(BQ) Part 2 book NMS surgery presentation of content: Head and neck surgery, bariatric surgery, minimal access surgery, surgical oncology, trauma and burns, organ transplantation, pediatric surgery, plastic and reconstructive surgery, neurosurgery,...
Part VI Special Subjects Chapter Cuts and Caveats CHAP TER 18 He a d a nd Ne c k Surg e ry: T e most common neck lesion is a reactive lymph node All adults with a persistent neck mass have a malignancy until proven otherwise Most head and neck cancers are squamous cell and are treated with surgery, radiation, or chemotherapy Cosmetic and unctional def cits may be requent Congenital lesions are abnormal variants o normal structures T yroglossal duct cysts are midline structures that rise and all with swallowing T ey should be resected i symptomatic, a er making sure there is adequate residual thyroid tissue onsillectomy was once an extremely common operation and is now reserved or those with repeated in ections, as the risk o surgery outweighs the benef ts or most patients CHAP TER 19 Ba ria tric Surg e ry: Obesity a ects more than one third o Americans and an increasing percentage o children and adolescents Obesity creates metabolic comorbidities and decreases li e span BMI is the most use ul marker or obesity; people quali y or bariatric surgery with BMI greater than 40 kg/m or 35 kg/m with medical comorbidities Bariatric procedures are classif ed as primarily restrictive or malabsorptive Roux-en-Y gastric bypass is the most common operation and is a blend o the two Gastric banding and sleeve gastrectomy are restrictive, and the duodenal switch operation is malabsorptive Postoperative bariatric patients are susceptible to a variety o unique complications, including internal hernia, marginal ulceration, and nutritional def ciencies achycardia in a postoperative patient is a surgical complication until proven otherwise T e patient must be assessed or anastomotic leak and DV /PE CHAP TER 20 Minim a l Ac c e s s Surg e ry: Minimally invasive surgery relies on technology to decrease the size o the access incisions; visual cues largely replace tactile ones T e f rst steps in minimally invasive procedures are establishment o pneumoperitoneum and diagnostic laparoscopy Pneumoperitoneum is an artif cial state that has a mechanical (pressure) component that can mimic abdominal compartment syndrome T e use o carbon dioxide gas also creates an acidosis T is does not have a signif cant clinical impact or brie procedures in patients who have minimal physiologic compromise Most general surgical procedures have minimally invasive options, including surgery on the gallbladder, appendix, intestines, and hernias Robotic procedures are especially use ul in anatomically conf ned cases, such as low pelvic surgery or prostatectomy CHAP TER 21 Surg ic a l Onc o lo g y: Oncology is increasingly multidisciplinary Benign and malignant re er to behavior, not outcomes—benign lesions may be atal, and malignant processes may be indolent Oncogenes drive the cell cycle; tumor suppressor genes provide a natural checkpoint Dysregulation o either may lead to cancer Imaging, serum markers, and genomics can all provide diagnosis well in advance o clinical symptoms Screening can reduce mortality in breast, colon, cervical, and prostate cancer T e NM system provides a common language to group and stage tumors CHAP TER 22 Tra um a a nd Burns : Primary survey: ABCs Remember the ABCDE o trauma: airway, breathing, circulation, disability, everything else Hemodynamically unstable patients should not go to the C scanner Intubate all patients with a low GCS or those with massive injury Fatal hemorrhage occurs in f ve major locations: chest, abdomen, retroperitoneum, thigh, and externally Hypovolemia is the most common cause o hypotension in trauma and is treated with uid resuscitation However, tension pneumothorax and cardiac tamponade cause hypotension, are not associated with hypovolemia, and are not treated with uid resuscitation T ey should be considered early during resuscitation FAS exam reliably detects ree uid and can provide an early, sa e means o diagnosing the need or operation Initial resuscitation o burn victims may be massive: use mL/kg/% BSA over the f rst 24 hours Use the rule o 9’s to estimate BSA Hypothermia may cause coagulopathy and resultant bleeding a er trauma Simple pneumothorax usually presents with dyspnea and is not emergent, whereas a tension pneumothorax presents with hypotension and requires emergent decompression CHAP TER 23 Org a n Tra ns p la nta tio n: Calcineurin inhibitors have considerable nephrotoxicity Organ transplantation is considered or irretrievable end-organ dys unction T e main complications o immunosuppression are susceptibility to in ections and the development o malignancy Kidney transplants are the most success ul solid organ transplants Although dialysis is a replacement option, patients live longer with kidney transplants than on dialysis; there ore, all endstage renal patients are considered transplant candidates Although outcomes are superior with living donors, deceased donors and extended criteria donors have produced acceptable results Because no alternative exists to replace a dys unctional liver, transplantation remains the only option or severe liver ailure but is raught with complications due to the extent o disease in most o these patients Most acute rejection occurs in the f rst year a er transplant and may be related to in ection or inadequate immunosuppression T e cornerstones o immunosuppression are corticosteroids, but immune modulators have been developed that a ect all aspects o -cell unction and di erentiation Islet cell transplantation may provide the cure o diabetes without the heavy immunosuppression o whole organ transplant o date, results are promising 297 CHAP TER 24 P e d ia tric Surg e ry: Pediatric surgery represents a separate discipline, since the physiology o children di ers rom that o adults Congenital hernias may be associated with other conditions and require care ul assessment be ore repair In general, umbilical hernias are not repaired, as they may close spontaneously Inguinal hernias are repaired with high ligation o the sac Diaphragmatic hernias are repaired but with caution, as pulmonary dys unction may also be present Many specif c problems can arise within the neonatal GI tract Malrotation and necrotizing enterocolitis may require urgent surgery and may result in long-term problems such as short gut syndrome Failure to pass meconium in the f rst 24 hours suggests a diagnosis o Hirschsprung disease, which is conf rmed on rectal biopsy Projectile vomiting in a 1-month old in ant may represent hypertrophic pyloric stenosis reatment is a surgical pyloromyotomy a er correction o any metabolic derangements Wilms tumor and neuroblastoma are the two most common childhood solid tumors Gastroschisis is an abdominal wall de ect with no sac and has rare associated congenital anomalies Omphalocele has a sac and has a high association with congenital anomalies Esophageal atresia is most commonly a proximal esophageal pouch and distal tracheoesophageal ( E) f stula and is associated with cardiac and VAC ERL anomalies Intestinal malrotation usually presents with bilious vomiting Duodenal atresia shows an abdominal double-bubble sign, is corrected by duodenoduodenostomy and is commonly associated with other congenital anomalies Jejunal and more distal bowel atresia occur rom in-utero vascular accidents and have ew associated congenital anomalies 298 Chapter 18 Head and Neck Surgery Andrea Hebert and Jef rey S Wol COMP ONENTS OF THE HEAD AND NECK EXAM Ge ne l I Bre a thing : Note whether the patient is breathing com ortably and the presence o stridor, stertor, or the use o accessory muscles II Vo ic e : Note the quality o the patient’s voice (e.g., hoarseness or mu ed or breathy qualities) and any dysarthria III Swa llo w: Note i the patient is able to tolerate secretions or i he or she is drooling Quic k Cut Stridor is a highpitched s ound produced by turbulent f ow through a partially obs tructed upper airway Stertor is lower pitched, s noring-type s ound He a d I Ge ne l A rauma: visible ecchymosis, edema, bony abnormalities, or lacerations B Masses/lesions: skin lesions, biopsy sites or surgical scars, edema, f rmness, induration, uctuance, or erythema II Eye s A Examination: Be sure to note extraocular motion and pupillary response and to report nystagmus B ests Visual acuity: i the patient is complaining o any change in vision Visual f eld test: i the patient is complaining o diplopia III Ea rs : Standard o ce assessment o hearing includes the Weber and Rinne tests A Weber test: uning ork is struck and placed on the midline o the patient’s head to determine i the sound lateralizes and identif es unilateral hearing loss B Rinne test: involves placing the vibrating tuning ork on Quic k Cut the mastoid process and comparing the perception to Per orm a Weber that o the sound directly adjacent to the ear; also helps and Rinne exam i the patient discriminate between conductive and sensorineural has any otologic complaints hearing loss C Auricle: Note any de ormity, tenderness to palpation o the tragus or mastoid, or tenderness with tugging o the pinna D External auditory canal: Note any canal stenosis, debris, erythema, or otorrhea E ympanic membrane: Note whether intact, the presence and characteristics o uid behind the tympanic membrane, presence o middle ear masses, and whether the membrane retracts IV No s e : Per orm anterior rhinoscopy on all patients A Septum: Examine or deviations or lesions B Nasal cavity: Note in erior turbinate hypertrophy, nasal masses or polyps, and the presence o rhinorrhea 299 300 Chapter 18 Neck Abscesses V Ora l c a vity/o ro p rynx: Note any masses or lesions and speci y the color, riability, and tenderness Note any ulceration and palpate with a gloved f nger to determine so ness or f rmness A eeth: Note the quality o the dentition and the presence o any tenderness B Assess: Look or any erythema, edema, palatal asymmetry, or tonsillar deviation Note any uvular deviation and trismus VI La rynx: Per orm a laryngeal mirror exam i not per orming f beroptic laryngoscopy VII Ne c k: Palpate or lymphadenopathy or thyroid masses Note surgical scars, crepitus, or decreased range o motion VII Ne uro lo g ic : Per orm a complete cranial nerve (CN) exam BENIGN LESIONS OF THE HEAD AND NECK Ove rvie w I Re a c tive lym p h no d e : most common neck mass and most o en secondary to bacterial or viral in ections II Ma lig na nc y: Most neck masses in children are benign; in adults, neck masses are more likely to be malignant Wo rkup o r Ac q uire d Le s io ns I De ta ile d his to ry: Obtain details about the ollowing A Family history: malignancy and personal history o cancer B Risk actors: smoking; alcohol consumption; exposure to radiation, sawdust, or other potential carcinogens; and exposure to human papillomavirus (HPV) 16 or 18 C Recent illnesses: upper respiratory in ection (URI), sinusitis, or tonsillitis; otitis or conjunctivitis; and dental problems II P hys ic a l e xa m ina tio n: See earlier discussion III La b o to ry te s ts : may include tuberculin test or tuberculosis, heterophil titer (monospot test) or mononucleosis, thyroid unction tests or thyroid scan, serologic tests or syphilis, and viral titers (especially or Epstein-Barr virus, which is associated with nasopharyngeal carcinoma and Burkitt lymphoma) IV Ra d io lo g ic s tud ie s : may include so tissue radiographs o the neck, barium swallow, chest x-ray, or scanning procedures such as computed tomography (C ) and magnetic resonance imaging (MRI) V End o s c o p y: indicated i a primary neoplasm is suspected VI Tre a tm e nt: depends on the f ndings (Fig 18-1) A Antibiotics: i a bacterial in ection is suspected B Consultation: may be help ul Dental consultation: i the teeth seem to be a source Dermatology consultation: i skin lesions are present C Surgical biopsy: may be indicated i a mass does not shrink signif cantly over weeks and a source o in ection is not ound Fine-needle aspiration (FNA): used with suspected malignancy Excisional biopsy: indicated or persistent cervical adenopathy NECK ABSCESSES Typ e s Quic k Cut The mos t common neck mas s is a reactive lymph node Quic k Cut The “rule o 7’s ” provides a guide or etiology o neck mas s es : A mas s that has been pres ent or days is inf ammatory; months , malignant; years , congenital Quic k Cut Scrofula is mycobacterial lymphadenitis in the neck Quic k Cut Endos copic biops y and radiologic s tudies s hould precede any open biops y o the neck Quic k Cut FNA can diagnos e carcinoma but is us ually inadequate to de ne lymphoma Quic k Cut A patient pres enting with ever and an erythematous , pain ul, f uctuant neck mas s mos t probably has an abs ces s I P e rito ns illa r a b s c e s s e s (q uins y): most common abscesses in the parapharyngeal space ( able 18-1) A Cause: arise as a complication o acute tonsillitis B Clinical presentation: Ipsilateral palatal edema, contralateral deviation o the uvula, “hot potato” voice, trismus, and dysphagia T e patient may have only a low-grade ever or be a ebrile Chapter 18 Head and Neck Surgery Ma s s Child Adult Infla mma tory (+) P hys ica l e xa mina tion (−) Antibiotics ; la bora tory te s ts (+) Ra diology; pos s ible biops y Endos copy; biops y of s us pe cte d prima ry tumor P os s ible infla mma tory ma s s (−) (+) Re s olve s Obs e rve (−) (+) Ra diology; pos s ible biops y; e xcis ion (−) Antibiotics ; la bora tory te s ts (+) FNA or biops y (−) Re s olve s Obs e rve FNA or biops y Fig ure 18-1: Bas ic algorithm or treatment o head and neck cancer FNA, ne-needle as piration Ta b le 18-1: Ne c k Ab s c e s s e s Sig ns a nd Sym p to m s Pain Swelling Dysphagia Dyspnea Leukocytosis Fever Air in soft tissue radiograph Tre a tm e nt Airway protection Incision and drainage Antibiotics 301 302 Chapter 18 Congenital Masses II P a p ryng e a l s p a c e a b s c e s s e s : Arise rom the posterior teeth or tonsils and can a ect the carotid sheath structures and multiple CNs T ey can cause mediastinitis and carotid “blowout” (i.e., erosion o the artery wall leading to massive hemorrhage) III Re tro p ryng e a l a b s c e s s e s : arise rom in ected retropharyngeal nodes or extension rom other spaces and can lead to airway obstruction or mediastinitis IV Lud wig a ng ina : abscess that occupies the sublingual space that generally arises rom a dental source Can cause death rom airway obstruction, commonly requires tracheostomy V Be zo ld a b s c e s s e s : arise rom in ection in the mastoid CONGENITAL MASSES Le s io ns o Thyro id Orig in Quic k Cut Neck in ections mus t be drained but s hould only be done by thos e amiliar with neck anatomy owing to the carotid artery, airway, and the cranial nerves Quic k Cut Abs ces s es in the head and neck can caus e airway compromis e, and intubation or tracheos tomy may be neces s ary I Ove rvie w: T yroid gland originates at the oramen cecum and descends centrally to the level o the thyroid and cricoid cartilages ( able 18-2) A T yroglossal duct: May pass in ront o , through, or behind the hyoid bone; it is generally obliterated but may persist Solid tumors o thyroglossal duct origin occur almost exclusively within the tongue and above the hyoid bone B T yroidal primordium: Some may remain at any site in the duct and give rise to cysts, f stulas, accessory thyroid tissue, and neoplasms II Thyro g lo s s a l f s tula s , c ys ts , a nd s inus e s : Occur in the midline; 20% are suprahyoid, 15% occur at the hyoid, and 65% are in rahyoid A Fistulas: almost always the result o in ection with spontaneous or surgical drainage B Cysts: Present by age 10 years in 50% o cases; no sexual predominance exists, but they are most o en ound in caucasians Size: usually measure 2–4 cm in diameter and gradually Quic k Cut increase in size, although the size may uctuate Imaging is important Behavior: rise and all with the larynx during swallowing to ens ure a normal thyroid C Sinus tract: may orm as direct connection to the skin and result gland is pres ent els ewhere in persistent drainage be ore excis ion o a thyroid D reatment: total surgical excision res t III Thyro id re s ts : may be lingual or may occur in the neck A Endotracheal ectopias: may occur B Palpation: o the normal position o the thyroid o en reveals no evidence o thyroid tissue C reatment: dictated by the degree o obstruction and by the presence o other thyroid tissue D T yroid scan: Ensures that unctional thyroid tissue exists in the usual location; 75% o patients have no other unctional thyroid Bra nc hia l Cle t Ano m a lie s I Em b ryo lo g y: In week 4, f ve ridges and grooves appear on the ventrolateral sur ace o the embryonic head that orm the branchial arches and cle s, respectively, and the pharyngeal pouches develop internally at the same level as the external grooves Ta b le 18-2: Co ng e nita l Ne c k Ma s s e s Typ e Lo c a tio n Exa m ina tio n Tre a tm e nt Thyroglossal cysts Midline Firm, nontender Surgical excision Branchial cleft cyst Preauricular anterior Firm, nontender Surgical excision Teratoma Anywhere Firm Surgical excision Hemangioma Anywhere Diffuse Observation; laser treatment Cystic hygroma Posterior triangle Diffuse Partial excision Chapter 18 Head and Neck Surgery 303 II Typ e s A Sinus (incomplete f stula): has either an internal or an external opening B Complete f stula: has both internal and external openings C Cyst: has neither internal nor external openings D Combinations (o any o the preceding types): can occur III Ana tom y: Anomalies are generally located along the anterior border Quic k Cut o the sternocleidomastoid (SCM) muscle or deep to it; they can occur Second brachial anywhere between the external auditory canal and the clavicle cle t anomalies are the mos t A First cle anomalies: always superior to the hyoid bone common and pres ent with an Fistula: i present, courses superiorly and end near the external opening two thirds external auditory canal o the way down the anterior border o the SCM mus cle Cyst and tract: may lie in the parotid gland, with a variable relationship to the acial nerve B Second cle anomalies: most common type External opening: approximately two thirds down the SCM muscle anteriorly i present Fistula: i present, ascends with the carotid sheath and ends at the tonsillar ossa C T ird cle anomalies: rare External opening: occurs in the same position as in a second cle f stula ract: ascends along the carotid sheath and opens in the piri orm sinus D Fourth cle anomalies: have never been seen in their entirety IV Cha c te ris tic s : generally smooth, round, nontender masses A Size increase: common during URI B In ected cyst: may abscess or rupture spontaneously to orm a sinus C Symptoms: determined by size and location o the anomaly Large cysts: may cause dysphagia, stridor, and dyspnea Small cysts: o en undiscovered until adulthood because o their slow rate o growth and minor symptoms Quic k Cut Cons ider a neck mas s to be a branchial cle t anomaly i it is located laterally, increas es in s ize with URIs , and has been pres ent s ince birth V Tre a tm e nt: Complete excision without damage to the surrounding vital structures is the def nitive treatment A iming: Excision is delayed until antibiotic treatment is completed B Incision and drainage: avoided, i possible, because it makes subsequent excision more di cult Te to m a s I De f nitio n a nd typ e s : growths that consist o multiple tissues oreign to the part o the body in which they arise A Epidermoid cysts: most common type; lined by squamous epithelium and have no adnexa B Dermoid cysts: epithelium-lined cavities containing skin appendages (e.g., hair, glandular tissue, and ollicles) C eratoid cysts (rare in the head and neck): lined with simple stratif ed squamous or respiratory epithelium and contain cheesy keratinous material Quic k Cut Epidermoid cys ts ectoderm; dermoid cys ts ectoderm and mes oderm; teratoid cys ts ectoderm, mes oderm, and endoderm II Ce rvic a l te to m a s : most commonly present at birth A Characteristics: usually 5–12 cm, semicystic, and unilateral B Symptoms: In ants usually have stridor, apnea, or cyanosis because o tracheal compression, and dysphagia may also be present Some in ants are asymptomatic at birth but become symptomatic within weeks or months C Associated anomalies: increased incidence o maternal hydramnios but no increase in associated in ant anomalies D reatment: Early excision in in ants is mandatory III Ma lig na nt te to m a s (o the ne c k): rare; occur exclusively in adults with a very poor prognosis IV Na s a l d e rm o id s : commonly apparent shortly a er birth A Location: Nasal dorsum is the most common site, but they may occur in the tip o the nose or the columella (the external end o the nasal septum) 304 Chapter 18 Congenital Masses Ta b le 18-3: Co ng e nita l Na s a l Ma s s e s As s o c ia te d Co ng e nita l Ano m a lie s Ca n Be Mid line As s o c ia te d with In e c tio ns o Skin De rm o id No Yes Yes Yes Yes No Glio m a No Yes No Yes No No Enc e p lo c e le Yes Yes No Yes No Yes Me ning itis Ris k Sinus Tra c t Co m p re s s ib le B Characteristics ( able 18-3): male predominance o 2:1; must be di erentiated rom encephaloceles and gliomas C reatment: Early removal is important; recurrences secondary to incomplete removal are common Va s c ula r Tum o rs I He m a ng io m a s : Most common tumors o the head and neck in children Girls are more o en a ected, and lesions are usually solitary A Capillary hemangiomas: Include nevus ammeus (port-wine stain) and strawberry nevus and are characteristically ound in the dermis T ey have an early period o evolution, a er which they o en regress T ey may develop suddenly and grow quite large B Cavernous hemangiomas: More permanent; spontaneous regression is more likely or hemangiomas present at birth than in those appearing later C Arteriovenous hemangiomas: occur almost exclusively in adults and have a predilection or the lips and perioral skin D Invasive hemangiomas: occur in the deep subcutaneous tissues, deep ascial layers, and muscles Presentation: Present as neck masses, predominantly in children; masseter and trapezius are the muscles most commonly involved Intramuscular hemangiomas most commonly present in young adults as palpable, mobile, noncompressible masses Characteristics: end to recur a er excision but not metastasize; they are generally without thrills, pulsations, or bruits; and pain secondary to compression o other structures is usually present E Subglottic hemangiomas: Usually capillary in type Owing to Quic k Cut their location, they o en present at birth with stridor and usually When evaluating with cutaneous involvement a newborn with s tridor, F reatment conducting a thorough s kin Congenital cutaneous hemangiomas: Many lesions regress exam is important spontaneously, but several treatment options exist or those that not a Medical: Glucocorticosteroids, inter eron al a, vincristine, and imiquimod have been used or treatment Propranolol has been shown to induce involution o in antile hemangiomas b Excision: Laser excision is pre erred in areas with cosmetic or unctional concern (pulsed dye laser is used) Surgical excision can also be per ormed Subglottic lesions: may require tracheotomy, steroids, propranolol, and, in some cases, laser excision Extensive lesions: Surgery may be needed Radiation therapy: Used to suppress tumor growth in areas that are inaccessible surgically; however, the use o radiation alone is controversial and is known to increase risk o thyroid, breast, and skin cancers II Cys tic hyg ro m a s : ound predominantly in the neck and are usually noted at birth A Location: T ey are more common in the posterior triangle and may extend up into the cheek or parotid region and down into the mediastinum or axilla Large masses: extend past the SCM muscle into the anterior compartment and may cross the midline Floor o the mouth and base o the tongue: may be involved Chapter 18 Head and Neck Surgery 305 B Signs and symptoms: di culty nursing, acial or neck distortion, respiratory distress, brachial plexus compression with pain or hyperesthesia, and a sudden increase in size secondary to spontaneous hemorrhage, which can be atal C Characteristics: Can be progressive, static, or regressive and generally transilluminate; no gender predilection exists, or right or le side Small lesions: unilocular and f rm Large tumors: loculated, shi able, and compressible Quic k Cut Cyst walls: Usually tense, and because the loculi tend to The greater the communicate, rupture o one locule can cause all o them lymphangiomatous component to partially collapse o a hygroma, the more likely it D reatment: Surgery is the mainstay o treatment, but recurrences is to recur are common because resection is o en incomplete III Ora l a nd p e rio l lym p ng io m a s : Relatively common lesions usually ound at birth or soon a er T ey behave very much like cystic hygromas ACQUIRED LESIONS To ns illa r a nd Ad e no id a l Hyp e rtro p hy I Ob s truc tive hyp e rtro p hy: Patients benef ting rom tonsillectomy with adenoidectomy are those with airway obstruction, sleep apnea, dysphagia, or ailure to thrive II Ad e no id e c to m y: per ormed in children with chronic nasal obstruction, especially when they also demonstrate chronic serous otitis media or orthodontic problems Le uko p la , Erythro p la , a nd Ke to s is I De f nitio n: Leukoplakia presents as white lesions that occur on the mucosa o the mouth, pharynx, or larynx Erythroplakia is a similar red patch II Etio lo g y: T ese lesions are associated with repeated trauma Quic k Cut (e.g., rom poorly f tting dentures and decayed teeth), smoking, or Leukoplakia and use o alcohol erythroplakia are cons idered III Tra ns o rm a tio n: Leukoplakia is precancerous, with a precancerous les ions ; biops y trans ormation rate ranging rom 11% to 36% Erythroplakia has and clos e obs ervation are recommended a higher trans ormation rate Little correlation exists between the clinical appearance and their histology IV Dia g no s is : Biopsy, to rule out squamous cell carcinoma, should be per ormed in high-risk patients (smokers and drinkers) and i the lesion persists a er the removal o an irritative ocus V Tre a tm e nt: Benign leukoplakic lesions require no treatment but require continued observation P a p illo m a s I Sq ua m o us p a p illo m a s o the o l c a vity: usually occur as one lesion but may be multiple and are common on the palate and aucial arches A Characteristics: usually pedunculated and cauli owerlike in appearance B Recurrence: rare a er excision II Na s a l (s c hne id e ria n) p a p illo m a s A Benign lesions o the sinonasal tract: rom the schneiderian mucosa and classif ed into three types: ungi orm, oncocytic, and inverted B Inverted papillomas: ypically arise rom the lateral nasal wall Quic k Cut and can invade the sinuses and orbits Grossly, the lesions appear Inverted papillomas bulky and deep red to gray in color and vary in consistency; are unilateral, aris e rom the unlike allergic polyps, they are unilateral lateral nas al wall, and can Characteristics: Patients generally present with nasal trans orm into s quamous cell obstruction, a postnasal drip, and headaches T ese lesions carcinoma occur mainly in men age 50–70 years Malignant trans ormation: Incidence is 10% reatment: Complete excision that includes the lateral nasal wall and ethmoid sinus Recurrence is common; there ore, li elong ollow-up is usually recommended ... Underweight 18.5 Low Normal 18.5 24 .9 Average Overweight 25 .0 29 .9 Mild Class I obesity 30.0–34.9 Moderate Class II obesity 35.0–39.9 Severe Class III obesity 40 Very severe 325 326 Chapter 19 Surgical... immunosuppression o whole organ transplant o date, results are promising 29 7 CHAP TER 24 P e d ia tric Surg e ry: Pediatric surgery represents a separate discipline, since the physiology o children... le s io ns : should be treated with combined surgery and radiation A Surgery: involves an en bloc resection and neck dissection B echnique: Either a partial mandibulectomy is included or the tumor