H&N—-DANIEL TODD, MD
H&N CA IMPLIES EPITHELIAL MALIGNANCY OF THE UPPER AERODIGESTIVE TRACT OR GLANDULAR MALIGNANCY OF THE THYROID OR SALIVARY GLANDS
STAGING
CT SCANNING PLAYS AN IMPORTANT ROLE
MELANOMA
STAGE I = LOCAL
STAGE II = REGIONAL
STAGE III = DISTANT
Tx, T0 = CIS = LENTIGO MALIGNA, MELANOMA IN SITU, HUTCHINSON’S FRECKEL, CLARK LEVEL I—->99% SURVIVAL
T1 = CLARK LEVEL II = BASAL CELL LAYER OF EPIDERMIS/PAPILLARY DERMIS, < 0.75 MM BRESLOWS LEVEL—-80% SURVIVIAL
T2 = CLARK LEVEL III = SUPERFICIAL RETICULAR DERMIS, O.76 – 1.5 MM BRESLOWS LEVEL—-50% SURVIVAL(15-20% INCIDENCE OF REGIONAL METS)
T3 = CLARK LEVEL IV = DEEP RETICULAR DERMIS = 1.51 – 4.0 MM BRESLOWS LEVEL—-30% SURVIVAL
T4 = CLARK LEVEL V = S.Q. TISSUE, OR SATALLITOSIS WITHIN 2 CM, > 4.0 MM IN DEPTH
NO
N1 = < 5 CM, SATALLITOSIS > 2 CM AWAY
CUTANEOUS BCCA AND SCCA STAGING:
T1 < 2 CM
T2 = 2-5 CM
T3 > 5 CM
T4 INVADING DEEP EXTRADERMAL STRUCTURES (CARTILAGE, MUSCLE, BONE)
N0 NO REGIONAL METS
N1 REGIONAL LYMPH NODE METS
HNSCC
TX=UNKOWN PRIMARY
T0=NOT CLINICALLY EVIDENT
TIS-IN SITU
T4 USUALLY IMPLIES INVASION OF ADJACENT STRUCTURES
OC/OP:
T1 < 2CM—–10% INCIDENCE OF MICROMETASTASIS
T2 2 – 4 CM—35% INCIDENCE OF MICROMETASTASIS
T3 > 4 CM
T4 INVADES ADJACENT STRUCTURES——BONE (MANDIBULAR) INVOLVEMENT IS DIFFICULT TO DETERMINE—-DO SOME TYPE OF IMAGING MODALITY—-OCCLUSAL SURFACE OF THE MANDIBLE IS MOST SUSCEPTIBLE TO INVASION—–FROZEN SECTION OF CANCELLOUS BONE MAY BE OF BENEFIT
THE MORE ANT THE LESION—THE LESS LIKELY REGIONAL Dz IS—THICKNESS IS ONLY A FACTOR IN TONGUE LESIONS
DORSAL TONGUE LESIONS—THINK OF SYPHILIS, GRANULAR CELL TUMORS, OR SCCA
HP/LP:
T1 LIMITED TO 1 SUBSITE (POST PHARYNGEAL WALL, POST CRICOID AREA, PIRIFORM SINUS)
T2 > 1 SUBSITE WITHOUT FIXATION
T3 HEMILARYNGEAL FIXATION
T4 INVADES ADJACENT STRUCTURES
LARYNX:
EASY WAY TO STATE IT IS ALWAYS ADDRESS THE NECKS EXCEPT IN T1 AND T2 GLOTTIC LESIONS—LESS THAN 4% INCIDENCE OF REGIONAL METS
PRE EPIGLOTTIC SPACE INVOLVEMENT IS THOUGHT BY SOME TO BE A SURGICAL Dz
SUPRAGLOTTIC:—-ALWAYS THINK ABOUT THE NECKS HERE
T1 1 SUBSITE—–THINK OF ENDOSCOPIC RESECTION
T2 > 1 SUBSITE
T3 FIXATION—-MUST DISTINGUISH MASS EFFECT FROM INVASION
T4 INVADES ADJACENT STRUCTURES
GLOTTIC:
T1A ONLY 1 TVC
T1B B TVC
T2 SUPRA OR INFRA GLOTTIC EXTENSION
T3 FIXATION—THINK ABOUT THE NECKS FOR ALL GLOTTIC T3 AND T4’S
T4 INVADES ADJACENT STRUCTURES
SUB/INFRA-GLOTTIC (10 MM BELOW TVC TO INF BORDER OF CRICOID)—ADDRESS THE NECK ALWAYS
T1 ISOLATED TO REGION
T2 EXTENDS TO TVC
T3 FIXATION
T4 INVADES ADJACENT STRUCTURES
TRANSGLOTTIC = EXTENDS FORM INFRA (10 MM BELOW GLOTTIS) TO SUPRAGLOTTIC (TO FVC’S) REGIONS—-
PAROTID
T1= <2CM
T2= 2-4CM
T3= 4-6CM
T4= >6CM
MAXILLARY SINUS
T1= TUMOR LIMITED TO ANTRAL MUCOSA
T2= INVADES INFRA STRUCTURE BONE
OHNGREN’S LINE—–PUNCTUM TO MANDIBULAR ANGLE
T3= INVADES SUPRA STRUCTURE BONE
T4= INVADES SKULL BASE OR ORBIT
NODAL STAGING
N1 = SINGLE, IPSI, < 3 CM
N2A= SINGLE, IPSI, 3-6CM
N2B = IPSI, MULT OR > 6 CM
N2C = CONTRA OR B, < 6 CM
N3 = CONTRA OR B, > 6 CM
DELPHIAN LN (PROPHETIC ORACLE OF DELPHI) INDICATIVE OF EITHER METASTATIC LARYNX OR THYROID CA
NP:
T1 CONFINED TO NP
T2A NP OR OP EXTENSION
T2B PARAPHARYNGEAL EXTENSION
T3 BONE INVASION
T4 INTRACRANIAL, CN NEUROPATHY, INFRATEMPORAL FOSSA, HP, ORBITAL EXTENSION
USE EBV IGA FOR SURVEILLENCE AND DETECTION OF UNKOWN PRIMARY
N1 = UNILAT, < 6, HIGH
N2 = B, > 6, HIGH
N3A = >6CM, HIGH
N3B = LOW (SUPRACLAVICULAR FOSSA LAD)
THYROID
T1= <1CM
T2= 1-4CM
T3= >4CM BUT CONFINED TO CAPSULE
T4= ANY SIZE WITH EXTRACAPSULAR EXTENSION
N1= REGIONAL LAD
N1A= IPSI LAD
N1B= CONTRA, B, MIDLINE, OR MEDIASTINAL LAD
SURVIVAL FOR H & N SCCA
TI,N0=70%,N1(IPSI<3CM)=50%,N2A OR WORSE (IPSI 3-6CM), ECS/FIXATION OR N3 NECK=10% 5 YEAR SURVIVAL (70% ECS IF LN > 3 CM)—-ECS ACTUALLY 23% IN LN METS LESS THAN 1 CM—ECS IS AN INDEPENDENT PREDICTOR OF BOTH REGIONAL RECURRENCE AND SURVIVAL
UP TO A 5% INCIDENCE OF 2ND PRIMARY PER YEAR IN THIS SUBSET OF PTS
PNI (PERINEURAL INVASION) IS A POOR Px INDICATOR—TUMOR CAN EXTEND UP TO 12 CM ALONG THE EPINEURIUM
CAROTID ARTERY RESECTION—20% SURVIVAL—20% INCIDENCE OF NEUROLOGIC SEQUELAE (DO AN OCCLUSION TEST AND CONSULT VASCULAR SURGERY)
YOUNG PTS (<40)—MORE FEMALES, LESS SMOKERS, LESS SECOND PRIMARIES, MORE OC, OP SITES——NO DIFFERENCE IN SURVIVAL
USUALLY DO AN ELECTIVE NECK DISSECTION IF > 20-25% CHANCE OF METS IN N0 NECK—DO NECK PLUS RT IF—STAGE I Dz WITH LEVEL III LAD OR STAGE II Dz WITH LEVEL II LAD
RECURRENCE—85% IN 1ST YEAR, 96% WITHIN 2 YEARS—THUS F/U CONCENTRATED IN 1ST 2 YEARS
NEW DATA IS SUPPORTING A MINIMALIST F/U BASED ON PTS SYMPTOMS—PT EDUCATION IS IMPERATIVE!
PET SCANNING MAY BE APPROPRIATE TO MONITOR RECURRENCE IN IRRADIATED PTS (A MINIMUM OF 4 MONTHS POST RT)
CAVEATES
P53 IS A LOCUS ON THE SHORT ARM(P) OF THE 17TH CHROMOSOME WHICH IS PROBABLY A TUMOR SUPPRESSOR GENE—ENCODES A PROTEIN WHICH KEEPS THE CELL FROM ENTERING THE CELL CYCLE—LOCKS IT IN G1
FIELD CANCERIZATION “CONDEMNED MUCOSA”—CONSIDER TOLUIDINE BLUE/SUPRAVITAL STAINING TO BETTER DEFINE SUSPICIOUS MUCOSA IN LEUKOPLAKIA, ERYTHROPLAKIA,SUBMUCOUS FIBROSIS AND CIS ARE ALL PREMALIGNANT——- PLACE ON BETA CIS-RETINOIC ACID (RETINAE)—–PRIMARY SIDE AFFECT IS ANGULAR CHELITIS—-CONSIDER LASER, WLE, AND RT
SPECKLED LEUKOPLAKIA HAS EVEN MORE MALIGNANT POTENTIAL
A 3-7% PER YEAR INCIDENCE OF A 2ND PRIMARY
FOR CHEMO RT PROTOCOL TO WORK THEY NEED A RESPONSE TO THE CHEMO!—-CHEMOS ROLE AS A NEOADJUVANT AGENT ISFIRST AND FORMOST TO PREDICT WHICH PATIENTS MAY BE CANDIDATES FOR ORGAN PRESERVATION AND SECONDLY TO DECREASE THE INCIDENCE OF DISTANT METASTASIS
NEO-ADJUVANT=GIVEN BEFORE, CONCURRENT=GIVEN WITH, ADJUVANT=GIVEN AFTER
FOR CHEMO RT “LARYNGEAL PRESERVATION PROTOCOL”—IDEAL TIME FOR ELECTIVE NECK IS 4-6 WEEKS AFTER—POINT AT WHICH INFLAMATION HAS DECREASED MOST IN RELATION TO INCREASING FIBROSIS
PERSISTENT LARYNGEAL EDEMA AFTER RT—MOST OFTEN REPRESENTS RECURRENCE—SECONDLY RADIOCHONDRONECROSIS
X-RAYS ARE PRODUCED BA A LINEAR ACCELERATOR MACHINE, GAMMA RAYS ARE PRODUCED BY RADIOACTIVE DECAY “COBOLT”
FOR RT XEROSTOMIE—FLOURIDE AND FLOSSING ARE PARAMOUNT—–PILOCARPINE(OPTHO DROPS ARE CHEAPER)—BEATING A DEAD HORSE, SUCRULFATE, AMIPHOSTINE—EXPERIMENTAL–COMBATS XEROSTOMIA AND MUCOSITIS FROM RT—-MAY ALSO HELP PROTECT THE KIDNEYS FROM CHEMO (A FREE RADICAL SCAVENGER), AND EARLY PEG
BILATERAL TONSILLECTOMY IS PROBABLY A GOOD IDEA IN PTS WITH THE UNKNOWN PRIMARY
HAVE A LOW THRESHOLD TO CT SCAN THE CHEST
STOMAL STENOSIS
DILATE TO A #8 LARYNGECTOMY TUBE, WEAR FOR 6 MONTHS. IF PROBLEM PERSISTS CONSIDER A STOMAL REVISION WITH LOCAL FLAPS
LAYERS
SKIN
SQ–ANT. CERVICAL N, GREATER AURICULARN,TRANSVERSE PORTION EJV
PLATYSMA(SUPERFISCIAL FASCIA)
SCM/TRAP(SUP DCF)
STRAPS/OMO(MIDDLE DCF)
DEEP DCF—FLOOR OF THE NECK DISSECTION—OVERLIES THE PHRENIC, BRANCHIAL PLEXUS, SCALENES, ECT….
NECK DISSECTION
RND
MRND
TYPE I SPARE CN 11
TYPE II SPARE CN 11 AND IJV
TYPE III SPARE CN 11 AND IJV AND SCM
SND (SELECTIVE)
SOM—LEVEL I, II, AND III
LATERAL—-LEVELS 2, 3, AND 4
POSTEROLATERAL—LEVELS 2, 3, 4, 5, SUBOCCIPITAL, AND RETROAURICULAR LN’S
ANTERIOR— LEVEL 6 (PRETRACHEAL, PARATRACHEAL, AND PRELARYNGEAL LN’S— -EVERYTHING BELOW THE HYOID AND MEDIAL TO THE CAROTID SHEATHS—OFTEN DONE FOR THYROID CA
EXTENDED RND
RND PLUS RESECTION OF OTHER LYMPHATIC (PAROTID, SUBOCCIPITAL, PARATRACHEAL OR MEDIASTINAL LN’S) OR NONLYMPHATIC (MUSCLE, NERVE, SKIN, CAROTID ARTERY AND VISCERA OF THE NECK
STEPS:
PRE-OP
SMOKING CESSATION > 48 HOURS PREOP VERY IMPORTANT TO CILIARY FIUNCTION—-HELPS PREVENT PNEUMONIA
KARNOFSCKY PERFORMANCE RATING PREOPERATIVELY IS CRUCIAL
IDDM SHOULD TAKE ½ OF THEIR NL SQ INSULIN DOSE ON THE AM OF SURGERY
NEW DATA SHOWS THAT A ROUTINE CT SCAN OF THE CHEST MAY BE WORTHWHILE!
CONSIDER PREOP STEROIDS AND HFN
MAXIMIZE WOUND HEALING—WASH OUT NC, OC, AND PHARYNX WITH BETADINE—VITAMINS MAY BE IMPORTANT (SEE WOUND HEALING)—VIT A 25,000 IU Q D, VIT C 500 MG P.O QD, ZINC AND B VITAMINS—–MAKE SURE HCT > 30, SYNTHROID AND ADEQUATE NUTRITION
CONSIDER DECADRON 10 MG OCOR AND 8 MG POST OP TO LESSON THE EDEMA AND LOCAL HYPOXEMIA ON THE CLOSURE LINES—-VIT A NEGATES THE COLLAGEN WEAKENING EFFECTS
CURRENT RECOMMENDATIONS FOR STRESS STEROIDS
MINOR SURGERY—25 MG HYDROCORTISONE (HYDROCORTISONE 4-5:1 PREDNISONE) OCOR THEN RESUME NL DOSE
MODERATE—50-75 MG HYDROCORTISONE EQUIVILENT Q D FOR 1-2 DAYS
MAJOR—-100-150 MG Q D FOR 2-3 DAYS—THEN RESUME WITH MAINTAINENCE—-OLD DATA REC THIS DOSING Q 8 HOURS—-MIGHT WANT TO COMPROMISE AND GIVE Q 12 HOURS—-DO NOT WANT PT TO GET ADDISONIAN
THE MOST A NL PERSON CAN MAKE IS 60 MG HYDROCORTISONE Q D
CONSIDER PRE AND INTRA-OP PHOTOS
ALBUMIN,TRANSFERRIN ,TSH—-NEED TO FOLLOW PRE AND POST RT,Ca,WT.,CXR,CBC—-TRANSFUSE PREOP IF LESS THAN 8 HB,SMAC
T&C, ?STRESS STERIODS
GET NERVE STIMULATOR AND DERMATOME—-?ALLODERM?
HANG CT SCANS
B SCD’S, FOLEY
BE PREPARED AND CONSENT FOR FOR PREOP PANENDOSCOPY—-8.5 TUBE FOR FLEXIBLE BRONCH
BE PREPARED FOR LYMPHOSCINTIGRAPHY
BE PREPARED AND CONSENTED FOR TRACH
WILL PROBABLY NEED A TRACH IF YOU DEVOID THE LARYNX OF ITS LYMPHATIC DRAINAGE—-MAX LYMPHADENOPATHY IN ABOU 72 HOURS
KEFZOL 2 G IVPB OCOR AND THEN Q 8 HOURS X 3 IN ALL CLEAN CONTAMINATED CASES AND ALL CLEAN CASES > 4 HOURS—IF ALLERGIC TO KEFZOL THEN GIVE CLEOCIN 600 MG IV OCOR AND THEN Q 6 HOURS X 4
SOME SOURCES ADVOCATE UNASYN 1ST LINE
RISKS FOR POST OP INFXN—-STAGE, COMLEXITY, DURATION, USE OF FLAPS, TRANSFUSION, DRAINS, NG TUBE, TRACH, NUTRITIONAL STATUS, ETOH Hx, AND PRE-OP RT!
CURRENT RECOMMENDATIONS FOR HIGH RISK SBE—–2 G AMOX 1 HOUR OCOR (50 MG/KG FOR PEDS)
IF NPO—SAME DOSE AMPICILLIN IV OR IM 30 MIN OCOR
IF ALLERGIC—-CLEOCIN 600 MG PO 1 HOUR OCOR (20 MG/KG PEDS)
IF NPO—-SAME DOSE 30 MIN OCOR
SUTURE IN FEEDING TUBE(MEMBRANOUS COLUMELLA) 2-0 SILK ON A CUTTER
CONSIDER A PEG
SHOULDER ROLL
OCCIPUT ON EDGE OF TABLE
SHAVE AND PREP FROM LIP TO UMBILLICUS
SHAVE MASTIOD
SHAVE AND PREP IPSI THIGH—CAN TAKE DERMAL AND STSG FROM ADJACENT SITES
MARK LANDMARKS: MANDIBULAR ANGLE, MASTIOD, MIDLINE, TRACHEOSTOME, FOR PEC FLAP MARK INTERCOSTAL SPACES 1-6(MEDIAL TO NIPPLE 4TH SPACE AND BELOW)-USE RAY TEC METHOD AND PREFERABLY USE NON-DOMINANT SIDE
DRAW INCISIONS:
CONSIDER–AGE, SEX, SKIN TYPE—LOCATION OF THE PRIMARY, UNILAT VS BILAT–RT STATUS–DM–NEED FOR A TRACH
USE RLST, STAY 2-3 CM(2 FINGER-BREADTHS) BELOW THE MANDIBULAR ANGLE
MODIFIED SCHOBINGER(NO TRIFURCATION OVER THE CAROTID-KEEP POST TO THE CAROTID)-SOME SOURCES SAY TO AVOID TRIFURCATE INCISIONS–KEEP RIGHT ANGLES FOR AT LEAST 2 CM THEN WITH A LAZY S-SHAPE TOWARD MIDLINE TO MINIMIZE POTENTIAL FOR SCAR CONTRACTURE
EXCISE ALL OLD SCARS–LEAVE 5 MM MARGINS–COULD BE SEEDED WITH TUMOR, HAS POOR BLOOD SUPPLY, MORE COSMETIC
ARTERIAL BLOOD SUPPLY–GENERALLY VERTICLE ARTERIAL BRANCHES–INCLUDE PLATYSMA IN FLAPS
INJECT(TELL ANESTHESIA)1% WITH EPI
PREP
DRAPE (PULL TIGHT) AND STAPLE(LEAVE TRAP EXPOSED)–THINK ABOUT WHERE YOU WILL NEED TO GO
MARK WITH METHYLENE BLUE—-DISTAL TO PROXIMAL SO ASSISTANT CAN FOLLOW YOU——-CROSS HATCH INCISIONS
INCISION THROUGH PLATYSMA (REMNANT OF PANNICULUS CARNOSUS)
WATCH OUT FOR EJV AND GREATER AURICULAR N—-THAT IS YOUR PLANE
SUP FLAP(RAISE ONLY TO INF BORDER OF MANDIBLE-CONTINUALLY FEEL FOR IT)
(CUT 1 MM BELOW PLATYSMA) UTILIZE LOTS OF TRACTION AND COUNTER TRACTION (3 POINT TRACTION)
SUTURE DRY LAP TO APEX OF FLAP WITH 4 SEPARATE 2-0 SILK POP OFFS LOADED BACKHAND–DISTAL TO PROX
MEDIAL FLAP (RAISE TO STRAPS AND CLAVICLE) LEAVE THE SUP. LAYER OF DCF ON THE SCM (LEAVE GREATER AURICULAR NERVE DOWN AT ERB’S POINT–PUNCTUM NERVOSUM OF ERB)
FOLLOW MEDIAL INF SCM TO ITS MEDIAL INF ORIGIN—STOP—-THIS WILL KEEP YOU OUT OF YOUR TRACH SITE
POST FLAP (HOLD HOOKS YOURSELF-USE FINGERS BEHIND) DO NOT BUTTON HOLE-WATCH OUT FOR CN 11- BEWARE OF TRANSVERSE CERVICLE VESSELS-GO TO ANT. TRAPEZIUS AND CLAVICLE
STAY ON SCM SUP—IF YOU SEE NODULAR FAT YOU ARE TOO CLOSE TO THE DERMIS
IDENTIFY CN 11(2 FINGER BREADTHS ABOVE CLAVICLE ON ANT. BORDER OF TRAPEZIUS) SPREAD DIRECTLY PERPENDICULAR TO ITS COURSE
ISOLATE IT AND FOLLOW IT UP INTO AND THROUGH SCM TO LAT. PROCESS OF C-1
NEW EVIDENCE OF PREDICTABLE MOTOR SUPPLY TO LEVATOR SCAPULAE MUSCLE FROM CERVICLE PLEXUS PARALLELING CNX1—2-4 BRANCHES—EXITING FROM POST SCM AT PUNCTUM NERVOSUM OF ERB—-SAVE TO AVOID SHOULDER SYNDROME
USE 6 PRONG RAKE—–DIVIDE INF. SCM (PROBABLY TAKE EJV) 2 COKERS GRASP HEALTHY BITE OF MID SCM–BOVIE 2 FINGER BREADTHS ABOVE CLAVICLE–CUT AND COAG WITH BOVIE
MAY PUT FINGER ANT TO POST IN “SUPRASTERNAL SPACE OF BURNS”
HEAVY INF AND SUP SWEEPS WITH LAP
IDENTIFY OMOHYOID(TAKE FASCIA OFF WITH CHURCH SCISSORS AND THEN GRAB IT WITH THE MARTINS AND FOLLOW IT UP ALONG THE INF BORDER ONLY TO THE HYOID)
IDENTIFY CAROTID SHEATH (RAISE FASCIA WITH CUSHINGS AND CUT INTO IT PERPENDICULARLY)
DEVELOPE A BROAD FRONT-IDENTIFY ALL STRUCTURES-DISSECT OUT VEIN-USE VEIN RETRACTOR-PASS LARGE RIGHT ANGLE CLAMP-TIE OFF WITH 3 SEPARATE 0-0 SILK TIES (USE EXAGERATED MOTIONS WITH THE RIGHT ANGLE CLAMP)
2 STRAIGHT CLAMPS-CUT BETWEEN THEM WITH 15 BLADE TOWARDS THE TIPS
FINISH THE DISSECTION ANT/INF TO THE STRAP MUSCLES—-AVOID DISRUPTING THE ADVENTITIA OVER THE CAROTID FASCIA AS THIS LENDS GREATLY TO THE BLOOD SUPPLY AND HELPS AVOID A POST OP BLOW OUT
ALWAYS GET 6 PRONG RAKE AND WORK POST/INF TO ANT/INF (CHURCHES AND CUSHINGS)–PLACE RAKE IN APEX OF FLAP
WORK POST TO ANT AND DO A LAYERED DISSECTION
ID AND LEAVE DOWN TRANSVERS CERVICAL A.,PHRENIC,BRANCHIAL PLEXUS,AND SYMP. TRUNK (USE NERVE STIMULATOR TO CONFIRM)
WATCH FOR THORACIC DUCT(CAN BE 4 CM ABOVE THE CLAVICLE)—-STICK TIE ANY LYMPHATIC—-CAN ALSO BE SUPRACLAVICULAR
BEWARE OF CUPULA (SIBSON’S SUPRAPLEURAL MEMBRANE)—COPD PTS MAY HAVE SUPRACLAVICULAR BLEBS—PROBABLY GET A POST OP CXR ANY TIME YOU ARE DOWN THERE
CUT THE SUPRACLAVICULAR NERVES—CLAMP AND TIE SUPRACLAVICULAR NERVES WHEN NECESSARY
USE 2 LAP SPONGES (SINGLE LAYER ON EACH FINGER) TO HELP YOU ID THE FLOOR OF (LOTS OF BLUNT DISSECTION)
ID AND LEAVE DOWN TRANSVERS CERVICAL A.,PHRENIC,BRANCHIAL PLEXUS,AND SYMP. TRUNK (USE NERVE STIMULATOR TO CONFIRM)
DOCUMENT THE STATUS OF THE TRANSVERS CERVICLE ARTERY FOR POSSIBLE LATERALLY BASED TRAP FLAP OR INF BASED SCM FLAP
CLAMP AND STICK TIE TISSUE OVER FLOOR OF NECK–ESPECIALLY TISSUE BETWEEN PHRENIC AND CAROTID SHEATH (DEEP LAYER OF DCF)—-BEWARE OF SYMP TRUNK–LIES ON THE LONGUS COLLI UNDER THE CAROTID SHEATH–IF YOU INJURE—POST OP HORNER’S
GO POST/SUP—–SEN RETRACTOR
ALWAYS USE SEN RETRACTOR POST SUP- DIVIDE SCM SKIN ATTACHMENTS AND SCM OFF MASTIOD TIP WITH BOVIE(POSTERIORLY EXPOSING FASCIA OF SPENIUS CAPITUS-LEAVE IT DOWN)
DEFINE POST BORDER(USE 10 BLADE-GO FROM KNOWN TO UNKNOWN) ID ENTIRE ANT BORDER OF TRAP)—-CUT IN SAME LINE AS ANT TRAP
ANGLE KNIFE ANT
CAN REALLY PROCEDE WITH RELATIVE IMPUNITY FROM POST UP TO THE LAT PROCESS OF C1—–CN II USUALLY LATERAL THEN POST TO THE IJV
BEGIN TO RAISE POST TRIANGLE CONTENTS ANT—MUST ANGLE KNIFE ANT—DO NOT TRY TO REMOVE ALL THE FATTY TISSUE UNDER THE TRAP—BEWARE OF SEPARATE MUSCLE BELLIES—(SPLENIUS CAPITUS SUP ONLY) LEVATOR SCAPULAE, MEDIAL SCALENE, ANT SCALENE (PHRENIC)
RAISE POST NECK CONTENTS WITH 4 COKERS AND 10 BLADE AROUND CN 11
DIVIDE SCM OFF MASTOID TIP
USE LOTS OF TRACTION/COUNTER TRACTION
BRANCHIAL PLEXUS AND CERVICAL PLEXUS BRANCHES COME OUT BETWEEN ANT AND MED SCALENE
BEWARE OF PHRENIC—(LEAVE STUMP FOR POSSIBLE WILBRANDT’S KNEE TYPE ANATOMY)–PHRENIC ENDS SUP AT C3
ID AND CLAMP CERVICAL PLEXUS BRANCHES(CUT – LEAVE CLAMP ON PTS SIDE)—AS YOU ELEVATE SPECIMENANT. SUP.
BEWARE OF SYMP TRUNK
DISSECT ON CAROTID AND VAGUS AS YOU RETRACT NECK CONTENTS MED/SUP
GO POST/SUP(BEWARE OF 12)-USE NERVE STIMULATOR-MAY USE DESCENDENS HYPOGLOSSI TO HELP ID 12
12 IS USUALLY ABOUT 1 CM BELOW TENDENOUS SLIP OF THE POST BELLY OF DIGASTRIC AND STYLOHYOID
CUT WITH BOVIE FROM MASTOID TIP TO ANGLE OF MANDIBLE (STAY JUST A LITTLE LOW TO AVOID MARG. MANDIBULAR N.)-MAY USE AND ARMY NAVY-CUT DOWN TO POST BELLY OF DIGASTRIC (RESIDENT’S FRIEND) – WILL COME ACROSS SOME SUBSTANTIAL NEUROVASCULAR STRUCTURES (CERVICLE BR OF 7,GREATER AURICULAR N.,COMMON POST FACIAL VEIN,OCCIPITAL A,POST AURICULAR A)DISSECT ON POST LAT SIDE OF POST DIGASTRIC
BESIDES THE FACIAL NERVE—EVERYTHING IS FREE GAME SUPERFICIAL TO THE DIGASTRIC——FACIAL NERVE IS ANT TO IT
OCCIPITAL A OVERLIES THE IJV
CN 11 JUST POST TO IJV—AT SKULL BASE
ID AND LIGATE SUP IJV(USE TRANSVERSE PROCESS OF C-1 AS YOUR GUIDE)
MAY ID SUP IJV FROM BEHIND USING POST DIGASTRIC OR FROM BELOW FOLLOWING IT UP
AFTER TAKING SUP IJV COMPLETE CN11 DISSECTION BY CUTTING ALL OVERLYING SCM WITH BIG BITE WITH CURVED MAYOS
SAFETY FLAP–REFLECT FASCIA UP OFF THE SUBMAX GLAND TO PROTECT MARGINAL MANDIBULAR N-SEW IT UP TO THE FLAP (START AT ANT. — CUT OVER THE ANGLE OF THE MANDIBLE)
MAY TAKE FACIAL VEIN UP WITH SAFETY FLAP AS MMN IS SUPERFICIAL TO IT—-ID AND CUT IT
DO LAYERED DISSECTION FROM ANGLE TO SYMPHYSIS ALONG INF EDGE OF MANDIBLE—BIG BITES
WILL COME ACROSS SEVERAL VASCULAR STRUCTURES– INCLUDING FACIAL ARTERY AND VEIN
ONLY NERVOUS STRUCTURE DEEP TO MMN AND SUP TO MYLOHYOID IS THE NERVE TO THE MYLOHYOID
FREE UP SUBMAX GLAND SUP TO MYLOHYOID
USE LAP TO RETRACT SUBMAX GLAND INF. (ID MYLOHYOID AND NERVE TO MYLOHYOID)
USE ARMY NAVY FOR RETRACTION OF MYLOHYOID ANTERIORLY
WILL COME ACROSS THE FACIAL(EXT MAXILLARY) ARTERY X 2–REALLY ONLY LARGE ARTERY IN THIS AREA, VEIN X 1
STICK TIE ARTERY ON PTS SIDE—-OFTEN EXITS POST GLAND—KNOW IT
LOOK FOR “V” OF LINGUAL N. (CLAMP AT LOXLEY’S/LANGLEY’S GANGLION)-THEORETICALLY LEAVE IT TO PRESERVE POST GANGLIONIC PARASYMP INNERVATION TO IPSI SUBLINGUAL GLAND)
CLAMP AND CUT WHARTON’S WHILE VISUALIZING 12
DISSECT OUT THE GLAND
USE MARTINS AND BOVIE TO COMPLETE SUBMENTAL DISSECTION—-SIMPLE ELECTRODISSECTION
PULL CONTENTS MEDIALLY AND DISSECT OFF CAROTID-SEPARTATE NECK CONTENTS AND ORIENT
TAKE MARGINS FOR FROZEN WITH JAMISONS AND CUSHINGS
IRRIGATE AND CLOSE
USE 2 DRAINS PER MRND AND PER PEC FLAP
ACCURATELY STAGE IN OP NOTE
POST FOR TUMOR CONFERENCE
POST OP CARE
ALWAYS CONSIDER POST OP CXR
B SCD’S FOR DVT PROPHYLAXIS
DRAINS OUT WHEN <30 CC/24 HOURS—OLIVER BEAHRS TAKES THEM OUT AT 50 CC/DAY—SO TRENDS AND CONSISTANCY OF THE DRAINAGE ARE IMPORTANT (SEROUS VS BLOODY)
TRACH CHANGE ON POST OP DAY #3 IF DOWN SIZING— –TEACH PT TO TALK
SPEECH THERAPY ON ABOUT DAY 4 TO DO SWALLOWING TRIAL—CONSIDER METHYLENE BLUE
MOST WAIT 7 DAYS MINIMALLY BEFORE INITIATING PO—-WAIT AN ADDITIONAL DAY FOR EVERY 1000 CGY RT THE PT HAS RECEIVED
STAPLES OR SUTURES OUT ON POST OP DAY 7 IN NON-IRRADIATED NECKS, POST OP DAY 10 WITH RT
PT FOR STRENGTH AND SHOULDER SYNDROME—REGARDLESS OF FATE OF CN 11—SHOULDER SYNDROME IS COMMON (TRAPEZIUS WASTING AND ADHESIVE CAPSULITIS) RESULTING IN SHOULDER DROP AND CHRONIC PAIN FROM UNOPPOSED PULL OF THE SERRATUS ANTERIOR (LONG THORACIC NERVE)—GET EXCELLENT BENEFIT FROM INTENSIVE CONSISTENT PHYSIOTHERAPY
ANY NECK WOUND —ALWAYS USE A DRAIN, IF YOU ARE THINKING YOU DON’T NEED A DRAIN USE A PENROSE—OTHERWISE USE A #10 JP
ALWAYS SEND HOME WITH PAIN PILLS– IF YOU THINK THEY DON’T NEED ANYTHING GIVE THEM T#3, OTHERWISE USE PERCOCET OR DEMEROL ELIXIR
CONSIDER ANABOLIC STEROID INJ FOR PUNEY PTS—- DECA-DURABOLIN (NANDROLONE DECANOATE) 100-200 MG/ML IM Q WEEKLY OR SO—-BEWARE OF RENAL DZ, HEPATIC DZ, HEART DZ, DIABETES, OR ELECTROLYTE ABNL
EARLY FISTULA PORTENDS TECHNICAL ERROR—-LATE FISTULA = BAD LUCK
USE 5 CC OF METHYLENE BLUE PO X 1 TO BETTER DEFINE THE FISTULA
CERTAINLY CAN GET SIADH FROM INCREASED ICP—-COMMON IN B ND OR UNILAT ND WITH Hx OF RT
COMPLICATIONS:
AIR EMBOLISM: “MACHINE LIKE MURMER” LOW PO2 (PO2 40 = SAT OF 75%)——TIE OFF THE LOWER IJV FIRST!
FIX THE DEFECT—COVER IT—DO NOT LET ANY OTHER AIR IN—–TURN OFF NITROUS OXIDE—-PLACE IN L LAT DECUB (LEFT SIDE DOWN—HEAD DOWN)—GET AIR INTO R ATRIUM—-GET A CENTRAL LINE IN AND ASPIRATE THE AIR FROM THE R ATRIUM
ATELECTASIS > 24 HOURS POST OP = PNEUMONIA UNTIL PROVEN OTHERWISE
FISTULA (FETID)-FOREIGN BODY, EPITHELIALIZATION, TUMOR, INFXN, DISTAL OBSTRUCTION/DRAINAGE
ABX HELP TO RESOLVE AND PREVENT
Rx—OPEN, CONTROL, NPO, ANTISIALOGOGUES—ATROPINE, PACK NASOPHARYNX, SUCTION DRAIN, ESOPHAGEAL BYPASS TUBE, WATCH NUTRITION STATUS, DSG CHANGES WITH 0.25% ACETIC ACID SOAKED GUAZED
PNEUMOTHORAX—SQ EMPHYSEMA IS A WARNING SIGN
TRACH COMP—SUBGLOTTIC STENOSIS—TOO HIGH, INOMINANT BLOW OUT—TOO LOW (OFTEN A SENTENEL BLEED)
CHYLE FISTULA—1-2% RND, AVOID BY TAKING JUG 2 FB ABOVE THE CLAVICLE—STICK TIE EVERYTHING BETWEEN THE CAROTID SHEATH AND PHRENIC, OBSERVE CLOSELY DURING INCREASED INTRATHORACIC PRESSURE, TIE SUTURE OVER A HEMOSTATIC SPONGE—-AVITINE, SURGICEL, GELFOAM
CONSIDERED MAJOR IF >600 CC/24 HOURS—OPEN
SEND CHYLE—HIGH FAT, LOW PROTEIN, LOW SPEFIC GRAVITY
OTHERWISE LOCAL MEASURES—CLOSED DRAIN, PRESSURE DSG—PLACE A DUODERM ON PTS BACK AND ABDOMENT AND USE ELASTIC TAPE OVER FLUFFS AND OVER THE SHOULDER AS A PRESSURE DSG, LOWTO NO FAT DIET (MEDIUM CHAIN TRIGLYCERIDES—-DIRECTLY ABSORBED THROUGH THE PORTAL SYSTEM)–PORTAGEN POWDER OR ELIXER ADDED FOR ESSENTIAL FATS
CONSIDER TETRACYCLINE SCLEROSIS
CONSIDER A CXR TO R/O A CHYLOTHORAX
HEMATOMA—LOW PRESSSURE VENOUS HEMATOMA FEELS LIKE A LIPOMA (SOFT)
CAROTID BLOW OUT—PRIMARY CAUSE—PERSISTENT OR RECURRENT TUMOR!!!!—USUALLY EXTERNAL AND USUALLY AT THE CAROTID BULB—IF IT HAPPENS INTERNALLY WALK SLOW TO THE CODE
3 OTHER CAUSES—OPEN WOUND (EXPOSED CAROTID), INFXN (FISTULA), PRIOR RT
88-90% WILL HAVE A “HERALD” OR “SENTINEL” BLEED—–AN ARTERIAL BLEEDING PRODROME
20% PTS DIE FROM THIS—CAROTID BULB> CC > ICA>ECA
CALL CODE—PUT ON A GLOVE—HOLD PRESSURE—T&C—GET TO OR—LIGATE DISTAL AND PROXIMAL VESSEL AND BURY EACH IN VIABLE MUSCLE—-25% OF THESE LIGATED STUMPS WILL REBLEED
TO AVOID THIS COMPLICATION—MAINTAIN NUTRITION, NO TRIFUCATIONS OVER THE CAROTID, USE A DERMAL GRAFT, CONSIDER A MUSCLE FLAP, KEEP ON ABX, AND AVOID TENSION IN THE CLOSURE
SOM ND—PROBABLY BETTER TO CALL IT A LEVEL I – IV SELECTIVE-FUNCTIONAL NECK DISSECTION
FOR SMALL LESIONS OF THE O.C.
TI ? PROBABLY GOOD IDEA FOR LESION > 1 CM
WILL LIKELY NEED A TRACH FOR TONGUE LESIONS
THINK ABOUT BILATERAL TREATMENT ALWAYS
DRAW AN APRON LIKE INCISION FROM MASTOID TIP TO MANDIBULAR SYMPHYSIS WITH INF APEX TO THYROHYOID MEMBRANE
ELEVATE SUP FLAP AND TIE LAP IN USUAL FASHION(2-0 SILKS LOADED BACKHAND)
RAISE INF FLAP TO ABOUT 2 CM ABOVE THE CLAVICLE
BEGIN SUP AND RAISE SAFETY FLAP TO PROTECT MMN
DO SUP DISSECTION FIRST–FROM ANGLE TO SYMPHYSIS
NEXT DO SUBMENTAL DISSECTION AND CARRY FATTY LYMPHOID TISSUE BACK TO CAROTID SHEATH
CREATE INF BORDER OF DISSECTION (USE INF BORDER OF INF OMOHYOID)
START RAISING INF BORDER OFF OF CAROTID SHEATH STRUCTURES
CONNECT THIS WITH POST BORDER
OFTEN TAKE EJV
BEGIN CUT ON MOST SUP. ASPECT OF SCM—MAY USE 10 BLADE
MAY SAVE GREATER AURICULAR NERVE
BASICALLY DO FASCIECTOMY AROUND ANT. AND THEN DEEP ASPECT OF MUSCLE
CONTINUE THIS FASCIECTOMY UNTIL YOU REACH THE CERVICAL PLEXUS AT ERB’S POINT– LEAVE THESE INTACT
DON’T WORRY ABOUT LEAVING SOME LYMPHOID TISSUE POST TO THIS–MUST CUT BAIT SOMEWHERE
CONT DISSECTION DOWN TO FLOOR–DEEP LAYER OF DCF (INVESTING LAYER)
BEWARE AND IDENTIFY PHRENIC AND BRANCHIAL PLEXUS (AND POSSIBLY THORACIC DUCT)
THIS DISSECTION WILL BE BROUGHT ANT TO CAROTID SHEATH
FINALLY MUST CREATE POST/SUP BORDER
TAKE EVERY THING ANT TO SCM–MUST BE EXCEEDINGLY CAREFUL SUP OF CN II
YOU WILL OFTEN SEE IT DOUBLING BACK OUT OF THE DEEP SIDE OF THE SCM AS YOU ARE DISSECTING UNDER IT
DO TAKE TAIL OF PAROTID
BASICALLY PEEL THE LYMPHOID TISSUE DOWN OFF OF THE CAROTID SHEATH
MUST BEWARE OF VENOUS BRANCHES OFF THE IJV AS WELL AS ARTERIAL BRANCHES OFF THE ECA (SUP THYROID)
DO NOT FORGET TO ALWAYS ORIENT THE SPECIMEN
CLOSE IN THE USUAL FASHION
SUPRAHYOID ND
REALLY A GLORIFIED SUBMAX GLAND EXCISION (LEVEL I-II CLEAN OUT)
GLOSSECTOMY
SUSPEND THE LARYNX FROM THE HYOID BONE TO THE GENIAL TUBERCLE OF THE MANDIBLE
PRIMARILY MET TO THE JUGULODIGASTRIC LNS
WITH ANY SIG GLOSSECTOMY MAY WANT TO CONSIDER A LARYNGECTOMY AND PEC FLAP
LARYNGECTOMY
ORGAN PRESERVATION IS NOW THE NEW STANDARD OF CARE—AT LEAST GIVE IT A TRY—PT CHOICE IS PROBABLY THE BEST OPTION
RESPONSE TO CHEMO INDICATES CANDICACY FOR LARYNGEAL PRESERVATION
CONSERVATION TECHNIQUES:
ALWAYS BE SURE PT IS PARALYZED TO AVOID LARYNGOSPASM AND RESULTANT DISASTER
ENDOSCOPIC EXCISION-—VOCAL CORD STRIPPING, PARTIAL SUPRAGLOTTIC RESECTION, LASER/NONLASER EXCISIONAL BIOPSY
CORDECTOMY VIA LARYNGOFISSURE (MEDIAL 1/3 OF THE CORD)
HPL (HORIZONTAL PARTHIAL LARYNGECTOMY) = SUPRAGLOTTIC (HORIZONTAL) LARYNGECTOMY —ALWAYS CONSENT FOR TOTAL, START THE CASE WITH A DL—BEFORE THE TRACH
NO TRUE QUADRANGULAR CARTILAGE BARRIER TO GLOTTIC INVASION OF METS—-SIZE OF PRIMARY CORRELATES WITH LOCAL CONTROL
SUTURE THE BOT TO THE THYROID CARTILAGE/PERICHONDRIUM (TAKE HYOID)
NEED TO ANTERIORIZE AND SUSPEND THE LARYNX—-NEED FEV1 > 50% OR ABILITY TO CLIMB 2 FLIGHTS OF STAIRS
VPL (VERTICAL PARTIAL LARYNGECTOMY) VERTICLE OR FRONTOLATERAL PARTIAL LARYNGECTOMY (VERTICLE HEMILARYNGECTOMY)
CONSENT FOR A TOTAL?—PROBABLY ABORT THE SURGERY IF NOT PREVIOUSLY IRRADIATED
ADDRESS THE NECK FOR T3 AND T4 DISEASE
PREOP ABX
INTUBATE
DL
FEEDING TUBE
RELATIVELY LOW SMALL TRACH VIA TRANSVERSE INCISION
HORIZONTAL INCISION—RAISE FLAPS UP TO HYOID AND DOWN TO SUP CRICOID
DISSECT DOWN TO THE PERICHONDRIUM IN THE MIDLINE–STAY IN THE MIDLINE FOR RECONSTRUCTION REASONS
DISSECT OFF THE PERICHONDRIUM ON THE SIDE TO BE RESECTED–USE A FREER
MARK THE CARTILAGE INCISIONS—LEAVE 3 MM TO 10 MM POSTERIORLY
CUT WITH THE SAGITALL SAW
ENTER THE LARYNX THROUGH THE ANT CONUS—COMPLET THE LARYNGOFISSUYRE WITH A 15 BLADE OVER A MOSQUITOE
ALWAYS LEAVE 2-3 MM OF MARGIN
MAKE YOUR MUCOSAL CUTS WITH A 15 BLADE
RESECT YOUR SPECIMEN — WILL GET SOME BLEEDING
BIPOLAR HEMOSTASIS
FROZENS—CAN TAKE OFF SPECIMEN
REESTABLISH BROYLE’S LIG WITH A 4-5-0 BIOSYN—SUTURE TO THE MIDLINE PERICHONDRIUM
SUTURE THE PETIOLE TO THE HYOID OR PERIOSTEUM TO FACILITATE AN ADEQUATE AIRWAY WITH A 3-0 NYLON?–ALSO ALLOWS YOU A BETTER POST OP VIEW
RESECT ANY PROJECTING ARYTENOID?—BALANCE AIRWAY WITH ASPIRATION RISK—-PROBABLY BETTER TO ERR ON THE SIDE OF ASPIRATION PROTECTION AS CHRONIC ASPIRATION COULD LEAD YOU TO A TOTAL LARYNGECTOMY
CONSIDER BRINGING IN OMOHYOID TO POST GLOTTIS FLAP—-LEAVE A-E FOLD UP TO ACT AS DAM TO PREVENT PIRIFORM FROM POURING INTO GLOTTIS
CONSIDER A BIPEDICLED MUSCLE FLAP OR INF BASED FLAP
SUTURE THINGS CLOSED—-PERICHONDRIUM HAS NO GIVE–DO NOT TAKE BIG BITES WHEN CLOSING
CLOSE OVER A 1/4″ PENROSE OR #10 JP—-MAY NEED TO BE TO WALL SUCTION
TRACHEOTOMY CAN BE DEFLATED QUICKER THAN A SUPRAGLOTTIC LARYNGECTOMY
SWALLOWING MAY BE TRIED AT ABOUT 1-2 WEEKS OR SOME WAIT UNTIL THE TRACH HAS CLOSED
GET SPEECH INVOLVED EARLY
SUPRACRICOID LARYNGECTOMY—BASICALLY JUST SUTURING THE CRICOID TO THE HYOID (SEEMS TO WORK)
LEAVE THE ARYNTENOIDS—SOME PATIENTS NOT DECANULATABLE
NEAR TOTAL(PEARSON)—FUNCTIONAL TEP—PT REQUIRES A TRACH
NARROW FIELD = EXCLUDE HYOID (NOT FOR CANCER–ONLY FOR ASPIRATION)
CONSERVATIVE TECHNIQUE:
WIDEFIELD = INCLUDE HYOID
FOR T3 ? AND T4, DIFFICULT T2, > 1.5 CM SUBGLOTTIC EXTENSION, BOT EXTENSION BEYOND CIRCUMVALLATE PAPILLA, RT FAILURE, ?PRE EPIGLOTTIC SPACE INVOLVEMENT?—-NEED TO INDIVIDUALIZE PT CARE AND BE FAMILIAR WITH THE CURRENT RTOG TRIALS
ADDRESS THE NECK ELECTIVELY FOR T3 AND T4 DISEASE
PULM CRIPPLES LOOSE ATHEIR AUTO PEEP AND THIS CAN BE A PROBLEM
STEPS:
IF EMERGENT LOCAL TRACH REQUIRED—CONSIDER “EMERGENT” LARYNGECTOMY—–SOME EVIDENCE THAT STOMAL RECURRENCE INCREASES WITH > 48 HOUR DELAY AFTER LOCAL TRACH—-THIS IS NO LONGER HELD TRUE—-THE ONLY VARIABLE WHICH COINCIDES WITH STOMAL RECURRENCE IS TUMOR SIZE WHICH CORRELATES WITH NEED FOR AN EMERGENT TRACH
STOMAL RECURRENCE IS CLASSIFIED INTO 4 SUBTYPES—I = SUP STOMA ONLY, II = SUP STOMA AND ESOPHAGUS, III = INF STOMA AND SUP MEDIASTINUM, IV = INOPERABLE (EVEN WITH TYPE I—SURGICAL CURE IS ONLY 25%)
PLEASE NOTE THAT A LOW TRACH IS ALMOST NEVER RELQUIRED—SUBGLOTTIC EXTENSION IS NEVER AS INF AS YOU THINK IT IS
T&C FOR 2 U PRBC’S
FEEDING TUBE—–SUTURE TO MEMBRANOUS COLUMELLA
CONSIDER PRIMARY TEP—MAY FEED THROUGH IT
SHOULDER ROLL
SHAVE, PREP FOR DERMAL GRAFT—-LOWER LIP TO UMBILLICUS—BE PREPARED FOR A PEC MAJOR FLAP
MARK INCISION FOR STOMA: MIDPOINT BETWEEN STERNAL NOTCH AND CRICOID CARTILAGE
DRAW INCISIONS—USUALLY A LARGE APRON—-UP TO MASTOID ON NECK DISSECTION SIDE—UP TO HYOID ON NON NECK SIDE—-SWING LOW TO AVOID DROPING A LIMB
INJECT (TELL ANESTHESIA)
METHYLENE BLUE
ADDRESS NECK LYMPHATICS FIRST
DIVIDE STRAPS WITH BOVIE ABOUT 2 FINGERBREADTHS ABOVE CLAVICLE
DIVIDE THYROID ISTHMUS
DISSECT THYROID OFF TRACHEA (BERRY’S LAT SUSPENSORY LIG)—MAY TAKE A LOBE IF ANY CONCERN
DIVIDE RLN BILAT—-BEWARE OF THE PARATHYROIDS AND THEIR BLOOD SUPPLY
DIVIDE INF THYROID ARTERY ON TUMOR SIDE
ID AND PROTECT ESOPHAGUS–MAY GRASP HYOID WITH ALLIS CLAMP
CUT ALL CONSTRICTOR ATTACHMENTS OFF OF HYOID BONE AND THYROID CARTILAGE—DO THIS WITH MOSQUITO AND BOVIE—WATCH 12!
FREE UP AND SKELETINIZE LARYNX PRIOR TO ENTERING
PROBABLY THEN CAN ENTER TRACHEA
PICK A SPOT—TELL ANESTHESIA TO GET READY FOR TUBE CHANGE
IF TUMOR IS VERY SUP MAY SPARE AND UTILIZE ALL TRACHEA—OTHERWISE USUALLY TAKE BETWEEN 3RD TO 4RTH ARCHES—-(BEVEL) CUT OBLIQUELY WITH CURVED MAYOS
HAVE ANESTHESIA PULL TUBE BACK AND THAN PLACE CANT KINK TUBE INTO TRACH—CAN SUTURE IT IN TO THE FIRST ARCH
ZITSCH LIKES TO IMMEDIATELY SUTURE THE TRACHEA TO THE SKIN WITH O-PROLENE
ENTER THE LARYNX OPPOSITE THE TUMOR–USUALLY FROM PRIRIFOM SINUS AND SOMETIMES THE VALLECULA—SPARE AS MUCH MUCOSA AS POSSIBLE—AN OROPHARYNGEAL SUCTION INSERTED THROUGH THE MOUTH CAN HELP YOU LOCATE THE PIRIFORM MUCOSA
TRY TO CUT 1 CM MARGIN AROUND TUMOR ON MUCOSA WITH SCISSORS
BOVIE TISSUES OTHER THAN THE MUCOSA
PUT AN ALLIS CLAMP ON THE EPIGLOTTIS TO HELP YOU MANIPULATE THE SPECIMEN
FOR A LARYNGEAL PRIMARY CUT INTO THE VALLECULA—SAVE AS MUCH MUCOSA AS POSSIBLE
PULL LARYNX DOWN WITH ALLIS AND MAKE YOUR POST CRICOID CUT WITH A 10 BLADE AS YOU PEEL THE LARYNX OFF
TAKE FROZEN MUCOSAL MARGINS OFF THE SPECIM VS THE PT—TO CONSERVE MUCOSA
IRRIGATE AND BIPOLAR HEMOSTASIS
RUNNING CLOSURE WITH 3-0 BIOSYN (CONNEL INVERTING STITCH) LEAVE LONG TAG AT STARTING POINT—REALLY JUST A RUNNING HORIZONTAL MATTRESS—GO FROM OUT TO IN TO OUT ALL THE WAY THROUGH THE MUCOSA–IMBRICATE/INVERT MUSOSA INTO PHARYNX
TENSION FREE CLOSURE—ESPECIALLY IN IRRADIATED PTS—MAY ALLOW BOT TO HEAL SECONDARILY—-IF UNSURE USE A PEC FLAP
A “T” SHAPED CLOSURE IS MOST COMMON—-SOME TIMES A VERTICLE CLOSURE IS MORE IDEAL
INTERUPTED LEMBERT WITH 3-0 BIOSYN—SUBMUCOSAL CLOSURE–AGAIN INVERTING CLOSURE—-DO NOT PENETRATE THE MUCOSA ALL THE WAY
TRIPLE LAYER CLOSURE IS BEST—THIRD LAYER APPROXIMATES THE MUSCLE REMNANTS
SOME SURGEONS PREFER AN INCOMPLETE MUSCLE CLOSURE TO FACILITATE SPEECH—A CP MYOTOMY MAY ALSO BE PREFORMED
AT LEAST CONSIDER CLOSING THE CONSTRICTORS
IRRIGATE, USUAL CLOSURE
MAY DO INTRAOP H2O OR METHYLENE BLUE TEST TO TEST CLOSURE
EARLY FISTULA PORTENDS TECHNICAL ERROR
CREATE STOMA WITH NYLON OR PROLENE
THYROID AND PARATHYROID FUNCTION SHOUD BE CONSIDERED
NPO MIN 5 DAYS IN NO RT
NPO FOR 7 DAYS OR 10 DAYS IF HX RT
REALLY INITIAL SWALLOWING TRIAL IS WHEN PT SWALLOWS THEIR OWN SALIVA(AVG PERSON SWALLOWS 1000-1500 TIMES / DAY WHILE AWAKE AND 50-100 TIMES WHILE SLEEPING—10-15 SWALLOWS/HOUR—-MAY ASK THEN TO TRY NOT TO SWALLOW BUT MOST H & N SURGEONS DON’T
PRODUCE 1 L NASAL SECRETIONS/DAY AND 1.5 L OF SALIVA/DAY
KEFZOL 2 G IV Q 8 HOURS X 48 HOURS
HUMIDIFIED O2
POST OP CXR
AVOID LARYNGECTOMY TUBE IF POSSIBLE
SPEECH THERAPY CONSULT—SHOULD GET COOPER-RAND ELECROLARYNX ASAP
POST FOR TUMOR, RT, DENTAL, DIETARY, SS CONSULT(SUPPORT AND HOME CARE)
KEEP HEAD FLEXED(PILLOW) FOR AT LEAST 3 DAYS
STOMA CARE—-3 CC NS SQUIRTS FOLLOWING MAXIMAL INSPIRATION QID AND PRN
MAXILLECTOMY
PALATAL ANESTHESIA—V2 ENCROACHMENT—ABOVE OHNGREN’S LINE—-POOR Px
APPROACHES: ENDOSCOPIC, ALATOMY, LAT. RHINOTOMY, TRANSORAL/TRANSPALATAL, MIDFACE DEGLOVING—CAN DO MANDIBULOTOMY TO HELP FACILITATE THIS, WEBER-FERGUSSON APPROACH, COMBINED CRANIOFACIAL APPROACH (WEBER-FERGUSSON + BICORONAL FLAP)
WEBER-FERGUSSON= LAT RHINOTOMY + LIP SPLIT (ON PHILTRAL RIDGE) +/- SUBCILIARY OR TRANSCONJ—-BRING THE ORBICULARIS OCULI UP IN YOUR FLAP—-PLANE IS RIGHT ON THE ORBITAL SEPTUM-UNDER THE MUSCLE
EXTENT OF RESECTION: MEDIAL MAXILLECTOMY, INFERIOR(INFRASTRUCTURE) MAXILLECTOMY, TOTAL WITH OR WITHOUT ORBITAL EXENT, ANTERIOR CRANIOFACIAL RESECTION
CALDWELL-LUC
AN ORAL CAVITY APPROACH TO THE MAX SINUS
INCISION THROUGH THE BUCCOGINGIVAL SULCUS
LEAVE ENOUGH MUCOSA TO SEW TO
CREATE AN INF ANTRAL WINDOW
INF ANTRAL WINDOW UNDER INF TURB WITH A CRILE OR GOLD
PASS 1/2″ GUAZE AND THEN GIGGLY SAW IT BACK AND FORTH TO DEBRIDE THE WINDOW
PACK THE SINUS WITH THE 1/2″ GUAZE AND TIE A SILK SUTURE TO BOTH THE PROX AND DISTAL ENDS
LEAVE THE PROX END IN THE NASAL CAVITY AND TAPE THE SUTURE TO THE CHEEK
TEP
PT MUST HAVE REASONABLE DEXTERITY, VISION, MOTIVATION, AND HEARING
DEMENTIA, MORBID OBESITY, ALCHOHOLISM, SEVERE GERD, SEVERE COPD, AND STOMAL STENOSIS < 1 CM ARE CONTRAINDICATIONS
INSUFFLATION TEST GIVES YOU AN “IMPRESSION” OF WHETHER OR NOT A SECONDARY TEP WILL SUCCEED
GET SPEECH THERAPY CONSULT EARLY
IF A PRIMARY OR SECONDARY TEP FAILS—AND PT IS UNSUCCESSFUL WITH INSUFFLATION TEST—CONSIDER BOTOX INJ OF CP OR CP MYOTOMY
DO PANENDO EXAM
INJECT SITE WITH 1% WITH EPI FOR HEMOSTASIS
PHARYGO ESOPHAGEAL DILATION AS NECESSARY
POSITION CERVICAL ESOPHAGOSCOPE UNDER PUNCTURE SITE WITH BEVEL UP
PUNCTURE SITE SHOULD BE 5 – 10 MM BELOW THE MUCOCUTANEOUS JUNCTION
PUT GENTLE 90 DEGREE CURVE ON 18 GUAGE NEEDLE (BEND WITH WIRE IN) AND ENTER IT UP INTO THE SCOPE
GUIDE WIRE—-OUT TO OC
REMOVE NEEDLE
15 BLADE HORIZONTAL INCISION (PREVENT VERTICLE TEARING)
CAN NOW INSERT DILATOR WITH PEEL AWAY UNDER DIRECT VISUALIZATION—–CAN THEN INSER RED RUBBER CATHODER IN AND OUT THROUGH OC
REMOVE ESOPHAGOSCOPE (WIRE IS STICKING OUT MOUTH AND TEP SITE)
DILATOR THROUGH TEP SITE AND THEN OUT
ATTACH PEDIATRIC FEEDING TUBE OVER WIRE BY PLACING 90 DEGREE BENDS OVER A 4 CM AREA—-PUSH 10 CM OF PED FEED TUBE OVER IT
DILATE THE DISTAL PEDS FEEDING TUBE AND STRETCH IT OVER THE TIP OF A RED RUBBER CATHODER (14 FRENCH)—-2-0 SILK TRANSFIXTION STITCH
PULL THE WHOLE THING THROUGH
FREE UP THE RED RUBBER CATHODER AND PUSH IT DOWN INTO THE STOMACH WITH THE ESOPHAGOSCOPE
TIE CATHODER CLOSED WITH UMBILLICAL TAPE AND AROUND NECK
SPEECH CONSULT TO PLACE PROSTHESIS ASAP (WITHIN 1 WEEK)
NOW JACKIE LIKES A 16 FR CATHODER (CHANGES)
RENNER USES A BULLET TIPPED HURST DILATOR
CUTS DOWN HORIZONTALLY ONTO IT
SPREAD WITH TENOTOMIES AND UP TO 4 GUTHRIE SKIN HOOKS
KEY IS USE OF THE SKIN HOOKS AND THE HURST DILATOR
PULL THE DILATOR BACK SOME AND PUSH IN THE RED RUBBER
TIE THE RED RUBBER IN A KNOT AND CUT OFF THE DILATED PORTION
SUTURE IT TO THE SUP NECK WITH A COUPLE OF NYLON STITCHES
CP MYOTOMY
WITH A FAILED INSUFFLATION TEST–TRY WITH LIDO BLOCK—THEN TRY BOTOX—THEN MAY WANT TO PROCEED TO CP MYOTOMY
MAY FIRST TRY SOME LOCAL/ BOTOX TO SEE IT THAT HELPS
DO A CP MYOTOMY ON THE L AS THE R RLN IS MORE VUNERABLE (MORE ANT), IDIOPATHIC RLN PARESIS IS USUALLY ON THE L, AND AN ANOMOLOUS SUBCLAVIAN IS USUALLY ON THE LEFT, AND THER IS JUST MORE ROOM OVER THERE—THE CAROTID SHEATH IS A BIT FURTHER AWAY
PEG
PT SELECTION IS KEY–CONTRAINDICATIONS = INABILITY TO TRANSILLUMINATE ABD WALL, ACITES, COAGULOPATHY, INTRA-ABD INFXN PEGPT SELECTION IS KEY–CONTRAINDICATIONS = INABILITY TO TRANSILLUMINATE ABD WALL, ACITES, COAGULOPATHY, INTRA-ABD INFXN
STANDIFORD SET UP (EF)/ RUSSEL TECHNIQUE—–NO RISK OF TUMOR SEEDING(ONE CASE REPORT)
#16 COOK INTRODUCER SET WITH PEEL AWAY SHEATH
14 FR BROWN FOLEY WITH 5 CC BALLOON AND CATH ADAPTER
#11 BLADE, 2-0 SILK, MEDIUM TEGADERM
ROUINE PREP AND DRAP OF THE ABD
DRIVE FLEXIBLE INTO STOMACH—-PREPARE SCOPE FIRST (LUBRICATE AND FAMILIARIZE YOURSELF)
PUSH ON STOMACH TO DEMONSTRATE POSITION
ID PYLORUS, RETROFLEX SCOPE AND ID GE JUNCTION
INSUFFLATE STOMACH EXTENSIVELY—THIS IS KEY
HAVE ENDOSCOPIST KEEP IMAGE ON ENTRY POINT
NEEDLE
WIRE
CUT SKIN WITH 11 BLADE—-MUST BE ADEQUATE
INTRODUCER(DILATOR)
PEEL AWAY + INTRODUCER
REMOVE INTRODUCER
PUT IN FOLEY
PEEL AWAY PEEL AWAY
INFLATE BALLOON
PULL FOLEY TIGHT AND SUTURE TO SKIN TIGHTLY WITH 2-0 SILK
PLACE TEGADERM
DEFLATE STOMACH
REMOVE SCOPE
MAY BEGIN TO BOLUS FEED WHEN BS PRESENT
LEAVE STITCH UNTIL 1 WEEK—MAY JUST LEAVE IT—WILL GROW OUT IN 3 WEEKS
CAN REMOVE TEGADERM IN 1 WEEK
1ST TUBE CHANGE USUALLY TO ANOTHER FOLEY
CAN USE A DISK—SKIN WILL TIGHTEN AROUND IT
CAN EVENTUALLY CHANGE TO A COMMERCIAL FEEDING TUBE OR A MALLENCOT
MOST COMMON COMPLICATION = GT OR LOCAL WOUND INFXN—-CAN USUALLY HANDLE WITH AGNO3, CORTISPORTIN SUSP., DUODERM, OR DRIED MAALOX