leak f r o m the mucosal defect can be ignored as it will he2l
w h e n covered by the large flap of healthy skin.

23b
Illustrations by Philip W i l s o n
A. Cheesman FRCS
Consultant Ear, Nose and Throat S u r g e o n , Royai National Throat, Nose and Ear Hospital, L o n d o n ;
Consultant Head and Neck S u r g e o n , Charing Cross Hospital, London, UK
T h e radical resection of ethmoidal tumours can only be
accomplished by a craniofacial approach. Initially such
resections required the cooperation of two surgical
teams; a neurosurgical team giving access to the floor of
the anterior fossa by a frontolateral craniotomy and an
otolaryngological team using a transfacial approach to
encompass the lower limits of the t u m o u r . T h e complex-
1
ities of such a procedure have tended to restrict its use to
extensive tumours, particularly those eroding the roof of
the-ethmoids. Clifford described a single otolaryngolo-
2 Conventional sinus X-rays a n d tomograms are limited to
gical approach using a central burr hole for access to the
anterior fossa. The present technique uses a w i n d o w
craniotomy (similar to the otologlca! middle fossa
approach to the internal auditory meatus) for exposure of
the central floor of the anterior fossa. A variety of
neurosurgical techniques is u s e d , and although on
occasions neurosurgical assistance is invaluable, the'
procedure is primarily otolaryngological.
Indications
Present experience indicates that ethmoidal tumours are
best treated by a combination of radiotherapy and radical
surgery. An intranasal debulkihg procedure at the time of
the biopsy probably facilitates radiotherapy, but the
radical resection is best performed following radiother-
apy. Although the classic lateral rhinotomy.allows w i d e
resection of a localized, anteriorly placed tumour it does
not permit safe en-bloc resection of the ethmoidal
complex, and experience has shown that local recurrence
is the common cause of failure.
T h e craniofacial approach exposes the walls of the
ethmoidal complex and potentially allows an en-bloc
resection. It is therefore indicated for all tumours of the
ethmoids. It is particularly useful for those tumours w h i c h
breach the ethmoidal boundaries a n d involve the dura of
the anterior fossa, the orbital periosteum and the
sphenoid sinuses; in such cases the excellent exposure
given permits an extended resection. T h e exact surgical
limits in each case must depend upon the experience of
the surgeon, but involvement-of the brain is unlikely to
result in cure although good palliation may be obtained.
Distant metastases are a definite contraindication, but
cervical metastases can be resected, and in these cases
craniofacial resection will generally control local disease.
Investigations
giving information about b o n e e r o s i o n , but computerized
tomography allows the experienced radiologist to distin-
guish between t u m o u r spread and mucocoele formation
in obstructed s i n u s e s . If the orbital plate is breached on
3
X-ray an ophthalmological assessment is obtained.
Careful clinical examination and a chest X-ray are
essential to exclude distant metastases and to assess
fitness for anaesthesia. Hypotensive anaesthesia is gener-
ally u s e d , so a preoperative electrocardiogram establishes
a cardiac baseline. Similarly, electrolytes and urea are
estimated. • .
Four units of blood should be available owing to the
proximity of the internal carotid artery. A preoperative
nasal swab establishes the bacteriological flora of the
nose, but all cases are covered with the following wide
spectrum of antibiotics started with the premedication:
amoxycillin 500 m g three times a day; cloxaciilin 500 mg
three times a d a y ; metronidazole 400 mg three times a
day.
Anaesthesia
General anaesthesia with peroral endotracheal intubation
and artificial ventilation allow careful control of the
cerebral circulation. Moderate hypotension facilitates the
surgery. Reduction of intracranial pressure and brain
shrinkage are usually obtained by deliberate hyperventila-
tion to lower the end-tidal PCO2 to 2 2 m m H g . Additional
shrinkage can be obtained by mannitol infusion (1g/kg
bodyweight) and all patients must be catheterized to cope
with this osmotic diuresis. T h e incision line is infiltrated
with 1:200000 adrenaline solution in the anaesthetic room
to reduce skin bleeding.
459
 ureicai aims
The approach is designed to expose safely the bony
margins of the total ethmoidal complex and then to
encompass them with an osteotomy, giving an en-bloc
resection- . .

1
The orbital osteotomy starts in the frontal process of the
maxilla and passes back in the orbital plate of the frontal
bone above the ethmoidal foramina. It descends onto the
orbital floor just anterior to the optic canal. T h e amount of
antral roof and anterior wall included depends on the
extent of the disease. Access to the floor of the anterior
cranial fossa for the cranial osteotomy is made through a
'window' craniotomy. A shield-shaped plate of bone is
temporarily removed from the centre of the forehead. Its
lower edge is level with the supraorbital ridge, and 1
generally enters the frontal sinus.

2
The cranial osteotomy encompasses both sides of the
ethmoidal complex. It starts posteriorly through the roof
of the sphenoid sinuses, and continues forward just
anterior to the optic canal 'and lateral to the orbital plate of
the ethmoids. Anteriorly it passes through the frontonasal
ducts in the floor of the frontal sinus.

Finally it must be remembered that the septum must be

divided to free the perpendicular ptate of the ethmoids,
and the anterior-inferior wall of the sphenoid must be
included In the resection. * * *
 Craniofacial approach tor ethmoidal tumours -4bI

The operation
Position ot patient
The patient lies supine on the table, with the head on a
movable extension. The surgeon stands initially at the side
of the table, but the cranial approach is best performed
with the surgeon sitting at the head of the table. This
allows a lower angle of vision through the window
craniotomy and improves visibility. Altering the amount of
head extension also aids exposure. The intracranial
dissection is performed with the operating microscope
(200 mm lens) which gives both magnification and excel-
lent illumination.
T h e whole face is prepared and draped: similarly, one
leg is prepared for the subsequent harvesting of fascia lata
and split skin grafts.
Both monopolar and bipolar diathermy are used. T w o
suction lines are set u p , one with a large-bore sucker, the
other with a fine-bore fenestrated sucker.

The incision
Preliminary temporary tarsorrhaphies are made to protect
the cornea. T h e classic lateral rhinotomy incision is
continued up onto the forehead, either in the midline or
in a prominent frown crease for better cosmesis.

Soft tissue approach

T h e soft tissues are dissected off the underlying facial
bones using a combination of sharp and gauze dissection.
T h e anterior ethmoidal vessels are bipolar coagulated
during the orbital dissection, and any bony defect in the
lamina papyracea is noted. T h e periosteum of the frontal
bone is carefully preserved and dissected laterally.

Bony approach

5
T h e window craniotomy is outlined in the midline of the
f o r e h e a d . The bone flap is outlined with a 2 mm rose-head
burr. T h e width is 2.5 cm and the height is 3 c m , permitting
the use of a Fisch middle fossa retractor for dural
retraction. T h e bone cuts are deepened with constant
suction-irrigation until the dura is reached. Inferiorly the
bone cuts penetrate the anterior wall of the frontal sinus
and should be continued on the posterior w a l l .
462 Craniofacial approach for ethmoidal tumours

The bone flap is finally freed by gently fracturing it out

with a bone elevator, and the edges of the craniotomy are
smoothed with a rongeur. The underlying dura is carefully
dissected off the frontal bones and off the floor of the
anterior fossa using a Freers' or a McDonald's elevator.
T h e dura in the region of the cribriform plate is very
adherent and sharp dissection is essential; the subse-
quent dura! tears are repaired later. Additional exposure is
obtained by removing the posterior wall of the frontal
sinus down to the floor with rongeurs. As the dura is
dissected back off the roof of the ethmoids any bony
defect Is noted, but at this stage the dural continuity is
preserved to protect the underlying brain. The anterior
and posterior ethmoidal vessels are bipolar coagulated or
clipped with neurosurgical clips and the dissection is
continued back on to the smooth bone of the jugum
sphenoidale.

Dural retraction is facilitated by brain shrinkage achieved

either by lowering the P c o by hyperventilation or by
2

osmotic diuresis with mannitol infusion. W i d e lateral

freeing of the dura over the orbital plates is also effective
in giving good dural retraction, but in some cases the use
of the Fisch middle fossa retractor with its Cushing's
spatula is also necessary. The dura in the elderly may be
thin and easily torn so it must be protected with moist
neurosurgical patties.

7
 Craniofacial approach for ethmoidal tumours 463

T h e crania! osteotomy is outlined with a rose-head burr to

encompass both ethmoids and the anterior wail of the
sphenoid sinus. Anteriorly the osteotomies are completed
with a fissure burr through the orbital approach, thus
uniting intracranial and extracranial cuts. During execu-
tion of the osteotomies careful inspection through both
cranial and orbital approaches is essential to prevent
soft-tissue damage.
 464 Craniofacial approach for ethmoidal tumours

1
T h e specimen is finally freed by dividing the perpendicu-
lar plate of the ethmoid from the rest of the septum with a
pair of M a y o scissors. Digital pressure is applied to the
specimen from above, and it is delivered via the facial
approach. Although the osteotomies outline the specimen
as a single block, tumour infiltration often results in it
becoming fragmented during removal; in particular the
anterior wall of the sphenoid often remains in place.

12
Completion of tumour resection 10
Following removal of the main tumour block it is
necessary to complete the removal of any remaining
ethmoidal fragments. The lamina papyracea, anterior wall
of the sphenoid and media! antral wall must all be
r e m o v e d , the sphenopalatine vessels being controlled
with a neurosurgical clip. This part of the procedure is
best performed under frozen section control to ensure
complete t u m o u r removal. The end-result is one large
cavity incorporating the nasal passages and all the sinuses.

Inferior
turbinate

Nasal Opening
septum into antrum

Orbital
periosteum Eustachian
cushion
Ant. wall
of sphenoid Optic canal
Pituitary
bulge

11
 Craniorau.il approach lor ethmoidal tumours AhS

Extended resections Frontal sinus

It is better to remove the main tumour block initially, and The front")! linn'! rrtn raw.-ia-l . : - "
ernmoiOal complex to give even better e x p o s u r e . T h e
w h i c h must be controlled with frozen section histology. resulting defect is easily repaired using free bone grafts
from the iliac crest or ribs.

Dura
If the tumour penetrates the bone of the ethmoid roof,
the overlying dura must be excised. T h e incision is started
with a blade through a coagulated part of the dura
elevated from the underlying brain with a dural hook, but
may be completed with scissors under direct vision. Any
dural vessels must be bipolar coagulated before division,
but the superior saggital sinus is rarely a problem. If the
t u m o u r has involved the brain, cure is. unlikely, but
removal of the involved dura gives good palliation. Before
repairing the dural defect, any hypotension must be
corrected to ensure there is no intracranial bleeding. T h e
defect is repaired with fascia lata placed between the brain
and the remaining dura. This must be very carefully
sutured in place to give a cerebrospinal fluid leak-proof
repair. Any small dural tears must be sutured, and then
the whole exposed dura is covered with a thin split skin
graft held in position at its edges with a .physiological
adhesive or sutures. This is then covered with Sterispon
foam sheet soaked in Sofradex topical antibiotic solution.
Pterygopalatine fossa
T h e pterygopalatine fossa can easiy be cleared by this
approach, the branches of the maxillary artery being
controlled with clips. If the tumour has spread into the
infratemporal fossa and involves the anterior wall of the
middle fossa it can still be removed if orbital exenteration
is planned. However, if the orbit is to be p r e s e r v e d , then a
lateral craniofacial approach should have been u s e d .
Maxilla
A classic maxillectomy can be performed in continuity
with this approach.
Facial skin
Involvement of facial skin is not a contraindication and it
can generally be replaced with an island flap of forehead
s k i n , as the vertical incision does not interfere w i t h the
arterial blood supply to this area of skin.

Clivus

This approach gives good access for the removal of

tumours of the clivus region, bone being removed
piecemeal to the level of the pontine dura. T h e support of
the head is not affected.

Orbital periosteum

T h e orbital periosteum is a good boundary to tumour, and

because it is involved on its ethmoidal aspect/ orbital
exenteration is not necessarily required. T h e craniofacial
approach affords excellent visualization of the orbital
periosteum, and wide local resection is possible. If the
t u m o u r has not breached the periosteum histologically it
is reasonable to preserve the eye. T h e periosteal defect
may be repaired either with fascia lata or merely a split
skin graft. Surprisingly, very little disturbance of ocular
function occurs.
If the orbital contents are involved by tumour the
resection can be extended to remove the roof of the orbit
a n d overlying dura without danger of brain prolapse
o w i n g to the tendency of split skin grafts to contract
postoperatively. At the apex of the orbit the resection can
be continued back to the cavernous sinus, by carefully
drilling away t h e ' b o n e of the optic c a n a l . T h e optic
chiasma and optic tracts are placed away from the dura
and are not in danger. T h e internal carotid artery is a
relation of the lateral wall of the sphenoid and may be
•exposed either anatomically or by t u m o u r .
466 Craniofacial approach for ethmoidal tumours

Closure

Following dural and orbital repair, all exposed soft tissue

is grafted with a thin split-skin graft. The graft is covered
with antibiotic-soaked gelatin sponge sheet, and finally
the cavity is packed via the nose with a 7.5 cm ribbon
gauze bandage soaked in Whitehead's varnish. This
provides excellent antisepsis and internal support. T h e
bone of the w i n d o w craniotomy is replaced and secured
with 2 4 s . w . g . stainless steel wire. T h e surrounding gap is
filled with bone chips.
The frontal periosteum is carefully closed as one layer,
and then the skin incision is closed in two layers. T h e
tarsorrhaphies are opened and antibiotic eye ointment is
applied. A firm forehead bandage is used.

Postoperative management
The patient is nursed flat for 5 days to allow stabilization of
the cerebral circulation. For the first 48 hours full
neurological recording of vital signs is made, and a careful
fluid balance is kept with serial urinary specific gravity
estimations. T h e urinary catheter is removed on the
second postoperative day. Oral feeding starts on the first
day, and the drip may be discontinued.
Analgesics are not generally required and opiates are
not used. Antibiotic cover is maintained for 10days.
T h e Whitehead's varnish pack is removed under general
anaesthetic on the 10th day, and the.patient is usually
discharged on the 14th day.
Considerable crusting of the cavity continues for several
months (depending on the amount of preoperative
radiotherapy). T h e patient cleans the cavity with a saline
nasal douche, but the surgeon needs to decrust the cavity
regularly under direct vision.
A routine inspection of the cavity under general
anaesthetic is made after 3 months to check for residual
disease, and this may be repeated regularly, because of
the difficulties in inspecting such a large cavity.
Complications
Careful surgical technique results in few of the potential
complications occurring. - -. ."
Meningitis Careful dural repair, split skin grafting and
antibiotic cover has minimized this complication. T h e
diagnosis is made by lumbar puncture, and the treatment
is the appropriate antibiotic.
Haemorrhage As the main vessels are controlled under
direct vision and the patient's blood pressure is restored
to normal before closure, this has not been a problem.
Persistent bleeding w o u l d require re-exploration.
Cerebral vascular accidents As with any craniotomy
these may occur if the patient is mobilized too quickly.
Eustachian tube dysfunction Long-term secretory
otitis media may occur following surgery in t h e
nasopharynx. This is controlled with grommets after
exclusion of tumour recurrence.
References
1. Ketcham, A. S., Chretien, P. B., van Buren, J . M., Hoye, R. C ,
Beazley,'R. M/, Herdt, J. R.The ethmoid sinuses; a
re-evaluation of surgical resection. The American Journal of
Surgcry1973; 126:469-476
2. Clifford, P. Transcranial approach for cancer of the antro-
€ • ethmoidal area. Clinical Otolaryngology 1977; 2:115-130

Cerebrospinal fluid leak A transient leak for a few days 3. Lund, V. U Howard, D.)., Uoyd, G. A. S. C T . evaluation of
is of no concern; a more persistent leak would require paranasal sinus tumours tor craniofacial resection. The British
re-exploration and repair. journal of Radiology 1983; 56: 439-446
 Abscess, Ballantyne neck dissection, 382
ethmoidal, 160 indications, 382
extradural, 158 - technique, 383
parapharyngeal, 202 Bitemporal coronal incision, 167
surgery of, 203-205 Blindness, complicating zygomatic bone fracture, 17
. peritonsillear, 201 Bocca's method of neck dissection, 382 -
retropharyngeal, 203 indications, 382
Achalasia of cardia, 241 technique, 392
Acromegaly, 170 Bone grafting, for zygomatic bone fracture, 24
Adenoidectomy, 178-180 Branchial cysts, 403-404
complications, 180 Brachial sinuses and fistula,407-40S
indications, 178 Bronchial tree, anatomy of, 260
postoperative care, 180 Bronchoscopy, 260-268
postoperative considerations, 178 biopsies with, 267
technique, 179 complications, 268
Airway obstruction, laryngotomy for, 274 fibreoptic, 266
Alae, flexible, 261
replacement of, 97 complications, 26S
spot welding, 85 indications and contraindications, 261
i Alar collapse, 85 passing glottis, 263
Amputation, of nose, 99 preoperative considerations, 261
Angiofibroma, nasopharyngeal, 122 rigid, 261,262
Angioneurotic oedema, 269 complications, 268
Anterior ethmoidal artery, bleeding from, 122 techniques, 262
Antrochoanal polypus, 118 Bronchus,
removal of, 153 foreign bodies in, 266
Antronasal wall, opening, 114 tumours, 261
Antrostomy, Buccal flap operation for oroantral fistula, 150
intranasal, 113-115
postoperative care, 115
preoperative considerations, 113
technique, 114
Apnoea, in tracheostomy, 273 Caldwell-Luc operation, 116,118-120
Arytenoidectomy, indications and contraindications, 118 '
for vocal cord paralysis, 349 technique, 119
frontal approach, 349 in zygomatic bone fractures, 22
lateral approach, 351 Carden tube for microlaryngoscopy, 263
postoperative care, 352 Carotid artery,
Asai method of voice restoration, 328,330 external ligation, 122
Ascending ramus, fractures of, 40 protection during neck dissection, 379
Atelectasis, following cricopharyngeal sphincterotomy, 244 rupture, in neck dissection, 381
468 index

caronci artery, external, ijybpnayid, p u r l i e u ! , .ifo

identification of, 399 Dysphonia,
ligature, 397-399 following removal of laryngoceie, 316
technique, 398 from laryngeal web, 301
Carotid sheath,
dissecting, 387
exposure of, 398
Cerebral oedema, complicating neck dissection, 381
Cerebrospinal fluid leak, Emphysema, subcutaneous, tracheostomy causing, 273
following excision of ethmoidal tumour, 466 Endocrine exophthalmos, (see Malignant exophthalmos)
in hypophysectomy, 176 Enophthalmos, 50
Cerebrospinal otorrhoea, Epiglottis, tumours of, 216,341
in maxillary fractures, 42 Epiglottopexy, 353-355
Cerebrospinal rhinorrhoea, Epiphora, following Howarth's operation, 162
in fracture of nasa! bones, 4 Epistaxis,
in maxillary fractures, 42 acute massive, 122
in nasal bone fractures, 16 control of, 59,155,397
Cerebrovascular accidents, after craniotomy, 466 following rhinoplasty, 79
Cervical cysts, sinuses and fistulae, 400-408 (see also specific recurrent non-specific, 122
lesions) Ethmoidal artery,
Cervical nerves, anatomy, 375 bleeding from, 122
Children, mandibular fractures in. 40 ligation of, 155
Choanal atresia, 185-188 Ethmoidal cells, clearance of, 141
operation, 186 Ethmoidal sinus,
preoperative considerations, 185 abscess, 160
Chyle leakage, from thoracic duct, 381 clearance of, 146
Clivus, tumours of, 465 exposure of, by Howarth's operation, 161
Coagulation diathermy, external operations on, 160
for nasal obstruction, 83-86 fracture of, 4
technique, 84 infection of, 121
Cocaine adrenaline paste, 152 lavage,112
Colon transplant, polypi from, 121,152
replacing oesophagus, 231,232,234,235 Ethmoidal tumours,
complications, 240 craniofacial approach to, 459-466
preparation of, 232, 234 complications, 466
Condyle, fractures of, 40 operation, 461
Conjunctiva, oedema of, 139 postoperative management, 466
Coplan's tube for laryngoscopy, 253
preoperative considerations, 459
Corneal ulceration, 140
surgical aims, 460
Craniofacial approach to ethmoidal tumours, 459-466 Ethmoidal vessels, ligation of, 161
Cricoid, coring out, 307 Ethmoidectomy, pernasal,153
Cricopharyngeal myotomy, 248 Eustachian tube dysfunction, following nasopharynx surgery, 466
Cricopharyngeal sphincterotomy, 241-244 Exophthalmos, malignant, (see Malignant exophtalmos)
Cricothyrotomy, 274-275 External carotid artery,
Cricotracheal separation, 286 identification of. 399
Crocodile tears, 133 ligature of, 397-399
Cushing's disease, 170 Eye,
Cystic hygroma, 400-402 care of,
complications, 402 in blow out fractures of orbit, 51
excision of, 401 in zygomatic bone fracture, 17,24
preoperative considerations, 400 Eyebrow incision, 167
Eyelids, in blow out fractures of orbit, 53

Deltopectoral flap,
in repair following oropharyngeal surgery, 208,209
in total pharyngolaryngectomy, 226
Denker's operation, 116,121 Face,
Dental cysts, 118 analgesia, following vidian neurectomy, 138
Dental injury, deformity of, 41
from bronchoscopy, 268 injuries to, 42
from laryngoscopy, 254 Facial nerve,
in tonsillectomy, 194 care of, in fractures of mandible, 38
Depressore anguli oris, paralysis of, 431 injury to, 431
Diabetes insipidus, following hypophysectomy, 177 preservation of, 368,370,404,408,409,439
Diplopia, 50,51,52 Facia! paralysis, following parotidectomy, 424
complicating transantral ethmoidal decompression, 143 Facial weakness, following parotidectomy, 416,419
following Howarth's operation, 162 Familial haemorrhagic telangiectasia, 59
following Patterson's operation, 164 Foramen rotundum,
Dura, anatomy of, 129
excision in ethmoidal tumours, 465 exposure of, 135
Forearm skin flaps, for pharyngolaryngectomy repair, 223
exposing of, 175
 Index 469

Foreign bodies, Hiatus hernia, 211

in broncb'JS-2^
HI O c S O f J I l d g U i , jH i Hypertension,
removai of, 214 epistaxis and, 122
nasal, 1 tracheostomy causing, 273
removai of, 118 Hypoglossal nerve,
tracheostomy in, 269 injury to, 408
Frontal sinus, palsy, 431
anatomy of, 165 Hypopharynx,
clearance of, 168 carcinoma of, 317
drainage, 162,164,169 pouch, 211
exposure, by Howarth's operation, 161 Hypophysectomy,
external operations on, 160-164 trans-sphenoidal, 170-177
infection of, 80 anaesthesia for, 171
involved in ethmoidal tumour, 465 cerebrospinal fluid escape, 176
lavage,112 contraindications, 171
osteoplastic flap operation, 165-169 exposing dura, 175
surface marking of, 166 external ethmoidal approach to, 173
trephine of, 157-159 haemorrhage in, 176
postoperative care, 159 indications, 170
preoperative considerations, 157 instruments for, 172
technique, 158 postoperative management, 177
Frontal sinusitis, 157,159 preoperative considerations, 170
Frozen shoulder, complicating neck dissection, 381 sublabial approach to, 174
technique, 172

Gigantism, 170
Gilette, retropharyngeal space of, 203 Infrahyoid muscles,
Glossectomy, 361 division of,319
partial, 361 exposure of, 246
total, 363 Intraorbital canal, anatomy, 129
Glossopharyngeal nerve, division of, in tonsillar fossa, 198-200 Infratemporal fossa,
Glottis, anatomy of, 435
laryngeal fracture involving, 283,284 tumours of,
oedema of, 202,205 anterior transantral approach, 441
Gunningsplints, approach to,434-447
for mandibular fractures, 33 complications, 439,440,443,445,446,447
for maxillary fractures,42 conservative lateral approach, 438
Gustatory sweating, following parotidectomy, 416 extended anterolateral approach, 444
inferior approach, 447
preoperative considerations, 434
preoperative preparation, 437
Haematoma, radical lateral approach, 440
following parotidectomy, 416 superior approach, 446
following pharyngolaryngectomy, 230 surgical anatomy, 435
Intranasal antrostomy, 113-115
following removai of submandibular gland, 431 postoperative care, 115
in blow out fractures of orbit, 52 preoperative considerations, 113
Haemorrhage, technique, 114
complicating hypophysectomy, 176
complicating pharyngolaryngectomy, 230
complicating submandibular gland removal, 431 ;•.
complicating surgery of quinsy, 202
complicating tracheostomy, 273 jansen-Horgen operation, 116,121
following adenoidectomy, 180 jejunal segment, replacing oesophagus, 229
following bronchoscopy, 268 Jugular vein,
following ethmoidal tumour excision, 466 anatomy, 371,376
following laryngectomy, 325 upper end of, 371,377
following parotidectomy, 416
following surgery of laryngeal stenosis, 299
ligature of external carotid artery for, 397
in neck dissection, 381 Lacrimal apparatus, damage to, 4
in tonsillectomy, 193,194 Lacrimal gland, 131
in turbinectomy, 82 Lacrimation, absence of following vidian neurectomy, 138
Hard palate, Laryngeal stenosis,
division of, 147 after partial laryngectomy, 340
fixation of, 44 caused by intubation, 292
Head injury, 42 fracture involving glottis, 283,284
Hemilaryngectomy, contraindications, 335 in adults,
Hemilarynx, reconstruction of, 340 fracture with cricotracheal separation, 286
Hemimandibulectomy, 206 indications for surgery, 278
Hereditary telangiectasis, 122 laryngeal fracture involving supraglottis, 279,284
470 Index

Laryngeal stenosis (coni.) Larynx (cont.)

in adults (conf.) paralysis,
postoperative care, 299 recurrent, 269
preoperative considerations, 276 surgery of, 347-352
in children, surgery of, 300-314 partial, reconstruction of, 340
preoperative considerations, 278 posterior adhesions, 292
surgery-of, separation from hypopharynx, 322
in adults, 277 Lasers, combined with laryngoscope, 258
in children, 300 Latissimus dorsi flap, in pharyngolaryngectomy, 222
Laryngeal vessels, division of, 320 Lingual nerve, damage to, 431,433
Laryngectomy, 317-325 Lung, infection, complicating tracheostomy, 273
care of tracheostome, 325 Lymph nodes, metastases in, 382
complications, 325
creation of tracheostome, 324
division of vessels, 320
drainage, 324 Malignant exophthalmos,
horizontal partial, 341-346 indications for decompression, 140
contraindications, 341 reduction of, 163
operation of, 342 transantral ethmoidal decompression in, 139-143
postoperative care, 346 effects of, 143
reconstruction after, 346 postoperative care and complications, 143
indications, 317 results of, 143
neck dissection with, 380 Mandible,
operation, 318 fixation, 358
pharyngocutaneous fistulae complicating, 448 fractures of, 25-40
postoperative care, 325 arch bars, 30
preoperative considerations, 317 assessment of, 25
restoration of voice after, 325,326-334 bilateral, 25
electromagnetic device methods, 330 bone plating, 39
future considerations, 333 cast silver alloy cap splint, 35
internal tracheo-oesophageal fistula/prosthesis method, 331 in children, 40
reed group of methods, 327 circumpalatal wiring, 35
results, 332 closed and open reduction,.36
vibrating tissue segment group, 328 dentures as splints, 32
total, 317-325 duration of fixation, 40
verticle partial, 335-340 early treatment, 26
complications, 340 eyelit wiring, 27,40
contraindications, 335 fixation methods, 27
operation, 336 • Gunning splints, 33
postoperative care, 340 haematoma formation in, 38
_ preoperative considerations, -335 investigations, 26
wound healing, 325 lower border wiring, 38
Laryngeotracheoplasty, 305 oedema in, 26
Laryngoceie, removal of, 315-316 peralveolarwiring, 34
Laryngoiissure, 302 postoperative care, 40
Laryngopharyngeal palsies, epiglottopexy in, 353 preoper?tive considerations, 25
Laryngopharyngectomy, neck dissection in, 380 radiography, 26
Laryngoscopy, 252-256 splinting, 35, 40
direct, 252 upper border wiring, 37
fibroptic, 259 wiring techniques, 33
instruments for, 253,254 removal of, 357
micro-, 253,257-258 tumours of, 357
passage of instrument, 255 Mandibulectomy, 357
position of patient, 254 marginal, 338
postoperative care, 256 Mandibutotomy, 363
preoperative considerations, 252 Maxilla,
surgical laser with, 258 fracture of, 20,41-49 -
technique, 254 aims of surgery, 41
Laryngotomy, 274-275 cap metal splints, 42
Laryngotracheal fracture, 297 circumzygomatic wiring, 45
Laryngotracheal reconstruction, 313 classification of, 42
Laryngotracheobronchitis, acute, 269 dental problems, 49
Larynx, disimpaction and reduction,43
carcinoma of, 253,317 external suspension,47
neck dissection in, 380 fixation of hard palate, 44
congenital webs, 300,301 Gunning splints, 42
postoperative treatment, 304 -operation for, 43
exposure of, 281,306 postoperative care, 49
fracture of, 297 prefrontal wiring, 46
involving glottis, 283, 284 preoperative cane, 42
involving supraglottis, 279,284 reconstruction of orbital margin, 44
papillomas, 258 splinting, 42, 43
 in':e\ -in

Maxilla (cont.) Nasal obstruction, 55

fracture of {cont.) coagulation diathermy treatment. 8'3-8f->
wiring, 43, 46 technique, 84
involved in ethmoidal tumour, 465 from choanal atresia, 185
> Maxillaryantrum, Nasal pyramid,
anatomy, 117 injury of, 3
foreign bodies in, 1 moulding of, 7
infection, following vidian neurectomy, 133 Nasal septum (see also Septodermoplasty and septoplasty)
lavage of, 110 anterior dislocation, 57
indications and contraindications, 110 deformities, correction of, 61
technique, 111 deviated, 55
opening, 141 haematoma of, 3,16
window in, 123,133,134 manipulation of, 7
Maxillary artery, replacement of, 3
anatomy of, 132 straightening, 13
cleaning,124,134 submucous resection of, 55-58
exposure of, 124,134
ligation of, 122-125 postoperative care, 58
postoperative care, 125 preoperative care, 55
special instruments for, 125 reduction of tubinate, 58
technique, 123 technique, 56
Maxillary sinus, tumours of, resection of, 105
carcinoma of, 144 Nasal sinuses (see also specific regions)
clearance,162,164 anatomy of, 117
infection in, 159 infection, Howarth's operation for, 160
Maxillectomv, lavage of, 110-112,159
radical, 144-148 complications, 111
j technique, 145 Nasofrontal processes, displacement of, 5
Nasolabial flaps, 94
with removal of orbital content, 145,146 Nasopharyngeal angiofibroma, 122,181
Medial canthal ligament, damage to, 4 Neck,
Mediastinitis, 205 anatomy of, 368,371, 373,375, 376, 377
complicating cricopharyngeal sphincterotomy, 244 lymph nodes, 367 (see also Neck dissection)
Meningitis, 159 posterior triangle, 373
complicating removal of ethmoidal tumour, 466 "Neck dissection,
postoperative, 49 anterior approach, 382,383
Microlaryngoscopy, 257-258 applied anatomy, 368, 371,373, 375, 377,378 '
instruments for, 253 Ballantyne method, 382
Motor neurone disease, 241 technique, 383
Mouth, Bocca's method, 382
l floor of, removal of tumour, 361 technique, 392
Muscular dystrophy, 241 carotid sheath, 387
Myocutaneous flaps, in pharyngolaryngectomy, 220 closure of, 380
Myocutaneous paddle, 220 functional, 382-396
technique, 383
indications and contraindications, 382
partial, 367
policy, 356
posterior cervical triangle, 385, 386, 395
Nasal bones, preoperative considerations, 367
fractures of, 2-16,48 principles and justification, 382
3 additional procedures, 16 protection of facial nerve, 368,370
| anaesthesia for reduction, 5 radical, 367-381 •
assessment of, 2,5 combined with other procedures, 380
associated injuries, 3 complications, 381
by osteotomies, 13 lower end of jugular vein, 371
complications, 16 occipital triangle, 375
disimpacition, 7 operation of, 368
fixation, 8,9 postoperative care, 380
moulding nasal pyramid, 7 submandibular triangle, 378
postoperative care, 16 supraclavicular, 373
preoperative considerations, 2 upper end of internal jugular vein, 376
radiography of, 4 recurrence of tumour after, 381
reduction of, 5 submaxillary triangle, 390
reduction by closed manipulation, 5 types of, 367
reduction by open method, 11 upper, 388,389
septum manipulation,? Nelson's syndrome, 170
Nasal cartilages, trimming of, 15 Neurectomy, transantral vidian, 126
Nasal cavity, Nose, (see also Rhinoplasty)
anatomy, 117 amputation of, 99
tumours of, 89 basal cell carcinoma of, 89
Nasal floor tumours, resection of, 107 bones, fractures of, see Nasal bones, fractures of
472 index

Nose \conc.i
carcinoma of, 89 access to,3b2
amputation for, 99 radiotherapy ot, 357
composite skin grafts, 92 soft tissue replacement, 359
full thickness skin grafts, 90 surgery of,
glabella flap for, 95 postoperative care, 363
incidence of, 89 tumours of, 346-365,445
lateral flaps for, 96 neck dissection in, 356, 380 {see also Neck dissection)
nasolabial flaps in, 94 Orbit,
operations for, 90 anatomy, 117
preoperative considerations', 89 blow out fractures of, 50-54,163
principles of excision, 89 assessment of, 51,53
reconstruction following operation, 94, 96,97,101 complications of, 52
cartilage, investigations, 51,53
dislocation, 57 medial, 53
repositioning, 63 oedema in, 51, 52
foreign bodies in, 1 operational, 53
lateral flaps, 96 postoperative care, 52
modification of tip, 77 comminuted and displaced, 21
polypi, 133 decompression, 140
complications of removal, 154 haematoma, 17
pernasal removal of, 152-154 from zygomatic bone fracture, 24
postoperative care, 154 herniation of content, 23
removal with snare, 153 infection,
prostheses, 105 following Howarth's operation, 162
fitting, 109 ' following Patterson's operation, 164
reconstruction of, 94, 96,97,101 involved in ethmoidal tumour, 465
skeletal support, 104 opening periobitum, 142
thinning, 103 reconstruction of margin, 44
total with forehead flap, 101 removal of content, 145,146
senile drip, 133 removal of lamina papyracea, 142
skin grafts, Orbital floor,
composite, 92 comminuted, 21
full thickness, 90 prolapsed, 22
glabellar flap, 95 removal of, 141
nasolabial flaps, 94 Oroantral fistula, 149-151
step shaped deformity, 71 buccal flap operation, 150
submucosal diathermy, 83 palatal flap operation, 151
tumours of, 98-109 postoperative care, 151
lateral rhinotomy for, 87,88 surgical closure, 150
Oropharyngeal cancer, neck dissection in, 380
Oropharynx,
tumours of, 206-209
operation for, 207
Oedema,
preoperative considerations, 206
angioneurotic, 269
repair following operation, 208
in blow out fractures of orbit, 51,52
Osler-Rendu-Weber disease, 59
cerebral, complicating neck dissection, 381
Osteoplastic frontal flap operation, 165-169
conjunctival, 139
following rhinoplasty, 79 technique, 167
in mandibular fractures, 26 . Oxygen desaturation, 268
subglottic, 275
Oesophagitis, 211
Oesophagoscopy, 211-215 Palatal flap operation, for orantral fistular, 151
.complications,215 Palate,
indications and contrainidications, 211 approach to postnasal space by, 181
instruments for, 212 hard and soft, see Soft palate and Hard palate
postoperative care, 215 Paltatine bone, anatomy, 128
Oesophagus, Panje method of voice restoration, 328,330
achalasia, 241 Papilledema, 140
biopsy, 214 Parapharyngeal abscess, 202
carcinoma of, 231 approach to, through neck, 205
nutrition in, 232 surgery of, 203-205
radiotherapy in, 232 Parotidectomy,
colon transplant (or, 231,232,234,235 partial,409-416
complications, 240 complications, 416
dilatation, 214 indications and contraindications, 409
foreign bodies in, 211 operation, 411
removal of, 214 postoperative care, 416
replacement with jejunal segment, 229 preoperative considerations, 409
separation of larynx horn, 322 radical, 420—424
Ophthalmoplegia, following vidian neurectomy, 138 modifications of, 420
Oral antral fistula, preoperative considerations, 149 total conservative, 417-419
 index 473

Parotidectomy (cont.) Plummer-Vinson syndrome, 211

wound healing after. 424 Pneumnthnrnx
. — jjiJHii/ complicating pnaryngolaryngo-oesophagectomv. 240
carcinoma of,440 complicating tracheostomy, 273
cystic hygroma extending into, 402 following bronchoscopy, 268
fistula, 416 Poilybeak deformity, 70, 76
surgical anatomy,409 Polypi,
tumours of, 409,417,420 antronasal, 118
Paterson-Brown-Keliy syndrome, 211 nasal,
Patterson's operation, 163-164 complications of removal, 154
Pearson's laryngectomy, 328 pernasal removal, 152-154
Pectoralis major myocutaneous flap in oral tissue surgery, 359 postoperative care, 154
Pectoralis skin flaps, in pharyngolaryngectomy, 220 removal with snare, 153
Peritonsillarabscess, 189 Post-cricoid carcinoma, 211
surgery of, 201 Postnasal space,
Pharyngeal artery, exposure of, 183
anatomy of, 132 transpalatal approach to, 181-184
anomalous, 125 complications, 184
Pharyngeal fistula, following laryngectomy, 325 postoperative care, 184
Pharyngeal mucosa, resection of complete segment, 225 technique, 182
Pharyngeal pouch, Prolactinomas, 170
diathermy treatment of, 250-251 Pterygoid canal, 129
excision of, 245-249 anatomy of, 130
operation, 246 diathermy of, 137
postoperative care, 249 exposure of, 137
preoperative considerations, 245 Pterygoid process, separation of, 147
location of, 247 Pterygopalatine canal, anatomy, 129
treatment of, 241 Pterygopalatine fossa,
Pharyngeal wall, damage to, from oesophagoscopy, 215
Pharyngocutaneous fistulae, anatomy of, 127
closure of, 448-458 fat in,132
type 1,449 foramina in, 129
type 11,452 involved in ethmoidal tumour, 465
type 111,454 transantral approach to, 128
small mucosal dehiscence, 458 veins of, 132
types of, 448 Pyriform fossa, tumours of, 216,225
unusual,457
very small, 457
Pharyngolaryngectomy, 216-230
Quinsy, 189
complications, 230
surgery of, 201
indications and contraindications, 216
myocutaneous flaps in repair, 220
postoperative care, 230 Radiotherapy,
preoperative considerations, 216 for oesophageal cancer, 232
replacement of oesophagus in, 229 of oral cavity, 357
with preservation of mucosal continuity, 217 Respiratory complications, following tonsillectomy, 194
with total thyroidectomy, 225-230 Respiratory insufficiency, tracheostomy for, 269
repair following, 226 Respiratory obstruction, tracheostomy for, 269
Pharyngolaryngo-oesophagectomy, 231-240 Retropharyngeal abscess, surgery of, 203
cervicoabdominal procedure, 234 Rhinitis,
repair by pharyngogastric anastomosis, 237,240 atrophic, following turbinectomy, 82
/ complications, 240 submucosal diathermy for, 83
indications and contraindications, 232 turbinectorny for, 80
operations for, 232 Rhinitis medicamentosa, 83
postoperative care, 240 Rhinoplasty, 66-79
preeoperative considerations, 232 anaesthesia for, 66, 68
preparation of colon transplant, 232,234 closure of wound, 78
technique, 233 complications, 79
variations in, 239 division of cartilages, 71
Pharynx, elevation of periosteum, 71
anastomosis of stomach to, 237, 238 excision of cartilage, 78
complications, 240 haematoma formation in, 79
carcinoma, neck dissection in, 380 incisions, 69
paralysis, 241 lateral osteotomies, 75
Pituitary, medial osteotomy, 74
anatomy, 171 modification of tip, 77
removal of, see Hypophysectomy postoperative care, 79
tumours, preoperative preparation, 66
extent of, 171 reduction of osteocartilaginous hump, 67
indications for removal, 170 removal of hump, 72
Pituitary fossa, technique of, 67
approach to, 160,163 trimming vibrissae, 69
474 Index

Rhinotomy, Taub's method of voice restoration, 328,330

lateral, 87-65 Teeth,
Ringertz tumour. 163 care of,
Rhinoplasty, 61 in laryngoscopy, 254
Rusch tube for microlaryngoscopy, 253 damage,
from bronchoscopy, 268
from oesophagoscopy, 215
in tonsillectomy, 194
Teflon paste, injection, in vocal cord paralysis, 348
Telecanthus, 4
Saddle nose, 16 Tellangiectasis, 122
Salivary fistula, following cricopharyngeal aphincterotomy, 244 Thoracic duct,
Salivary gland, submandibular, removal of, 425-431 anatomy of, 371
Salivary tumours, 206 chyle leakage from, 381
Secretomotor rhinopathy, 133 Thyroglossal duct cyst, 405-406 ^
Secretory retention, tracheostomy for, 269 Thyroid,
Septodermoplasty, 59-60 carcinoma of, 367
Septoplasty, 61-65 Thyroid artery, ligature of, 243
creation of mucoperichondrial flaps, 62 Thyroidectomy,
dissection of inferior part, 63 with total pharyngolaryngectomy, 225-230
dressing, 65 repair following, 226
operative details, 62 Tongue,
postoperative care, 65 carcinoma of, 198
preoperative care, 61 partial removal of, 361
repositioning cartilage, 63 quilted grafting, 361
Singer-Blom method of voice restoration, 328,330, 331 radiotherapy, 357
Sinuses, see Nasal sinuses and specific sinuses repair of, 208"
Sinusitis, 118 removal of, 363
following transantral ethmoidal decompression, 143 tumour of, 198,206,357
from foreign body, 1 removal, 361
trephine of frontal sinus for, 157 Tonsillar area, carcinoma of, 198
Soft palate, Tonsillar fossa,
repair after operation, 210 division of glossopharyngeal nerve in, 198-200
separation of, 183 styloid process in, division of, 195-197
tumours of, 210 " Tonsillectomy,
Sphenoid, approach to, 172 by dissection, 189-194
Sphenoidal sinus, complications, 194
external operations on, 160 haemorrhage in, 193,194
lavage,112 operation, 190
Sphenopalatine artery, postoperative care, 194
anatomy, 132 preoperative considerations, 189
care of, 115 removal of tonsil, 193
resection of, 136 complications, 194
Sphenopalatine bundle, 135 contraindications, 189
Sphenopalatine foramen, anatomy of, 128,130 indications for, 189
Splenopalatine ganglion, anatomy, 129,130,132 . in division of glossopharyngeal nerve, 199
Sphenopalatine ganglionectomy, 131 • in division of long styloid process, 196
Staffieri's method of voice restoration, 328,330
in peritonsillar abscess, 202
Stomach,
Trachea,
anastomosis to pharynx, 237,238
complications, 240 fracture of, 297
Stylohyoid ligament, calcification in, 195 opening of, 271
Subglottic oedema, 275 reconstruction, 313
Subgolottic stenosis, Trachea! crusting, following laryngectomy, 325
acquired, 313 Trachea! stenosis,
complicating tracheostomy, 273
with webbing of posterior commissure, 314 fracture involving glottis, 283,284
congenital, 305 inadults,
postoperative care, 312 fracture with cricotracheal separation, 286
complications of surgery, 312 indications for surgery, 278
Submandibular duct, laryngeal fracture involving supraglottis, 279,284
removal of calculus, 432-433 postoperative care, 299
stenosis, 433 preoperative considerations, 278
Submandibular gland, in children, surgery of, 300-314
removal of, 425-431 Tracheitis sicca, 273
complications, 431 Tracheobronchial aspiration, 244
operation,427 Tracheobronchial tree, anatomy of, 260
postoperative care, 431 Tracheo-oesophageal fistula, 286
preoperative preparation, 426 Tracheostomy, 269-274
surgical anatomy426 care of tube, 272
tumours of, 425 complications of, 273
Submandibular triangle, anatpmy, 378 displacement of tube, 272, 273
Supraglottis, laryngeal fracture involving, 279,284 elective, 270
 index 475

Tracheostomy {cont.) Vocal cords {cont.)

emergency, 274 paralysis of {cont.)

fixation of tube, 272 Teflon paste injection, 348

humidification in, 272 unilateral, 348
indications and contraindications, 269 Voice,
insertion of tube, 271 • following surgery of laryngeal and tracheal stenosis, 299
postoperative care, 272 restoration after laryngectomy, 326-334
preoperative considerations, 269 electromagnetic device methods, 330
laryngeal stenosis and, 278 future considerations, 333
stenosis following, 293,295, 300 internal tracheo-oesophageal fistula/prosthesis method, 331
at cuff site, 295 reed methods, 327
stoma stenosis, 293 results, 332
Transantral ethmoidal decompression in malignant vibrating tissue segment group, 328
exophthalmos, 139-143 tracheostomy and, 272
Turbinate,
neoplasms of, 80
reduction of, 58
Turbinectomy, 80-82 Wharton's duct, calculus in, 425,432
complications, 82
indications and contraindications, 80
technqiue,81
Zygomatic bone and arch,
fractures of, 17-24,42
anaesthesia for, 17
Vallecula, tumours of, 198,206,216 bone grafting in, 24
Vidian nerve, comminuted orbit, 21
anatomy of, 126,131 complications, 24
Vidian neurectomy, delayed treatment, 24
anatomy of, 126 elevation of, 43
complications of, 138 indications and contraindications for operation, 17
postoperative care, 138 investigation, 17
preoperative considerations, 133 open reduction, 19
technique, 133,136 operation for, 18
transantral, 126-138 orbital herniation of content, 23
preoperative considerations, 133 percutaneous facial elevation in, 18
Vocal cords, postoperative care, 24
carcinoma of, 335 preoperative consideration, 17 •
fixation, 335 prolapsed orbital floor In, 22
paralysis of, 347 temporal elevation in, 18
arytenoidectomy for, 349 unstable and comminuted, 19,23
bilateral, 349 in maxillectomy, 146