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Specialty: Head and Neck Surgery

Right Neck Dissection

Introduction 

Neck dissection stands as a crucial surgical procedure predominantly utilized in addressing head and neck cancers. It involves the methodical elimination of lymph nodes and potentially adjacent tissues to curb cancer dissemination. This procedure can be delineated into several types based on the extent of surgery and the structures targeted, including radical neck dissection (RND), modified radical neck dissection (MRND), selective neck dissection (SND), and extended neck dissection.[1]

Neck dissection is recommended for various conditions such as metastatic neck cancer, cancers affecting the oral cavity, pharynx, larynx, or thyroid with a high risk of lymphatic spread, and as a prophylactic measure in cases of head and neck cancers with a high risk of occult metastasis.[1] Understanding the anatomy of the cervical lymphatic system, which is divided into distinct levels (I-VII) each containing specific groups of lymph nodes, is essential for conducting effective neck dissection.[2,3] The radical neck dissection (RND), introduced by George Crile Sr. in 1906, was long regarded as the standard treatment for metastatic neck disease.[2,4] However, modifications to the procedure have been developed over time to reduce associated morbidity while ensuring oncological safety.[1]

Surgical procedure 

The surgical procedure of neck dissection typically involves a series of steps: an incision is made along an existing neck crease, subplatysmal flaps are then elevated to expose underlying anatomical structures and lymph nodes, different groups of lymph nodes are systematically removed depending on the type of dissection, and finally, the surgical site is closed in layers with the placement of a drain.[4] Complications of neck dissection may include nerve damage resulting in shoulder dysfunction, bleeding and hematoma formation, infection and issues with wound healing, as well as the development of lymphedema.[1]

Conclusion 

Neck dissection is a vital procedure in the management of head and neck cancers, designed to remove lymph nodes that may harbor metastatic disease. The type of neck dissection performed is tailored to the extent of disease and the need to preserve function and reduce morbidity. A thorough understanding of the anatomy and careful surgical technique are essential to optimize outcomes and minimize complications.

References 

Harish K. Neck dissections: radical to conservative. World J Surg Oncol. 2005 Apr 18;3(1):21. doi: 10.1186/1477-7819-3-21. PMID: 15836786; PMCID: PMC1097761.
Jiang, Z., Wu, C., Hu, S. et al. Research on neck dissection for oral squamous-cell carcinoma: a bibliometric analysis. Int J Oral Sci 13, 13 (2021). https://doi.org/10.1038/s41368-021-00117-5
Rigual NR, Wiseman SM. Neck dissection: current concepts and future directions. Surg Oncol Clin N Am. 2004;13(1):151-166. doi:10.1016/S1055-3207(03)00119-4
Antonio Riera March, M. (2023, November 28). Radical neck dissection. Background, History of the Procedure, Problem. https://emedicine.medscape.com/article/849895-overview?form=fpf

Eagle Syndrome (Calcification of the Stylohyoid Ligament) Excision

Abstract

Introduction: Eagle syndrome can affect many patients of any age, anywhere from 25 to 80 years old. The most common symptoms are ear and anterior superior neck pain underneath the angle of the jaw, tinnitus, some throat symptoms, and dizziness. There are two approaches that can be done for surgery, with our preference being for the intraoral approach.

The pathophysiology is that the stylohyoid ligament becomes calcified and can cause pressure on blood vessels and nerves, causing variable symptoms. It is frequently undiagnosed causing patients to visit several physicians before correctly identifying the problem.

A CT scan of the neck with or without contrast, can help identify the problem.

Case presentation: A 39-year-old female with a history of ear and upper neck pain at the angle of the jaw. CT imaging showed calcification of the stylohyoid ligament. Surgery was recommended and a trans-oral approach was used.

Methods: General anesthesia with muscle relaxation was used. A crow Davis or Dingman tractor was used to retract the endotracheal tube to allow exposure of the Oropharynx. Betadine was used to help sterilize the oropharynx. Palpation on each side is done to localize the calcified ligament and if present, the surgery is much easier to do. A 2.5 cm vertical incision is made in the anterior tonsillar pillar, being careful not to go too high on the soft palate because it can paralyze the soft palate causing significant reflux into the nasopharynx and nose, with speech and swallowing problems.

The tonsil capsule and the medial pterygoid muscle are identified, and the dissection is between the two. The calcified ligament is usually about 2.5 cm deep to that area. It is in or under the fat pad in the prevertebral area. It may be difficult to find, and it is helpful if your finger is passed through the incision to palpate deeper to feel the bony process.

The stylohyoid muscle and fat must be cleaned off the bone as high and low as can be dissected ideally using a combination of the monopolar and bipolar cautery. It is important to be careful in this area with the monopolar cautery because of the proximity to the internal carotid artery and jugular vein. Also, the vagus nerve can be injured.

A Kerrison rongeur is used to fracture the bone superiorly. The ligament is connected at the inferior part which can be divided with the cautery.

It is important to obtain good hemostasis using the bipolar cautery and saline irrigation. The wound is closed by sewing the tonsil capsule to the medial pterygoid muscle after which the mucosal incision is sewed. Preferably, vicryl sutures are used so that it will last approximately four weeks.

Bupivacaine 0.5% can be injected around the surgical site to decrease postop pain.

The surgery is done as an outpatient basis and the patient is given pain medication and antibiotics for significant throat pain lasting 7 to 10 days postop.

Conclusion: The removal of the calcified Stylohyoid ligament via an intraoral approach, can be simple or very complicated, and must be done carefully by an experienced surgeon to avoid major complications.

Most patients benefit significantly with relief of their symptoms and are very grateful. This case illustrates the surgical procedure that was easy to perform, but they are not all that easy.

Surgeons:

Siddharth Patel, MD

James Y Suen, MD

Conflicts of Interest: None

Funding: This research received no external funding

Department of Otolaryngology – Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA

Excision of supratrochlear and supraorbital nerves

Abstract

Introduction: Frontal  headache is a common, costly and debilitating disease process.When treatments, including medication management and physical therapy, prove ineffective, surgical interventions become a viable consideration  Among these interventions, the excision of supratrochlear and supraorbital nerves stands out as a potential therapeutic option.

Case presentation: 24-year-old female with history of chronic frontal headaches who presents for resection of supraorbital and supratrochlear nerves.

Methods: A 4 cm incision was carefully made along the right eyebrow. This incision extended through the subcutaneous tissue. Employing a combination of blunt and sharp dissection techniques, we successfully identified supratrochlear nerves, observing multiple branches emerging from the orbit. All branches were excised via scissors . Subsequently, we located the supraorbital nerve exiting through a foramen, just above the mid-orbital rim, and proceeded to excise it. The wound was thoroughly irrigated with normal saline to ensure cleanliness, and hemostasis was  maintained throughout the procedure using both monopolar and bipolar cautery. Closure of the incision was executed in a layered fashion, employing 3-0 Monocryl and 5-0 Chromic sutures. To minimize postoperative discomfort, 0.5% Marcaine with epinephrine was injected into the nerve areas.

Conclusion :The excision of the supraorbital and supratrochlear nerves offers a promising option for managing chronic frontal headaches when conventional treatments prove ineffective. This case report underscores the successful outcome of this procedure in a 24-year-old female who had been enduring debilitating headaches.

Surgeons:

Dang-Khoa Nguyen, MD

James Y Suen,MD

Conflicts of Interest: None

Funding: This research received no external funding

Department of Otolaryngology – Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA

Excision of greater occipital nerves and 3rd occipital nerves

Abstract

Introduction: Occipital headache is a common, costly and debilitating disease process.When traditional therapies such as medication management and physical therapy fail to provide relief, surgical interventions may be considered. This procedure involves the excision of the 3rd and  both greater occipital nerves. 

Case presentation: 36 years old. female with history of chronic refractory occipital headaches  involving both greater occipital nerves and 3rd occipital nerves who presented for resection of those nerves.

Methods: A 10cm incision was marked on the posterior neck, positioned inferior to the occipital  skull base. Subsequently, the incision was carefully extended through the subcutaneous tissue. By means of both blunt and sharp dissection through the posterior muscle fascia where it inserts into the skull base, the right greater occipital nerve was identified and dissected into the paravertebral muscles and several centimeter of the nerve was resected so it could not grow back together. A corresponding procedure was employed for the left greater occipital nerve, located approximately 3 cm from the midline, and excised using the same technique. Additionally, the third occipital nerves situated in the midline were excised to address the entirety of the issue. Following these procedures, the wound was thoroughly irrigated with normal saline to ensure cleanliness, and hemostasis was diligently maintained throughout the surgical intervention using both monopolar and bipolar cautery. To alleviate postoperative discomfort, 0.5% Marcaine with epinephrine was carefully injected into the nerve areas.

The fascia needs to be closed with  strong sutures and  the skin and subcutaneous tissue were closed  in two layers. 

Conclusion :The excision of  greater occipital nerves presents a viable option for the management of chronic occipital headaches when conservative treatments prove ineffective. This case report highlights the successful outcome of such a procedure in a 36-year-old female suffering from debilitating headaches

Surgeons:

Dang-Khoa Nguyen, MD

James Y Suen,MD

Conflicts of Interest: None

Funding: This research received no external funding

Department of Otolaryngology – Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA

Thyroid Cyst Removal with Hemithyroidectomy

This video shows a thyroid cyst removal that resulted in a hemithyroidectomy. The patient is placed under general anesthesia and intubated using a mac video laryngoscope and an EMG endotracheal tube. The ET tube has 4 stainless steel wire electrodes which touch the vocal cords for monitoring during surgery. After video intubation electrode placement is verified by direct stimulation of the area.

The surgeon makes a curvilinear skin crease incision in the front of the neck, to minimize the visibility of a scar. Afterwards, subplatysmal flaps are elevated and the midline raphe is dissected exposing the sternohyoid muscle, which is retracted laterally, and the sternothyroid muscle that is dissected off the left thyroid gland.

The thyroid cyst is found superficial and dissected, keeping in mind that anything suspicious for the recurrent laryngeal nerve is stimulated prior to dissection. The cyst is ruptured and sent for frozen pathology. The results returned as thyroid, so the surgeon proceeded with a hemithyroidectomy. The superior and inferior parathyroids were identified and dissected free. Hemostasis was achieved with electrocautery and confirmed with Valsalva. Strap musculature platysma and skin are closed. And lastly, mastisol and steri-strips are placed perpendicular to the wound.

Midline Cervical Cleft Excision of Fibrous Cord – Z Plasty Closure

Z-plasty allows broken-line closure, reorientation of the defect in the horizontal plane with re-creation of a cervicomental angle, and most importantly, a lengthening of the anterior neck skin that aids in preventing recurrent contracture. We present our experience managing a congenital cervical midline cleft in a 3-month-old patient and describe a simple technique for planning the ideal Z-plasty closure. No simple description for planning the ideal closure for this defect could be found in the otolaryngology literature.

Branchial Cleft Cyst Excision

Branchial cleft cysts are a benign anomaly caused by incomplete obliteration of a primordial branchial cleft.  They typically appear in childhood or adolescence, but can appear at any age. They present as a non-tender, fluctuant mass following an upper respiratory infection, most commonly at the anterior border of the sternocleidomastoid muscle. These lesions are thought to originate during the 4th week of gestation when the branchial arches fail to fuse. The second branchial cleft is the most common site (95%) and cysts from in this distribution can affect cranial nerves VII, IX, and XII. 

Rectus Abdominis Myocutaneous Flap Harvest

This video highlights the surgical nuances of rectus abdominis myocutaneous free flap harvest.

Transoral Robotic Assisted Radical Tonsillectomy

Contributors: Jeffery Scott Magnuson (University of Central Florida)

1) Purpose: The patient had a history of biopsy proven squamous cell carcinoma of the right palatine tonsil and elected for surgical resection as a primary treatment.

2) Instruments: The DaVinci surgical robot was used with the Maryland dissector and a monopolar cautery on the arms. The FK retractor was used to suspend the patient and gain exposure.

3) Landmarks: The right palatine tonsil is resected along with a cuff of pharyngeal musculature.

4) Procedure: In sequence, the initial incision on the anterior tonsillar pillar, the exposure of the parapharyngeal space, the removal of the specimen, and the final defect are shown.

5) Conflicts of interest: for JSM: Intuitive Surgical: Instructor/Proctor, Honoraria; Lumenis: Consultant, Honoraria; Medrobotics: Member Strategic Advisory Panel, Honoraria.

6) References: Chung, T. K., Rosenthal, E. L., Magnuson, J. S. and Carroll, W. R. (2014), Transoral robotic surgery for oropharyngeal and tongue cancer in the United States. The Laryngoscope. http://dx.doi.org/10.1002/lary.24870

DOI: http://dx.doi.org/10.17797/kjwgjsgxwk

Multinodular Thyroid Gland with Cervical Lymphadenopathy Followed by Total Thyroidectomy

Purpose of procedure: To remove enlarged multinodular thyroid gland which was causing airway obstruction along with feeding difficulties.

Landmarks: Two horizontal collar incision with skin crease above 2 finger breadths above the sternal notch.

Procedure:

1. A horizontal incision of 2 finger breadth was made above the sternal notch and silk sutures were used for retraction of skin flaps. Subcutaneous flaps and platysma were divided and subplatysmal dissection was made above the incision up to the level of thyroid cartilage above and the sternal notch.

2. Strap muscles were separated with the help of retractor, exposing anterior surface of thyroid.

3. Thyroid gland was rotated medially to and middle thyroid vein was ligated.

4. Superior laryngeal artery was also ligated and external laryngeal nerve was spared during procedure.

5. Superior parathyroid was spared and identified at upper two third of thyroid at 1cm above crossing point of recurrent laryngeal nerve and inferior thyroid artery.

6. Similarly, inferior parathyroid was identified and spared which was located on the posterolateral surface of the lower pole of the thyroid.

7. Recurrent laryngeal nerve was preserved which was located between the common carotid artery laterally, the oesophagus medially, and the inferior thyroid artery superiorly.

8. Sternocleidomastoid was resected to explore the area adjacent to the lymph nodes involved.

9. Cervical lymph node involved was also removed, whereas the carotid artery, jugular vein, phrenic nerve, sympathetic ganglia, brachial plexus, were spared.

10. Eventually, thyroid gland was dissected and neck was sutured.

Conflict of Interest and Source of Funding: none

Acknowledgments: Author thanked the patient and surgeons later.

DOI: http://dx.doi.org/10.17797/74w05qqfns

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