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Miscellaneous Head andNeck
Surgery andtheSurgical Steps
18
NorhazaMat Lazim
18.1 Excision oftheBrachial Cyst
Brachial cyst is a common ENT presentation in
young and middle-aged patients. Typically, a patient
presents with a lateral neck mass, which slowly
increases in size. It rarely causes symptoms, but
infection and enlarging mass can cause some discomfort, pain and cosmesis concern especially in
female patients’ group. Clinical examination shows
the mass that is located anterior to the anterior border
of sternocleidomastoid muscle and occupies levels II
and III of the neck regions. It is mostly soft and uctuant in nature, and the transillumination test is positive. In some cases where it has been a long-standing
presentation, the mass may feel rm on palpation.
The main treatment of a branchial cyst is surgical excision. In selected cases of a longstanding branchial cyst, especially in elderly
patients, suspicion of coexisting malignancy
should be considered. A study suggests that in
patients older than 35years, a cystic lateral neck
mass should be considered potentially malignant
[1]. The author reported that of the total 135
patients preoperatively diagnosed with lateral
neck mass, a malignant post-operative histopathological diagnosis was revealed in 15% of cases.
Thus, the clinician should be alert that the branchial cyst is a great mimicker of malignancy.
Initial diagnosis of a cervical branchial cleft
cyst on the basis of the clinical examination
should always be conrmed by means of ultrasonography. The ultrasonography gives detailed
assessment of the mass in relation to major vessels of the neck, i.e. carotid artery and internal
jugular vein. This information can also be used to
guide the dissection during the surgery. In a huge
cyst with a long-standing history, a CT scan of the
neck would be ideal to assess the detailed nature
of the mass, the border and the relationship to
critical neurovascular structures of the neck.
In case of suspicion of a coexisting infection,
or in cases of highly cystic lesion, ne needle
aspiration cytology (FNAC) under ultrasound
control is recommended [2]. Generally, a FNAC
is recommended in all cystic neck lumps to rule
out malignancy [3]. Complete excision of the
branchial cyst under general anaesthesia is the
treatment of choice for symptomatic cases [4].
The surgery of a branchial cyst may cause complications to structures like last four cranial
nerves, IJV and carotid artery as the cyst is commonly located at levels II and III of the neck.
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
© 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_18
18.1.1 Case Illustration 1
This is a 35-year-old Malay male presented
with a history of left neck mass for 3-year dura-
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a
N. Mat Lazim
b
Fig. 18.1 The neck mass measures 10.0cm × 6.0cm and is positive for transillumination: (a) anterior view and (b)
lateral view
18.1.2 Surgical Steps
Step 1: Patient positioning
Patient lies supine with neck hyperextended and
turned contralaterally. The area is cleaned
with diluted chlorhexidine or povidone. The
draping is done with sterile towel.
Step 2: Skin incision and landmark marking
A pen marker is used to draw the landmarks. This
includes mandible, border of mass, sternoclei-
domastoid muscle and clavicle (Fig.18.2).
Step 3: Skin ap
A subplatysmal skin ap is raised using a blade
Fig. 18.2 The border of the mass is drawn in dotted lines.
The angle of mandible and clavicle are also outlined
size 11. An assistant assists in retracting the
ap and skin laterally together with SCM.A
retractor is used to retract the SCM and lateral
tion. The mass slowly increases in size and
causes him discomfort and mild difculty in
swallowing. There was no other signicant
symptom. Clinical examination revealed a
10.0cm×6.0cm in size, soft to rm in consistency (Fig.18.1), and the transillumination test
is positive. The imaging showed a heterogenous
mass, well encapsulated medial to the sternocleidomastoid muscle. The mass has displaced
the carotid sheath medially.
The FNAC conrmed that it was a branchial
cyst. He was planned for excision of the branchial cyst under general anaesthesia.
tissue (Fig.18.3).
Step 4: Mass dissection
The dissection continues at around the border of
the mass. The mass is meticulously dissected
while lifting the mass (Fig.18.3).
Step 5: Deep dissection
The dissection continues to the deep and medial
aspect of the mass. The sternomastoid muscle
is retracted laterally (Figs.18.4 and 18.5). The
carotid artery, IJV and vagus nerve are identied and retracted away from the mass to avoid
inadvertent injury like transection or puncture
on these structures.
18 Miscellaneous Head andNeck Surgery andtheSurgical Steps
439
Step 6: Carotid sheath isolation
The carotid artery wall is a thicker wall in con-
trast to the IJV wall, which can be easily punc-
tured and results in bleeding. The IJV also has
many small branches that can be easily tran-
sected during the dissection. Thus, a meticu-
lous dissection is necessary when delineating
the tissue and fascia layers on the IJV
(Figs.18.6 and 18.7).
The mass is retracted superiorly during the dis-
section so as to facilitate the tissue medial and
deep to the cyst (Fig.18.5). The capsule of the
cyst is thick, and the Allis forceps can be
applied to hold the tissue capsule nicely.
Step 7: Vagus nerve
Vagus nerve resides in between the IJV and carotid
artery. Together they are enveloped by a thin
carotid sheath. These structures are deep and
medial to the branchial cyst and need to be
identied and preserved during dissection
(Figs.18.6 and 18.7).
Fig. 18.5 The mass with its capsule is dissected and
retracted superiorly
Fig. 18.3 The skin ap is raised, and sternocleidomastoid muscle is visible. The skin ap is retracted superiorly
and laterally
Fig. 18.4 The sternomastoid muscle is retracted laterally
exposing the mass capsule
Fig. 18.6 The mass is out, leaving the surgical bed with
the IJV and carotid artery in situ
Fig. 18.7 The vagus nerve is located in between the IJV
and carotid artery. The nerve functionality is tested with a
nerve stimulator probe
440
ce
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N. Mat Lazim
Step 8: Homeostasis
Once the mass is removed, the surgical bed is
inspected for any active bleeding. If any bleeder
is identied, either ligaclip or bipolar cautery is
used to stop the bleeding. The wound mass is
irrigated with warm saline to reinspect for
residual bleeding, before the wound closure.
Step 9: Drain and skin closure
A size 10 Redivac drain is secured. The drain is
anchored to the skin with a 2.0 silk non-
absorbable suture. The wound is closed in two
layers with a 3.0 silk absorbable suture. The
skin is sutured subcuticularly with a 3.0 white
Vicryl or Prolene.
Another case of left branchial cyst (Fig.18.8) is
presented who had surgical excision. The
scar is inline with the neck skin crease
(Fig. 18.9). This improves the aesthetic
post-operatively.
a
Fig. 18.8 The left branchial cyst in a young Malay male: (a) lateral view and (b) anterior view
Fig. 18.9 Post-surgical excision of left branchial cyst: (c) at 1-week follow-up and (d, e) at 3-month follow-up
b
18 Miscellaneous Head andNeck Surgery andtheSurgical Steps
18.2 Case Illustration 2
18.2.1 Voice Prosthesis Insertion
During Total
LaryngectomyCase
Total laryngectomy results in loss of voice, dysphagia and impairment of olfaction. Vocal rehabilitation plays an important role in the
management of laryngectomized patients.
Generally, voice prosthesis can be placed in the
patient during the initial total laryngectomy surgery or as a second surgery. This primary TEP
versus secondary TEP has its own merits and
demerits. At a centre where the prosthesis is
available, the primary TEP is preferable as it
gives immediate post-operative vocalization.
This is highly desired by the patients. The primary
TEP and voice prosthesis insertion are preferable
as it can give immediate and reliable voice, and
there is no need for second general anaesthesia
which will add more risks and complications.
This is a case of a 53-year-old Malay gentleman
with diagnosed carcinoma larynx and T3 staging
and who underwent total laryngectomy with bilateral anterolateral neck dissection. Intraoperatively,
after removal of larynx and neck dissection, voice
prosthesis is inserted. This is primary puncture of
the prosthesis. For secondary puncture, the prosthesis is inserted at a later date of surgery.
The prosthesis is prepared on the sterile table
near the patient and checked for its functioning.
The accessories are a loading tube, an inserter,
pharyngeal protector, guide wire with trocar and
the prosthesis itself (Fig.18.10).
The pharyngeal protector is placed at the cut
end of pharynx (Figs. 18.11, 18.12, 18.13 and
18.14) to guide the wire insertion from the tra-
chea side. The tube in the stoma is secured, and
preoxygenation is done to allow manipulation.
Trocar will be placed 1.0cm below the mucocutaneous junction at the tracheal mucosa. The wire
is placed into the trocar and pushed through so
that it will come off through the pharyngeal protector on proximal side.
The closure of neopharynx is performed in
three layers (Fig. 18.15). The rst layer is the
mucosal approximation via a Connell stitch
suturing (Fig.18.16). Secondly, the submucosal
Fig. 18.10 Provox voice prosthesis set with a pharyngeal
protector, a guide wire and a trocar
Fig. 18.11 Pharyngeal protector is placed at the pharyngeal site before the creation of neopharynx. The intubation tube is stabilized
Fig. 18.12 Pharyngeal protector is placed at the pharyngeal site before the creation of neopharynx. The intubation tube is stabilized
layer closure is performed. Lastly, the tissue and
muscles are approximated (Fig.18.17).
Post-operatively, the patient is allowed to use
the prosthesis as early as day 1. This is to
441
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N. Mat Lazim
Fig. 18.13 Pharyngeal protector is placed at the proximal part of the open pharyngeal area
Fig. 18.14 Pharyngeal protector is inserted at the proximal end where the pharynx is open to safe guide the insertion of the trocar and prosthesis
Fig. 18.15 The pharyngeal closure is performed by
using three-layer closure. This is done after the prosthesis
has been stabilized. The mucosa, submucosa and subcutaneous tissue are sutured by Connell stitching technique
encourage an early correct technique and better
vocalization. Once the wound has dried and
healed, the patient can use the prosthesis over
the 24-h period.
Fig. 18.16 Pharyngeal closure for neopharynx creation
by performing a continuous Connell suturing technique
Fig. 18.17 Formation of neopharynx; the last layer of
muscle is sutured to secure the neopharynx
18.3 Stomatoplasty
Stomal stenosis is a dreadful complication of
total laryngectomy. It compromises the
patient’s breathing as well as complicates the
cleaning of voice prosthesis. Risk factors of
stoma stenosis include persistent infection post
TL, patient who had previous chemoradiation,
higher stage tumour or patient with multiple
comorbidities such as diabetes. Medical treatment such as use of dilator or stenting can be
used at night-time to avoid voicing interruption
during daytime. If treatment fails at 4–6weeks,
the surgical revision, i.e. stomatoplasty, can be
performed.
There are a few techniques of stomatoplasty
that can be practised by the treating clinician.
These include anterior advancement ap, V-Y
ap, etc. Here, we describe a technique using
anterior V-Y advancement ap.
18 Miscellaneous Head andNeck Surgery andtheSurgical Steps
443
Fig. 18.18 The monopolar is used to undermine the tissue underneath the skin ap. The tracheal end and skin
have been refreshened
Step 1: Patient lies supine with smaller intubation
tube used for GA.This will allow ample surgical access for dissection and manipulation.
Step 2: The edges of trachea and skin are refresh-
ened using a blade size 11, a monopolar cautery or a small tissue scissors. We prefer to use
a monopolar cautery (Fig.18.18).
Step 3: The trachea wall is undermined, and tis-
sue is dissected away from the wall, exposing
two tracheal rings. If the voice prosthesis is in
situ, the posterior skin and trachea wall at posterior part overlying the prosthesis is leaving
intact. This is to facilitate the tracheal cut.
Step 4: The V incision on the anterior skin is done
with a blade. The ap is elevated anteroinferiorly (Fig.18.19).
The cautery is used to dissect the tissue. The
Colorado tip is preferable as it allows ne dissection and easy control and handling. The subcutaneous tissue dissection is performed under the
‘V’ skin incision and elevated.
The trachea edge is refreshened. The tracheal
cut is made inferiorly at 6 o’clock. The trachea
will splay open. The skin apex is retracted superiorly and attached and sutured to the apices of
splayed tracheal wall. By doing this, the tracheal
wall diameter is widened.
The suturing of the new stoma edge is carried
out using a Dalon 3.0 by interrupted sutures
(Fig.18.20). During suturing, the assistant needs
to adjust the intubation tube to provide space for
suturing. A meticulous suturing is performed to
Fig. 18.19 The V cut has been made on the inferior skin
part, and the edge of the stoma has been refreshened
Fig. 18.20 The new stoma and V skin ap have been
sutured. The prosthesis is visualized in situ
Fig. 18.21 The new stoma at 4weeks post-operatively
with Provox prosthesis in situ
avoid excessive tractions and tissue damage that
can cause signicant scarring.
Post-operatively, the patient is able to use his
Provox prosthesis better as the stoma has widened (Fig.18.21).
444
18.4 Submandibulectomy
withAbdominal Fat Graft
This is the case of a 35-year-old Malay lady with
a history of right submandibular swelling for
3years. She is also a newly diagnosed diabetic
patient. Clinical examination revealed a rm
mass at the right submandibular area measuring
6.0 cm × 4.0 cm (Fig. 18.22). It is mobile and
ballottable. The FNAC reported as benign salivary gland tumours. The ultrasound showed a
homogenous mass with well-dened capsule.
Patient was planned for a submandibulectomy
with dermal fat graft as the mass is huge. This can
cause signicant cosmesis embarrassment postoperatively as retromandibular depression can be
disguring, especially in a young female patient.
Intraoperatively, a regular transcervical skin
incision is made with a scalpel along the skin
crease two nger breadths below the inferior border of mandible (Fig.18.23). The subplatysmal
skin ap is raised (Figs. 18.24 and 18.25). The
dissection continues and exposes the submandibular mass and its capsule. The marginal mandibular nerve should be identied and preserved
(Fig.18.26).
The dissection continues around the glands
(Figs.18.27 and 18.28). The facial artery and
vein are ligated, anterior and posterior to the
mass. The LigaSure, an ultrasonic appliance, is
used to dissect the tissue inferiorly below the
N. Mat Lazim
Fig. 18.23 The skin incision is made with a blade size 11
Fig. 18.24 The skin ap is raised while observing for
platysma muscle
Fig. 18.22 The border of submandibular mass is marked
as a dotted line. The skin incision is at the epicentre of the
mass. The incision is at two nger breadths below the
angle of mandibular. This is to avoid marginal mandibular
nerve paresis
Fig. 18.25 The platysma muscle is very thin and is visualized beneath the subcutaneous and fatty tissue
submandibular mass (Fig.18.29). The lingual
nerve and hypoglossal nerve need to be identied and preserved before the submandibular
mass is excised (Figs. 18.30 and 18.31). The
18 Miscellaneous Head andNeck Surgery andtheSurgical Steps
445
Fig. 18.26 The platysma ap has been raised superiorly
and inferiorly, exposing the submandibular mass
Fig. 18.27 The capsule of submandibular mass is intact
Fig. 18.29 The ultrasonic scissors or LigaSure is used to
cut the surrounding tissue during dissection. The LigaSure
is also used to cauterize the vessels. This shortens the
duration of surgery in contrast if suture ligation is used
Fig. 18.30 The submandibular mass is retracted inferiorly exposing the tendon of digastric muscle
Fig. 18.28 Subsequent dissection facilitates mass
removal by exposing the medial, lateral and inferior borders of the mass
Fig. 18.31 The lingual nerve is identied. It forms a V
shape as the submandibular gland and its duct are retracted
inferiorly
446
N. Mat Lazim
Fig. 18.32 The pedicle of submandibular mass together
with a submandibular duct is transected with the LigaSure
Fig. 18.33 The submandibular mass is out. It measures
2.5cm × 3.0cm
Fig. 18.34 The abdominal skin incision is marked. The
size is 1.0cm bigger than the mass considering the dermal
fat graft atrophies with time
LigaSure is used to cauterize and cut the tissue
pedicle (Fig. 18.32). Once the mass is out
(Fig.18.33), the haemostasis is secured, and a
wet gauze is placed on the surgical bed. Then,
the abdominal fat graft is harvested using a
monopolar (Fig.18.34). The size is measured
accordingly. Once the dermal fat graft is ready,
it is placed in the submandibular surgical
defect and the two- layer sutures are applied to
secure the graft. Post- operatively, the wound
appeared as mild oedematous as it is in early
healing period (Fig.18.35). Patient had infection of the wound that requires regular dressing. The wound completely healed at 5months
post-surgery.
Fig. 18.35 Post-op wound at days 1 and 3 showed oedematous wound