Surgical Atlas of pediatric otolaryngology - part 7 pdf

Congenital Malformations of the Neck 507 FOURTH BRANCHIAL POUCH SINUS The fourth branchial pouch sinus is an uncommon congenital anomaly with two characteristic clinical presentations: 1. Neonatal neck mass. A neonate presents with a lateral neck cyst or abscess associated with actual or impending airway compromise. The mass mimics a cystic hygroma, and may contain air or increase in size during crying or Valsalva. 2. Recurrent deep neck infection. A child, adolescent, or occasionally an adult, presents with recurrent deep neck abscess or suppurative thy- roiditis, despite several attempts at drainage or neck exploration. The fourth branchial pouch sinus is not a complete fistula, but rather a brief, internal tract originating in the piriform sinus. After exiting the pyri- form apex, caudal to the superior laryngeal nerve (Figure 22–9), the tract descends translaryngeally under the thyroid ala to emerge beneath the infe- rior constrictor muscle, and exit the larynx near the cricothyroid joint. Nearly all reported sinuses have been left sided. Indications • Fourth branchial pouch sinus diagnosed by barium swallow, sinogram (when an external fistula exists), or hypopharyngoscopy • Suspected fourth branchial pouch sinus based on clinical history, particu- larly unexplained recurrent deep neck infection or suppurative thyroiditis Figure 22–9 Fourth branchial pouch sinus originating in the piriform apex (dashed lines), caudal to the superior laryngeal nerve (SLN), and terminating as a small cyst in the superior pole of the thyroid gland. The sinus tract is near the recurrent laryn- geal nerve (RLN) at the cricothyroid joint. 508 Surgical Atlas of Pediatric Otolaryngology Preparation • Acutely infected sinuses are treated with antibiotics, and incision and drainage if necessary; definitive excision is delayed several weeks until inflammation has resolved. • Perioperative antibiotics are given routinely. • Equipment is available for direct microlaryngoscopy to examine the ipsi- lateral piriform apex for a sinus tract. Anesthesia and Preparation • General anesthesia with orotracheal intubation is required. • The patient’s neck is extended and draped from the clavicle to the chin. Procedure • Direct laryngoscopy is performed and the ipsilateral piriform apex is inspected for a sinus tract opening. If a distinct opening is found, two options exist: 1. Endoscopic cauterization. The sinus tract is obliterated by endoscopic cauterization using an insulated needlepoint electrocautery, and the procedure is concluded. Preliminary results with limited follow-up have been favorable. Cauterization is at low power and limited to the superficial mucosal layer, which leads to scarring and closure of the sinus tract with low risk of perforation. 2. Open surgical excision. The sinus tract is excised retrograde, beginning with complete exposure of the piriform fossa. Recurrence has not been reported with this approach, but morbidity is higher than with cauterization. In contrast, excising only the extralaryngeal portion of the tract almost guarantees recurrence. • External excision begins by exposing the thyroid ala and carotid sheath, which allows the operation to begin in a region relatively free of postin- flammatory fibrosis. 1. An incision is made along the anterior border of the sternocleido- mastoid muscle, from superior aspect of the thyroid cartilage to the level of the cricoid cartilage (Figure 22–10). 2. The sternocleidomastoid muscle is retracted, exposing the posterior edge of the lateral thyroid cartilage, with the attached inferior con- strictor muscle. 3. If a tract is discovered exiting from the thyrohyoid membrane, rostral to the superior laryngeal nerve, the diagnosis of a third pouch sinus is confirmed and exposure of the piriform fossa is not required. The tract is ligated and dissected retrograde. 4. If a tract or fibrosis is not apparent near the thyrohyoid membrane, a fourth pouch sinus is likely, and the piriform fossa is exposed as described below. • To expose the piriform fossa, a vertical incision is made along the poste- rior edge of the lateral thyroid cartilage and inferior cornu down to and through the perichondrium. The inferior constrictor is separated poste- 510 Surgical Atlas of Pediatric Otolaryngology riorly, hugging the cartilage closely and elevating the perichondrium around the posterior edge and on the medial side sufficiently to detach the inferior constrictor muscle. • A tracheal hook distracts the posterior edge of the thyroid ala anteriorly (Figure 22–11), and the facet-like joint between the inferior cornu and the cricoid cartilage is separated. To avoid recurrent laryngeal nerve injury, the joint is divided as close to the inferior cornu as possible. • The thyroid perichondrium is elevated anteriorly to expose the posteri- or thyroid cartilage. A 1-cm strip of posterior thyroid ala is excised, exposing the underlying piriform sinus. • The fourth pouch sinus tract is ligated from its origin at the piriform apex and any pharyngeal defect is repaired with pursestring closure. Recur- rence is likely if the pharyngeal connection is incompletely ligated. • The sinus tract is then excised retrograde, ending with a surrounding ellipse of skin if a fistula was present. ♦ Part of the superior pole of the thyroid gland may be included if nec- essary (see Figure 22–11), but the superior parathyroid gland should be preserved. ♦ If the tract descends paratracheally, exposure of the recurrent laryn- geal nerve is necessary to prevent injury. When the nerve cannot be identified because of inflammation or scarring, the excision should end at the cricothyroid region to prevent nerve injury. • A Penrose rubber drain is inserted and the incision is closed in layers. Postoperative Care • Perioperative antibiotics are continued for 24 hours. • The drain is removed on the first postoperative day unless drainage is excessive. 512 Surgical Atlas of Pediatric Otolaryngology FIBROMATOSIS COLLI Fibromatosis colli (sternomastoid tumor of infancy) is thought to represent an injury to the sternomastoid muscle, incurred either in utero or during delivery. The deformity is usually noted at birth or within the first 10 days of life, and may be associated with congenital hip dislocation. A firm mass becomes palpable in the muscle and progresses to a maximal size (1-3 cm), generally within 1 month. The head is usually tilted toward the side of the shortened muscle, and the chin rotates toward the opposite (normal) side. Fine needle aspiration aids in diagnosis. If left untreated, the condition may cause developmental asymmetry of the face and ocular imbalance. Conservative management, which consists of range of motion exercises, is generally successful in resolving the prob- lem; however, surgery may be necessary in rare cases. Other evidence of injury should be looked for, such as a fracture of the clavicle or cervical spine injury or abnormality. Indications • A mass within the body of the sternomastoid muscle that does not resolve with aggressive physical therapy, consisting of passive range of motion exercises performed by the parent three to four times daily • Long standing torticollis in older children may benefit from tenotomy or release of the shortened sternomastoid muscle. Evaluation of the underlying cervical spine should be performed to detect any abnormal- ities. Anesthesia and Preparation • General endotracheal anesthesia is necessary. • The patient’s neck is extended, and the head is rotated away from the side of the torticollis to make the mass as prominent as possible. • The neck is prepped from the clavicle to the chin. Procedure • A horizontal incision is created over the mass and carried through the subcutaneous tissue (Figure 22–12). • The greater auricular nerve is preserved if possible. • The mass can generally be separated from normal muscle fiber with preservation of the portion of the sternomastoid muscle that is not involved with the fibrosis. The accessory branch to the sternomastoid muscle should also be preserved. • The incision is closed immediately in the standard fashion. Postoperative Care • Postoperatively, the patient performs range of motion exercises to main- tain the release that has been surgically created. 514 Surgical Atlas of Pediatric Otolaryngology Kennedy TL. Cystic hygroma-lymphangioma: a rare and still unclear entity. Laryngoscope 1989;99 Suppl:1–10. Landing BH, Farber S. Function of the cardiovascular system. In: Atlas of tumor pathology, Wash- ington (DC): Armed Forces Institute of Pathology; 1956. p. May J, D’Angelo AJ Jr. The facial nerve and the branchial cleft surgical challenge. Laryngoscope 1989;99:564–5. Mickel RA, Calcaterra TC. Management of recurrent thyroglossal duct cysts. Arch Otolaryngol Head Neck Surg 1983;109:34–6. Prasad S, Grundfast G, Milmoe G. Management of congenital preauricular pit and sinus tract in children. Laryngoscope 1990;100:320–1. Ricciardelli EJ, Richardson MA. Cervicofacial cystic hygroma: patterns of recurrence and manage- ment of the difficult case. Arch Otolaryngol Head Neck Surg 1991;117:546–53. Riechelmann H, Muehlfay G, Keck T, et al. Total, subtotal, and partial surgical removal of cervico- facial lymphangiomas. Arch Otolaryngol Head Neck Surg 1999;125:643–8. Rosenfeld RM, Biller HF. Fourth branchial pouch sinus: diagnosis and treatment. Otolaryngol Head Neck Surg 1991;105:44–50. Sedwick CE, Walsh JF. Branchial cysts and fistulas: a study of seventy-five cases relative to clinical aspects and treatment. Am J Surg 1952;83:3–8. Simpson RA. Lateral cervical cysts and fistulas. Laryngoscope 1969;79:30–58. Sistrunk WE. The surgical treatment of cysts of the thyroglossal tract. Ann Surg 1920;71:121–4. Tom LW, Handler DS, Wetmore RF, Potsic WP. The sternocleidomastoid tumor of infancy. Int J Pediatr Otorhinolaryngol 1987;13:245–55. Tom LW, Rossiter JL, Sutton LN, et al. Torticollis in children. Otolaryngol Head Neck Surg 1991;105:1–5. Woodman D. A modification of the extralaryngeal approach to arytenoidectomy for bilateral abduc- tor paralysis. Arch Otolaryngol 1946;43:63–5. Work WP. Newer concepts of first branchial cleft defects. Laryngoscope 1972;82:1581–93. CHAPTER 23 SALIVARY GLAND SURGERY Michael J. Cunningham, MD PAROTIDECTOMY During childhood, the parotid glands and paraparotid lymph nodes are subject to infection, inflammation, and neoplasia. Vasoformative and con- genital cystic lesions often are clinically apparent. Conversely, chronic inflammation may present as an indolent firm mass indistinguishable from a benign or malignant neoplasm. Serology, skin tests, and radiologic imag- ing (contrast sialography, ultrasonography, computed tomography, or mag- netic resonance imaging) may suggest, but typically cannot confirm, the specific underlying disease process. Fine-needle aspiration (FNA) biopsy has a limited role in diagnosing solid parotid masses. If the child needs general anesthesia for needle biop- sy, then excisional biopsy will yield greater histopathologic information. More importantly the definitive treatment of many inflammatory and neo- plastic causes of solid parotid masses in children is surgical excision. Exci- sional biopsy, or superficial parotidectomy, is therapeutic and diagnostic in such circumstances. As in adults, neither incisional biopsy nor the isolated enucleation of solitary parotid lesions is recommended. Total parotidecto- my is rarely necessary in children. Indications • Solid parotid mass of unknown or uncertain etiology • Chronic recurrent parotitis • First and second branchial system anomalies • Vasoformative lesions Anesthetic Considerations and Preparation • The procedure is performed under general anesthesia. • Paralytic agents are avoided to allow for intraoperative facial nerve stim- ulation. • Informed consent regarding the risk of facial nerve injury is an absolute necessity. 516 Surgical Atlas of Pediatric Otolaryngology • The child is positioned supine with the head turned toward the unin- volved side. The operative field is draped with sterile transparent plastic sheeting to provide exposure of the entire face on the involved side, including the corners of the eye and mouth (Figure 23–1). This allows for the intraoperative assessment of facial nerve function. Procedure • The planned incision is infiltrated with 1% lidocaine and 1:100,000 epinephrine solution for local hemostasis. ♦ In older children and adolescents, an S-shaped face lift–type incision is used (Figure 23–2 A). This incision begins in the preauricular crease, runs under the lobule, continues up and over the mastoid process, and extends in a curvilinear fashion down into the neck approxi- mately two finger breadths below the angle of the jaw. A Y-shaped incision with a retroauricular extension is an alternative approach (Figure 23–2 B). ♦ In infants and very young children, a single curved incision, beginning 1.5 to 2 cm below the mandible and extending posterior and superi- or over the mastoid prominence, reportedly protects the superficially located facial nerve (Figure 23–2 C). Figure 23–1 The patient is posi- tioned so that facial nerve func- tion can be assessed. 518 Surgical Atlas of Pediatric Otolaryngology • The skin flaps are elevated in a plane of dissection deep to the subcuta- neous tissues and superficial to the investing fascia of the parotid gland. The anterior margin of elevation is the parotid gland’s anterior border to avoid inadvertent transection of small facial nerve branches emerging from the gland over the masseter muscle (Figure 23–3). • Posteroinferior flap dissection is performed in the subplatysmal plane until the anterior border of the sternocleidomastoid muscle is clearly identified. ♦ Care is particularly necessary in infants and young children because limited posterior development of the parotid gland may expose a large portion of the facial nerve (Figure 23–4). ♦ In older children, the tail of the parotid gland often needs to be separat- ed from the sternocleidomastoid muscle. Both the greater auricular nerve and the posterior facial (retromandibular) vein are typically encountered and need to be sacrificed for gland retraction and exposure. • Using both superior traction on the earlobe and anterior traction on the parotid gland, blunt dissection along the tragal cartilage and adjacent mastoid bone allows separation of the small fibrous bands that attach the posterior border of the parotid gland to these structures (Figure 23–5). Figure 23–3 Elevation of the anterior and posteroinferior flaps. 520 Surgical Atlas of Pediatric Otolaryngology ♦ The goal of progressive medial dissection in this fashion is to identi- fy the main trunk of the facial nerve as it emerges from the stylomas- toid foramen. ♦ In older children and adolescents, the location of the facial nerve can be anticipated approximately halfway between the tip of the mastoid process and a triangular extension of the cartilaginous external ear canal, the so-called pointer. 1. Immediately before encountering the facial nerve, the tem- poroparotid fascia often arises from the tympanomastoid fissure as a firm band extending into the parotid gland. 2. Conservative use of the nerve stimulator during this portion of the procedure helps to distinguish fascia from nerve. 3. Hemostasis is crucial for visualization purposes; bipolar cauteriza- tion in a moist field is advocated to decrease the likelihood of cautery-induced neural damage. ♦ In infants and young children, limited mastoid development results in less well-defined bony landmarks for facial nerve identification (Fig- ures 23–6 A and B). In addition, some of the inflammatory condi- tions necessitating parotidectomy in children pathologically involve the external auditory canal, creating scarring in this region and plac- ing the main trunk of the facial nerve in further jeopardy. 1. An alternative method of finding the facial nerve in such circum- stances is to follow the anterior border of the sternocleidomastoid muscle superiorly to its temporal bone insertion and to locate the posterior belly of the digastric muscle just deep to this insertion site. 2. Using blunt dissection and working anteriorly, the facial nerve trunk typically can be found within the triangle formed by these two muscles and the cartilaginous ear canal (Figure 23–7). • In revision surgical procedures with extensive cervical scarring, an alter- native approach is to use the retroauricular extension of a Y-shaped skin incision (see Figure 23–2 B). A limited mastoidectomy is then per- formed to provide access to the facial nerve in the descending portion of the fallopian canal prior to its skull base exit. • Once the main trunk of the facial nerve is clearly identified, it is fol- lowed anteriorly to the pes anserinus. ♦ In adolescents and older children, this requires dissection into the parotid gland. ♦ In infants, the pes may actually be in the retromandibular region out- side of the parotid gland proper (see Figure 23–4). [...]... the site of ranula origin (Figure 23–21) • The anatomic proximity of these glandular structures often dictates the removal of the submandibular gland with ligation of its duct to allow complete removal of the plunging ranula cyst The cervical approach provides greater exposure and protection of the lingual nerve than is possible transorally (Figure 23–22) 534 Surgical Atlas of Pediatric Otolaryngology. ..522 Surgical Atlas of Pediatric Otolaryngology • A plane of cleavage through the parotid gland is developed as proximal to distal dissection of both the upper zygomaticotemporal and lower cervicofacial divisions of the facial nerve is performed (Figure 23–8) ♦ Branches of the posterior facial (retromandibular) vein require ligation during this portion of the procedure, as does... pole vessels further decreases the likelihood of SLN injury Figure 24–12 Ligation and division of the inferior and middle thyroid veins (Adapted from Silver CE Atlas of head and neck surgery New York: Churchill Livingstone; 1986 p 265.) 550 Surgical Atlas of Pediatric Otolaryngology • Following transection of the superior vascular pedicle, the superior pole of the thyroid lobe is reflected inferiorly... Otolaryngol Head Neck Surg 1985;93: 173 –6 Loré JM Jr Excision of ranula In: Loré JM An atlas of head and neck surgery Philadelphia: WB Saunders; 1988 p 628–9 Loré JM Jr The parotid salivary glands In: Loré JM An atlas of head and neck surgery Philadelphia: WB Saunders; 1988 p 70 8–25 Loré JM Jr Resection of the submandibular salivary gland for benign disease In: Loré JM An atlas of head and neck surgery Philadelphia:... and distant extrathyroidal disease, particularly to the lungs Documenting regional or systemic metastases significantly influences initial surgical management, but does not necessarily imply a poor prognosis 540 Surgical Atlas of Pediatric Otolaryngology • Fine-needle aspiration (FNA) biopsy with cytopathologic examination is a valuable tool in the diagnostic work-up of thyroid masses, given the high... mucosal margins and deeper floor -of- mouth structures (Figure 23–26) Care is taken not to injure the lingual nerve or the cannulated submandibular duct, both of which should be identifiable on the surface of the floor -of- mouth musculature (Figure 23– 27) ♦ The sublingual gland ideally is removed in continuity with the ranula cyst • Hemostasis is achieved by bipolar cauterization of numerous small lingual veins... per mL (10 mg) of propofol, and begin the infusion at 75 µg/kg/min of propofol (0.150 µg/kg/min of remifentanil) PROPOFOL The intravenous hypnotic propofol has become a mainstay in the anesthetic approach to laryngeal laser surgery This agent provides complete amnesia, good control of hemodynamic responses, the ability to use O2/air for jet ventilation, and rapid smooth emergence Propofol has antiemetic... high-quality reproduction Since the higher-quality digital camcorders may record up to 60 blurfree frames per second, one may download a frame to a computer and then print a hard copy This may be a less expensive option than use of a digital capture device; however, the disadvantage of this technique is that selection of the “perfect” image can be time consuming 562 Surgical Atlas of Pediatric Otolaryngology. .. Figure 2 3-8 : Dissection along the facial nerve develops a plane of cleavage through the parotid gland (Adapted from Welch KJ, Randolph JC, editors Pediatric surgery Vol I Chicago: Year Book Medical Publishers; 1986 p 500.) 524 Surgical Atlas of Pediatric Otolaryngology ♦ The deep parotid tissue is separated from the underlying facial musculature, temporomandibular joint, and mandible ♦ Ligation of the... be observed on the side of the operation for days or even weeks postoperatively, depending on the extent of nerve mobilization If gentle retraction was performed and no significant branches of the facial nerve have been severed, complete recovery is the rule 526 Surgical Atlas of Pediatric Otolaryngology • Gustatory sweating (Frey’s syndrome) occurs secondary to the regrowth of parasympathetic motor . patient performs range of motion exercises to main- tain the release that has been surgically created. 514 Surgical Atlas of Pediatric Otolaryngology Kennedy TL. Cystic hygroma-lymphangioma: a rare. poste- rior edge of the lateral thyroid cartilage and inferior cornu down to and through the perichondrium. The inferior constrictor is separated poste- 510 Surgical Atlas of Pediatric Otolaryngology riorly,. assessed. 518 Surgical Atlas of Pediatric Otolaryngology • The skin flaps are elevated in a plane of dissection deep to the subcuta- neous tissues and superficial to the investing fascia of the parotid