بِسْمِ اللهِ الرَّحْمنِ الرَّحِيم
Surgery of the Tongue(2)Investigations of ca tongue:
Biopsy= either FNAC or. incisional biopsy for Any ulcer ,white or red patch (erythroplakia and speckled leucoplakia) or fissure >4 wks. Enlarged cervical lymph nodes.-Plain radiography of the jaw
-MRI of head and neck for extent of tumor (soft-tissue infiltration ) and lymph nodes.-. A radioisotope bone scan of the facial skeleton shows high uptake in bone if mandible is involved ,
Additional studies
Ultrasound &CT ( limited value) for Cervical LN metastasis CT if bony invasion is suspected
T1 (< 2 cm diameter) tumour = A- Surgery (COMMANDO OPERATION ) by team of ENT, plastic & surgeons. It includes Surgical excision of tumour by partial (hemiglossectomy) using either a diathermy or laser +/- hemi -mandibulectomy +/- temporary tracheostomy & Rx neck LN by .Ipsilateral selective neck dissection to excise suspicious cervical LN containing micro-deposits or B- Radiotherapy .
Definitive treatment of ca tongue
Depends on site, TNM stage & patient's nutritional status . Carcinoma in situ Rx = ---localized small lesions, on the lateral border of tongue Rx by surgical excision + primary closure. --- Larger lesions = laser vaporisation
Radiotherapy Palliative debulking of big primary Combination Chemotherapy
Radiofrequency thermal ablation: A minimally invasive new Rx used in localized, inoperable tumors.Supportive care =Analgesia , nasogastric feeding or tracheostomy
Treating ca tongue cont.
Advanced tumours (T3 and T4 cross midline)= Rx= total glossectomy, floor of the mouth and mandible+ bilateral neck dissection Palliative treatment Indicated for recurrence, metastasis ,fixed LN or unresectable tumours:Prognosis Depends on: 1-Site : posterior 1/3 poor prognosis 2- TNM Stage Size (T)= large tumours more LN metastasis. Cervical node metastasis (N)= is the most significant factor in determining prognosis . 3-Concomitant medical problems as CVS or resp. disease.
NECK SURGERY
LUMPS IN THE NECK TRAUMA TO THE NECK SURGICAL INFECTIONS OF THE NECK.
SURGERY OF THE NECK ANATOMY
Extends from the level of the base of skull to the clavicles STRUCTURES: SKIN, SUPERFICIAL FASCIA, VEINS, NODES DEEP CERVICAL FASCIA MAIN ARTERIES, VEINS, NERVES VISCERA OF THE NECK THE ROOT OF THE NECK Prominent landmarks Hyoid bone Thyroid cartilage (men) Cricoid cartilage (women) Trachea Sternocleidomastoid muscle Triangle Anatomy Anterior Subdivisions: superior carotid, inferior carotid, submandibular, submental Posterior Subdivisions: subclavian, occipital
Size Site Shape Surface Consistency
Fixation:deep/superficial Pulsatility Compressibility Transillumination BruitWork up of Head and Neck mass
1- Careful and complete history includingOnset, time, no. multiplicity, rate of growth, disappearance, cause.Associated symptoms (pain, dysphagia, otalgia, hoarseness ,discharge swollen or sore tongue, blood in the saliva? cachexia, fever, fetor )Personal habits (smoking, alcohol)Prior trauma, irradiation or surgery2-Complete head and neck exam (including ENT exam)Visualize all mucosal surfaces Palpate oral and pharyngeal surfaces, salivary gl.Look for scars& Changes in the skin – Examine lumpExamine neck LN.
Work up of Head and Neck mass cont.
2-Imaging if FNA positive either: US= solid versus cystic (noninvasive) Computed tomography (CT)= Solid versus cystic & for metastasis Magnetic resonance imaging (MRI) for soft tissue mass better than C.T Radionucleotide scanning e.g in nodular goiter PET scan /SPECT (Single Photon Emission Tomography for functional activity of a mass , grading of a tumor & to distinguish between ca & dead or scar tissues 3- Panendoscopy with guided biopsy for staging & search for primary. 4- Open biopsy with frozen sections if primary not found.* .
1--Investigate any swelling for > 2 weeks by Fine needle aspiration cytology (FNAC)
site
Midline Enlarged LN Thyroid nodule (moves on deglution ) Thyroglossal cyst( moves tongue protrusion) Dermoid cyst (moves on tongue protrusion) Goiter (moves on swallowing) Plunging ranula Subhyoid bursa lateral Pulsatile Carotid aneurysm Carotid tumour Non-pulsatile Lymphadenopathy* Branchial cyst Pharyngeal pouchPOSTERIOR TRIANGLE Lymph nodes (common) Cystic hygroma Sternomastoid tumours Parotid swellings Cervical rib Pan coast's tumour Subclavian aneurysm
ANTERIOR TRIANGLE
ddX OF Neck Lumps
Most neck lumps result from congenital or inflammatory processes
BRANCHIAL CYST
Remnant of the 2nd branchial cleft. Lined by squamous epith. & contains thick, turbid fluid with cholesterol crystals Painless unilateral left sided neck usually at junction of the upper 1/3 and middle 1/3 of ant. border of SCM muscle . soft, fluctuant may transilluminate in early or middle adulthood . DDx: if infected; =TB abscess Dx: US and FNAC . Rx surgical excision or incision and drainage if infected, preventing injuries to the CCA, IX,XI &XII nn.Branchial sinus/fistula
Persistent 2nd branchial cleft. lined by ciliated columnar epithelium May be unilateral or bilateral .The external orifice is in the lower 1/3rd of the ant. border of sternocleidomastoid, while the internal orifice is behind the tonsil on tonsillar fossa or at or near to lat. pharyngeal wall There may be a recurrent glairy mucinous or mucopurulent discharge. Rx: Tract courses over 12th nerve between internal and external carotids and requires complete surgical excision.Surgical excision- difficult with poor cosmetic result Injection of sclerosing picibanil (OK-432) to size Incision and drainage when infected
CYSTIC HYGROMA (Cavernous lymphangioma)
lymphatic malformations resulting in multi-cystic mass lined by a single layer of epith. (hamartoma). Present at birth or early childhood & large lesions can be diagnosed prenatally and can result in obstructed labour Painless expanding multilocular masses just below the angle of the mandible (post. triangle) in 60% &rarely in cheek, axilla, groin or mediastinum May be bilateral , soft , fluctuant partially compressible, visibly in size when the child coughs or cries. Contain clear fluid and transilluminate brilliantly Complications 1-rapid expands respiratory difficulty needing aspiration or tracheostomy 2-Infection Rx=THYROGLOSSAL DUCT CYST
The commonest midline neck cystChildren (50% before age 20).The thyroglossal tract arises form foramen caecum at junction of anterior 2/3 and posterior 1/3 of the tongueAny part of tract can persist causing a sinus, fistula or cyst Found anywhere in midline from the tongue base to the thyroid isthmus attached hyoid bone. Rarely, it may contain the only functioning thyroid tissue Painless mass (or tender when infected) in midline in 75% usually in subhyoid area , elevates on tongue protrusion due to attachment to hyoid bone.Cyst May rupture onto the skin of the neck if infected or incised presenting as discharging sinus called acquired thyroglossal fistula (sinus) Rx= If infected aspirate cyst rather than incise it.Surgical excision with central 1/3 of the hyoid bone and any suprahyoid tract extending into the tongue dissected (Sistrunk’s operation).* Neurogenic tumours Carotid Body Tumor chemodectoma (potato tumor )
It is a rare tumor at age of fifth decade & 10% +ve family history. There is an association with phaeochromocytoma Chronic slowly growing painless ,firm, rubbery (potato like), pulsatile compressible mass firmly adherent to bifurcation of the CCA , emptied by pressure, then it slowly refills,+ bruit.. Mobile side to side but not up and down About 1/3 present as a pharyngeal mass that pushes the tonsil medially and anteriorly. Diagnosis confirmed by angiography or MRI. The tumour must not be biopsied or FNAC Treatment Elderly =Observation, operation is best avoided Young =Resection of small tumors but if large, it may be adherent to the vessels and a bypass vein graft indicated
Only in elderly Is posteromedial pulsion diverticulum through Killian's dehiscence between thyropharyngeus &cricopharyngeus mm Dysphagia, halitosis, regurgitation , cough aspiration A neck lump may gurgles on palpation & is left sided Investigation=Ba. swallow & IL Rx =Depends on size and age Diverticulectomy Dohlman's procedure
• Mass in middle 1/3 of SM• Results from muscle damage during labour• Presents as neck lump and torticollois (Wry neck) away from affected side• Treatment = physiotherapy to correct the torticollois• Surgery to the lump is rarely required. Miscellaneous neck lumps