2. Introduction
Surgery on Head and Neck has major impact on swallowing,
speech and aesthetic appearance.
Organ preserving radiation techniques.
New chemotherapeutic regimens.
Greater understanding of tumour biology.
Introduction of CO2 laser- transoral.
endoscopes
4. Conservation surgery for Neck
Single most imp factor for prognosis of SCC of HN – cervical nodes.
5yr survival rate reduces by 50% if nodes involved.
Memorial Sloan-Kettering Cancer Center – Levels I to VII.
5. N0 disease – Neck dissection
N0 – 15-20% risk of occult metastatic disease.
Selective neck dissection
Spares all non-lymphatic tissue including SCM, IJV and SpAN.
Only selected nodes on involved site removed.
8. Extended SupraOmoHyoid Neck
Dissection
SCC of Lateral Tongue
Small but increased risk of Skip Metastasis to level IV
Lymph nodes of level I to IV
Submandibular Gland
9. Anterolateral Neck Dissection
Also called Jugular Neck Dissection.
SCC of Larynx or Pharynx
If primary tumour crosses midline A.N.D. is carried out bilaterally.
Not required if Radiotherapy planned.
Lymph nodes of level II to IV
10. Posterolateral Neck Dissection
Primary cutaneous malignancies of Posterior Scalp.
Lymph nodes of level II to IV and suboccipital LN.
11. Central compartment Neck Dissection
Diferentiated Thyroid carcinoma.
Lymph nodes of level VI to VII and
Delphian
Perithyroid
Tracheo-osophageal groove
Anterior-superior mediastinum
12. N+ disease - Neck Dissection
Comprehensive neck dissection – removal of all lymphatic tissue in
lateral neck.
Classified into Radical and Modified Radical depending upon other
structures removed.
Gold standard – Radical Neck Dissection.
Modified Radical Neck Dissection three types
13. Structures removed in RND along
with level I to V LN
RND
SSG
IJV
SCM
Sp Acc N
14. Structures removed in MRND along
with level I to V LN
MRND type I – (Spinal Accessory spared)
SSG
IJV
SCM
15. Structures removed in MRND along
with level I to V LN
MRND type II –( Spinal Accessory + SCM spared)
SSG
IJV
16. Structures removed in MRND along
with level I to V LN
MRND type III – (Spinal Accessory + SCM + IJV spared)
SSG
17. N+ Disease post Chemoradiation
Generally acepted that N0 and N1 disease can be treated by
Chemoradiation alone.
Insufficient data for N2 and N3
Brizel et al – reported 4yr disease free survival rate
75% in RT + ND
53% in RT only
Therefore ND is recommended for N2/N3.
19. Conservation surgery for cancer of
Larynx
Main aim is to
Maintain speech
Maintain swallowing
Avoid tracheostomy
Conservation laryngeal surgery may be
Open
endoscopic
securing negative margins is crucial to success of procedure.
20. Crico-arytenoid unit
It is the basic functional unit of larynx.
Consists of
An Arytenoid cartilage
Cricoid cartilage
Associated musculature
Nerve suply
Allows physiological speech and swallowing without the need for
tracheostomy.
21. Open Partial Laryngeal surgery
General principles
Consent for Total Laryngectomy
Speech rehabilitation – patient and family active
Good pulmonary function
No medical problem
24. Vertical Partial Laryngectomy
Vertical cuts through laryngeal cartilage
Removal of majority of
Ipsilateral thyroid cartilage
True vocal cord
Portions of subglottic mucosa
False cord
Tracheostomy 3-7 days.
25. Vertical Partial Laryngectomy
Criteria for selection
Lesion of mobile cord extending to anterior commissure
Lesion of mobile cord involving vocal process and anterosuperior arytenoid
Subglottic extension ≯5mm
Fixed cord lesion not extending midline
Anterior commissure/ VC lesion ≯ anterior 1/3 of opposite VC
26. Vertical Partial Laryngectomy
Oncological results
T1 glottic cancer
Recurrence rates are <10%
If ant comm not invoved 93% local control
If ant comm invoved 75% local control( subglottic recurrence)
T2 glottic cancer
Failure rates of 4-26% ( cricoid and thyroid involvement)
T3 glottic cancer
Higher recurrence rates of 11-46%
27. Vertical Partial Laryngectomy
Functional results
Some degree of hoarseness
Most impairment – if no reconstruction
Least – replacement of glottis with adjacent false cord flap
28. Supracricoid Partial Laryngectomy with
Cricohyoidoepiglottopexy
Resection of
Both true cords and Both false cords
Entire thyroid cartilage and One arytenoid
Paraglottic spaces bialterally
29. Supracricoid Partial Laryngectomy with
Cricohyoidoepiglottopexy
Reconstruction is done using
Hyoid bone, Epiglottis, Cricoid and tongue
Temporary tracheostomy and feeding tube
Used for T1b with ant commissure involvement and selected T2 / T3
glottic carcinoma.
30. Supracricoid Partial Laryngectomy with
Cricohyoidoepiglottopexy
Local recurrence rate
T2 4.5% (3 of 67)
T3 10% (2 of 20)
Temporary dysphagia and aspiration is expected
Nasogastric feeding tube for 9 to 50 days.
Hyoid necrosis and neolaryngeal stenosis
Voice quality is initially poor but improves over several months
32. Horizontal Supraglottic Partial
Laryngectomy
Parts removed
Epiglotis and Pre-epiglottic space
Hyoid bone
Thyrohyoid membrane
Upper half of thyroid cartilage
Supraglottic mucosa
33. Horizontal Supraglottic Partial
Laryngectomy
Closure is by approximating base tongue to lower half of thyoid
cartilage
Temporary tracheostomy is required.
Bilateral selective lymph node dissection is carried out at the same
time
It is important to identify and preserve internal and external
branches of superior laryngeal nerve
34. Horizontal Supraglottic Partial
Laryngectomy
Selection criteria
At least 5mm margin at anterior commissure
True VC must be mobile
Only one arytenoid may be removed
No cartilage invasion by the tumour
Tongue mobility should be normal
No extension to interarytenoid or postcricoid area
Apex of pyriform sinus should be free
Generally lesions should be <3cm
36. Other Laryngectomies
Subtotal Laryngectomy =
supralottic partial laryngectomy+ipsilateral vertical partial
laryngectomy
Near Total Laryngectomy =
this is a technically complex procedure to create a physiological
voice shunt based around one mobile arytenoid.
Requires permanent stoma
37. Supracricoid Partial Laryngectomy with
Cricohyoidoepiglottopexy
Supraglottic carcinomas not amenable to supraglottic
laryngectomy due to
Glottic level involvement through anterior commissure or ventricle
Pre-epiglottic space invasion
Decreased cord mobility
Limited thyroid invasion
38. Supracricoid Partial Laryngectomy with
Cricohyoidoepiglottopexy
Operation involves resection of
Both true cords and both false cords
Entire thyroid cartilage
Both paraglottic spaces
Maximum of one arytenoid
Thyrohyoid membrane
epiglottis
39. Supracricoid Partial Laryngectomy with
Cricohyoidoepiglottopexy
Reconstruction using
Hyoid bone
Cricoid
tongue
Temporary tracheostomy tube and feeding tube is required.
40. Supracricoid Partial Laryngectomy with
Cricohyoidoepiglottopexy
Indications
T1 and supraglottic lesions with ventricle extension
T2 infrahyoid epiglottis or posterior 1/3 of false cord
Supraglottic lesions extending to glottis or anterior commissure
T3 transglottic carcinoma
Selective t4 lesions invading thyroid cartilage
42. Supracricoid Partial Laryngectomy with
Cricohyoidoepiglottopexy
No local recurrence reported by Laccourreye et al
3.3% reported by chevalier
Nasogastric feeding is required for 30-365 days
Total laryngectomy may be required in 10% of cases
43. Transoral Endoscopic LASER Resection
Outpatient procedure possible
Shorter operating time
Less overtreatment
Better voice quality
Low morbidity
No feeding tube
No tracheostomy
Similar oncologic results
44. Transoral Endoscopic LASER Resection
As compared to radiotherapy it has similar oncologic and
functional results, lower cost.
Radiotherapy is possible after endocopic laser if it fails
46. Conservation surgery for cancer of
Hypopharynx
Cancer of hypopharynx includes
Cancer of pyriform sinus (70%)
Postcricoid (15%)
Posterior pharyngeal wall (15%)
Of all Head and Neck sites Hypopharyngeal Cancer has poorest
prognosis – 5yr survival rate of <20%
Patients usually present with advanced diseaseAbout 66% of
patients have nodal disease at presentation
Thus it requires treatment of primary and also of neck
47. Conservation surgery for cancer of
Hypopharynx
T1 and small volume T2 without neck metastasis
Usually treated by radiation
Partial pharyngectomy and bilateral selective neck dissection can also be
performed
T1 and small volume T2 with neck metastasis
Comprehensive neck dissection
Radiation to the primary
48. Conservation surgery for cancer of
Hypopharynx
Large volume T2 / T3 / T4
Radical surgery
Excision of primary tumour
Reconstruction
Radiotherapy
Endoscopic laser
Excellent functional results
With synchronous or separate neck dissection
50. Conservation surgery for cancer of the
Oral cavity
Limited resection of oral cavity is to be condemned
However it is possible to perform conservative surgery to mandible
Careful assessment is carried out by bimanual palpation.
CT is helpful in assessing cortical invasion
MRI helps to find marrow invasion and inferior alveolar nerve
51. Segmental mandibulectomy is carried out if
Gross invasion by cancer
Tumour close to mandible in irradiated patient
Invasion of inferior alveolar nerve or canal by tumour
Massive soft tissue disease adjacent to tumour
Marginal mandibulectomy is done if
Superficial aspect of cortical bone is involved
52. Marginal mandibulectomy is done if
Superficial aspect of cortical bone is involved
Marginal mandibulectomy is contraindicated
Gross invasion into cancellous part
Irradiated mandible
Edentulous patient with pipestem mandible
54. Conservation surgery for cancer of
Oropharynx
Transoral laser resection is an alternatve to chemoradiation and
radical surgery
With the use of appropriate retractors and distending
pharyngoscopes adequate access is obtained
Temporary tracheostomy may be required
Postoperative radiotherapy is recommended
TORS
56. Conservation surgery for cancer of
Nose and PNS
Certainly, endoscopic approach for benign disease has advantage
over open surgical resection
Better function as well as cosmesis
Availability of
real time image guidance,
neuro-navigation and
intraoperative MRI has furthur improved the safety and accuracy of endoscopic
resections
However, malignant disease management is still questionable
57. Conservation surgery for cancer of
Nose and PNS
Indications
Midline lesions with limited lateral extension
Benign tumours – inverted papilloma and angiofibroma
Low grade malignant tumours
Palliation
Medical comorbidity limiting open approach
58. Conservation surgery for cancer of
Nose and PNS
Contraindications
Lateral extension of tumour
Intracranial invasion
Intraorbital invasion
High grade malignant tumours
60. Conservation surgery for Tumours of
Parotid Gland
Warthin’s tumour excision without parotidectomy
Preservation of facial nerve unless they are adherent to or directly
invaded by tumour
If major branches or the main trunk are involved, then immediate
cable grafts should be done using branches of Cervical plexus or
Sural nerve
61.
62. NEXT
05.09.13 Dr Sonu Kumar Singh
M.S.(ENT,PGY2)
Benign tumours of
mouth and jaw