Phẫu Thuật Tai Mũi Họng Và Phẫu Thuật Đầu Cổ

Chapter 55
Pharyngectomy
Jonas T. Johnson and Stephen Y. Lai
A hollow viscus located immediately posterior to the
larynx, the hypopharynx is related to the oral pharynx
superiorly and the cervical esophagus inferiorly. It is
divided into three anatomic sites: the piriform sinuses
(bilateral), the postcricoid mucosa, and the posterior
pharyngeal wall. The postcricoid mucosa is the mucosa
lying on the posterior aspect of the cricoid cartilage,
which is in fact the anterior wall of the hypopharynx.
The hypopharynx plays an important role in deglu-
tition, as well as respiration. Coordinated activity in this
laryngopharyngeal segment is essential for swallowing
and protection of the airway from aspiration.
The hypopharynx is directly related to the carotid
sheath, which lies just lateral to the hypopharynx on
either side. Sensory fi bers are derived from the glosso-
pharyngeal nerve, as well as the internal branches of
the superior laryngeal nerve. The motor supply to the
inferior constrictor muscles comes via the pharyngeal
plexus.
Lymphatic drainage of the hypopharynx is directed
toward the upper deep cervical lymph nodes (zones II
and III); however, there is concern that some cancers
of the hypopharynx may drain to the retropharyngeal
lymphatics, and bilateral drainage is also possible.
Cancer involving the medial wall of the piriform sinus
has a 20% risk of contralateral lymph node metastasis.1
The lateral wall of the piriform is less likely to metasta-
size to the contralateral lymphatics. Both postcricoid
and posterior pharyngeal sites would be expected to
demonstrate potential for bilateral metastasis.
Squamous cell carcinoma is the cancer most com-
monly encountered in the hypopharynx, and it accounts
for more than 90% of malignant tumors originating in
this region. Development of squamous cell carcinoma
of the hypopharynx is closely associated with the use of
both tobacco and alcohol products.2,3 Most patients
have dysphagia, referred otalgia, or evidence of cervical
lymph node metastasis at initial evaluation. At least two
thirds of patients are initially found to have stage IV
cancer.
Direct extension of cancer of the posterior pharyn-
geal wall to involve the prevertebral fascia or cancer of
the piriform sinus involving the carotid sheath is gener-
ally considered a sign of inoperability. Postcricoid
cancer, the most unusual of the hypopharyngeal tumor
locations, may be manifested as vocal cord fi xation and
stridor.
Assessment of the extent of the cancer may be
undertaken with computed tomography or magnetic
resonance imaging. These fi ndings can be corroborated
at endoscopy. Fixation to the prevertebral fascia or
bone can be ascertained preoperatively with video fl uo-
roscopy when fi xation of the tumor to the spine is rec-
ognized during swallowing.
The standard approach to hypopharyngeal cancer
has been surgical excision with postoperative radiation
therapy.4 Primary radiation therapy with surgical salvage
of failures has resulted in poor outcomes.5,6 The most
recent data suggest that patients with advanced cancer
of the pharynx may benefi t more with adjuvant concur-
rent chemoradiation therapy than with adjuvant radia-
tion alone.7 The use of so-called organ-sparing protocols
in the treatment of hypopharyngeal cancer is currently
under investigation.8 Many investigators have reported
that the intense mucositis associated with chemoradia-
tion therapy in this setting often results in pharyngeal
stenosis with complete obstruction, which may be total
and permanent.
PATIENT SELECTION
Cancer involving the hypopharynx requires histologic
confi rmation. Examination under anesthesia allows the
physician to evaluate the extent of the lesion and the
possibility of fi xation to the prevertebral fascia and to
rule out the presence of a second primary cancer. Most
surgeons agree that 15 to 20 mm of tumor-free soft
tissue should be left at resection margins. Needless to
say, this may not be possible with deep margins at the
prevertebral fascia or the carotid artery.
467

468
Section 4
Hypopharynx and Cervical Esophagus
Small cancers involving the medial wall of the
piriform sinus or the anterior aspect of the piriform
sinus may be treated by partial laryngopharyngectomy,
whereas more locally advanced cancer requires total
laryngopharyngectomy. It is essential that the surgeon
preoperatively estimate the extent of resection required
and, accordingly, the amount of pharyngeal mucosa
that will be available for reconstruction. Cancer involv-
ing the medial wall of the piriform sinus allows primary
closure (Fig. 55-1). A cancer that extends to involve the
lateral wall of the piriform sinus can be closed primarily
if the contralateral mucosa is preserved (Fig. 55-2).
Cancer involving the ipsilateral piriform sinus that
extends to the midline of the posterior wall cannot be
closed primarily (Fig. 55-3). Generally speaking, a
minimum of 3 cm of pharynx (measured from side to
side) is required to afford an opportunity for primary
closure (Fig. 55-4). Similarly, cancer extending into the
postcricoid mucosa or cervical esophagus cannot be
closed primarily.
When a narrow strip of mucosa is maintained that
is less than 3 cm in transverse measurement, tissue aug-
mentation will be required to afford successful re -
construction and allow postoperative swallowing. The
pectoralis major myocutaneous fl ap and a variety of free
fl ap alternatives such as the radial forearm free fl ap
(fasciocutaneous), lateral arm fl ap, or lateral thigh fl ap
may be reliable alternatives for reconstruction.
When the entire pharynx is resected (total laryngo-
pharyngectomy), 360-degree reconstruction of the
pharynx is required. We favor free jejunal transfer,
although others have suggested a tubed free tissue
transfer (such as the radial forearm) or gastric
pull-up.
Advanced cancer involving the postcricoid mucosa
invariably requires total laryngopharyngectomy and
total pharyngeal reconstruction. The proximity of these
tumors to the larynx and the high likelihood of direct
Figure 55-1. This patient has advanced laryngeal cancer. Most of
the cancer is confi ned to the intrinsic larynx; however, resection of
the medial wall of the ipsilateral piriform sinus is required to get a
deep margin. Preservation of the contralateral piriform sinus, as well
as the ipsilateral lateral wall, will allow primary closure.
Figure 55-2. This cancer of the piriform sinus extends to involve
the entire lateral wall. During resection, the contralateral piriform
sinus was carefully preserved.
Figure 55-3. This extensive hypopharyngeal cancer crossed the
midline posteriorly. Near-total pharyngectomy was required.

Chapter 55
Pharyngectomy
469
involvement make laryngectomy mandatory. The
narrow circumference of the lumen at the level of the
postcricoid mucosa makes total pharyngectomy neces-
sary (Fig. 55-5).
Small cancers of the posterior wall of the hypophar-
ynx may occasionally be encountered. We have success-
fully treated them by transhyoid pharyngotomy and
excision (Fig. 55-6) (refer to Chapter 29 for details of
Figure 55-4. This narrow island of residual hypopharynx cannot
be closed primarily. It needs to be supplemented with a tissue transfer
or resected and replaced with new tissue.
Figure 55-5. This circumferential postcricoid lesion required total
laryngectomy and reconstruction.
Figure 55-6. Direct access to the posterior wall of the hypopharynx
can be accomplished via transhyoid pharyngotomy.
techniques). The defect can be reconstructed with
either a split-thickness skin graft or direct approxima-
tion of the mucosa to the prevertebral fascia, which
allows healing by secondary intention. In either circum-
stance, scar contracture may compromise the eventual
swallowing result.
Larger cancers of the posterior hypopharynx can
occasionally be accessed through either transhyoid
pharyngotomy or lateral pharyngotomy. The cancer is
resected and the defect repaired with a free fl ap. The
outcome in terms of swallowing is not entirely predict-
able. At least 50% of these patients never swallow suc-
cessfully. Most patients with advanced cancer of the
posterior hypopharynx require total laryngopharyngec-
tomy and reconstruction.
Patients with hypopharyngeal cancer have a very
high risk for the development of cervical lymph node
metastasis. Overall, metastatic cancer develops in 60%
to 80% of patients with hypopharyngeal cancer. Occult
metastasis is present in at least 20% to 40% of patients.
The risk is bilateral in patients with tumors involving
the postcricoid mucosa, the medial wall of the piriform
sinus, or the posterior wall of the pharynx. Accordingly,
most patients treated surgically benefi t from either
therapeutic or elective neck dissection. In the case of
an N-0 neck, selective neck dissection should include at
least levels II to IV.
SURGICAL APPROACHES
Partial Laryngopharyngectomy
This procedure is appropriate for patients with cancer
limited to the aryepiglottic fold, medial wall of the piri-

470
Section 4
Hypopharynx and Cervical Esophagus
form sinus, and anterior wall of the piriform sinus, as
long as they have adequate pulmonary function. Exten-
sion to the apex or lateral wall of the piriform sinus is
a contraindication to this procedure.
The surgeon proceeds as though performing a
supraglottic laryngectomy (see Chapter 47). The supra-
glottic larynx is removed with the adjacent hypopharyn-
geal mucosa in an effort to achieve a 15-mm margin in
the mucosa in all directions. Reconstruction is accom-
plished by impacting the base of the tongue into the
residual larynx. Closure of the residual hypopharyngeal
mucosa is indirect and requires a second layer consist-
ing of the residual strap muscles and digastric muscle.
All wounds are drained with negative pressure, and
perioperative antibiotic prophylaxis is administered.
Total Laryngectomy and
Partial Pharyngectomy
This procedure is most commonly performed in patients
with carcinoma of the piriform sinus that extends to
involve the larynx medially, the apex of the piriform
sinus inferiorly, or the lateral wall of the hypopharynx
laterally.
The patient is prepared for total laryngectomy. We
prefer a superiorly based apron fl ap. Neck dissection is
accomplished bilaterally for cancer involving the medial
wall of the piriform sinus. Unilateral neck dissection
may suffi ce for patients with cancer isolated to the
lateral wall.
After completion of the neck dissection, the
pharynx is opened in the vallecula contralateral to the
tumor. Effort is made to preserve 100% of the unin-
volved piriform mucosa, which can be accomplished by
releasing the piriform sinus after having fi rst incised the
contralateral constrictor muscles along the posterior
lamella of the thyroid cartilage. The piriform sinus is
then gently dissected free from the endolarynx. The
resection is next carried from the vallecula down along
the lateral aspect of the epiglottis to the bilateral aspect
of the contralateral arytenoids. The remaining incisions
in the mucosa are made under direct visualization so
that the surgeon can ensure an adequate (15 to 20 mm)
mucosal margin around the cancer.
At the completion of the resection, frozen section
assessment of margins is mandatory. Patients with 3 cm
of residual mucosa in the transverse dimension can
usually undergo primary closure. If less than 3 cm of
mucosa remains, pedicle fl ap or free fl ap reconstruc-
tion may be required.
Postoperative Management
All patients have negative pressure drains in the neck
bilaterally. Perioperative antibiotics are administered
for 24 hours. Nasal gastric feeding is maintained until
the patient is able to swallow saliva comfortably, at
which time the integrity of the pharyngeal closure can
be ascertained by either diatrizoate meglumine (Gastro-
grafi n) swallow or the administration of colored juice
by mouth, after which the physician can observe the
cervical drains for evidence of a pharyngeal fi stula.
Total Laryngopharyngectomy
Cancer involving the postcricoid mucosa, advanced
cancer of the posterior hypopharyngeal wall, and cancer
involving the piriform sinus with extension across the
midline posteriorly require total laryngopharyngec-
tomy. More extensive lesions that extend into the
cervical esophagus are resected via total laryngoesopha-
gectomy (Fig. 55-7). Reconstruction is usually accom-
plished with a gastric pull-up.
Bilateral neck dissection is always performed. Elec-
tive neck dissection would require removal of zones II,
III, and IV. Reconstruction requires free jejunum or
tubed free tissue transfer such as the radial forearm
(Fig. 55-8). Drains are placed bilaterally. When free
jejunum is chosen for reconstruction, a jejunostomy
tube is placed at the time of surgery to allow early
renewal of nutritional support (Fig. 55-9).
Postoperative Management
Perioperative antibiotics are always administered for 24
hours. The integrity of the mucosa suture lines is deter-
mined by contrast barium swallow between 7 and 10
days postoperatively. If the suture lines are intact, oral
alimentation with clear liquids is initiated. The diet can
be advanced gradually as tolerated.
Figure 55-7. When tumor extends into the cervical esophagus,
total laryngoesophagectomy is required, primarily because recon-
structive techniques are not adequate to allow a suture line in the
mediastinum.

Chapter 55
Pharyngectomy
471
Figure 55-8. The radial forearm free fl ap provides thin pliable
tissue for partial pharyngeal reconstruction. It can be tubed for total
pharyngeal reconstruction.
Figure 55-9. The jejunum has vascular arcades, each serving
approximately 25 cm of small intestine. This offers an ideal opportu-
nity for free tissue transfer.
References
1. Johnson JT, Bacon GW, Myers EN, Wagner RL: Medial vs. lateral
wall pyriform sinus carcinoma: Implications for management of
regional lymphatics. Head Neck 16:401-405, 1994.
2. Menvielle G, Luce D, Goldberg P, Leclerc A: Smoking, alcohol
drinking, occupational exposures and social inequalities in hypo-
pharyngeal and laryngeal cancer. Int J Epidemiol 33:799-806,
2004.
3. Menvielle G, Luce D, Goldberg P, et al: Smoking, alcohol drinking
and cancer risk for various sites of the larynx and hypopharynx.
A case-control study in France. Eur J Cancer Prev 13:165-172,
2004.
4. Chu PY, Wang IW, Chang SY: Surgical treatment of squamous cell
carcinoma of the hypopharynx: Analysis of treatment results,
failure patterns, and prognostic factors. J Laryngol Otol 118:443-
449, 2004.
5. Godballe C, Jorgensen K, Hansen O, Bastholt L: Hypopharyngeal
cancer: Results of treatment based on radiation therapy and
salvage surgery. Laryngoscope 112:834-838, 2002.
6. Gourin CG, Terris DJ: Carcinoma of the hypopharynx. Surg Oncol
Clin N Am 13:81-98, 2004.
7. Cooper JS, Pajak TF, Forastiere AA, et al, for the Radiation Therapy
Oncology Group 9501/Intergroup: Postoperative concurrent
radiotherapy and chemotherapy for high-risk squamous-cell
carcinoma of the head and neck. N Engl J Med 350:1937-1944,
2005.
8. Okamoto M, Takahashi H, Yao K, et al: Clinical impact of using
chemoradiotherapy as a primary treatment for hypopharyngeal
cancer. Acta Otolaryngol Suppl 547:11-14, 2002.
• Most hypopharyngeal cancers have a high risk of
bilateral metastasis.
• Involvement of the postcricoid mucosa or extension
across the midline requires total
laryngopharyngectomy with appropriate
reconstruction.
• Involvement of the prevertebral fascia by the cancer
indicates inoperability.
• Chemoradiation protocols are exploring the
potential for organ preservation.
PITFALLS
• Hypopharyngeal cancers extending into the
esophagus will not allow primary closure.
• Failure to administer prophylactic antibiotics may
result in wound infection.
• Failure to preserve uninvolved mucosa may make
closure more complex.
• Failure to recognize airway obstruction may result in
an emergency tracheotomy.
• Tight closure with inadequate mucosa may result in
fi stula and dysphagia.
PEARLS
• Some cancers of the posterior wall may be resected
through a transhyoid pharyngotomy.
• At least 3 cm of mucosa measured from side to side
is needed to close the pharynx without a fl ap.

Chapter 56
Cancer of the Cervical Esophagus
Eugene N. Myers
Cancer arising in the cervical esophagus is an aggressive
cancer, usually squamous cell carcinoma, and is typi-
cally diagnosed at an advanced stage.1 It is often associ-
ated with involvement of the larynx and trachea, as well
as with a high rate of metastasis to regional lymph nodes
and distant organs.2
Because the cervical esophagus may be secondarily
invaded by cancer of the hypopharynx, it is very diffi cult
to determine actual survival rates for cancer of the cervi-
cal esophagus since these cases are usually embedded
in the literature on cancer of the hypopharynx.3,4
Patients with squamous cell carcinoma of the cervical
esophagus have a dismal prospect for survival, less than
a 20% survival rate 5 years after treatment.5,6 In com-
parison, squamous cell carcinoma of the hypopharynx,
which is closely related anatomically and histologically,
has a 5-year survival rate of nearly 40%.6,7
The poor cure rate for cancer of the cervical esoph-
agus is thought to be related to several factors. Symp-
toms of cancer of the cervical esophagus are vague and
nonlocalizing. Early symptoms usually include mild dif-
fi culty swallowing, although some patients may com-
plain only of excessive mucus or a globus sensation.
These symptoms are diffi cult to differentiate from those
associated with laryngopharyngeal refl ux, which is a
very common problem. Thus, these patients may be
ignored or treated medically for a long time while the
cancer continues to grow. Dysphagia is a late symptom
that occurs only when obstruction of the esophageal
lumen impairs swallowing function. Pain, marked
weight loss, debilitation, and enlarged cervical lymph
nodes are also late signs and symptoms of cancer in this
anatomic site. Adding to the diffi culty in diagnosis is
the fact that cancer of the cervical esophagus cannot be
visualized by transnasal laryngopharyngoscopy in the
outpatient setting.
The aggressive clinical course of cancer of the cervi-
cal esophagus is also infl uenced by the high incidence
of submucosal spread, ipsilateral or bilateral cervical
lymph node metastasis, and the high rate of a second
primary cancer in the esophagus. In the long term
there is a high incidence of distant metastasis, intercur-
rent disease, and second primary malignancies. Despite
these aggressive features of the disease, in some cases
we have the ability to achieve locoregional control or
preservation of organ function (or both) and im -proved
survival rates.
Cancer of the cervical esophagus is at an advanced
stage in most patients at the time that the diagnosis is
made and is treated by surgical resection, usually total
laryngopharyngoesophagectomy, total thyroidectomy,
and bilateral neck dissection. Chemotherapy has been
added to the standard postoperative radiation therapy
because recent studies have shown a better outcome for
this combined treatment than for radiation therapy
alone.4,8
There has been a trend in recent years to use a
multidisciplinary approach to the treatment of patients
with laryngopharyngeal cancer. The multidisciplinary
team must include a head and neck surgeon, recon-
structive surgeon, thoracic surgeon, radiation and
medical oncologists, radiologist, and speech-language
pathologist. This multidisciplinary approach allows us
to tailor the treatment program to each patient’s needs
with the main goals of cure and functional rehabilita-
tion to maximize quality of life.1 Forastiere and coau-
thors reported cure rates with chemoradiation therapy
to be comparable to those with surgery followed by
adjunctive radiation therapy.9 This treatment program,
when successful, has the advantage of laryngeal preser-
vation. Unfortunately, this type of nonsurgical treat-
ment may be problematic because the activity of
radiation therapy is intensifi ed by the chemotherapy,
thus delivering a high dose to the musculature of the
pharynx and cervical esophagus, which may render the
preserved organ nonfunctional. Scar formation also
occurs after destruction of the cancer and produces
ulceration of the mucosa. These two factors may result
473

474
Section 4
Hypopharynx and Cervical Esophagus
in permanent dysphagia and the need for some form
of enteral feeding.
ANATOMY
The cervical esophagus is a short tube that extends
from the cricopharyngeal sphincter to the thoracic
inlet. The cervical esophagus is lined by nonkeratiniz-
ing squamous epithelium over a loose stroma and a
muscular layer consisting of an inner circular and an
outer longitudinal layer covered by a fascial sheath.
Anteriorly, the cervical esophagus has a direct relation-
ship with the posterior wall of the trachea. Laterally lie
the recurrent laryngeal nerves, the paratracheal lymph
nodes, and the thyroid gland and carotid sheath. Pos-
teriorly, the fascia separates the esophagus from the
retroesophageal space, which is continuous with the
retropharyngeal space above and the posterior medias-
tinum below.
There is a rich submucosal lymphatic network that
terminates in the lymph nodes along the jugular vein
(levels II, III, and IV) and the paratracheal lymph nodes
(level VI).
EPIDEMIOLOGY
Squamous cell carcinoma of the cervical esophagus is
strongly linked to excessive cigarette smoking, heavy
consumption of alcohol, lower socioeconomic class,
and lower educational levels. The possibility of a genetic
predisposition to the development of cancer of the
hypopharynx and cervical esophagus is currently under
investigation. Genotypic and phenotypic defi ciencies in
the metabolism of tobacco-related carcinogens, as well
as abnormalities in the mechanism of DNA repair, may
be implicated in the predisposition to cancer of the
pharynx and cervical esophagus.1
PATHOLOGY
Squamous cell carcinoma is the most frequent histo-
logic type of cancer found in the cervical esophagus.
Submucosal spread around the macroscopic margins of
the tumor is a frequent feature either in direct continu-
ity with the cancer or at some distance from the main
tumor mass, thus making complete excision diffi cult.9
Liberale and coworkers10 added a case of verrucous
carcinoma, a variant of squamous cell carcinoma, to the
literature, which previously included 20 such cases. The
authors mentioned the recent hypothesis that human
papillomavirus (HPV) plays a causative role in the
development of verrucous carcinoma. Qualitative
polymerase chain reaction assay of a biopsy sample of
this tumor revealed the presence of HPV infection. The
patient was not deemed fi t for surgery and was treated
with a local antiviral preparation; the patient’s good
initial response was unfortunately followed by sudden
progression of disease leading to death 6 months
later.
Primary adenocarcinoma of the cervical esophagus
is rare and may arise from Barrett’s esophagus. Less
common are tumors that arise from heterotopic gastric
mucosa without evidence of Barrett’s disease. Alrawi
and coauthors reported a patient in whom a primary,
moderately differentiated adenocarcinoma with no evi-
dence of Barrett’s esophagus was diagnosed. The
authors referenced 19 other cases reported in the litera-
ture. They also pointed out that these patients had a
much better prognosis than those whose cancer arose
from Barrett’s esophagus.11
Abe and colleagues12 reported a patient with adeno-
carcinoma arising from ectopic gastric mucosa (inlet
patch). Their review of the literature revealed only 17
similar cases. von Rahden and associates13 also reported
a patient with unresectable adenocarcinoma arising in
heterotopic gastric mucosa who was successfully treated
with chemotherapy and radiation therapy and, after a
good response, underwent limited esophageal resec-
tion. The patient exhibited no evidence of cancer and
had normal swallowing after a 3-year follow-up.
Benign tumors occur infrequently in the cervical
esophagus. The most common benign lesions reported
in the cervical esophagus are pedunculated hyperplas-
tic or fi brovascular polyps. Oguma and coworkers14
reported a patient with a hyperplastic polyp arising in
ectopic gastric mucosa. Matsushita and Okazaki15
reported a patient who had a pedunculated hyperplas-
tic polyp treated by snare polypectomy. Caceres and
coauthors16 reported a case and carried out the largest
review of the literature consisting of 110 cases of fi bro-
vascular polyp. Sargent and Hood17 described a patient
who asphyxiated because of airway obstruction caused
by a giant fi brovascular polyp. Szumilo and associates18
reported a patient in whom a leiomyoma was diagnosed
that was asymptomatic and discovered unexpectedly
during esophagoscopy. It was removed uneventfully
with electrodissection. Marin and colleagues19 described
two patients with rare tumors of the cervical esophagus.
One was a granular cell tumor and one a schwannoma.
Both patients were treated by excision of the tumor
and reconstruction of the defect with a radial forearm
free tissue transfer, which maximized the functional
outcome.
PATIENT SELECTION
Patients with locally advanced cancer typically have a
history of sore throat, dysphagia, odynophagia, referred
otalgia, a mass in the neck, and weight loss. Early in the
development of the cancer there may be some nonspe-
cifi c swallowing diffi culty and perhaps a globus sensa-
tion. In the life of every practicing otolaryngologist,
patients are seen every day with similar symptoms that
are either the result of upper aerodigestive tract mani-
festations of gastroesophageal refl ux disease (GERD)
or stress related. Some patients will exhibit dysphonia
as a result of paralysis of one or both vocal cords second-
ary to spread of the cancer through the wall of the
esophagus and into the recurrent laryngeal nerve.
Patients with some or all of the aforementioned symp-
toms that may be suggestive of cancer of the cervical
esophagus should certainly undergo appropriate

Chapter 56
Cancer of the Cervical Esophagus
475
imaging such as barium esophagography and computed
tomography (CT) with intravenous contrast enhance-
ment, including imaging of the head, neck, and chest.
These studies contribute to diagnosis and staging and
also give information about whether the cancer appears
to be technically operable.
Patients in whom distant metastasis has been identi-
fi ed on imaging studies should not be considered for
surgical resection. Patients must also undergo diagnos-
tic endoscopy and biopsy, which could include direct
laryngoscopy, hypopharyngoscopy, tracheoscopy, cervi-
cal esophagoscopy, and when possible, examination of
the entire esophagus. With the amount of tumor found
in the cervical esophagus it is often not possible or
safe to try to examine the thoracic esophagus for fear
of perforating this structure. Pesko and colleagues20
described a technique of intraoperative endoscopy in
patients with obstructive hypopharyngeal carcinoma
that could be adapted to carcinoma obstructing the
cervical esophagus. In seven patients, preoperative
endoscopic evaluation of the esophagus and stomach
could not be performed because of obstruction of the
lumen by the tumor. In these patients, intraoperative
endoscopy of the esophagus and stomach was carried
out through an incision in the cervical esophagus. In
one patient a synchronous carcinoma was found in the
esophagus despite the fact that neither the preoperative
barium esophagogram or CT scan revealed this second
primary cancer. Tracheoscopy should be carried out to
rule out invasion of the trachea by cancer of the cervical
esophagus. Such a fi nding would not necessarily render
the patient inoperable but would have an impact on the
extent of the surgery and the type of the reconstruction
to be performed. Imaging would also be helpful in
detecting whether there is local involvement or encase-
ment of adjacent structures such as the great vessels.
Occasionally, there is extension into the midthoracic
esophagus, which is often associated with involvement
of adjacent structures such as the pericardium.2
Patients often have severe comorbid conditions
such as chronic obstructive pulmonary disease (COPD)
related to the cigarette smoking that has been impli-
cated as the primary cause of squamous cell carcinoma
of the cervical esophagus. Resection of the cervical
esophagus generally requires using a gastric transposi-
tion (pull-up) and pharyngogastric anastomosis for
reconstruction, and patients with severe COPD may not
tolerate this procedure. Severe cardiac or other comor-
bid conditions may also be strong contraindications to
surgery. A history of previous abdominal surgery such
as gastrectomy or colectomy will likewise limit the
choices for reconstruction.
Physical examination plays a key role in the selec-
tion of patients for treatment. The oral cavity and oro-
pharynx are examined so that asymptomatic second
primary cancers will not be overlooked. At the same
time the patient’s dental status can be evaluated. Indi-
rect mirror examination of the hypopharynx may be
complemented by fl exible fi beroptic endoscopy, which
provides a global view of the entire pharynx and larynx,
including assessment of vocal cord mobility. Failure to
identify a tumor in the hypopharynx in a patient with
pooling of saliva in the hypopharynx is an indirect sign
of cancer of the cervical esophagus. Bilateral vocal cord
paralysis may be encountered in patients with cancer of
the cervical esophagus. The mechanism is invasion of
cancer through the wall of the esophagus into the tra-
cheoesophageal sulcus and then into the recurrent
laryngeal nerves. Palpation of the neck is necessary to
detect cervical adenopathy. The fi nding of fi xation of a
cervical mass on palpation is a contraindication to surgi-
cal management of the cancer because of encirclement
of the carotid artery.
Many of these patients have lost signifi cant weight
and are nutritionally depleted. Attempting to perform
extensive surgery on such individuals will result in an
unacceptable rate of complications, lengthy hospitaliza-
tion, and mortality. The Veterans Administration Surgi-
cal Risk Study21 dramatically demonstrated that low
levels of serum albumin correlate with an increased
incidence of postoperative complications. Low hemo-
globin has also been shown to be a negative prognosti-
cator for survival. Hence, assessment of the patient’s
nutritional status must be an integral component of
the preoperative evaluation. Enteral feeding through a
nasogastric or percutaneous endoscopic gastrostomy
(PEG) tube is necessary to replenish the nutritional
status of patients who are being considered for surg -
ery, as well as those who will be treated with
chemotherapy.
Certainly, the most obvious contraindication to
surgery is refusal of the patient to provide consent for
the procedure. There is a great deal of interest and
publicity concerning the use of chemoradiation therapy
for the treatment of cancer, as well as for the treatment
of other diseases not related to cancer of the head and
neck. Patients may wish to forego laryngectomy, which
is oncologically necessary in most of these cases, and
prefer to have the cancer treated by nonsurgical means
such as chemoradiation therapy. Patients who are found
to have invasion of the prevertebral fascia or bone are
incurable and may simply be assigned to palliative
care.
PREOPERATIVE PLANNING
Physical examination should certainly include an evalu-
ation of the head and neck. One would expect on either
indirect mirror laryngoscopy or fl exible fi beroptic
laryngoscopy to fi nd pooling of secretions in the hypo-
pharynx as a result of distal obstruction by tumor in the
cervical esophagus. Either unilateral or bilateral paraly-
sis of the vocal cords may be present because of exten-
sion of cancer through the wall of the cervical esophagus
into the vagus or recurrent laryngeal nerves. In the
presence of vocal cord paralysis, a history of chronic
aspiration would be anticipated.
Imaging studies are invaluable for evaluating the
presence and extent of locoregional disease, as well as
for determining the possibility of distant metastasis,
which would rule out the possibility of extirpative
surgery. Barium esophagography remains a very impor-

476
Section 4
Hypopharynx and Cervical Esophagus
tant study for evaluation of the extent of the primary
tumor, particularly if esophagoscopy is not feasible (Fig.
56-1A). This study is used to determine the extent of
mucosal involvement and to establish the presence of a
second primary cancer in the more distal part of the
esophagus. Perhaps the most valuable aspect of this
study is fl uoroscopic determination of whether invasion
through the posterior wall of the esophagus has
occurred. Obliteration of the retropharyngeal and ret-
roesophageal space or invasion of the prevertebral
fascia can be estimated through dynamic fl uoroscopic
evaluation rather than still images. In the presence of
aspiration, it would be prudent to carry out a diatrizoate
meglumine (Gastrografi n) esophagogram rather than
a barium esophagogram because less reaction occurs if
the patient aspirates Gastrografi n into the lungs than if
barium is aspirated.
A CT scan of the head, neck, and chest with intra-
venous contrast enhancement is still the most widely
used imaging modality for the initial evaluation of
patients with cancer of the cervical esophagus (Fig.
56-2). Fine-cut CT scanning can be done very quickly,
even in patients who have diffi culty lying supine because
of their advanced cancer. The goals of CT scanning are
to accurately evaluate the location and size of the
primary cancer and determine whether there is direct
extension of tumor into the neck (see Fig. 56-1B), espe-
cially posteriorly into the retropharyngeal and esopha-
geal space, prevertebral fascia, or vertebral column. An
anterior-posterior diameter of the cervical esophagus
greater than 24 mm must be considered abnormal. The
average thickness of the wall is 4.8 mm laterally and
3.8 mm posteriorly. Two criteria with the best sensitivity
are thickening of the esophageal wall and effacement
of the fat plane. Another criterion that has a reported
sensitivity of 100% is the presence of a circumferential
mass surrounding the esophagus greater than 180 or
270 degrees.1
Determination of the presence or absence of cervi-
cal lymph node metastasis by contrast-enhanced CT is
fundamental in preoperative planning. Encasement
of the carotid artery is a defi nite contraindication to
surgery. CT scanning is preferably performed before
endoscopy and biopsy so that the surgeon is aware of
the extent of the disease and also to prevent distortion
A
B
Figure 56-1. A, Barium esophagogram demonstrating carcinoma of the cervical
esophagus (arrow). B, Computed tomography scan of same patient demonstrating
the cancer with narrowing of the lumen of the cervical esophagus (arrow).
Figure 56-2. Squamous cell carcinoma of the cervical esophagus
with extensive invasion of surrounding structures in the neck
(arrow).

Chapter 56
Cancer of the Cervical Esophagus
477
of tissues, which may result in overestimation of cancer
infi ltration.
Magnetic resonance imaging (MRI) is not routinely
performed for staging of cancer of the cervical esopha-
gus. Although MRI has superior resolution for
demonstrating soft tissue detail, its susceptibility
to motion-induced artifact makes CT a superior
technique.
Positron emission tomography (PET)/CT scanning
has recently been accepted as a useful technique for
staging cancer of the head and neck. Fusion of the
qualitative analysis of the PET portion with the precise
details and volumetric analysis of the CT portion makes
this a valuable staging procedure. Whole-body PET/CT
scanning also provides information about the presence
or absence of distant metastasis and second primary
cancers. In addition, this technique plays a valuable role
in the reevaluation of a patient who has undergone
chemoradiation therapy.
Ultrasonography is useful in the assessment of cer-
vical lymph node metastasis. It is a simple, noninvasive,
highly sensitive technique that when combined with
fi ne-needle aspiration biopsy, provides valuable infor-
mation in the staging process.
A complete medical evaluation should be carried
out to determine the patient’s ability to undergo diag-
nostic endoscopy and biopsy. Because of their smoking
history, many of these patients will have COPD with
poor pulmonary reserve. Many of the patients who have
undergone laryngopharyngoesophagectomy for treat-
ment of cancer of the cervical esophagus have been
reconstructed via gastric transposition, which requires
dissection of the posterior mediastinum and insertion
of chest tubes because pulmonary complications may
occur. If very severe COPD is present, the patient may
be eliminated as a candidate for such surgery. Previous
cardiac surgery, including coronary artery bypass graft-
ing, can cause scarring that may make it dangerous
when the mediastinum is entered during reconstructive
surgery. The patient’s liver function should be evalu-
ated. Many of these patients have a history of chronic
alcoholism with cirrhosis of the liver, which may not
allow them to qualify for chemotherapy either in the
postoperative adjuvant setting or as part of a protocol
with organ preservation. A chronic alcoholic who con-
tinues to drink heavily before surgery is at high risk for
delirium tremens.
Endoscopy should be carried out under general
anesthesia; however, some of these patients will also
have upper airway obstruction or an unstable airway
because of bilateral vocal cord paralysis. These patients
are best served by performing a tracheostomy under
local anesthesia before endoscopy. Tracheoscopy is also
necessary because of the possibility of cancer of the
cervical esophagus invading the posterior wall of the
cervical trachea. Although such invasion is not neces-
sarily a contraindication to surgery, it does have an
impact on the extent of surgery and surgical reconstruc-
tion and should be known ahead of time for proper
procedure planning. If there is involvement of the pre-
vertebral fascia or vertebral column or encasement of
the carotid arteries, surgery is contraindicated. Gener-
ous biopsy samples of the cancer should be taken at the
time of endoscopy.
If the patient has previously undergone abdominal
surgery or if there is a history of gastric or colonic
disease, additional evaluation may require gastrointes-
tinal endoscopy. Operative reports from previous
abdominal surgery should be obtained. In Weisberger’s
experience,2 coexisting hypertrophic gastritis increases
the risk for ischemia of the stomach when gastric trans-
position is used as a method of reconstructing the
esophagus. If a free tissue transfer or colon transposi-
tion is used, it is important to exclude any signifi cant
pathology involving the colon. Therefore, colonoscopy
should also be carried out in such patients.
Patients with comorbid conditions should be opti-
mized before surgery. For instance, patients with low
hemoglobin should undergo transfusion, and patients
whose nutritional status would not allow them to be
surgical candidates should be treated with intravenous
hyperalimentation; alternatively, if it was thought that
the stomach would not be used for reconstruction, a
percutaneous gastrostomy tube may be placed and
nutritional replenishment carried out before surgery.
After the patient has been thoroughly evaluated
and the biopsy report is available, staging of the cancer
should be performed. The current staging system for
cancer of the cervical esophagus is identical to that for
the intrathoracic esophagus (Table 56-1).
There are two reasons for the lack of evidence-
based decision making in cancer of the cervical esopha-
gus: cancer in this anatomic site is rare, and the results
of treatment of these cancers are usually embedded in
the literature on treatment of the much more com-
monly encountered cancer of the hypopharynx. His-
torically, cure rates with radiation therapy alone were
Table 56-1
STAGING OF CERVICAL ESOPHAGEAL
CANCER
For cancer of the cervical esophagus, the recommended
staging is identical to that for the intrathoracic
esophagus:
Tis Carcinoma in situ
T1 Tumor invades the lamina propria or submucosa
T2 Tumor invades the muscularis propria
T3 Tumor invades the adventitia
T4 Tumor invades adjacent structures
The nodal classifi cation for the hypopharynx is the same
as that for other sites in the head and neck. For the
cervical esophagus, the nodal classifi cation differs as
follows:
N0 No regional lymph node metastasis
N1 Regional lymph node metastasis
From Lefebvre JL, Chevalier D, Coche-Dequeant B: Cancer of
the hypopharynx and cervical esophagus. In Myers EN, Suen JY,
Myers JN, Hanna EY (eds): Cancer of the Head and Neck, 4th ed.
Philadelphia, WB Saunders, 2003, pp 379-390.

478
Section 4
Hypopharynx and Cervical Esophagus
poor, but newer protocols using concurrent chemora-
diation therapy appear to offer improved cure rates
with occasional effective palliation. Most patients
require long-term gastrostomy tube feeding, and some
require palliative laryngectomy or laryngotracheal sepa-
ration to control aspiration. Control rates of 88% were
reported by Burmeister and coworkers, with surgical
salvage successful in fi ve patients.4 Peracchia and col-
leagues, however, reported local control in only approx-
imately 33% of their patients randomized to one of
two chemoradiation arms.3 Successful surgical salvage
was reported in 25 patients treated by Meunier and
associates.22
Reconstruction of an intact swallowing tube is a
prerequisite for the rehabilitation of patients with
cancer of the cervical esophagus. With the exception of
the very few patients with limited cancer, most are
treated by total laryngopharyngoesophagectomy with
gastric transposition (pull-up) and pharyngogastric
anastomosis as described by Ong and Lee more than 40
years ago.23 This technique permits removal of the
primary cancer, as well as the entire esophagus, which
has the attendant risk of submucosal spread and “skip”
lesions. Such “skip lesions” were identifi ed in 3% of
a series of 209 patients treated by Peracchia and
coworkers.3
SURGICAL TECHNIQUE
The patient is taken to the operating room and endo-
tracheal anesthesia is induced. A rolled towel is placed
under the patient’s shoulders to provide extension of
the neck. The patient is then prepared and draped in
such a way that there is access not only to the head and
neck but also to the chest and abdomen. Appropriate
draping is carried out so that after the head and neck
procedure is complete, the drapes may be removed and
the reconstruction carried out.
An apron fl ap is elevated. One sternocleidomastoid
muscle is retracted laterally and the larynx medially.
The carotid sheath is retracted laterally and the prever-
tebral fascia is identifi ed by blunt dissection. Finger
palpation is then used to determine whether the cancer
has infi ltrated into the retropharyngeal or retroesopha-
geal space or into the prevertebral fascia. If cancer is
present in the retropharyngeal or retroesophageal
space, the surgery should be terminated because it is
impossible to get a clear margin of resection posteriorly
when invasion of the prevertebral fascia is present. In
such cases, a gastrostomy and possibly a tracheostomy
should be carried out to provide a means of nutrition
and maintenance of the airway. If the retropharyngeal
space is clear, surgery should proceed. Bilateral selec-
tive neck dissection is performed. If the patient has an
N0 neck, levels II, III, IV, and VI are dissected. Dissec-
tion of level VI is mandatory because multiple lymph
nodes in the tracheoesophageal groove may be involved.
For more information on neck dissection, see Chapter
78.
The extent of tracheal resection is dictated by
the imaging studies and tracheoscopy. If there is
no tracheal involvement, the usual transection of
the trachea between the second and third tracheal
rings is appropriate. However, if cancer has extended
into the trachea, more of the distal trachea may
need to be resected. It is important to remove the
thoracic esophagus because of the frequent presence
of multifocal disease and second primaries of the
esophagus.
A transhyoid pharyngotomy is carried out (Fig. 56-
3) and the retropharyngeal fascia is separated from
the prevertebral fascia in the retropharyngeal space up
into the level of the transhyoid incision. At this point
scissors can be used to cut through the posterior wall
of the pharynx. After this is carried out, the specimen
containing the larynx and pharynx attached to the cer-
vical esophagus is then elevated by sharp and blunt
dissection down as far as possible into the anterior
mediastinum (Fig. 56-4). Ligation of the superior
laryngeal arteries and veins is carried out during this
procedure. The adjacent lymph nodes, including the
retropharyngeal group, should also be taken at this
point. Inspection of the thyroid gland will determine
whether the thyroid gland should be left intact or be
totally or partially removed. Oftentimes the thyroid
tissue has been infi ltrated by cancer and must therefore
be removed (see Fig. 56-2). Specimens should be taken
from the superior margin of resection of the pharynx
and sent to the pathology department to make certain
that the margins of resection are free of cancer. If not,
additional specimens must be taken until clear margins
are obtained. The specimen remains attached until the
stomach is mobilized.
It should be known beforehand, with the combina-
tion of imaging studies and endoscopy, whether the
tumor is fi xed to the prevertebral fascia or is encasing
the carotid arteries. If, however, the surgeon unexpec-
tedly fi nds encasement of the carotid arteries, the extir-
pative part of the procedure should be continued with
the understanding that this is palliative rather than
curative surgery. The stomach is then mobilized in the
abdomen. Blunt dissection in the mediastinum from
the abdomen into the neck allows the specimen to be
delivered and the stomach to be delivered into the neck
by applying gentle traction to each (Fig. 56-5). The
esophagus is separated from the stomach at the gastro-
esophageal junction, the lumen of the pharynx and
esophagus is opened, and the edges of the specimen
are checked microscopically for tumor clearance
(Fig. 56-6).
Most tumors arising in the cervical esophagus are
malignant, and pharyngolaryngoesophagectomy is nec-
essary to obtain clear margins of resection. For the
occasional patient with a small cancer or in the event
of a benign tumor, limited resection of the cervical
esophagus with preservation of the larynx and the func-
tion of the cricopharyngeus muscle and vocal cords may
be possible. However, an intact larynx and cervical
trachea severely limit exposure of the cervical esopha-
gus and make reconstruction technically diffi cult. Mizo-
buchi and colleagues24 used a Weerda laryngoscope to
remove an early esophageal cancer.

Chapter 56
Cancer of the Cervical Esophagus
479
Reconstruction
Reconstruction of the esophagus is carried out by a
reconstructive team, with some exceptions, which will
be explained later. Several types of surgical reconstruc-
tive techniques can be used in the case of total laryngo-
pharyngoesophagectomy, including enteric procedures
such as gastric and colonic transposition, free fl aps, and
a combination of free fl aps and regional fl aps.
A
B
Figure 56-3. A, Transhyoid phar-
yngotomy is carried out and the
pharyngeal lumen is explored. B,
The incision is carried through the
lateral and posterior pharyngeal
wall to separate the pharynx from
the base of the tongue. (From Silver
CE: Surgery for Cancer of the Larynx
and Related Structures. New York,
Churchill
Livingstone,
1981,
pp
198-199.)
Figure 56-4. The specimen is elevated off the prevertebral fascia
by fi nger dissection as far inferior as the superior mediastinum, where
it is pedicled on the cervical esophagus.
Figure 56-5. Using gentle traction on the specimen and the
stomach allows the specimen to be delivered and the stomach to be
brought
into
the
neck
to
complete
the
pharyngogastric
anastomosis.

480
Section 4
Hypopharynx and Cervical Esophagus
Gastric Transposition
The late Sir Donald Harrison6 reported his experience
in 1986 with a review of 101 operations carried out at
the Royal Nose, Throat and Ear Hospital on patients
with cancer of the hypopharynx and cervical esophagus.
He popularized the use of laryngopharyngoesophagec-
tomy with gastric transposition for cancer of the cervical
esophagus. Most head and neck surgeons believe that
resection of the entire esophagus gives the best oppor-
tunity both for control of the primary cancer in the
cervical esophagus and for removal of second primary
cancers in the thoracic esophagus.
Rapid re-establishment of deglutition is very desir-
able, and gastric transposition also has the advantage of
being a reliable single-stage method of reconstruction.
The disadvantages are that abdominal dissection is
required and gravity creates tension on the suture line,
which may involve previously irradiated tissue. Intro-
duction of the laparoscopic technique of mobilizing
the stomach should overcome the disadvantage of
the extensive open abdominal dissection.25 Patients
commonly exhibit early satiety because of the loss of
stomach-fi lling capacity.26
After the stomach has been transposed up into the
neck, a two-layer closure with nonabsorbable suture is
carried out to sew the stomach to the remaining
walls of the hypopharynx and the base of the tongue
(Fig. 56-7). Postoperative chest radiography shows the
stomach widening the mediastinal shadow (Fig. 56-8).
Figure 56-6. Laryngopharyngoesophagectomy specimen. It will be
opened lengthwise to inspect the mucosa of the pharynx and esopha-
gus and to be certain that tumor clearance is microscopically
adequate.
Figure 56-7. Diagram of gastric transposition with pharyngogastric
anastomosis.
Figure 56-8. Postoperative chest radiograph demonstrating the
stomach widening the mediastinal shadow.

Chapter 56
Cancer of the Cervical Esophagus
481
Colonic Interposition
This procedure is usually reserved for the rare situation
in which either a gastric transposition or a free tissue
transfer is not possible. Preparation of the bowel with a
pure liquid diet and oral intake of antibiotics directed
at colonic fl ora is instituted 48 hours before surgery.
Cheng and coauthors27 reported a series of cases in
which colonic interposition was used for reconstruction
in patients who had cancer of the esophagus that
occurred after partial or subtotal gastrectomy. The
authors believed that the reconstruction was performed
without major complications and provided good func-
tion. Colonic interposition has somewhat limited reach
cephalad, and the presence of inherent bacteria places
the mediastinum and abdomen at risk if a leak
occurs.26
At the end of the procedure a tracheostoma is
fashioned in the usual way (see Chapter 49). We have
performed, with a reasonable degree of success,
“tracheogastric” puncture in patients in whom recon-
struction involves gastric transposition and “tracheoje-
junal” puncture in those in whom repair is accomplished
with a jejunal interposition fl ap. This procedure is
simple and safe, and puncture into the jejunum pro-
duces a rather “moist” voice but one that is under-
standable. Puncture through the posterior wall of
the trachea into the transposed stomach also produces
a suboptimal, though understandable low-volume
voice. The reader is referred to Chapter 81 to obtain
more
information
about
reconstruction
after
laryngopharyngoesophagectomy.
Free Flaps
In 1959, Seidenberg and colleagues28 reported using a
free jejunal autograft for reconstruction after pharyn-
goesophagectomy for recurrent cancer. This was the
fi rst use of a free tissue transfer in humans. Since that
time, several other free tissue transfers have been intro-
duced for reconstruction after esophageal resection,
including gastro-omental fl aps, the radial forearm fl ap,
and the anterolateral thigh fl ap. A gastro-omental fl ap
has several advantages. The stomach mucosa can be
used to line defects in the oral cavity and oropharynx
and can be tubed for pharyngeal reconstruction. The
mucosa of the stomach is non–hair bearing, pliable,
and easily fashioned to reconstruct a three-dimensional
defect.26 Perhaps the most unique advantage of this fl ap
is its ability to secrete mucus. This improves the quality
of life of patients, particularly in those who have
postradiation xerostomia. Righini and associates29 also
described the use of a tubed gastro-omental free
fl ap for hypopharyngeal and cervical esophageal recon-
struction after total laryngectomy. Five of their six
patients had previously undergone chemoradiation
therapy, and three had previously undergone surgery.
Patients who survived had a normal diet and esophageal
voice.
The free jejunal autograft (FJA) is a versatile
fl ap that is most useful in patients with cancer of
the hypopharynx because the distal suture line is not
placed in the mediastinum. However, in surgical
management of cancer of the cervical esophagus,
use of the jejunum is limited. Some authors have
reported success in a limited series of cases. Shirakawa
and coauthors30 reported use of the FJA in a series of
54 patients. Cervical esophageal resection with success-
ful laryngeal preservation and reconstruction with an
FJA was performed in six patients with cancer of the
cervical esophagus, all of whom enjoyed a good quality
of life.
Wadsworth and colleagues31 described for the fi rst
time in humans laparoscopic harvesting of an FJA for
reconstruction of hypopharyngeal and cervical esopha-
geal lesions. Bardone and associates32 also described
their experience with laparoscopic techniques and
reported good results with a low complication rate.
These advances in harvesting eliminate the potential
morbidity of an open abdominal procedure. Ascioti and
coworkers33 described a long-segment, supercharged,
pedicled jejunal free tissue transfer for total esophageal
reconstruction. Microvascular augmentation of a pedi-
cled jejunal fl ap allows the creation of a longer conduit,
thus making it possible to replace the entire esophagus
in one stage. The authors reported excellent functional
outcomes despite the severity of disease and the techni-
cal challenge. Takushima and colleagues34 described a
double vascular pedicled free jejunal transfer for total
esophageal reconstruction. A long jejunal segment with
this vascular pedicle can be transferred as a free fl ap
and used to reconstruct the entire esophagus in one
stage.
Microvascular free jejunal transfer combined with
a deltopectoral fl ap has been reported by McCarthy and
coauthors35 for reconstruction of the tracheostoma and
cervical esophagus after exenteration of the contents of
the central portion of the neck. Combined defects of
the skin, larynx, pharynx, and esophagus after exentera-
tion of the central compartment of the neck can be
extremely diffi cult to reconstruct. These complex
defects can be effectively reconstructed with free jejunal
transfer to restore continuity of the alimentary tract and
with a deltopectoral fl ap to reconstruct the tracheos-
toma and surrounding cutaneous defects. The delto-
pectoral fl ap provides a large volume of well-vascularized
tissue that affords reliable coverage of the newly recon-
structed cervical esophagus and exposed major vessels
after exenteration of the central compartment. Its thin,
pliable nature allows suturing of the trachea to the skin
edge without tension and avoids intraluminal prolapse
of excess soft tissues, thus maintaining patency of the
tracheostoma.
Yu36 described a novel technique performed in
10 patients for reconstruction of combined pharyngo-
esophageal, tracheal, and anterior neck defects with
a single anterior thigh fl ap. The skin paddle was
divided into two islands based on cutaneous perfora-
tors. One paddle was tubed and used for esophageal
reconstruction and the other for repair of cutaneous
defects. This technique provides good cosmetic and
functional results with minimal morbidity and quick
recovery.

482
Section 4
Hypopharynx and Cervical Esophagus
POSTOPERATIVE MANAGEMENT AND
COMPLICATIONS
Postoperative management and complications of neck
dissection are described in Chapter 78 and complica-
tions of laryngectomy in Chapter 49. The principles are
not different for patients undergoing surgery for cancer
of the cervical esophagus and include progressive
resumption of an oral diet. Postoperative management
of patients who have undergone gastric transposition
includes the insertion of a nasogastric tube to facilitate
decompression of the gastrointestinal tract. If for some
reason the condition of the patient precludes early
resumption of oral intake, total parenteral nutrition
through a central venous catheter can be instituted.
Chest tubes are used routinely in patients undergoing
gastric transposition and placed in water-sealed suction
bottles.
Postoperative complications may include pleural
effusion and pneumonia. This is related to the transme-
diastinal dissection and is usually self-limited, and the
chest tubes are removed when no longer necessary.
Intrathoracic chyle leak in which several liters of fl uid
can accumulate has been reported. Such high-volume
chyle leaks need to be repaired surgically in the near
term because they may produce severe metabolic abnor-
malities. Necrosis of the gastric transposition tube is a
known complication that may be associated with a high
mortality rate because the abdomen, thorax, mediasti-
num, and neck compartments all become contaminated
with oral cavity bacteria. Stricture of the gastropharyn-
geal junction, though a possibility, has not been re -
ported, and in fact the match between the stomach and
hypopharynx is quite good and remains patulous, which
fortunately, on the positive side, allows good swallow-
ing, but it can also promote refl ux and regurgitation
both in the recumbent position and when the patient
stands upright and then bends over.
Triboulet and coauthors37 reported a total mortality
rate of 4.8% and an overall morbidity rate of 38.3% in
a series of 209 patients, including 78 with cancer of
the cervical esophagus. Reconstruction was carried out
via gastric transposition, colonic transposition, or a
jejunal free fl ap. Gastric transposition is the most fre-
quent cause of respiratory complications. The survival
rate without dysphagia is better in patients with gastric
transposition than in those with jejunal grafts. The
authors found no signifi cant difference in survival
between the techniques of reconstruction. However,
better results were obtained with gastric transposition
because of fewer postoperative complications, faster re-
establishment of oral feeding, and better quality of
life.
Podrecca and colleagues,38 in their review of 346
patients who underwent free fl ap reconstruction in the
head and neck, found that poor preoperative condi-
tion, previous treatment, and requirement for a vein
graft were signifi cantly associated with an increased risk
for fl ap failure and other morbidities. Fistula formation
occurs in 7% to 37% of patients.37 Necrosis and fi stula
rates are higher when jejunal free fl aps are used than
with gastric transposition. Murray and coworkers39 re -
ported that in none of the 14 patients reconstructed
with a combination of anterior thigh fl ap and salivary
bypass did a fi stula develop despite the fact that some
had been treated previously. In one of their patients a
stricture developed that was successfully treated by
dilatation.
Stricture formation after pharyngolaryngoesopha-
gectomy is a complication that can be treated in several
ways. The most direct approach is surgical revision of
the stricture. However, the stricture is often the result
of fi stula formation with healing by secondary inten-
tion. Because of intense scarring and previous irradia-
tion therapy, this surgical approach may cause greater
problems than the stricture with the potential for wound
breakdown and fi stula formation.
Balloon dilatation of strictures of the cervical anas-
tomosis after pharyngoesophageal resection was per-
formed successfully by Szentkereszty and associates.40
The mean time from surgery to dilatation was 7.8
months, and the mean number of dilatations was 3.2.
A stent was placed in patients whose strictures were due
to recurrent cancer.
Self-expanding metal stents have been used to
provide rapid relief from dysphagia and may seal off
tracheoesophageal fi stulas.41 Some stents incorporate
an antirefl ux valve, which has been shown to reduce
symptoms of GERD. These stents are also useful for
starting early feeding in patients. Tomifuji and col-
leagues42 used silicone stents for the treatment of
pharyngocutaneous fi stula.
Replacement of thyroid hormone is necessary in
patients whose thyroid gland has been removed at the
time of the surgery with the specimen. Similarly, calcium
replacement is necessary when the parathyroid glands
have been removed. GERD precautions should be taken
and every patient should receive proton pump inhibi-
tors in the postoperative period.
PEARLS
• Survival is heavily infl uenced by early diagnosis.
• Carcinoma arising in the cervical esophagus is rare,
and cancer involving this site is more often direct
extension from the hypopharynx.
• The best opportunity to cure squamous cell
carcinoma of the cervical esophagus is provided by
complete excision of the tumor.
• Gastric transposition after excision of cancer of the
cervical esophagus is a reliable single-stage
procedure that allows complete tumor extirpation
and early resumption of swallowing.
• Resection of cancer of the cervical esophagus that is
obstructing the patient’s swallowing is a legitimate
palliative procedure and may result in cure.

Chapter 56
Cancer of the Cervical Esophagus
483
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therapy and radiotherapy for organ preservation in advanced
laryngeal cancer. N Engl J Med 349:2091-2098, 2003.
10. Liberale G, De Simone P, Snoeck R, et al: Verrucous carcinoma
of the esophagus. A case report. Minerva Chir 60:61-65, 2005.
11. Alrawi SJ, Winston J, Tan D, et al: Primary adenocarcinoma of
the cervical esophagus. J Exp Clin Cancer Res 24:325-330, 2005.
12. Abe T, Hosokawa M, Kusumi T, et al: Adenocarcinoma arising
from ectopic gastric mucosa in the cervical esophagus. Am J Clin
Oncol 27:644-645, 2004.
13. von Rahden BH, Stein HJ, Becker K, Siewert RJ: Esophageal
adenocarcinomas in heterotopic gastric mucosa: Review and
report of a case with complete response to neoadjuvant radioche-
motherapy. Dig Surg 22:107-112, 2005.
14. Oguma J, Ozawa S, Omori T, et al: EMR of a hyperplastic polyp
arising in ectopic gastric mucosa in the cervical esophagus: Case
report. Gastrointest Endosc 61:335-338, 2005.
15. Matsushita M, Okazaki K: Pedunculated hyperplastic polyps in
the cervical esophagus: EMR vs. snare polypectomy. Gastrointest
Endosc 61:335-338, 2005.
16. Caceres M, Steeb G, Wilks SM, Garrett HE Jr: Large pedunculated
polyp originating in the esophagus and hypopharynx. Ann
Thorac Surg 81:393-396, 2006.
17. Sargent RL, Hood IC: Asphyxiation caused by giant fi brovascular
polyp of the esophagus. Arch Pathol Lab Med 130:725-727,
2006.
18. Szumilo J, Kotarska M, Chroscicki A, Korobowicz E: Leiomyoma
of the cervical esophagus: A case report. Ann Univ Mariae Curie
Sklodowska 58:22-24, 2003.
19. Marin VP, Yu P, Weber RS: Isolated cervical esophageal recon-
struction for rare esophageal tumors. Head Neck 28:856-860,
2006.
20. Pesko P, Bjelovic M, Sabljak P, et al: Intraoperative endoscopy in
obstructive hypopharyngeal carcinoma. World J Gastroenterol
28:4561-4564, 2006.
21. Gibbs J, Cull W, Henderson W, et al: Preoperative serum albumin
level as a predictor of operative mortality and morbidity: Results
from the National VA Surgical Risk Study. Arch Surg 134:36-42,
1999.
22. Meunier B, Raoul J, Le Prise E, et al: Salvage esophagectomy after
unsuccessful curative chemoradiotherapy for squamous cell car-
cinoma of the esophagus. Dig Surg 15:224-226, 1998.
23. Ong GB, Lee TC: Pharyngogastric anastomosis after oesophago-
pharyngectomy for carcinoma of the hypopharynx and cervical
oesophagus. Br J Surg 48:193-200, 1960.
24. Mizobuchi S, Nakatani H, Akimori T, et al: Novel use of a Weerda
laryngoscope to remove early cervical esophageal cancer. Ann
Thorac Surg 79:34-35, 2005.
25. DePaula AL, Macedo AL, Cernea CR, et al: Reconstruction of
upper digestive tract: Reducing morbidity by laparoscopic pull-
up. Otolaryngol Head Neck Surg 135:710-713, 2006.
26. Lorenz RR, Alam DS: The increasing use of enteral fl aps in
reconstruction for the upper aerodigestive tract. Curr Opin Oto-
laryngol Head Neck Surg 11:230-235, 2003.
27. Cheng BC, Xia J, Shao K, et al: Surgical treatment for upper or
middle esophageal carcinoma occurring after gastrectomy: A
study of 52 cases. Dis Esophagus 18:239-245, 2005.
28. Seidenberg B, Rosenak SS, Hurwitt ES, Som ML: Immediate
reconstruction of the cervical esophagus by a revascularized iso-
lated jejunal segment. Ann Surg 149:162-171, 1959.
29. Righini CA, Bettega G, Lequeux T, et al: Use of tubed gastro-
omental free fl ap for hypopharynx and cervical esophageal
reconstruction after total laryngopharyngectomy. Eur Arch Oto-
rhinolaryngol 262:362-367, 2005.
30. Shirakawa Y, Naomoto Y, Noma K, et al: Free jejunal graft for
hypopharyngeal and esophageal reconstruction. Langenbecks
Arch Surg 389:387-390, 2004.
31. Wadsworth JT, Futran N, Eubanks TR: Laparoscopic harvest of
the jejunal free fl ap for reconstruction of hypopharyngeal and
cervical esophageal defects. Arch Otolaryngol Head Neck Surg
128:1384-1387, 2002.
32. Bardone M, Alessiani M, Zonta S, et al: Laparoscopic harvest of
the jejunal free fl ap for cervical esophageal reconstruction.
Minerva Chir 61:171-175, 2006.
33. Ascioti AJ, Hofstetter WL, Miller MJ, et al: Long-segment, super-
charged, pedicled jejunal fl ap for total esophageal reconstruc-
tion. J Thorac Cardiovasc Surg 130:1391-1398, 2005.
34. Takushima A, Momosawa A, Asato H, et al: Double vascular ped-
icled free jejunum transfer for total esophageal reconstruction. J
Reconstr Microsurg 21:5-10, 2005.
35. McCarthy CM, Kraus DH, Cordeiro PG: Tracheostomal and cervi-
cal esophageal reconstruction with combined deltopectoral fl ap
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teration. Plast Reconstr Surg 115:1304-1310, 2005.
36. Yu P: One-stage reconstruction of complex pharyngoesophageal,
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956, 2005.
37. Triboulet JP, Mariette C, Chevalier D, Amrouni H: Surgical
management of carcinoma of the hypopharynx and cervical
esophagus: Analysis of 209 cases. Arch Surg 136:1164-1170,
2001.
38. Podrecca S, Salvatori P, Squadrelli SM: Review of 346 patients
with free-fl ap reconstruction following head and neck surgery for
neoplasm. J Plast Reconstr Aesthet Surg 59:122-129, 2006.
PITFALLS
• Attempts to resect the cervical esophagus while
maintaining an intact laryngotracheal tract are
challenging and require a nearly perfect combination
of tumor location, stage, and surgical skill.
• Failure to adequately assess tumor extent
preoperatively will often result in inadequate
resection of the cancer.
• Previous gastric surgery or placement of a
gastrostomy tube to correct malnutrition may make
gastric transposition impossible.
• Postoperative complications are common after
extensive procedures performed on nutritionally
depleted patients.
• Salvage laryngopharyngoesophagectomy for failed
chemoradiation therapy is associated with a high
incidence of wound complications.

484
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39. Murray DJ, Gilbert RW, Vesely MJJ, et al: Functional outcomes
and donor site morbidity following circumferential pharyngo-
esophageal reconstruction using an anterolateral thigh fl ap and
salivary bypass tube. Head Neck 29:147-154, 2007.
40. Szentkereszty Z, Szegedi L, Boros M, et al: Balloon dilatation of
strictured cervical anastomosis after subtotal esophagus resec-
tion. Orv Hetil 147:2421-2423, 2006.
41. Costamagna G, Marchese M, Iacopini F: Self-expanding stents in
oesophageal cancer. Eur J Gastroenterol Hepatol 18:1177-1180,
2006.
42. Tomifuji M, Shiotani A, Takaoka T, et al: Clinical experience with
silicon pharyngeal tube for pharyngocutaneous fi stula and cervi-
cal esophagus stenosis. Nippon Jibiinkoka Gakkai Kaiho 109:530-
534, 2006.

section 5
Salivary Glands
Offi ce-Based Procedures
Chapter 57
Transoral Removal of Salivary Duct Calculi
David E. Eibling
Acute, painful enlargement of the major salivary gland
is usually caused by a calculus within the excretory
ducts. Occasionally, these calculi will pass spontane-
ously, but removal of impacted calculi, when necessary,
is the optimal management strategy. If the calculus
cannot be removed, alternative techniques, usually sur-
gical removal of the gland itself, may be required.
Recently developed instrumentation facilitates diagnos-
tic endoscopy of the excretory ductal system, and
removal of calculi by a variety of methods may be pos-
sible in selected cases in centers in which this expertise
has been developed.1
Salivary calculi are composed of both organic and
inorganic substances. Calcium apatite is the most
common mineral substance encountered, although
other calcium compounds can be found. Recent
polymerase chain reaction–based studies suggests a
bacterial cause, and there may be correlation with a
history of tobacco use. The majority of calculi (60% to
90%) arise within the submandibular gland, although
centers using newer diagnostic instrumentation have
identifi ed greater numbers of parotid calculi than in
earlier reports.1
PATIENT SELECTION
Salivary calculi obstructing any of the four major sali-
vary glands can lead to sudden and painful swelling of
the gland (Fig. 57-1A). Typically, there is a history of
recurrent swelling, particularly with meals. Occasion-
ally, patients may have acute, rather severe bacterial
infection with or without cellulitis that requires treat-
ment with antibiotics. Severe infection in an obstructed
submandibular duct with marked cellulitis can lead to
airway obstruction requiring aggressive management, at
times including tracheotomy.
Physical examination remains an important diag-
nostic tool, even today, and should not be replaced by
imaging! Careful bimanual palpation of the affected
gland and its excretory duct is required in all cases.
Identifi cation of a palpable calculus in an accessible
location may dictate the choice of therapy. It is not
necessary to wait for antibiotic therapy to be instituted
before transoral removal of a calculus because release
of the obstruction will often result in rapid resolution
of the symptoms and infection.
Physical examination reveals an enlarged, tender
gland. Associated soft tissue infl ammation may preclude
discrete palpation of the gland itself. In patients with
severe infl ammation of the submandibular gland, swell-
ing may extend into the fl oor of the mouth. The fi nding
of edema of the fl oor of the mouth suggests secondary
cellulitis, and the surgeon must ensure that adequate
monitoring and airway support are available.
Some patients will have marked swelling and abscess
formation. In these cases calculus removal alone may
be insuffi cient for management. Occasionally, a patient
may have cellulitis of the entire neck and require emer-
485

486
Section 5
Salivary Glands
gency airway management, including tracheotomy and
external surgical drainage. Patients with long-standing
obstruction may form a fi stulous tract to the skin and
actually extrude the calculus (Fig. 57-2).
Intraoral examination may reveal the calculus pal-
pable at or just proximal to the orifi ce of the duct (see
Fig. 57.1B). In these instances, transoral removal of the
calculus and release of the obstruction should result in
complete resolution of the patient’s symptoms almost
immediately. In other patients, however, the calculus
may be in a more proximal position. Radiologic imaging
is often helpful and may be supplemented (or poten-
tially replaced) by sialoendoscopy (Fig. 57-3).1 Calculi
within the submandibular duct or hilum of the gland
can often be visualized on plain radiography of the
lateral mandible or an occlusal plain radiograph. An
occasional calculus is not suffi ciently radiopaque to be
visualized on radiographs, so a negative plane fi lm
should not rule out the presumptive diagnosis.
Computed tomography (CT) scanning is often of
considerable benefi t when the diagnosis is unclear,
especially for identifi cation of calculi within the parotid
duct. CT imaging must be performed both with and
without contrast enhancement because a calculus can
be confused with a contrast-enhanced vascular struc-
ture. Sialography performed with injection of contrast
medium into the duct has been a standard tool for
evaluation for some years; however, it is technically
diffi cult and sometimes impossible to perform, may be
A
B
Figure 57-1. A, Infl amed right parotid gland as a result of a stone
impacted in Stenson’s duct. B, Purulent exudate from the duct after
stone manipulation.
Figure 57-2. Fistulous tract that developed after prolonged obstruc-
tion of the left parotid duct by a large calculus.
Figure 57-3. Occlusal plane radiograph demonstrating a calculus
impacted at the orifi ce of Wharton’s duct (small arrow). Unfortunately,
a second calculus was noted more posteriorly in the proximal duct
(large arrow). Although removal of the anterior calculus may be per-
formed easily via the transoral route, unless the more proximal cal-
culus passes spontaneously, excision of the entire submandibular
gland may be necessary.

Chapter 57
Transoral Removal of Salivary Duct Calculi
487
associated with considerable discomfort, and is contra-
indicated in the face of acute infl ammation. Recently
introduced signal acquisition techniques using new
magnetic resonance imaging equipment and protocols
may replace sialography.1,2
Sialoendoscopy using 1-mm rigid optical endo-
scopes with a variety of working sheaths and channels
for irrigation and with instrumentation for retrieval has
been introduced by Marchal and Dilguerov and has
demonstrated excellent utility in experienced hands.1
This technology may become routine as both the instru-
mentation and surgeons trained in its use become more
available.
Large calculi impacted in the hilum of the subman-
dibular or parotid glands have historically not been
considered removable via the transoral route, but recent
reports of transoral removal of stones from the hilum
of the submandibular gland have been published.3
Newer techniques using sialoendoscopy with stone frag-
mentation and retrieval may further alter the treatment
paradigms in the near future. At this time, however,
surgical excision of the affected gland is necessary in
most such instances.
The submandibular gland is most commonly
excised for chronic sialoadenitis secondary to calculus.
The procedure has low risk and is relatively straightfor-
ward (see Chapter 61). In contrast, parotidectomy for
chronic infection is technically diffi cult because of peri-
neural scarring and carries a high rate of temporary
facial paralysis. These procedures are best performed
by one of the small number of individuals who are
experienced in these diffi cult dissections.
Transoral extraction of calculi impacted at the
orifi ce of the duct can be removed in the outpatient
setting with common offi ce instrumentation. Topical
anesthesia supplemented by minimal local injection is
usually adequate, and sedation is not required.
SURGICAL TECHNIQUE
Magnifi cation is essential for this procedure and may
consist of either loupes or the operating microscope. If
the latter is used, it is easiest to have the patient recline
on a table and for the surgeon to hold the mouth open
with the nondominant hand and to cradle the head of
the patient in the crook of the arm. Loupes or “naked
vision” can be used with the patient sitting or reclining.
In a sitting position, patients must lean forward and
open their mouth. Oral suction is necessary because
patients will be unable to swallow during the course of
the procedure. An assistant should be available to assist
in suctioning the oral cavity.
After palpation has revealed the presence of a cal-
culus in the distal duct, the overlying mucosa is anes-
thetized by the topical application of 10% lidocaine
(Xylocaine), 4% lidocaine, or 2% tetracaine (Ponto-
caine). The effectiveness of topical anesthesia can be
enhanced by drying the mucosa with a sponge before
application of the anesthetic. Additional anesthesia and
hemostasis are achieved by injection of a small amount
of lidocaine with 1:100,000 epinephrine. Waiting for
5 to 10 minutes before proceeding will improve the
hemostatic effect of the epinephrine and reduce bleed-
ing in the site. Some surgeons place a probe within the
duct before injection of local anesthetic because of the
deformity caused by the injection.
If the calculus is readily palpated and is bulging
through the duct orifi ce, simply excising the mucosa
adjacent to the calculus may release it suffi ciently to
allow removal. More commonly, however, the calculus
may be palpated but is not directly at the orifi ce. The
orifi ce must fi rst be probed with a lacrimal probe in
these cases (Fig. 57-4A). Identifi cation of the punctum
can be challenging, especially in the presence of an
infl amed papilla. Magnifi cation is helpful and patience
is required to identify and cannulate it. Trauma caused
by indelicate probing will lead to bleeding and loss of
visualization, so it is critical to use gentle technique.
The probe is inserted into the duct and the calculus
is palpated, after which the orifi ce of the duct is dilated
with lacrimal dilators of increasing size (see Fig. 57-4B).
One point of the iris scissors is then placed within the
duct, and with a single snip, the duct mucosa and over-
lying oral mucosa are incised to open the duct widely
(Fig. 57-5). The calculus can usually be easily retrieved
at this stage, and the procedure is completed (Fig.
57-6). Some surgeons use small absorbable suture to
marsupialize the now-open duct. Because continued
fl ow of saliva will maintain an adequate duct orifi ce in
most patients, marsupialization is rarely necessary.
Additional calculi are often found posterior to the
A
B
Figure 57-4. A, A lacrimal probe is inserted into the orifi ce of
Wharton’s duct. B, The duct is then dilated with a lacrimal dilator.

488
Section 5
Salivary Glands
excised calculus, so examination via repeat probing of
the duct should be performed.
Calculi located in the midportion of the subman-
dibular duct can be removed by incising the lateral
fl oor of the mouth and dissecting the soft tissue down
to the duct. Care must be taken to avoid injury to the
lingual nerve. Access to the duct is enhanced by having
the assistant apply pressure on the submandibular
space. When the duct and calculus have been identi-
fi ed, the duct is incised just over the calculus. Before
the calculus is removed, 4-0 silk suture is passed through
the mucosa of the fl oor of the mouth and the wall of
the duct on either side of the calculus. The calculus is
then extracted, and several more sutures are placed to
marsupialize the duct (Fig. 57-7).
Figure 57-5. Scissors are placed within the orifi ce of the duct to
incise the puncta of the duct.
Figure 57-6. Calculus removed from the anterior duct superim-
posed on the radiograph that demonstrated its presence. This calcu-
lus was easily removed by widening the orifi ce with iris scissors.
A
B
Figure 57-7. A, The duct is marsupialized to prevent strictures by
sewing the mucosa of the duct to the mucosa of the fl oor of the
mouth. B, Detail of the marsupialization sutures.
Calculi can frequently be identifi ed in the more
proximal portion of the duct by palpating them with a
probe. Removal may require milking the gland after
incision of the duct. Occasionally, calculi can be freed
by oral rinses and secretagogues more easily than by
surgical manipulation. Most calculi impacted in the
hilum of the gland or the proximal portion of the duct
cannot be removed, and excision of the submandibular
gland will be required. Nonetheless, transoral removal
of hilar stones has been reported3 and is performed in
a manner similar to that for transoral excision of the
submandibular gland (see Chapter 61).
Because the parotid duct passes lateral to the mas-
seter muscle, calculi impacted proximal to the orifi ce
of the duct require alternative techniques for removal.
Marchal has developed an approach to removing calculi
from the proximal end of Stensen’s duct.4 He uses the
sialoscope to identify the calculus in Stensen’s duct and
then exposes the duct through an external approach.
The light from the endoscope helps the surgeon iden-
tify the calculus. He then opens the duct, extracts the
calculus, and repairs the damage that has been done to
the duct from the calculus.

Chapter 57
Transoral Removal of Salivary Duct Calculi
489
Endoscopic Removal
Full discussion of endoscopic removal is beyond the
scope of this chapter. In addition to appropriate in -
strumentation, extensive training and experience are
required for successful completion of examination and
removal of calculi. A 1.3-mm operating sheath contain-
ing the endoscope, a 0.25-mm irrigation channel, and
a 0.65-mm working channel (Fig. 57-8) are inserted into
the dilated duct. A small Domia basket or laser fi ber can
be passed through the working channel of the sheath.
Small calculi are visualized and retrieved from within
B
A
Figure 57-8. A and B, Photographs of an optical telescope for sialoendoscopy. The largest working sheath is 1.3 × 1.1 mm in size, with an
irrigation channel of 0.25 mm and a working channel of 0.65 mm.
Figure 57-9. Endoscopic view of a salivary calculus captured in a
basket before removal.
the ducts, whereas larger ones are fragmented by laser
before retrieval. Because the parotid duct is smaller,
calculi impacted in the parotid duct are a signifi cantly
greater challenge than those within the submandibular
duct (Fig. 57-9).
PEARLS
• A history of recurrent swelling of the submandibular
or parotid gland suggests obstruction of the
excretory duct, usually by calculus.
• Calculus impacted at the orifi ce of the duct can
easily be palpated and removed.
• The submandibular gland must usually be removed
in the case of calculi impacted in the hilum of the
duct.
• Parotid duct stones impacted proximal to the duct
orifi ce will require parotidectomy for removal.
• New technology consisting of miniature endoscopes
to illuminate Stensen’s duct, together with external
exposure of the duct, can lead to extraction of
calculi and reconstruction of the duct.4
PITFALLS
• Failure to identify and remove a stone impacted at
the duct orifi ce can result in prolonged swelling,
infection, and potentially avoidable morbidity.
• Excessive trauma to the duct orifi ce will lead to
edema and bleeding.
• Recurrent calculus may be an indication of
hypercalcemia.
• Failure to extract the calculus may result in cellulitis
of the gland and surrounding tissue.

490
Section 5
Salivary Glands
References
1. Marchal F, Dilguerov P: Sialolithiasis management: The state of
the art. Arch Otol 129:951-956, 2003.
2. Becker M, Marchal F, Becker C, et al: Sialolithiasis and salivary
ductal stenosis: Diagnostic accuracy of MR sialography with a
three-dimensional extended-phase conjugate-symmetry rapid spin
echo sequence. Radiology 217:347-358, 2000.
3. Capaccio P, Bottero A, Pompilio M, Ottaviani F: Conservative
transoral removal of hilar submandibular calculi. Laryngoscope
115:750-752, 2005.
4. Marchal F: Personal communication, December 2, 2005.

Chapter 58
Biopsy of Minor Salivary Glands of the Lip
Rebecca E. Fraioli and Jennifer R. Grandis
Sjögren’s syndrome is a chronic autoimmune disorder
characterized by the immune-mediated destruction of
exocrine glands. Biopsy of the minor salivary glands of
the lip has been considered the gold standard for the
diagnosis of Sjögren’s syndrome. Symptoms of Sjögren’s
syndrome are primarily related to the loss of glandular
function: dry eyes due to destruction of the lacrimal
glands, dry mouth due to destruction of the major and
minor salivary glands, dry nose, throat, and trachea due
to the destruction of the minor salivary glands, and
chronic parotid swelling due to the destruction of the
parotid gland.1,2
PATIENT SELECTION
Biopsy of a minor salivary gland of the lip is positive for
Sjögren’s syndrome when one or more lymphocytic foci
containing more than 50 lymphocytes adjacent to
normal-appearing acini is identifi ed per 4 mm2 of glan-
dular tissue. However, lip biopsy alone is not diagnostic;
symptoms of dry eyes or dry mouth must also be present
to make the diagnosis.3 In addition to lip biopsy, the
other main objective diagnostic criteria used are serum
measurements of the autoantibodies SS-A (Ro) and SS-
B (La). In 2002, an American-European consensus
group attempted to standardize the diagnosis of
Sjögren’s syndrome. This group put forth a set of crite-
ria by which Sjögren’s syndrome may be diagnosed, and
the criteria were shown to be approximately 95% sensi-
tive and specifi c (Table 58-1).3 The criteria do not spe-
cifi cally require salivary gland biopsy for the diagnosis
of Sjögren’s syndrome; however, either positive salivary
gland biopsy or positive serum tests for SS-A or SS-B are
required.
It has been suggested that measurement of SS-A or
SS-B antibodies may be a preferable method of estab-
lishing the diagnosis of Sjögren’s syndrome.4 However,
both false-positives and false-negatives may occur with
this method. SS-A is not specifi c for Sjögren’s syndrome,
but is also positive in a number of other autoimmune
diseases.2 Both SS-A and SS-B antibodies may be absent
in a patient with Sjögren’s syndrome diagnosed on
minor salivary gland biopsy.4 Therefore, although SS-A
and SS-B testing is a reasonable option and may make
the diagnosis of Sjögren’s syndrome when found in
association with symptoms of the disease, a negative
result does not rule out Sjögren’s syndrome, and in
these patients, a lip biopsy is indicated. Some authors
advocate routine lip biopsy in the diagnosis of Sjögren’s
syndrome. Four percent of patients with Sjögren’s syn-
drome will eventually be diagnosed with lymphoma,
mainly of the B-cell mucosa-associated lymphoid tissue
(MALT) type. Case reports have described lymphoma
being diagnosed in an otherwise asymptomatic patient
on routine lip biopsy.5
Recently, biopsy of a minor salivary gland of the lip
has also proven useful in the diagnosis of amyloid poly-
neuropathy6 and neonatal hemochromatosis.7 In each
of these cases, biopsy of the minor salivary glands of the
lip represents a less invasive option for diagnosis than
the gold standard of nerve biopsy or liver biopsy, respec-
tively. In amyloid polyneuropathy, minor salivary gland
biopsy also has the advantage of identifying Sjögren’s
syndrome, which may have an associated sensory neu-
ropathy similar to that seen in amyloid polyneuropathy.
Neonatal hemochromatosis is a rare disorder consisting
of liver failure in newborns with associated extrahepatic
iron deposition. The disorder is rapidly fatal if untreated,
but early diagnosis and subsequent treatment with
medical treatment or liver transplantation can lead to
long-term survival.7 Liver biopsy is especially dangerous
in these patients, in that most have coagulopathy as a
result of their liver failure. Minor salivary gland biopsy,
as opposed to liver biopsy, can be performed at the
bedside with very little risk even in the face of
coagulopathy.7
It has been suggested that patients diagnosed with
primary biliary cirrhosis should also be evaluated for
491

492
Section 5
Salivary Glands
Sjögren’s syndrome. Primary biliary cirrhosis is highly
correlated with Sjögren’s syndrome.
PREOPERATIVE EVALUATION
Other than the laboratory studies discussed above, very
little preoperative evaluation is necessary. Biopsy can
be performed under local anesthesia and with little risk
of bleeding, even in the face of documented
coagulopathy.7
SURGICAL APPROACHES
Biopsy of a minor salivary gland is performed through
an incision in the mucosal surface of the lower lip (Fig.
58-1). The procedure is performed under local anesthe-
sia. The lower lip is everted, and 1% or 2% lidocaine
with epinephrine 1:100,000 is injected (Fig. 58-2). The
optimal site for biopsy is approximately 2 cm lateral to
the midline, because the density of minor salivary glands
is higher there than in the midline.8 The optimal inci-
sion for glandular biopsy is debated; however, a linear
or elliptical incision is standard. These minor salivary
glands are superfi cial (Fig. 58-3) and should be easily
identifi ed with minimal dissection using scissors and
forceps (Fig. 58-4). Care must be taken to avoid the
neighboring branches of the mental nerve. Two to
Table 58-1
CLASSIFICATION CRITERIA FOR
SJÖGREN’S SYNDROME
These six criteria may be used in either of two ways to
make the diagnosis. First, a diagnosis may be made if any
four of the following six items is positive, provided that
either the histopathology or the serum autoantibodies
are positive. Alternatively, the diagnosis may be made if
three of the four objective criteria are positive.
Subjective Criteria
1. Ocular symptoms (dry eyes)
2. Oral symptoms (dry mouth)
Objective Criteria
1. Ocular signs. Requires a positive result for at least one
of the following objective tests:
a. Schirmer’s test
b. Rose Bengal or other ocular dye score ≥4 (van
Bijsterveld’s scoring system)
2. Histopathology
a. Minor salivary gland biopsy is positive if focus score
≥1
b. Focus score = number of lymphocytic foci per
4 mm2 of glandular tissue
c. Lymphocytic focus must be adjacent to normal
mucous-acini and contain >50 lymphocytes
3. Salivary gland involvement, considered positive if at
least one of the following criteria is positive:
a. Unstimulated salivary fl ow ≤1.5 mL in 15 minutes
b. Parotid sialography demonstrating diffuse
sialectasia but no obstruction in the large ducts
c. Salivary scintigraphy demonstrating delayed uptake
or excretion or reduced concentration of the
radioactive tracer
4. Autoantibodies. Presence in the serum of antibodies
to one or both of the following antigens:
a. Ro (SS-A)
b. La (SS-B)
Figure 58-1. Line of incision drawn on mucosal surface of the
lip.
Figure 58-2. Local anesthesia is infi ltrated into the lip along the
line of the proposed incision.
Figure 58-3. Once the incision is made through the mucosa, the
minor salivary glands immediately become apparent (arrows).

Chapter 58
Biopsy of Minor Salivary Glands of the Lip
493
three minor salivary glands should be taken for micro-
scopic analysis (Fig. 58-5). Alternatively, the gland may
be divided and one half sent for frozen section to ensure
the presence of salivary gland tissue in the biopsy speci-
men. Following removal of these glands, hemostasis
may be achieved with electrocautery or direct pressure.
The incision is then closed using silk sutures in an inter-
rupted fashion (Fig. 58-6).
Variations on the above method have been sug-
gested. One group reports that the use of a chalazion
forceps allows good retraction of the lower lip and also
helps evert the minor salivary glands and helps elimi-
nate bleeding.9 A second group suggests that minor
salivary glands be labeled individually with a marking
pen as they are seen through the buccal mucosa before
the incision. Glands are then removed individually
through stab incisions made in the form of an X directly
overlying the gland. In this method, sutures are not
necessary due to the small size of each individual
incision.10
POSTOPERATIVE MANAGEMENT
Postoperative management is minimal. The patient will
likely not notice more than temporary pain at the inci-
sion site, which should be controlled with acetamino-
phen. Healing is rapid, and the patient can return to a
normal diet and normal activity level the same day as
the procedure. Antibiotics (perioperative or postopera-
tive) are not required for biopsy of the minor salivary
glands.
Branches of the mental nerve exist in close proxim-
ity to the labial salivary glands. Even with careful dissec-
tion, small branches may be transected. An oblique
incision made in an inferior-lateral direction approxi-
mately 1.5 cm lateral to the midline may minimize this
risk; however, patients should be cautioned preopera-
tively about the risk of postoperative numbness of the
lip.8
Figure 58-4. The minor salivary gland is gently grasped and bluntly
dissected out and removed.
Figure 58-5. Multiple minor salivary glands are removed for patho-
logic analysis.
Figure 58-6. The incision is closed with 4-0 silk suture.
PEARLS
• Biopsy should be performed through a transoral
incision to ensure good healing.
• Two or three glands should be removed for analysis.
• A chalazion forceps may assist in lip eversion and
hemostasis.
PITFALLS
• Inadvertent injury to the mental nerve can be
avoided by an oblique incision parallel to the nerve.
• Hemostasis can be a problem in patients who are
anticoagulated despite the small size of the incision.
References
1. Ramos-Casals M, Tzioufas AG, Font J: Primary Sjögren’s syn-
drome: New clinical and therapeutic concepts. Ann Rheum Dis
64:347-354, 2005.

494
Section 5
Salivary Glands
2. Kassan SS, Moutsopoulos HM: Clinical manifestations and early
diagnosis of Sjögren syndrome. Arch Intern Med 164:1275-1284,
2004.
3. Vitali C, Bombardieri S, Jonsson R, et al: Classifi cation criteria for
Sjögren’s syndrome: A revised version of the European criteria
proposed by the American-European consensus group. Ann
Rheum Dis 61:554-548, 2002.
4. Kessel A, Toubi E, Rozenbaum M, et al: Sjögren’s syndrome in
the community: Can serology replace salivary gland biopsy? Rheu-
matol Int 26:337-339, 2006.
5. Van Mello NM, Pillemer SR, Tak PP, et al: B cell MALT lym-
phoma diagnosed by labial minor salivary gland biopsy in patients
screened for Sjögren’s syndrome. Ann Rheum Dis 64:471-473,
2005.
6. Lechapt-Zalcman E, Authier FJ, Creange A, et al: Labial salivary
gland biopsy for diagnosis of amyloid polyneuropathy. Muscle
Nerve 22:105-107, 1999.
7. Smith SR, Shneider BL, Magid M, et al: Minor salivary gland
biopsy in neonatal hemochromatosis. Arch Otolaryngol Head
Neck Surg 130:760-763, 2004.
8. Alsaad K, Lee TC, McCartan B: An anatomical study of the cuta-
neous branches of the mental nerve. Int J Oral Maxillofac Surg
32:325-333, 2003.
9. Seoane J, Varela-Centelles PI, Diz-Dios P, et al: Use of chalazion
forceps to ease biopsy of minor salivary glands. Laryngoscope
110(3 pt 1):486-487, 2000.
10. Peloro TM, et al: Surgical pearl: “X” marks the spot for the sali-
vary gland biopsy. J Am Acad Dermatol 45:122-123, 2001.

Chapter 59
Treatment of Gustatory Sweating
(Frey’s Syndrome) with Botulinum Toxin A
John C. Sok and Clark A. Rosen
Gustatory sweating, also known as Frey’s syndrome,
Baillarger’s syndrome, auriculotemporal syndrome, or
gustatory hyperhidrosis, is a consequence of parotid
gland surgery, infection, or trauma. The condition is
characterized by sweating and fl ushing of the facial skin
overlying the parotid bed during mastication and may
be accompanied by general discomfort in the region.
Once gustatory sweating and fl ushing are established,
there is no spontaneous resolution, even many years
later. The area involved is usually in the parotid region
or upper part of the neck, but it may also be seen
behind the ear lobe, in the hair-bearing area in front
or behind the pinna (Fig. 59-1), or even inside the
external auditory canal.
Even though “Frey’s syndrome” is a well-established
eponym, the fi rst case of gustatory syndrome was actu-
ally reported in a French study by Baillarger in 1853.1
Later, in 1897, Weber was the fi rst to describe Frey’s
syndrome in the English literature, which was also
noted to be the fi rst case of bilateral Frey’s syndrome.2
Finally, in 1923, Lucie Frey, a neurologist at the Univer-
sity of Warsaw, described a 25-year-old soldier in whom
facial sweating and fl ushing during meals developed
after a gunshot wound to the parotid region.3 Although
Lucie Frey did not describe the fi rst case of gustatory
facial sweating and fl ushing, she correctly identifi ed the
relevant autonomic innervation of the parotid gland
and facial skin, thereby implicating the auriculotempo-
ral nerve in its pathogenesis.
Mechanistically, Frey’s syndrome is caused by mis-
directed regeneration of the severed postganglionic
parasympathetic secretomotor fi bers of the parotid
gland to the severed postganglionic sympathetic fi bers
of the sweat glands of the overlying facial skin. The
action of both these nerves is mediated by acetylcho-
line. Clinically, this results in facial sweating and fl ush-
ing during mastication. Although many patients who
have undergone parotidectomy do not report any symp-
toms when asked about gustatory sweating, Frey’s
syndrome has been reported in 50% of patients with
symptomatic hyperhidrosis.4
Initial management of gustatory hyperhidrosis
should consist of the use of topical anticholinergics
(scopolamine, glycopyrrolate, diphemanil methylsul-
fate) or aluminum chloride. In advanced cases, surgical
management of symptomatic Frey’s syndrome includes
elevation of a skin fl ap with the interposition of vascu-
larized tissue, free fat, or AlloDerm. In addition, divi-
sion of preganglionic parasympathetic nerves has been
reported. However, this is associated with only tempo-
rary relief and symptoms recur 6 to 12 months later.
In 1995, Drobik and Laskawi fi rst described the
intracutaneous injection of botulinum toxin type A
(Botox) as an effective therapeutic option for treating
gustatory sweating.5 Injection of Botox leads to tempo-
rary chemodenervation with loss or a reduction of the
activity of the target organ. At the level of the presyn-
aptic nerve fi bers, the biotoxicity of Botox results from
proteolysis of SNARE (soluble N-ethylmaleimide–
sensitive factor attachment protein receptor) proteins,
which are required to mediate vesicle membrane fusion
and subsequent release of acetylcholine for transmis-
sion of nerve impulses. Recently, intracutaneous Botox
injection has emerged as the fi rst-line treatment of
Frey’s syndrome because of its long-lasting effects in
patients with symptomatic gustatory sweating, coupled
with its relatively low complication rates.
PATIENT SELECTION
Patients with Frey’s syndrome are often identifi ed after
surgical resection of the parotid gland or after incision
495

496
Section 5
Salivary Glands
and drainage of a parotid abscess. However, it has also
been reported several weeks to months after various
injuries to the parotid gland, including blunt trauma,
bullet wounds, condyle fractures, infections (e.g., herpes
zoster), and infl ammatory parotid disorders; in associa-
tion with central nervous system diseases such as syrin-
gomyelia, encephalitis, and epilepsy; and in surgical
treatment of meningioma of the cerebellopontine
angle.6 In addition, gustatory sweating has developed as
a result of iatrogenic causes, such as a rare case after
reconstruction with a deltopectoral fl ap (Fig. 59-2).
Because of the location, one might suspect that the
cause is related to severing of postganglionic parasym-
pathetic fi bers from the submandibular gland. More-
over, idiopathic causes with no history of antecedent
injury have been reported.7
Patients with symptomatic gustatory sweating after
parotidectomy are closely monitored for 6 months and
are initially managed with the application of topical
anticholinergic products on the affected sites (non-
scented deodorants, Etiaxil). For mild cases, this is
often successful and further intervention is not neces-
sary. If conservative measures fail, the patient should be
evaluated with a qualitative hyperhidrosis severity ques-
tionnaire. Many validated assessment tools for primary
hyperhidrosis have been reported in the literature,
including the Hyperhidrosis Impact Questionnaire
(HHIQ), the Dermatology Life Quality Index (DLQI),
and the Illness Intrusiveness Rating Scale (IIRS).8-10 The
most current and the simplest assessment tool is the
Hyperhidrosis Disease Severity Scale (HDSS), which is
a reliable single-question, 4-point scale for assessing the
severity of hyperhidrosis in which patients rate their
tolerability of hyperhidrosis symptoms and the extent
to which it interferes with daily activities (Table
59-1).11,12 In patients with a score greater than 2 (hyper-
hidrosis is barely tolerable or intolerable and frequently
or always interferes with daily activities), Botox treat-
ment is recommended, with the goal being a decrease
in the patient’s hyperhidrosis symptoms to a more toler-
able level of 1 or 2 on this scale. Because the HDSS
Table 59-1
HYPERHIDROSIS DISEASE
SEVERITY SCALE
Question: How Would You Rate the
Severity of Your Hyperhidrosis?
Score
My sweating is never noticeable and never
interferes with my daily activities
1
My sweating is tolerable but sometimes
interferes with my daily activities
2
My sweating is barely tolerable and frequently
interferes with my daily activities
3
My sweating is intolerable and always
interferes with my daily activities
4
Figure 59-1. The area typically involved in gustatory sweating is
usually overlying the parotid region; however, it may also be seen
behind the ear lobe and in the hair-bearing area in front or behind
the pinna.
Figure 59-2. Gustatory sweating that developed in the region of a
patient’s distal deltopectoral fl ap.

Chapter 59
Treatment of Gustatory Sweating (Frey’s Syndrome) with Botulinum Toxin A
497
consists of only one question, it can be completed
rapidly and offers a practical, validated tool for deter-
mining the effi cacy of treatment.
PREOPERATIVE EVALUATION
The area of excessive sweating can vary considerably
from patient to patient. The sweat glands are distrib-
uted over the entire surface of the head and neck,
except at the margins of the lips. They are most numer-
ous in hair-bearing skin. Because of this interpatient
variability, mapping the area of excessive sweating is a
very important fi rst step in the chemodenervation pro-
cedure with Botox. An objective method of mapping
the hyperhidrotic area is to perform Minor’s iodine-
starch test, which makes direct visualization of the area
possible.13 Specifi cally, the symptomatic side of the face
and neck is fi rst cleaned and dried thoroughly. The
area is then painted with a 2% iodine solution (2 g of
iodine in 10 mL of almond or castor oil and 90 mL of
alcohol). An alternative is to use povidone-iodine with
alcohol (e.g., Betadine) swabs. After the solution has
dried, fi ne starch powder (e.g., potato or rice starch) is
dusted evenly over the painted site. After several minutes
the patient chews on a sialagogue (e.g., lemon wedge
or lemon candy) for several minutes. The appearance
of dark blue-purple spots along the face confi rms gusta-
tory sweating. This discoloration is the result of reduc-
tion of the dissolved starch with iodine, which makes
the location of the sweating readily discernible. The
borders of the darkened, hyperhidrotic area are then
outlined with a surgical pen, photographs are taken
with a 10-cm ruler, and the area is reprepared with
antimicrobial solution for subsequent Botox injection.
Finally, the patient should be counseled regarding the
risk for temporary facial weakness and should be care-
fully evaluated for any facial nerve weakness and synki-
nesis before the injection.
INJECTION TECHNIQUES
Botox injections delivered at the level of the superfi cial
dermis diffuse radially in an approximately 5-mm radius.
Therefore, intradermal botulinum toxin should be
placed at regular intervals to allow overlap of the diffu-
sion patterns. This serves to maximize the paralytic
effect on the eccrine units while minimizing the local
supratherapeutic dosage of Botox. After morphometric
evaluation by Minor’s starch test, the affected skin area
is marked with a surgical pen in an evenly spaced square-
grid pattern (to ensure adequate delivery, we prefer a
grid with points 0.5 cm apart) (Fig. 59-3). Lyophilized
botulinum toxin type A (Botox, 100 units per vial) is
reconstituted with 1 mL of preservative-free, sterile
saline to a fi nal concentration of 10 U/0.1 mL (preser-
vative may destroy the toxin). Overdilution of the
product should be avoided. The total injection volume
(1 mL) is then drawn into a 1-mL syringe. To minimize
patient discomfort, a 30-gauge needle should be used
to deliver the toxin. Intracutaneous injections are per-
formed with 5 to 10 units of Botox injected in the center
of each 0.5-cm2 grid. Botox has the potential (deter-
mined by volume) to diffuse from the point of injec-
tion.14 The injection should be performed slowly and
carefully into the intradermal plane. A visible wheal
should be present, which confi rms placement of the
toxin in the proper plane of the skin and decreases the
likelihood of unwanted weakness of the facial muscles.
Gentle pressure should then be applied to facilitate
hemostasis and even distribution of the toxin. Because
of the large quantities injected and the proximity of the
underlying facial muscles, undesired outcomes can also
occur, particularly if the injections are too deep. This
mild weakness is temporary and resolves after a few
weeks. After all of the grids have been injected, the skin
is cleaned, the markings are removed with alcohol, and
the patient is observed for potential side effects for
approximately 30 minutes.
POSTOPERATIVE MANAGEMENT
After the procedure, the patient is advised that the
therapeutic effects of the Botox treatment will not be
evident for 36 to 48 hours. The patient should be seen
1 to 2 weeks after treatment to assess therapeutic effi -
cacy. In some instances patients may show incomplete
results, which generally indicates that some of the sites
were injected in the wrong plane of the skin. If such is
the case, the problematic area should be remapped
with Minor’s iodine-starch test to visualize the hyperhi-
drotic area, and the patient should be treated again.
Figure 59-3. The area affected by gustatory sweating is marked with
a surgical pen and a grid is drawn with points 0.5 cm apart to delin-
eate the multiple Botox injection sites.

498
Section 5
Salivary Glands
References
1. Baillarger M: Mémoire sur l’oblitération du canal de Sténon.
Gazette Médicale de Paris 23:194-197, 1853.
2. Weber FP: Clinical cases, V: A case of localized sweating and
blushing on eating, possibly due to temporary compression of
vasomotorfi bers. Trans Clin Soc London 31:277-280, 1897.
3. Frey L: Le syndrome du nerf auriculo-temporal. Rev Neurol 2:92-
104, 1923.
4. Laskawi R, Ellies M, Rödel R, et al: Gustatory sweating: Clinical
implications and etiological aspects. J Oral Maxillofac Surg
57:642-648, 1999.
5. Drobik C, Laskawi R: Frey’s syndrome: Treatment with botulinum
toxin. Acta Otolaryngol Stockh 115:459-461, 1995.
6. Santa Cruz Ruiz S, Muñoz Herrera A, Santa Cruz Ruiz P, et al:
[Idiopathic Frey’s syndrome under the appearance of a recurrent
otitis externa.] Acta Otorrinolaringol Esp 56:83-85, 2005.
7. Forbes J, Doy R: Unilateral gustatory sweating. Cent Afr J Med
9:398-404, 1963.
8. Teale C, Roberts G, Hamm H, Naumann N: Development, valid-
ity, and reliability of the Hyperhidrosis Impact Questionnaire
(HHIQ) [abstract]. Qual Life Res 11:702, 2002.
9. Finlay AY, Khan GK: Dermatology Life Quality Index (DLQI):
A simple practical measure for routine clinical use. Clin Exp
Dermatol 19:210-216, 1994.
10. Cina CS, Clase CM: The Illness Intrusiveness Rating Scale: A
measure of severity in individuals with hyperhidrosis. Qual Life
Res 8:693-698, 1999.
11. Kowalski JW, Eadie N, Daggett S, et al: Validity and reliability of
the Hyperhidrosis Disease Severity Scale (HDSS) [Poster P198].
Poster presented at the 62nd Annual Meeting of the American
Academy of Dermatology, February 6-10, 2004, Washington,
DC.
12. Lowe NJ, Glaser DA, Eadie N, et al, for the North American Botox
in Primary Axillary Hyperhidrosis Clinical Study Group: Botuli-
num toxin type A in the treatment of primary axillary hyper-
hidrosis: A 52-week multicenter double-blind, randomized,
placebo-controlled study of effi cacy and safety. J Am Acad Der-
matol 56:604-611, 2007.
13. Minor V: Ein neues Verfahren zu der klinischen Untersuchung
der Schweissabsonderung. Dtsch Z Nervenheilkd 101:302-303,
1927.
14. Borodic GE, Pearce LB, Smith K, Joseph M: Botulinum A toxin
for spasmodic torticollis: Multiple vs. single injection points per
muscle. Head Neck 14:33-37, 1992.
15. Laskawi R, Dobrik C, Schönbeck C: Up-to-date report of botuli-
num toxin type A treatment in patients with gustatory sweating
(Frey’s syndrome). Laryngoscope 108:381-384, 1998.
16. Carruthers A, Carruthers J: Botulinum toxin type A: History and
current cosmetic use in the upper face. Semin Cutan Med Surg
20:71-84, 2001.
17. Guntinas-Lichius O: Injection of botulinum toxin type B for the
treatment of otolaryngology patients with secondary treatment
failure of botulinum toxin type A. Laryngoscope 113:743-745,
2003.
18. Luna Ortiz K, Rascon Ortiz M, Sanson Riofrio JA, et al: Control
of Frey’s syndrome in patients treated with botulinum toxin type
A. Med Oral Patol Oral Cir Bucal 12:E79-E84, 2007.
PEARLS
• Because adverse effects of Botox are frequently the
result of diffusion of toxin from the target tissue to
adjacent tissues, many smaller-volume injections are
recommended over fewer, larger-volume injections.
• The duration of treatment effects in patient’s with
Frey’s syndrome (mean duration, 17.3 months) is
much longer than in patients treated for other
indications, such as hemifacial spasm,
blepharospasm, or even hyperhidrosis in other
locations.15
• Although the optimal dose has not been established
(in diverse studies doses from 0.5 to 5 U/cm2 have
been used), we typically administer a total dose of
50 to 100 units.
• Botulinum toxin type A is quite stable in its
lyophilized form, but once it is reconstituted in
preservative-free saline, it should be refrigerated at
2º C to 8º C and used within 4 hours.16
• In refractory cases when patients respond poorly to
treatment with Botox, injections of type B
botulinum toxin (Myobloc) can be considered
because it is antigenically distinct from type A and
has a different mechanism of action on the release
of acetylcholine.17
• Studies report no difference in the severity of
gustatory hyperhidrosis in patients who were
subjected to superfi cial or total parotidectomy.18
PITFALLS
• Overzealous injection with Botox, especially with
large injection volumes, has the potential to cause
numbness and temporary facial weakness on the
injected side.
• The application of EMLA cream (lidocaine-prilocaine
hydrochloride) 45 minutes before injection can
prevent pain at the time of injection.
• Hyperhidrosis control rates after the initial Botox
injection are high, and it is rare for patients to have
recidivism after the fi rst successful treatment.
Treatment failure after the initial injection may
indicate that the toxin was placed too deep (i.e., not
producing a visible wheal) or that the injection did
not adequately cover the entire target area and
would therefore warrant a second procedure.
• Violent agitation or freezing of rehydrated botulinum
toxin type A will denature the toxin in solution,
thereby signifi cantly decreasing its potency.
• The therapeutic dosage of type B botulinum toxin
(Myobloc) is 50 to 100 times higher than that of the
conventional type A Botox, so injection of Myobloc
at Botox dosages can result in lack of effi cacy or
incomplete benefi t.

Chapter 60
Surgical Management of Ranula
Eugene N. Myers
Various intraoral masses may represent salivary gland
abnormalities. Such masses may consist of common
small retention cysts or the occasional rare benign or
malignant tumor arising in the minor salivary glands.
The most commonly encountered intraoral salivary
gland mass is a ranula, which arises in the sublingual
gland. The term ranula is derived from the Latin word
rana, meaning “frog.” It refers to the appearance of a
sublingual gland cyst in the fl oor of the mouth that
when expanded with fl uids, resembles a frog’s belly
(Fig. 60-1).
The sublingual gland lies directly beneath the
mucosal surface of the anterior fl oor of the mouth. The
major duct of Bartholin carries saliva directly into
the submandibular duct, and the superior projection of
the sublingual gland itself is just below the raised plica
sublingualis, where 5 to 15 ducts of Rivini carry saliva
into the oral cavity.1 The submandibular duct passes
directly adjacent to the sublingual gland and for the
distal 10 to 15 mm lies just deep to the mucosa of the
fl oor of the mouth. It is easily injured during the resec-
tion of the sublingual gland. For this reason some sur-
geons routinely stent the duct during the procedure to
avoid injury. Others routinely resect the duct in conti-
nuity with the sublingual gland and then marsupialize
the orifi ce of the duct in the posterior aspect of the
wound to prevent later obstruction to submandibular
salivary gland outfl ow. The other structure to be con-
cerned with during excision of the sublingual gland
is the lingual nerve, which is closely related to the
posterior part of the gland before crossing beneath
the submandibular duct to enter the substance of the
tongue.
The mechanism of formation of a ranula is believed
to be that of a cyst-like lesion originating from an
incompletely encapsulated sublingual gland, extravasa-
tion as a result of disruption, or obstruction of the sub-
lingual duct or ruptured acini with subsequent spillage
of mucus into the adjacent tissues, thereby resulting in
a cavity lined with granulation tissue surrounded by
condensed connective tissue.1 Aspiration and biochemi-
cal analysis performed on the ranula reveal a high
protein and amylase concentration consistent with
secretions from the mucous acini of the sublingual
gland.2
Excision can be performed with a variety of dissec-
tion tools. We favor the use of electrodissection. The
CO2 laser may be used because of a perceived decrease
in bleeding and resultant improvement in intraopera-
tive visualization. Techniques that involve the use of
sharp dissection commonly result in signifi cant bleed-
ing, thus making dissection diffi cult.
PATIENT SELECTION
Most patients with a ranula are asymptomatic. The
ranula appears as a bluish mass and is discovered in the
fl oor of the mouth immediately beneath the mucosa of
the anterior fl oor of the mouth. An oral ranula is gener-
ally small to medium in size. The lesion may be large
enough to interfere with articulation and displace the
tongue superiorly and anteriorly. A very large oral
ranula located in the area of the sublingual ducts may
lead to partial obstruction of Wharton’s duct with sub-
sequent swelling of the submandibular gland.
Patients with a ranula may also have a mass in the
neck, particularly in the submandibular area, which is
usually associated with the typical appearance of a mass
in the fl oor of the mouth. This so-called plunging
ranula is generally limited to the submandibular space,
but it may also involve the entire neck (Fig. 60-2). A
recent report by Pang and colleagues described the
unusual case of a 19-year-old man with a large (32 cm
in diameter) mass on the chest wall.3 The mass was in
499

500
Section 5
Salivary Glands
continuity with a scar in the left submandibular region.
The patient gave a history of removal of a mass in the
left side of the neck 1 year previously. Treatment
included removal of the submandibular gland, the sub-
lingual gland, and the cyst in the neck and on the chest
wall. Pathology was consistent with a ranula, and the
patient had no recurrence detected over a 3-year follow-
up period. It was postulated that the patient originally
underwent incomplete removal of the ranula without
excision of the sublingual gland.
The diagnosis of ranula is based principally on
clinical examination and, in the case of a plunging
ranula, on computed tomography (CT) or magnetic
resonance imaging (MRI). In cases of plunging ranula,
imaging studies are helpful to determine the entire
extent of the ranula so that it is staged and treated
properly (Fig. 60-3). When a ranula manifests as a
cervical swelling without an oral cavity component, the
differential diagnosis may be more diffi cult. Other
lesions that should be considered include a thyroglossal
duct cyst, branchial cleft cyst, parathyroid cyst, cervical
thymic cyst, dermoid cyst, cystic hygroma, and benign
teratoma.4
Treatment of ranula has varied, and simple drain-
age of the cyst, marsupialization, excision, and sublin-
gual gland excision have all been described. Simple
drainage or incision is commonly associated with recur-
rence of the ranula and is not suggested. Marsupializa-
tion may be effective, but it is usually technically diffi cult
to perform and often results in recurrence. A ranula
A
B
Figure 60-1. A, Ranula arising in the left sublingual gland.
B, Computed tomography scan demonstrating a ranula in the right
submandibular space.
B
A
C
Figure 60-2. A, Massive plunging ranula manifested as a neck mass.
B, The ranula was exposed via a cervical incision. C, Complete excision
required two incisions. The chin is to the left.

Chapter 60
Surgical Management of Ranula
501
that recurs after an initial attempt at excision makes
subsequent attempts at excision signifi cantly more dif-
fi cult. Therefore, the initial complete surgical excision
of the ranula and the sublingual gland is the procedure
most likely to result in control.
Treatment of a ranula remains controversial. Zhao
and coauthors reported a series of 571 patients with the
diagnosis of ranula.5 The ranulas were classifi ed into
three clinical types according to the site of primary
swelling: oral ranula (intraoral swelling only), plunging
ranula (submandibular or submental swelling, or both,
without intraoral swelling), and mixed ranula (intraoral
and extraoral swelling). A total of 571 patients under-
went 606 procedures; 580 were for primary lesions and
26 for recurrent ranula. Of 606 procedures, 9 consisted
of marsupialization, 28 involved excision of the ranula,
356 involved excision of the sublingual gland, and 213
consisted of excision of the sublingual gland in con-
junction with the ranula. When the lesion was operated
on through a submandibular excision, it was often
found that on elevation of the platysma muscle there
was a thin wall cyst immediately associated with the
anterior portion of the submandibular gland. However,
further dissection revealed that the lesion involved the
sublingual gland. Recurrence rates were 66% for mar-
supialization, 57% for excision of the ranula, and 1.2%
for excision of the sublingual gland and the ranula. The
marsupialization procedure itself gives rise to the largest
number of recurrences, and the authors suggest that
marsupialization is still performed because of fear on
the part of the surgeon about the potential for injury
to surrounding structures, especially the lingual nerve.
Kobayashi and coworkers reported a series of six
cases of plunging ranula treated by excision of the cyst
wall and the sublingual gland.6 After removal of the
sublingual gland, careful examination with a telescope
confi rmed the absence of a sublingual gland and an
intact lingual nerve. Simple drainage of mucus within
the ranula was performed by dividing the mylohyoid
muscle. Any potential residual cyst contents are expected
to disappear spontaneously after complete resection of
the source of secretions from widening of the sublin-
gual gland.
Kolker and coauthors reported a Jehovah’s Witness
who while 32 weeks pregnant underwent ultrasound as
part of a high-risk obstetric-gynecologic protocol.7 The
developing fetus was noted to have a cystic mass encom-
passing the entire oral cavity. The tongue was displaced
anterosuperiorly, compressed against the palate, and
protruding from the mouth. Expecting airway obstruc-
tion at the time of delivery, an ex utero intrapartum
treatment (EXIT) team was created, and at 38 weeks’
gestation, a cesarean section and the EXIT procedure
were performed, leaving the umbilical cord attached to
the baby for constant oxygenation. A large sublingual
mass was excised intraorally. The mass was consistent
with a congenital ranula. There was no recurrence or
complication noted at 6 months.
Onderoglu and colleagues reported a 34-year-old
woman who was seen at 21 weeks’ gestation for sched-
uled prenatal care.8 Routine ultrasound revealed a fetus
with an intraoral cystic lesion measuring 2 × 2 cm. At
34 weeks, the cyst had enlarged to 3 × 4.2 cm and
appeared to force the tongue to protrude out of the
mouth. At 38 weeks’ gestation an EXIT procedure was
performed by cesarean section, and 40 mL of fl uid was
aspirated from the lesion before the cord was clamped
(Fig. 60-4). Ultrasound and MRI revealed a cystic,
necrotic mass in the sublingual area of the neck. At the
time the paper was written, the infant was 6 months old
without recurrence.
SURGICAL TECHNIQUE
General anesthesia is required because of diffi culty
holding the oral cavity open and controlling bleeding
in an awake patient. Bimanual palpation of the ranula
will often reveal its depth, as well as its relation to the
adjacent submandibular gland. The submandibular
duct is probed and stented to maintain identifi cation
of the course of the submandibular duct during
dissection.
An elliptical excision is made in the fl oor of the
mouth such that it includes the entire sublingual gland
(Fig. 60-5). Dissection is carried along the lateral aspect
of the sublingual gland down to the level of the underly-
ing mylohyoid muscle. In the medial aspect of the
gland, dissection is carried between the sublingual
gland and the submandibular duct (Fig. 60-6). The dis-
section is extended more posteriorly, and the lingual
nerve is identifi ed and preserved (Fig. 60-7). Care
should be taken to avoid rupturing the ranula if possi-
ble. The use of peanut dissectors, careful hemostasis,
and judicious application of electrocautery or laser will
help maintain a dry fi eld and ensure complete excision.
If excessive bleeding results, hemostasis should be
obtained before proceeding with dissection. Injury to
the lingual nerve or submandibular duct or inadequate
removal is more likely if visualization has been impaired
by a bloody fi eld.
Figure 60-3. Axial T2-weighted magnetic resonance image (TR/TE
5000/96) showing a high–signal intensity collection of fl uid in the
fl oor of the mouth and extending behind the mandibular ramus and
lateral to the mandibular angle. (Reprinted with permission from Shelley
MJ, Yeung KH, Bowley NB, Sneddon KJ: A rare case of an extensive plunging
ranula: Discussion of imaging, diagnosis, and management. Oral Surg Oral
Med Oral Pathol Oral Radiol Endol 93:743-746, 2002.)

502
Section 5
Salivary Glands
When the sublingual gland has been excised and
hemostasis ensured, the submandibular duct should
be carefully identifi ed. If interrupted, the posterior
remnant of the duct should be opened and marsupial-
ized into the wound using several small absorbable
sutures (Fig. 60-8). The wound in the fl oor of the mouth
can be closed with absorbable suture, although some
surgeons leave the wound open to preclude the devel-
opment of hematoma.
Plunging ranulas occasionally require neck inci-
sions for exposure (see Fig. 60-2B and C). Most, however,
can be delivered transorally by bimanual palpation and
judicious retraction during excision of the gland.
Several different methods of treatment have been
used for removal of ranulas, including cold knife exci-
sion, cryosurgery, marsupialization, laser excision, and
intralesional injection of OK-432. Choi and Oh recom-
mended the hydrodissection technique for complete
removal of the ranula.9 This procedure involves injec-
tion of saline and lidocaine between the ranula and the
surrounding soft tissue. The fl uid dissects along the
A
B
Figure 60-4. A, The cyst fi lled the mouth completely at birth.
B, Clear fl uid was aspirated to open the airway before the cord was
clamped. (Reprinted with permission from Onderoglu L, Saygan-Karamursel
B, Deren O, et al: Prenatal diagnosis of ranula at 21 weeks of gestation.
Ultrasound Obstet Gynecol 22:399-401, 2003.)
Figure 60-5. The incision is outlined on the fl oor of the mouth.
The entire sublingual gland must be resected along with the ranula.
Figure 60-6. The dissection is carried between the submandibular
duct and the sublingual gland. Stenting the duct is often helpful to
preserve the integrity of the duct. Alternatively, the duct can be tran-
sected, opened, and marsupialized into the fl oor of the mouth.

Chapter 60
Surgical Management of Ranula
503
Submandibular duct
Lingual nerve
Sublingual gland
Figure 60-7. Dissection of the sublingual gland exposes the lingual
nerve. Injury to this nerve must be prevented.
Figure 60-8. If the duct has been interrupted, it should be marsu-
pialized by suturing the edges of the duct to the edges of the excision
site.
sure.12 The technique consists of making an incision in
the ranula, inserting a Penrose drain, and leaving it in
place for 3 weeks. Continuous pressure is applied to the
submandibular triangle to prevent pooling of saliva.
This technique resulted in complete resolution of
plunging ranulas in four patients. They were free of
recurrence 17 months later.
Shelley and coworkers described a cyst in a 38-year-
old man who had a history of a mucous retention cyst
in the left fl oor of the mouth discovered 13 years previ-
ously.13 A large fl uctuant cyst was present in the sub-
mental and submaxillary space. However, the fl oor of
the mouth looked normal. MRI confi rmed a large cyst
occupying the aforementioned spaces. In addition, the
mass extended to the anterior fl oor of the mouth and
along the entire length of the medial pterygoid muscle,
almost to the pterygoid plates. It was diagnosed as an
extensive plunging ranula. The left sublingual gland
was removed and a Penrose drain was inserted into the
cavity and sutured into the wound after draining
the fl uid out of the cyst. Over the next several weeks
the neck returned to its normal contour. There was
no sign of recurrence 6 months postoperatively. MRI
demonstrated a large plunging ranula (Fig. 60-9).
The authors believe this case well illustrates and sup-
ports the theory that a plunging ranula should be
managed by simple intraoral excision of the sublingual
A
B
ranula and creates a safe plane of dissection. Niccoli-
Filho and Morosolli reported complete excision with a
laser without evidence of recurrence or damage to sur-
rounding structures and advocated that technique.10
Guerrissi and Taborda described an endoscopic
approach for excision of the sublingual gland.11
These procedures are anatomically safe and can be
performed with minimal morbidity. The essential surgi-
cal steps include (1) careful identifi cation of Wharton’s
duct and the lingual nerve, (2) retraction of the mylo-
hyoid muscle, and (3) protection of the sublingual
gland. External pressure on the submandibular gland
allows intraoral protrusion of the cyst. Careful dissec-
tion of the posterior one third of the submandibular
gland while avoiding the facial artery and vein is then
carried out.
Takagi and colleagues describe treatment of a
plunging ranula by fenestration and continuous pres-
Figure 60-9. A and B, Clinical photographs of a patient with sub-
mandibular swelling. (Reprinted with permission from Shelley MJ, Yeung
KH, Bowley NB, Sneddon KJ: A rare case of an extensive plunging ranula:
Discussion of imaging, diagnosis, and management. Oral Surg Oral Med
Oral Pathol Oral Radiol Endol 93:743-746, 2002.)

504
Section 5
Salivary Glands
salivary gland and drainage of the contents of the
ranula.
POSTOPERATIVE MANAGEMENT
The patient is maintained on a liquid diet for several
days because of discomfort and then gradually advanced
to a regular diet. No specifi c postoperative care is
required, and overnight observation is not generally
necessary. If drains are used in the neck wound, they
can be removed on the fi rst postoperative day.
COMPLICATIONS
The most common complication of surgery for ranula
is recurrence. The risk of recurrence can be minimized
by preoperative imaging that can provide an assessment
of the lesion and dictate the extent of surgery. Excision
of the sublingual gland together with the ranula is the
most important means of preventing recurrence. Exci-
sion of the sublingual gland rarely allows preservation
of the anterior aspect of the Wharton’s duct. The pos-
terior portion of the duct should be more marsupial-
ized (see Fig. 60-8) to prevent stenosis of the duct with
subsequent submandibular sialadenitis. If the sublin-
gual gland is injured, numbness of the tongue results.
The complication can be avoided by maintaining a dry
fi eld and identifying and preserving the lingual nerve.
References
1. Baurmash HD: Treating oral ranula: Another case against blanket
removal of the sublingual gland. Br J Oral Maxillofac Surg 39:480-
482, 2001.
2. Pandit RT, Park AH: Management of pediatric ranula. Otolaryn-
gol Head Neck Surg 127:115-118, 2002.
3. Pang CE, Lee TS, Pang KP, Pang YT: Thoracic ranula: An
extremely rare case. J Laryngol Otol 119:233-234, 2005.
4. Zhao YF, Jia YL, Chen XM, Zhang WF: Clinical review of 580
ranulas. Oral Surg Oral Med Oral Pathol Oral Radiol Endod
98:281-287, 2004.
5. Zhao YF, Jia J, Jia YL: Complications associated with surgical
management of ranulas. J Oral Maxillofac Surg 63:51-54, 2005.
6. Kobayashi T, Ochi K, Komatsuzaki Y, et al: Blanket removal of
the sublingual gland for treatment of plunging ranula. Laryngo-
scope 113:386-388, 2003.
7. Kolker MT, Batti JS, Schoem SR: The ex utero intrapartum treat-
ment procedure for congenital ranula in a Jehovah’s Witness.
Otolaryngol Head Neck Surg 130:508-510, 2004.
8. Onderoglu L, Saygan-Karamursel B, Deren O, et al: Prenatal
diagnosis of ranula at 21 weeks of gestation. Ultrasound Obstet
Gynecol 22:399-401, 2003.
9. Choi TW, Oh CK: Hydrodissection for complete removal of a
ranula. Ear Nose Throat J 82:946-951, 2003.
10. Niccoli-Filho W, Morosolli ARC: Surgical treatment of ranula with
carbon dioxide laser radiation. Lasers Med Sci 19:12-14, 2004.
11. Guerrissi JO, Taborda G: Endoscopic excision of the subman-
dibular gland by an intraoral approach. J Craniofac Surg 12:299-
303, 2001.
12. Takagi S, Mizukawa N, Kimura T, Assaumi J-I: Treatment of a
plunging ranula with fenestration and continuous pressure. Br J
Oral Maxillofac Surg 41:410-413, 2003.
13. Shelley MJ, Yeung KH, Bowley NB, Sneddon KJ: A rare case of an
extensive plunging ranula: Discussion of imaging, diagnosis, and
management. Oral Surg Oral Med Oral Pathol Oral Radiol Endol
93:743-746, 2002.
PEARLS
• Imaging with CT or MRI is helpful in defi ning the
projections of a plunging ranula.
• The best chance to cure a ranula limited to the fl oor
of the mouth is excision of the ranula and the
sublingual gland.
• Dissection must be carried out transorally with
particular attention to preservation of the lingual
nerve and Wharton’s duct.
• A plunging ranula is best treated by transoral
excision of the cyst and sublingual gland in
conjunction with a cervical approach to excise the
plunging ranula.
PITFALLS
• Failure to use imaging studies may result in
understaging of a plunging ranula.
• Failure to remove the sublingual gland in the
treatment of a ranula results in a high risk of
recurrence.
• Failure to properly identify Wharton’s duct and the
lingual nerve will result in injury to these structures.
• Recurrent ranula after inadequate excision or
marsupialization is very diffi cult to excise because of
scarring of the fl oor of the mouth and related
structures.
• Lack of ultrasound imaging with a high-risk fetus
may result in the birth of a child with an unexpected
large ranula that may produce airway obstruction at
birth.

Chapter 61
Excision of the Submandibular Gland
Rebecca E. Fraioli and Jennifer R. Grandis
The submandibular gland is one of three pairs of major
salivary glands that drain into the oral cavity. It is midway
in size and location between the largest, the parotid
gland, and the smallest, the sublingual gland. Histologi-
cally, it consists of both serous and mucinous acini,
which collectively drain into an excretory duct that
carries the secreted saliva into the oral cavity.
The gland is located within the submandibular tri-
angle, superior and lateral to the hyoid bone and digas-
tric sling, and inferior to the mandible. Its excretory
duct, known as Wharton’s duct, passes deep to the
mylohyoid muscle, paralleling the course of the lingual
nerve. The duct and nerve lie immediately adjacent to
the sublingual gland, just deep to the mucosa of the
fl oor of the mouth. The duct opens through the sub-
lingual papilla adjacent to the lingual frenulum (Fig.
61-1). The narrowest point in the duct is at the orifi ce;
therefore, calculi that form in the gland may become
impacted at the orifi ce and be visible or palpable in the
fl oor of the mouth. Impacted calculi that obstruct sali-
vary outfl ow will result in gland enlargement, stasis of
secretions, and ultimately, infl ammation of the gland
(sialadenitis) and should be removed.
In older persons, the submandibular glands tend
to become ptotic and assume a more inferior position,
often even prolapsing lateral to the greater cornu of the
hyoid bone. In this ptotic position, the gland may be
interpreted as a neoplastic mass and lead to referral for
further evaluation.
PATIENT SELECTION
The two most common indications for excision of the
submandibular gland are (1) calculus with secondary
ductal obstruction and sialadenitis and (2) suspicion of
a neoplasm within the gland. Submandibular gland
excision has been performed for the treatment of
chronic sialorrhea in patients with chronic neuromus-
cular disease.1
Submandibular Calculi
A single isolated calculus in Wharton’s duct that results
in obstruction of the gland can often be managed by
transoral removal of the stone from the duct (see
Chapter 57). In some cases this satisfactorily resolves
the diffi culties, and no further intervention is required.
Unfortunately, most patients have a history of recurring
bouts of obstruction as a result of recurrent calculus
formation. The chronically infl amed gland becomes
enlarged, with recurring episodes of painful swelling
associated with eating. Once chronic changes have
developed, resolution of symptoms with conservative
treatment such as secretogogues, hydration, and antibi-
otics is unlikely, and the patient is usually best served
by excision of the gland.
PREOPERATIVE EVALUATION
Physical examination should include palpation of the
fl oor of the mouth, primarily the duct papilla, as well
as bimanual palpation of the gland. Milking the gland
and the duct in the fl oor of the mouth normally releases
clear saliva into the oral cavity. This examination is
made simpler and more accurate by drying the mucosa
of the fl oor of the mouth with the power air blower on
the offi ce suction machine. When the blower is turned
off, pressure is placed on the gland to assess salivary
fl ow.
In acute infection, thick, cloudy saliva or purulent
exudate is common. The absence of salivary fl ow in the
presence of an enlarged gland suggests outfl ow obstruc-
tion, usually secondary to impacted calculus or stricture
of the duct. Attempts to excise a gland in the midst of
acute infl ammation is inherently diffi cult and can result
in signifi cant untoward risk to the structures adjacent
to an infl amed and hyperemic gland, which may not be
easily identifi able. In most cases the patient can be
treated with antibiotics and gland excision scheduled
505

506
Section 5
Salivary Glands
for a later date. Rarely, however, acute infl ammation
results in life-threatening infection because of elevation
of the fl oor of the mouth and tongue by infectious
phlegmon adjacent to the gland. In these circumstances,
tracheostomy may be needed as a potentially lifesaving
maneuver.
Radiographic examination should include not only
a plain fi lm of the gland itself (which can best be
obtained by ordering mandible views) but also a trans-
oral occlusal view of the fl oor of the mouth to detect
any radiopaque calculi in the duct. Radiographic evalu-
ation may reveal evidence of a radiopaque stone in the
hilum of the gland (Fig. 61-2). Unfortunately, approxi-
mately 20% of calculi may not be radiopaque and there-
fore diffi cult to identify. Preoperative knowledge of the
presence of calculi in the duct is important during exci-
sion of the submandibular gland, because failure to
excise the duct up to the fl oor of mouth can result in
retained calculi, which can later produce chronic swell-
ing in the fl oor of mouth, postoperative wound infec-
tion, and untoward effects in the patient.
Computed tomography (CT) is not typically
required in the evaluation of calculi unless the history
is unclear or the surgeon is unsure whether the palpa-
ble mass within the gland is a potential malignancy.
However, when the history is unclear or there is no
history of recurring episodes of swelling, CT may provide
useful information in the differentiation between gland
enlargement, an isolated mass within the substance of
the gland, and a mass adjacent to the gland.
A sialogram may reveal narrowing of the duct from
scarring with secondary ductal ectasia within the hilum
and the gland itself.
SURGICAL APPROACHES
The traditional approach to excision of the subman-
dibular gland is via the transcervical route. Recently,
intraoral excision and endoscopic excision of the sub-
mandibular gland have been described.
Transcervical Approach
Exposure is facilitated by placing a rolled blanket under
the shoulders to allow the neck to be extended, thereby
better exposing the submandibular triangle. The patient
is then positioned with the head elevated slightly and
rotated toward the opposite side. This position results
in inferior displacement of the skin, platysma muscle,
and subcutaneous tissue in relation to the mandible on
the surgical side. As a result, the marginal mandibular
nerve is found more inferiorly and is more likely to be
injured by an incision directly over the gland. There-
fore, the incision is made in a natural skin crease,
usually slightly above the level of the hyoid bone at the
inferior margin of the submandibular gland. Localiza-
tion of a smaller submandibular gland can be simplifi ed
by placing a gloved fi nger in the mouth and depressing
the fl oor of the mouth on the affected side.
The incision is carried through skin, subcutaneous
tissue, and platysma muscle. Once through the platysma
muscle, the nerve is at risk and dissection should fi rst
be directed toward the inferior portion of the subman-
dibular gland rather than superiorly in the plane
between the platysma and the submandibular gland.
After exposure of the submandibular gland (often facil-
itated by intraoral fi nger palpation), the fascia overlying
the gland is incised and the superior fl ap of fascia is
elevated from the lateral surface of the gland. As this is
performed, the facial vein is encountered. Ligation and
elevation of this vein will help preserve the marginal
mandibular nerve (Fig. 61-3). If the gland is excised as
a part of a neck dissection, the nerve must be dissected
free of the underlying vein and adjacent prevascular
and postvascular nodes (Fig. 61-4).
When the superior aspect of the gland has been
encountered, blunt dissection will free it from the sur-
rounding soft tissue. The marginal mandibular nerve
Figure 61-1. The opening of Wharton’s duct (arrow) adjacent to
the frenulum of the tongue.
Figure 61-2. Lateral radiograph demonstrating calculus (arrow) in
the hilum of the submandibular gland.

Chapter 61
Excision of the Submandibular Gland
507
will be preserved if dissection is maintained directly on
the gland and deep to the fascia.
If the gland has been chronically infl amed and is
adherent to surrounding soft tissue, the dissection may
not proceed as easily as described. In these circum-
stances it is often necessary to identify the nerve, which
generally requires the use of magnifi cation and a nerve
stimulator. Use of a facial nerve monitor with leads
inserted in the depressor labialis muscle may be helpful
when the clinical picture suggests that a particular case
will be technically diffi cult.
Once the entire fl ap has been elevated off the
lateral aspect of the gland, the anterior portion of the
gland is freed from soft tissue at the level of the anterior
belly of the digastric muscle. This is best done by incis-
ing the fascia over the anterior belly of the digastric
muscle and refl ecting it posteriorly. As this refl ection
occurs, the mylohyoid muscle is encountered. The
muscle can be identifi ed by the direction of its fi bers
extending from posterosuperior to anteroinferior (at a
signifi cantly different angle from that of the anterior
belly of the digastric muscle). The dissection is carried
posterior to the edge of the mylohyoid muscle. The
mylohyoid muscle is occasionally diffi cult to identify,
especially with chronically infected glands adherent to
the muscle. This muscle may also be dehiscent in areas
and lead to diffi culty identifying its posterior aspect.
Several perforating vessels, as well as its motor nerve,
enter the mylohyoid muscle. The vessels must usually
be sacrifi ced to free the overlying portion of the sub-
mandibular gland. As the gland is retracted posteriorly,
the posterior aspect of the mylohyoid muscle is encoun-
tered. A small right-angled retractor can be used to
retract the muscle anteriorly off the deep portion of the
gland (Fig. 61-5). This retraction is usually easy except
in chronically infl amed cases with marked fi brosis. In
such cases, sharp dissection may be required to free the
mylohyoid muscle from the gland and its surrounding
soft tissue.
The anterior portion of the gland, the duct with the
closely adherent sublingual gland, and the lingual nerve
will be encountered immediately deep to the mylohyoid
muscle. The lingual nerve can be seen superiorly as a
broad band extending from deep to the mandible pos-
teriorly and looping close to the anterior portion of the
gland, where it gives rise to nerve roots extending into
the submandibular ganglion. The nerve ascends supe-
riorly as it extends anteriorly to innervate the anterior
aspect of the tongue and fl oor of the mouth. This nerve
must be carefully dissected free and the rootlets incised.
Every effort should be made to identify and preserve
the lingual nerve, because injury will result in loss of
sensation of the lateral aspect of the oral tongue. In
patients with signifi cant scarring secondary to chronic
infl ammatory disease, this dissection may be diffi cult
and tedious.
After the nerve has been identifi ed and the rootlets
incised, the duct can usually be identifi ed in the fascial
planes superfi cial to the fl oor of the submandibular
triangle. A large vein generally accompanies the duct
and should be ligated separately.
The hypoglossal nerve can then be seen extending
along the fl oor of the triangle, where it emerges from
deep to the posterior belly of the digastric muscle. Care
Marginal mandibular
nerve crossing
facial vein
Figure 61-3. Exposure of the submandibular gland by elevating the
platysmal muscle with the skin fl ap. Note the position of the marginal
mandibular nerve (arrow).
Figure 61-4. Elevation of the marginal mandibular nerve can be
done by dividing the facial vein low on the gland and elevating the
nerve along with the vein. Note the prevascular and postvascular
lymph nodes (arrows).
Lingual
nerve
Figure 61-5. The posterior edge of the mylohyoid muscle is exposed
and then retracted to expose the duct of the gland and the associated
lingual nerve. In patients who have had chronic infl ammation, expo-
sure of the lingual nerve may be very diffi cult. The facial artery can
be preserved, as demonstrated in the illustration, or divided. Division
is usually easier in cases of infl ammation and has no untoward effect
on the patient.

508
Section 5
Salivary Glands
must be taken to avoid injury to the hypoglossal nerve
as it courses along the fl oor of the submandibular tri-
angle. Injury is unusual unless previous infl ammation
has made it diffi cult to identify the plane deep to the
gland.
Once the hypoglossal nerve has been identifi ed, the
duct can be divided (Fig. 61-6). Care must be taken to
include dissection of the duct up to the mucosa of the
fl oor of the mouth; otherwise, stones can be retained
in the duct and result in postoperative chronic infl am-
matory disease of the duct remnant. Bimanual palpa-
tion at this stage often helps prevent retained stones in
the duct.
When the anterior portion of the gland has been
freed from the lingual nerve and submandibular duct,
the remainder of gland is easily detached from the
underlying fascial planes over the fl oor of the subman-
dibular triangle. The gland can then be retracted infe-
riorly with countertraction placed on the soft tissue
superior to the gland, and the superior aspect of the
gland is dissected free from the soft tissue just inferior
to the mandible. Care must be taken to avoid injury to
the marginal mandibular nerve because it courses just
lateral and superior to the gland. Injury is avoided by
either identifying the nerve or maintaining dissection
within a plane immediately adjacent to the substance of
the gland. Although the latter technique is relatively
simple in most cases, in a severely infl amed gland, dis-
section may be diffi cult and bleeding persistent; the
surgeon must identify the nerve under magnifi cation to
avoid injuring it.
As the gland is refl ected inferiorly, the facial artery
can be seen indenting the posterosuperior surface of
the gland. It is usually divided as it leaves the gland
superiorly and then again as it enters the gland inferi-
orly. It is possible, however, to preserve the artery in
noninfl amed cases by dissecting the artery free of the
gland and individually identifying, dividing, and ligat-
ing the feeding vessels extending into the gland proper.
When the gland has been freed from the artery by
either dissection or transection, the gland is removed.
Once the gland has been removed, the subman-
dibular triangle should be examined for vessels that
require ligation. Particular care should be taken to
examine the anterior portion of the triangle deep to
the mylohyoid muscle to rule out potential bleeding
vessels. The wound is irrigated, a Hemovac suction
drain is inserted, and the wound is closed in layers
beginning with the platysma muscle and followed by
subcutaneous closure and then a cuticular closure that
approximates the skin in a cosmetically acceptable
manner.
An alternative technique is to expose the duct and
lingual duct and ligate the facial artery posteriorly as it
enters the submandibular triangle from deep to the
posterior belly of the digastric muscle. The subman-
dibular gland can then be pedicled on the lingual nerve
and Wharton’s duct, and the gland is excised.
This technique allows better exposure of the lingual
nerve and Wharton’s duct during dissection of these
structures.
Intraoral Approach
An alternative surgical approach to the submandibular
gland is the intraoral approach. This procedure has the
potential to circumvent the two most common unto-
ward sequelae of the transcervical approach, namely,
scarring from the cervical incision and the risk of injury
to the marginal mandibular branch of the facial nerve.
Intraoral excision of the submandibular gland requires
nasotracheal intubation followed by injection of lido-
caine with epinephrine (1:100,000) into the mucosa for
hemostasis. Adequate lighting, preferably with a fi ber-
optic headlight, is essential. After insertion of a probe
into the orifi ce of Wharton’s duct, the intraoral incision
is made through the mucosa of the fl oor of the mouth
from the duct orifi ce posteriorly to the lingual aspect
of the retromolar region.2 Dissection and removal of
the sublingual gland will facilitate exposure of the duct.3
Careful dissection along the course of Wharton’s duct
will reveal its close relationship to the lingual nerve.
Retraction of the tongue and fl oor of the mouth, includ-
ing the lingual nerve, allows visualization of the mylo-
hyoid muscle.2 Anterior retraction of the posterior
margin of the mylohyoid muscle allows visualization of
the superfi cial portion of the submandibular gland.
Blunt dissection is used to free the submandibular
gland from surrounding structures. Transcervical pres-
sure on the gland will elevate the gland in the fl oor of
mouth and aid in visualization. The facial artery and
vein and their branches are identifi ed and may be either
avoided or ligated. The gland is then carefully removed
and hemostasis is achieved. A drain may be inserted
through the incision site, and the mucosa is reapproxi-
mated with absorbable suture.
The intraoral approach appears to achieve its goals
of obviating the need for a transcervical incision and
minimizing risk to branches of the facial nerve. The
marginal mandibular nerve is the most frequently
injured nerve in the traditional transcervical approach,
with reported injury rates ranging from 1% to 7%.3
Hypoglossal
nerve
Figure 61-6. The branches of the lingual nerve passing to the sub-
mandibular ganglion are divided to free the nerve from the speci-
men. The duct is divided (arrow) and the specimen is removed. Care
must be taken to ensure that there are no calculi distal in the duct,
or postoperative infection in the duct remnant will result.

Chapter 61
Excision of the Submandibular Gland
509
Branches of the facial nerve are not at risk with the
intraoral approach, so they are not identifi ed during
this dissection. Pitfalls of the intraoral approach,
however, stem from signifi cant retraction of the fl oor
of the mouth, including the lingual nerve and mylohy-
oid muscle, which is necessary for adequate exposure
of the gland. In one study, temporary injury to the
lingual nerve was observed in almost all patients, and
68% reported a temporary decrease in tongue mobility
that resolved within 2 weeks of surgery and was attrib-
uted to edema of the fl oor of the mouth rather than
injury to the hypoglossal nerve.2
Endoscopic Approach
Two methods for endoscopic resection of the subman-
dibular gland have recently been proposed. The fi rst is
a modifi cation of the intraoral approach in which the
incision and technique are virtually identical to that just
described. An endoscope is introduced through an
intraoral incision for visualization of the surgical fi eld
by lighting and magnifi cation.4
The second technique entails a modifi ed transcervi-
cal approach for endoscopic excision of the subman-
dibular gland. To date, it has been reported only in a
cadaver model. A single 14-mm and two 5-mm incisions
placed in the inferior aspect of the neck provide entry
for the instruments. Subcutaneous dissection is per-
formed with a 1000-mL hernia balloon infl ated to 500
to 700 mL. The balloon is then removed and carbon
dioxide is insuffl ated to a pressure of 4 mm Hg to main-
tain the operating fi eld. The submandibular gland is
identifi ed with the endoscope and endoscopic dissec-
tion tools, and the dissection is performed much as in
the traditional transcervical approach. Not surprisingly,
the authors reported subcutaneous emphysema in two
of six of their specimens.5 We have no personal experi-
ence with this technique, but nonetheless, the endo-
scopic approach will no doubt undergo further study.
POSTOPERATIVE MANAGEMENT
Postoperative management is minimal and includes
elevation of the head of the bed and removal of the
drain after 24 to 48 hours. Excessive persistent drainage
will require re-exploration, because uncontrolled hema-
toma in this area may result in airway diffi culty second-
ary to displacement of the tongue musculature. Patients
undergoing excision of the submandibular gland are
customarily observed for 24 hours postoperatively, pri-
marily to avoid the risk of airway compromise because
of unanticipated postoperative swelling.
• When the gland is removed in conjunction with
radical neck dissection, the nerve must be identifi ed
to avoid injury posterior to the gland, where it may
often dip a signifi cant distance below the level of
the mandible.
• Routine identifi cation of the nerve in neck dissection
is also necessary for removal of the prevascular and
postvascular nodes. These nodes require removal,
particularly with lesions involving the lateral oral
cavity, alveolus, and sinus.
• Incomplete removal of submandibular duct calculi
can be managed in the postoperative period by
probing the duct intraorally and removing the stone
via an intraoral route. It is highly desirable to
remove the calculus at the time of excision of the
submandibular gland.
• The proximal stump of the facial artery should be
double-ligated and the wound examined for
bleeding vessels before closure.
• Care must be taken in patients who have had
signifi cant infection and scarring to ensure
identifi cation of the lingual nerve before sectioning
the duct.
• Care should be taken after the gland is free
posteriorly to visualize the hypoglossal nerve as it
courses deep to the vessels, parallel to the
submandibular duct. If infl ammation hinders
identifi cation of the nerve, it is advisable to fi nd the
nerve inferior to the posterior belly of the digastric
muscle and follow it in a posterior-to-anterior
direction through the submandibular triangle to
avoid injury.
PEARLS
• The marginal mandibular nerve should be identifi ed
and protected by dissecting along the lateral surface
of the gland. Facial nerve monitoring with a hand-
held nerve stimulator is helpful in diffi cult cases,
especially in patients with a long history of chronic
infl ammatory disease.
PITFALLS
• The marginal mandibular nerve can be injured and
result in paralysis of the lower lip, especially in
patients with chronic infl ammation.
• Interruption of the smaller accessory nerves that
loop inferiorly over the lateral surface of the gland is
less signifi cant than injury to the main branch of the
marginal mandibular nerve, which usually courses
immediately superior to the gland overlying the
prevascular and postvascular nodes.
• Failure to dissect Wharton’s duct all the way to the
mucosa of the fl oor of the mouth during excision of
the submandibular gland can result in retained
calculus later on.
• Postoperative hemorrhage can lead to signifi cant
airway obstruction as a result of swelling of the
tongue musculature.
• The lingual nerve can be injured by injudicious
sectioning of the duct without fi rst identifying and
freeing the nerve where it lies directly superior to the
duct.
• The hypoglossal nerve may be adherent to the medial
aspect of the gland and inadvertently resected.

510
Section 5
Salivary Glands
3. Smith AD, Elahi MM, Kawamoto HK Jr, et al: Excision of the sub-
mandibular gland by an intraoral approach. Plast Reconstr Surg
105:2092-2095, 2000.
4. Guerrissi JO, Taborda G: Endoscopic excision of the submandibu-
lar gland by an intraoral approach. J Craniofac Surg 12:299-303,
2001.
5. Terris DJ, Haus BM, Gourin CG: Endoscopic neck surgery: Resec-
tion of the submandibular gland in a cadaver model. Laryngo-
scope 114:407-410, 2004.
References
1. Stern Y, Feinmesser R, Collins M, et al: Bilateral submandibular
gland excision with parotid duct ligation for treatment of sialor-
rhea in children: Long-term results. Arch Otolaryngol Head Neck
Surg 128:801-803, 2002.
2. Hong KH, Kim YK: Intraoral removal of the submandibular gland:
A new surgical approach. Otolaryngol Head Neck Surg 122:798-
802, 2000.

Chapter 62
Parotidectomy
Jonas T. Johnson
The most frequent indication for surgery of the parotid
gland is the removal of a neoplasm. It is estimated that
75% to 80% of parotid neoplasms are benign.1-4 Pleo-
morphic adenoma and Warthin’s tumor (papillary cyst-
adenoma lymphomatosum) account for the majority of
the tumors encountered.5 When malignancy is encoun-
tered, adenoid cystic carcinoma and mucoepidermoid
carcinoma are approximately equally represented.
Adenocarcinoma, acinic cell carcinoma, carcinoma
expleomorphic adenoma, squamous cell carcinoma,
and malignant mixed tumor may occasionally be
encountered. Lymphoma may arise in the intraparotid
or paraparotid lymph nodes. The lymph nodes may also
be the site of metastases from a squamous cell carci-
noma or melanoma when the primary tumor arises on
the face or scalp. Rarely, tumors may metastasize to
parotid lymph nodes from distant sites.
Parotidectomy also plays an important role in the
management of chronic/recurrent sialadenitis that fails
medical therapy.6-8 The relationship of the facial nerve
to the parotid gland serves to make surgical manage-
ment of these neoplasms a challenge. The facial nerve
exits the stylomastoid foramen and passes through the
substance of the parotid gland as it branches to inner-
vate the muscles of facial expression. Surgeons fre-
quently speak of a lateral and a deep lobe of the parotid
gland. This is somewhat ephemeral inasmuch as no
anatomic boundaries exist between the lateral and the
deep lobes of the parotid gland except in regard to its
relationship to the facial nerve.
Before the 1950s, enucleation of benign pleomor-
phic adenoma was the most common extirpative proce-
dure for these tumors, but this was associated with a
recurrence rate of 20% to 45%.9-11 This procedure was
carried out to avoid injury to the facial nerves. The
apparent explanation for this observation is the fact
that the benign pleomorphic adenoma may recur if the
capsule is not excised. Accordingly, enucleation should
be avoided and the benign pleomorphic adenoma
should be removed with its capsule and a margin of
normal glandular tissue margin when possible. Benign
pleomorphic adenoma does not invade adjacent struc-
tures. Accordingly, it is unnecessary to resect the facial
nerve, masseter muscle, and other structures when
these are found to be immediately adjacent to the
tumor capsule. Preservation of the integrity of the facial
nerve requires that these procedures be undertaken
only after fi rst identifying the facial nerve. The goal in
surgery of the parotid gland for benign lesion, there-
fore, is to remove the entire neoplasm without injuring
the facial nerve. This can best be accomplished by per-
forming superfi cial parotidectomy with facial nerve dis-
section. Inasmuch as the so-called superfi cial lobe of
the parotid gland is a surgical colloquialism and does
not defi ne an anatomic unit, it is unnecessary for the
surgeon to actually remove all parotid salivary tissue
lateral to the facial nerve and “partial” parotidectomy
may suffi ce.12-14 It is, however, necessary that the surgeon
remove the entire neoplasm with its entire capsule. This
procedure should be accomplished with the facial nerve
carefully identifi ed and protected.
PATIENT SELECTION
The triad of symptoms suggesting a malignant tumor
of the parotid gland include facial nerve dysfunc -
tion, pain, and rapid increase in the size of the
mass. Physical fi ndings include facial nerve paralysis,
fi xation to surrounding tissue, and associated cervical
lymphadenopathy.
511

512
Section 5
Salivary Glands
The most commonly encountered presenting sign
in a patient with a parotid neoplasm is a mass in the
parotid gland. Physical examination demonstrates a dis-
crete mass within the substance of the parotid gland.
The presence of multiple paraglandular and intraglan-
dular nodes means that the pathology could be meta-
static disease or infl ammatory disease either adjacent to
or within the parotid gland. Accordingly, this should
always be considered in the differential diagnosis. The
benign parotid mass is usually mobile. Lack of mobility
may suggest infl ammation, malignancy, or a deep lobe
tumor. The physician must examine the oral cavity to
rule out involvement of the parapharyngeal space.
The fi nding of preoperative facial nerve paresis,
paralysis, or fi xation of the neoplasm to the skin is
highly suggestive of malignancy (Fig. 62-1). Indicators
such as rapid growth and hard consistency should be
considered relative indicators of malignancy. Pain is a
reasonably unreliable indicator of malignancy inas-
much as infl ammatory conditions may cause pain as
commonly as malignant conditions do.
Diffuse enlargement of the gland suggests involve-
ment with a nonneoplastic condition. A study of more
than 140 parotidectomies performed at the University
of Pittsburgh Medical Center found that approximately
25% of parotidectomies were undertaken for nonneo-
plastic disease.4 These pathologies include fi rst bran-
chial cysts and infl ammatory nodes that may be
indistinguishable from neoplasms preoperatively. Infi l-
trative pathologies that may be encountered include
sarcoid and the benign lymphoepithelial lesion associ-
ated with collagen vascular disease.
PREOPERATIVE EVALUATION
Physical examination alone is adequate investigation in
the vast majority of patients presenting with discrete
neoplasms involving the lateral lobe of the parotid
gland in the absence of danger signs. Scanning with
computed tomography (CT) or magnetic resonance
imaging (MRI) is indicated when involvement of the
deep lobe or parapharyngeal space is suspected. This
includes tumors that are located immediately posterior
to the ascending ramus of the mandible and those that
manifest with an oropharyngeal mass displacing the
ipsilateral pharyngeal wall or tonsil (Fig. 62-2). Preop-
erative identifi cation of tumors lying in the deep lobe
medial to the facial nerve is useful inasmuch as it allows
the patient to be counseled that the risk to the facial
nerve is greater when performing total parotidectomy
with facial nerve dissection. Imaging is also advocated
if malignancy is suspected.
Fine-needle aspiration biopsy (FNAB) of salivary
gland neoplasms may be useful in distinguishing malig-
nant from benign conditions. When malignancy is sus-
pected by history, physical examination, and imaging,
the routine use of FNAB allows the surgeon to counsel
the patient preoperatively relative to the increased risk
to the facial nerve and the possibility that elective sac-
rifi ce of a branch of or the entire nerve may be appro-
priate. Alternatively, FNAB may be helpful in establishing
the diagnosis of a benign tumor in an older patient in
whom elective surgery may be contraindicated. For
many patients with parotid neoplasms, however, biopsy
and tumor removal are accomplished in a single step
employing partial parotidectomy with facial nerve
dissection.
All reports of FNAB acknowledge a signifi cant inci-
dence of false-positive results. This suggests that elective
resection of vital structures (e.g., facial nerve) should
be deferred until permanent pathology results are
available.
Figure 62-1. The presence of a mass in the parotid gland and facial
paresis or paralysis is highly suggestive of carcinoma of the parotid.
This woman has weakness in the lower lip owing to mucoepidermoid
carcinoma.
B
Figure 62-2. A, Medial displacement of the soft tissue of the palate
may be due to extension of tumor from the deep lobe of the parotid.
B, A dumbbell tumor of the parotid that probably began in the “deep
lobe” is demonstrated with this axial computed tomography scan.
Arrows outline the dimensions of the tumor.
A

Chapter 62
Parotidectomy
513
Open biopsy of parotid neoplasms is rarely indi-
cated. In fact, open biopsy without facial nerve dissec-
tion of the routinely encountered parotid mass is
contraindicated because it places the facial nerve at risk
and may predispose to dissemination of pleomorphic
adenoma in the skin and adjacent soft tissue, thereby
increasing the risk of recurrence.
We advocate open biopsy of parotid neoplasms in
a highly select population of patients in whom clinical
indicators strongly suggest malignancy and the diagno-
sis is not adequately confi rmed on FNAB. This includes
patients who present with facial nerve paralysis or fi xa-
tion of tumor to the skin. Biopsy without identifi cation
of the facial nerve is something of a calculated risk
undertaken to obtain a diagnosis so that patients can
be appropriately counseled before the defi nitive surgery.
In most cases, no real risk is encountered because of
preexistent paralysis. The surgeon can avoid being
forced to rely on frozen section diagnosis intraopera-
tively when making diffi cult decisions relative to preser-
vation of the integrity of the facial nerve. The author’s
group acknowledges that most experienced patholo-
gists are highly successful in making frozen section diag-
noses of parotid neoplasms; however, the relative rarity
of these malignancies makes the use of frozen section
diagnosis in community hospitals imprecise at best.
Similarly, open biopsy may be necessary to substan-
tiate the diagnosis of some infi ltrative diseases. Sarcoid-
osis, for instance, can produce either unilateral or
bilateral parotid enlargement. Typically, the gland is
diffusely enlarged. This is an important clinical fi nding
that should be distinguished from a discrete nodule
within the gland. Imaging may demonstrate calcifi ca-
tion refl ecting the granulomatous changes. Sarcoid
may be associated with uveitis and facial paralysis (Heer-
fordt’s syndrome). Biopsy is appropriate and treatment
with steroids is effective. Parotidectomy is not appropri-
ate for sarcoidosis.
The benign lymphoepithelial lesions associated
with the collagen vascular disease (systemic lupus,
Sjögren’s syndrome) also produce diffuse glandular
enlargement (Fig. 62-3). Biopsy of the minor salivary
glands in the lip is the procedure of choice in this cir-
cumstance. Patients who display the longstanding lym-
phoepithelial lesions of Sjögren’s syndrome are at risk
to develop non-Hodgkin’s lymphoma. This most com-
monly manifests as gland asymmetry due to a solitary
solid nodule. Biopsy is needed to make this diagnosis.
SUPERFICIAL LOBE
PAROTIDECTOMY WITH
FACIAL NERVE DISSECTION
SURGICAL APPROACHES
Parotid surgery is almost always undertaken with the
patient under general anesthesia. It is important to
advise the anesthesiologist that muscle paralysis must be
avoided to allow observation of facial nerve function
during surgery. Electromyographic (EMG) facial nerve
monitoring, which is commonly used in complex oto-
logic surgery, is used infrequently during parotid
surgery. We believe that the sensitivity of such monitor-
ing results in excessive alarm tones with dissecting adja-
cent to the nerve. Nevertheless, the use of monitoring
is helpful in revision surgical cases in which the anatomy
has been disrupted or in the chronically infl amed gland.
The patient should be draped such that the entire side
of the face is exposed and facial motion can be observed
during the procedure. A modifi ed Blair incision is made
beginning anterior and superior to the tragus. It is
carried along a skin crease down to the earlobe, then
extended around the earlobe to the postauricular area,
and then in a curvilinear fashion brought around to a
natural skin crease in the submandibular area (Fig. 62-
4). An alternative is to extend the incision along the
hairline (Fig. 62-5). The skin is elevated in the superfi -
cial fascial layer anteriorly to expose the mass to be
resected. At this point, the parotid gland is separated
from the cartilaginous external auditory canal and the
anterior border of the sternocleidomastoid muscle.
Hemostasis is carefully secured with electrocautery or
suture ligatures. The greater auricular nerve is invari-
ably identifi ed crossing the sternomastoid muscle.
Branches that enter the parotid are divided. Efforts to
spare postauricular branches are appropriate.
A
B
Figure 62-3. A, Bilateral diffuse enlargement of the parotid gland
is often due to systemic disease. B, This patient demonstrates massive
enlargement of the parotid gland due to Sjögren’s syndrome. Treat-
ment with steroids resulted in dramatic improvement.

514
Section 5
Salivary Glands
facial nerve stimulator may be used to confi rm the loca-
tion of the nerve. The nerve is encountered just inferior
to the “pointer” or vaginal process of the external audi-
tory canal between the mastoid tip and the bony exter-
nal auditory meatus. Structures that resemble the nerve
should be electrically stimulated before cutting;
however, the electrical stimulator should be used spar-
ingly once the nerve is identifi ed because these devices
cause temporary weakness to the facial nerve if they are
used excessively. Bipolar cautery and magnifi cation are
often helpful at this stage of the procedure.
When the facial nerve has been identifi ed, dissec-
tion is carried out along each of the various branches
of the facial nerve, dividing the parenchyma of the
parotid gland in such a way as to allow the lateral lobe
to be removed intact (Fig. 62-7). Soft tissue should be
carefully spread parallel to the direction of the facial
nerve. Dissection within the facial tunnel surrounding
Figure 62-4. An incision commonly employed to expose the parotid
and facial nerve begins in the preauricular skin crease. It is extended
posteriorly in the retroauricular crease and then again inferiorly in a
naturally occurring horizontal crease in the neck.
A
B
Figure 62-5. A, An alternative parotid incision brings the posterior
aspect along the hairline. This gives adequate exposure for most
benign parotid neoplasms. B, This photo shows how this incision is
hidden in the hairline.
The stylomastoid foramen is located medial to the
insertion of the digastric muscle on the mastoid tip.
Accordingly, the digastric muscle should next be identi-
fi ed (Fig. 62-6). Great care should be employed in iden-
tifying the main trunk of the facial nerve. A hand-held
Figure 62-6. Before identifi cation of the facial nerve, the basic
landmarks are identifi ed, including the posterior belly of the digastric
(under the retractor) and the external auditory canal.
Figure 62-7. Dissection is carried out along the branches of the
facial nerve. Vascular structures are ligated.

Chapter 62
Parotidectomy
515
the nerve enables the surgeon to continuously visualize
the nerve, assuming knowledge of its position. This
requires that the glandular tissue be cut along the plane
of the facial nerve (Fig. 62-8). The face should be
observed for motion during this dissection, and exces-
sive pressure or traction on the nerve branches must be
avoided.
When the dissection has been carried anterior to
the neoplasm, the tumor is removed (Fig. 62-9). Com-
plete removal of all parotid glandular tissue is not nec-
essary (and probably not possible without sacrifi ce of
the facial nerve). The single most important principle
is to never cut through the tissue of the gland without
knowing the precise location of the branches of the
facial nerve.
When tumor is adherent or in close proximity to
the facial nerve, every effort should be made to dissect
the nerve off the tumor and preserve the integrity of
the nerve even in cases of known or suspected malig-
nancy. The sole exception to this principle is in patients
with malignant disease in whom preoperative paresis or
paralysis of the facial nerve was present. These patients
rarely (or never) recover function postoperatively, and
elective removal of the nerve is justifi ed. Elective removal
of the facial nerve for benign parotid neoplasms is not
indicated. Experience has demonstrated that benign
pleomorphic adenoma can be removed with no margin
at the facial nerve with a 0% recurrence rate.5 An excep-
tion to this rule may be patients with recurrent pleo-
morphic adenoma. In highly selected cases, excision of
all or part of the nerve with nerve grafting may be
necessary.
When the superfi cial parotidectomy has been com-
pleted, hemostasis should be secured with ligatures,
with care being maintained to avoid injury to the facial
nerve. The wound should be irrigated. The anatomic
integrity of the facial nerve should be confi rmed by
inspection and the functional integrity confi rmed by
electrical stimulation. A negative-pressure suction drain
is inserted and brought out through a separate stab
wound inferior to the incision and the incision is closed
in layers. The skin is closed with fast-absorbing sutures
and Steri-Strips. A bulky compressive dressing is
applied.
POSTOPERATIVE MANAGEMENT
The patient is observed as soon as possible in the recov-
ery room for evidence of facial function. A full recovery
can be expected, even if some element of paresis is
encountered, as long as the nerve is anatomically intact.
Reexploration for facial nerve paralysis is indicated only
if the surgeon has failed to identify any branches of the
facial nerve during the procedure.
The suction drain should be maintained on wall
suction. Drains are removed when the total amount of
drainage is less than 15 mL per 24 hours. Most patients
require a drain for 18 to 30 hours. When drainage is
less than 5 mL per 8-hour shift, the author’s group
allows removal of the drain in midday to facilitate early
discharge. The compressive dressing is not removed
until the drain is removed.
Discharge instructions should include keeping the
wound clean and dry for at least 24 hours, following
which the patient may be allowed to shower, wetting the
Steri-Strips and then carefully patting them dry. Patients
should avoid strenuous exercise and lifting for at least
21 days. The patient is asked to return to the offi ce 7
to 10 days postoperatively for wound care, removal of
Steri-Strips, and discussion of the pathology report.
All patients have anesthesia of the periauricular
skin. This is attributable to intentional transection of
the greater auricular nerve. Recovery requires months
and is rarely complete.
Figure 62-8. Parotid tissue lateral to the facial nerve is fi lleted in
the plane of the nerve, with care being taken to ensure that the
branches are always under direct vision before cutting soft tissue.
Figure 62-9. When the dissection has been carried anterior to all
palpable tumor, the portion of the parotid gland lateral to the facial
nerve can be amputated with the tumor in it.

516
Section 5
Salivary Glands
The most commonly encountered postoperative
complication is wound hematoma. This is most fre-
quently recognized in the recovery room as swelling of
the fl ap with associated bright-red blood in the drain-
age tube. Patients should be returned to the operating
room to reexplore the wound, evacuate the hematoma,
and reestablish hemostasis. Failure to adequately drain
a hematoma may result in an increased risk of infection,
prolonged resolution of edema, and potential compro-
mise of the skin fl ap. Hematoma following parotidec-
tomy has occurred in patients taking aspirin or
nonsteroidal anti-infl ammatory drugs. The author’s
group always counsels patients against the use of these
medications for 7 to 10 days preoperatively.
Inadvertent injury to the facial nerve occurs in 3%
to 5% of cases. This assumes that the facial nerve has
been adequately identifi ed and preserved during the
course of the surgery. When branches of the nerve are
electively divided because of malignancy, the postopera-
tive fi ndings are predictable. On occasion, seemingly
innocuous trauma to the facial nerve may be associated
with neuropraxia and temporary paresis. More com-
monly, this paresis is due to excessive stimulation of the
nerve intraoperatively or stretching the nerve with
retraction. The observation of postoperative movement,
however slight, should be considered an indication of
good prognosis and full recovery can be predicted.
Steroid administration to reduce the incidence of neu-
ropraxia associated with parotidectomy failed to dem-
onstrate effi cacy in a randomized trial.15 If weakness is
due to neuropraxia, recovery is expected in 3 or 4 weeks
postoperatively. If the injury results in axon death,
recovery may require 6 months and may result in per-
manent weakness and synkinesis. If the nerve was tran-
sected and not repaired, it will never recover.
Postoperative wound infection rarely occurs follow-
ing parotidectomy. In a series of 175 parotidectomies
performed without perioperative antibiotics, infection
occurred in less than 5% of patients.6 Routine adminis-
tration of antibiotic prophylaxis is not indicated
unless infection exists preoperatively (which should be
deemed treatment rather than prophylaxis under these
circumstances). If infection is encountered, the wound
should be drained and antibiotics administered based
on fi ndings of Gram stain and culture and sensitivity
data.
Development of a postoperative sialocele or persis-
tent drainage through an incisional sinus is occasionally
encountered. Traditional therapy includes needle aspi-
ration and compressive dressings. Some authors have
reported more rapid resolution with botulinum toxin
therapy.16
Necrosis of skin fl aps is rarely encountered. Flap
necrosis occur following hematoma or occurs due to
poor design of the excessively long and narrow postau-
ricular extension. Similarly, when the skin is elevated in
a very superfi cial plane, compromise of the blood supply
may ensue. The best management of skin necrosis is
prevention. This includes proper planning of the skin
incision, elevation of the fl ap in the correct plane, and
evacuation of hematoma if encountered.
Unsightly scarring is rarely encountered in prop-
erly performed parotid surgery. The facial scar is located
in a preauricular skin crease and then an appropriate
cervical crease when properly executed. Keloid-forming
patients may be managed expectantly with intrainci-
sional steroid injections (Fig. 62-10). Wound closure
should include approximation of subcutaneous tissues
and careful reapproximation of the epithelium with
fast-absorbing sutures and Steri-Strips. This results in a
highly acceptable and easily camoufl aged scar similar
in many ways to the scar widely accepted for
rhytidectomy.
First bite syndrome describes pain in the area of the
resected parotid gland when a meal is started. It is
hypothesized that sympathetic denervation of the
incompletely removed parotid gland causes pain (pos-
sibly a cramp). This is a benign, self-limiting postopera-
tive occurrence.17
Only a small percentage of patients encounter
symptomatic Frey’s syndrome (gustatory sweating).
However, it has been estimated that many patients do
have detectable aberrant innervation of the cutaneous
sweat glands if carefully tested. Troublesome Frey’s syn-
drome may be due to excessive thinning of the skin fl ap
in an extensive “complete” parotidectomy. Some
authors have suggested that transposition of muscle
(sternomastoid) fascia (superfi cial muscular aponeuro-
sis) or implantation of acellular dermis into the wound
may effectively reduce these symptoms.17-19 Manage-
ment of symptomatic Frey’s syndrome should fi rst
employ use of topical anticholinergic products (non-
scented deodorants). Botulinum toxin injection results
in good temporary relief. Division of the preganglionic
parasympathetic nerves is associated with only tempo-
rary relief, with recurrence of symptoms 6 to 12 months
later. Elevation of the skin fl ap with interposition of
vascularized tissue (muscle-fascia) or even free fat has
been reported to achieve relief. These procedures
should be reserved for very symptomatic patients
because of the risk of injury while elevating the skin fl ap
off of the previously dissected facial nerve.
Recurrence of benign pleomorphic adenoma can
perhaps be considered the ultimate complication.
Happily, recurrence following a properly performed
parotidectomy with facial nerve dissection is an exceed-
ingly unusual occurrence. “Old” reports suggest one
fourth to one half of patients may experience recur-
rence following removal of pleomorphic adenoma.7,9
These reports, perhaps, are misleading because sur-
geons in the fi rst half of this century employed enucle-
ation as a treatment of choice for parotid lesions.
Surgeons today recognize the importance of removing
the entire capsule of the lesion while preserving the
integrity of the facial nerve. It is clear, however, that the
facial nerve can be safely peeled off the capsule of the
tumor without encountering a signifi cant incidence of
recurrent pleomorphic adenoma.5
Capsular rupture during surgery may provoke
great anxiety in the surgeon. Reports suggest that tumor
spillage need not be associated with an increased
incidence of recurrence.20,21 The author’s group