Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4451_Библиотеки_им_академика_М_И_Перельмана
.pdf
Cutaneous Malignancies of Head and Neck
https://t.me/medicina_free
39
Fig. 26 The Mustarde ap is rotated onto the defect, and
the incision can be extended inferiorly, if the ap does not
reach the defect without tension
Fig. 25 The Mustarde ap was raised by staying in the
supra-SMAS plane. The incision was planned along
Pitanguy’s line which is 0.5cm inferior to the tragus to a
point 1.5cm superior and lateral to the eyebrow to preserve the temporal and frontal branch of facial nerve [4]
Fig. 27 Closure done
40
https://t.me/medicina_free
P. S. Dange et al.
Fig. 29 Extensive ulceroproliferative growth on the nasal
dorsum
Fig. 28 A 6-month postoperative follow-up with no
residual nerve weakness
9 Excision ofNasal Basal Cell
Carcinoma withForehead
Flap Reconstruction
9.1 Case 5
A 63-year-old male patient presented with a
7-month history of gradually progressive growth
on the nasal dorsum. CECT was suggestive of
epithelial lesion with involvement of the lateral
nasal cartilage. Preoperative biopsy was suggestive of BCC, and the nal HPE report was also
suggestive of BCC.
9.2 Operative Technique
The surgical steps are depicted in Figs.29, 30,
31, 32, 33, 34 and 35.
Fig. 30 Adequate margin all around the tumour
Fig. 31 Meticulous dissection was performed, and the
muscle was taken as the base
Cutaneous Malignancies of Head and Neck
https://t.me/medicina_free
41
Fig. 32 The specimen must be oriented for accurate histopathological examination
Fig. 33 Post-resection defect with exposure of the left
nasal cavity
Fig. 35 The donor defect was closed with full-thickness
skin grafting. The nasopharyngeal airway was placed to
prevent collapse and adhesion between the septum and
reconstructed left nasal ala. Flap division was performed
at 3weeks
10 Excision ofTemporal Region
Tumour withRadial Free
Forearm Flap
10.1 Case 6
A 69-year-old male presented with a 4-month
history of gradually progressive growth on the
skin over the right temporal region (Fig. 36).
CEMRI was suggestive of epithelial lesion without bony involvement; no lymph nodes were
found in the bilateral parotid glands and bilateral
neck. A preoperative biopsy was suggestive of
WDSCC, and the patient underwent circumferential three-dimensional resection preserving the
zygomatic nerve to preserve eye closure. A free
radial artery forearm ap was done to close the
defect (Fig. 37). Following surgery, the patient
received adjuvant RT as per the standard
protocol.
Fig. 34 Full-thickness forehead ap was raised to close
the primary surgical defect
10.2 Operative Technique
A postoperative 9-month follow-up shows a good
ap uptake (Fig.38).
42
https://t.me/medicina_free
P. S. Dange et al.
Fig. 36 A 3×4cm ulcerative lesion in the right temporal
region. The lesion was just lateral to the lateral canthus
Fig. 37 A circumferential three-dimensional resection
was done by preserving the zygomatic nerve to preserve
eye closure. A free radial artery forearm ap was done to
close the defect. The radial artery and its vena comitantes
were anastomosed with the facial vessels
Cutaneous Malignancies of Head and Neck
https://t.me/medicina_free
43
References
1. Raasch B, Maclennan R, Wronski I, Robertson
I.Body site specic incidence of basal and squamous
cell carcinoma in an exposed population, Townsville,
Australia. Mutat Res. 1998;422(1):101–6.
2. Ciążyńska M, Kamińska-Winciorek G, Lange D,
Lewandowski B, Reich A, Sławińska M, et al. The
incidence and clinical analysis of non-melanoma skin
cancer. Sci Rep. 2021;11(1):4337.
3. Janjua OS, Qureshi SM. Basal cell carcinoma of the
head and neck region: an analysis of 171 cases. J Skin
Cancer. 2012;2012:943472.
4. Pitanguy I, Ramos AS.The frontal branch of the facial
nerve: the importance of its variations in face lifting.
Plast Reconstr Surg. 1966;38(4):352–6.
Fig. 38 A 9-month postoperative follow-up photograph
showing good ap uptake and preserved eye closure
Salivary Glands
https://t.me/medicina_free
NitinMNagarkar, KarthikNRao,
andPrajwalSDange
1 Parotid Gland Lesions
The most morphologically and clinically varied
solid epithelial tumours are salivary gland neoplasms. The current World Health Organization
(WHO) classication lists 25 various forms of
salivary gland tumours (Table 1). Salivary gland
neoplasms exhibit a diversity that is arguably
unmatched by any other organ in comparison, notwithstanding their rarity. Less than 4% of all head
and neck neoplasms are salivary gland neoplasms,
making them rare. The parotid gland is where
most salivary gland neoplasms are found, and in
adults, 80% of these are benign. Recent years have
seen a clearer denition of the cytologic characteristics of salivary gland neoplasms on ne-needle
aspiration, making documenting and diagnosis
easier. More and more often, salivary gland
tumours are found to have genomic abnormalities,
such as translocations and gene fusions.
Based on histopathologic traits and the extent of
the tumour at presentation, salivary gland tumours
are widely divided into benign and malignant categories. Grossly, benign tumours have well-dened
N. M. Nagarkar (*)
SRM Medical College Hospital and Research Centre,
SRMIST, Kattankulathur, Potheri, Tamil Nadu, India
K. N. Rao · P. S. Dange
All India Institute of Medical Sciences,
Raipur, Chhattisgarh, India
Table 1 Overview of the World Health Organization
classication of benign salivary gland tumours (2017)
Benign tumours Pleomorphic adenoma
Myoepithelioma
Basal cell adenoma
Warthin tumour
Oncocytoma
Lymphadenoma
Cystadenoma
Sialadenoma papilliferum
Ductal papillomas
Sebaceous adenoma
Canalicular adenoma and other
ductal adenomas
Other epithelial
lesions
Soft tissue
lesions
Borderline
tumour
Sclerosing polycystic adenosis
Nodular oncocytic hyperplasia
Lymphoepithelial lesions
Intercalated duct hyperplasia
Hemangioma
Lipoma/sialolipoma
Nodular fasciitis
Sialoblastoma
borders, are thinly encapsulated and range in consistency from soft to somewhat rm. According to
histology, these neoplasms typically have a consistent composition of myoepithelial and/or epithelial
cells in a variety of forms. Malignant tumours, on
the other hand, typically exhibit hard, less mobile,
poorly dened and inltrative characteristics.
Tumours exhibit a variety of neoplastic cellular and
structural characteristics histologically.
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023
N. M. Nagarkar et al. (eds.), Atlas of Head Neck and Skull-base Surgery,
https://doi.org/10.1007/978-981-99-6132-0_4
45
46
https://t.me/medicina_free
N. M. Nagarkar et al.
1.1 Preoperative Evaluation
1.1.1 Ultrasonography
• Ultrasonography has the advantage of being
inexpensive, non-invasive and simple to
perform.
• It can be used to differentiate solid from cystic
masses in the salivary glands.
• Ultrasound (US) guidance may also enhance
the accuracy of FNAC in nonpalpable tumours
and in masses with a heterogeneous architec-
ture [1].
• A colour Doppler sonography has been used
to evaluate the vascular anatomy of the sali-
vary glands.
• It can distinguish between physiologic
changes that occur during salivary stimulation
in normal subjects and ow alterations that
occur in diseased glands.
• Currently, the role of ultrasonography is lim-
ited and is generally used to determine the
presence of hypo- or anechoic collection from
a solid mass.
• It can also determine the presence of enlarged
intraparotid nodes.
• The sensitivity of US is reported to range from
62% to 84%, the specicity from 88% to 96%
and the accuracy from 57% to 96% [2].
1.1.2 Fine-Needle Aspirations
• Initial assessment of salivary tumours com-
monly entails a ne-needle aspiration cytol-
ogy evaluation.
• The primary purpose of this procedure is to
exclude metastasis, lymphoreticular disorders,
infectious processes and reactive lesions and
to ascertain the primary salivary nature of
mass.
• FNAC, however, is limited in delineating
benign and malignant nature of basaloid and
oncocytic and myoepithelial and of carcinoma
ex pleomorphic adenoma.
• The procedure is also valuable as a followup tool for harvesting cells for ancillary
testing.
• The overall sensitivity ranges from 85.5% to
99%, and the overall specicity ranges from
96.3% to 100% [3].
• Seeding along the needle track after FNAC or
core needle biopsy of a lump in the head and
neck is rarely reported, and an accurate estimate of its incidence is difcult to ascertain.
Crude estimates suggest 0.00012% and
0.0011% after FNAC and core needle biopsy,
respectively [4].
• The Milan System for Reporting Salivary
Gland Cytopathology is shown in Table2.
1.1.3 Core Biopsy
• Occasionally, core biopsy is performed for
salivary tumour diagnosis; however, this procedure should be limited to non-resectable,
recurrent and metastatic tumours.
• Open biopsy is rarely indicated but can be
considered in (1) skin-invading tumours where
an incisional biopsy is in the area where the
skin will have to be resected anyway in an
eventual subsequent extended parotidectomy
and in (2) advanced tumours that, at presentation, are already beyond surgical cure, so the
Table 2 The Milan system for reporting salivary gland cytopathology [5]
Category Diagnosis Risk of malignancy Management
1 Nondiagnostic 25% Clinical and radiologic correlation or
2 Non-neoplastic 10% Clinical follow-up and radiologic
3 Atypia of undetermined
signicance (AUS)
4 Neoplasm Surgery or clinical follow-up
4a Benign <5%
4b Salivary gland neoplasm of
uncertain malignant potential
(SUMP)
5 Suspicious for malignancy 60% Surgery
6 Malignant 90% Surgery
repeat ne-needle aspiration (FNA)
correlation
10%–35% Repeat FNA or surgery
35%
Salivary Glands
https://t.me/medicina_free
47
biopsy may be the only tissue sample obtained.
(3) Increasingly, molecular biological studies
can be carried out, also on the incisional
biopsy material, especially when lymphoma is
suspected.
1.1.4 Magnetic Resonance Imaging
• Magnetic resonance imaging (MRI) is the
modality of choice for staging salivary gland
tumours due to its optimal soft tissue
contrast.
• High-resolution turbo-spin-echo T1-weighted
(T1W) and T2-weighted (T2W) sequences, in
addition to post-contrast images with fat saturation (FS), are the essentials for the assessment of salivary gland neoplasms [6].
• T1W sequences provide excellent information
regarding tumour margins, tumour deep extension and pattern of inltration. In addition,
post-contrast T1W images with fast spin (FS)
technique are useful to best address bone invasion, meningeal inltration or perineural
spread [7].
• T1W fat-saturated sequences of the bone marrow, the cortex and the skull base will have
suppressed signal compared to the hyperintense, enhancing tumoural lowing for the
detection of bony and meningeal invasion as
well as tumour spread along the facial and trigeminal nerves (up the stylomastoid foramen,
the foramen ovale and the foramen
rotundum).
• T2W images have been reported to be helpful
in predicting whether a salivary gland neoplasm is benign or malignant.
• A mass with low-to-intermediate signal intensity on T2W images is associated with malignancy, while hyperintense masses on T2W
images might be considered benign. An exception is represented by malignant tumour that
shows cystic/necrotic changes, which may be
a confounding factor with benign ones.
• Flow void in the retromandibular vein is taken
as a surrogate radiological marker to identify
the plane of the facial nerve.
• MRI sensitivity and the specicity in predicting malignancy were reported to be 70% and
73%, respectively, and MRI sensitivity for
perineural spread has been reported to be up to
95% [6].
• A tumour characterized by high cellular density shows high signal on DWI sequence. The
signal on DWI sequence can be quantitatively
expressed by means of apparent diffusion
coefcient (ADC).
• An overlap in terms of ADC values has
been reported between a large part of low-/
high- grade malignant neoplasm and benign
lesion [8].
1.1.5 Computed Tomography
• Computed tomography (CT) is the preferred
modality in patients with MR contraindication
(claustrophobia, cardiac pacemakers, metallic
devices) or when further information about
bone structures is required.
• A satisfactory CT examination should always
provide images with thin slices (up to 1mm)
and multiplanar reconstruction with bone and
soft tissue algorithms.
• It is well known that soft tissue contrast of CT
images is lower compared to MRI.
• Perineural spread could be suspected only in
the case of skull base foramina asymmetry,
due to cortical erosion consequent to neural
thickening.
• The use of iodinated contrast medium is mandatory to increase soft tissue resolution and
depict pathology with better accuracy.
• CT scans are more widely available and easier
to perform, compared to MRI, due to shorter
time of acquisition.
1.1.6 Positron Emission Tomography
• An increase of uorodeoxyglucose (FDG)
uptake, expressed by standardized uptake
value (SUV), is associated with cell vitality
and proliferative activity.
• Positron emission tomography (PET)-CT is
not a useful imaging method for distinguishing between benign and malignant tumours.
• FDG PET-CT might be useful in the detection
of cervical lymph nodes and distant metastases in patients with high-grade tumours.
48
https://t.me/medicina_free
N. M. Nagarkar et al.
• The use of hybrid PET/MRI images might
offer a higher sensitivity and specicity to
assess the presence of malignancy on initial
staging [9].
1.2 Principles ofTreatment
• Management of tumours of the salivary glands
requires a detailed understanding of the anatomy and pathologic processes that affect these
glands.
• Benign salivary gland tumours should be
excised completely with an adequate margin
to avoid local recurrences.
• Generally, tumours in the parotid gland are
removed with an adequate cuff of the
surrounding normal tissue, and the facial
nerve is dissected and carefully preserved.
• The malignant nature is frequently unclear
before surgery but is suggested in many other
instances by clinical signs, rapid growth,
enlarged neck lymph nodes (29%), deep xation or skin invasion (9%), pain (44%) and CN
VII dysfunction (19%), a nding independent
of the tumour diameter [10].
• The extent of surgery of the primary tumour is
determined by the size of the lesion, the relationship to the facial nerve and eventual extraparotid tissue invasion.
• Initially, Tweedie and Jacob had proposed a
classication system for parotidectomies that
included total parotidectomy with or without
facial nerve dissection, complete supercial
parotidectomy, partial supercial parotidectomy (involving the upper, middle or lower
segment), selective deep lobe parotidectomy
and extracapsular dissection [11].
• The different types of parotidectomies that are
classically described all have identication of
the facial nerve—and preservation if possible—as a common principle:
– Partial supercial parotidectomy implies
resection of the tumour with a cuff of the
normal tissue where possible.
– Supercial or lateral parotidectomy implies
removal of all tissue lateral to the facial
nerve.
– Total parotidectomy implies removal of all
tissue lateral and medial to the facial nerve.
– Radical parotidectomy implies all tissue,
including the nerve.
– Extended parotidectomy implies a radical
parotidectomy with adjacent invaded structures such as the skin, bone of the mastoid
or mandible, temporomandibular joint,
masticatory muscles and infratemporal
fossa.
• The ESGS classication for partial parotidectomies includes the following: supercial
superior (I), supercial inferior (II), deep inferior (III), deep superior (IV) and accessory
(V) [12].
• The parotidectomy performed is described by
an enumeration of the levels resected in combination with additional non-parotid structures that are sacriced. These are represented
by capital letters placed in between brackets
after the resected levels (CN VII, facial nerve
trunk and/or all the main branches; CN VII
t-z-b-m-c, when only facial nerve branches
have been resected; ECA, external carotid
artery; GAN, greater auricular nerve; LTB,
lateral temporal resection; MB, mastoid bone;
MM, masseter muscle; S, skin).
• Katz and Catalano described the common
variations in facial nerve anatomy within the
parotid gland. Approximately 24% of patients
had a straight branching pattern (type I), 14%
of patients had a loop involving the zygomatic
division (type II), 44% of patients had a loop
involving the buccal division (type III), 14%
of patients had a complex pattern with multiple interconnections (type IV) and 3% of
patients had two main trunks, one major and
one minor (type V) [13].
1.3 Supercial Parotidectomy
1.3.1 Case 1
A 34-year-old female presented with a 3-year history of left parotid gland swelling. On examination- 2x3 cm rm and partially mobile swelling in
the left parotid gland. FNAC—Milan IVa—
Pleomorphic adenoma.
Salivary Glands
https://t.me/medicina_free
49
1.3.2 Operative Technique
• Under GA. Without long-acting paralytic
agents, short acting—20min.
• The head and thorax elevated at least 20
degrees—venous return and reduce congestion. The head is rotated to the opposite side
and slightly extended. Table tilt by 10 to 15
degrees. 1:1 lakh saline Adr to help in hydrodissection and vasoconstriction. Shaving—
minimal to no shaving; ladies hair knot. Eye
ointment—vertical taping; facial muscles
exposed.
• Marking of skin incision (Fig.1).
• Flap elevation must be supercial to SMAS
and supercial cervical fascia (Fig. 2).
Supra- SMAS adipose tissue is easier and can
Fig. 1 The modied Blair/Bailey incision is most commonly used. The classic modied Blair incision is marked
in the preauricular crease at the level of the meatus, behind
the lobule and down into a neck crease
Fig. 2 Flaps—raised in the subcutaneous adipose tissue,
avoiding injury to the hair follicles—Frey’s syndrome.
Avoid buttonhole. Identication of the greater auricular
nerve. Scars must be included in the incision especially in
the reoperations. Skin ap at the mastoid portion must be
over 2cm; else it leads to necrosis. Rhytidectomy incision
and facelift have a cosmetic approach; they utilize the
SMAS as the plane of dissection. Yellow arrow, greater
auricular nerve; blue arrow, parotid tumour
have less bleeding. Sub-SMAS—better ap
vascularity and lower Frey’s but higher
chances of VIIn Injury.
• While dissecting the ap, avoid monopolar
surgery to restrict the thermal spread. The dissection must be parallel to the nerve. The skin
aps must not be raised too anteriorly or at the
level of masseter. Inferiorly, it must be elevated along the planes of platysma.
• Stay suture and lobule stitch will improve the
exposure. Posterior border of the gland is dissected off from sternocleidomastoid (SCM)
muscle, and the posterior belly of digastric
muscle is exposed. The GAN especially the
posterior division must be preserved, as it supplies the skin over the pinna and mastoid area.
Early ligation of EJV and RMV may increase
venous pressure and cause bleeding.
• Dissection is carried along the cartilaginous
external auditory meatus, the cartilaginous
tragal pointer is identied and the parotid
gland is retracted anteriorly. From here it is
helpful to continue dissection in a plane parallel to the oor; a more perpendicular course
will lead to the styloid, deep to the facial
nerve.
• The parotidomasseteric fascia is incised. This
exposes the parotid tissue and allows access to
the plane in which the nerve courses.
• Palpation of the tympanomastoid suture line,
which is located between the tragal pointer
and mastoid tip, helps identify the spot at
which the nerve will enter the gland parenchyma (large tumours may displace the main
trunk in a more vertical direction, paralleling
the course of the sternocleidomastoid (SCM)).
Staying over the suture line and carefully
dividing small pieces of the fascia and parotid
are very reliable methods of exposing the
facial nerve.
• Identication of the posterior belly of the
digastric muscle is also helpful, as the stylomastoid foramen lies just medial to its attachment to the mastoid and facial nerve course is
posterosuperior to its attachment.
• Retrograde dissection and tracing of the marginal mandibular nerve to the main trunk are
seldom used but are reliable techniques used
Соседние файлы в папке Библиотека им академика М.И. Перельмана