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14 Head andNeck Surgical Access intheManagement ofHead andNeck Malignancy
reected to the right by the left innominate vein,
left carotid, and subclavian arteries. The trachea
may also be pushed anteriorly in some cases.
Hence, at times an anterior approach, namely
sternotomy, would give access to these tumours,
especially the ones in the posterior mediastinum.
In these circumstances, a lateral or posterolateral
thoracotomy is a much easier approach.
14.6 Mandibulotomy
andMandibulectomy
Mandibulotomy is a mandibular osteotomy which
is normally performed for surgical access to the
oral cavity. This is an important bony approach
for surgical removal of, for example, tongue cancer as it provides ample space and exposure for
Fig. 14.10 Post-operative wound after combined cervicotomy and partial sternotomy
is important to provide adequate airways during
healing post-operatively (Fig. 14.10). A more
advanced access to either thorax can also be
enhanced further by performing a clavicle osteotomy on the respective side.
14.5.2 Other Approaches inThyroid
andSuperior Mediastinal
Tumour
Most intrathoracic goitres lie anterior to the
recurrent laryngeal nerve and anterolateral to the
trachea. Goitres in the anterior mediastinum arise
from the isthmus or the lower part of the thyroid
lobes. As the mass grows, the great vessels may
be displaced laterally. Goitres that grow posteriorly into the mediastinum arise from the posterolateral aspect of the gland and descend posterior
to the great vessels. Most are right sided, and
even the ones originating from the left lobe are
instrumentation and manipulation. Occasionally,
it is also used for access and resection of maxillary carcinoma through the hard palate exposure
and removal of tumours in the parapharyngeal
space. The mandibulotomy may also be combined
with midline glossotomy as an approach for
pathology in the cervical spine region.
There are several types of mandibulotomy that
are commonly performed. These include midline
mandibulotomy, paramedian mandibulotomy,
and lateral mandibulotomy (Fig.14.11). Most of
the time, lip split needs to be performed before
exposing the mandible for osteotomy (Fig.14.12).
The paramedian mandibulotomy uses the cut that
is placed lateral to the genioglossus and digastric
muscle attachment in the midline (Fig. 14.13).
This cut is also medial to the mental foramen.
The midline Z-type incision is better than a
circummental lip split as the muscles, i.e. the
mentalis, the depressor angular oris, and the
depressor labii inferioris, will be somewhat disrupted. The canine is the best tooth to use as a
dental abutment for tissue-borne dental prosthesis. Thus, the mandibulotomy should not compromise this tooth and its root.
355
356
ac
b
bc
Fig. 14.11 A canine can be extracted before a mandibulotomy in selected cases. In majority of cases, this can be
voided (a). Paramedian mandibulotomy (b) and midline mandibulotomy (c)
N. Mat Lazim et al.
a
Fig. 14.12 (a–c) Types of lip split soft-tissue approach for mandibulotomy
Surgical Steps of Mandibulotomy
1. Before performing soft- tissue cut or lip
split, any necessary dental extraction
should be performed rst.
2. Lip split (Fig.14.12) is carried out by starting the incision on the lip mucosa with the
assistant holding the lip with strong pressure on either side to reduce the bleeding,
as the lips are highly vascularized.
3. The skin incision is extended inferiorly
vertically from vermilion border about
1.0cm above the mental crease. Then it is
angled 1.0 cm away from the midline to
unite with the mental crease. The incision
is then descended horizontally for 2.0cm
or so before angled back to the midline.
4. A step at vermilion border allows incision
at the lip, gingivolabial sulcus, and FOM
to be in a paramedian on the side opposite
the paramedian mandibulotomy. This
incision places the incision through
mucosa away from the intended mandibulotomy site.
5. The cut is then deepened using cautery till
muscular layer in midline. Care should be
taken not to injure the mentalis muscle.
14 Head andNeck Surgical Access intheManagement ofHead andNeck Malignancy
surgical access and exposure to remove tumour
with negative surgical margins. The neurovascular structures close to clavicle can be either compressed or pushed to this tight area, and this
makes it difcult to explore and free them from
the tumour. Mobilizing the attachments of pectoralis major and minor with clavicle osteotomy
signicantly opens the space for mobilizing the
brachial plexus and major vessels. This ensures
that a good oncological margin tumour extension
below the clavicle can be achieved. Meticulous
dissection is necessary in order to avoid inadver-
Fig. 14.13 Paramedian mandibulotomy (dotted lines) is
the most commonly performed mandibulotomy as it
spares the mental nerves (mn) and is not within the radiation eld, if the patient requires adjuvant radiation postoperatively. The lower cheek ap must be made rst
before mandibulotomy can be performed
tent injury to these vital structures. This includes
the subclavian artery and vein, brachial plexus,
and deep muscle of the neck such as scalene
muscle.
Extensive tumours that originate from the base
of the neck may also require clavicle osteotomy
for an adequate surgical access. This will allow en
6. The mark for mandibulotomy is done. The
cut is vertical between the medial and lateral incisors. Then the cut is angled to pos-
bloc removal of the tumour. Examples of this
tumour include soft-tissue bromas, bromatoses, sarcomas, neuromas, or haemangiomas.
terior direction, lateral to digastric muscle.
7. The plates are needed for mandibular stabilization. It can be contoured and mapped
14.7.1 Case Illustration
along the inferior border of mandible and
the other 1–2.0cm above this depending on
the mandible height. At least a minimum of
three screws should be used on either side.
8. The plates are removed to allow a bone cut
on the mandible. In a dentate patient, care
should be taken to avoid injury to the cuff
of the bone around the roof if there is any.
9. In edentulous patients, there is no need to
contour the plates prior to mandibulotomy.
The risk of malocclusion is very low.
10. After extirpation of the tumour, the previous contoured plates are reapplied.
11. The closure of intraoral mucosa is
performed meticulously. Any tear or breakdown may cause contamination of mandibulotomy site with leaky saliva.
14.7.1.1 Case 1
This is a case of female patient with papillary
thyroid carcinoma who had modied radical
neck dissection (MRND), and again had recurrent tumour at left level IV, where the inferior
border of the mass was abutting the clavicle.
After reviewing her CT scan, the decision for
clavicle osteotomy was made, as the mass
extended deep to the clavicle. Detailed examination revealed the left level IV nodes measuring
5.0cm×4.0cm, and it was hard in consistency
and xed to the underlying structures. The endoscopy examination of larynx revealed a right vocal
cord bowing with a minimal phonatory gap.
Repeat CT scan in August 2016 showed the presence of left supraclavicular mass that compressed
both the left subclavian vein and internal jugular
vein (Fig.14.14).
14.7 Clavicle Osteotomy
A multidisciplinary meeting consensus is that
the best approach for the tumour clearance was to
Clavicle osteotomy is an effective approach for
addressing the recurrent neck tumour at levels IV
and V.This is vital in order to provide adequate
do a clavicular osteotomy for maximal exposure
in view of the proximity of the tumour to the left
subclavian vein and internal jugular vein. Access
357
358
Fig. 14.14 The recurrent tumour at level IV neck node
region with irregular margin (arrows)
N. Mat Lazim et al.
Fig. 14.16 Two cut ends of clavicle are separated for
access and dissection of the tumour underneath this
Fig. 14.15 An osteotomy on clavicle is performed. Its
two end cuts are widely separated
to the tumour infraclavicular spaces was performed by detaching the pectoralis major and
minor muscle. The platysma muscle was reected
superiorly to expose the entire mass and clavicle.
Subsequently, the subclavian vein and artery
were mobilized inferiorly from the tumour mass.
To get the entire medial and lateral marginal
control of the mass, the clavicle was osteotomized at the middle segment and reected subperiosteally (Figs.14.15, 14.16, and 14.17). The
entire mass was removed in total with a cuff of
normal tissue to achieve wide resection oncological margin (Fig. 14.18) [23]. Post-operatively,
the patient is well with evident titanium plate
on the neck X-ray (Fig. 14.19) and clinically
(Fig.14.20).
Fig. 14.17 The cut ends of clavicle are retracted with a
cold retractor to facilitate the dissection of the tumour
Fig. 14.18 The recurrent tumour is removed in total and
measured before sending for histopathological
examination
14 Head andNeck Surgical Access intheManagement ofHead andNeck Malignancy
359
The use of a clavicle osteotomy as an approach
for a low-lying recurrent neck tumour in the
vicinity of the subclavicular area provides an
optimal access to the surgical site. This approach
is highly suggested for tumours that encroach the
supraclavicular and subclavicular region so that a
complete tumour resection can be carried out. In
addition, the scapular tumour can also be accessed
better via a clavicle osteotomy. This allows a safe
tumour excision with free surgical margins as
well as avoids the inadvertent injury to critical
adjacent neurovascular structures.
Fig. 14.19 Post-resection photo with plate and X-ray.
The osteotomized clavicle is nally stabilized with titanium locking plate to allow rehabilitation of the shoulder
motion
14.8 Base-of-Neck Tumour
Surgical technique that addresses the base of
neck such as a huge scapula tumour is technically
challenging. This is attributed to multiple factors,
namely:
1. The close proximity of critical structures such
as subclavian artery, subclavian vein, and brachial plexus.
2. In case of huge tumour, the surgical access
will be very limited.
3. In a long-standing tumour, the inltration to
brachial plexus poses another treatment
challenge.
Additionally, the attachment of bulky muscles to
scapula and spine such as levator scapulae and erector spinal will add to the difculty in manipulation
and mobilization of the tumour. Anterior extension
of the tumours may compress the major vessels and
nerve in a tight and small compartment, which
translates to difcult exploration of the vessels. In
contrast, superior extension of the tumour between
scalene muscles will cause difculties in mobilization of the root of brachial plexus.
a
Fig. 14.20 Post-operative photo at 3-month follow-up (a) and 1-year follow-up (b)
b
360
ab
N. Mat Lazim et al.
Soft-tissue sarcoma and bromatoses
(Fig.14.21) not uncommon occur around the base
of neck or superior scapula border. The surgery
is tedious due to close proximity with major vital
structures of subclavian artery and brachial plexus.
The surgical eld is also tight due to direct pressure
by the tumour that compresses vital structures, and
manipulation to achieve margin is difcult.
A ne surgical technique is by mobilization of
the entire scapula and upper limb anteriorly
together with neurovascular bundle. Posterior
scapula stabilizer muscles of trapezius, levator
scapulae, rhomboid, and erector spinal are
detached with clavicular osteotomy able to create
a mobile window for resection of the base-ofneck tumour.
Fibromatoses which involve base of neck and
extending inferiorly to the erector spinae, below
the scapula: This tumoural mass pushes the entire
brachial plexus and subclavian vessels anteriorly
to create a tight surgical eld for exploration.
Trapezius muscle which is not involved is
mobilized to the tip of spinous process for future
closure (Fig.14.22). The erector spinae muscle is
elevated and mobilized laterally and included as
margin. Scapula is mobilized laterally by detaching all the medial muscle of rhomboid and levator
scapulae (Fig.14.23).
Fig. 14.21 (a, b) An enhanced tumour mass on the MRI with irregular border and mild heterogeneity. This is consis-
tent with a bromatosis
Fig. 14.22 The trapezius muscle is mobilized to facilitate a later closure
14 Head andNeck Surgical Access intheManagement ofHead andNeck Malignancy
Fig. 14.23 The erector spinae muscle is mobilized laterally and all the medial muscles of rhomboid and levator scapulae are detached
361
Fig. 14.24 The pectoralis major and minor were
detached and released inferiorly. The entire tumour can be
resected with good oncological margin, the dissection can
The pectoralis major and minor were detached
and released inferiorly followed by clavicular
osteotomy (Fig. 14.24). This manoeuvre will
open the anterior base of neck space and make
exploration of plexus and subclavian artery possible (Fig.14.25).
be done directly over the thoracic cage, and the neurovascular structures are protected anteriorly to minimize the
injury
Shoulder stability is maintained by xation of
the clavicle by a plate and repair of the remaining
medial soft tissue to the scapula and upper scapula (Fig.14.26).
Evaluation of subclavian artery and brachial
plexus at each level is important in view of the
362
Fig. 14.25 A clavicular osteotomy is performed. This manoeuvre will open the anterior base of neck space and make
exploration of plexus and subclavian artery possible
N. Mat Lazim et al.
Fig. 14.26 Fixation of the scapula and repair of the soft
tissue Extensive tumour at the base of neck (Fig.14.27)
needs more extensive exploration of brachial plexus prox-
expected morbidities that may arise post-surgery
and it is useful for planning for possibility of primary nerve reconstruction (Figs.14.28 and 14.29).
imally to the root. The posterior muscle of scalene can be
resected and included together for better oncological
margin
The entire posterior muscle is attached to
medial scapulae together with erector spinae
(Figs. 14.28 and 14.29). The posterior base of
14 Head andNeck Surgical Access intheManagement ofHead andNeck Malignancy
Fig. 14.27 An extensive base-of-neck tumour which is enhanced on MRI, with a well-dened capsule
363
Fig. 14.28 An extensive base-of-neck tumour which is enhanced on MRI, with a well-dened capsule
neck including scalenus posterior was removed
after mobilizing the root of brachial plexus
(Fig. 14.30). Subclavian and brachial plexus
were mobilized by mobilizing the lateral shoulder girdle including scapulae by detaching medial
muscle attachment and clavicle osteotomy.
364
Fig. 14.29 Skin incision and ap creation for access to the base-of-neck tumour
N. Mat Lazim et al.
Fig. 14.30 The entire posterior muscle attached to
medial scapulae together with erector spinae. Extensive
tissue loss will create a scapular instability that requires a
local rotational ap with latissimus dorsi ap for softtissue reconstruction