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Acknowledgment
This book, “Head and Neck Surgery: Surgical Landmarks and Dissection
Guide,” is a great addition to the current head and neck surgery literature collection for academia and scientic community. It is a highly useful reference
book, especially for the young trainees and junior surgeons practicing in the
head and neck surgery arena.
Preparation of this book has been a great experience for me myself. This
has been accomplished with tremendous effort and contribution from various
teams, including the editors, all esteemed authors (both local and international), and Springer Nature editorial team. My sincere appreciation goes to
the two eminent editors of this book, Associate Professor Zul Izhar Mohd
Ismail and Professor Baharudin Abdullah, who have reviewed the chapters
and gures for the book.
I would also like to express my deepest gratitude and acknowledgment
especially to the main illustrator for the chapters, Mr. Muhamad Nor Firdaus
Ab Rahman, from the Anatomy Department, School of Medical Science,
USM Health Campus, Kelantan, who has worked continuously and tirelessly
in preparing the images and redrawn the gures used for this book. Without
his strong commitment, completion of this book would not have been
possible.
Last but not least, thanks go to the staffs and postgraduate students of
ORLHNS, who have assisted in many ways during routine clinical activities
at numerous venues, especially the head and neck surgery subspecialty clinic
and the operation theatre. Thank you very much for your kind assistance.
Associate Professor Dr. Norhaza Mat Lazim
Department of Otorhinolaryngology—Head and Neck Surgery,
School of Medical Sciences, Universiti Sains Malaysia,
Health Campus, Kubang Kerian, Kelantan, Malaysia
xv
Contents
1 Introduction to Head and Neck Surgery . . . . . . . . . . . . . . . . . . . . 1
Norhaza Mat Lazim
2 Principle of Head and Neck Surgery and the
Importance of Anatomical Characteristics . . . . . . . . . . . . . . . . . . 25
Norhaza Mat Lazim
3 Significance of Anatomical Versus Surgical
Landmarks in Head and Neck Surgery . . . . . . . . . . . . . . . . . . . . 59
Norhaza Mat Lazim, Zul Izhar Mohd Ismail, Muhamad Nor
Firdaus Ab Rahman, and Baharudin Abdullah
4 Radiological Assessment and Its Roles in Head and
Neck Surgical Oncology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
Luca Bertana, Marco Maria Maceroni, Silvia Karem Janet
Flores Quispe, Giacomo Contro, Samuele Frasconi,
Matteo Todisco, and Giacomo Spinato
5 Approach Towards Oral Cavity Cancers . . . . . . . . . . . . . . . . . . . 119
Devendra Arvind Chaukar, Arjun Gurmeet Singh,
Adhara Chakraborty, and Gurukeerthi Balakrishna
6 Oropharyngeal and Hypopharyngeal
Tumours and Their Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
Jeyasakthy Saniasiaya and Norhaza Mat Lazim
7 Surgical Management of Nasopharyngeal Carcinoma . . . . . . . . 169
Irfan Mohammad, Azliana Aziz, Norzaliana Zawawi,
Avatar Parhar Singh Mohan Singh, Purushotman Ramasamy,
Vigneswaran Kumarasamy, and Tang Ing Ping
8 Salivary Glands Tumours and Its Surgery . . . . . . . . . . . . . . . . . . 191
Norhaza Mat Lazim
9 Thyroid Gland Tumour and Surgical
Approach with Case Illustration . . . . . . . . . . . . . . . . . . . . . . . . . . 223
Norhaza Mat Lazim, Zul Izhar Mohd Ismail,
Muhamad Nor Firdaus Ab Rahman, and Baharudin Abdullah
xvii
xviii
10 Endoscopic Nasal and Paranasal Sinus Surgery . . . . . . . . . . . . . 249
Ramiza Ramza Ramli, Sakinah Mohamad,
and Norasnieda Md Shukri
11 Surgical Approaches to the Maxilla, Maxillary Sinus,
Pterygopalatine Fossa, and Infratemporal Fossa
for Malignant Tumors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 275
Giacomo Spinato, Cristoforo Fabbris, Leonardo Franz,
Gloria Schiavo, Andrea Fior, Riccardo Nocini,
Vittorio Favero, and Paolo Boscolo Rizzo
12 Laryngeal Disease and Tumours and Its Related Surgery . . . . . 295
Carmelo Saraniti and Barbara Verro
13 Neck Dissections in Head and Neck Malignancy . . . . . . . . . . . . . 323
Norhaza Mat Lazim
14 Head and Neck Surgical Access in the Management
of Head and Neck Malignancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 347
Norhaza Mat Lazim, Ahmad Zuhdi Mamat,
and Wan Faisham Nu’man Wan Ismail
15 Orbital Exenteration in Head and Neck Malignancy . . . . . . . . . 367
Norhaza Mat Lazim, Giacomo Spinato,
Roman Carlos Zamora, and Paolo Boscolo Rizzo
Contents
16 Temporal Bone Diseases and Tumours and
Its Related Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 377
Gabriela Ramírez Arroyo, Carolina Tella Vega,
Daniella A. Monroy Llaguno, and Juan Carlos Cisneros
Lesser
17 Paediatric Head and Neck Pathology and Surgery . . . . . . . . . . . 407
Jeyasakthy Saniasiaya and Norhaza Mat Lazim
18 Miscellaneous Head and Neck Surgery and the
Surgical Steps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 437
Norhaza Mat Lazim
19 Updates and Controversies in the Management
of Head and Neck Malignancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 455
Belayat Hossain Siddiquee
About the Editors
Norhaza Mat Lazim is a Consultant at the
Department of Otorhinolaryngology—Head and
Neck Surgery, School of Medical Sciences,
Universiti Sains Malaysia, Health Campus,
Kubang Kerian, Kelantan, Malaysia. She
obtained her MBBS from the University of
Queensland, Australia, in 1999 and completed
her Master of Medicine in Otorhinolaryngology—
Head and Neck Surgery at the Universiti Sains
Malaysia, USM, in 2012. Subsequently, she
obtained her Clinical Fellowship in Head and
Neck Surgical Oncology from Antoni van
Leeuwenhoek- Netherlands Cancer Institute
(NKIAVL), Amsterdam, Netherlands, in 2014
and from the VUMC, Free University Hospital,
Amsterdam, in 2015. In addition, she had her
clinical training at the Sydney Head and Neck
Cancer Institute, Chris O’Brien Lifehouse,
Australia, in 2019. Her main interest is in head
and neck surgical oncology, and she has received
several national and international grants on head
and neck diseases and tumors. She has published
multiple papers in peer-reviewed journals and
several book chapters and books. Additionally,
she is a reviewer for multiple international journals and also serves as an editorial board member
to numerous international journals. She is a
member of the American Head and Neck Society
(AHNS), the European Head and Neck Society
(EHNS), the Asian Society of Head and Neck
Oncology (ASHNO), the American Thyroid
Association (ATA), the British Association of
Head and Neck Oncologists (BAHNO), the
International Academy of Oral Oncology
(IAOO), and the Australian Institute of Medical
and Clinical Scientists (AIMS).
xix
xx
About the Editors
ZulIzharMohd Ismail is a Senior Lecturer in
the Department of Anatomy, School of Medical
Sciences, Universiti Sains Malaysia, Health
Campus, Kubang Kerian, Kelantan, Malaysia. He
received his MBBS degree from the University of
Queensland, Brisbane, Australia, in 1999. He
later obtained his Master of Philosophy (MPhil)
degree in the eld of Biomedical Science from
the same university in 2005. He has been a lecturer of anatomy in USM since the year 2005,
teaching anatomy to both undergraduate and
postgraduate medical students. He had held several academic and administrative positions during the tenure of his service in USM. He is a
member of the Malaysian Medical Association
and lifetime member of the Malaysian Anatomical
Society. He has written numerous publications in
both local and international journals and presented his research ndings in scientic conferences. As an anatomist, he has a particular interest
in histomorphometry, neurotoxicology, radiological anatomy, clinical anatomy, and anatomy
education.
Baharudin Abdullah is a Senior Consultant in
the Department of Otorhinolaryngology-Head and
Neck Surgery, School of Medical Sciences,
Universiti Sains Malaysia, Health Campus,
Kubang Kerian, Kelantan, Malaysia. He graduated
with MBBS of Medicine and Surgery from
Universiti Malaya (1994) and Master of Medicine
(MMED) in Otorhinolaryngology—Head and
Neck Surgery from Universiti Sains Malaysia
(2002). He was an Honorary Visiting Scholar at
Chinese University of Hong Kong, Asian Surgical
Association Clinical Fellow at the University of
Hong Kong, and Fellow in Rhinology and
Endoscopic Sinus Surgery at the University of
Graz, Austria. He is on the editorial board of reputable medical journals. He has published widely in
allergy, rhinology, and head and neck surgery in
several international and national journals and presented many scientic studies and papers, both at
the national and international levels. He has contributed signicantly to the successes of symposiums and workshops in Universiti Sains Malaysia
(USM) and other symposiums, congresses, and
workshops, both at national and international levels. He is the Past President of the Malaysian
Society of Allergy and Immunology (MSAI).
Introduction toHead andNeck
Surgery
1
NorhazaMat Lazim
1.1 Introduction
Head and neck surgery is crucial as it involves a
complex head and neck region, which harbours
multiple delicate anatomic structures. Many of
the human vital functions such as breathing,
speech, mastication, swallowing, hearing, and
vision are carried out by the structures and organs
that are located in the head and neck region
(Fig. 1.1). Importantly, numerous major neurovascular structures, namely the cranial nerves,
jugular vein, and carotid artery, are residing in
this critical region in which any injury to these
structures may lead to serious complications. For
instance, cranial nerve palsy like facial nerve
palsy will lead to facial asymmetry that can cause
social embarrassment and is associated with
drooling and incomplete closure of the eye that
affect a patient’s aesthetics. Jugular vein and
carotid artery (Fig.1.2) injury will lead to inevitable blood loss and risk of hypovolaemic shock.
Hypoglossal nerve palsy will interfere with swallowing, speech, and so forth. All of these complications are avoidable if the practicing surgeons
and the managing team have a sound anatomic
knowledge of the head and neck regions, ade-
N. Mat Lazim (*)
Department of Otorhinolaryngology-Head and Neck
Surgery, School of Medical Sciences, Universiti Sains
Malaysia, Health Campus, Kubang Kerian,
Kelantan, Malaysia
e-mail: norhaza@usm.my
quate clinical skills and practice, and a good
teamwork during management of clinical cases.
To illustrate further, nasal cavity and paranasal sinuses (PNS) (Fig.1.1) are critical anatomic
regions in the facial and head region. They are
responsible for multiple functions, for instance
humidication of the inspired air, immune protection, mucociliary clearance, and facilitation of
smell. An excellent knowledge of delicate vascular supply and innervation at the nasal cavity and
PNS area will dictate safe surgical and endoscopic procedures necessary to treat related diseases and tumours in this region. Maxillary sinus
is commonly affected by carcinoma, which
sometimes necessitates maxillectomy. Different
types of maxillectomy entail different segments
of maxilla resection and lead to signicant surgical and post-surgical sequelae. This again highlights the necessity of in-depth knowledge of
anatomy of each subsite region of the head and
neck region.
At the end of the other spectrum, oral cavity
carcinoma such as tongue carcinoma has a different surgical management approach. The tongue
has a rich lymphatic drainage to the neck nodes.
This lymph node drainage area is also greatly different for a different part of the tongue. Tip of
tongue drains to submental nodes, lateral tongue
drains to ipsilateral jugular nodes, and base of
tongue drains to both ipsilateral and contralateral
deep cervical nodes. Thus, hemiglossectomy for
tongue carcinoma (T1 and T2 lesion) should
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022
N. Mat Lazim et al. (eds.), Head and Neck Surgery : Surgical Landmark and Dissection Guide,
https://doi.org/10.1007/978-981-19-3854-2_1
1
2
Middle turbinate
(pharyngeal tonsils)
Thyroid gland
External jugular vein
N. Mat Lazim
Frontal sinus
Inferior turbinate
Nose
Nares
Hard palate
Tongue
Lingual tonsils
Epiglottis
Hyoid bone
Thyroid cartilage
Glottis
Vocal cord
Larynx (”voice box”)
Superior turbinate
Sphenoid sinus
Opening of
eustachian tube
Fig. 1.1 Neck anatomy comprises vital soft-tissue structures and cartilaginous structures
Nasopharynx
Adenoids
Softpalate
Palatine tonsil
(faucial tonsil)
Oropharynx
Laryngopharynx
Esophagus
Sternal notch
Fig. 1.2 Structures like sternocleidomastoid, jugular vein, hyoid bone, and cricoid cartilage are important landmarks
at the neck
Sternocleidomastoid
muscle
Hyoid
Cricoid
e
1 Introduction toHead andNeck Surgery
3
Hyoid
External jugular vein
Sternocleidomastoid muscl
Cricoid
Thyroid gland
Sternal notch
Fig. 1.3 The relationship of soft-tissue structures such as external jugular vein (EJV) to sternocleidomastoid muscle
(SCM), or carotid sheath deep to SCM, is vital for deciding the surgical approach to the neck
always be accompanied by ipsilateral neck dissection of level I, II, III, and sometimes IV.If the
tumour reaches the midline or the tumour originates from the tongue base, bilateral neck dissection should be performed. In neck dissection,
relation of sternocleidomastoid muscle (Fig.1.3)
to vascular and adjacent structures is critical to be
considered to facilitate a safe surgery.
ORL, OMF, dental, and plastic reconstructive
and oncologists, are required to have an optimal
understanding of this critical head and neck
region. This is crucial for the clinicians to accurately communicate ndings and generate meaningful differential diagnoses, so that a better
treatment plan can be incorporated.
The head and facial complex region is further
subdivided into anterior or superior face, midfacial, and inferior facial regions. This complex
1.2 Head andNeck Anatomy
structure of the midface presents a greater challenge to the clinician evaluating the outcomes of
Head and neck anatomy is a critical region as it
encompasses highly vascularized areas with the
involvement of multiple organs and structures
required for vital human functioning. Such structures include oral cavity, nasal cavity and paranasal sinuses, pharynx, larynx and trachea, thyroid
glands, salivary glands, cranial nerves, and eyes
and orbits. The practicing surgeons, especially
the junior trainees in the related eld such as
facial aesthetic. Numerous factors need to be
considered when addressing the surgical
approach for the head and neck region. The diversity and changes in the soft tissue of the midface
region will alter the surgical techniques. The
variable thickness of soft tissue and presence of
multiple structures, such as the orbit, nose, and
upper lip, each with variable anatomy, need to be
considered when planning the surgical steps. The
4
Supraorbital foramen
Inferior nasal concha
Frontal bone
Nasal bone
Nasal septum
Infraorbital foramen
Maxilla
Mandible
N. Mat Lazim
Optic canal
Lacrimal bone
Zygomatic bone
Middle nasal concha
Fig. 1.4 The bony structures like maxilla, mandible, and temporal bones house many critical organs and tissues
effect of the musculature of facial structures may
alter its dynamics and function [1].
The skull and the facial bones have their own
critical features in humans (Fig. 1.4). Among
these, the pillars of the maxilla, enlarged jaw, and
robust orbits are the protective buttress of the
face [2]. The paranasal sinuses are signicant as
they contain air that gives some weight support as
the head houses muscular structures, which are
heavy. Within the head and its structural regions,
multiple vessels and nerves are vital as they supply these structures. Most of the surgical procedure involves or interrupts with the vascular
supply; thus, surgeons need to be fully familiar
with these vessels, its distribution, and their relation to the adjacent organ. In addition, dentofacial deformities, as well as malocclusion and
consequent functional decit, can cause disharmony of the facial form. Major and complex surgeries like total maxillectomy will cause
Mental foramen
signicant impairment to the facial appearance.
The treatment goals vary depending on the stage
of the tumour and the wishes of each patient. In
addition to achieving better oncological outcomes, the surgery should also aim to improve
facial aesthetics. This can be achieved with multiple soft-tissue constructions. This is the cosmesis goal that clinicians need to consider when
performing any surgery in the head and neck
region [1].
The neck and its deeper structures are equally
important in the head and neck surgical oncology arena. This begins with surface anatomy
inspection for apparent surgical scar (Fig.1.5).
This will give clue to the possibility of difcult
dissection due to the presence of scarring and
brotic tissue. In order to perform neck dissection, the detailed knowledge of the deeper tissue
planes, vasculatures, nerves, and lymphatic
drainage is a prerequisite. Otherwise, the risk of
1 Introduction toHead andNeck Surgery
5
a
Fig. 1.5 Surface anatomy of head and neck structures
and presence of surgical scars are important assessments
during the outpatient clinic review: (a) The outline of
SCM, lower border mandible, level Ia, Ib, II, III, IV, thy-
bleeding, cranial nerve neuropathies, and chylous leaks can be very severe and life-threatening. Sternomastoid muscle is useful as a ap in
selected head and neck malignancy surgery.
This includes parotidectomy, temporal bone
tumour dissection, and neck dissection. The
segmental arterial supply of the sternomastoid
makes it suitable for superiorly or inferiorly
based ap. The spinal accessory nerves enter the
sternomastoid at its superior third part and
should be identied and preserved during harvesting the muscle for the rotational ap or during neck dissection. This illustrates how detailed
anatomy of a structure is critical in ensuring a
safe and effective surgery.
Importantly, the carotid sheath and last four
cranial nerves are located deep in the neck. These
structures will be encountered in the majority of
head and neck cancer surgeries such as submandibulectomy, selective neck dissection, excision
of vagal schwannomas, and thyroid surgery.
Injury to these structures will result in signicant
morbidity to the patients. Occasionally, the internal jugular vein has many small branches that
need to be identied during the dissection and
clipped or ligated to avoid unnecessary bleeding
during neck dissection. The carotid artery
branches are sometimes used for donor vessels
for ap reconstruction and should be properly
identied and dissected.
b
roid cartilage, cricoid cartilage sternal notch should be
identied during inspection and palpation (b) A surgical
scar, post modied Blair skin incision for parotidectomy
(arrow)
1.3 Role ofImaging
Complementing
theAnatomical Details
Necessary foraSurgical
Mapping
In order to know the detailed anatomy and extent
of the tumour, imaging has signicant roles in
delineating the extent of tumoural and pathology
details in relation to adjacent structures’ involvement. Even a simple neck X-ray (Fig. 1.6) can
provide many critical information about the disease and for surgical mapping. The other conventional imaging modalities are ultrasound, CT
scan, MRI, and PET scan. Other newly developed imaging tools have been used in select institutes and centres around the world, in order to
enhance the disease and tumour detection and
staging for a better management plan. This
ensures an optimal treatment outcome for the
majority of patients (Fig.1.7).
Ultrasound is the mainstay of imaging
modality in thyroid and salivary gland tumour,
especially in small- to moderate-size tumours.
In large and extensive tumours, CT scan is
required in order to assess the extent of tumour
and adjacent tumour involvement. For instance,
in the suspected case of a submandibular malignancy, assessment of neck nodes and mandible
involvement is important (Figs. 1.8 and 1.9).