Phẫu Thuật Tai Mũi Họng Và Phẫu Thuật Đầu Cổ

518
Section 5
Salivary Glands
its anatomic position for closure. They provide normal
contour to the face. Patients should be counseled that
total parotidectomy is associated with an increased risk
to the facial nerve owing to the necessity to dissect out
and retract the facial nerve during tumor removal. Nev-
ertheless, the vast majority of deep lobe tumors are
benign and every effort must be made to preserve the
integrity of the facial nerve.
Recurrent painful swelling of the parotid gland
with purulent sialorrhea characterizes chronic parotitis.
This somewhat unusual condition may be diagnosed in
patients with Sjögren’s syndrome. In other circum-
stances, chronic parotitis may be caused by structural
abnormality of the duct or through development of
ductal stricture subsequent to sialolithiasis, infection, or
trauma. Every effort should be made to manage these
patients conservatively. Antibiotics, sialogogues, warm
compresses, and massage may be effective in some situ-
ations. Unfortunately, recurrent infection with pain
may eventually be deemed intolerable by both patient
and physician. Under these circumstances, parotidec-
tomy is the treatment of choice. Superfi cial parotidec-
tomy for chronic parotitis is advocated by some and, no
doubt, is generally effective.24,25 Retained glandular
tissue and remnants of Stensen’s duct may be the source
of recurrent symptoms in some patients, however.
Accordingly, we recommend total parotidectomy in
patients requiring surgical management of chronic
parotitis.6
Other forms of treatment can be considered but
have shortcomings. Tympanic neurectomy may have an
immediate effect on the volume of parotid secretions.
Reduction in parasympathetic input may result in ame-
lioration of symptoms. Unfortunately, tympanic neurec-
tomy is unreliable for the management of chronic
parotitis. This probably refl ects the complex para-
sympathetic innervation of the salivary tissue and the
propensity for spontaneous reinnervation. Low-dose
external beam irradiation therapy may be effective. It is
unlikely that the irradiation exerts its effect through
sterilization of saliva. In all likelihood, the irradiation
destroys the glandular tissue, which in turn promotes
fi brosis and eventual resolution. The author’s group
does not advocate irradiation for chronic parotitis. This
represents the general trend toward avoidance of irra-
diation therapy for benign disease. However, in older
patients deemed too fragile for surgical intervention,
this approach may be appropriate. Ligation of the
parotid duct produces acute obstruction with resultant
swelling and pain. Eventually, parenchymal atrophy
ensues, resulting in fi brosis and dysfunction that may
produce resolution of the recurring infectious prob-
lems. Unfortunately, this approach almost invariably
results in acute pain and swelling and may be accompa-
nied by fi stulization of the duct with continuing
problems.
Patients undergoing total parotidectomy for chronic
parotitis have an increased risk of injury to the facial
nerve compared with patients undergoing superfi cial
parotidectomy for benign neoplasms. This refl ects the
fi brosis and obscuration of tissue planes that may ensue
following acute infection. Every effort should be made
to postpone surgery until the gland can be rendered as
quiescent as possible through the administration of
antibiotics and local measures. The author’s group’s
experience with 26 patients requiring total parotidec-
tomy for chronic parotitis confi rms this observation.7
Five patients (26%) experienced immediate postopera-
tive facial weakness, which resolved in 3 months in all
but one patient. The use of intraoperative facial nerve
monitoring has made identifi cation of the facial nerve
easier in the setting of chronic infl ammation, fi brosis,
and obscured planes. The availability of newer tech-
niques of sialoendoscopy, which allows stone removal
and duct dilatation, may reduce the incidence of
chronic parotitis in future years.
SURGICAL APPROACHES
Total parotidectomy must be preceded by superfi cial
parotidectomy. This requires the somewhat “nononco-
logic” dissection of the facial nerve with removal of the
superfi cial lobe of the parotid gland. This approach,
however, has proved highly satisfactory in managing
benign neoplasms of the parotid and, in fact, may be
employed to successfully manage many parotid malig-
nancies when combined with the use of postoperative
radiation therapy, thereby allowing preservation of the
integrity of the facial nerve. The facial nerve is gently
dissected off the deep lobe of the parotid gland and
retracted, and the residual gland is passed under
its branches and delivered to the operative fi eld
Figure 62-11. This axial computed tomography scan displays a
tumor that arose in the parotid gland medial to the facial nerve and
has extended through the stylomandibular tunnel into the parapha-
ryngeal space.

Chapter 62
Parotidectomy
519
(Fig. 62-12). Continued stimulation of the nerve with
the electrical unit should be avoided because it may
contribute to postoperative paresis. The operation must
be modifi ed somewhat in patients with chronic sialade-
nitis such that all identifi able salivary gland tissue be
removed. This may require dissection and retraction of
multiple branches of the facial nerves. The initial super-
fi cial lobe parotidectomy should be modifi ed by carry-
ing the dissection along Stensen’s duct anterior to the
masseter muscle, through buccal space, and down the
mucosa. This is of greatest importance in patients with
sialadenitis caused by calculus. Leaving a segment of
Stensen’s duct with a calculus will be followed by sub-
sequent infection. We have also encountered patients
who have had spontaneous fi stulization of Stensen’s
duct owing to complete obstruction from a large calcu-
lus. In such cases, an ellipse of chronically infected skin
should be excised in continuity with the specimen and
the skin defect closed. Hemostasis should be ensured
by the use of ligatures, the wound irrigated, and a
suction drain inserted into the depth of the wound with
an attempt to avoid direct contact with the nerve. The
wound is closed in layers, employing fast-absorbing
sutures for the skin and Steri-Strips applied to support
the wound. A bulky compressive dressing is employed
in every case.
Mandibulotomy is sometimes advocated to improve
access to very large lesions of the deep lobe of the
parotid gland (Figs. 62-13 and 62-14). Before division
of the bone, a fi xation plate should be fi tted and screw
holes drilled. This helps ensure accurate reduction at
the completion of surgery, thereby maintaining occlu-
sal relationships.
POSTOPERATIVE MANAGEMENT
The patient should be observed in the recovery room
for facial motion. Paresis is an indication that the facial
Figure 62-12. The facial nerve is gently retracted as a pleomorphic
adenoma that developed in the tissue medial to the facial nerve is
dissected out.
nerve is intact and will recover. The patient can be reas-
sured that even if paresis progresses to paralysis in the
early postoperative hours, recovery is expected.
RADICAL PAROTIDECTOMY
When the facial nerve is dissected out and preserved
during the course of parotid surgery, the procedure is
compromised from an oncologic point of view. However,
experience with the management of even high-grade
parotid malignancies suggests that it is appropriate
to dissect out and preserve a functional facial nerve,
even in the face of high-grade malignancy involving
the glandular parenchyma (Fig. 62-15). This refl ects the
devastating impact of facial nerve resection and the
observation that local regional control can be achieved
Figure 62-13. Mandibulotomy may occasionally be employed to
better expose a tumor that extends medial to the mandible.
Figure 62-14. The mandible is retracted, allowing dissection of the
tumor and delivery into the wound.

520
Section 5
Salivary Glands
A
B
C
Figure 62-15. A, This patient presents with normal facial nerve function. Biopsy
demonstrates adenoid cystic cancer. B, Computed tomography confi rms extension into
the deep lobe medial to the facial nerve. C, The facial nerve is preserved during total
parotidectomy.
with the appropriate application of postoperative irra-
diation therapy. A more radical en bloc resection of the
parotid gland is appropriate in treating patients who
present with facial paralysis as well as in the manage-
ment of patients with extensive carcinoma with involve-
ment of surrounding structures such as the skin,
masseter muscle, mandible, or temporal bone.
Patients presenting with a high-grade malignancy
involving the parotid gland and normal facial function
are counseled that resection of all or part of the facial
nerve may be necessary. Additionally, manipulation of
the nerve during surgery may result in temporary paresis
of branches that are preserved. Under normal cir-
cumstances in dealing with a moderate-sized or small

Chapter 62
Parotidectomy
521
neoplasm, it is possible to anticipate that some branches
of the facial nerve will be at greater risk than others. At
the time of surgery, facial nerve branches that can be
successfully dissected free from the tumor are pre-
served. The branches with evidence of preoperative
paresis or those that cannot be successfully dissected
free from the tumor may require resection and subse-
quent repair (Fig. 62-16). Neck dissection is required
in case of high-grade malignancy and can be easily per-
formed at the same setting as the parotidectomy. The
incision is carried into the head and modifi ed as appro-
priate for the type of neck dissection being planned.
Although keeping the specimen in one piece is possi-
ble, it is not necessary and may impair facial nerve
identifi cation.
SURGICAL APPROACHES
When patients present with total facial paralysis owing
to tumor infi ltration, recovery should not be expected.
Accordingly, attempts to dissect out and preserve the
facial nerve are unnecessary. On the other hand, it is
appropriate to identify the facial nerve proximal and
distal to the neoplasm so that facial nerve repair can be
achieved after resection of the tumor. This may require
some form of a mastoidectomy (e.g., taking down the
mastoid cortex, removing the mastoid tip, and identify-
ing the facial nerve in the vertical section of the tempo-
ral bone). Frozen section of the distal as well as the
proximal nerve should be accomplished before nerve
repair. Similarly, the distal branches of the facial nerve
should be identifi ed during tumor resection. This is
facilitated through the use of an electrostimulator in
patients with some residual intact function. Unfortu-
nately, patients who present with total paralysis may not
be stimulated. Accordingly, the surgeon may be chal-
lenged by the need to fi nd the distal branches as they
exit the parotid gland. In general, reconstruction of the
facial nerve in cases is which it is resected anterior to
the lateral canthus produces such minimal functional
recovery that it is not generally undertaken. These
patients are better served with some form of reconstruc-
tion for the corner of the mouth and a gold weight in
the upper lid. “Dynamic” reconstruction with inner-
vated muscle, for example, the temporalis, may result
in some voluntary motion. Fascial sling procedures and
facelifts produce “static” improvement, the results of
which, unfortunately, may deteriorate with aging. Fol-
lowing extended radical parotidectomy, soft tissue
defects are covered with regional fl aps or split-thickness
graft.
FACIAL NERVE REPAIR
When the facial nerve is injured either inadvertently or
as a planned part of the procedure, it should be repaired
in almost every circumstance. The best functional
results with facial nerve repair are obtained by anasto-
mosis of the divided nerve. More often, however, an
anatomic portion of the nerve is lost. In such cases, the
continuity can be reestablished through insertion of a
free nerve (cable) graft (see Fig. 62-16). Reanimation
of the face through use of an adjacent cranial nerve
(the 12th cranial nerve) is only undertaken when rees-
tablishment of the continuity of the facial nerve is not
possible.
SURGICAL APPROACHES
When the facial nerve has been divided, as in surgical
or external trauma, it should be anastomosed. This
requires trimming the cut ends of the nerve and apply-
ing two or three extremely fi ne (7-0 or 8-0) sutures,
employing the operating microscope. Only the epineu-
rium need be approximated. This should be accom-
plished with no tension on the suture line and the cut
ends of the nerve must oppose each other.
When a segment of facial nerve is removed, for
instance, during excision of a malignant tumor, it is
appropriate to harvest a nerve of appropriate diameter
and length to reconstruct the facial nerve. The greater
auricular or the sural nerve is most appropriate. The
fascicles of these nerves may be separated to allow
reconstruction of more than one branch of the facial
nerve when indicated. Efforts should be made to pref-
erentially reconstruct orbital and perioral branches at
the expense of the buccal, frontal, and cervical branches.
The fourth cervical nerve may also be used to good
advantage where peripheral branches are removed. It
provides an anatomic unit similar to that of the facial
nerve with a larger “main trunk” and distinct smaller
branches similar in diameter to the remaining branches.
If a neck dissection is performed at the same procedure,
it is important to plan ahead for possible nerve graft
harvest when dissecting in the vicinity of the cervical
and greater auricular nerves.
Postoperative radiation therapy may have a detri-
mental effect on nerve regeneration from grafts. Some
Figure 62-16. A cable graft is used to construct the lower division
of the facial nerve. The upper division has been preserved intact. The
nerve graft has been split to accommodate two branches.

522
Section 5
Salivary Glands
authors report minimal impact,26,27 whereas others
report results that suggest the compromised function
when the graft is irradiated.28,29 Some return of function
can be expected, however, and reconstruction is indi-
cated. Use of an adjacent motor cranial nerve is only
indicated when reestablishment of the integrity of the
facial nerve is not possible. This situation rarely exists
in routine parotid surgery; however, when the facial
nerve has been injured in the internal auditory meatus
or at the brain stem, reconstruction may not be possi-
ble. In these cases, it may be appropriate to employ
adjacent motor cranial nerves, recognizing that this
requires sacrifi ce of other functions to achieve some
improvement in facial function. Use of the hypoglossal
nerve is most widely acknowledged as being the most
successful in achieving facial tone. Use of the hypoglos-
sal nerve to reinnervate facial musculature may result
in discrete return of facial motion and improved tone.
Use of the hypoglossal nerve results in ipsilateral tongue
paralysis. Most patients tolerate this remarkably well;
however, it is nonetheless a defi cit that must be dis-
cussed with the patient preoperatively.
The hypoglossal nerve is identifi ed as it passes ante-
rior to the external carotid artery. It is dissected far
anteriorly, to obtain suffi cient length to allow anasto-
mosis with the distal facial nerve without tension. Fas-
cicles of the hypoglossal nerve can be separated to allow
reconstruction of various branches of the facial nerve
(Fig. 62-17).
Success is defi ned as improved tone. This is an
important concept because selective discrete reinnerva-
tion is not possible. Accordingly, the patient should be
counseled preoperatively that improved tone is a
victory.
References
1. Spiro RH: Salivary neoplasms: Overview of 35-year experience
with 2,807 patients. Head Neck Surg 8:177, 1986.
2. Eneroth CM: Salivary gland tumors in the parotid gland, subman-
dibular gland, and the palate region. Cancer 27:1415, 1971.
3. Woods JE, Cheng GC, Beahrs OH: Experience with 1,360 primary
parotid tumors. Am J Surg 130:460, 1975.
4. Johnson JT, Gallia L: The incidence of neoplastic versus infl am-
matory disease in major salivary gland masses diagnosed by
surgery. Laryngoscope 91:512-516, 1981.
5. Donovan DT, Conley JJ: Capsular signifi cance in parotid tumor
surgery: Reality and myths of lateral lobectomy. Laryngoscope
94:324-329, 1984.
6. Arriaga MA, Myers EN: The surgical management of chronic
parotitis. Laryngoscope 100:1270-1275, 1990.
7. Wood FC: Mixed tumors of the salivary glands. Ann Surg 39:57,
1904.
8. Benedict EG, Meigs JV: Tumors of the parotid gland. A study of
225 cases with complete end-results in 80 cases. Surg Gynecol
Obstet 51:626-647, 1930.
9. Stein I, Geschickter CF: Tumors of the parotid gland. Arch Surg
28:482-526, 1934.
10. Senn N: The Pathology and Surgical Treatment of Tumors.
Philadelphia, WB Saunders, 1895, pp. 173, 296.
11. Sistrunk WE: Tumor of the parotid gland. Surg Clin North Am
1:1515-1521, 1921.
Figure 62-17. Hypoglossal-facial nerve anastomosis. The hypoglos-
sal nerve has been split to allow reinnervation of the upper and lower
divisions of the facial nerve.
PEARLS
• FNAB is a test. Sensitivity approaches 90% to 95%;
however, false-positive results are observed 5% to
15% of the time.
• Open biopsy and permanent pathologic evaluation
are indicated when resection of a normal facial
nerve is required.
• Sarcoid can cause facial paralysis.
• Pleomorphic adenoma must be completely excised.
• Comprehensive removal of all parotid tissue may be
most effective in control of recurrent bacterial
parotitis.
• The facial nerve is at highest risk during surgery for
cancer, chronic parotitis, and deep lobe tumors.
• Postoperative radiation is indicated for high-grade
parotid cancer.
PITFALLS
• All patients will have a scar and should be so
advised.
• The greater auricular nerve is intentionally transected
during parotidectomy. This results in periauricular
numbness. Recovery takes months and is
incomplete.
• First bite syndrome refers to pain upon eating. It is
believed to be due to spasm and may resolve
spontaneously.
• Symptomatic Frey’s syndrome, a relatively unusual
problem, may be treated with topical antiperspirants
or injection of Botox.

Chapter 62
Parotidectomy
523
12. O’Brien CJ: Current management of benign parotid tumors—the
role of limited superfi cial parotidectomy. Head Neck 25:946-952,
2003.
13. McGurk M, Thomas BL, Renehan AG: Extracapsular dissection
for clinically benign parotid lumps: Reduced morbidity without
oncological compromise. Br J Cancer 89:1610-1613, 2003.
14. Witt RL: The signifi cance of the margin in parotid surgery for
pleomorphic adenoma. Laryngoscope 112:2141-2154, 2002.
15. Lee KJ, Fee WE Jr, Terris DJ: The effi cacy of corticosteroids in
postparotidectomy facial nerve paresis. Laryngoscope 112:1958-
1963, 2002.
16. Chow TL, Kwok SP: Use of botulinum toxin type A in a case of
persistent parotid sialocele. Hong Kong Med J 9:293-294, 2003.
17. Filho WQ, Dedivitis RA, Rapoport A, Guimaraes AV: Sterno-
cleidomastoid muscle fl ap preventing Frey syndrome following
parotidectomy. World J Surg 28:361-364, 2004.
18. Angspatt A, Yangyuen T, Jindarak S, et al: The role of SMAS fl ap
in preventing Frey’s syndrome following standard superfi cial
parotidectomy. J Med Assoc Thai 87:624-627, 2004.
19. Sinha UK, Saadat D, Doherty CM, Rice DH: Use of AlloDerm
implant to prevent Frey syndrome after parotidectomy. Arch
Facial Plast Surg 5:109-112, 2003.
20. Natvig K, Soberg R: Relationship of intraoperative rupture of
pleomorphic adenomas to recurrence: An 11-25-year follow-up
study. Head Neck 16:213-217, 1994.
21. Buchman CA, Stringer SP, Mendenhall WM, et al: Pleomorphic
adenoma: Effect of tumor spill and inadequate resection on
tumor recurrence. Laryngoscope 104:1231-1234, 1994.
22. Stennert E, Wittekindt C, Klussmann JP, et al: Recurrent pleo-
morphic adenoma of the parotid gland: A prospective histo-
pathological and immunohistochemical study. Laryngoscope
114:158-163, 2004.
23. Koral K, Sayre J, Bhuta S, et al: Recurrent pleomorphic adenoma
of the parotid gland in pediatric and adult patients: Value of
multiple lesions as a diagnostic indicator. Am J Roentgenol
180:1171-1174, 2003.
24. Nichols RD: Surgical treatment of chronic suppurative parotitis:
A critical review. Laryngoscope 87:2066-2081, 1977.
25. Beahrs OH, Devine KD, Woolner LB: Parotidectomy in the treat-
ment of chronic sialoadenitis. Am J Surg 102:760-768, 1961.
26. Conley JJ: Facial nerve grafting. Arch Otolaryngol 73:322-327,
1961.
27. McCabe BF: Facial nerve grafting. Plast Reconstr Surg 45:70-75,
1970.
28. Pillsbury HC, Fisch U: Extratemporal facial nerve grafting and
radiotherapy. Arch Otolaryngol 105:441-446, 1979.
29. Lathrop FD: Management of the facial nerve during operations
on the parotid gland. Ann Otol Rhinol Laryngol 72:780-801,
1963.

Chapter 63
Prestyloid Parapharyngeal Space
Jonas T. Johnson
The prestyloid parapharyngeal space (PSPS) is a trian-
gular space that extends from the hyoid bone inferiorly
to the skull base superiorly. The medial limit of the
space is the lateral pharyngeal wall, whereas laterally it
is limited by the fascia of the pterygoid muscles superi-
orly and the soft tissues of the neck inferior to the angle
of the mandible. The anterior aspect of the parapha-
ryngeal space ends at the pterygoid mandibular raphe
anteriorly and is posteriorly limited by the carotid
sheath and the contents of the poststyloid parapharyn-
geal space. The PSPS is separated from the poststyloid
parapharyngeal space by the fascia of the tensor veli
palatini muscle, which extends from the styloid process
posterolaterally to the pterygoid plates anteromedially
(Fig. 63-1).1
Normally, the PSPS contains adipose tissue, lym-
phatics, and small unnamed vessels. Tumor involve-
ment of the PSPS most commonly refl ects expansion of
benign salivary gland neoplasms into the PSPS from
either the deep lobe of the parotid gland or minor sali-
vary gland rests.1-4 Accordingly, the most common neo-
plasm encountered is pleomorphic adenoma. Malignant
salivary gland neoplasms may develop, but they are
unusual. We have also observed lipoma in the PSPS
(Fig. 63-2). Metastatic neoplasms to the lymphatics of
the PSPS may occasionally be encountered (Fig. 63-
3).5,6 Other neoplasms developing, for instance, in the
mandible, the maxilla, or the various soft tissues sur-
rounding the PSPS, may extend into the PSPS; however,
according to more strict defi nition, they should not be
considered parapharyngeal space neoplasms but rather
neoplasms arising from adjacent structures (Fig.
63-4).
PATIENT SELECTION
The most commonly encountered initial symptom of a
neoplasm involving the PSPS is an asymptomatic mass
located either immediately posterior or immediately
inferior to the angle of the mandible in the neck or
submucosally in the soft palate or lateral pharyngeal
wall. Medial expansion of these tumors may interfere
with the fi t of a dental prosthesis and, on occasion, may
become symptomatic as a result of partial obstruction
of the aerodigestive tract because of size (Fig. 63-5). We
have been impressed by the rather remarkable size that
may be attained by a benign pleomorphic adenoma in
the parapharyngeal space with relatively innocuous
symptoms. The presence of pain or neuropathy should
lead the clinician to suspect an alternative diagnosis
such as a primary or metastatic malignant tumor.
PREOPERATIVE EVALUATION
Imaging with either computed tomography (CT) or
magnetic resonance imaging (MRI) is a critical aspect
of patient evaluation. In fact, it was only with the advent
of CT that there was a clear understanding of the para-
pharyngeal space and the biology of tumors arising in
this area. The site of origin of large tumors is sometimes
diffi cult to assess. Displacement of parapharyngeal fat
posteromedially is a strong indication that the lesion
arose in the PSPS (Figs. 63-6 and 63-7). Conversely,
displacement of parapharyngeal fat anteriorly and later-
ally strongly suggests the presence of a neoplasm arising
in the poststyloid space. Tumors arising in the deep
lobe of the parotid gland may pass through the stylo-
mandibular tunnel to reach the parapharyngeal space
(Fig. 63-8). These tumors have a characteristic dumb-
bell shape (Fig. 63-9). The imaging characteristics of a
normal parotid gland allow the surgeon to make this
assessment without need for concurrent sialography.
When tumors pass posterior or inferior to the styloman-
dibular ligament, a more rounded confi guration is
attained.
Tumors arising from minor salivary glands or minor
salivary gland rests in the parapharyngeal space are
commonly diagnosed by displacement of the soft palate
525

526
Section 5
Salivary Glands
Figure 63-1. The parapharyngeal space in the axial plane.
Figure 63-2. Axial computed tomography scan demonstrating
massive lipoma in the parapharyngeal space with extension across the
midline through the retropharyngeal space. This patient was remark-
ably asymptomatic. The diagnosis is apparent because of the fat
density of the lesion.
Figure 63-3. Axial computed tomography scan demonstrating a
lesion in the parapharyngeal space (arrows). The displacement of
parapharyngeal fat was not characteristic of either a prestyloid or a
poststyloid lesion. The patient had previously been treated for papil-
lary carcinoma of the thyroid. It was subsequently removed and
proved to be metastatic thyroid cancer.
Figure 63-4. Axial magnetic resonance image demonstrating a
large mass that involved the parapharyngeal space. Anterior exten-
sion into the mandible (open arrow) and maxilla (solid arrow) with
involvement of the pterygoid muscle suggests that this lesion is malig-
nant, originated in structures adjacent to the parapharyngeal space,
and extended posteriorly. This tumor proved to be a chondro -
sarcoma.

Chapter 63
Prestyloid Parapharyngeal Space
527
Figure 63-5. An oral view of a parapharyngeal mass displacing the
soft palate anteromedially.
Figure 63-6. Computed tomography scan of a pleomorphic
adenoma. This mass (arrows) originated in the parotid and extended
into the prestyloid parapharyngeal space.
Figure 63-7. Axial computed tomography scan clearly demonstrat-
ing a dumbbell tumor (arrows) originating in the parotid and extend-
ing medially. It was a pleomorphic adenoma.
A
B
Figure 63-8. A, Relationship between the styloid process, the
ascending ramus, the mandible, and the stylomandibular ligament.
Some tumors develop in the deep lobe of the parotid gland and may
extend through the stylomandibular tunnel into the parapharyngeal
space. B, Deep lobe parotid tumor passing through the stylomandibu-
lar ligament into the parapharyngeal space.

528
Section 5
Salivary Glands
Figure 63-9. The confi nes of the stylomandibular tunnel tend to
create an isthmus in deep lobe parotid tumors that gives them a
characteristic dumbbell confi guration.
and lateral pharyngeal wall toward the midline. Biman-
ual examination facilitates clinical determination of the
size and site. Imaging demonstrates the characteristic
displacement of parapharyngeal fat; however, the pres-
ence of fat between the deep lobe of the parotid gland
and the neoplasm confi rms that the neoplasm arose
independently of the parotid gland (Fig. 63-10).
Preoperative fi ne-needle aspiration biopsy of para-
pharyngeal space tumors is frequently undertaken. This
technique requires the close cooperation of a skilled
cytopathologist. Interpretation of the cytology should
be closely correlated with the clinical fi ndings. Trans-
oral incisional biopsy of parapharyngeal space masses is
to be discouraged. The possibility of inadvertent biopsy
of a highly vascular tumor originating in the poststyloid
parapharyngeal space can be minimized through initial
use of contrast-enhanced imaging techniques; nonethe-
less, transmucosal biopsy invariably soils the mucosa
with tumor, creates infl ammation and adhesions, and
compromises subsequent total tumor removal. We do
not recommend preoperative incisional transoral biopsy
of parapharyngeal space masses. This technique might
be advocated only for tumors that are clearly atypical
and therefore demand preoperative histologic estab-
lishment of the diagnosis.
SURGICAL APPROACHES
The PSPS is ideally approached with the transcervical-
submandibular technique. A skin incision is developed
approximately 2 to 3 cm inferior to the lower border of
the mandible in a horizontal skin crease (Fig. 63-11).
The incision is carried through subcutaneous tissue
and the platysma, after which the mandibular branch
of the facial nerve should be identifi ed, elevated, and
preserved. Identifi cation of the anterior border of the
Figure 63-10. This pleomorphic adenoma displaced fat medially
(closed arrow). Separation from the parotid gland (open arrow) is also
noted.
Figure 63-11. A horizontal incision in a submandibular skin crease
affords adequate exposure to the parapharyngeal space.

Chapter 63
Prestyloid Parapharyngeal Space
529
sternomastoid muscle facilitates identifi cation of the
posterior belly of the digastric muscle, which is retracted
inferiorly as the submandibular gland is refl ected ante-
riorly (Fig. 63-12). This provides direct access to the
PSPS and allows identifi cation of the facial artery as it
enters the submandibular space. The artery is divided
and ligated so that the gland can be more fully retracted
anteriorly. This provides access to the apex of the PSPS.
Retractors are then used to facilitate blunt dissection of
the mass from the adjacent soft tissue so that it can be
delivered through the wound and removed (Fig. 63-13).
Delivery of very large tumors is facilitated by dividing
the digastric tendon and then repairing it with suture.
Pleomorphic adenoma does not invade surrounding
soft tissue, and a cuff of normal tissue need not be
excised. Efforts should, however, be made to preserve
the capsule of the neoplasm intact. Should the capsule
be violated, every effort should be made to remove all
tumor and the wound should be copiously irrigated
before closure.7,8 When tumor removal is complete and
hemostasis is obtained, a suction drain is placed in the
depths of the wound and brought out through a sepa-
rate incision just adjacent to the incision. The wound is
closed in layers and a dressing applied.
Successful removal of a tumor arising from the
deep lobe of the parotid gland is dependent on proper
identifi cation and dissection of the facial nerve. An inci-
sion is made anterior to the tragus around the earlobe
into the postauricular area, and a horizontal subman-
dibular skin incision is created to afford adequate expo-
sure (Fig. 63-14). The skin fl ap is elevated and the facial
nerve is identifi ed. The superfi cial lobe of the parotid
gland is mobilized off the facial nerve. This step is nec-
essary to fully expose the facial nerve. The facial nerve
is then carefully elevated with nerve hooks as the facial
nerve is dissected free of the deep lobe of the parotid.
With this maneuver the remaining medial aspect of the
tumor can be dissected free and delivered into the
wound. Occasionally, the stylomandibular ligament
must be divided to allow suffi cient access to the medial
aspect of the tumor (Fig. 63-15). In patients with a
benign parotid tumor, the superfi cial lobe of the parotid
gland can be returned to its anatomic position and
preserved. This maintains the normal contour of the
face and reduces the incidence of Frey’s syndrome.
The literature is replete with descriptions of tech-
niques by which exposure of the parapharyngeal space
may be improved. The common technique is exposure
through a mandibulotomy,9-14 which can be carried out
either directly through the body of the mandible or
anteriorly with retraction of the mandible laterally. The
use of subcutaneous mandibulotomy may reduce the
occurrence of facial scars.15 Alternatively, the temporo-
mandibular joint can be disarticulated and the mandi-
ble displaced anteriorly. Our experience with many very
Figure 63-12. After ligation of the external branch of the facial
artery, the submandibular gland is retracted anteriorly and the para-
pharyngeal space tumor is visible just anterior to the posterior belly
of the digastric muscle.
A
B
Figure 63-13. A, A submandibular incision has been used to expose
the parapharyngeal space. An army-navy retractor (arrow) is retracting
the submandibular gland. B, A benign pleomorphic adenoma was
removed from the prestyloid parapharyngeal space. This lesion was
not connected to the parotid gland.

530
Section 5
Salivary Glands
large neoplasms of the parapharyngeal space suggests
that a mandibulotomy is rarely necessary, especially
with benign pleomorphic adenoma involving the deep
lobe of the parotid gland or of minor salivary gland
origin. Dumbbell tumors invariably require that the
stylomandibular ligament be divided. Malignant tumors
with involvement of the mandible, posterior aspect of
the maxilla, or skull base represent special cases in
which the procedure should be developed to afford
three-dimensional excision (see Fig. 63-8). Further dis-
cussion of these issues is beyond the scope of this
chapter and is presented in Chapter 101.
Infratemporal Fossa
PSPS neoplasms may achieve rather remarkable size
before coming to the attention of either the patient or
the physician. The amount of dissection required to
free the facial nerve from the deep lobe of the parotid
gland frequently results in temporary postoperative
facial nerve paresis. Accordingly, patients requiring
total parotidectomy should be counseled preoperatively
that some degree of temporary facial paresis or paralysis
is to be expected. We have encountered a benign pleo-
morphic adenoma that required mandibulotomy to
achieve adequate exposure for removal. This technique
does permit direct visualization of the carotid sheath
and skull base and is an important addition to the surgi-
cal management of tumors of the poststyloid parapha-
ryngeal space and tumors that are malignant or require
resection of adjacent structures.
POSTOPERATIVE MANAGEMENT
Discharge from the hospital may take place several
hours after the drains have been removed. Routine
administration of perioperative antibiotics is not indi-
cated unless the pharyngeal mucosa has been violated.
A compressive cervical dressing frequently serves to
coapt the superfi cial tissues and helps reduce dead
space. Removal of tumors from the PSPS creates a “dead
space.” Patients may resume a soft diet as soon as they
are comfortable enough to swallow. Drains are placed
on wall suction, and drainage is monitored daily. Drains
are discontinued when total drainage is less than 15 mL
per 24 hours.
COMPLICATIONS
Hematoma is the most commonly encountered compli-
cation of PSPS surgery and can be avoided by meticu-
lous hemostasis before closure. Ties placed on the facial
artery are especially important and should be secure.
The sudden development of a hematoma may compro-
mise the oropharyngeal airway and may be considered
an indication for tracheotomy.
The parapharyngeal space is closely related to many
crucial anatomic structures. Nevertheless, trauma to the
great vessels or cranial nerves is unusual and should not
be anticipated. Critical to this assumption is accurate
preoperative establishment of the site of origin of the
tumor. Neuromas involving the vagus or cervical sympa-
thetic chain originate in the poststyloid parapharyngeal
space. These lesions must be distinguished preopera-
tively with modern imaging techniques. When neuro-
mas are identifi ed, the patient should be counseled that
a postoperative nerve defect is to be expected.
Transoral excision of PSPS neoplasms has been
advocated,16 but this technique is suited only to patients
with neoplasms arising in salivary gland rests. The deep
Figure 63-14. A horizontal submandibular incision is carried
around the earlobe and up to the preauricular skin to afford expo-
sure for superfi cial parotidectomy and simultaneous removal of a
deep lobe parotid tumor.
Figure 63-15. Subsequent to superfi cial parotidectomy, the facial
nerve can be elevated and protected while the deep lobe tumor is
removed. Note that the exposure is obtained just anterior to the pos-
terior belly of the digastric muscle.

Chapter 63
Prestyloid Parapharyngeal Space
531
lobe of the parotid gland cannot be removed safely
when undertaken transorally. Transoral excision does
not afford the surgeon an opportunity to identify closely
related neurovascular structures such as the facial nerve.
Additionally, it compromises the wound through con-
tamination with oral secretions. We continue to recom-
mend that tumors involving the parapharyngeal space
be removed through a transcervical approach.
First bite syndrome is the occurrence of facial pain
at the initiation of a meal after parotid surgery. It is
attributed to loss of sympathetic nerve function to the
parotid and has been described after surgery on the
PSPS.17 Medical management is of little help. Surgical
cure requires a tympanotomy and excision of Jacob-
son’s nerve in the middle ear.
References
1. Curtin HD: Separation of the masticator space from the parapha-
ryngeal space. Radiology 163:195-204, 1987.
2. Som PM, Biller HF, Lawson W: Tumors of the parapharyngeal
space: Preoperative evaluation, diagnosis and surgical approaches.
Ann Otol Rhinol Laryngol 90:3-15, 1981.
3. Som PM, Biller HF, Lawson W, et al: Parapharyngeal space
masses: An updated protocol based upon 104 cases. Radiology
153:149-156, 1984.
4. Som PM, Braun IF, Shapiro MD, et al: Tumors of the parapha-
ryngeal space and upper neck: MR imaging characteristics. Radi-
ology 164:823-829, 1987.
5. Lombardi D, Nicolai P, Antonelli AR, et al: Parapharyngeal lymph
node metastasis: An unusual presentation of papillary thyroid
carcinoma. Head Neck 26:190-196, 2004.
6. Desuter G, Lonneux M, Plouin-Gaudon I, et al: Parapharyngeal
metastases from thyroid cancer. Eur J Surg Oncol 30:80-84,
2004.
7. Natvig K, Soberg R: Relationship of intraoperative rupture of
pleomorphic adenomas to recurrence: An 11–25-year follow-up
study. Head Neck 16:213-217, 1994.
8. Buchman C, Stringer SP, Mendenhall WM, et al: Pleomorphic
adenoma: Effect of tumor spill and inadequate resection on
tumor recurrence. Laryngoscope 104:1231-1234, 1994.
9. Attia EL, Bentley KC, Head T, Mulder D: A new external approach
to the pterygomaxillary fossa and parapharyngeal space. Head
Neck Surg 6:884-891, 1984.
10. Biller HF, Shugar JMA, Krespi YP: A new technique for wide-fi eld
exposure of the base of the skull. Arch Otolaryngol 107:698-702,
1981.
11. Ulku CH, Uyar Y, Arbag H: Management of parapharyngeal space
tumors. Irish Med J 97:140-142, 2004.
12. Brennan PA, Smith GI, Webb AA, Ilankovan V: Double man-
dibular osteotomy with coronoidectomy for tumours in the
parapharyngeal space. Br J Oral Maxillofac Surg 42:79-80,
2004.
13. Pang KP, Goh CH, Tan HM: Parapharyngeal space tumours: An
18 year review. J Laryngol Otol 116:170-175, 2002.
14. Malone JP, Agrawal A, Schuller DE: Safety and effi cacy of trans-
cervical resection of parapharyngeal space neoplasms. Ann Otol
Rhinol Laryngol 110:1093-1098, 2001.
15. Teng MS, Genden EM, Buchbinder D, Urken ML: Subcutaneous
mandibulotomy: A new surgical access for large tumors of the
parapharyngeal space. Laryngoscope 113:1893-1897, 2003.
16. Goodwin WJ, Chandler JR: Transoral excision of lateral parapha-
ryngeal space tumor presenting intraorally. Laryngoscope 98:266-
269, 1988.
17. Chiu AG, Cohen JI, Burningham AR, et al: First bite syndrome:
A complication of surgery involving the parapharyngeal space.
Head Neck 24:996-999, 2002.
PEARLS
• CT or MRI can reliably distinguish prestyloid
parapharyngeal pathology from other entities.
• Salivary gland neoplasia accounts for the most
commonly encountered pathology.
• The potential for metastasis to the prestyloid space
should not be discounted.
• Excision of a deep lobe parotid tumor requires that
the facial nerve be identifi ed and mobilized.
• The lateral lobe of the parotid need not be excised
in the case of a benign tumor of the deep lobe and
may be returned to its anatomic position to
preserve the contour of the face.
• Mandibulotomy is rarely necessary, even with
removal of very large tumors in the PSPS.
PITFALLS
• Transoral biopsy of a parapharyngeal space tumor
will contaminate the mucosa and make eventual
resection more diffi cult.
• Failure to identify the marginal branch of the facial
nerve may lead to permanent dysfunction of the
lower lip.
• Failure to provide adequate postoperative drainage
may necessitate performance of a tracheotomy.
• Attempted transoral excision of even benign
pleomorphic adenoma is an error if the tumor is
attached to the parotid or near the facial nerve.

Chapter 64
Masses in the Buccal Space
Eugene N. Myers
A mass appearing within the substance of the cheek is
unusual and suggests a tumor of the buccal space or the
accessory lobe of the parotid gland. The buccal space
is a compartment within the masticator space that was
described by Kostrubala in 1945.1 There are a number
of reports of buccal space masses, and many surgical
approaches have been suggested in the literature.1-9
Lesions in the buccal space are readily apparent because
they are easily palpated just beneath the buccal mucosa
or the skin of the cheek.10 Defi nitive diagnosis of a mass
in the buccal space is made by excision of the mass and
histopathologic evaluation.
Understanding the anatomy of the buccal space is
necessary for proper management.4,5 The medial wall is
formed by the buccinator muscle and its overlying
fascia, which extends from the mandible inferiorly to
the zygomatic arch superiorly (Fig. 64-1). The deep
portion of the lateral wall is formed by the muscles
of facial expression (risorius, zygomaticus major, and
levator labii superioris) and their fascia. More superfi -
cial to these muscles lie the superfi cial fascia and skin.
The anterior border of the buccal space is formed by
the orbicularis oris muscle. The posterior border is the
anterior border of the masseter muscle and the parotid
gland. Posterior to the buccal space is the parotid gland
and the masticator space. The superior and inferior
limits are formed as the fascia attaches to the perios-
teum of the zygomatic arch and mandible, respectively.
Anatomic structures found in the buccal space include
Stensen’s duct medially, the facial artery and vein, lym-
phatic channels, minor salivary glands, accessory parotid
lobules, and most laterally, the buccal branches of the
facial nerve. These nerve branches enter the medial
surface of the muscles of facial expression. Most of the
buccal space is fi lled with adipose tissue, referred to as
the buccal fat pad, and lymph nodes.
The accessory lobe of the parotid gland is an island
of salivary gland tissue found anterior to and separate
from the main parotid gland. Frommer demonstrated
in cadaver studies that an accessory lobe of the parotid
gland is found in approximately 21% of the popula-
tion.11 He described the accessory lobe as being clearly
separate from the main parotid gland by an average of
6 mm, as opposed to the anterior facial process of the
parotid gland, which is an anterior extension of the
main gland. The accessory lobe of the parotid gland is
usually located in the soft part of the cheek along
Stensen’s duct. The lobe drains through one or more
ducts into nearby Stensen’s duct and is usually closely
related to the buccal and zygomatic branches of the
facial nerve.12 The normal size of an accessory lobe of
the parotid gland, when present, is approximately 0.5
to 2.5 cm in diameter. One percent to 7% of all parotid
neoplasms arise within the accessory lobe of the parotid
gland, depending on inclusion criteria12,13 (Table 64-1).
These neoplasms are similar in histology to those found
in the parotid gland, although up to 50% can be malig-
nant, a rate higher than that in the parotid gland itself.13
Most malignant tumors of the accessory lobe of the
parotid gland are primary salivary gland cancers.
However, there are a few case reports of metastases to
this area from primary tumors in the head and neck or
distant site.16 We recently described a case of metastasis
to the accessory lobe of the parotid gland from renal
cell carcinoma (Fig. 64-2).17
The typical history encountered in patients with a
mass in the buccal space is that of a slowly growing,
painless mass in the cheek. If the mass is more deeply
seated, it tends to lie more medial and the patient may
be able to feel the intraoral mass with the tongue. When
the mass is located in the oral cavity, patients are often
seen initially by their dentist or an oral maxillofacial
surgeon. Physical examination provides information
that is useful in establishing a working diagnosis
and usually reveals a mobile mass within the substance
of the cheek that can be seen in the oral cavity and
533

534
Section 5
Salivary Glands
Figure 64-1. The left buccal space and its contents.
can clearly be demonstrated by bimanual palpation
(Fig. 64-3). The differential diagnosis of a mass in the
buccal space includes lesions originating from each
of the tissue components in the space. Table 64-1
lists the lesions that have been found in the buccal
space.2-4, 13,15,18-31
Imaging studies can often provide useful informa-
tion about a mass in the buccal space. The purpose of
a computed tomography (CT) scan is primarily to
determine the type and extent of the lesion for plan-
ning surgical treatment. This may be particularly helpful
in deciding whether the mass is benign or malignant.
Kurabayashi and coworkers evaluated the CT features
of buccal space masses in 53 patients.6 CT images were
assessed to determine the number, location, internal
architecture, and margins of lesions and their relation-
ship to surrounding structures. Their series included 44
tumors (33 benign and 11 malignant) and 9 masses that
were not tumors. Tumors of the buccal space were
found adjacent to the outer surface of the buccinator
muscle, in contrast to epidermoid cysts and tumors of
the accessory lobe of the parotid gland, which were
completely separate from it. None of the cases in their
series were tumors of the accessory lobe of the parotid
gland. Tumors of the accessory lobe of the parotid
gland, epidermoid cysts, lipomas, and lymphoma
could be differentiated from other lesions in this series.
In all other cases, the CT features were nonspecifi c.
Hemangiomas were characterized by multiple masses
and the presence of phleboliths. When ill-defi ned
margins, violation of fascial planes, and aggressive
bone destruction were used as the criteria for malig-
nancy, only seven malignant tumors were correctly
diagnosed preoperatively. The authors concluded that
CT was useful in demonstrating the presence and loca-
tion of masses in the buccal space and sometimes in the
differential diagnosis, and that the value of CT in dif-
ferentiating malignant from benign buccal space lesions
is limited.
Table 64-1 REPORTED BUCCAL SPACE LESIONS
Glandular
Accessory parotid or aberrant salivary gland tumors
Mixed tumor (benign* and malignant)
Mucoepidermoid carcinoma (low and high grades)
Acinic cell carcinoma
Adenoid cystic carcinoma7
Carcinoma ex pleomorphic adenoma
Metastatic clear cell carcinoma
Chronic sialadenitis*
Oncocytoma*
Papillary cystadenoma lymphomatosum
Sebaceous adenoma*
Parotid duct tumor or calculus
Minor salivary gland calculus
Lymph Node
Calcifi ed node
Benign reactive node
Lymphoma*
Lymphosarcoma
Metastatic nodal involvement
Lymphangioma
Neural
Neurofi broma
Neuroma
Vascular
Hyalinized thrombus*
False aneurysm
Hemangioma
Hemangioendothelioma
Hemangiopericytoma
Connective
Fibromatosis
Lipoma
Liposarcoma
Spindle cell lipoma*
Fibroma
Fibrosarcoma
Rhabdomyosarcoma
Nodular fasciitis*
Muscular
Myositis ossifi cans
Masseteric hypertrophy
Infl ammatory
Abscess formation
Bacterial abscess
Aspergilloma
Sarcoidosis*
Polymorphic low-grade adenocarcinoma14
Tuberculous granuloma and adenoid cystic carcinoma
manifested as a single buccal space mass15
Clear cell carcinoma metastatic from the kidney
*Identifi es the diagnoses of 10 patients treated between 1975 and 1987.

Chapter 64
Masses in the Buccal Space
535
Kurabayashi and colleagues also studied 30 patients
with benign and malignant lesions in the buccal space
with magnetic resonance imaging (MRI).7 The authors
evaluated the MRI characteristics of lesions in the
buccal space and concluded that MRI was useful in
demonstrating the extent of lesions in the buccal space
but that its diagnostic value in predicting malignancy
was very limited. This was especially true for malignant
tumors of minor salivary gland origin, which were typi-
cally seen as well-defi ned masses without infi ltration
into surrounding structures on MRI.
Neoplasms of the salivary glands are uncommon
and account for only 2% of all tumors. Of these, 85%
are found in the parotid glands, with most of the
remainder occurring in the submandibular glands. A
small proportion are found in the sublingual and minor
salivary glands. Tumors of minor salivary gland origin
are most commonly located on the palate, with the
tongue and buccal space being the next most common
locations.32
Tumors of the minor salivary glands are more likely
to be malignant (>50%) than tumors of the major sali-
vary glands (20%). Tumors of the minor salivary glands,
even when malignant, tend to progress slowly. Regard-
less of whether the tumor is benign or malignant,
patients usually have a nontender, mobile palpable
mass that has been present for 1 to 5 years. At the time
of diagnosis, most tumors range from 2 to 6 cm in
diameter. Patients with a malignant tumor can exhibit
pain, numbness, paresthesia, or facial paralysis. These
tumors rarely infi ltrate into adjacent structures.32
Most neoplasms in the buccal space are tumors of
minor salivary gland origin. Benign tumors are most
often pleomorphic adenoma, monomorphic adenoma,
or Warthin’s tumor. Malignant tumors in the buccal
space include adenocarcinoma; adenoid cystic, muco-
epidermoid, acinic cell, anaplastic, and small cell
carcinoma; carcinoma ex pleomorphic adenoma;
A
B
Figure 64-2. A, T2-weighted axial magnetic resonance imaging
(MRI) through the parotid gland demonstrating a round 10-mm mass
(arrows) overlying the masseter muscle (m). The mass has a signal
intensity slightly higher than the adjacent gland, but not high enough
to be defi nitive for pleomorphic adenoma. It proved to be renal cell
carcinoma metastatic to the accessory lobe. B, Sagittal post–contrast-
enhanced spoiled-gradient MRI of the abdomen with T1 weighting
shows two distinct masses in the left kidney. The superior mass (s)
has cystic and solid components. The inferior mass (i) is predomi-
nantly cystic and has extensive septations. This renal cell carcinoma
was the primary tumor.
Figure 64-3. Preoperative frontal view illustrating swelling in the
cheek.

536
Section 5
Salivary Glands
polymorphous low-grade adenocarcinoma; and metas-
tasis from other sites.14,33,34 Other less common primary
tumors include fi broma, fi brosarcoma, lipoma, lym-
phoma, melanoma, nerve sheath tumor, and hemangi-
oma. For tumors other than lipoma, biopsy is necessary
because no clinical or radiographic criteria are reliable
in establishing a histologic diagnosis.
SURGICAL APPROACHES
Several surgical approaches to the buccal space have
been described. The approach used most commonly is
a direct transmucosal intraoral incision with dissection
and removal of the mass. This approach is appealing,
because the bulging of the tumor into the intraoral area
appears to lend itself to easy excision and of course
eliminates a skin incision with its inevitable scar (Fig.
64-4). Despite this apparent advantage, the intraoral
approach may not provide adequate exposure. While
removing these tumors through the external approach
I have observed that the buccal branches of the facial
nerve are always closely associated with or actually incor-
porated into the capsule on the lateral aspect of the
tumor, which cannot be visualized through the intra-
oral approach. Stensen’s duct is also closely associated
with these tumors. Without proper exposure, these vital
structures are at risk for injury, which could produce
facial paralysis and sialocele. Although the direct trans-
cutaneous approach is also appealing because of the
apparent advantage of requiring less time and dissec-
tion and no need to raise skin fl aps, thereby avoiding
the possibility of fl ap necrosis, it is not recommended,
however, because of the highly visible scar. This
approach also makes it diffi cult to use local tissue to fi ll
in the depressed area left by removal of the tumor.
Preoperative Planning
The history, physical characteristics of the mass, and
select imaging studies may suggest a specifi c diagnosis.
Fine-needle aspiration biopsy may be used to obtain
information for planning treatment while recognizing
that this procedure poses a potential risk to the facial
nerve. Such injury, however, is often elusive, and
removal of the mass is required for histologic
evaluation.
I designed the extended parotid-submandibular
incision for removal of tumors in the buccal space
because it provides excellent exposure and minimizes
the risk of complications such as injury to Stensen’s
duct or the facial nerve during excision of these
tumors.4,5 I have found that this technique also provides
an excellent cosmetic result. Patients are counseled that
the buccal branch of the facial nerve will be dissected
and elevated off the tumor and is therefore vulnerable
to intraoperative injury and postoperative weakness as
a result of dissection and stretching of the nerve. I have
also successfully used the rhytidectomy approach for
removal of these tumors. Use of this technique for
tumors of the buccal space has been very well described
by Madorsky and Allison.8 These two techniques will
now be described.
Surgical Technique
Extended Parotid-Submandibular Incision
The incision is a modifi cation of the standard paroti-
dectomy incision (Fig. 64-5). Extension of the preau-
ricular incision somewhat superiorly and extension of
the cervical incision into a submandibular space skin
crease allow wide undermining of the fl ap, which is
A
B
Figure 64-4. A, External view of
a right buccal space mass. B, Inter-
nal view. Note the intraoral bulge
produced by the mass.

Chapter 64
Masses in the Buccal Space
537
necessary to gain exposure anterior to the parotid gland
for visualization of the tumor. It is not necessary to carry
out a formal parotidectomy or to identify the facial
nerve at the stylomastoid foramen, because the tumor
is anterior to the anterior border of the parotid gland
and therefore only the buccal branches of the nerve are
anatomically associated with these tumors.
The skin fl ap is elevated anterior to the anterior
border of the parotid gland where the mass is encoun-
tered. Further elevation of the fl ap provides exposure
of the entire mass. The location of the buccal branches
of the facial nerve is easily identifi ed, usually during
blunt dissection of the mass, and confi rmed with a facial
nerve stimulator (Fig. 64-6). Stensen’s duct is usually
also identifi ed during this phase of the dissection. Dis-
section of the branches of the nerves somewhat anterior
and posterior to the mass itself will allow undermining
and mobilization of the nerve. A small nerve retractor
is then used to retract the branches of the nerve away
from the mass. Once dissected, the nerves may be
marked with arterial loops. The mass itself is then
removed by sharp and blunt dissection. After removal
of the mass, the nerves are returned to their normal
anatomic position. Removal of the tumor leaves a
noticeable defect in the facial contour that is elimi-
nated by approximating the superfi cial musculoapo-
neurotic system (SMAS).
Hemostasis is obtained, the wound is irrigated, and
a Hemovac drain is inserted under the skin fl ap and
brought out through a separate stab wound posterior
to the incision. The skin fl ap is closed with subcutane-
ous chromic catgut suture and then continuous closure
with 6-0 plain catgut suture. Steri-Strips and a pressure
dressing are applied. The patient is allowed to recover
from anesthesia. Within 24 hours the drainage has
usually stopped, the pressure dressing and drain are
removed, and the patient is discharged.
Rhytidectomy Approach
Mitz and Peyronie in 1976 described the rhytidectomy
approach and how this technique allows reconstruc -
tion of the contour defect associated with tumor extir-
pation by SMAS interposition.9 They used this technique
in fi ve patients: two tumors of the accessory lobe of the
parotid gland, one parotid cyst, one case of nodular
fasciitis of the anterior masseter muscle, and one
lymphoma.
The incision used in these cases is the one used for
rhytidectomy. The incision begins at the temple and
continues in a preauricular crease and then post-
tragally. The incision is carried inferior to the ear lobe,
up to the level of the posterior auricularis muscle pos-
teriorly, and posteriorly into the hairline. The skin is
undermined anterior to the tumor, mobilized, and
retracted away from the tumor. The tumor is then
excised as described earlier. After removal of the tumor,
the SMAS is closed directly to give suffi cient support to
the cheek to avoid deformity. Rotation of a fl ap of
SMAS has been recommended for defects that are too
large for direct closure or advancement closure. This
technique distributes the volume defect over a wider
A
B
C
Figure 64-5. A, Lateral view of a mass in the buccal space. B, Surgi-
cal exposure of the mass. C, Surgical closure over closed-suction
drains.

538
Section 5
Salivary Glands
area and converts the depression to a gradual transition
that is less noticeable.
Madorsky and Allison relied on their extensive
experience with the rhytidectomy approach in manag-
ing 126 patients who had a tumor of the parotid gland
and adjacent structures.8 They described the relation-
ship of the SMAS as being superfi cial to the facial nerve.
If too much tension is placed on the SMAS closure, the
SMAS is mobilized by dissecting the facial nerve
branches underlying it and advancing it for closure.
POSTOPERATIVE MANAGEMENT
The only complication that I have encountered in my
series is a hematoma in a patient who had histiocytic
lymphoma. It is unclear why the hematoma occurred,
but I assume that it was due to inadequate hemostasis
rather than the underlying disease. Injury to the facial
nerve is avoided by early identifi cation of the nerve and
gentle retraction and dissection.
Care must be taken when undermining the supe-
rior aspect of the fl ap because the zygomatic branch of
the upper division of the facial nerve is superfi cial in
this area and the branch could be injured with resultant
facial nerve paralysis.
COMPLICATIONS
Complications are minimized with this procedure,
which is exactly why I use it systematically for tumors in
this space. The experience of caring for a patient who
had a mass previously removed through an incision in
the buccal mucosa, during which an injury to the facial
nerve was sustained and a sialocele developed
in the buccal space because of inadvertent injury to
Stensen’s duct, was the incentive to design the extended
parotid-submandibular incision. The need to identify
Stensen’s duct and the branches of the facial nerve are
the fundamental advantages of the transcutaneous
approach. The general principles of surgery are never
better demonstrated than in this procedure, which
include (1) adequate exposure, (2) potential to extend
the surgery should it be necessary, and (3) an accept-
able cosmetic result.
Figure 64-6. Surgical exposure of a buccal space tumor demon-
strating the facial nerve branches adherent to the lateral aspect of the
mass.
PEARLS
• Evaluate the patient with fi ne-needle aspiration
biopsy and imaging before surgery to enhance
planning for the surgical procedure and patient
counseling.
• Evaluate the patient’s needs regarding cosmetic
appearance. The modifi ed parotid incision leaves a
visible scar, so for a female patient, a rhytidectomy
approach should be used, whereas the incision in a
male patient is usually hidden in the beard line and
is acceptable.
• Undermine in the plane between the subcutaneous
tissue and the SMAS.
• Begin to look for divisions of the buccal branch of
the facial nerve once the soft tissues have been
undermined as far as the anterior border of the
parotid gland.
• Identify the branches of the facial nerve with the
nerve stimulator and dissect them off the tumor.
• Retract the branches of the nerve away from the
tumor to excise it without nerve injury.
• Closing the SMAS either primarily or with a fl ap will
prevent an unsightly depression in the cheek.
PITFALLS
• Failure to select the proper incision based on the
patient’s perceived needs can leave visible scars.
• Failure to identify and preserve the important
structures contained in the buccal space, especially
the facial nerve, can lead to complications.
• Failure to close the SMAS properly will result in an
unsightly depression in the cheek.
References
1. Kostrubala JG: Potential anatomical spaces in the face. Am J Surg
68:28-37, 1945.
2. Maguire CP, Horton CE, Pickrell KL: Tumors of the cheek. Arch
Surg 71:896-906, 1955.
3. Weaver DF: Tumors of the cheek. Arch Otolaryngol 79:229-238,
1964.
4. Gallia L, Rood SR, Myers EN: Management of buccal space
masses. Otolaryngol Head Neck Surg 89:221-225, 1981.

Chapter 64
Masses in the Buccal Space
539
5. Rodgers GK, Myers EN: Surgical management of the mass in the
buccal space. Laryngoscope 98:749-753, 1988.
6. Kurabayashi T, Ida M, Yoshino N, et al: Computed tomography
in the diagnosis of buccal space masses. Dentomaxillofac Radiol
26:347-353, 1997.
7. Kurabayashi T, Ida M, Tetsumura A, et al: MR imaging of benign
and malignant lesions in the buccal space. Dentomaxillofac
Radiol 31:344-349, 2002.
8. Madorsky SJ, Allison GR: Management of buccal space tumors by
rhytidectomy approach with superfi cial musculoaponeurotic
system reconstruction. Am J Otolaryngol 20:51-55, 1999.
9. Mitz V, Peyronie M: The superfi cial musculoaponeurotic system
(SMAS) in the parotid and cheek area. Plast Reconstr Surg 58:80-
88, 1976.
10. Harnsberger HR: The masticator space. In Harnsberger HR (ed):
Handbook of Head and Neck Imaging, 2nd ed. St Louis, Mosby–
Year Book, 1995, pp 46-59.
11. Frommer J: The human accessory parotid gland: Its incidence,
nature and signifi cance. Oral Surg 43:671-676, 1977.
12. Perzik SL, White IL: Surgical management of preauricular tumors
of the accessory parotid apparatus. Am J Surg 112:498-503,
1966.
13. Johnson FE, Spiro RH: Tumors arising in accessory parotid tissue.
Am J Surg 138:576-578, 1979.
14. Kwong MD, Bert RJ: Case 2: Polymorphous low-grade adenocar-
cinoma of a minor salivary gland in the right buccal space. AJR
Am J Roentgenol 173:808-809, 1999.
15. Landa LE, Kathju S, Nepomuceno-Perez MC, et al: Tuberculous
granuloma and adenoid cystic carcinoma presenting as a single
buccal space mass. J Craniofac Surg 13:533-537, 2002.
16. Klotz DA, Coniglio JU: Prudent management of the mid-cheek
mass: Revisiting the accessory parotid gland tumor. Laryngoscope
110:1627-1632, 2000.
17. Daamen N, Ozolek JA, Branstetter BF, Myers EN: Occult renal
cell carcinoma metastatic to the accessory lobe of the parotid
gland. Abstract presented at the Eastern Section Program. Wash-
ington DC, Jan. 28, 2005. Available at
PastMeetingPrograms/2005ProgramLongEastern.pdf.
18. Polayes IM, Rankow RM: Cysts, masses and tumors of the acces-
sory parotid gland. Plast Reconstr Surg 64:17-23, 1979.
19. Allen JH, Finch LD, Chippendale I: Sialolithiasis of the minor
salivary glands. Oral Surg 27:780-785, 1969.
20. Fritz GW, Petti NA, Abitbol A: Extranodal malignant histiocytic
lymphoma of the cheek: Report of a case. J Oral Surg 38:200-202,
1980.
21. Barnard JD: Primary clinical manifestation of bronchial carci-
noma as a buccal metastasis. Br Dent J 138:174-178, 1975.
22. Robbins JP, Fitz-Hugh S, Constable WC: Involvement of the buc-
cinator node in facial malignancy. Arch Otolaryngol 94:356-358,
1971.
23. Ewbank RL, Standish M, Mitchell DF: Hyalinized thrombus of the
cheek: Report of a case. J Oral Surg 22:456-459, 1964.
24. Merchant NE: Cavernous hemangioma of the cheek. Dent Pract
Dent Res 22:436, 1972.
25. Tomizawa M, Nakajima T, Fukushima M: False aneurysm of the
cheek: Report of two cases. J Oral Surg 37:515-518, 1979.
26. Calhoun NR: Lipoma of the buccal space. Oral Surg 16:246-249,
1963.
27. Smith JF: Nodular fasciitis of the buccal pad. Arch Otolaryngol
86:111-112, 1967.
28. Larsson A, Svartz K: Nodular fasciitis in the oral cavity. Int J Oral
Surg 5:122-127, 1976.
29. Trestu PH, Markovitch E, Zambito RF: Myositis ossifi cans, circum-
scripta and progressiva with surgical correction of the masseter
muscle: A report of two cases. J Oral Surg 27:201-205, 1969.
30. Tate RJ: Unusual facial abscess: Report of a case. Br J Dent
131:504, 1971.
31. Rodriguez V, Bardwill JM, Bodey GP: Primary aspergilloma cured
with amphotericin B. South Med J 64:396-398, 1971.
32. DeVita VT, Hellman S, Rosenberg S: Cancer: Principles and Prac-
tice of Oncology, 4th ed. Philadelphia, JB Lippincott, 1993, pp
664-666, 822-826.
33. Crean SJ, Bryant C, Bennett J, Harris M: Four cases of polymor-
phous low-grade adenocarcinoma. Int J Oral Maxillofac Surg
25:40-44, 1996.
34. Pinto PX, Coleman N: Regional metastasis in polymorphous low-
grade adenocarcinoma: Report of a case. Int J Oral Maxillofac
Surg 26:447-449, 1997.

section 6
Thyroid and Parathyroid
Chapter 65
Thyroidectomy
Eugene N. Myers
Although thyroid disease has been recognized since the
earliest recorded history, consistent techniques of
surgery on the thyroid gland, with a few exceptions,
date back only 100 years. Kocher in 1895 reported 900
cases of thyroidectomy for benign goiter with an opera-
tive mortality rate of just higher than 1%. An advocate
of safe, meticulous surgery, he won the Nobel Prize in
Medicine in 1909 for his contributions to thyroid gland
surgery. Crile, Lahey, and the Mayo brothers founded
their internationally famous private clinics largely on
their ability to perform thyroid surgery safely.1
Carcinoma of the thyroid is an uncommon disease
that accounts for approximately 1% of all cancers. It is
estimated that 8000 to 9000 new cases occur every year
in the United States. Nonmalignant thyroid abnormali-
ties, such as adenoma and thyroiditis, are quite common.
Thyroid nodules are found in approximately 4.2% of
the population in the United States. The incidence of
either benign or malignant thyroid disease is higher in
females and increases with age. A solitary nodule in the
thyroid gland may be benign or malignant and demands
evaluation (Fig. 65-1).
PATIENT SELECTION
Clinical evaluation of a patient with a mass in the thyroid
gland begins with a careful history and physical exami-
nation. The typical fi nding is an asymptomatic mass in
the thyroid gland. Pain, dysphagia, and rapid enlarge-
ment of a mass in the thyroid gland are signs more
typical of the development of a malignancy.
The age and sex of the patient are very important
in decision making because benign nodules tend to be
more prevalent in women in the 20- to 40-year-old age
group. In this group, the risk of cancer is approximately
5% to 10%. However, a mass in the thyroid gland in
males, in patients younger than 20 years, in those older
than 40 years, or in those of advanced years is associated
with an increased incidence of cancer. Although symp-
toms such as diffi culty swallowing, stridor, and hoarse-
ness suggest cancer, patients with a large goiter or
substernal thyroid may also have diffi culty swallowing
and respiratory obstruction. Hoarseness is almost invari-
ably associated with cancer.2
Thorough physical examination is very important.
The usual mass in the thyroid is well circumscribed and
nontender and moves with swallowing. A characteristic
fi nding of cancer is a mass greater than 2 cm in diame-
ter with a very hard consistency and fi xation to the skin
or the underlying tissues. Direct or indirect laryngos-
copy in the outpatient setting is of utmost importance
to detect vocal cord paralysis. The neck should also
be thoroughly examined for the presence of cervical
lymphadenopathy. The presence of enlarged lymph
nodes associated with a mass in the thyroid is suggestive
of cancer of the thyroid gland. It is not uncommon for
a patient to have a mass in the lateral aspect of the neck
without an obvious mass in the thyroid gland and to
541

542
Section 6
Thyroid and Parathyroid
have a mass in the thyroid gland discovered only after
the neck mass has been excised and diagnosed as meta-
static cancer of the thyroid. A similar sequence of events
occurs when fi ne-needle aspiration biopsy (FNAB) of
the metastatic lymph node is performed and the diag-
nosis of thyroid cancer is made.
A mass in the thyroid gland in children will usually
prove to be well-differentiated papillary cancer because
benign tumors in the pediatric population are unusual.
Medullary carcinoma may also appear in the pediatric
age group. There is usually a familial history of this
cancer, and these tumors may have the same aggressive
behavior as seen in adults.
Proper management of a patient with a mass in the
thyroid gland is controversial, particularly a young adult
with a solitary thyroid nodule. Each of the following
situations is an indication for thyroid surgery:
• An individual in the pediatric age group with a mass
in the thyroid gland
• An individual with a mass in the thyroid gland who
underwent radiation therapy in childhood
• An individual with a mass accompanied by an ele-
vated calcitonin level
• An individual with a mass in the thyroid gland with
recent onset
• An individual with a mass in the thyroid gland associ-
ated with pathologic cervical lymphadenopathy
Physical fi ndings suggestive of malignancy include
a hard nodule, especially if larger than 2 cm, paralysis
of the ipsilateral recurrent laryngeal nerve, and the
presence of associated palpable cervical lymphadenopa-
thy. Patients with these signs warrant lobectomy regard-
less of the FNAB, thyroid scan, or ultrasound fi ndings.
The risk of cancer in a solitary thyroid nodule in
an individual in the pediatric age group increases with
decreasing age (Fig. 65-2). Papillary adenocarcinoma is
the type most commonly encountered. These patients
should undergo total lobectomy. Total thyroidectomy
is advocated if the lesion is diagnosed as malignant
on frozen permanent section. Patients who prove to
have medullary carcinoma should undergo total thy-
roidectomy and bilateral neck dissection.
Patients with a history of exposure to radiation
therapy in childhood who have a palpable mass should
undergo total thyroidectomy. A third of abnormalities
in the thyroid gland in patients with a history of radio-
therapy will be malignant. A patient with a history of
head and neck radiation therapy is more likely to have
multifocal cancer, is considered to be in the high-risk
category, and should undergo total thyroidectomy.3
Patients with a mass in the neck or an abnormal
thyroid scan associated with an elevated serum calcito-
nin level will have medullary carcinoma. Because of the
association with other endocrine tumors (e.g., multiple
endocrine neoplasia type II [MEN-II]), screening for
pheochromocytoma is required preoperatively. Calcito-
nin assay is appropriate in younger people (<40 years
old) with a mass in the thyroid gland that is suggestive
of malignancy (vocal cord paralysis or enlarged neck
nodes) and in individuals with a family history of medul-
lary carcinoma.4
Thyroid surgery in the geriatric age group can be
performed safely with low morbidity as in younger
patients. The chance for success is determined by analy-
sis of individual risk factors and potential benefi ts, and
careful preoperative preparation is essential because of
the high rate of comorbid conditions.5
Patients in the older age group who have a rapidly
expanding mass in the thyroid, especially if associated
with pain and vocal cord paralysis, must be suspected
of having anaplastic cancer or lymphoma of the thyroid
gland. Many of these patients will require urgent tra-
cheotomy to relieve airway distress, at which time a
biopsy specimen should be obtained. Radical resection
of anaplastic cancer is not usually feasible because of
extensive infi ltration of surrounding structures. Patients
with anaplastic thyroid cancer (ATC) have a poor prog-
nosis with a median survival of less than 6 months. Most
patients suffering from ATC die of uncontrolled local
tumor invasion causing suffocation. Although patients
with ATC can rarely be cured, every effort should be
made to control the primary cancer to improve the
quality of their remaining life. Surgery or radiation
therapy used alone is seldom suffi cient to control the
disease; however, a combination of these modalities
may improve local control. Tennvall and colleagues6
prospectively evaluated a combined regimen consisting
of hyperfractionated radiotherapy, doxorubicin, and
when feasible, debulking surgery in 55 consecutive
patients with ATC. Five patients survived for 2 years
and in only 13 patients (24%) was death due to local
failure.
Lymphoma of the thyroid may also be manifested
as a rapidly enlarging mass in the neck, respiratory dis-
tress, vocal cord paralysis, hemoptysis, and dysphagia.
Biopsy is usually performed at the time of tracheotomy.
Distinction between undifferentiated carcinoma and
lymphoma is often diffi cult on frozen section evalua-
tion. Therefore, appropriate therapy is decided after
the fi nal diagnosis is made with immunohistochemical
techniques. Lymphoma of the thyroid is usually treated
Figure 65-1. A mass in the thyroid that contained papillary, follicu-
lar, and anaplastic carcinoma.

Chapter 65
Thyroidectomy
543
with chemotherapy or radiation therapy, or both, with
generally good results if the disease is localized to the
thyroid gland.
The role of neck dissection in the management of
cancer of the thyroid is controversial, as is the amount
of thyroid tissue to be removed. In patients with single
or multiple cervical metastases, selective neck dissection
is performed with preservation of the spinal accessory
nerve, the internal jugular vein, and the sternocleido-
mastoid muscle. Dissection of the central compartment
(level VI) is carried out at the time of thyroidectomy
once the diagnosis of cancer of the thyroid is made.
Care must be taken to avoid the possibility of inadver-
tently removing the parathyroid glands or injuring the
recurrent laryngeal nerves.
Shaha and coworkers,7 in an interesting analysis of
1038 patients, stated that the most important prognos-
tic factors in survival of patients with differentiated
thyroid cancer are age, grade, extracapsular extension,
distant metastasis, and the size of the tumor. The
patients were divided into low-, medium-, and high-risk
categories. Ten- and 20-year survival rates were 99%.
Locoregional distant recurrence rates were 5%, 9%,
and 20%. The authors concluded that low-risk patients
could be treated by thyroid lobectomy. Patients in the
high-risk category required surgical treatment and
administration of 131I because of extensive thyroid
cancer and the presence of distant metastasis.
Beenken and associates8 analyzed their series of 208
patients with well-differentiated thyroid cancer (WDTC)
and concluded that total thyroidectomy may provide
a survival benefi t for intermediate-risk patients. This
group includes patients younger than 45 years with
unfavorable tumor-related prognostic factors and
patients older than 45 years with favorable tumor-
related prognostic factors. Although the optimal extent
of thyroidectomy in this group remains controversial,
there was a trend in their series toward better survival
in patients treated with total thyroidectomy. A recent
study published by Esnaola and coauthors9 indicated
that total thyroidectomy maximizes the quality-adjusted
life expectancy in low- and high-risk patients.
Shaha and coworkers10 reviewed the patterns of
failure in differentiated carcinoma of the thyroid on the
basis of risk groups and found that the overall incidence
of recurrence in the low-risk group was just 13% versus
A
B
C
Figure 65-2. A, A mass in the
thyroid was found on routine pre-
season physical examination of a
16-year-old football player. B, Cold
nodule in the upper pole of the
right lobe of the thyroid gland
(arrow). C, Specimen demonstrat-
ing
papillary
cancer
in
the
thyroid.

544
Section 6
Thyroid and Parathyroid
50% in the high-risk group. The incidence of distant
metastasis in the low-risk group was just 2% as com-
pared with 34% in the high-risk group. Understanding
of the patterns of treatment failure in different risk
groups affi rms the need to plan treatment strategies
according to individual risk groups and intraoperative
fi ndings.
PREOPERATIVE EVALUATION
Routine laboratory blood tests are generally of little
value in diagnosing an asymptomatic solitary thyroid
nodule. Thyroid function studies are usually normal.
Elevated thyroxine (T4) or triiodothyronine (T3) levels
in a patient with a solitary thyroid nodule may indicate
the presence of a hyperfunctioning adenoma, which
has a very low incidence of malignancy. Low thyroid
hormone levels in a patient with a solitary nodule are
generally of little diagnostic value.
Serum thyroglobulin levels are typically elevated in
patients with WDTC but are usually normal or decreased
in patients who have anaplastic or medullary carcinoma.
If elevated thyroglobulin levels are demonstrated in
well-differentiated cancer, thyroglobulin testing should
be repeated postoperatively because elevation of thyro-
globulin may be a predictor of tumor recurrence. Hall
and colleagues11 stated that advanced tumor stage at
diagnosis and a stimulated thyroglobulin level greater
than 20 pmol/L 3 months after total thyroidectomy
were independent predictors of disease recurrence.
Patients with a thyroglobulin level greater than 20 pmol/
L are at increased risk for recurrence and may be
candidates for more intensive follow-up or additional
treatment.
A more specifi c indicator of malignancy is the
serum calcitonin level, which is elevated in 75% of
patients with medullary thyroid carcinoma.2 If there are
either symptoms or a family history suggestive of medul-
lary carcinoma, serum calcitonin levels and evaluation
for MEN-II are suggested.
Radionuclide Scanning
Radionuclide scanning with iodine or technetium has
been a standard diagnostic procedure; however, this
test is not diagnostic of cancer. When a cold nodule is
identifi ed, the most that can be said is that the fi nding
is abnormal. In a patient who has a history of previous
thyroid surgery, the scan may be useful in determining
the amount of residual thyroid tissue present.
Campbell and Pillsbury2 performed a meta-analysis
in which they reviewed 10 reports in the literature that
correlated the results of radionuclide scans in patients
who had solitary thyroid nodules with the pathology
reports after surgery. The meta-analysis revealed that
17% of cold nodules, 13% of warm or cool nodules, and
4% of hot, hyperfunctioning nodules were malignant.
The cumulative data suggest that for clinically detected
solitary thyroid nodules, although nonfunctioning
nodules are most likely to be malignant, “warm” or
“hot” nodules may also occasionally be malignant.
Because the vast majority of solitary cold nodules are
benign, this focuses attention on the inability to distin-
guish benign from malignant lesions with radionuclide
scans.
Ultrasound
Although ultrasonography can differentiate between a
cystic and a solid nodule, we believe that this is of
minimal value in differentiating benign from malignant
lesions. There are, however, two areas in which ultraso-
nography may be useful. One is in the accurate follow-
up evaluation of the size of the nodule in patients who
have had an FNAB that was benign, and the other is its
value in helping to accurately perform FNAB. Ultra-
sound-guided FNAB may increase diagnostic reliability,
especially in patients in whom the nodule cannot be
palpated because of its small size, in those with a multi-
nodular goiter, or in individuals with a short or muscu-
lar neck.
Fine-Needle Aspiration Biopsy
FNAB has come into widespread use in the diagnosis
and management of patients with a solitary nodule
in the thyroid gland. The technique is safe and cost-
effective. Cytologic evaluation may be useful, and it may
diagnose a lesion as being either absolutely benign or
absolutely malignant. It may also be reported as being
nondiagnostic, which indicates the need for repeat
FNAB for diagnosis. Cytopathology may not always be
able to distinguish carcinoma from adenoma, but
reports such as a follicular lesion or an atypical or
Hürthle cell lesion would be an indication for thyroid
lobectomy to make the most accurate diagnosis.
In the meta-analysis carried out by Campbell and
Pillsbury2 of nine studies in which the results of FNAB
cytology were compared with those of histology after
surgery on the same patients, the false-negative rate
(the percentage of benign cytology readings that were
found to be cancer at surgery) ranged between 0.5%
and 11.8%, with an average of 2.4%. This study suggests
that 1 in 40 patients with a cytology report of a benign
lesion can be expected to have cancer. The false-
positive rate (the percentage of malignant cytology
readings that were found to be benign at surgery) for
these studies ranged between 0% and 7%, with an
average of 1.2%, so the gland may be expected to be
benign at surgery in 1 in 100 patients with a diagnosis
of malignancy. Therefore, the overall degree of accu-
racy is higher than 95%, thus suggesting the effi cacy of
this technique. FNAB is also useful in patients who have
a history of the onset of sudden pain with a concomitant
increase in the size of the nodule and in whom hemor-
rhage into a cyst is suspected. Aspiration of such lesions
by FNAB is useful in establishing a diagnosis, as well as
in collapsing the mass.
FNAB is carried out with the patient under local
anesthesia. The skin is prepared with an alcohol wipe,
and the mass is grasped between the thumb and fore-
fi nger. A 22-gauge needle attached to a 20-mL syringe
pistol is inserted into the mass, and suction is applied
to the aspirating syringe after the needle has passed

Chapter 65
Thyroidectomy
545
through the skin to avoid aspirating epithelial cells into
the needle. The needle is then moved in and out in
different quadrants to get an adequate sampling of the
mass. The suction is released, and the needle is with-
drawn. The aspirate is smeared on glass slides and
immersed in 95% ethanol for Papanicolaou staining.
The specimen is then studied by the cytopathologist.
If the specimen is inadequate or the diagnosis is in
question, additional samples may be taken for diagnosis
while the patient is still in the offi ce. There is usually
little, if any bleeding with this procedure. In some
centers, FNAB is carried out under ultrasound guid-
ance to be certain that the most representative areas of
the mass are sampled.12 The Mayo Clinic experience,
however, showed that only 3 of 439 patients who had
benign fi ndings on FNAB were found to have malig-
nancy during a 6-month follow-up period.13
Patients who have no evidence of malignancy on
FNAB and no other fi nding suggestive of malignancy
may be given a trial of thyroid suppression. The objec-
tive is to reduce thyroid-stimulating hormone (TSH)
levels to below normal. Forty percent to 60% of patients
with benign adenoma will experience resolution of the
nodule. The patient is advised to undergo repeat ultra-
sound or ultrasound-guided FNAB in 6 months unless
there are objective signs or an increase in size of the
mass in the interim. Some patients with an obvious mass
will opt to have surgery for cosmetic reasons or because
they are concerned about malignancy, even in the event
of benign FNAB fi ndings.
Computed Tomography
Computed tomography (CT) scanning is not of much
value in the usual patient with a solitary nodule. Its
routine use is discouraged by endocrinologists because
the contrast material contains iodine, which interferes
with postoperative radioactive 131I studies. CT scanning
may be of considerable help in determining tracheal
infi ltration in patients with a large mass believed to be
malignant (Fig. 65-3). It may also be useful in determin-
ing the amount of tracheal and esophageal deviation,
compression, or invasion of these structures, as well as
substernal extension (Fig. 65-4). Moreover, CT scan-
ning may identify previously undetected cervical lymph
node enlargement.
Positron Emission Tomography–Computed
Tomography
Routine follow-up of patients with WDTC includes
whole-body 131I scintigraphy and serum thyroglobulin
assay. Limitations in detecting local-regional recurrence
or distant metastasis occur when progressive dediffer-
entiation of thyroid carcinoma cells leads to loss of
iodine-concentrating capacity. Recent reports indicate
the utility of positron emission tomography (PET) in
the detection of a variety of malignant tumors. Frilling
and associates14 underlined the superiority of 18F-
fl uorodeoxyglucose (FDG) PET in the management of
patients with WDTC in whom failed concentration of
131I interferes with standard follow-up and treatment in
Figure 65-3. Computed tomography scan demonstrating tracheal
deviation and compression by Hürthle cell carcinoma. The patient
was treated by insertion of a tracheal stent and two vascular stents.
Figure 65-4. Computed tomography scan demonstrating a large
substernal goiter.
cases of tumor recurrence. They also found PET-CT to
be very sensitive in the search for distant metastasis in
the setting of negative 131I scanning.
The recent advent of PET-CT follow-up of patients
with malignant tumors throughout the body or those
with colon and breast cancer has increased referrals

546
Section 6
Thyroid and Parathyroid
for thyroid nodules. We now routinely have patients
referred for evaluation of previously unknown tumors
in the head and neck, especially the parotid and thyroid
gland, that were detected by follow-up PET-CT scans
in patients with colon and breast carcinoma. These
patients undergo ultrasound-guided FNAB to rule out
distant metastasis and are often operated on to remove
these tumors (Fig. 65-5).
SURGICAL TECHNIQUE
Three specifi c techniques are discussed:
• Thyroid lobectomy
• Total thyroidectomy
• Surgery for substernal goiter (SSG)
Thyroid surgery is usually performed with the
patient under general anesthesia. However, for a select
group of patients, local anesthesia may be preferable.
Hisham and Aina15 reported a series of 65 consecutive
patients who underwent either thyroid lobectomy and
isthmusectomy or total thyroidectomy under local
anesthesia with light intravenous sedation. The pa -
tients were discharged 6 hours postoperatively. Thyroid
surgery under local anesthesia offered the best alterna-
tive to general anesthesia in patients with poor cardiac
function or in pregnant patients.
Perioperative antibiotics are not required. Patients
are placed in the supine position, and endotracheal
intubation is carried out. There has been concern in
the past about whether intubation is possible in patients
who have had substernal thyroid or massive goiters,
given the narrow caliber of the trachea or displacement
of the trachea from a unilateral mass. Intubation is
almost always possible, and the anesthesiologist should
be encouraged to consider this a normal case and not
make it unnecessarily diffi cult or dangerous by using
an exotic technique. Rarely, the airway is so distorted
that intubation is not possible and tracheotomy is
necessary.
After endotracheal intubation has been achieved, a
rolled blanket is positioned under the patient’s shoul-
ders and the head placed in a donut-shaped head
holder. This is an important maneuver in this proce-
dure because extreme extension of the head brings the
thyroid gland into the operative fi eld. The entire face,
neck, and upper part of the chest are prepared with
povidone-iodine (Betadine) solution, and sterile drapes
are applied to provide a sterile fi eld. Placement of the
incision in a skin crease is very important to make the
scar as inconspicuous and acceptable as possible. It
should be made approximately one fi nger breadth
above the clavicles and carried approximately to the
anterior edge of the sternocleidomastoid muscle bilat-
erally (Fig. 65-6).
Jancewicz and colleagues16 studied the optimal
position for a cervical collar incision. They observed
that migration of a proposed cervical collar incision
does occur. An inappropriately placed incision may
lead to excessive scarring if it is too low or to an unusu-
ally prominent appearance if it is too high. On the basis
of their study they believe that a good place to make
A
B
Figure 65-5. Combined posi-
tron
emission
tomography–
computed tomography (PET-CT)
performed for surveillance of
breast cancer identifi ed a suspi-
cious thyroid nodule. A, The CT
portion of the examination showed
a subcentimeter hypodense thyroid
nodule (arrow) that would not
merit tissue sampling by CT crite-
ria alone. B, The corresponding
PET image shows focal uptake,
which is suffi ciently suspicious to
prompt ultrasound-guided fi ne-
needle aspiration biopsy despite
the lesion’s small size.

Chapter 65
Thyroidectomy
547
such an incision is one fi nger breadth above the sternal
notch with the patient in the neutral, upright position
before the patient is anesthetized and then placed into
extension.
The best time to plan the incision is before the
patient is placed into extension and preferably while in
the sitting position. If the incision is planned when the
patient is in the extended position, the scar will come
to rest over the clavicles, which may produce a stretched
or prominent scar that can be disguised only by cloth-
ing or jewelry. In a patient who has a long, slender neck,
the incision must be placed somewhat more superior to
be able to achieve adequate exposure.
The incision may be made with a cold knife, elec-
trocautery, a Shaw scalpel, or a harmonic scalpel.
Shemen17 reported use of the harmonic scalpel in
making an incision and achieved safe and expeditious
control of the feeding vessels of the thyroid gland. The
procedures were completed in 50% less time than when
the conventional technique was used. Siperstein and
coworkers18 used the harmonic scalpel for control of
thyroid vessels and found that this technique was safe
and shortened operative time by 30 minutes.
The incision is carried down through the platysma
muscle. Once the platysma has been incised, the tissues
are shifted laterally and the platysma muscle is incised
lateral to the end of the skin incision; the incision is
then carried into subcutaneous tissue. This is done
bilaterally and results in 50% more exposure in the
wound while minimizing the incision. It should be done
very precisely and with good countertraction on the soft
tissue so that the large anterior jugular veins will not be
entered (Fig. 65-7). Lahey clamps are then applied to
the superior aspect of the incision, and the superior
cervical fl ap is undermined in the plane between the
platysma muscle and the strap muscles. The inferior
fl ap is then undermined in the same plane. Hemostasis
is obtained. Large vessels should be ligated with 2-0 silk
suture. Small bleeding points may be electrocoagulated.
Self-retaining retractors should then be placed in the
wound to secure adequate exposure.
Thyroid Lobectomy
Surgeons performing total thyroid lobectomy should
work from the side of the dominant thyroid mass. The
strap muscles are divided in the midline (Fig. 65-8A)
and are then undermined with small blunt-tipped dis-
secting scissors (Fig. 65-8B). We have not found it nec-
essary to divide the strap muscles to gain adequate
exposure except in cases of massive goiter. If the strap
muscles are adherent to or infi ltrated by tumor, the
Figure 65-6. Incision placed in a skin crease in the root of the neck
above the clavicle.
Figure 65-7. Cervical fl aps are undermined while taking care to
avoid the anterior jugular veins.

548
Section 6
Thyroid and Parathyroid
A
B
C
D
E
F
Figure 65-8. A, Incision of the strap muscles in the midline. B, Undermining of the strap muscles. C, The strap muscles are retracted and
the trachea and thyroid isthmus are identifi ed. D, The triangle bounded by the trachea, the carotid artery, and the lower pole of the thyroid
lobe is identifi ed, and the recurrent laryngeal nerve is located in the triangle. E, Dissection of soft tissue off the recurrent laryngeal nerve. F,
Identifi cation and transection of Berry’s ligament.

Chapter 65
Thyroidectomy
549
muscle should be removed with the tumor. When suf-
fi cient undermining has been carried out, Green retrac-
tors are used to retract the strap muscles (Fig. 65-8C).
This procedure is carried out on both sides; each lobe
should be palpated to determine whether other nodules
are present. The trachea is then identifi ed and skele-
tonized to expose the trachea and thyroid isthmus (Fig.
65-8D). The isthmus is cross-clamped and divided with
electrocautery, and the cut edges are oversewn with 2-0
silk suture.
A Kitner sponge on a Kelly clamp is then used to
gently separate any remaining strap muscle fi bers and
loose areolar tissue from the thyroid lobe. The gland is
next mobilized from the deep tissues into the wound
G
H
Figure 65-8, cont’d. G, The thyroid lobe is pedi-
cled on the superior thyroid artery. H, The superior
thyroid artery is cross-clamped, divided, and doubly
ligated.
(Fig. 65-8E). Care is taken to identify and gently sepa-
rate the parathyroid glands from the thyroid gland. The
typical golden brown color of the gland and its location
near the inferior thyroid artery make the inferior para-
thyroid gland easy to identify. The carotid artery is iden-
tifi ed laterally by blunt dissection (Fig. 65-8E). The
carotid artery, the trachea, and the lower pole of the
thyroid gland form the triangle in which the recurrent
laryngeal nerve will be identifi ed (Fig. 65-8F).
We do not use the inferior thyroid artery as a land-
mark for identifi cation of the recurrent laryngeal nerve
because it is inconstant in its relationship with the
nerve. Having identifi ed the triangle, blunt dissection
with the closed tip of the dissecting scissors is carried

550
Section 6
Thyroid and Parathyroid
out in the triangle along the tracheoesophageal sulcus
until the nerve is identifi ed. Occasionally, a nonrecur-
rent inferior laryngeal nerve may be found coming
directly off the vagus nerve. This anomaly occurs infre-
quently on the right side and is said to be associated
with an anomalous retroesophageal right subclavian
artery. It occurs even more rarely on the left side and
then only in the setting of situs inversus. There are
usually small veins, as well as branches of the inferior
thyroid artery, in the area near the nerve. We believe
that every time a vein or an artery is identifi ed during
thyroidectomy it should be clamped, divided, and tied
at that time rather than running the risk of clamping
the vessel and leaving the clamp in place because there
is a high risk that the clamp could come off, the vessel
would not be tied off, and postoperative hemorrhage
would result. Searching for the lost vessel or the pres-
ence of the clamp lying loose in the wound may also set
the stage for injury to the recurrent laryngeal nerve.
With gentle traction on the thyroid gland, dissec-
tion along the recurrent laryngeal nerve is carried supe-
riorly. This is done by grasping the tissue surrounding
the nerve, retracting it from the nerve, and then moving
the closed scissors up along the nerve and opening
them gently to spread the tissue overlying the nerve
(Fig. 65-8G). Branches of the inferior thyroid artery will
need to be cross-clamped, divided, and ligated to mobi-
lize the thyroid gland.
Once the recurrent laryngeal nerve is seen entering
the foramen in the cricoid cartilage, traction is exerted
on the gland to retract it away from the trachea. Berry’s
suspensory ligament is then transected (Fig. 65-8H).
This maneuver dramatically releases the thyroid gland
from the trachea. Dissection is continued superiorly
until the gland itself is pedicled on the superior thyroid
artery. The artery and vein should be skeletonized by
blunt dissection, separation of the overlying soft tissue,
and retraction of the gland superiorly. This helps
prevent injury to the superior laryngeal nerve. Right-
angled clamps are used to doubly clamp the artery and
vein, the pedicle is transected, and the gland is deliv-
ered. The superior thyroid artery is doubly ligated with
2-0 silk suture. Leaving dissection of the superior thyroid
artery as the last maneuver protects against injury to the
superior laryngeal nerve.
The specimen is then sent to the pathology depart-
ment appropriately marked along with suffi cient clini-
cal history for frozen section diagnosis. If this is a
completion thyroid lobectomy, frozen section is unnec-
essary. All bleeding points are ligated, and the wound
is irrigated. A Hemovac drain is inserted approximately
1 cm lateral to the lateral extent of the incision on one
side and placed in the thyroid compartment. The strap
muscles are then approximated in the midline with
chromic catgut suture. The wound is closed with subcu-
taneous catgut suture and running 6-0 mild chromic or
fast-absorbing catgut suture in the skin. Care should be
taken during closure to not inadvertently put a ligature
around the Hemovac drain within the wound. The
Hemovac drain should be fi xed to the skin approxi-
mately 0.5 to 1 cm lateral to the incision so that it is
camoufl aged and blends with the incision itself. Adhe-
sive is then applied to the skin, and Steri-Strips are
applied. If the frozen section is benign or deferred, the
patient is allowed to recover from anesthesia, extubated,
and taken to the recovery room.
If the frozen section diagnosis is cancer, the wound
is reopened and the remaining lobe is removed. Unfor-
tunately, diagnosis will be deferred in a small percent-
age of the patients, particularly those with a follicular
lesion. Cheng and coauthors19 reported that the selec-
tive use of frozen section to complement FNAB cytology
fi ndings of suspicious or follicular lesions was effi ca-
cious, especially in the subset with papillary carcinoma,
and allowed one-stage total thyroidectomy. Tan and
colleagues20 reported that there was no defi nite impact
of the timing of surgery on the rate of complications
after completion thyroidectomy. Erdem and associates21
analyzed their series of patients who underwent lobec-
tomy elsewhere and were referred for completion thy-
roidectomy when WDTC was diagnosed. They pointed
out that many WDTCs are multicentric, with the inci-
dence of residual cancer being 22% to 64%. Failure to
perform completion thyroidectomy may leave cancer in
place. The authors advocate completion thyroidectomy
because of decreased recurrence rates and increased
effi cacy of 131I. This operation can be done safely with
low morbidity and is not signifi cantly different from
primary total thyroidectomy. Randolph and Daniels22
used 131I lobe ablation as an alternative to completion
thyroidectomy for minimally invasive follicular carci-
noma of the thyroid. This was done with minimal mor-
bidity 3 to 6 months after lobe ablation. Whole-body 131I
scanning was performed.
Total Thyroidectomy
If after thyroid lobectomy the pathologic diagnosis is
WDTC, a contralateral lobectomy is carried out.
Extreme caution is taken on the contralateral side to
preserve the parathyroid glands, particularly if those on
the fi rst side have not been clearly identifi ed. Although
the issue remains controversial, we believe that it is best
to perform total thyroidectomy to eradicate all vestiges
of thyroid tissue. This removes all possible areas of
cancer because it is well known that microscopic cancer
may exist in the contralateral lobe, and it helps consid-
erably in the postoperative management of differenti-
ated thyroid cancer by radioactive iodine (131I) scanning
and treatment.
If cancer is diagnosed, the central compartment
(paratracheal level VI) nodes are removed as thor-
oughly as possible while making every effort to preserve
the parathyroid glands. The recurrent laryngeal nerve
must be kept in view at all times to avoid injury. In the
absence of palpable or otherwise demonstrable positive
metastatic nodes, dissection beyond the central com-
partment is not required. If there are palpable or other-
wise demonstrable nodes, selective or modifi ed radical
neck dissection is performed.
In cases in which fi xation of the gland to the under-
lying structures or associated recurrent laryngeal nerve

Chapter 65
Thyroidectomy
551
involvement is apparent, the possibility of invasion of
the recurrent laryngeal nerve, trachea, larynx, or esoph-
agus should be suspected. Although invasion of local
and regional structures is common with anaplastic car-
cinoma, invasion by WDTC is unusual. When WDTC
does invade the upper aerodigestive tract structures, it
causes considerable morbidity and mortality. Life-
threatening airway problems, hemorrhage, and suffoca-
tion can be the consequences of invasion of the airway
by thyroid cancer.23 There are no clear guidelines
regarding the extent of surgery for patients with carti-
lage invasion only. Shave resection is defi ned as removal
of all macroscopic disease without formal resection of
the full thickness of the adherent trachea or larynx.24
The rationale for shave resection for locally invasive
WDTC stems from the belief that the residual cancer
can be successfully treated with 131I. Fear of the morbid-
ity of a failed repair or anastomotic leak after formal
tracheal resection with reconstruction is another reason
why shave resection is sometimes preferred. This,
coupled with the unproven benefi ts of more extensive
surgery with reconstruction, has been used to support
shave resection over formal tracheal resection. No sur-
vival benefi t has been demonstrated with extensive
resection versus shave resection. In addition, shave
resection has been associated with relatively low rates of
recurrence.24
Total thyroidectomy may be carried out for benign
or malignant disease. Friguglietti and colleagues25
reported a retrospective study of 1789 patients who
underwent total thyroidectomy from 1990 to 2000.
Patients treated by total thyroidectomy included those
with multinodular goiter and chronic thyroiditis when
there was bilateral involvement of glandular paren-
chyma posterior to the middle thyroid vein and when
there were doubts on frozen section analysis. They also
recommended the use of total thyroidectomy for mul-
tinodular goiter. In patients with Graves’ disease, total
thyroidectomy was indicated because of severe hyper-
parathyroidism, severe ophthalmopathy, or allergic
reactions to antithyroid medications. Mittendorf and
McHenry26 also reported on the effi cacy of total thyroid-
ectomy for thyrotoxicosis. Indications for surgery in
patients with Graves’ disease were massive enlargement
of the thyroid gland with compressive symptoms from
substernal extension.
Extracapsular spread and invasion have been shown
to have negative prognostic signifi cance in WDTC;
however, they can be treated successfully. Extrathyroi-
dal invasion is highly associated with a risk for local
recurrence, development of metastases to the cervical
lymph nodes and distant sites, and death. Intraluminal
invasion of the larynx, trachea, or esophagus appears to
have a more grave prognosis than extraluminal carti-
lage invasion does.23
Surgery for Substernal Goiter
SSG was fi rst described by Haller in 1749.27 Crile
described SSG as a situation in which the goiter went
down to the aortic arch.28 Although the term remains
somewhat ill defi ned, Katlic and coworkers29 character-
ized SSG as having greater than 50% of its mass inferior
to the thoracic inlet. Indications for surgery include
compression of adjacent structures, prevention of the
same, and diagnosis.30
The majority of SSGs originate from downward
extension of a cervical goiter along the fascial planes of
the neck, through the thoracic inlet, and into the medi-
astinum. The blood supply of an SSG arises primarily
from the interior thyroid artery. Absence of a palpable
mass in the neck does not exclude SSG. Sometimes a
cervical component is not enlarged because the bulk of
the gland is in the mediastinum.
Unlike a goiter in the neck, which can grow to
enormous proportions and remain asymptomatic, SSG
is symptomatic early in its course. The clinical symp-
toms are attributed to compression of the adjacent
aerodigestive tract and the mediastinal great vessels at
the thoracic inlet. Shortness of breath while lying in
bed and diffi culty swallowing, even pills, are the most
common symptoms. Patients with SSG are vulnerable to
acute airway obstruction, which generally arises from
hemorrhage in the gland.
CT scanning is a valuable source of information
about SSG because it will demonstrate the relationship
of the goiter to the trachea, the esophagus, and the
great vessels and heart. We have had many cases in
which SSG extended to the aorta, which we removed
through a cervical approach, and one that went poste-
rior to the heart and required a combined transcervi -
cal and partial medial sternotomy approach. Patients
should be seen in consultation by a thoracic surgeon
for examination and review of the CT scan. The patient’s
best interest is served by having thoracic surgical col-
leagues standing by in the possible, but unlikely event
that a medial sternotomy is necessary.
An SSG can virtually always be removed through a
cervical incision. The important consideration is that
the neck must be placed in extreme extension to mobi-
lize the gland out of the mediastinum. Both recurrent
laryngeal nerves must be identifi ed. The inferior and
superior thyroid arteries are ligated. Before any attempt
at mobilization of the thyroid gland from the mediasti-
num, Berry’s ligament is transected bilaterally. Transec-
tion may be facilitated by dividing the isthmus in the
midline to separate the thyroid gland from the larynx
and trachea and permit upward traction on the subster-
nal component of the thyroid gland. There are instances
in which an SSG is actually linked to the thyroid lobe
by a very small isthmus of thyroid tissue, or it may in
fact not be attached to the thyroid lobe at all. At this
point the surgeon’s fi nger can be introduced into the
superior mediastinum and a cleavage plane developed
around the capsule of the gland to separate the gland
from the soft tissues. At the same time that the gland is
being mobilized from below, gentle but fi rm traction
should be exerted in the superior direction to deliver
the thyroid gland from the mediastinum. The excep-
tion to this technique may be cancers with extracapsu-
lar extension and adherence to vital structures.
This condition can be anticipated by imaging and

552
Section 6
Thyroid and Parathyroid
preoperative diagnosis of cancer by FNAB. In these cir-
cumstances, medial sternotomy may be required for
identifi cation and control of vascular structures.
Endoscopic Thyroidectomy
In recent years, endoscopic surgery has emerged as an
option for thyroid and parathyroid abnormalities. Sur-
geons in Japan and Italy have provided leadership in
this fi eld. It appears to be driven by patient demand for
either a smaller scar on the neck or in fact no scar at
all.
Gagner31 described the fi rst endoscopic subtotal
parathyroidectomy with constant gas insuffl ation for
hyperparathyroidism in 1996 and achieved good clini-
cal and cosmetic results. Ikeda and colleagues32 devel-
oped novel techniques for endoscopic thyroidectomy
that involved use of the anterior chest approach and
the axillary approach with CO2 insuffl ation. They com-
pared these two types of endoscopic procedures with
conventional open surgery. Their indications for endo-
scopic thyroidectomy included a thyroid tumor less
than 6 cm in diameter and benign follicular adenoma
diagnosed on FNAB. Patients with a history of thyroid-
itis or previous neck surgery and irradiation were
excluded. All patients in the axillary group were satis-
fi ed with the cosmetic results, whereas those in the
anterior chest wall or open cervical group complained
about the cosmetic appearance.
Nakano and coworkers33 modifi ed the anterior
chest wall technique. They did not use gas insuffl ation.
Two Kirschner wires were attached to a winching device
and inserted horizontally beneath the skin to lift the
neck skin. A specially made retractor was passed through
the tunnel on the chest wall into the neck. The fi nal
pathology diagnosis was follicular adenoma in 34
patients, minimally invasive follicular carcinoma in 4
patients, and adenomatous goiter in 4.
Bellantone and associates34 carried their technique
a step further to include removal of the central neck
lymph nodes during minimally invasive video-assisted
thyroidectomy for small papillary carcinoma. The pro-
cedure is gasless and carried out through a 2-cm inci-
sion above the sternal notch. The authors encountered
unexpected lymph nodes in the central compartment.
After thyroidectomy, these nodes were removed
uneventfully and sent for frozen section. In the case of
positive lymph nodes with frozen section, dissection of
the central compartment was completed. Kitagawa and
colleagues35 operated on a series of patients with FNAB-
positive papillary carcinoma. They used a totally gasless
anterior neck skin-lifting technique through an incision
on the chest wall. They performed hemithyroidectomy
or subtotal thyroidectomy, as well as lymph node clear-
ance of the lateral and central compartments, without
incident.
Takami and Ikeda36 classifi ed minimally invasive
thyroid procedures as follows:
1. Minimally invasive—mini-incision
2. Video assisted
3. Completely closed endoscopic
• Supraclavicular approach
• Axillary approach
• Anterior chest approach
• Breast approach
Park and coauthors37 reported a series of 100
patients who underwent endoscopic thyroidectomy via
a breast approach. Incisions were made in both upper
circumareolar areas. Subcutaneous tunnels were dis-
sected up to the neck through which endoscopes were
placed. CO2 insuffl ation was used. The remaining dis-
section was carried out under visual endoscopic guid-
ance. The incisions on the breast yielded a satisfactory
cosmetic result with minimal scarring. Shimazu and col-
leagues38 described an axillary, bilateral breast approach.
This led to acceptable scars on the breast, and the axil-
lary approach eliminated the scar from the parasternal
port, as occurs with the pure breast approach.
Management of the Neck
Although the techniques for neck dissection are
described in Chapter 78, some concepts should be
understood. Despite the fact that in multivariate analy-
ses cervical lymph node metastasis has no prognostic
importance in dealing with papillary carcinoma of the
thyroid, now that we have improved diagnostic tools
such as ultrasound, PET scanning, and thyroglobulin
studies, we are recognizing recurrences in the neck
more frequently. The question of how to manage the
neck in WDTC remains controversial.
Some valuable information can be obtained from
the work of Shaha and coworkers,39 who analyzed 1038
patients at Memorial Sloan-Kettering Cancer Center in
New York. All these patients had WDTC. Figure 65-9
shows the incidence of cervical node and distant metas-
tasis at the time of initial evaluation. This information
should be quite helpful in making practical decisions
in patients with WDTC. The authors suggest perform-
ing a modifi ed neck dissection in patients with palpable
cervical metastasis. More recent philosophy suggests
that paratracheal (level VI) lymph node dissection
should be carried out at the time of thyroidectomy.
Although the literature on thyroid cancer is exten-
sive and varied, it appears that elective neck dissection
is not indicated in WDTC. Selective neck dissection in
levels II to VII or a modifi ed radical neck dissection is
the treatment of choice in patients with palpable metas-
tases.40 If the nodes of the central compartment are
thought to be involved on the basis of preoperative
imaging studies or examination at the time of surgery,
paratracheal lymph node dissection should be carried
out (level VI). Musacchio and associates41 found that
patients who underwent formal neck dissection at the
initial operation for WDTC with suspected lymph node
metastasis had a signifi cantly lower rate of recurrence
than did patients who underwent a “berry-picking”
procedure.
Cheah and colleagues42 examined the complica-
tions of neck dissection carried out for thyroid cancer.
The most frequent complication was hypocalcemia,
which was more common when neck dissection was

Chapter 65
Thyroidectomy
553
combined with thyroidectomy than when it was not
(60% versus 17%). In the group of patients who under-
went thyroidectomy with concurrent neck dissection,
the incidence of hypocalcemia was highest in those with
central compartment dissection (75%), less with central
compartment and modifi ed radical neck dissection
(67%), and even less with modifi ed radical neck dissec-
tion alone (46%).
The presence of distant metastasis in patients at the
time of initial evaluation for WDTC is a rare event.
Shaha and coworkers43 analyzed a series of 1038 con-
secutive patients at Memorial Sloan-Kettering from
1930 to 1985 and identifi ed only 44 (4%) patients who
had distant metastasis on initial examination. The inci-
dence was higher in patients with follicular than with
papillary carcinoma and in patients older than 45 years.
The long-term survival rate in patients with distant
metastasis was 40% (Fig. 65-10). This outcome pre-
sumes treatment with total thyroidectomy and 131I. The
most common sites of metastasis are the lung and bone.
Shoup and coauthors44 reported a series of 242 patients
in whom distant metastasis was either the fi rst site of
recurrence or was detected at the time of discovery of
the primary cancer. They concluded that long-term sur-
vival is possible in patients with distant metastasis from
WDTC. Their institutional policy of treatment of
patients with distant metastasis is completion thyroidec-
tomy when necessary and follow-up treatment with
radioactive iodine. Stojadinovic and associates45 studied
a series of 260 patients with metastatic WDTC, 59 of
whom (23%) underwent operations for their distant
metastasis. They concluded that solitary distant metas-
tases amenable to complete resection are infrequent.
Complete removal of metastases may be associated with
improved survival in patients with localized distant
metastasis. Palliative resection may be indicated to
improve quality of life in patients with symptomatic
distant metastasis.
POSTOPERATIVE MANAGEMENT
Postoperative care is best undertaken by nurses experi-
enced with thyroidectomy patients because of the
potential for airway problems. The Hemovac drains are
attached to wall suction and are removed when drain-
age has stopped, typically within 24 hours. Perioperative
antibiotics are not required in these cases because of
the very low incidence of wound infection. In patients
who have undergone lobectomy, calcium and phospho-
rus levels are not routinely determined postoperatively
unless the patient is symptomatic or has previously
undergone thyroid lobectomy. After total thyroidec-
tomy, calcium and phosphorus levels are determined
on the second postoperative day. Patients with symp-
tomatic hypocalcemia are treated with calcium. Patients
are quickly advanced to a regular diet, are ambulatory
on the evening of surgery, and are usually discharged
on the fi rst postoperative day. In some centers there is
a distinct trend away from draining the wound and to
discharge the patient the same day.
COMPLICATIONS
Hematoma after thyroidectomy is generally detected in
the fi rst few hours after surgery. The diagnosis is made
by noting ecchymosis of the skin of the neck and chest,
an obvious mass in the anterior aspect of the neck, an
abnormally large volume of blood in the Hemovac
drain, or all of the aforementioned. If the patient has
a tight dressing around the neck, respiratory obstruc-
tion may develop rapidly because of compression of the
trachea by hematoma. Treatment of this condition is to
immediately remove the dressing and open the wound.
The wound can be evacuated quickly by removing the
clots with suction or by hand, which alleviates the airway
problem immediately. The patient is then taken back
to the operating room, hemostasis is achieved under
general anesthesia, and the wound is copiously irrigated
and resutured over new drains because the drains
invariably become clotted. This complication is quite
unusual, and its occurrence is directly related to the
absence of meticulous attention to hemostasis during
surgery. Safety of the patient after thyroidectomy is also
enhanced by nursing staff familiar with the care of such
patients. The use of pulse oximetry for postoperative
monitoring offers an advance in patient safety by placing
% at risk
Nodal
Papillary
810
Follicular
169
Hürthle
59
Distant
60
2%
56%
21%
11%
9%
12%
50
40
30
20
10
0
Figure 65-9. Incidence of cervical node metastasis and distant
metastasis at initial evaluation. (Reprinted from Shaha AR, Shah JP, Loree
TR: Patterns of nodal and distant metastasis based on histologic varieties in
differentiated carcinoma of the thyroid. Am J Surg 172:692-694, 1996, with
permission from Excerpta Medica, Inc.)
1
0.8
94%
M0
86%
43%
P < .001
M1
52%
M0 n=994
n=44
M1
0.6
0.4
0.2
00
2
4
6
8
10
12
14
16
18
20
TIME (years)
Figure 65-10. Overall survival in patients with or without distant
metastasis. (Reprinted from Shaha AR, Shah JP, Loree TR: Patterns of nodal
and distant metastasis based on histologic varieties in differentiated carcinoma
of the thyroid. Am J Surg 172:692-694, 1996, with permission from Excerpta
Medica, Inc.)

554
Section 6
Thyroid and Parathyroid
immediately postoperative thyroidectomy patients near
the nurse’s station under direct observation.
The recurrent and superior laryngeal nerves are
vulnerable to injury during thyroidectomy. Every
attempt must be made to identify and preserve the
nerves. Unilateral paralysis is usually suspected in a
patient who has a breathy voice and aspiration early in
the postoperative period. Such patients should have
laryngoscopy performed to confi rm the presence of
vocal cord paralysis. The nerve may have been cut,
clamped, stretched, or heated when electrocoagulation
was used in the area near the nerve. Any bleeding that
occurs around the nerve should be controlled initially
by pressure and then the bleeding point clamped, but
only with the nerve under direct observation. Laryngeal
electromyography can be carried out to predict return
of function. If return of function is likely, nothing need
be done unless the patient is very symptomatic from
aspiration or is a professional voice user. Speech and
swallowing therapy may be useful. Vocal cord medializa-
tion by injection of an absorbable substance may be
useful. Patients whose electromyographic fi ndings are
class V have little chance for recovery, and early surgical
intervention may be indicated, such as injection or
medialization laryngoplasty.46
This complication is more likely to occur after a
second thyroid operation. In patients with a history of
having had one nerve paralyzed by previous surgery or
trauma, additional caution must be taken during dissec-
tion of the remaining nerve. There is controversy over
whether a nerve severed during thyroidectomy should
be anastomosed. The vocal cord does not develop
normal motion after immediate anastomosis, but tonus
may be achieved in the thyroarytenoid muscle, thereby
eliminating the necessity for thyroplasty or injection to
medialize the paralyzed vocal cord.
Bilateral recurrent nerve injury will produce airway
distress postoperatively. It is usually recognized minutes
to hours after extubation, and immediate reintubation
or tracheotomy may be necessary. It is generally
possible to carry patients over the fi rst day or two
with continued endotracheal intubation rather than
tracheotomy. These patients can then be extubated,
and further surgery may not be necessary. In the
near and longer term, if unable to tolerate the airway
compromise associated with bilateral vocal cord paraly-
sis, the patient is faced with the choice of wearing a
permanent tracheostomy tube with a speaking valve
or undergoing cordotomy or arytenoidectomy (see
Chapter 41).
Intraoperative monitoring of the recurrent laryn-
geal nerve is fi nding increased acceptance during thy-
roidectomy and other surgical procedures that place
this nerve at risk for iatrogenic injury. Such procedures
include thyroidectomy, parathyroidectomy, tracheal
resection, and anterior cervical spine surgery. Several
techniques can be used for intraoperative monitoring,
including hand-held nerve stimulators to observe con-
traction of the cricopharyngeus muscle and laryngeal
electromyography with a hook wire or a needle elec-
trode. Surface electrodes eliminate the potential
dangers encountered with needle electrodes. The
Xomed endotracheal tube with stainless steel electrodes
that are in contact with the vocal cords (Medtronics
Xomed, Inc., Jacksonville, FL) has been found to be
reliable. Recently, a laryngeal surface electrode was
introduced to enable another form of noninvasive mon-
itoring. Yet another technique uses a concave surface
electrode placed laryngoscopically against the posterior
cricoarytenoid muscle. Responses from the recurrent
laryngeal nerve during surgery confi rm proper posi-
tioning of the electrodes.47 However, until a prospective
randomized trial documents the effi cacy of continued
intraoperative monitoring in reducing permanent
nerve
paralysis,
its
use
cannot
be
routinely
recommended.48
Hypoparathyroidism occurs in 1% to 5% of patients
undergoing thyroidectomy. When a thyroid lobectomy
is carried out, there is virtually no chance of hypopara-
thyroidism occurring, even though both ipsilateral
parathyroids may have been removed inadvertently or
their blood supply interrupted, unless the patient has
previously undergone thyroid surgery. Kocher1 pointed
out the need to ligate the inferior thyroid artery as close
to the thyroid gland as possible to avoid devasculariza-
tion of the parathyroid. Because both the superior and
the inferior parathyroid glands obtain their blood
supply from the inferior thyroid artery, the blood supply
will be preserved if this advice is followed. Sometimes
the most diffi cult task is distinguishing the parathyroid
glands from fat, lymph nodes, and thyroid nodules. The
parathyroid glands are usually identifi ed by their golden
brown color and size, although their position is vari-
able. Magnifi cation may be useful in identifi cation of
the parathyroid gland.
Hypoparathyroidism may result from inadvertent
removal of the glands, ligation of their blood supply, or
a hematoma.49 In experienced hands, the incidence of
permanent hypoparathyroidism should be less than
2%.50 Lin and coauthors51 reported a 9% incidence in
220 patients whose parathyroid was inadvertently
removed during thyroidectomy. In primary surgery the
incidence was 7.7% and in repeat surgery, 20%. This
complication has, in fact, been the most important
deterrent to the use of total thyroidectomy in the treat-
ment of patients with carcinoma of the thyroid.
We routinely determine baseline calcium and phos-
phorus levels before surgery. If only a thyroid lobec-
tomy has been carried out, no further testing is done
in the postoperative period unless the patient has previ-
ously undergone thyroid surgery. When a total thyroid-
ectomy is carried out, blood for determination of
calcium and phosphorus levels is drawn on the second
postoperative day because hypocalcemia usually occurs
48 to 72 hours after the operation. It is prudent to ask
the patient about subjective symptoms such as circum-
oral paresthesia or paresthesia of the fi ngers and toes.
The patient should be checked for the presence of
Chvostek’s sign during this period. Carpopedal spasm,
laryngeal spasm, seizures, or cardiac abnormalities may
occur in more severe cases. The use of rapid intraopera-
tive parathyroid hormone monitoring in parathyroid

Chapter 65
Thyroidectomy
555
surgery may make monitoring of postoperative calcium
simpler in years to come.
To treat tetany or other severe symptoms, the
patient is given 1 ampule of 10% calcium gluconate
infused over a 5- to 10-minute period. For moderate
symptoms or for a calcium level less than 7 mg/dL, an
intravenous drip of calcium gluconate, 4 ampules, and
dextrose in water, 250 mL, is infused over a 4- to 8-hour
period. The infusion is repeated, if necessary, with titra-
tion depending on signs, symptoms, and the serum
calcium level, which is rechecked every 6 to 12 hours.
Calcium carbonate is started orally and provides 2 g of
elemental calcium daily. Administration of calcitriol
(Rocaltrol; the active form of vitamin D) may be initi-
ated at 0.25 µg twice daily, and the dose may be increased
on an outpatient basis if necessary. Vitamin D should
not be given if prompt return of parathyroid function
is anticipated. Vitamin D and calcium can usually be
tapered and discontinued within several months if
viable parathyroid tissue has been preserved in the
patient.
Hypothyroidism will occur after total thyroidec-
tomy. Replacement therapy with levothyroxine sodium
(Synthroid) may be initiated in the immediate postop-
erative period in patients with benign disease. In patients
with WDTC, thyroid replacement may be withheld to
facilitate subsequent 131I testing and treatment. Many
physicians, however, prefer treatment with liothyronine
sodium (Cytomel), which is discontinued 1 week before
the scan to avoid excessive symptoms of hypothyroid-
ism. The patient can begin taking Synthroid after the
scan is carried out, and the level can be monitored with
thyroid function tests. Suppression therapy is given with
the goal of keeping TSH levels less than 0.5 mg/dL so
that any residual cancer cells will not be stimulated and
thus hopefully preventing recurrence.
131I scanning is necessary postoperatively to deter-
mine the completeness of the surgical procedure and
to detect residual or metastatic disease. Small foci of
residual disease or occult distant metastasis can be ade-
quately treated with therapeutic doses of radioactive
iodine. Current indications for administration of an
ablative dose of 131I include the following:
• Radioactive uptake greater than 2%
• A large amount of residual functioning thyroid
tissue
• Invasion of local structures (trachea, larynx, esopha-
gus) by cancer
• Metastatic foci
Patients who have carcinoma of the thyroid should
undergo total thyroidectomy for several reasons. Some
surgeons believe that total thyroid lobectomy or sub-
total thyroidectomy is satisfactory for this disease.52
Numerous reports attest to the fact that recurrences
and fatalities are more frequent after less-than-total thy-
roidectomy in the treatment of WDTC.53-55 The primary
reason that some surgeons perform less-than-total thy-
roidectomy is fear of complications or injury to the
recurrent laryngeal nerve and hypoparathyroidism.
Their approach is justifi ed by the fi nding that most
patients do well with less extensive procedures. Approx-
imately 80% of patients do well regardless of the extent
of surgery, and about 5% do poorly regardless of the
treatment administered. The remaining 15% benefi t
from total thyroidectomy followed by radioactive thyroid
ablation if indicated by postoperative scanning. Total
thyroidectomy eliminates microfoci and macrofoci in
the contralateral lobe, thus reducing the risk for recur-
rent central neck disease. Complete surgical ablation of
the thyroid gland provides the opportunity to effectively
eradicate distant metastases, particularly pulmonary
metastases, with 131I. Treatment of distant metastasis
with 131I in the face of a large amount of remaining
thyroid tissue is not as effective because of preferential
uptake of 131I by normal thyroid tissue. Serum thyro-
globulin has proved to be quite useful in monitoring
for recurrence in patients with WDTC. Hall and col-
leagues11 observed that advanced-stage cancer at initial
evaluation and a stimulated thyroglobulin level greater
than 20 pmol/L 3 months after total thyroidectomy
were independent predictors of cancer recurrence.
Follow-up care consists of thyroglobulin assay and radio-
active scanning.
PEARLS
• Patients with a mass in the thyroid gland should
undergo fi ne-needle aspiration biopsy.
• Complete removal of the thyroid gland gives the
patient the best chance to be cured.
• Identifi cation of the recurrent laryngeal nerve offers
the best opportunity to avoid injury to the nerve.
• Accurate identifi cation and preservation of the
parathyroid glands and their vascular supply should
prevent postoperative hypocalcemia.
• A substernal goiter can almost always be removed
through the neck.
PITFALLS
• Failure to identify the recurrent laryngeal nerves may
lead to bilateral vocal cord paralysis, which will
produce airway obstruction in the immediate
postoperative period.
• Meticulous hemostasis is necessary to prevent the
formation of a hematoma, which may result in
airway obstruction and could be fatal.
• Incomplete removal of thyroid cancer predisposes
patients to recurrence.
• An unsightly scar may result from selecting the
incision site after the patient is placed in extension.
• Failure to perform total thyroidectomy in a patient
with a history of exposure to radiation puts the
patient at risk for recurrence because such patients
are known to have multifocal disease in the thyroid.

556
Section 6
Thyroid and Parathyroid
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Chapter 65
Thyroidectomy
557
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Chapter 66
Parathyroidectomy for Sporadic Primary
Hyperparathyroidism
Robert L. Ferris
The incidence of sporadic primary hyperparathyroid-
ism (HPT) has risen dramatically since the advent of
chemical screening with an autoanalyzer in the 1960s,
and most cases are discovered in asymptomatic patients
with hypercalcemia. Patients may also present with non-
specifi c complaints of back pain, or they may have
osteopenia, as depicted on radiographic studies. Primary
hyperparathyroidism is the most common cause of
hypercalcemia in the outpatient population, second
only to malignancy in the inpatient population. Fortu-
nately, primary HPT is usually easily and successfully
treated by parathyroidectomy. The genetic etiology and
risk factors for this disease have been described else-
where.1 Due to advances in localization2 and widespread
implementation of rapid biochemical hormone assays,
failed exploration is rare. The success or failure of
the procedure depends on the training, expertise, and
experience of the operating surgeon. Reoperative para-
thyroid surgery is a considerably more complex opera-
tion with signifi cantly greater failure and complication
rates. Neck exploration and parathyroidectomy should
not be undertaken by a surgeon who has not been
trained specifi cally to localize abnormal parathyroid
glands and to perform parathyroidectomies, or one
who performs such operations infrequently.
PATIENT SELECTION
Parathyroidectomy is usually an elective operative pro-
cedure. Although urgent parathyroidectomy is seldom
necessary, its indications include signifi cant hypercalce-
mia in the second trimester of pregnancy and parathy-
rotoxicosis characterized by serum calcium levels
greater than 15 mg/dL with or without symptoms of
signifi cant mental obtundation. The sensitivity and
specifi city of the clinical algorithm for the assessment
of patients with suspected hyperparathyroidism are very
high (>98%). Patients selected for parathyroidectomy
should meet the following criteria: documented history
of kidney stones, gastric symptoms (peptide ulcer or
pancreatitis), depression, and/or bone pain. In addi-
tion, the National Institutes of Health (NIH) consensus
conference statement in 1991 recommended surgery
for asymptomatic patients with markedly elevated serum
calcium levels (>11.4 mg/dL), low bone density (more
than 2 standard deviations less than age, race, and
gender-matched controls), reduced creatinine clear-
ance (>30%), and hypercalciuria (>400 mg in 24 hours)
who were 50 years of age or younger and who had inad-
equate follow-up care and no compelling contraindica-
tions to a general anesthetic.
PREOPERATIVE PLANNING
Preoperative parathyroid hormone (PTH) measure-
ment confi rms not only the diagnosis of primary HPT,
but also provides a baseline with which intraoperative
PTH levels can be compared. Although some variation
between assay techniques may be observed, a value just
above the normal range (i.e., 70) will need to drop
below a value of 35, the lower limit of detection of some
intraoperative rapid assays. Several radiologic proce-
dures are available to localize an abnormal parathyroid
gland preoperatively, including planar or three-dimen-
sional single photon emission computed tomography
(SPECT) sestamibi parathyroid scans, neck ultrasound,
computed tomography and magnetic resonance
imaging scans, selective arteriography, and highly selec-
tive venous catheterization to localize a PTH step-up. A
combination of two of these techniques is occasionally
useful, particularly in the setting of suspected, coinci-
dent thyroid disease. The sensitivity, specifi city, and
559

560
Section 6
Thyroid and Parathyroid
expense vary from procedure to procedure. Preopera-
tive localization is currently standard-of-care and signifi -
cantly assists in targeting the surgeon’s exploration.
Some surgeons employ intraoperative, radio-guided
localization, using a hand-held gamma probe after sys-
temic, intravenous 99Tc-sestamibi infusion preopera-
tively. Others add the use of methylene blue injection,3
which is said to concentrate in parathyroid glands,
assisting their identifi cation from surrounding lymph
nodes and adipose tissue. The dye stains adenomas and
hyperplastic glands a deep purple-blue color. Normal
parathyroid tissue stains to a lesser extent or not at
all.
Medications that cause perioperative bleeding (i.e.,
acetylsalicylic acid and ibuprofen, high-dose vitamin E)
should be discontinued 7 to 10 days in advance. Because
the procedure is generally elective, patients who are
signifi cantly overweight and are willing and capable of
losing weight should be encouraged to do so. Related
endocrinopathies should be ruled out when suggested
by history or physical examination, and a positive family
history of hypocalcemia should be sought. In particular,
pheochromocytoma and medullary thyroid carcinoma
can occur in the context of a multiple endocrine neo-
plasia (MEN) type IIa. Patients with pheochromocy-
toma should fi rst undergo adrenalectomy, and patients
with hypercalcemia and a solitary thyroid nodule that
cannot be resolved by fi ne-needle aspiration biopsy for
cytology should undergo a pentagastrin-stimulated cal-
citonin assay to rule out thyroid cancer of the medullary
type. An abnormal 24-hour urine calcium measurement
is useful to rule out familial hypocalciuric hypercalce-
mia, although this condition is rare and the history
usually elicits a familial calcium disorder.4
SURGICAL TECHNIQUE
Approach to the “Localizing Gland”
Following the induction of general endotracheal anes-
thesia or intravenous sedation and local anesthesia, the
patient’s neck is moderately hyperextended with the
head adequately supported. A low anterior collar inci-
sion roughly 1 fi ngerbreadth above the clavicular heads
is mapped out in a preexisting skin crease and is carried
out from the lateral margin of one sternocleidomastoid
muscle to the other. If clear identifi cation of laterality
is found on a localization study, the incision may be
shifted toward that side and thus shortened. In the
subplatysmal plane, the median raphe is dissected up
to the thyroid cartilage and down to the manubrial
notch. A self-retaining thyroid retractor is positioned
beneath the strap muscles above and below to facilitate
adequate exposure (Fig. 66-1). Thyroid and perithyroi-
dal tissues are palpated through the strap muscles with
an occasional palpation of an enlarged parathyroid
gland, which is generally felt to be more fi rm than a
rubbery lymph node. The overlying strap muscles are
bluntly dissected from the ipsilateral thyroid lobe and
retracted laterally, using compulsive hemostasis and
control of any bridging vessels. The middle thyroid
vein, if present, is doubly ligated with 4-0 silk suture and
divided, facilitating medial mobilization of the thyroid
lobe (Fig. 66-2). Blunt fi nger dissection at this juncture
greatly facilitates the dissection up to the apex of the
superior pole of the thyroid and down to below the
inferior pole. During this maneuver, the surgeon may
have an indication of the tumor location, correspond-
ing to the preoperative localization, using digital palpa-
tion. With the assistant maintaining maximal medial
traction of the thyroid lobe, the surgeon dissects the
loose areolar tissue using a blunt dissector and nudging,
Median raphe
Platysma
Figure 66-1. The undivided median raphe beneath the incised,
retracted platysma.
Ligated middle
thyroid vein
Figure 66-2. Middle thyroid vein ligation with medial traction of
the right thyroid lobe.

Chapter 66
Parathyroidectomy for Sporadic Primary Hyperparathyroidism
561
spreading, and dividing to expose the carotid sheath,
the inferior thyroid artery, and the recurrent laryngeal
nerve (Fig. 66-3). The inferior thyroid artery is an
invaluable landmark, in that nonectopic superior para-
thyroid glands lie above its junction with the recurrent
laryngeal nerve and nonectopic inferior parathyroid
glands lie below this structure (Fig. 66-4).
Approach to the “Nonlocalizing Gland”
If a nodule is palpated lateral or deep to the thyroid on
one side and not on the other, the side of the palpated
nodule is explored initially. Preoperative ultrasound
may demonstrate an echogenic focus suggestive of an
extrathyroidal or intrathyroidal nodule that merits
intraoperative exploration. In the absence of such a
fi nding, a bilateral exploration may occasionally be nec-
essary, if laterality is not determined by a preoperative
localization study. However, the surgeon may elect to
explore one side fi rst. This may be arbitrary or is occa-
sionally guided by concomitant thyroid pathology. If an
abnormal parathyroid gland is identifi ed, and the other
ipsilateral gland is grossly and pathologically (on frozen
section) normocellular, the termination of the proce-
dure is determined by the drop in intraoperative PTH
of more than 50%. Four-gland exploration may be nec-
essary if all of these criteria are not fulfi lled, to ensure
identifi cation of the single or multiple abnormal para-
thyroid glands. Intraoperative localization using a hand-
held gamma probe may also assist in this situation.5
Because nonlocalizing glands may be of smaller volume
(and thus emit less detectable 99Tc), the use of intraop-
erative radio detection may be assisted by reducing the
soft tissues preventing detection of the radioactivity.
The collimated probe also may enable exclusion of one
side from likely pathologic involvement. The modifi ed
procedure is as follows.
Ectopic and Nonectopic Parathyroid
Tissue Locations
The parathyroid glands are subject to predictable pat-
terns of descent during embryologic development.
Therefore, those that fail to be localized within the
commonly encountered position adjacent to the thyroid
gland often can be found anomalously. When parathy-
roid glands are abnormally located, they pursue pre-
dictable patterns of descent and may either hypodescend
or hyperdescend along a specifi c route. Hence, famil-
iarity with the embryologic origins and descent of the
parathyroids is essential to the success of exploration
(Fig. 66-5). The inferior parathyroid arises from the
third branchial cleft along with the thymus and travels
a greater distance than the superior parathyroid (which
arises from the fourth branchial cleft with the lateral
anlage of the thyroid); therefore, it is more likely to be
ectopic in its location. Hypodescended superior and
inferior parathyroids may be identifi ed adjacent to the
carotid bulb, but this is a most unusual fi nding. Roughly
one half of abnormal superior parathyroids will lie
beneath the capsule of the thyroid from the apex of the
superior pole down to the insertion site of the inferior
thyroid artery. The other (extracapsular) one half may
be, and frequently are, ectopic, particularly the larger
adenomas that descend posterior to the inferior thyroid
artery along the tracheoesophageal groove and on occa-
Superior
parathyroid
Inferior
thyroid
artery
Recurrent
laryngeal
nerve
Inferior
parathyroid
Figure 66-3. With medial thyroid lobe retraction and loose areolar
tissue dissected away, the carotid sheath, inferior thyroid artery, recur-
rent laryngeal nerve, and parathyroid glands are exposed.
Superior parathyroid
gland
Inferior
thyroid
artery
Inferior
parathyroid
gland
Figure 66-4. Nonectopic superior parathyroid glands lie above and
inferior parathyroid glands lie below the inferior thyroid artery.

562
Section 6
Thyroid and Parathyroid
sion into the posterior superior mediastinum. Under
such circumstances, a vascular pedicle arising from the
inferior thyroid artery is identifi able and provides a
critical clue to the location of the ectopic adenoma.
Ectopic inferior parathyroids are frequently adjacent to
or within the thymus within either the neck or the
superior anterior mediastinum, usually identifi able and
retrievable through the low anterior collar incision
(Fig. 66-6).
Once an enlarged parathyroid is identifi ed, every
effort, short of removing the thymus, thyroid, and
related soft tissues, should be made to identify the
second ipsilateral parathyroid. When the ipsilateral
gland is located and appears “normal,” its vascular
pedicle is identifi ed and preserved. We prefer biopsy of
a normal-appearing parathyroid gland, using a stitch or
surgical clip, to exclude multigland hyperplasia. Inci-
sional biopsy has been shown to lead to “parathyrosis”6
and provides complementary information in the era of
intraoperative quick PTH measurement. If intraopera-
tive PTH measurement is not available, biopsy confi r-
mation (using a stitch or clip) of an “abnormal”
parathyroid gland may be submitted for frozen section
(hemolysin and eosin stain and oil red O staining)
analysis. If the enlarged gland is not identifi ed on the
fi rst side explored, the other thyroid lobe is mobilized
and retracted as described previously, and the neck is
thoroughly explored to identify the superior and infe-
rior parathyroids, once again maintaining meticulous
hemostasis to facilitate identifi cation of the glands. If
three normal glands are identifi ed and the fourth (pre-
sumably adenomatous) gland is not, fi rst a thymectomy
and then a thyroid lobectomy (which may rarely contain
an adenoma) are performed on the side of the “missing”
gland. The pathologist immediately and thoroughly
evaluates both structures. If the adenoma remains
elusive and the intraoperative PTH levels remain ele-
vated, the soft tissues of the neck from the level of the
hyoid bone down to the arch of the aorta are removed,
respecting the integrity of the superior and recurrent
laryngeal nerves, vagus nerve, trachea, esophagus,
common carotid artery, and internal jugular vein.
Rarely will a parathyroid be identifi ed in the carotid
sheath, but as a fi nal maneuver, exploration of this
compartment superiorly to the carotid bulb should be
included in the dissection.
If, after completing the more extensive dissection
outlined previously, one still fails to locate the missing
parathyroid adenoma and the operating surgeon is sat-
isfi ed with the thoroughness of the supraclavicular
exploration, the location of each normal parathyroid
should be marked with a metallic clip and the neck
should be closed. Mediastinal exploration (via sternot-
omy) may be required later after a symptomatic patient
is biochemically reevaluated with repeat serum calcium
measurements, an intact PTH immunochemilumino-
metric assay, and a 24-hour urine calcium. A battery of
localization tests should be repeated as well to assist in
localization of the missing gland.
Approximately 10% of patients with sporadic
primary hyperparathyroidism will have either the diffuse
or the nodular form of parathyroid hyperplasia. A sub-
total parathyroidectomy is performed to control the
HPT in these patients. At least four parathyroids should
be identifi ed and at least 31/2 glands removed. The
most accessible (usually an inferior) and smallest para-
thyroid should be selected for partial resection. In the
course of dissecting out the gland, its vascular pedicle
should be identifi ed and avoided so as to avoid compro-
mising the blood supply and therefore the viability of
the remnant. A metallic clip should be placed across
III
IV
Figure 66-5. Embryologic pharyngeal origins of the inferior (III)
and superior (IV) parathyroid glands.
A
B
C
D
E
F
G
H
Figure 66-6. Ectopic locations of the superior (B, partially
descended; D, tracheoesophageal groove; G, mediastinal) and infe-
rior (A, undescended; C, intrathyroid; E, mediastinal outlet; F, intra-
thymic; H, anterior mediastinal) parathyroid glands.

Chapter 66
Parathyroidectomy for Sporadic Primary Hyperparathyroidism
563
Surgical clip
Parathyroid
vascular pedicle
Figure 66-7. The parathyroid is clipped in preparation for transec-
tion on the avascular side of the surgical clip.
A
B
Figure 66-8. Two-dimensional planar 99Tc images showing early (A) and delayed (B) images, localizing the adenoma in the left paratracheal
region. A persistent focus of radiotracer activity is evident posterior to the right inferior thyroid lobe, consistent with a parathyroid adenoma.
Ultrasound or three-dimensional single photon emission computed tomography techniques can be used (not shown) to localize the adenoma
in the anteroposterior direction in addition to the left or right side.
the midportion of the gland (Fig. 66-7) and the tissue
distal to this removed with scalpel dissection and
submitted for histologic confi rmation. The remnant
inferior gland can be tacked to the anterior trachea or
other landmark for future safe identifi cation if multi-
gland hyperplasia develops. Before removing each one
of the three remaining parathyroids, the viability of the
remnant should be reassessed by observing its gross
appearance.
After the dissection is completed, hemostasis is
achieved and a suction drain is brought out through a
separate skin strap incision. The fascia overlying the
strap muscles is reapproximated with interrupted 4-0
Vicryl sutures, the platysma is reapproximated in a
similar fashion, and the skin is reapproximated with a
running, fi ne, absorbable subcuticular closure and
adhesive dressing strips. No neck dressing is applied to
avoid obscuring hematoma formation.
POSTOPERATIVE MANAGEMENT
The head of the bed should be elevated at least 30
degrees for the fi rst 12 to 18 hours to minimize venous
oozing in the operative site. Signifi cant postoperative
hypocalcemia is rarely encountered in the absence of
subtotal parathyroidectomy for hyperplasia or the
removal of a parathyroid adenoma or carcinoma with a
preoperative calcium greater than 12 mg/dL. A full
preoperative diet and level of activity are resumed the
evening of surgery. The majority of patients are dis-
charged the day of or the fi rst day after surgery.

564
Section 6
Thyroid and Parathyroid
PEARLS
• Successful parathyroidectomy depends on an
accurate diagnosis, appropriate patient selection
and preparation, and a thorough understanding of
the embryology and anatomy of the parathyroid
glands and related neck and mediastinal structures.
• Preoperative localization of abnormal glands should
be standard procedure in all centers in which the
surgery is to be performed. In our experience, three-
dimensional SPECT acquisition using the 99Tc
isotope has enabled the localization of glands not
identifi ed by two-dimensional planar imaging (see
Fig. 66-8). This is likely due to the ability to rotate
the scan 360 degrees, reducing the tissue
obstructing the emitting glands and the SPECT
detector.
• Intraoperative PTH monitoring (not currently
mandatory in confi rming that the abnormal glands
have been removed) substantially assists the surgeon
and decreases dissection to the extent that patient
safety and complications are positively impacted.
• When parathyroid carcinoma is present, it must be
recognized early in the operative procedure. Optimal
management consists of an en bloc resection of the
carcinoma, adherent tissues, and ipsilateral thyroid
lobe with at least a central compartment node
dissection.
section examination of all excised “parathyroid”
tissue.
• The anatomic course and integrity of the recurrent
and superior laryngeal nerves must be known and
respected, so as to avoid impairing laryngeal
function. Meticulous dissection is required to
preserve the arterial supply and venous drainage of
any retained parathyroid gland. Abnormal
parathyroid glands are frequently ectopic. They may
fail to descend from the retropharyngeal area, may
descend within and therefore be concealed by the
thyroid or thymus, or may hyperdescend into the
anterior mediastinum (inferior parathyroid) or
posterior mediastinum (superior parathyroid).
Hyperdescended glands frequently carry their blood
supply with them as derivatives of the inferior
thyroid artery, and vascular pedicles should be
carefully sought and dissected out.
• Although the reported half-life of circulating PTH is
reported to be 10 minutes,7 the surgeon should wait
at least 15 to 20 minutes before the post-excision
venipuncture is performed. Manipulation of the
abnormal, enlarged glands may produce a
temporary spike in circulating PTH after the
preoperative PTH value is drawn, temporarily
confounding the greater than 50% decline rule for
successfully terminating the procedure.
PITFALLS
• The suspected malignant parathyroid must not be
biopsied or its capsule violated, to avoid tumor
seeding.
• In the absence of intraoperative circulating PTH
decline of greater than 50% of the baseline value,
an adenoma may not be differentiated from
parathyroid hyperplasia. Confi rmation depends on
the accurate assessment (e.g., by fat-staining
techniques) of the biopsied “normal” gland by the
surgeon and the pathologist together. Failure to
recognize hyperplasia inevitably results in persistent
or recurrent hypercalcemia. Double adenomatas are
uncommon (less than 2%).
• Ectopic thyroid tissue, lymph nodes, “brown
fat,” and thymic tissue may grossly mimic a
parathyroid gland, supporting the use of frozen
References
1. Ferris RL, Simental AA Jr: Molecular biology of primary hyperpara-
thyroidism. Otolaryngol Clin North Am 37:819-831, 2004.
2. Ruda J, Stack BC Jr, Hollenbeak CS: The cost-effectiveness of
sestamibi scanning compared to bilateral neck exploration for
the treatment of primary hyperparathyroidism. Otolaryngol Clin
North Am 37:855-70, x-xi, 2004.
3. Orloff LA: Methylene blue and sestamibi: Complementary tools
for localizing parathyroids. Laryngoscope 111:1901-1904, 2001.
4. Thakker RV: Diseases associated with the extracellular calcium-
sensing receptor. Cell Calcium 35:275-282, 2004.
5. Lee WJ, Ruda J, Stack BC Jr: Minimally invasive radioguided para-
thyroidectomy using intraoperative sestamibi localization. Otolar-
yngol Clin North Am 37:789-798, ix, 2004.
6. Lentsch EJ, Withrow KP, Ackermann D, Bumpous JM: Parathyro-
matosis and recurrent hyperparathyroidism. Arch Otolaryngol
Head Neck Surg 129:894-896, 2003.
7. Emmolo I, Corso HD, Borretta G, et al: Unexpected results using
rapid intraoperative parathyroid hormone monitoring during
parathyroidectomy for primary hyperparathyroidism. World J Surg
29:785-788, 2005.

section 7
Trachea and Mediastinum
Chapter 67
Bronchoscopy and Tracheoscopy
Peter F. Ferson and David E. Eibling
Examination of the subglottic, tracheal, and bronchial
airways is a fundamental skill required of all otolaryn-
gologists. The surgeon must be familiar with available
endoscopic instruments that are used in this examina-
tion. The surgeon must also be able to use the tech-
niques required for examination, surgical biopsy, and
other interventions on the infraglottic respiratory tract.
Thorough knowledge of the various techniques will
help the practitioner best manage each patient.
BRONCHOSCOPIC ANATOMY
Examination of the lower airway requires knowledge of
the endoscopic anatomy of the tracheobronchial tree.
The trachea begins immediately inferior to the cricoid
cartilage. The distance from the cricoid to the tracheal
bifurcation is approximately 10 cm in most adults. In
this short distance the trachea moves posteriorly from
a nearly subcutaneous location in the neck at the level
of the cricoid cartilage to deep within the chest, behind
the aorta and pulmonary artery, at the level of the
carina. This deep and complex location of the distal
airway and its relative inaccessibility increase the neces-
sity for endoscopic evaluation and therapy when
feasible.
The lung is divided into three lobes on the right
and two on the left. There are a total of 18 segments,
each of which is associated with a named bronchus
(Fig. 67-1). The bronchoscopist should memorize this
anatomy.
DEVELOPMENT
Gustave Killian is credited with performing the fi rst
translaryngeal examination of the trachea in 1897 with
a hollow gastroscope.1-3 This particular episode had
little clinical signifi cance because it was performed on
a paid volunteer; however, later that same year Killian
reported the removal of a foreign body from the
bronchus.4
The art of bronchoscopy was fully developed by
Jackson in the early part of the past century. This
pioneer spent his career in the design of instruments,
development of anesthetic techniques, and perfection
of the skills required for management of diseases of
the tracheobronchial tree. His clinical activities in
Pittsburgh and Philadelphia achieved international rec-
ognition, and his clear and precise written descriptions
of ope rative techniques are still essential reading for
endoscopists.5
The technology improved dramatically in 1968
when Ikeda and associates introduced a fl exible bron-
chofi berscope.6 The use of fl exible endoscopes for
evaluating and treating disorders of the larynx and tra-
cheobronchial tree has since become routine. Flexible
endoscopic procedures generally require less anesthetic
565

566
Section 7
Trachea and Mediastinum
and sedation than do similar endeavors with rigid
instruments. Moreover, fl exible endoscopes will often
provide more direct vision over a greater fi eld of view;
hence, their use is standard in the diagnosis of endo-
bronchial abnormalities. Despite these potential advan-
tages, the airway control and versatility of rigid
endoscopic instrumentation are frequently essential.
Thus, the endoscopist must have a working knowledge
of both types of instruments.
ENDOSCOPIC EQUIPMENT
Flexible Fiberoptic and “Chip-Tip”
Bronchoscopes
The fl exible bronchoscope is a fl exible tube containing
one to three bundles of tiny glass fi bers that are fl exible
and can be angulated mechanically when a knob or
lever is moved. In the traditional fi beroptic broncho-
scope, one bundle transmits images from the distal
objective to the eyepiece or camera. More recently,
“chip-tip” bronchoscopes have been developed in which
a charged-coupled device (CCD) chip camera is placed
at the tip of the scope, thereby eliminating this fi berop-
tic bundle. Working light is transmitted to the distal
end of the instrument by adjacent bundles of fi bers in
both the traditional and “chip-tip” versions. The image
created by the fi beroptic systems is a composite of those
formed by the optical bundle wherein each fi ber carries
one pixel. The smaller the fi bers, the more fi bers that
can be placed in the scope and the greater the defi ni-
tion of the image. In actuality, there is a fi nite limit,
both technical and fi nancial, in the number of fi bers
that can be placed in a scope small enough to pass into
the tracheobronchial tree. The newer “chip-tip” bron-
choscopes provide higher resolution because the image
is captured directly, with elimination of the intermedi-
ate bundle of optic. However, they must be used with
dedicated light sources and integrated camera control
systems and are considerably more costly. A suction
channel that doubles for insertion of instruments is also
contained in the working tube.
Flexible bronchoscopes are produced in a variety
of lengths and diameters (Fig. 67-2). The standard,
commercially available bronchoscopes currently pro-
duced by a popular manufacturer (Olympus Corp.,
Strongsville, OH) range in diameter from 2.2 to 6.4 mm.
Although a smaller diameter will often provide greater
fl exibility and ease of passage into narrow airways, this
advantage is achieved at the cost of decreased lighting
and image resolution, as well as smaller or absent
suction and working channels. The length of fl exible
fi berscopes also varies, with shorter and less costly
instruments being used for examination of the naso-
pharynx and the larynx.
The image that is transmitted through a fl exible
bronchoscope may be viewed in several ways. The easiest
and most direct method is for the operator to observe
the image directly in the eyepiece. This is the best way
to maintain anatomic orientation, but it limits the
viewing to a single individual, and it is not an option
with the newer bronchoscopes that have a distally
Lateral basal
Posterior basal
Medial basal
Superior segment
lower lobe
Lower lobe
bronchus
Medial basal
Lateral basal
Anteromedial
Inferior
lingula
Superior
lingula
Superior
Anterior
Apicoposterior
Upper lobe
bronchus
Upper lobe
bronchus
Apical
Posterior
Anterior
Middle lobe bronchus
Lateral
Medial
Anterior basal
Figure 67-1. Tracheobronchial anatomy. (Copyright 1996,
Ciba-Geigy Corporation. Redrawn with permission from the Atlas of
Human Anatomy, illustrated by Frank Netter, M.D. All rights
reserved.)

Chapter 67
Bronchoscopy and Tracheoscopy
567
located camera chip. As a result, most training pro-
grams now routinely use video monitors, whether
required (for the “chip-tip” bronchoscope) or optional
(with fi beroptic systems), to familiarize trainees and
staff with working off the video monitor (Fig. 67-3).
Rigid Bronchoscopes
Rigid bronchoscopes are hollow tubes through which
the patient can be ventilated during visual inspection
and therapeutic manipulation. The distal end is beveled
to facilitate insertion through the vocal cords and to
enhance manipulation of the distal bronchi. The distal
end of the bronchoscope tube also contains side perfo-
rations that allow ventilation of the trachea and contra-
lateral bronchus when the bronchoscope is advanced
into a distal lobar bronchus (Fig. 67-4). Illumination is
usually provided by a distally placed light fi ber, but
proximal illumination is also possible with a light beam
diverted by a small prism that projects a small distance
into the lumen.
Rigid bronchoscopes can be obtained in several
diameters and lengths (Fig. 67-5). A variety should be
immediately available for any planned bronchoscopic
procedure to match the size of the bronchoscope to the
airway of the patient. This is particularly critical in hos-
pitals in which management of airways in children may
occur. Working instruments, such as biopsy forceps,
A
B
C
Figure 67-2. A, Two fi beroptic bronchoscopes (top), a “chip-tip”
bronchoscope (middle), and a nasopharyngoscope (bottom) for compari-
son. The smallest of the bronchoscopes is a pediatric bronchoscope;
the other two are for adults. Note that the “chip-tip” bronchoscope is
no larger than the adult one. B, Comparison of the tips of the endo-
scopes. Note that the pediatric bronchoscope (second from the left) is
approximately the same diameter as the nasopharyngoscope (left). C,
Note the differences in size of the working channels.
Figure 67-3. For the surgeon, fl exible bronchoscopy is easiest to
perform while standing at the head of the table and viewing the
anatomy either directly through the endoscope or on the video
monitor. This position permits the procedure to be performed in the
same orientation as that used for rigid bronchoscopy.
foreign body forceps, and rigid suction tubes, should
be matched to the respective bronchoscope for size and
length.
As with the fl exible bronchoscope, there are several
alternatives for image display. Viewing down the open

568
Section 7
Trachea and Mediastinum
tube or through a window plug is the most direct
method, but the distance and small visual angle are
limiting. Most endoscopists routinely use rigid tele-
scopes, either straight or angled view, that are inserted
through the bronchoscope. These instruments provide
magnifi ed images, a wider fi eld of view, and lateral
viewing of areas not in the direct line of vision through
the bronchoscope. As in fl exible bronchoscopy, video
cameras are attached to the telescopes to permit group
viewing and documentation.
When positive pressure ventilation is used through
the rigid bronchoscope, the proximal end must be
occluded with a tightly fi tting window plug. If a tele-
scope is inserted and positive pressure ventilation is
desired, the open end can be occluded with a perfo-
rated rubber diaphragm through which the telescope
is introduced. Most manufacturers provide a proximally
located port to attach a jet ventilator as an alternative
to conventional positive pressure ventilation (Fig.
67-6).
PATIENT SELECTION
The indications for bronchoscopy include a variety of
conditions as noted in Table 67-1. Such conditions
include evaluation of pulmonary masses, infi ltrates,
Figure 67-4. Tip of a bronchoscope. The ventilation side ports
permit aeration of the contralateral bronchus when the tip of the
scope is impacted in the bronchus being examined. The beveled end
of the bronchoscope facilitates passage through the larynx, past the
carina, and into the distal main stem bronchi.
Figure 67-5. Bronchoscopes are available in various diameters and
lengths. Inner diameters range from 3 mm (not shown) to 8.5 mm.
Maintenance of a complete set of sizes is vitally important in a facility
in which procedures are performed on both children and adults.
A
B
Figure 67-6. A, Proximal end of a bronchoscope with a 15-mm anesthesia adapter (large arrow) for control of ventilation, an adapter for jet
ventilation (small arrow) through the angled port, a clear glass eyepiece (curved arrow) to permit simultaneous ventilation while observation is
ongoing, and a light connector (open arrow) for distal fi beroptic illumination. Pediatric bronchoscopes have an adapter for proximal illumina-
tion that uses a prism in the proximal airway (see Fig. 67.5). B, A sliding eyepiece holder permits the use of various eyepieces (magnifying or
plain glass), an open tube, or rubber grommet through which a Hopkins rod telescope can be passed.

Chapter 67
Bronchoscopy and Tracheoscopy
569
hemoptysis, and strictures of the airway. Routine bron-
choscopy is often included in the evaluation for second
primary tumors in patients with head and neck malig-
nancies. Bronchoscopy is most commonly used by the
otolaryngologist or head and neck surgeon for either
removal of foreign bodies or diagnosis and manage-
ment of airway masses or strictures. These procedures
are technically diffi cult and usually require a rigid
scope. For this reason, rigid endoscopy remains a vital
component of the training program in otolaryngology
and head and neck surgery.
BRONCHOSCOPY TECHNIQUE
The decision to perform either fl exible or rigid bron-
choscopy must be made before the procedure and is
based on the relative risks and advantages of each tech-
nique for the specifi c patient. A rigid bronchoscope
provides more secure control of the airway and permits
ventilatory support. The rigid method also allows the
insertion of larger working instruments and suction
tubes. A fl exible bronchoscope, however, provides visi-
bility further peripherally in the distal bronchi and
enhanced viewing angles to observe around angles in
the main stem and segmental bronchi. The two tech-
niques can be combined if preoperative planning has
considered this eventuality. A rigid bronchoscope may
be inserted initially and then a fl exible bronchoscope
advanced through the rigid bronchoscope. This tech-
nique takes advantage of the particular strengths of
each method and is particularly useful for complex
procedures involving strictures, tumors, or foreign
bodies.
Flexible Bronchoscopy
Although examination of the pharynx and visualization
of the larynx can readily be accomplished at the bed-
side, formal bronchoscopic examination requires more
extensive anesthesia and monitoring than is generally
available outside the operating room or endoscopy
suite. Flexible bronchoscopy is routinely performed
under topical anesthesia with sedation. Preoperative
sedation with intravenous diazepam or midazolam is
usually suffi cient for patient relaxation. The posterior
pharynx is anesthetized with 10% lidocaine spray, and
if transnasal passage of the bronchoscope is intended,
the nasopharynx is treated with 2% lidocaine jelly or
4% lidocaine solution slowly dripped into the nose. A
small piece of cotton soaked in 4% lidocaine is held in
a spring-loaded right-angled forceps and applied to
each piriform sinus.
When the gag and cough refl exes are suppressed,
a fl exible bronchoscope may be inserted either nasally
or orally with a bite block in place. When the larynx is
visualized, 2 to 4 mL of 4% lidocaine is injected into the
trachea through the bronchoscope, and then the bron-
choscope is advanced through the vocal cords. Addi-
tional lidocaine can be delivered as a bolus as needed
into the distal airway to suppress cough, but the total
dose administered must always be considered.
Monitoring by continuous pulse oximetry, electro-
cardiography, and noninvasive blood pressure record-
ing is standard. The patient should be observed
afterward until the gag refl ex and alertness have
returned.
General anesthesia is required for patients who
cannot tolerate local anesthesia, either because of
severe anxiety or when an excessive gag refl ex cannot
be suppressed. General anesthesia for fl exible bron-
choscopy may also be required for situations in which
the planned bronchoscopic procedure will require total
immobility.
With general anesthesia, a fl exible bronchoscope
can be passed either adjacent to or through the endo-
tracheal tube. Passage adjacent to the tube is usually
performed during suspension laryngoscopy. The endo-
tracheal tube cuff must be defl ated for a moment to
pass the endoscope by the cuff, after which it can be
reinfl ated. Insertion of a fl exible bronchoscope through
a large-diameter endotracheal tube is often used for
examination of the distal trachea and bronchi. This is
facilitated by a right-angled adapter with a perforated
rubber diaphragm (Portex Corp., Wilmington, MA). If
the surgeon elects to pass the bronchoscope through
the endotracheal tube, care must be taken to select a
bronchoscope and endotracheal tube that ensure suffi -
cient residual airway to ventilate the patient. If the bron-
choscope is too large for the respective endotracheal
tube or if it is insuffi ciently lubricated, the broncho-
scope may become stuck in the endotracheal tube and
impede ventilation. In such a case, common sense must
prevail because the anesthesiologist will be anxious
about the inability to ventilate and the surgeon will pull
harder on the bronchoscope and thereby cause the
anesthesiologist to squeeze the endotracheal tube. Irri-
gating saline solution into the endotracheal tube along
the bronchoscope will usually loosen the scope and
allow it to be withdrawn. If irrigation fails, it is best to
extubate the patient with the bronchoscope in the
endotracheal tube and insert a new endotracheal tube.
Persisting in efforts to force the bronchoscope when it
Table 67-1
INDICATIONS FOR BRONCHOSCOPY
AND TRACHEOSCOPY
Diagnosis
Hemoptysis
Mass lesion noted on a chest radiograph
Transbronchial biopsy
Infectious process
Search for a second primary malignancy
Evaluate tracheal/bronchial stenosis
Therapeutic
Removal of a foreign body
Suction of inspissated mucus
Bronchoalveolar lavage
Transbronchial drainage of an abscess
Removal of an obstructing lesion
Dilatation/resection of a cicatricial scar

570
Section 7
Trachea and Mediastinum
seems to be stuck in the endotracheal tube will fre-
quently damage the bronchoscope.
It is of critical importance to maintain anteroposte-
rior and lateral orientation during fl exible bronchos-
copy. Without correct orientation it is impossible to
reliably locate and correctly identify the primary and
segmental bronchi. Anatomic and spatial orientation is
best preserved when the patient is supine and the oper-
ator stands directly behind the patient’s head. Fre-
quently, this is impractical, but it is the easiest way to
establish orientation when the anatomy becomes con-
fusing. Working off a video monitor can also lead to
disorientation for an inexperienced observer. When
using a fi beroptic bronchoscope, it is best to remove
the camera and observe directly through the eyepiece
while standing behind the patient. If a “chip-tip” bron-
choscope is used, this is not feasible. In these situations,
one can withdraw into the trachea and note the posi-
tion of the tracheal rings to determine anterior and
posterior orientation.
Rigid Bronchoscopy
Rigid bronchoscopy can be performed safely and effi -
ciently if proper care is taken with anesthetic manage-
ment, patient positioning, and atraumatic exposure of
the larynx. General anesthesia is preferable for rigid
bronchoscopy unless a compelling reason exists to
avoid it. Rigid bronchoscopic examination under local
anesthesia can be performed, but such a procedure is
stressful to both the patient and operator.
General anesthesia is initiated via a face mask until
the patient is suffi ciently anesthetized and relaxed to
permit intubation of the airway. Alternatively, spontane-
ous ventilation can be sustained until the trachea is
intubated with the bronchoscope. Spontaneous ventila-
tion is typically used when anatomically deforming
abnormalities are present in the pharynx or larynx.
Initial positioning with the head slightly elevated in a
“sniffi ng” position should enhance exposure of the
larynx. A movable headrest or assistant “head holder”
permits repositioning of the head as the bronchoscope
is later manipulated within the trachea and bronchi.
Insertion of the bronchoscope through the larynx and
into the trachea requires careful visualization of the
larynx and is the most challenging part of the entire
procedure. The uvula, tonsillar fossa, epiglottis, aryte-
noids, and vocal cords can be located and identifi ed by
viewing directly through the tube of the rigid broncho-
scope (Figs. 67-7 through 67-10). Although this is the
most direct method, many inexperienced observers will
often become disoriented because of the long distance
and small fi eld of view. Even experienced observers can
fi nd it diffi cult to clearly view the larynx through a rigid
bronchoscope with unfavorable anatomy. An alterna-
tive method uses a laryngoscope, either an anesthesia
laryngoscope or a Jackson slide laryngoscope, to visual-
ize the larynx. The bronchoscope can then be advanced
to the vocal cords under direct vision with the laryngo-
scope and the line of sight switched to view down the
bronchoscope as it is advanced through the cords (Figs.
67-11 through 67-15). This method has been well out-
lined by Jackson and Jackson.5 Care should be taken to
insert the bronchoscope with the longer edge of the
bevel in the center of the larynx and the shorter edge
against the left vocal cord (see Figs. 67-6 and 67-14).
This avoids catching and traumatizing the right vocal
cord with the leading edge of the bronchoscope.
As the bronchoscope is advanced through the
trachea and into each main stem bronchus, the upper
teeth must be protected with the fi ngers of the left hand
while the bronchoscope is supported on the left thumb
to avoid injury to the teeth. The distal end of the bron-
choscope must remain free within the lumen of the
airway. To accomplish this, the head can be reposi-
tioned by a change in elevation or lateral rotation.
Viewing directly through the bronchoscope tube is
effi cient, but visibility is limited. Visibility is enhanced
by inserting telescopes that provide either straight or
laterally angled fi elds of view. The telescopes may be
attached to a video camera for group display and to
allow the operator to work with the head away from the
bronchoscope. Care must be taken to avoid advancing
A
A
B
B
Figure 67-7. Technique of intubation. The bronchoscope is aligned
in the midline of the tongue while the mouth is held open with the
thumb and fi ngers. The bronchoscope is supported with the thumb,
and the uvula (A) and epiglottis (B) are visualized to maintain
midline orientation.