Phẫu Thuật Tai Mũi Họng Và Phẫu Thuật Đầu Cổ

Chapter 20
Bleeding during Endoscopic Sinus Surgery
147
tine vessel in the pterygopalatine space. This is done to
identify proximal branching of the vessel and to create
more room for instrumentation. Blunt dissection of the
proximal vessel and its branches can be performed with
Montgomery hooks or similar instruments (Fig. 20-12).
Medium-size hemoclips are then placed across the main
trunk and its two distal branches with a fl at adjustable
hemoclip applier (Fig. 20-13).
Figure 20-9. The mucoperiosteum at the posterior margin of the
antrostomy is elevated to identify the sphenopalatine foramen.
(Reprinted with permission from Snyderman CH, Carrau RL: Endoscopic
ligation of the sphenopalatine artery for epistaxis. Op Tech Otolaryngol Head
Neck Surg 8:85-89, 1997.)
corner of the maxillary sinus at the posterior attach-
ment of the middle turbinate (Fig. 20-10). A small
triangle of bone (crista ethmoidalis) usually projects
medially just superfi cial to the foramen. A suction ele-
vator facilitates dissection when bleeding is present.
Alternatively, a 7F Frazier suction can be used as a
dissector.
Once the foramen is identifi ed, the overlying bone
is removed with a 1-mm angled Kerrison rongeur (Fig.
20-11). The use of larger rongeurs increases the risk of
additional injury to the vessel. Approximately 1 cm of
bone is removed to expose the proximal sphenopala-
Figure 20-10. Vessels are seen exiting the right sphenopalatine
foramen.
Figure 20-11. The foramen is enlarged with rongeurs to expose
the main trunk of the sphenopalatine artery in case there is proximal
branching. (Reprinted with permission from Snyderman CH, Carrau RL:
Endoscopic ligation of the sphenopalatine artery for epistaxis. Op Tech Oto-
laryngol Head Neck Surg 8:85-89, 1997.)
PTF
PWA
Figure 20-12. The distal vessels are dissected with blunt hooks.
(Reprinted with permission from Snyderman CH, Carrau RL: Endoscopic
ligation of the sphenopalatine artery for epistaxis. Op Tech Otolaryngol Head
Neck Surg 8:85-89, 1997.)

148
Section 1
Nasal Cavity, Nasopharynx, and Sinuses
Exposure of the Petrous Internal
Carotid Artery
Most injuries to the ICA occur in the sphenoid sinus
along its vertical segment. In the event of an injury to
the ICA, direct repair is not feasible and packing should
be placed in the sphenoid sinus to control hemorrhage.
The choice of packing material is not a critical factor
inasmuch as a multitude of biologic and inorganic
materials have been used successfully. In the absence of
intracranial communication, there is time to transport
the patient to the radiology department for assessment
and occlusion of the artery by the interventional radi-
ologist. If a breach of the skull base has also occurred,
there is a signifi cant risk of blood tracking intracranially
with potentially disastrous consequences. In such a situ-
ation, it is desirable to expose the ICA more completely
so that it can be focally occluded. This is best performed
by an experienced team of endoscopic skull base
surgeons.
A transpterygoid approach is used to expose the
petrous portion of the ICA proximal to the site of
injury.10,11 A large middle meatal antrostomy is per-
formed and the sphenopalatine and posterior nasal
arteries are cauterized and transected as already
described. The sphenoidotomy is enlarged inferolater-
ally so that the walls of the sphenoid sinus can be visual-
ized (Fig. 20-14). The contents of the pterygopalatine
space are elevated from the underlying pterygoid bone
and displaced laterally. The vidian artery and nerve are
identifi ed at the pterygoid canal along the inferolateral
aspect of the sphenoidotomy. The bone inferior and
medial to the vidian artery is drilled with a 3-mm hybrid
diamond bit until the plane of the ICA is reached (Fig.
20-15).12 Careful drilling along the course of the ICA is
performed until the bone of the canal is thin enough
to fracture with the tip of a 1-mm angled Kerrison
rongeur. Removal of bone continues to the level of the
vascular injury (see Video 20-2). The ICA is compressed
within the canal to control bleeding. It is possible to
seal a small laceration of the vessel wall with bipolar
cautery. The goal in most cases, however, is to occlude
the vessel with a focal pack (hemostatic material, muscle,
and cottonoids) to allow more defi nitive management
in a controlled setting.
Blood pressure should be kept at a normal level
when injury to the ICA occurs to maintain adequate
collateral cerebral circulation. Neurophysiologic moni-
toring of cortical function can be very helpful in such
situations to assess the adequacy of collateral cerebral
blood fl ow and take steps to optimize it.
Figure 20-13. The vessels are ligated with medium-size hemoclips
via an endoscopic clip applier. (Reprinted with permission from Snyder-
man CH, Carrau RL: Endoscopic ligation of the sphenopalatine artery for
epistaxis. Op Tech Otolaryngol Head Neck Surg 8:85-89, 1997.)
Figure 20-14. The sphenoidotomy is maximally enlarged by ligat-
ing the sphenopalatine artery and elevating the contents of the ptery-
gopalatine space from the medial pterygoid plate. This allows removal
of bone over the lateral recess (outlined areas) between the foramen
rotundum and pterygoid canal (arrow).
Sella
CR
Figure 20-15. Bone medial and inferior to the left pterygoid canal
(arrows) is drilled to expose the second genu of the internal carotid
artery. CR, clival recess.

Chapter 20
Bleeding during Endoscopic Sinus Surgery
149
POSTOPERATIVE CARE
After ligation of the ethmoidal or sphenopalatine
vessels, postoperative care is the same as for any
endoscopic sinus surgery and may include temporary
nasal packing or splints, as well as saline irrigation
and gentle débridement. If a tampon is inserted
intranasally at the completion of surgery, it should
be done under direct endoscopic vision so that
hemoclips are not accidentally displaced. If the perior-
bita has been violated, patients should be instructed
to not blow their nose because of the risk of orbital
emphysema. Preexisting hypertension should be treated
and medications with antiplatelet effects should be
avoided.
Injury to the ICA requires emergency consultation
from a neurosurgeon with vascular experience and an
interventional neuroradiologist (Fig. 20-16). Extremes
of blood pressure should be avoided. Even in the pres-
ence of a negative preoperative balloon occlusion test
of the ICA, hypotension can result in cerebral infarc-
tion in watershed areas of the brain. There is also a risk
of embolic episodes from clot distal to the site of occlu-
sion. With any vascular injury, postoperative angiog-
raphy is essential to rule out pseudoaneurysm
formation.
Recurrent bleeding after surgery may be multifac-
torial. Proper management depends on the extent of
the surgery and how bleeding complications were
managed intraoperatively. Selective electrocautery or
ligation of offending vessels may be the most expedient
way to manage signifi cant bleeding. When the site of
bleeding is unclear and vessels have already been
ligated, angiography (with embolization) should be
both diagnostic and therapeutic.
COMPLICATIONS
Knowledge of anatomic relationships is important for
locating the major vessels of the sinonasal cavities.
Bipolar electrocautery should not be used in proximity
to neural tissue, the skull base, the orbit, and the ICA
to minimize the risk of thermal injury. Monopolar elec-
trocautery should never be used beyond the anterior
wall of the sphenoid sinus.
Risks related to exposure of the anterior ethmoid
artery include a dural injury with CSF leakage, retrac-
tion of a transected vessel into the orbit with the forma-
tion of an orbital hematoma, and stenosis of the
nasofrontal duct. Identifi cation plus ligation of the
vessel along the orbital side of the bone helps minimize
these risks.
Ligation of the sphenopalatine vessels may fail as a
result of displaced hemoclips, unrecognized proximal
branching with separate foramina (Fig. 20-17), and
bleeding from other sites (anterior ethmoid artery).
Wide exposure of the sphenopalatine foramen with
elevation of mucoperiosteum and removal of overlying
bone prevents missing a separate vessel exiting through
its own foramen. Excessive removal of bone posterior
to the sphenopalatine foramen risks injury to the greater
palatine nerve with resultant palatal anesthesia. Exces-
sive dissection of pterygopalatine tissues risks additional
vascular injury from other branches of the internal
maxillary artery, as well as injury to the vidian nerve and
decreased tearing.
ICA Injury
Blood transfusion
Uncontrolled
bleeding
Packing: Apply additional suction, enlarge the ostium of the sphenoid; drill
sharp bony edges, packing with Gelfoam, Surgicel, Oxycel, fat, muscle, fascia,
and/or surgical glue. Support with balloon catheter or regular nasal packing
If it is not bleeding,
send the patient to angiography
CCF
PA
No complication,
follow the patient periodically
with CT or MRI angiography
Acute
Interventional neuroradiology
Temporary balloon occlusion test, or if
there is time, stable Xe-CT CBF examination
Poor collateral
blood flow
Covered stent
A shunt
with a vein graft
between the petrous
and supraclinoid ICA
Coil occlusion
Balloon occlusion
Try to preserve ICA
Compress CCA in the neck
Bleeding
If a small laceration,
bipolar cauterization
Figure 20-16. Algorithm for the
management of an injury to the inter-
nal carotid artery (ICA). CBF, collat-
eral blood fl ow; CCA, common carotid
artery; carotid-cavernous fi stula; CT,
computed tomography; MR, magnetic
resonance; PA, pseudoaneurysm.

150
Section 1
Nasal Cavity, Nasopharynx, and Sinuses
SUMMARY
Most intraoperative bleeding during endoscopic sinus
surgery can be effectively controlled with conservative
measures, including the application of hemostatic mate-
rial and hot-water irrigation. Injury to major arteries
traversing the nasal cavity and sinuses can be avoided
with anatomic knowledge, good visualization, and
proper operative technique. Ligation of major vessels
may be necessary for control of hemorrhage and can
be done endoscopically through a transnasal approach.
Every surgeon should have a treatment algorithm for
dealing with inadvertent injury to the ICA.
Figure 20-17. This patient failed right sphenopalatine artery liga-
tion. Re-exploration with performance of middle meatal antrostomy
revealed a separate foramen with missed vessels inferior to the site of
the previous hemoclips (arrows).
PEARLS
• Preoperative radiologic studies should be reviewed
to identify anatomic variations to decrease the risk
of vascular complications.
• The anterior ethmoid artery is located in the coronal
plane tangential to the posterior surface of the
globe.
• The sphenopalatine foramen is situated at the
posterior attachment of the middle turbinate.
• The sphenopalatine artery branches proximal to the
sphenopalatine artery more than 40% of the time.
• The vidian (pterygoid) canal is a useful landmark for
identifi cation of the second genu of the ICA.
References
1. Snyderman CH, Carrau RL: Advances in the treatment of epi-
staxis. In Myers EN (ed): Advances in Otolaryngology–Head and
Neck Surgery, vol 14. St Louis, CV Mosby, 2000, pp 213-223.
2. Stangerup SE, Thomsen HK: Histological changes in the nasal
mucosa after hot-water irrigation. An animal experimental study.
Rhinology 34:14-17, 1995.
3. Stangerup SE, Dommerby H, Siim C, et al: New modifi cation of
hot-water irrigation in the treatment of posterior epistaxis. Arch
Otolaryngol Head Neck Surg 125:686-690, 1999.
4. Schlegel-Wagner C, Siekmann U, Linder T: Non-invasive treat-
ment of intractable posterior epistaxis with hot-water irrigation.
Rhinology 44:90-93, 2006.
5. Schwartzbauer HR, Shete M, Tami TA: Endoscopic anatomy of
the sphenopalatine and posterior nasal arteries: Implications for
the endoscopic management of epistaxis. Am J Rhinol 17:63-66,
2003.
6. Snyderman CH: Resection of the carotid artery. In Myers EN
(ed): Decision Making in ENT Disorders. Philadelphia, WB Saun-
ders, 2001.
7. Kassam A, Snyderman CH, Carrau RL, et al: Endoneurosurgical
hemostasis techniques: Lessons learned from 400 cases. Neuro-
surg Focus 19(1):E7, 2005. Available at
education/journal/neurosurgical/July05/19-1-7.pdf.
8. Snyderman CH, Goldman SA, Carrau RL, et al: Endoscopic sphe-
nopalatine artery ligation is an effective method of treatment for
posterior epistaxis. Am J Rhinol 13:137-140, 1999.
9. Snyderman CH, Carrau RL: Endoscopic ligation of the spheno-
palatine artery for epistaxis. Op Tech Otolaryngol Head Neck
Surg 8:85-89, 1997.
10. Alnashar IS, Carrau RL, Herrera A, Snyderman CH: Endoscopic
transnasal transpterygopalatine fossa approach to the lateral
recess of the sphenoid sinus. Laryngoscope 114:528-532, 2004.
11. Bolger WE: Endoscopic transpterygoid approach to the lateral
sphenoid recess: Surgical approach and clinical experience. Oto-
laryngol Head Neck Surg 133:20-26, 2005.
12. Snyderman CH, Kassam AB, Carrau RL, Mintz A: Endoscopic
approaches to the petrous apex. Op Tech Otolaryngol 17:168-
173, 2006.
PITFALLS
• Transection of the anterior ethmoid artery too close
to the orbit can result in retraction of the severed
artery into orbital tissue and the development of a
retrobulbar hematoma.
• Dissection of the anterior ethmoid artery at the skull
base risks a CSF leak, especially at the junction of
the fovea ethmoidalis and lateral lamella of the
cribriform.
• Incomplete exposure of the sphenopalatine foramen
risks missing one of the vessels when there is
proximal branching with separate foramina.
• Aggressive removal of lateral septations in the
sphenoid sinus can injure the ICA.
• Monopolar electrocautery should not be used within
the sphenoid sinus because of the risk of injury to
the optic nerve or ICA.

section 2
Oral Cavity/Oropharynx
Chapter 21
Surgery for Obstructive Sleep Apnea
Jonas T. Johnson and Thomas W. Braun
PATIENT SELECTION
Uvulopalatopharyngoplasty (UPPP) has evolved as the
surgical technique of choice for the management of
limited obstructive sleep apnea (OSA) in selected
patients.1-4 Patients presenting with socially unaccept-
able snoring, a history of restless sleep (often indicative
of myoclonus), and daytime hypersomnolence should
be referred for overnight polysomnography (Fig.
21-1).
When OSA is diagnosed, most patients should
undertake a trial of continuous positive airway pressure
(CPAP) before considering surgical management.
Whereas CPAP effectively reduces or eliminates apnea
with its attendant desaturation in 75% to 80% of
patients, no more than 40% to 60% of the patients who
respond to CPAP will accept this therapy (Fig. 21-2).
Another nonoperative consideration for patients with
OSA is the use of an oral retaining device (ORD). A
wide variety of designs are available, the proponents of
which are often responsible for device design. Gener-
ally, these ORDs work either by holding the tongue
forward (with negative-pressure suction between device
and tongue) or through anterior displacement of the
mandible. Effi cacy of these devices is marginal when
compared with CPAP.5
Patients unwilling or unable to tolerate CPAP are
candidates for surgery. Unfortunately, UPPP alone is
not uniformly successful in correcting OSA.6-10 This may
refl ect the multifactorial causes of OSA. We estimate
that 50% of patients treated with UPPP have persistent
apneic episodes following surgery. Review of the litera-
ture that addresses outcomes following UPPP is con-
founded in that there is no standard format for the
reporting of results of surgical therapy for sleep apnea.
For instance, some surgeons report that some patients
are “improved.” Unfortunately, improvement does
not necessarily mean normal. Normal individuals have
fewer than fi ve apneic episodes per hour and each
episode lasts less than 10 seconds. Some patients are
encountered with an apneic index (AI) of greater than
100 episodes per hour. Reduction of the AI to less than
50 episodes per hour is a “great improvement.” It is,
nevertheless, not normal and the patient remains at risk
for the cardiovascular and other sequelae of persistent
OSA.
The population of individuals seeking treatment
for OSA is heterogeneous. At one end of the spectrum
are patients with morbid obesity, carbon dioxide reten-
tion, hypertension, and right-sided heart failure with an
AI of more than 100. At the other end of the spectrum
are those individuals with minimal sleep-disordered
breathing whose chief complaint is snoring. Evaluation
of treatment outcomes is further confounded because
many patients undergo more than one procedure and
some patients do not return for postoperative evalua-
tion in the sleep laboratory. This is understandable,
perhaps, because polysomnography is intrusive and
151

152
Section 2
Oral Cavity/Oropharynx
expensive; however, it has been clearly demonstrated
that reduction in snoring does not accurately indicate
a reduction of apneic episodes. Our experience has
been that approximately 85% of patients have a remark-
able reduction in snoring. This includes complete elim-
ination of snoring in approximately 50% of patients
and a vast improvement in another 35%. For some
reason, 10% to 15% of patients continue to snore.
In the cohort of patients who undergo postopera-
tive polysomnography, we have designated individuals
as either “responders” or “successes.”11 Those who
“respond” are defi ned as individuals with 50% reduc-
tion in the AI. Those labeled as “successes” have an AI
of less than fi ve per hour, reduction of respiratory dis-
turbance greater than 50%, and nadir desaturation
greater than 82%. Patients with a history of prior tonsil-
lectomy were less likely to benefi t from surgery. In
patients without previous tonsillectomy, 88% responded
compared with only 59% response in the group of 27
patients who had previous tonsillectomy. Isolated UPPP
was successful (as defi ned previously) in 52% of patients
without prior tonsillectomy, whereas success was
achieved in only 7% of patients after prior tonsillec-
tomy. It seems medically plausible to speculate that the
persisting tonsil contributes to the obstruction of the
airway at the level of the oropharynx, hence tonsillec-
tomy in these individuals results in a higher success
rate. Conversely, our experience has been that the
variety of maneuvers employed to assess the airway such
as fl exible endoscopy, the Mueller maneuver, and com-
puted tomography evaluation of the airway do not
signifi cantly improve the surgeon’s ability to predict
success. All forms of preoperative evaluation of airway
obstruction are imperfect and patients must, therefore,
be counseled about the possibility that surgery will fail
to completely control the symptoms and they may still
require CPAP.
It is critical that patients be counseled preopera-
tively that postoperative sleep study evaluation is neces-
sary because it is possible that the surgery may not fully
alleviate the problem. Accordingly, the procedure itself
should be considered a form of therapeutic empiricism.
There is general agreement among experts in sleep
physiology that patients tend to over-report the success
of their surgery, inasmuch as postoperative results
reported by patients do not correlate well with objective
fi ndings at polysomnography.
Concurrent nasal septoplasty is frequently under-
taken in patients undergoing UPPP. The decision to
perform septoplasty is based on the patient’s history of
nasal obstruction and the physical examination. Scat-
tered reports indicate that a nasal airway obstruction
may contribute to OSA. More importantly, however,
many patients with signifi cant OSA cannot tolerate
nasal CPAP (N-CPAP). If the nasal airway is improved,
N-CPAP may be better tolerated postoperatively if the
results of UPPP are inadequate and further interven-
tion for OSA is necessary.
Figure 21-1. Socially unacceptable snoring and daytime hypersom-
nolence are the cardinal symptoms of obstructive sleep apnea.
Figure 21-2. Some patients fi nd nasal continuous positive airway
pressure intrusive and uncomfortable.

Chapter 21
Surgery for Obstructive Sleep Apnea
153
PREOPERATIVE EVALUATION
Patients with retrognathia and other cranial facial
anomalies that result in relative reduction in the size of
the oropharyngeal airway may not be good UPPP can-
didates and should be considered for maxillomandibu-
lar reconstructive procedures. Reported results with
advancement genioplasty and maxillary-mandibular
advancement have been encouraging, especially in the
subgroup of patients with signifi cant retrognathia. The
fundamental principle is to advance the muscular
attachments of the tongue and suprahyoid soft tissue in
an anterior direction.
Before surgical therapy for OSA, the upper aerodi-
gestive tract should be carefully evaluated. The patient
with sleep apnea may demonstrate disproportion of
the oropharyngeal soft tissue (Fig. 21-3). The struc -
tures may be morphologically normal but out of
proportion.
Consideration should be given to the repair of
severe nasal septal deviation before or at the same time
as UPPP. Occasional patients may be encountered who
respond to correction of nasal airway obstruction alone.
Fairbanks has suggested that a physiologic estimate of
the effi cacy of nasal surgery may be obtained by the
patient using the “Afrin test.”11 A long-acting nasal
decongestant spray is used at bedtime. If snoring and
OSA are improved, nasal surgery alone may be
effective.
Under some circumstances, nasal septoplasty may
be undertaken concurrently with UPPP. Nasal septo-
plasty is frequently of benefi t to OSA patients undergo-
ing UPPP. Relief of nasal airway obstruction rarely goes
unnoticed. Inasmuch as UPPP fails to alleviate apnea in
a signifi cant number of patients, septoplasty may facili-
tate subsequent use of N-CPAP through relief of nasal
obstruction. N-CPAP is better tolerated at lower pres-
sures. Unfortunately, the relative effect on the OSA of
correcting the nasal airway is largely unquantitated
under these circumstances.
In our experience, physical examination, the use of
the Mueller maneuver, and various imaging techniques
are imperfect, but do help. The fl exible fi beroptic
laryngoscope is introduced through the nose and the
airway is evaluated. When the obstruction seems pri-
marily in the oropharynx (palate, uvula, and tonsils)
and there is a normal retrolingual airway, we believe
UPPP (with tonsillectomy if present) is indicated.
Patients demonstrating retrolingual collapse may
be predicted to have incomplete response to UPPP and
should be recommended for skeletal surgery. Observa-
tions are made at the level of the epiglottis, tongue base,
tonsils, and velum with successive inspirations. The
patient is also to inhale sharply and snore. The site of
collapse and snoring is often identifi ed. These observa-
tions may help predict the site of obstruction and the
relative effi cacy of intervention.12
As previously noted, patients with a history of prior
tonsillectomy are less suitable for UPPP.13 Nevertheless,
we have encountered occasional patients who benefi t
from UPPP despite prior tonsillectomy. Accordingly, we
continue to perform UPPP on patients with OSA with
a variety of oropharyngeal morphology. Overall, the
best candidates for UPPP are patients with a normal-
appearing tongue, an obstructive palate, normal occlu-
sion, and limited OSA.9
SURGICAL APPROACHES
UVULOPALATOPHARYNGOPLASTY
UPPP is performed with the patient under general
endotracheal anesthesia. The tonsils are removed bilat-
erally, with care being taken to preserve the mucosa
of the posterior tonsillar pillar and to avoid injury to
the mucosa of the posterior oropharynx. The anterior
tonsillar pillar is resected with the tonsil (Fig. 21-4);
however, excessive removal of the mucosa of the poste-
rior wall and posterior pillar may result in stenosis of
the nasopharynx. Adenoidectomy is never performed
in conjunction with UPPP because of the potential for
pharyngeal stenosis.
Resection of the anterior pillar is carried superiorly
to meet the intended horizontal incision line approxi-
Figure 21-3. Oropharyngeal disproportion is the most commonly
observed fi nding in patients with obstructive sleep apnea.
Figure 21-4. This specimen demonstrates the palatal mucosa
removed in continuity with the uvula during uvulopalatopharyngo-
plasty (UPPP). The tonsils are removed as well.

154
Section 2
Oral Cavity/Oropharynx
mately 8 to 10 mm anterior to the posterior edge of the
soft palate. A 90-degree angle between the vertical inci-
sion of the anterior pillar and the horizontal palatal
resection should be constructed. It should not be
“rounded” at the site of the resection, which affords a
wider entrance to the nasopharynx postoperatively (Fig.
21-5). The palatal incision is carried through into the
nasopharynx, and 1.5 cm of the free edge of the soft
palate with the uvula is resected (Fig. 21-6). Hemostasis
Figure 21-5. The incision along the anterior pillar meets the hori-
zontal incision through the palate at approximately a 90-degree
angle.
Figure 21-6. Following uvulopalatopharyngoplasty, the orophar-
ynx is widely patent.
Figure 21-7. The mucosa of the posterior tonsillar pillar is advanced
and sutured to the anterior pillar employing long-lasting absorbable
sutures.
is achieved with the use of electrocautery, following
which the mucosa of the posterior tonsillar pillar is
advanced and sutured anteriorly to close the tonsillar
fossa bilaterally (Fig. 21-7). Long-lasting absorbable
sutures such as Vicryl are recommended (Fig. 21-8).
Subsequently, the mucosa of the oropharyngeal side of
the palatal defect is closed by approximation with the
Figure 21-8. The free edge of the soft palate is closed on itself
employing long-lasting absorbable sutures.

Chapter 21
Surgery for Obstructive Sleep Apnea
155
mucosa of the nasopharyngeal side of the soft palate
(Fig. 21-9).
POSTOPERATIVE MANAGEMENT
All patients are monitored with an oximeter postopera-
tively. Patients who desaturate may require overnight
observation. Most patients can be discharged when fully
recovered from anesthesia and taking a liquid or soft
diet satisfactorily.
Management of oropharyngeal pain is complicated
by the fact that the administration of excessive amounts
of narcotics may compromise respiratory status. Liquid
acetaminophen and oxycodone combinations are rou-
tinely used (Fig. 21-10).
COMPLICATIONS
All patients experience postoperative pain and discom-
fort. Hemorrhage is relatively unusual (<5%) owing to
the techniques employed to close the mucosal incision
lines. Fifteen percent to 30% of patients experience
temporary velopharyngeal insuffi ciency with refl ux;
however, this is rarely a long-standing diffi culty. The
patient should be instructed to drink slowly. In some
circumstances, temporary avoidance of fl uids may be
necessary. Nasopharyngeal stenosis (Fig. 21-11), a seri-
ous and nearly insurmountable postoperative com-
plication, occurs in less than 2% of patients. Avoidance
of excessive removal of mucosa of the posterior tonsillar
pillar and posterior pharyngeal wall appears to be essen-
tial in preventing this complication. Repair of stenosis
requires mobilization of pharyngeal rotation fl aps,
Figure 21-9. The fi nal result is a wide opening into the
oropharynx.
Figure
21-10. Six
weeks
after
successful
uvulopalatopha -
ryngoplasty.
Figure 21-11. Nasopharyngeal stenosis, a dire complication of uvu-
lopalatopharyngoplasty. Prevention requires preservation of the
mucosa of the posterior pharyngeal wall.
which are used to break up the circular scar contrac-
ture. Unfortunately, however, a functional velopharyn-
geal valve is diffi cult or impossible to reestablish and
some degree of refl ux and hypernasal speech may
accompany a “successful” repair.
In a study of adults undergoing UPPP, mortality
and serious complications were calculated from the
Department of Veterans Affairs National Surgical
Quality Improvement Program. The serious nonfatal
complication rate was 1.5% (n = 3130) and the mortal-
ity rate (30 days) was 0.2%.14
The most troublesome side effect of UPPP is its
apparent lack of effi cacy in almost 50% of patients. A
number of studies have suggested that only 50% of
patients are cured as measured by follow-up polysom-
nography.7,13 Long-term follow-up suggests that recur-
rent snoring and apnea may occur in some patients.4,6
In the area of sleep-disordered breathing, weight gain
is often associated with recurrent symptoms. All patients
should be so advised. Patients who have signifi cant
apnea with desaturation following UPPP may require
further intervention. Mandibular advancement with or
without partial glossectomy may improve some of these

156
Section 2
Oral Cavity/Oropharynx
patients. Others require maxillomandibular advance-
ment or tracheotomy.
SKELETAL SURGERY FOR
TREATMENT OF OBSTRUCTIVE
SLEEP APNEA
Skeletal surgery is an accepted, and when properly
planned, successful mode of treatment for OSA when
less invasive modalities fail or are not tolerated. Skeletal
treatment ranges from window or trephine osteot-
omies of the genial tubercle of the mandible with or
without hyoid suspension to maxillary, mandibular, or,
most
commonly,
combined
maxillomandibular
advancements.
Overnight polysomnography with airway pressure
monitoring has shown that, in approximately 50% of
the cases, the upper airway collapses in the posterior
maxillary (retropalatal area) and velopharyngeal areas.15
Studies by Morrison and colleagues revealed that, while
retropalatal constriction occurred in 80% of their
patients, two or more sites of narrowing were observed
in more than 80% of those patients.16 Factors such as
morbid obesity, a hypoplastic maxilla, and retrognathia
create additional considerations for surgical reconstruc-
tion. Even though it is thought that site-specifi c surgery
would be desirable, the surgical, diagnostic, and man-
agement aspects have not been accurate enough to date
to support this. Skeletal surgery, therefore, is directed
to increasing airway diameter by anteriorly positioning
the skeletal attachment of the tongue, fl oor of mouth,
and lateral oropharyngeal tissues; by increasing the
transverse diameter of the maxilla and upper airway; or
by combining components of these.
In the mid to late 1980s, Riley and colleagues intro-
duced a two-phased protocol for surgically reconstruct-
ing the airway in patients with sleep apnea.17 Following
presurgical evaluation, patients were classifi ed by site of
obstruction according to Fujita type I (retropalatal),
type II (combined retropalatal and retroglossal), and
type III (retroglossal only). The phased approach to
surgery described phase I surgery for patients with type
I obstruction (velopharyngeal) and treated with UPPP.
Patients with type III obstruction (retroglossal) received
a genioglossus advancement procedure in an attempt
to alleviate retroglossal obstruction. This genioglossal
advancement was originally described with osteotomy
and advancement of the anterior osseous attachment of
the genial tubercles in the supramental area of the
mandible, whereas the hyoid bone was released from
the infrahyoid muscles and suspended anteriorly and
superiorly. Patients with Fujita type II obstruction (com-
bined site) received both UPPP and genioglossal
advancement surgery. Those patients who did not
respond adequately to phase I surgery were offered
maxillomandibular advancement surgery as a second
line treatment, hence “phase II.” The criteria for success
included a postoperative respiratory disturbance index
(RDI) of less than 20 with at least a 50% reduction of
episodes over the preoperative state and oxygen satura-
tions equivalent to those seen with CPAP. Notably, 24
of the 94 patients who received an outcome considered
unsuccessful underwent phase II surgery with a success
rate of approximately 97%.18 This, among other studies
and experiences, has led many surgeons to consider
phase II (maxillomandibular advancement surgery) a
fi rst line option in surgical management.
We have noted a success rate of approximately 50%
to 60% with phase I surgery performed as a modifi ca-
tion of that described by Reilly and Powell,17 Lee,19 and
others.20 The specifi c technique employed includes an
extraoral submental incision with osteotomy of the
anterior mandible including the genial tubercle portion
in the mortised fashion with or without UPPP (Fig.
21-12). This permits advancement of not only the
genioglossus muscles, but also the digastric muscles
and associated suprahyoid muscles of that area. When
advanced, the technique requires a near, if not total,
overlap of the osteotomy segments. Through an exter-
nal incision, transosseous screws can be placed, mini-
mizing excessive placement of hardware. Because the
osteotomy is created below the level of the mental
nerves, there is no permanent sensory defi cit. Earlier
attempts at this procedure resulted in a substantially
narrow isthmus of alveolar bone in the anterior man-
dible that was prone to fracture. Subsequent proce-
dures now include placement of a prophylactic rigid
fi xation plate in this region (Fig. 21-13). Simultaneous
with the advancement, dissection along the anterior
Figure 21-12. Illustration of mandibular advancement with rigid
fi xation and hyoid suspension.

Chapter 21
Surgery for Obstructive Sleep Apnea
157
belly of the digastric to the level of the hyoid bone
permits placement of a circumhyoid Mersilene tape,
which is secured to the unosteotomized portion of the
mandible by feeding the ends in the space between
digastric and genioglossus muscles and tying it anteri-
orly (Fig. 21-14). This method of superior attachment
of the hyoid permits a controlled suspension and has
not required infrahyoid myotomy. When combined
with UPPP, this procedure has proven to be one of
benefi t for that select group of patients. The submental
incision, when appropriately placed in a line of tension
and properly managed, heals with minimal scarring.
Multiple variations of this procedure exist, including
intraoral access through a vestibular incision, a “keyhole
osteotomy” to include only the genial tubercles for
genioglossal advancement, and variations on the
hyoid myotomy and suspension either superiorly or
inferiorly.
Maxillomandibular advancement is a procedure
designed to address the needs of patients with obstruc-
tion of virtually all nasal and perioral sites. The surgery
has long been performed for orthognathic reconstruc-
tion of the maxilla and mandible and for occlusion.
Kuo and colleagues21 and subsequently Bear and Priest22
were early to describe the effects of orthognathic surgery
and mandibular osteotomies in patients with sleep
apnea. Waite and colleagues described a high level of
success using maxillomandibular advancement in con-
junction with a geniotomy.23 The technique is one of a
standard intraoral maxillary Le Fort I level osteotomy
with advancement and simultaneous sagittal osteotomy
Figure 21-13. Rigid fi xation of mandibular osteotomy.
and advancement of the mandible (Fig. 21-15). The
advent of rigid fi xation and fi beroptic lighting has
improved access and stability. However, there is a subset
of patients who undergo this procedure and require
modifi cation of those typical osteotomies based on a
higher propensity for development of a postoperative
anterior dental open bite when having undergone prior
UPPP. This requires a planned differential maxillary
impaction to create a posterior maxillary open bite to
compensate accordingly. Furthermore, occlusal dis-
crepancies occasionally become unmasked and require
compensatory management in the form of orthodon-
tics, prosthetics, or occlusal equilibration because most
Figure 21-14. Osteotomy and advancement of anterior mandible
with suspension of the hyoid to the mandible.
Figure 21-15. Le Fort I osteotomy and bilateral sagittal osteotomy
of the mandible with advancement.

158
Section 2
Oral Cavity/Oropharynx
of these patients have not undergone preoperative
orthodontics (based on the acuity of the disease and
nature of procedure) and are past their second or third
decade of life (Figs. 21-16 and 21-17).
Standard Le Fort osteotomy and mandibular oste-
otomies with advancement create an increased sagittal
dimension. They provide lesser benefi t in individuals
who have transverse defi ciencies. This subset of patients
benefi ts from horizontal expansion when possible,
especially of the maxilla. Enhancement of the nasal
valve through osteoplasty of the anterior maxilla, septal
repositioning and reconstruction, and subsequent soft
tissue nasal reconstruction may provide benefi t to some
patients.
POSTOPERATIVE MANAGEMENT
Operating times are generally 4 hours or less using
hypotensive anesthesia with no need for blood replace-
ment. Rigid osseous fi xation eliminates the need for
maxillomandibular fi xation. Patients can resume oral
intake within 12 hours and can begin chewing soft
foods in 48 to 72 hours. Narcotic and non-narcotic
analgesics are provided, but pain is rarely considered
severe. Perioperative and postoperative antibiotics and
steroids are used routinely. Hospital stays are deter-
mined largely by the patient’s edema, postoperative O2
saturation as determined by oximetry, and postopera-
tive responsiveness. Patients are usually discharged in
24 to 48 hours.
COMPLICATIONS
Most patients experience facial edema and some level
of maxillary or mandibular nerve paresthesia, which
generally resolves in 2 to 8 weeks.
Hematoma is rarely encountered. The potential for
mandibular fracture is reduced with application of a
rigid fi xation plate at the initial surgery.
TRACHEOTOMY
A tracheotomy is the most reliable treatment for severe
OSA. Tracheotomy results in immediate resolution of
obstruction in properly diagnosed patients. Unfortu-
nately, a tracheotomy does not solve primary hypoven-
tilation or central sleep-related disorders. Accordingly,
careful consultation with the diagnostic sleep labora-
tory is essential for patient selection.
Tracheotomy for OSA is modifi ed from the stan-
dard procedure ordinarily performed in the operating
room under general anesthesia. The tracheal stoma is
matured at the time of the original surgery by approxi-
mating skin and mucosa. A multitude of techniques
have been reported to afford this skin to mucosa closure
at the time of the tracheotomy. This almost always
requires rotation of skin fl aps with removal of excessive
subcutaneous tissue (fat).
POSTOPERATIVE MANAGEMENT
All patients requiring a tracheotomy for OSA are admit-
ted to the hospital. Patients are monitored with an
oximeter. Those individuals with severe OSA (RDI > 70
events per hour) should undergo postoperative moni-
toring of respiratory status in an appropriate unit. Occa-
sionally a patient may develop postobstructive acute
respiratory distress syndrome when the chronic airway
obstruction is suddenly relieved by tracheotomy. Treat-
ment is positive pressure (CPAP), which requires a
cuffed tracheotomy tube.
On the second and third postoperative day, an
uncuffed tracheotomy tube is inserted and an oral diet
is reintroduced. Patients are taught to care for their
tracheotomy tube. Patients who have successfully com-
Figure
21-16. Preoperative
radiograph
of
airway
space
constriction.
Figure 21-17. Postoperative radiograph of maxillomandibular
osteotomies and airway space enhancement.

Chapter 21
Surgery for Obstructive Sleep Apnea
159
pleted the educational component of their postopera-
tive care can be discharged to home.
COMPLICATION
Post-tracheotomy hemorrhage is exceedingly unusual.
Accidental displacement of the tracheotomy tube is not
life-threatening in patients in whom skin has been
sutured to mucosa, because reintroduction of the tra-
cheotomy tube is relatively easy.
Most patients requiring tracheotomy for OSA suffer
from morbid obesity. Many of the tracheotomy tubes
currently available are too short, although aggressive
resection of subcutaneous fat reduces the required
length somewhat. The surgeon must be prepared pre-
operatively with a selection of tubes appropriate to the
individual patient. Most manufacturers customize tube
length, but preoperative planning is required. Addi-
tionally, an inner cannula may not be available in extra
long tubes. Nursing care is accordingly more diffi cult.
References
1. Simmons FB, Guilleminault C, Dement WC, et al: Surgical man-
agement of airway obstruction during sleep. Laryngoscope
87:326-338, 1977.
2. Fujita AS, Conway W, Zorick F, et al: Surgical correction of ana-
tomic abnormalities in obstructive sleep apnea syndrome: Uvulo-
palatopharyngoplasty. Otolaryngol Head Neck Surg 89:923-934,
1981.
3. Dickson RI, Blokmanis A: Treatment of obstructive sleep apnea
by
uvulopalatopharyngoplasty.
Laryngoscope
97:1054-1059,
1987.
4. Hassid S, Afrapoli AH, Decaestecker C, Choufani G: UPPP for
snoring: Long-term results and patient satisfaction. Acta Oto
Rhino Laryngol Belg 56(2):157-62, 2002.
5. Hoekema A, Stegenga B, De Bont LG: Effi cacy and co-morbidity
of oral appliances in the treatment of obstructive sleep apnea-
hypopnea: A systematic review. Crit Rev Oral Biol Med
15(3):137-155.
6. Hicklin LA, Tostevin P, Dasan S: Retrospective survey of long-
term results and patient satisfaction with uvulopalatopharyngo-
plasty for snoring. J Laryngol Otol 114(9):675-681, 2000.
7. Macaluso RA, Reams C, Gibson WS, et al: Uvulopalatopharyngo-
plasty: Postoperative management and evaluation of results. Ann
Otol Rhinol Laryngol 88:502-507, 1989.
8. Fujita S, Conway WA, Zorick FJ, et al: Evaluation of the effective-
ness of uvulopalatopharyngoplasty. Laryngoscope 95:70-74,
1985.
9. Katsantonis GP, Walsh JK, Schweitzer PK, Friedman WH: Further
evaluation of uvulopalatopharyngoplasty in the treatment of
obstructive sleep apnea syndrome. Otolaryngol Head Neck Surg
93:244-249, 1985.
10. DeBerry-Borowiecki B, Kukwa AA, Blanks RHI: Indications for
palatopharyngoplasty. Arch Otolaryngol 111:659-663, 1985.
11. Fairbanks DNF: Effect of nasal surgery on snoring. South Med J
78:268-270, 1985.
12. Millman RP, Carlisle CC, Rosenberg C, et al: Simple predictors
of uvulopalatopharyngoplasty outcome in the treatment of
obstructive sleep apnea. Chest 118(4):1025-1030, 2000.
13. McGuirt WF, Johnson JT, Sanders MH: Previous tonsillectomy as
prognostic indicator for success of uvulopalatopharyngoplasty.
Laryngoscope 105:1253-1255, 1995.
14. Kezirian EJ, Weaver EM, Yueh B, et al: Incidence of serious
complications after uvulopalatopharyngoplasty. Laryngoscope
114(3):450-453, 2004.
15. Shephard JW, Thawley SE: Localization of upper airway collapse
during sleep in patients with obstructive sleep apnea. Am Rev
Respir Dis 141:1350-1355, 1990.
16. Morrison DL, Launois SH, Isono S, et al: Pharyngeal narrowing
and closing pressures in patients with obstructive sleep apnea.
Am Rev Respir Dis 148:606-611, 1993.
17. Riley RW, Powell NB, Guilleminault C: Inferior sagittal osteotomy
of the mandible with hyoid myotomy-suspension: A new proce-
dure for obstructive sleep apnea. Otolaryngol Head Neck Surg
94:589-593, 1986.
18. Riley RW, Powell NB, Guilleminault C: Obstructive sleep apnea
syndrome: A review of 306 consecutively treated surgical patients.
Otolaryngol Head Neck Surg 108:117-125, 1993.
19. Lee NR: Genioglossus muscle advancement techniques for
obstructive sleep apnea. Oral Maxillofacial Surg Clin N Am
14:377-384, 2002.
20. Johns FR, Sandler NA, Braun TW: Management of obstructive
sleep apnea. Selected Readings in Oral and Maxillofacial Surgery
5:34-36, 1997.
21. Kuo PC, West RA, Bloomquist DS, et al: The effect of mandibular
osteotomy in three patients with hypersomnia sleep apnea. Oral
Surg Oral Med Oral Pathol 48:385, 1979.
22. Bear SE, Priest JH: Sleep apnea syndrome: Correction with surgi-
cal advancement of the mandible. J Oral Surg 38:543, 1980.
23. Waite PD, Wooten V, Lachner J, et al: Maxillomandibular
advancement surgery in 23 patients with obstructive sleep apnea
syndrome. J Oral Maxillofac Surg 47:1256-1261, 1989.
PEARLS
• Preoperative assessment is needed to identify the
site and the severity of obstruction.
• Positive pressure with CPAP or one of the alternative
systems remains the gold standard for therapy.
• Lateral advancement of the posterior tonsillar pillars
is essential during UPPP.
• Patients who maintain adequate oxygen saturations
may be discharged to home after surgery.
• Most patients with snoring (75%-85%) are cured
with palate surgery.
• Patients who fail UPPP may be aided with skeletal
advancement surgery.
• Tracheotomy may be the best alternative for severe
OSA with cardiopulmonary comorbidity.
PITFALLS
• Palate surgery, such as UPPP, may fail to adequately
control OSA in 50% of unselected patients.
• Nasopharyngeal stenosis results from excessive
mucosa resection on the posterior wall and posterior
tonsillar pillars or concurrent adenoidectomy.
• Maxillomandibular advancement may be associated
with temporary or permanent numbness of the lips
due to injury of the inferior alveolar or mental nerve.
• Obese patients present a number of anesthetic
challenges.
• Standard tracheotomy tubes often will not fi t
morbidly obese patients.
• Failure to establish hemostasis may further
compromise the airway in the patient with OSA.

Chapter 22
Tongue Reduction Procedures
Eugene N. Myers
Macroglossia was fi rst described by Galen in the second
century.1 Other cases were recorded during the 16th
and 17th centuries. Surgical treatment of macroglossia
was fi rst reported in 1658.2 Macroglossia may be classi-
fi ed as true macroglossia when the tongue is enlarged
or as relative macroglossia when there is insuffi cient
space in the oral cavity. Tongue reduction is an uncom-
mon procedure that may be required in such patients
for functional or aesthetic reasons. Ring2 presented a
fascinating overview of the treatment of macroglossia
before the 20th century that should be read by all sur-
geons interested in the management of patients with
this condition.
The most common conditions giving rise to macro-
glossia are lymphangioma, neurofi broma, amyloido -
sis, hemangioma, Beckwith-Wiedemann syndrome,
mucopolysaccharidosis,
hypothyroidism,
cretinism,
rhabdomyosarcoma, gigantism, acromegaly, muscular
dystrophy, Down syndrome, lipoid protein triploid syn-
drome, and idiopathic muscular hypertrophy.3 Neuro-
fi broma, in a localized manner, may give rise to
problems with articulation and may promote malocclu-
sion. The tongue may be the only site of neurofi broma
or may be part of neurofi bromatosis. Lymphangioma-
tous macroglossia may interfere with articulation and
deglutition. These lymphatic malformations increase in
size with upper respiratory tract infections, and the
enlarged tongue may cause partial airway obstruction.4
Patients with hemangioma or a mixture of hemangio-
matous and lymphangiomatous macroglossia may also
have problems with intermittent bleeding.
PATIENT SELECTION
Patients with symptoms of diffi culty articulating or swal-
lowing, malocclusion, and bleeding and those in whom
physical examination confi rms the presence of general-
ized or localized enlargement of the tongue or heman-
gioma should be considered for this procedure. These
patients may have extreme macroglossia that precludes
closing of the mouth. If biopsy reveals amyloidosis and
its associated signs and symptoms, the diagnosis should
be systemic amyloid. An exuberant form of amyloidosis
has been reported by Moura and coauthors (Fig.
22-1).5
The decision to treat macroglossia surgically should
be based on the presence and degree of three types of
problems: functional defi cits, such as deglutition, drool-
ing, phonation diffi culty, and airway obstruction; dental-
skeletal alterations from excessive action of the tongue
on surrounding structures, such as an increase in the
gonial angle and the anterior facial height with the
development of an anterior open-bite and excessive
vestibularization of the inferior incisors; and psycho-
logical consequences of the physical appearance of the
patient that give the false impression of mental defi -
ciency, such as lingual protrusion, dyslalia, and drool-
ing. In cases in which uniform tongue reduction is not
necessary, such as in patients with cystic neoplasms, we
perform partial glossectomy with the aim of resecting
the entire mass. In every case surgical treatment must
preserve the vital functions of taste, sensitivity, and
mobility.4
Beckwith-Wiedemann syndrome consists of macro-
glossia, exomphalos, somatic gigantism, neonatal hypo-
glycemia, organomegaly, hemihypertrophy, and risk of
tumor development.6 Macroglossia is due to hyperplasia
of the muscle fi bers of the tongue. It may be symmetri-
cal, or hemihypertrophy may be present. Of the many
consequences of macroglossia, the most important is
obstruction of the upper airway at rest or during feeding.
It may also interfere with normal articulation and
feeding. A major consequence of macroglossia is pro-
trusion of dentoalveolar structures resulting in an ante-
rior open bite and the appearance of a prognathic
mandible. Laroche and associates7 described two
patients with Beckwith-Wiedemann syndrome associ-
ated with a cleft palate. Treatment is complex, but the
161

162
Section 2
Oral Cavity/Oropharynx
authors prefer to not repair the cleft palate before per-
forming tongue reduction procedures. This sequence
would enable the patient to heal more effi ciently.
PREOPERATIVE PLANNING
A history and physical examination are of vital impor-
tance in evaluating patients for tongue reduction pro-
cedures. In most of these patients the history will reveal
a lifelong presence of localized or generalized enlarge-
ment of the tongue. Patients with neurofi broma should
undergo a complete physical examination because in
some of these patients, neurofi broma involving the
tongue may be a localized manifestation of neurofi bro-
matosis (von Recklinghausen’s disease). The presence
of café au lait spots is pathognomonic of this condition
(Fig. 22-2). A large epidermal cyst of the tongue will
produce the same symptoms as a localized form of mac-
roglossia (Fig. 22-3).
Patients with lymphangiomatous macroglossia will
not only have a history of lifelong diffi culty with enlarge-
ment of the tongue (Fig. 22-4A) but may also have
marked enlargement and ulceration of the tongue as a
result of upper respiratory tract infection or minor
trauma (see Fig. 22-4B). These patients respond to anti-
biotic therapy. In young children, the mandibular
incisor and canine teeth may fail to erupt from pressure
of the enlarged tongue. After tongue reduction proce-
dures these teeth will erupt (see Fig. 22-4D). Patients
with lymphangiomatous macroglossia often have
involvement of the fl oor of the mouth and submental
space (see Fig. 22-4C), and unless these areas are
included in the tongue reduction procedure, the
outcome will be less than satisfactory.
Macroglossia is also thought to be an etiologic
factor in open bite. Bimaxillary protrusion and special
dental arches may cause instability after orthognathic
Figure 22-1. Patient suffering from exuberant macroglossia.
(Reprinted with permission from Moura CG, Moura TGG, Duräes AR, Souza
SP: Exuberant macroglossia in a patient with primary systemic amyloidosis.
Clin Exp Rheumatol 23:428, 2005.)
B
C
A
Figure 22-2. A, Neurofi broma of the tongue. B, Malocclusion
caused by an enlarged tongue. C, Café au lait spots confi rm the
diagnosis of von Recklinghausen’s disease.
treatment.8 Patients with hemangioma may have a
history of not only enlargement of the tongue but also
bleeding from the tongue. Physical examination will
reveal localized or generalized areas of obvious heman-
gioma (Fig. 22-5A). Patients who have the previously
mentioned symptoms and are troubled by bleeding,
swelling, or interference with eruption of dentition or
occlusion should be considered appropriate candidates
for these procedures.
Physical examination should include a thorough
inspection of the tongue, fl oor of the mouth, and sub-

Chapter 22
Tongue Reduction Procedures
163
mental space, as well as bimanual palpation of these
structures. Palpation will give the examiner an idea of
the extent of these lesions, particularly in the case of
more localized lesions. Computed tomography or mag-
netic resonance imaging may provide an estimate of the
size and location, particularly of smaller tumors, which
is helpful in planning.
SURGICAL TECHNIQUE
Wang and colleagues6 presented an interesting array of
surgical procedures but prefer the keyhole procedure.
Kacker and associates9 described a wide variety of tongue
reduction procedures, some of which they used in their
series of six cases of macroglossia. These authors also
prefer the anterior keyhole procedure, which was able
to uniformly reduce the tongue and provide good func-
tion and mobility (Fig. 22-6A to D).
Symmetrical macroglossia can be corrected with a
variety of techniques well illustrated in a paper by Daval-
bhakta and Lamberty (Fig. 22-7).8 With the excision
kept in a medial location, the hypoglossal nerves are
preserved anteriorly and the vascular supply more pos-
teriorly. A new tongue tip is created by approximation
of the sides of the wedge. This technique not only
narrows but also shortens the tongue. Approximation
Figure 22-3. Patient with a lifelong history of diffi culty articulating
because of a large epidermal cyst of the tongue.
B
D
B
A
C
Figure 22-4. Lymphangiomatous macroglossia. A, Usual appearance. B, Appearance during an upper respiratory tract infection. C, Involve-
ment of the submental space with lymphangioma. D, Appearance after a tongue reduction procedure, including the submental space. The
incisor teeth erupted after the decrease in size of the tongue.

164
Section 2
Oral Cavity/Oropharynx
B
A
C
A
B
D
Figure 22-5. A, Hemangioma of the tongue that was unresponsive to repeated partial surgery, sclerosing agents, and radiation therapy.
B, Appearance after a tongue reduction procedure (note the anterior displacement of the central and lateral incisions).
Figure 22-6. A and B, Intraoperative pictures showing a keyhole tongue reduction. C, Postoperative picture showing the reconstructed tongue.
D, Postoperative patient at 3-year follow-up with good tongue reduction and an intraoral tongue. (Reprinted with permission from Kacker A, Honrado
C, Martin D, Ward R: Tongue reduction in Beckwith-Weidemann syndrome. Int J Pediatr Otorhinolaryngol 53:1-7, 2000.)

Chapter 22
Tongue Reduction Procedures
165
Kole
Edgerton
Gupta
Dingman & Grabb
Mixter et al
Morgan et al
Egyedi & Obwegeser
Harada & Enomoto
Figure 22-7. Various techniques of tongue reduction. (Reprinted
with permission from Davalbhakta A, Lamberty BGH: Technique for uniform
reduction of macroglossia. Br J Plast Surg 53:294-297, 294-297, 2000.)
A
B
Figure 22-8. A and B, Partial exci-
sion of the tongue.
should be performed in layers with absorbable suture
to close the dead space.
Tongue reduction procedures, particularly in
patients with involvement of the entire tongue, have the
potential for airway obstruction. Therefore, a prelimi-
nary tracheotomy should be performed because the
large size of the tumor may also preclude the possibility
of easy endotracheal intubation. Antibiotics are admin-
istered perioperatively. Some surgeons routinely admin-
ister perioperative steroids to reduce the immediate
postoperative edema that commonly accompanies
tongue surgery.
Patients with localized neurofi broma may be
approached in a way similar to that described for partial
glossectomy. A Jennings mouth gag is inserted, and a
suture is placed approximately 1 cm posterior to the tip
of the tongue in the exact midline. Using right-angled
retractors to retract the buccal mucosa, the lesion in
question is identifi ed. The tongue is dried with gauze,
and based on physical examination and imaging (if
used), marks are made that describe an ellipse on the
tongue overlying the lesion. An ellipse of mucosa and
the underlying lesion are excised to facilitate closure
(Fig. 22-8).
Patients with lymphangiomatous macroglossia that
involves the submental space and fl oor of the mouth
must be approached extraorally through the neck, as
well as intraorally. An incision is made in a skin crease
just below the submental space (Fig. 22-9A). Skin fl aps
are elevated, and the anterior belly of the digastric
muscle is identifi ed (see Fig. 22-9B). An incision is
made in the fascia between the two anterior bellies. The
mylohyoid muscle is often very thin because of stretch-
ing by the lymphangioma and may be diffi cult to see.
Before any resection in this area, the lingual arteries
and hypoglossal nerves are identifi ed and dissected up

166
Section 2
Oral Cavity/Oropharynx
A
B
C
Figure 22-9. A, Incision made in the submental space. B, Retraction of the
anterior bellies of the digastric muscle. C, The lingual arteries and hypoglossal
nerves are identifi ed and retracted, the mylohyoid muscles are transected, and
the submental space is entered.
into their entrance in the anterior portion of the tongue
(Fig. 22-9C). A small Penrose drain or vessel loop is
placed around each hypoglossal nerve to protect it from
injury and retract them out of the way of the incision.
The mylohyoid muscles are transected to gain entry
into the fl oor of the mouth (Fig. 22-9C). The area of
lymphangioma is identifi ed and excised as completely
as possible. These tumors are usually infi ltrative and not
encapsulated, which makes it very diffi cult to know pre-
cisely when to stop. In such cases the excision is
“sculpted” rather than attempting complete excision.
Hemostasis is obtained, and the wound is irrigated and
closed in layers over a Hemovac drain.
Jian10 reported a series of seven patients with lymph-
angioma or hemangioma of the tongue from 1992 to
2002 who were treated by a technique designed to sig-
nifi cantly reduce the entire volume of the tongue.
Endotracheal intubation was used in these cases to
protect the airway. Cosmesis and function were improved
after surgery, and none of the patients had a
recurrence.
POSTOPERATIVE MANAGEMENT
The perioperative antibiotics are continued for one
week. Steroids, if used, are generally discontinued in 24
hours. Local irrigation with half-strength hydrogen per-
oxide is used to mechanically débride the suture lines
and promote good healing. If a tracheostomy has been
performed, the patient is decannulated as soon as the
potential for airway obstruction has passed. Aspiration
will usually be reduced or eliminated by plugging the
tracheostomy tube or by decannulation. Patients should
be fed by nasogastric tube during this time. Those who
have undergone localized excision may be fed intrave-
nously for several days, with oral feeding begun once
the pain in the tongue has decreased to the point at
which swallowing may be resumed. Involvement of a
speech and swallowing therapist may be helpful in
assessing the patient’s readiness to eat.
COMPLICATIONS
Complications include edema, airway obstruction,
paralysis, anesthesia, and devascularization of the
tongue. Edema and airway obstruction may be pre-
vented by adequate hemostasis in the deep musculature
of the tongue. Even though airway obstruction may be
prevented in this manner, it may be wiser to perform a
preliminary tracheostomy in patients who will undergo
major tongue reduction procedures, particularly those
with hemangiomas. The use of perioperative steroids
and antibiotics is helpful in reducing or preventing
postoperative edema.
One of the potential pitfalls of this procedure is
injury to the neurovascular bundle, which may produce
either partial or complete paralysis of one or both hypo-
glossal nerves. Although function is only minimally

Chapter 22
Tongue Reduction Procedures
167
impaired by interruption of one hypoglossal nerve, total
paralysis caused by interruption of both hypoglossal
nerves is devastating and will result in the patient
becoming an “oral cripple.” If the hypoglossal nerve is
inadvertently cut, neurorrhaphy with 8-0 or 9-0 nylon
should be performed by microscopic technique.
Similarly, interruption of a lingual nerve will result
in unilateral anesthesia of the oral tongue. Nerve
injury should be repaired via neurorrhaphy. Devascu-
larization of the tongue with resultant necrosis and loss
of tongue substance may occur if both lingual arteries
are lost.
Although tongue vascularity can be maintained
with one artery, loss of both arteries is incompatible
with survival of viable tongue. This complication can be
prevented by preliminary identifi cation of the arteries
and avoidance of bilateral posterolateral tongue
resection.
References
1. Harris T: Chronic intumescence of the tongue. Am J Med Sci
7:17-22, 1830.
2. Ring ME: The treatment of macroglossia before the 20th century.
Am J Otolaryngol 20:28-36, 1999.
3. Dinerman WS, Myers EN: Lymphangiomatous macroglossia.
Laryngoscope 86:291-296, 1976.
4. Gasparini G, Saltarel A, Carboni A, et al: Surgical management
of macroglossia: Discussion of 7 cases. Oral Surg Oral Med Oral
Pathol Oral Radiol Endod 94:566-571, 2002.
5. Moura CG, Moura TGG, Duräes AR, Souza SP: Exuberant mac-
roglossia in a patient with primary systemic amyloidosis. Clin Exp
Rheumatol 23:428, 2005.
6. Wang J, Goodger NM, Pogrel MA: The role of tongue reduction.
Oral Surg Med Oral Pathol Oral Radiol Endod 95:269-273,
2003.
7. Laroche C, Testelin S, Devauchelle B: Cleft palate and Beckwith-
Wiedemann syndrome. Cleft Palate Craniofac J 42:212-217,
2005.
8. Davalbhakta A, Lamberty BGH: Technique for uniform reduc-
tion of macroglossia. Br J Plast Surg 53:294-297, 294-297, 2000.
9. Kacker A, Honrado C, Martin D, Ward R: Tongue reduction in
Beckwith-Weidemann syndrome. Int J Pediatr Otorhinolaryngol
53:1-7, 2000.
10. Jian XC: Surgical management of lymphangiomatous or lymphan-
giohemangiomatous macroglossia. J Oral Maxillofac Surg 63:15-
19, 2005.
PEARLS
• Macroglossia may be a local disorder or a local
manifestation of a systemic disease.
• Many techniques have been described for tongue
reduction, all of which require careful patient
selection and meticulous surgical technique.
• Edema and postoperative bleeding are usually
preventable with meticulous hemostasis in the deep
musculature of the tongue.
• Preservation of important anatomic structures, such
as the lingual arteries and hypoglossal nerves, will
ensure maintenance of the viability and function of
the tongue.
• Speech and swallowing therapists, as well as
psychologists, are valuable team members in the
more exuberant form of macroglossia (see Fig.
22-1).5
PITFALLS
• Systemic disease, such as primary amyloidosis,
should not be overlooked as a cause of
macroglossia.
• Failure to identify and preserve the hypoglossal
nerves will result in paralysis of the tongue with the
patient becoming an oral cripple.
• Loss of both lingual arteries will result in necrosis
of the tongue.
• Potential airway obstruction should be anticipated
by performing a tracheostomy in cases in which
large amounts of tongue may be removed.
• The possibility of cleft palate in association with
macroglossia (Beckwith-Wiedemann syndrome)
should not be overlooked.

Chapter 23
Tonsillectomy
Suman Golla
Tonsillectomy is one of the very few surgical procedures
that originated in ancient times and is still performed
today. In the 1940s the incidence of tonsillectomy
in the United States peaked at 2 million, most likely
because it was performed not only for recurrent tonsil-
litis but also for a wide range of conditions, including
poor feeding, failure to gain weight, overbite, “tongue
thrust,” and enuresis. In the 1960s and 1970s there
continued to be a trend to perform tonsillectomy, with
1 to 2 million tonsillectomies and adenoidectomies
being performed annually in the United States.1 Tonsil-
lectomy is still one of the most commonly performed
procedures today, with approximately 400,000 proce-
dures performed annually.2 The decrease in the number
of operations is thought to be related to clinical trials
that
resulted
in
well-defi ned
indications
for
tonsillectomy.3
Waldeyer’s ring consists of the adenoids, lateral
pharyngeal bands, palatine tonsils, and lingual tonsils.
Although any or all of these condensations of lymphoid
tissue can become hypertrophic and be susceptible to
chronic infection, it is the palatine tonsils to which the
term tonsils is applied. Because of the frequent coexis-
tence of nasopharyngeal lymphoid hyperplasia (adenoid
hypertrophy) and tonsillar hypertrophy, the adenoids
are often removed at the time of tonsillectomy, particu-
larly in prepubertal children.
The palatine tonsils are invaginated on the medial
surface by crypts lined with squamous mucosa (Fig.
23-1). These crypts number from 6 to 20 and vary in
depth and diameter. Epithelial debris collecting in
these crypts and mixed with bacteria from the oral
cavity cause chronic infection when the crypts become
obstructed. These conditions predispose to the forma-
tion of tonsilloliths, which are often malodorous. The
surrounding lymphoid tissue may hypertrophy in
response to this infection and result in increased
obstruction and persistence of infl ammation. Purulent
exudate may appear on the surface of the tonsils as it
drains from the infected crypts (Fig. 23-2).
Although classic tonsillitis is due to group A β-
hemolytic streptococci, tonsillitis can also be caused by
various other agents such as coxsackievirus and Epstein-
Barr virus (mononucleosis). Pillsbury and colleagues,
using quantitative techniques, demonstrated that the
number of bacteria found in the crypts of chronically
infected tonsils exceeds by several hundred–fold the
number of bacteria in the same quantity of uninfected
tonsils. Their fi ndings suggest that it is the state of
chronic tissue sepsis rather than any specifi c organism
that results in chronic tonsillitis.4
The tonsil is lined with a capsule on its deep surface
and is separated by loose areolar tissue from the under-
lying superior constrictor muscle. Peritonsillar abscess,
a condition thought to develop secondary to acute ton-
sillitis, is a collection of purulent exudate in this space.
The walls of the abscess are made up of the tonsil
capsule and the superior constrictor muscle. Penetra-
tion of the superior constrictor muscle by this abscess
results in infection and, in some cases, abscess forma-
tion in the parapharyngeal space. The resultant anaero-
bic infection in the deep neck spaces can progress
rapidly secondary to necrosis of surrounding tissue and
can occasionally result in fatal vascular complications.
The blood supply to the palatine tonsils includes
the ascending pharyngeal and ascending palatine arter-
ies, which lie deep to the tonsillar fossa. Other vessels
include the anterior tonsillar branches of the dorsal
lingual artery, the inferior tonsillar branches of the
facial artery, and the superior tonsillar branch of the
descending palatine artery. Venous drainage occurs
through the pericapsular plexus of veins into the lingual
169

170
Section 2
Oral Cavity/Oropharynx
pharyngeal veins and then into the internal jugular.
The internal carotid artery is located approximately
2.5 cm posterolateral to the tonsils. Efferent lymphatics
pass to the superior deep jugular nodes. Alternative
lymphatic pathways exit to the submandibular and
superfi cial cervical lymph nodes. The efferent lymphat-
ics that are located in the previously described areas are
often the enlarged nodes that are seen clinically in
patients with tonsillitis.
The tonsils are located in a fossa between folds of
palatal musculature known as the anterior and poste-
rior tonsillar pillars. These pillars are the palatoglossus
and palatopharyngeal muscles, respectively. Preserva-
tion of these muscular regions and the overlying mucosa
is critical to maintaining physiologic function of the
palate postoperatively.
Tonsillitis and related problems are estimated to
account for health care expenditures approaching half
a billion dollars per year. There has been a decrease in
the number of tonsillectomies performed over the past
several years that is thought to be related to the use of
antibiotics and to adherence to defi ned indications for
tonsillectomy. In addition, economic issues that have
led to occasional restrictions on reimbursement for the
procedure have further decreased the number of ton-
sillectomies performed. Frequently, third-party payers
require that certain specifi c indications be present
before authorizing these procedures.
Attempts to perform outcome studies and develop
rigid, formal indications for tonsillectomy have been
diffi cult as a result of subjective aspects attributed
to this procedure. Nevertheless, in Paradise’s classic
outcome study from the University of Pittsburgh pub-
lished in 1984, some estimation of the value of the
procedure can be appraised.3 With the use of rigid entry
criteria, 187 children were enrolled to determine the
effi cacy of the tonsillectomy procedure. Approximately
half the children were randomized to either surgical
management or observation; the other half were not
randomized, but the course of therapy was chosen by
the parents. A total of 95 children underwent tonsillec-
tomy. For the fi rst 2 years, a signifi cant decrease in the
number of throat infections occurred in the surgical
group, although some children in the group under
observation had very few infections. The author recog-
nized the diffi culty in predicting the likelihood of future
infections and suggested that therapy should be indi-
vidualized and not based on infl exible regulations. Nev-
ertheless, these guidelines have been incorporated into
the offi cial recommendation of the American Academy
of Otolaryngology–Head and Neck Surgery (AAO-HNS)
(Table 23-1).5
In a recent study on indications for tonsillectomy
and adenoidectomy, an evidence-based medicine
approach was used. Absolute indications for tonsillec-
tomy included adenotonsillar hyperplasia with obstruc-
tive sleep apnea, failure to thrive, abnormal dental and
facial growth, suspicion of malignant disease, and hem-
orrhagic tonsillitis. Relative indications for tonsillec-
tomy included tonsillar hyperplasia with upper airway
obstruction, dysphagia, speech impairment, halitosis,
recurrent or chronic pharyngotonsillitis, peritonsillar
abscess, and streptococcal carriers.6
In an open, multicenter, randomized controlled
trial in the Netherlands, 300 patients 2 to 8 years of age
underwent adenotonsillectomy for mild symptoms of
throat infections. Mild symptoms were defi ned as three
or more infections per year; excluded, however, were
children with seven or more infections, fi ve within the
past 2 years, or three within the past 3 years. In this
study with a mean follow-up of 22 months, there were
no major clinical benefi ts over watchful waiting in these
patients with regard to the number of future episodes
of fever, throat infection, or upper respiratory tract
infection.7
Unlike the outcomes studies for tonsillectomy per-
formed for mild recurrent infection, there are numer-
ous studies that indicate improvement in quality of life
for pediatric patients with upper airway obstruction or
obstructive sleep apnea who undergo adenotonsillec-
tomy. The patients with obstructive sleep apnea con-
sistently
showed
improvement
on
quality-of-life
questionnaires.8
Figure 23-1. Microscopic view of a tonsil demonstrating debris-
fi lled crypts (large arrow) and a lymphoid follicle (small arrow).
Figure 23-2. Acute follicular tonsillitis.

Chapter 23
Tonsillectomy
171
PATIENT SELECTION
Indications for the procedure cover a wide range of ill-
nesses and conditions; some of them are listed in Table
23-2. The most frequent indication is recurrent tonsil-
litis; hence, the most specifi c guidelines have been
developed for this indication (Table 23-1).5 These
guidelines suggest that a patient who experiences four
or more episodes of acute tonsillitis per year would
benefi t from performance of the procedure. We believe
that these guidelines, though helpful, should not be
rigid. The decision to perform tonsillectomy may be
based on the amount of time that the patient is “non-
productive.” Nonproductivity may be assessed by dis-
cussing the severity of illness and the impact of the
illness on the patient and family. The decision to
perform tonsillectomy may also be based on the impact
on the patient’s chronic medical conditions and exac-
erbation of these conditions secondary to tonsillitis. For
instance, few very severe infections may represent more
of an indication for surgical intervention than frequent
mild infections. Often, an adult patient has experienced
recurrent tonsillitis for some years, usually has excessive
time away from work or school, and has reached the
point of frustration and a desire to “fi x the problem.”
In children, a watch-and-wait attitude is often warranted
if the otolaryngologist is the fi rst physician consulted by
the parents to evaluate the child. However, if the patient
has been seen by a pediatrician who has referred the
patient, the history usually suggests that the patient has
failed to respond to conservative treatment and would
benefi t from tonsillectomy.
The decision to proceed with adenoidectomy at the
same time is made by taking into consideration the
symptoms and age of the patient. Younger patients will
frequently have physiologically large adenoids, tonsillar
hypertrophy, and chronic tonsillitis and will have symp-
toms of mouth breathing and chronic rhinorrhea.
These patients would benefi t from adenoidectomy.
Adults and adolescents are less likely to have adenoid
hypertrophy because adenoid tissue usually regresses by
adolescence and does not typically require adenoidec-
tomy. However, visualization of the nasopharynx should
be performed during the procedure if there is concern
about hypertrophic adenoid tissue.
Patients who have episodes of tonsillitis and known
coagulopathies themselves or have family members with
such a history represent a very signifi cant problem and
one that should be approached with great caution.
Although such patients may undergo tonsillectomy
uneventfully, there is a possibility of signifi cant and
prolonged bleeding at any point from the time of the
procedure through healing of the fossae some weeks
later. Reluctance should be the rule in scheduling these
patients for tonsillectomy, and active involvement of a
consultant hematologist is necessary. There have been
studies indicating that preoperative assessment based
on a history of bleeding cannot predict abnormal labo-
ratory data, to therefore performance of routine blood
tests is not cost-effective.9 Preoperative autogenous
blood banking and the use of designated donors may
assist in ensuring a satisfactory outcome. Patients with
bleeding dyscrasias who come from specifi c religious
groups that prohibit the use of blood or blood products
should not undergo tonsillectomy in the community
hospital setting but rather should be referred to aca-
demic institutions prepared to handle this type of
medical-ethical dilemma.
Table 23-1
CLINICAL INDICATORS FOR TONSILLECTOMY
A
B
C
D
E
F
G
H
History
(one
required)
*Patient
with three
or more
infections
of the
tonsils
and/or
adenoids
per year
despite
adequate
medical
therapy
†Hypertrophy
causing dental
malocclusion
or adversely
affecting
orofacial
growth
documented
by an
orthodontist
Hypertrophy
causing upper
airway
obstruction,
severe dysphagia,
sleep disorders,
or
cardiopulmonary
complications
Peritonsillar
abscess
unresponsive
to medical
management
and drainage
documented
by a surgeon,
unless surgery
is performed
during the
acute stage
Persistent
foul taste
or breath
as a result
of chronic
tonsillitis
not
responsive
to medical
therapy
Chronic or
recurrent
tonsillitis
associated
with the
streptococcal
carrier state
and not
responding
to β-
lactamase–
resistant
antibiotics
Unilateral
tonsillar
hypertrophy
presumed
neoplastic
Recurrent
suppurative or
otitis media
with effusion
(adenoidectomy
alone). Addition
of tonsillectomy
requires one of
the indications
listed (A-G)
*For infectious conditions it is recommended that there be information regarding dates of the last two infections, description of fever, severity of discomfort,
information about throat cultures, use of antibiotics, and history of otitis media management.
†For hypertrophy or noninfectious conditions it is recommended that the history include information regarding growth and weight gain, any medical condi-
tions necessitating removal of the tonsils and adenoids, and polysomnography (optional), including the hourly number of apnea or hypopnea episodes.
From Clinical Indicators Compendium. Alexandria, VA, American Academy of Otolaryngology–Head and Neck Surgery, 1995.
Table 23-2
INDICATIONS FOR TONSILLECTOMY
Recurrent tonsillitis
Airway obstruction
Sleep apnea
Acute mononucleosis
Peritonsillar abscess
Biopsy
Spontaneous tonsillar hemorrhage

172
Section 2
Oral Cavity/Oropharynx
SURGICAL TECHNIQUE
Types of Procedures
Various surgical techniques are available for the perfor-
mance of tonsillectomy, as listed in Table 23-3. We favor
electrodissection because this technique results in
minimal blood loss, as well as decreased operating time
without healing problems. All of the techniques
described use the principle of careful dissection in the
subcapsular plane and meticulous hemostasis at the
conclusion of the procedure. New techniques as listed
in the Table 23-3 usually meet with initial enthusiasm
by ear, nose, and throat surgeons. This enthusiasm
often dissipates, however, when these procedures and
their complications are compared with those of tradi-
tional techniques such as electrodissection and cold
knife techniques.
Coblation
Electrosurgery, a technique in which an electrical
current is applied, has been used for cutting, ablation,
coagulation, and hemostasis during tonsillectomy. In
coblation technology the mechanism of action differs
in that tissue ablation occurs as a result of dissociation
of organic molecules rather than the conventional heat-
based processes described. This altered mechanism of
action is thought to minimize thermal damage to adja-
cent tissue structures.
The coblation technique, unlike previous radiofre-
quency, uses bipolar current to create a plasma fi eld,
which can then split tissue. Creation of the fi eld occurs
at temperatures of only 60º C to 70º C, which is less than
those produced with conventional radiofrequency and
electrocautery. This decreased temperature require-
ment for electrocautery is thought to diminish sur-
rounding tissue damage. When used correctly, the
plasma fi eld slices the peritonsillar connective tissue
while a coexisting low-power current coagulates vessels.
Larger vessels are controlled with the coagulation-only
pedal without creation of the plasma ion fi eld.
The literature indicates an improved quality of life
and decreased pain associated with coblation. In a study
of 150 patients who underwent coblation tonsillectomy,
coblation subtotal tonsillectomy, or cold dissection ton-
sillectomy, the end points of pain, return to regular diet
and normal activity, and the use of pain medication
were studied. The coblation procedures were found to
be safe with decreased postoperative pain and earlier
resumption of normal diet and activity levels. Other
studies have also demonstrated signifi cantly decreased
pain levels with fewer patient contacts with physicians
regarding complications in the coblation group.10 There
is also less need for prescription narcotics in the cobla-
tion group than in the electrocautery patients, and
parents rate the postoperative experience as better than
expected. This led to the conclusion that children who
undergo tonsillectomy via coblation experience a better-
quality postoperative course than do those who undergo
conventional electrocautery.
Bleeding rates for tonsillectomy are diffi cult to
compare because they are not always reported. This is
also the case for bleeding rates reported for coblation
tonsillectomy. Numerous articles report a bleeding rate
after coblation tonsillectomy that is less than the
national rates of approximately 1% to 7 %.11
Other studies, however, report a higher rate, one
citing a 24% rate of hemorrhage.12 Coblation may offer
an alternative, safe technique that affords decreased
or similar postoperative hemorrhage rates, as well as
decreased pain, and therefore more rapid return to
function for patients in the future. There does appear
to be less postoperative pain in patients who have
undergone coblation surgery; however, operative time
is generally increased.
The author has used the coblation technique and
fi nds it easy to incorporate into daily practice. Bleeding
rates do not appear to differ between conventional elec-
trosurgical tonsillectomy and coblation; however, bleed-
ing severity may be more pronounced.
Radiofrequency Ablation
The radiofrequency technique, which is somewhat
similar to the coblation technique, has also been listed
in the literature as a method for performing tonsillec-
tomy. There is also mention of using the radiofrequency
technique to perform partial tonsillar ablation or tonsil
reduction in children with tonsil hypertrophy. The tem-
perature-controlled radiofrequency technique operates
by heating the target tissue through an electrode placed
submucosally. The radiofrequency generator regulates
energy fl ow to form a precise lesion. This lesion is then
gradually reabsorbed by the body, thus shrinking tissue
volume while leaving the overlying mucous membrane
intact. An electrode is available for tonsil reduction.
There is an apparent decrease in postoperative morbid-
ity when compared with the traditional tonsillectomy
technique in patients undergoing tonsillotomy or abla-
tion rather than complete removal.13,14
Harmonic Scalpel
The harmonic scalpel has also been used for tonsillec-
tomy. In this procedure, ultrasonic technology is used
to cut and coagulate tissue at temperatures lower than
Table 23-3
SURGICAL TECHNIQUES
FOR TONSILLECTOMY
Guillotine
Tonsillotome
Dissection with a snare
Electrodissection
Laser dissection
Coblation
Harmonic scalpel dissection
Radiofrequency dissection
Power tool dissection

Chapter 23
Tonsillectomy
173
those associated with electrocautery and lasers. This
scalpel has been used for other techniques in otolaryn-
gology and other fi elds of surgery. In contrast to elec-
trocautery or laser dissection, cutting and coagulation
occur at temperatures typically three to four times lower
than the temperatures that occur in the traditional elec-
trocautery technique. The decreased thermal damage
is thought to lead to decreased postoperative pain.
There are limited studies with the harmonic scalpel.
Several indicate decreased postoperative pain, although
other studies showed an increase in the postoperative
pain rate, and still others found no difference between
traditional electrocautery and the harmonic scalpel
technique in terms of intraoperative blood loss or post-
operative hemorrhage.15 Use of the harmonic scalpel
for tonsillectomy may be a promising technique in the
future.
Laser Ablation
Lasers have also been used for the performance of ton-
sillectomy. Initially, they were described in the early
1980s and involved the use of argon plasma coagula-
tion. Good results were obtained in comparison to con-
ventional electrocautery tonsillectomy, and there was
a reported reduction in operative time. Subsequently,
the CO2 laser as well as the neodymium : yttrium-
aluminum-garnet (Nd : YAG) laser were incorporated
to control bleeding. The contact diode laser has also
been reported to decrease postoperative pain rates
when compared with traditional monopolar cautery.
The use of lasers is not routine for the performance of
tonsillectomy. Future studies may be needed to further
describe techniques for laser tonsillectomy.16,17
Powered Instruments
Power tools have recently gained favor for the perfor-
mance of procedures in otolaryngology, such as sinus
surgery and adenoidectomy. They have also been used
for tonsillectomy. The majority of reports involve partial
tonsillectomy or intracapsular tonsillectomy. There
have been reports of lower postoperative hemorrhage
rates, as well as rapid recovery, in young children after
the use of powered instruments for intracapsular tonsil-
lectomy. This technique does not appear to be feasible
for complete tonsillectomy and is therefore listed only
for informational purposes.18,19
Monopolar Cautery
In a survey of 332 otolaryngologists, the majority (222)
performed monopolar cautery procedures and cited
decreased blood loss as the reason. The consensus of
the majority of studies is that electrocautery dissection
is associated with less operative time and intraoperative
blood loss compared with sharp techniques. This tech-
nique, however, may cause increased postoperative
morbidity with respect to pain and return to normal
diet and activity. Fifty percent to 60% of otolaryngolo-
gists nationally who completed both literature surveys,
as well as online surveys, perform monopolar cautery as
their technique of choice for tonsillectomy.
Sharp Dissection
Some otolaryngologists continue to use “cold” or sharp
dissection techniques to perform tonsillectomy. Of the
73 of the 224 respondents who used sharp dissection,
the reason cited was decreased pain.20 The early tech-
niques of performing tonsillectomy with cold dissection
followed by suture ligation was initially used by all oto-
laryngologists approximately 20 years ago. Now,
however, it is used in only 10% of cases nationally.21
In summary of the techniques listed, electrocautery
appears to be the most commonly performed. There
have been numerous articles that have compared elec-
trocautery and cold knife techniques. Electrocautery
groups appear to have decreased surgery, anesthesia,
and operating room times. There are no reported dif-
ferences in hemorrhage rates, but there does appear to
be a need for signifi cantly more analgesic doses after
surgery. The other articles cite a slightly higher rate of
hemorrhage with a “steel tonsillectomy technique.”20-23
Positioning
Regardless of the technique used, positioning of the
patient is critical. A rolled-up towel or blanket under
the shoulders is necessary in most young patients
because of the relatively large size of their head in com-
parison to the anterior-to-posterior diameter of their
chest. Care must be taken during positioning to ensure
that the head is not “hanging” to avoid ligamentous
injury to the cervical spine and postoperative neck pain.
Patients with Down syndrome may need to be evaluated
initially with cervical spine fi lms (extension and fl exion)
to check for C1-C2 subluxation. Hyperextension of the
neck should be avoided at all times, and if possible,
procedures on these patients should be performed in a
neutral, nonextended manner. Patients with Down syn-
drome may have unusual laxity of their cervical liga-
mentous structure, and a shoulder roll should not be
used to preclude the risk of subluxation of the cervical
spine.
A Crowe-Davis or McIvor mouth gag with a ring
blade is gently placed into the patient’s mouth with the
endotracheal tube securely fi xed between the tongue
and blade anteriorly and in the midline (Fig. 23-3). The
ring blade has the safety feature of a midline groove to
accommodate the endotracheal tube. Occasionally, the
most diffi cult portion of the procedure is proper inser-
tion of the mouth gag. The mouth gag should be placed
so that the tongue is in the midline position directly
behind it. Occasionally, with a large tongue or with a
narrow oropharynx or mandibular angle, the mouth
gag may need to be repositioned after the procedure is
performed on one side. Blades for the mouth gag come
in several sizes. Children as well as some adults (women
typically) accommodate a no. 3 blade, whereas men are
more likely to require a no. 4 blade.
Procedure
Before beginning the procedure, the surgeon must
palpate the tonsils, tonsillar fossa, and hard and soft
palate. Defects in the soft palate suggest the possibility

174
Section 2
Oral Cavity/Oropharynx
of a submucous cleft palate and raise the issue of post-
operative velopharyngeal insuffi ciency, especially if
adenoidectomy is being contemplated as part of the
procedure. Typically, the adenoidectomy is performed
before the tonsillectomy. In this case, red rubber cath-
eters are used to retract the soft palate, and a mirror is
used to visualize the nasopharynx. Placement of an
adenoid or nasopharyngeal pack after the adenoidec-
tomy allows time for bleeding in the adenoid bed to
abate during performance of the tonsillectomy. As with
tonsillectomy, there have been novel procedures pro-
posed for adenoidectomy.
When the mouth gag is slid into position and dis-
placed inferiorly, care should be taken that the tip of
the blade does not traumatize the palate, pharynx, lip,
or superior portion of the tonsil, which may result in
excessive bleeding. If this occurs and bleeding obstructs
the fi eld of view, cautery may need to be performed
before beginning the procedure. Once the blade is in
position and the endotracheal tube and tongue are
centered, the rubber portion of the curved wire is
hooked on the lateral incisors or canines of the upper
teeth. This should be performed under direct visualiza-
tion to preclude injury to any loose teeth or to the oro-
pharyngeal mucosa. Such injury is especially a problem
in children who are transitioning to adult teeth. Once
the mouth gag is opened, careful examination should
reveal that the tube is adequately protected, the upper
lip is not entrapped, most of the tongue base is covered
by the blade, and the tonsils are visible from the supe-
rior to the inferior pole. If there is excessive tongue
base herniating into the oral cavity, the blade on the
mouth gag is too small. If the tongue is so large that it
prolapses around the blade, it may become necessary
to position the blade for removal of the fi rst tonsil
and then reposition it for removal of the second tonsil.
With the head extended, the mouth gag is elevated
and connected to the Mayo stand on which the instru-
ments to perform the tonsillectomy are placed. Compli-
cations may occur from placement of the mouth gag,
of which the surgeon should be cognizant. Such com-
plications include dislodgement of teeth, dislocation of
the temporomandibular joint, kinking of the endotra-
cheal tube, or accidental dislodgement of the endotra-
cheal tube resulting in premature extubation. Small
children require an uncuffed tracheal tube, and it is
essential that moist radiopaque gauze be placed in the
hypopharynx to prevent escape of oxygen and anes-
thetic agent from the endotracheal tube during the
procedure.
The tonsillectomy is begun by making an incision
in the anterior pillar just lateral to the mucosal refl ec-
tion onto the tonsillar surface. This incision is facili-
tated by initially grasping the tonsil with curved Allis
forceps and retracting it medially and slightly inferiorly
to place the mucosa of the anterior pillar under tension
(Fig. 23-4). The anterior pillar should be preserved.
There has been an article suggesting that defi ciency of
the anterior tonsillar pillar predisposes patients to
obstructive sleep apnea with increased collapse of the
soft palate.24
Examination of the superior pole of the tonsil and
the adjacent soft palate during medial retraction of the
tonsil will usually reveal the extent of the superior pole
above the mucosal refl ection before the incision. If the
incision is made by electrocautery, it is essentially blood-
less and can be carried down without diffi culty to the
tonsil capsule (Fig. 23-5). It is necessary to dissect the
mucosa and underlying soft tissue from the tonsil
capsule. Entry into the tonsil at the superior pole is a
technical error that leads to diffi culty in further dissec-
tion of the tonsil because of an inability to identify the
plane between the capsule and the surrounding soft
tissue.
Once the capsule of the superior pole has been
identifi ed, the tonsil is retracted inferiorly. This is often
assisted by repositioning the Allis clamp. Countertrac-
tion on the soft palate by suction held by the assistant
often makes this dissection easier and assists in identi-
fi cation of the correct plane of dissection. If the dissec-
tion is performed in a meticulous manner, vessels can
frequently be identifi ed as they enter the tonsil capsule
and can be controlled with electrocautery before being
transected. As the tonsil is dissected inferiorly and freed
from the surrounding muscular attachments, the
remaining mucosa of the anterior and posterior pillars
must be incised (Fig. 23-6). Postoperative discomfort
and deformity can be minimized by keeping the line of
the mucosal incision immediately adjacent to the tonsil,
thereby preserving as much mucosa as possible.
When the inferior pole of the tonsil has been
reached, the tonsil can easily be amputated by elec-
trodissection. Care must be taken to avoid leaving
excessive tonsil tissue at the inferior pole, as well as
avoid unnecessary excessive dissection into the hypo-
pharynx and tongue base. This latter caveat is particu-
larly important in older patients with massive tonsillar
hypertrophy because the tonsillar tissue can extend
onto the tongue base and be contiguous with the lingual
tonsil.
At the completion of the procedure, the pharynx is
irrigated with saline solution. The mouth gag should be
closed and opened once or twice to ensure that bleed-
ing is not being controlled merely by mouth gag com-
Figure 23-3. Patient with chronic tonsillitis before surgery.

Chapter 23
Tonsillectomy
175
A
B
A
B
Figure 23-4. A and B, Placing
the tonsil under tension before
removal. (A, Redrawn from Hibbert J:
Tonsils and adenoids. In Evans JNG
[ed]: Pediatric Otolaryngology. In Kerr
AG [ed]: Scott Brown’s Otolaryngol-
ogy, London, Butterworth-Heinemann,
1987, pp 368-383.)
Figure 23-5. Incision of the
mucosa with electrocautery and
exposure of the capsule. Often it
is wise to reposition the clamp at
this point in the procedure. (A,
Redrawn from Hibbert J: Tonsils and
adenoids. In Evans JNG [ed]: Pediat-
ric Otolaryngology. In Kerr AG [ed]:
Scott Brown’s Otolaryngology, London,
Butterworth-Heinemann, 1987, pp
368-383.)
pression. If no bleeding is evident, the pharynx is
suctioned and the patient is returned to the anesthesia
staff for awakening and extubation. If at any time during
this period there appears to be evidence of bleeding,
the surgeon should immediately examine the pharynx
and control the bleeding. If bleeding occurs before
extubation, the patient should be reanesthetized and
the bleeding controlled before extubation. If bleeding
occurs after extubation, rapid clinical judgment is
necessary to determine whether reintubation is
warranted.
The most critical part of the surgical procedure
may be awakening from anesthesia. Diffi cult emergence
from anesthesia and extubation with coughing and
“bucking,” wild thrashing of the head and thorax, or
laryngospasm triggered by blood and secretions on the
vocal cords can result in immediate postoperative bleed-
ing and, occasionally, airway catastrophe. It is of vital
importance that the surgeon understand airway dynam-
ics and be in the operating suite when the patient is
emerging from the anesthesia during the extubation
process.
It is critical that the operating room team not
remove electrocautery devices or the suction tubing
before the patient exits the operating room in case of
postoperative hemorrhage or complications during the
wakening period. Intervention frequently requires the
ability to rapidly examine the hypopharynx and remove
blood clots. This may be crucial to ensuring an unevent-
ful emergence from general anesthesia.

176
Section 2
Oral Cavity/Oropharynx
When the tonsil has been removed, it should be
properly labeled regarding right and left before sending
the specimen to pathology. This is especially applicable
if there is concern regarding squamous cell carcinoma
or lymphoma. Appropriate patient information should
be sent with the pathology request form so that the
pathologist can perform either careful entire sections
or routine sections (that may miss a small foci of carci-
noma). Discussion with the pathologist regarding clini-
cal suspicion is always appropriate. If lymphoma is
suspected, the tissue may need to be handled according
to specifi c guidelines as dictated by the pathology
department within the institution. Knowledge of the
specifi c institutional policy regarding histologic exami-
nation, the specifi c complaints of the patient, and the
need for microscopic examination will dictate the
appropriate comments on the pathology request form.
It is important to realize that in many institutions, his-
tologic examination of the tonsils is not routine. If the
tonsillectomy is performed as part of a diagnostic evalu-
ation for an unknown primary cancer, the entire tonsil
must be sectioned because the cancer may be micro-
scopic. In these cases, discussion with the pathologist is
the best way to avoid inappropriate handling of the
specimen. If lymphoma is suspected, the tissue must be
handled very gently to avoid distortion of the architec-
ture of the tonsil.
To achieve hemostasis with suction electrocautery,
the area of bleeding is initially suctioned and the tip
of the suction electrocautery is positioned for several
seconds on this bleeding site. Occasionally there is
profuse bleeding. The suction portion of the suction
cautery may be used, as well as a pediatric Yankauer
suction. With the two suction devices at hand, the bleed-
ing source is often more readily identifi ed. Despite this
technique, if bleeding continues with an unidentifi able
focus point, a tonsil sponge may be placed for several
minutes to further control the bleeding and identify the
site that requires attention. Alternatively, the bleeding
vessel may be grasped with the tonsil hemostat and
retracted medially. The hemostat may then be touched
with the electrocautery by the assistant. During this pro-
cedure, however, care should be taken to ensure that
other portions of the hemostat are not in contact with
the tongue, gingiva, or lips. Hemostasis may also be
achieved with sutures and ties. Although these tech-
niques are occasionally diffi cult to perform, they are
useful to control diffuse areas of bleeding. Suturing is
usually performed with absorbable material and a
tapered needle. Care must be taken to not pass the
needle too deeply into the fossa because large vessels
may be encountered and punctured, thereby further
exacerbating the problem.
Quality of Life
Parent satisfaction after adenotonsillectomy is quite
pronounced. One study in which the parents of 664
children who underwent adenotonsillectomy were
polled with a questionnaire showed a high rate (91%)
of parent satisfaction after tonsillectomy.25 Tonsillec-
tomy and adenoidectomy have been shown by some to
signifi cantly decrease health care costs in children with
obstructive sleep apnea syndrome. There is a reported
33% reduction in annual health care costs in children
who underwent tonsillectomy and adenoidectomy;
however, the health care costs were decreased as a result
of decreased admissions, department visits, consulta-
tions, and medications prescribed.26
Children
undergoing
adenotonsillectomy
for
obstructive sleep apnea had improved quality of life on
domains of sleep disturbance, physical symptoms, emo-
tional symptoms, and daytime functioning as reported
by their caregivers.27
A
B
Figure 23-6. Freeing the tonsil
from the underlying areolar tissue
and
the
superior
constrictor
muscle. (Redrawn from Hibbert J:
Tonsils and adenoids. In Evans JNG
[ed]: Pediatric Otolaryngology. In Kerr
AG [ed]: Scott Brown’s Otolaryngol-
ogy, London, Butterworth-Heinemann,
1987, pp 368-383.)

Chapter 23
Tonsillectomy
177
Other studies have shown that not only is there an
improved parent satisfaction rate but there is also an
improvement in the behavioral response of children
after tonsillectomy and adenoidectomy.28
Obstructive Sleep Apnea
Obstructive sleep apnea in children, as well as adults, is
an indication for tonsillectomy. Although recurrent
tonsillitis is cited as the most common indication for
performance of tonsillectomy in adults and older chil-
dren, it is usually hypertrophy or obstructive sleep
apnea that is a more common indication for tonsillec-
tomy in children. Rosenfeld and Green reported that
the frequency of obstructive sleep apnea rose from 0%
in 1978 to 19% in 1986 as an indication for tonsillec-
tomy in children.29
The reported incidence of obstructive sleep apnea
or hyperventilation syndromes varies within the litera-
ture. There is a high incidence of snoring in children,
however, with approximately 27% of children habitu-
ally snoring in the age group from birth to 10 years.30
Even in preschool children this incidence is greater
than 10%.31 The incidence of obstructive sleep apnea,
however, has been reported to be 1% to 3% in the
pediatric population.32
Unlike adult manifestations of obstructive sleep
apnea in which patients may have hypertension, right-
sided heart failure, and cardiac abnormalities, the
majority of children have less severe clinical manifesta-
tions, snoring, restless sleep, daytime somnolence, and
behavioral disturbances and enuresis. Polysomnogra-
phy, which is the “gold standard” for diagnosis in adults,
is not always performed in children. Often the diagnosis
is made clinically, although in one study only half the
children with symptoms suggestive of obstructive sleep
apnea actually had the condition as confi rmed by poly-
somnography. This may suggest an observation period
rather than surgical correction as the treatment of
choice.33 Polysomnography in childhood obstructive
sleep apnea differs from that in the adult state. Chil-
dren usually have fewer discrete obstructive episodes.
The criterion that obstructive apnea events be longer
than 10 seconds is inappropriate, in part because of
children’s higher respiratory rates. Patients generally
exhibit patterns of hypoventilation characterized by
snoring and paradoxical rib cage motion. It is therefore
crucial that analysis of polysomnography be performed
in laboratories skilled in pediatric problems. The peak
age for adenoid and tonsillar hypertrophy and related
obstructive sleep symptoms is 3 to 6 years.34
Peritonsillar Abscess
Peritonsillar abscess occurs when there is a collection
of purulent exudate in the space between the tonsillar
capsule and the loose areolar tissue separating the ton-
sillar capsule from the superior constrictor muscle.
These abscesses are thought to occur secondary to acute
tonsillitis. The walls of the abscess cavity are composed
of the tonsillar capsule medially and the superior con-
strictor muscle laterally. Patients with a peritonsillar
abscess usually have a several-day history of unilateral
sore throat, unilateral otalgia, and odynophagia. Physi-
cal examination reveals trismus, unilateral erythema of
the tonsil, deviation of the uvula, soft palate fullness or
peritonsillar bulging, and dehydration. Frequently it is
diffi cult to differentiate peritonsillar cellulitis from
peritonsillar abscess. The simplest way to distinguish
the two is to aspirate the peritonsillar bulge or soft
tissue fullness. Treatment of peritonsillar abscess, once
properly diagnosed, is incision and drainage, hydra-
tion, and antibiotic therapy. The resulting anaerobic
and gram-positive bacteria may spread through deep
fascial planes in the neck and rapidly progress to a more
serious infection. This condition therefore needs to be
promptly addressed. Peritonsillar abscess has an inci-
dence of approximately 30 per 100,000 patients, which
accounts for approximately 45,000 cases of peritonsillar
abscess per year.35 The goal of peritonsillar abscess man-
agement is to provide quick resolution of the abscess,
as well as prevent recurrence. Although incision plus
drainage, as well as hydration and antibiotic therapy,
has been the mainstay of acute management, the deci-
sion whether to perform tonsillectomy, in addition to
the timing of tonsillectomy, remains controversial.
Parker and Tami, in an analysis of the literature,
suggested that individuals older than 40 years who have
a peritonsillar abscess were more likely than younger
patients to experience only one episode. As a result,
a single peritonsillar abscess occurring in a patient
older than 40 years most likely does not require
tonsillectomy.35
However, patients who are younger than 40 years,
who have experienced multiple episodes of tonsillitis,
and who have had previous peritonsillar abscesses
should be considered for tonsillectomy. Although the
recurrence rate for peritonsillar abscess has been
reported to be 0% to 30%, reviews of studies have found
that possibly 90% of patients who do have a peritonsillar
abscess do not suffer recurrence. Additionally, only
approximately 30% of patients who have peritonsillar
abscesses have a history of recurrent tonsillitis.35 Patients
who experience recurrent peritonsillar abscesses and
have a history of recurrent tonsillitis would benefi t by
tonsillectomy. On the other hand, patients who are
younger than 40 may be eligible for tonsillectomy either
in the acute setting, known as “quinsy” tonsillectomy,
or in the delayed setting. The controversy involves the
timing of the tonsillectomy. When performed in the
acute setting known as “quinsy” tonsillectomy (quinsy
was the name applied to peritonsillar abscess at one
time), the procedure ensures resolution of the problem
with a single hospitalization and avoids protracted
recovery after drainage of the abscess. There is, however,
an increased incidence of bleeding intraoperatively that
may lead to more diffi cult dissection.
Opponents point out that the risk of local tissue
sepsis secondary to operating in the midst of an acute
infection is signifi cant. Moreover, they suggest that
there is an increased risk for bleeding, which can be
particularly diffi cult to manage if one attempts to use
the suture or tie technique. Furthermore, with limited

178
Section 2
Oral Cavity/Oropharynx
access to operating room time in many facilities, sched-
uling an interval tonsillectomy seems more rational
than attempting to perform quinsy tonsillectomy on an
emergency basis.
The actual performance of quinsy tonsillectomy is
very similar to that of routine tonsillectomy in that an
incision is made in the anterior pillar to enter and
evacuate the abscess cavity, after which the tonsil is dis-
sected free and removed with either electrocautery or
a snare. Hemostasis is obtained with electrocautery.
POSTOPERATIVE CARE
An essential in the postoperative care of patients is an
understanding of expectations after surgery. During
discussions with the patient’s caregivers regarding anes-
thetic risks such as nausea and vomiting; pain, otalgia,
odynophagia, halitosis, and dehydration should be
extensively discussed. Treatment plans, including diet,
should be discussed. Intravenous fl uids are continued
until the patient awakens suffi ciently to begin oral
intake. Routinely beginning a liquid diet with progres-
sion to a soft diet is standard. Patients who are unable
to tolerate an adequate oral diet, have excessive vomit-
ing, or have evidence of bleeding should not be dis-
charged on the same day but rather be observed until
they stabilize. There is also controversy regarding hos-
pitalization of patients based on age. In general, patients
who have an unusual postoperative recovery or are
younger than 2 years and have a history of obstructive
sleep apnea should be admitted to the hospital for over-
night observation.
Most surgeons advocate postoperative administra-
tion of antibiotics. A randomized study by Grandis and
associates revealed decreased pain and fetor oris in
patients treated with antibiotics postoperatively.36
Choices should include an antibiotic that is active
against oral fl ora, usually an oral form of penicillin.
Patients who have undergone tonsillectomy for acute
infection or peritonsillar abscess or who have a history
of recurrent streptococcal pharyngitis should be treated
with antibiotics, possibly including perioperative intra-
venous antibiotics. The use of prophylactic periopera-
tive antibiotics should be routine in any similar
procedure when performed on a patient with a cardiac
abnormality. The role of antibiotics is to decrease post-
operative pain, perhaps by decreasing pharyngeal
infl ammation secondary to bacterial colonization. The
majority of otolaryngologists do routinely administer
antibiotics with the knowledge that antibiotics may
decrease pain, improve oral intake, and reduce oral
odor.20
The use of steroids has recently become popular.
The most commonly used perioperative steroid is dexa-
methasone, which apparently decreases nausea and
vomiting and leads to improved pain control. However,
there are reports of both measured benefi t and lack of
improvement after the administration of steroids. It
appears that in the early postoperative period, children
who receive dexamethasone seem to have less morbid-
ity secondary to an antiemetic effect. After 24 hours,
however, there does not appear to be any measurable
differences, so a single perioperative dose may be
warranted.37,38
Analgesics should be prescribed as necessary;
however, excessive analgesia can result in decreased
oral intake and lethargy and may lead to worsening of
nausea and vomiting, and ultimately dehydration.
Usually, narcotics such as Tylenol with codeine or oxy-
codone (Roxicet) have been incorporated. Narcotics
have in many cases been replaced with nonsteroidal
anti-infl ammatory drugs (NSAIDs). There are reports
of decreased emesis with the use of NSAIDs. The
decreased postoperative nausea and vomiting may be
offset, however, by a higher incidence of bleeding.
Therefore, the use of NSAIDs as an alternative to nar-
cotics or opioids should be done with caution.39,40
COMPLICATIONS
Postoperative bleeding is the most common and poten-
tially most devastating complication after tonsillectomy.
Bleeding occurring during the fi rst 24 hours is known
as early (or primary) bleeding and is probably due to
inadequate hemostasis at surgery; late or delayed bleed-
ing generally occurs 7 to 10 days after the procedure.
The cause of late bleeding is unclear.41 Although bleed-
ing rarely results in rapid exsanguination, it can result
in airway compromise. Inappropriate treatment can
lead to a series of events that may even result in demise
of the patient. Death can occur as a result of an inability
to control the airway in the midst of a blood-fi lled oral
cavity and oropharynx. Care must be taken during the
repeat operative procedure (for control of tonsillar
bleeding) to avoid undue trauma to the surrounding
tissue that can result in diffi culty in hemostasis. Careful
dissection on the tonsil capsule will avoid exposing
the vessels deep within the constrictor muscles
and facilitate hemostasis both intraoperatively and
postoperatively.
Coagulation Disorders
Although the majority of patients do not have any coag-
ulopathies, in a survey conducted by the AAO-HNS,
otolaryngologists often did obtain complete blood
counts. The likelihood of obtaining blood tests preop-
eratively was decreased in members of the American
Society of Pediatric Otolaryngologists.
Hemorrhage can occur late after tonsillectomy as
a result of both technical and unpreventable patient
factors. Sutures placed through large vessels can result
in bleeding when the suture is absorbed and the lumen
of the larger vessel is exposed. For this reason, if bleed-
ing increases during suture placement, the suture
should be removed rather than tied. Similarly, electro-
cautery deep within the tonsillar fossa can result in
injury to the wall of major blood vessels (such as the
internal carotid artery), which can be manifested as
devastating bleeding days to even weeks after comple-
tion of the procedure. Cautery should be conservative

Chapter 23
Tonsillectomy
179
and localized to bleeding sites. It should not be used
deep within a torn muscle bed or lateral to the plane
of the superior constrictor.
Patients must be advised regarding the need to
continue oral intake. Patients who refuse to swallow are
subject to increased swelling of their soft palate because
of immobility and increased debris and secretions. They
may require admission for intravenous hydration as a
result of an inability to maintain adequate oral intake.
Control of Postoperative Hemorrhage
All patients should undergo an examination of the oral
cavity before discharge, including examination of both
tonsillar fossae to rule out the presence of a clot. A clot
within a tonsillar fossa can be assumed to represent
underlying bleeding. The clot should be removed and
the tonsillar fossa inspected. If a clot is present or frank
bleeding is visualized, either immediately postopera-
tively or days later, tonsillar bleeding is occurring and
intervention is necessary.42
Vital signs, pulse and blood pressure, should be
obtained immediately and monitored closely. If airway
distress is present, oxygen saturation should be moni-
tored with a pulse oximeter. The surgeon needs a head-
light for examination because both hands will be
required for management. Young children and unco-
operative older patients will require general anesthesia,
although most patients older than 5 or 6 years will toler-
ate a certain degree of manipulation, and general
anesthesia can often be avoided in these patients.
Instrumentation should be obtained, and assistance will
be required. Most hospitals have prepared “T&A hem-
orrhage trays.” These trays should be examined before
they are actually needed. The patient is best examined
in a sitting position or in a semisitting position on a
stretcher.
The pharynx can be sprayed with a topical
anesthetic such as benzocaine, tetracaine, and benzal-
konium (Cetacaine). Care must be taken to not over-
anesthetize the pharynx and hypopharynx because
doing so can result in aspiration secondary to ablation
of the laryngeal protective refl exes. In a similar manner,
sedation should be either avoided or minimized. Using
a tongue blade for retraction and suction, the clot can
be removed from the tonsillar fossa. Even if there is no
further bleeding, inpatient observation is warranted. If
the bleeding point is visualized, injection of 1% lido-
caine (Xylocaine) with epinephrine 1 : 100,000 into the
tissue immediately adjacent to the bleeding vessel may
result in cessation of the bleeding. Once an injection
has been performed, cauterization with either electro-
cautery or silver nitrate may be effi cacious in control-
ling the bleeding. If these maneuvers are not successful,
a fi gure-of-eight suture may be placed. This requires an
exceptionally cooperative patient and signifi cant hand-
eye coordination on the part of the surgeon for accom-
plishment in an awake patient.
If the previously described efforts are unsuccessful
and bleeding continues, if the patient is uncooperative,
or if the bleeding is massive, general anesthesia will be
required. Anesthetizing a patient with postoperative
tonsillar bleeding can be a challenge for the anesthetist.
The surgeon should insist that the most experienced
and skillful anesthesiologist be available for the induc-
tion. The patient may be hypovolemic, combative, and
suffering airway compromise because of the volume of
blood in the mouth. Moreover, because the stomach is
usually fi lled with blood and other secretions, the risk
of perioperative aspiration is signifi cant. Control of
hemorrhage with direct pressure to permit fl uid resus-
citation and suctioning of blood from the pharynx may
be lifesaving. Care must be taken to avoid aspiration of
blood and stomach contents by overzealous local and
topical anesthesia of the pharynx, hypopharynx, and
larynx. Patients who are hypovolemic must have their
fl uid and blood defi cits replaced as rapidly as possible
during preparation for anesthesia. The combination of
hypovolemia and hypotension from anesthetic agents
may produce cardiovascular arrest.
Rarely, patients will have a history of vigorous bleed-
ing, which then stops spontaneously. When presented
with such a “sentinel bleed,” the possibility of internal
carotid injury must be entertained. If the patient is not
bleeding at the time, angiography may provide the diag-
nosis, as well as an opportunity for balloon occlusion of
the artery if the patient can tolerate loss of a carotid
artery. Emergency angiography is probably preferable
to emergency surgery in this situation if personnel with
the appropriate skills and equipment are available in
the facility.
In addition to the complications described, rare
complications include hypernasal speech, pharyngeal
stenosis, and lesions of the tongue, teeth, tonsillar
pillars, soft palate, or uvula. Although the complica-
tions themselves have remained the same, the complica-
tion rate has decreased, no doubt as a result of better
training of otolaryngologists, anesthesiologists, and
paraprofessional staff.
CONCLUSION
Tonsillectomy is a commonly performed procedure
that is effective in the control of recurrent pharyngitis,
management of peritonsillar abscess, and treatment of
upper airway obstruction and sleep disturbances sec-
ondary to tonsil hypertrophy. It is occasionally per-
formed for biopsy of a tonsillar mass or in a search for
an unknown primary tumor. It is often performed in
conjunction with adenoidectomy in young children.
Various surgical techniques are available; we favor use
of the electrocautery technique with discrete vessel elec-
trocautery for hemostasis. The rate of postoperative
bleeding can range from 1% to 4%, and it is a serious
management challenge for the otolaryngologist–head
and neck surgeon. Tonsillectomy is not an easy opera-
tion and must be viewed with respect because of its
potentially fatal outcome. Current indications are rigor-
ous and, if followed, will result in the selection of only
patients who will benefi t from the procedure.43

180
Section 2
Oral Cavity/Oropharynx
7. van Staaij BK, Van den Akker EH, Rovers MM, et al: Effectiveness
of adenotonsillectomy in children with mild symptoms of throat
infections or adenotonsillar hypertrophy: Open, randomized
controlled trial. BMJ 329:651, 2004.
8. Flanary VA: Long-term effect of adenotonsillectomy on quality of
life in pediatric patients. Laryngoscope 113:1639-1644, 2003.
9. Gabriel P, Mazoit X, Ecoffey C: Relationship between clinical
history, coagulation tests, and perioperative bleeding during ton-
sillectomies in pediatrics. J Clin Anesth 12:288-291, 2000.
10. Stoker KE, Don DM, Kang R, et al: Pediatric total tonsillectomy
using coblation compared to conventional electrosurgery: A pro-
spective, controlled single-blind study. Otolaryngol Head Neck
Surg 130:666-675, 2004.
11. Timms MS, Temple RH: Coblation tonsillectomy: A double blind
randomized controlled study. J Laryngol Otol 116:450-452,
2002.
12. van der Meulen J: Tonsillectomy technique as a risk factor for
postoperative haemorrhage. Lancet 364:697-702, 2004.
13. Nelson LM: Temperature-controlled radiofrequency tonsil reduc-
tion in children. Arch Otolaryngol Head Neck Surg 129:533-537,
2003.
14. Hultcrantz E, Ericsson E: Pediatric tonsillotomy with the radio-
frequency technique: Less morbidity and pain. Laryngoscope
114:871-877, 2004.
15. Walker RA, Syed ZA: Harmonic scalpel tonsillectomy versus elec-
trocautery tonsillectomy: A comparative pilot study. Otolaryngol
Head Neck Surg 125:449-455, 2001.
16. D’Eredita R, Marsh RR: Contact diode laser tonsillectomy in
children. Otolaryngol Head Neck Surg 131:732-735, 2004.
17. Younis RT, Lazar RH: History and current practice of tonsillec-
tomy. Laryngoscope 112(Suppl 100):3-5, 2002.
18. Bent JP, April MM, Ward RF, et al: Ambulatory powered intracap-
sular tonsillectomy and adenoidectomy in children younger than
3 years. Arch Otolaryngol Head Neck Surg 130:1197-1200,
2004.
19. Koltai PJ, Solares CA, Koempel JA, et al: Intracapsular tonsillar
reduction (partial tonsillectomy): Reviving a historical procedure
for obstructive sleep disordered breathing in children. Otolaryn-
gol Head Neck Surg 129:532-538, 2003.
20. Krishna P, LaPage MJ, Hughes LF, Lin SY, et al: Current practice
patterns in tonsillectomy and perioperative care. Int J Pediatr
Otorhinolaryngol 68:779-784, 2004.
21. Maddern BR: Electrosurgery for tonsillectomy. Laryngoscope
112(Suppl 100):11-13, 2002.
22. Leinbach RF, Markwell SJ, Colliver JA, et al: Hot versus cold ton-
sillectomy: A systematic review of the literature. Otolaryngol
Head Neck Surg 129:360-364, 2003.
23. O-Lee TJ, Rowe M: Electrocautery versus cold knife technique
adenotonsillectomy: A cost analysis. Otolaryngol Head Neck Surg
131:723-726, 2004.
24. Chan J, Akst LM, Eliachar I: The roles of the anterior tonsillar
pillar and previous tonsillectomy on sleep-disordered breathing.
Ear Nose Throat J 836:408-413, 2004.
25. Wolfensberger M, Haury JA, Linder T: Parent satisfaction 1 year
after adenotonsillectomy of their children. Int J Pediatr Otorhi-
nolaryngol 56:199-205, 2000.
26. Tarasiuk A, Simon T, Tal A, et al: Adenotonsillectomy in children
with obstructive sleep apnea syndrome reduces health care utili-
zation. Pediatrics 113:351-356, 2004.
27. Mitchell RB, Kelly J, Call E, et al: Quality of life after adenotonsil-
lectomy for obstructive sleep apnea in children. Arch Otolaryngol
Head Neck Surg 130:190-194, 2004.
28. Goldstein NA, Post JC, Rosenfeld RM, et al: Impact of tonsillec-
tomy and adenoidectomy on child behavior. Arch Otolaryngol
Head Neck Surg 126:494-498, 2000.
29. Rosenfeld RM, Green RP: Tonsillectomy and adenoidec -
tomy: Changing trends. Ann Otol Rhinol Laryngol 99:187-191,
1990.
30. Capper R, Canter RJ: A comparison of sleep quality in normal
children and children awaiting (adeno)tonsillectomy for recur-
rent tonsillitis. Clin Otolaryngol 26:43-46, 2001.
31. Ali NJ, Pitson D, Stradling JR: Natural history of snoring and
related behavior problems between the ages of 4 and 7 years.
Arch Dis Child 71:74-76, 1994.
PEARLS
• Tonsillectomy is most commonly performed for
recurrent infections.
• Identifi cation of the plane between the capsule of
the tonsil and the constrictor muscle, regardless of
the method used for removal, will facilitate the
procedure.
• Grasp as much of the tonsil as possible before
beginning the dissection to prevent repeated
handling of tonsillar tissue during the dissection.
• With the tonsil retracted medially and the tonsillar
tissue under tension, coagulate any bleeding or
visible vessels.
• Irrigate the tonsillar beds before reversal of
anesthesia to visualize any oozing vessels that might
not be apparent in an existing bloody fi eld.
PITFALLS
• Failure to identify the proper plane of dissection,
especially in the superior pole of the tonsil where the
tonsillar tissue may extend more laterally than
expected, may result in cumbersome bleeding.
• Permitting ancillary staff to remove the tonsillectomy
equipment before the patient exits from the room
may lead to a delay in visualizing and controlling
immediate bleeding.
• “Chasing” inferior pole tonsillar tissue rather than
creating an arbitrary transition of tonsillar lymphoid
tissue from lingual lymphoid tissue may result in
troublesome immediate and delayed bleeding.
• Failure to consider von Willebrand’s disease in a
patient who provides a preoperative history of
previous unexplained postsurgical bleeding may
result in postoperative bleeding.
• Failure to relax the McIvor mouth gag between the
right and left tonsillectomy procedures may result in
complaints of painful paresthesias of the tongue
postoperatively and possible bleeding during
emergence from anesthesia intraoperatively.
References
1. Kornblut AD: A traditional approach to surgery of the tonsils and
adenoids. Otolaryngol Clin North Am 20:349-363, 1987.
2. Kozak LJ, Hall MJ, Pokras R, et al: Ambulatory surgery in the
United States, 1994. Adv Data 1997; 283:1-15. Available at www
.cdc.gov/nchs.
3. Paradise JL: Tonsillectomy and adenoidectomy. In Bluestone CD,
Stool SE (eds): Pediatric Otolaryngology, 2nd ed. Philadelphia,
WB Saunders, 1990, pp 915-926.
4. Pillsbury HC, Kveton JF, Sasaki CT, et al: Quantitative bacteriol-
ogy in adenoid tissue. Otolaryngol Head Neck Surg 89:355-363,
1981.
5. Clinical Indicators Compendium. Alexandria, VA, American
Academy of Otolaryngology–Head and Neck Surgery, 1995.
6. Darrow DH, Siemens C: Indications for tonsillectomy and ade-
noidectomy. Laryngoscope 112:6-10, 2002.

Chapter 23
Tonsillectomy
181
32. Rosen CL: Evaluation of the child with snoring or suspected
obstructive sleep apnea. UpToDate Online 12.3.
33. Nieminen P, Tolonen U, Lopponen H: Snoring and obstructive
sleep apnea in children: A 6-month follow-up study. Arch Otolar-
yngol Head Neck Surg 126:481-486, 2000.
34. Greenfeld M, Tauman R, DeRowe A, et al: Obstructive sleep
apnea syndrome due to adenotonsillar hypertrophy in infants. Int
J Pediatr Otorhinolaryngol 67:1055-1060, 2003.
35. Herzon F: Peritonsillar abscess. In Gates GA (ed): Current
Therapy in Otolaryngology–Head and Neck Surgery, 6th ed. St
Louis, CV Mosby, 1998, pp 418-421.
36. Grandis JR, Johnson JT, Vickers RM, et al: The effi cacy of
perioperative
antibiotic
therapy
on
recovery
following
tonsillectomy in adults: Randomized double-blind placebo-
controlled trial. Otolaryngol Head Neck Surg 106:137-148,
1992.
37. Heatley DG: Perioperative intravenous steroid treatment and ton-
sillectomy. Arch Otolaryngol Head Neck Surg 127:1007-1008,
2001.
38. Hanasono MM, Lalakea L, Mikulec AA, et al: Perioperative ste-
roids in tonsillectomy using electrocautery and sharp dissection
techniques. Arch Otolaryngol Head Neck Surg 130:917-921,
2004.
39. Møiniche S, Rømsing J, Dahl JB, et al: Nonsteroidal anti-infl am-
matory drugs and the risk of operative site bleeding after tonsil-
lectomy: A quantitative systematic review. Anesth Analg 96:68-77,
2003.
40. Desikan SR, Meena NG: Do non-steroidal anti-infl ammatory
drugs increase the risk of bleeding after tonsillectomy? Arch Dis
Child 89:493-494, 2004.
41. Cressman WR, Myer CM: Management of tonsillectomy hemor-
rhage: Results of a survey of pediatric otolaryngology fellowship
programs. Am J Otolaryngol 16:29-32, 1995.
42. Handler SD, Miller L, Richmond KH, et al: Post-tonsillectomy
hemorrhage: Incidence, prevention and management. Laryngo-
scope 96:1243-1247, 1986.
43. Bluestone CD: Current indications for tonsillectomy and ade-
noidectomy. Ann Otol Rhinol Laryngol 101:58-64, 1992.

Chapter 24
Cancer of the Lip
Robert L. Ferris and Grant S. Gillman
The lip is the most common site of origin for squamous
cell carcinoma of the oral cavity. These cancers are most
frequently found on the lower lip. The cause and clini-
cal behavior of carcinoma of the lip, however, more
closely parallel squamous cell carcinoma of the skin
than they do squamous cell carcinoma of the oral cavity.
Occasionally, full-thickness cancer of the lip may have a
signifi cant mucosal (oral) component, thus making this
distinction more diffi cult.1 Carcinoma of the lip occurs
most frequently in older white men, with the average
age at onset being in the sixth decade of life. It appears
that the major risk factors for the development of lip
cancer are male gender, a fair ruddy complexion, and
an outdoor occupation.2 In the United States, there is a
marked male preponderance (19:1 for cancer of the
lower lip and 5:1 for cancer of the upper lip).
Although prolonged exposure to sunlight is
believed to be a causative agent,3 other factors, such as
poor dental hygiene, syphilis, chronic alcoholism, and
pipe smoking, have been proposed. When pipes were
made with clay stems, the high temperature generated
within the stem may have caused irritation suffi cient to
induce malignant degeneration. However, pipes are
now made with plastic stems, which are poor conduc-
tors of heat and no longer considered a risk factor. A
viral etiology has been suggested, particularly onco-
genic subtypes of human papillomavirus (types 16 and
18). Carcinoma of the lip has been found to be associ-
ated with chronic immunosuppression. The highest
rates of cancer occurrence in such patients appear to
be in the lip and skin, the former perhaps a variant of
the latter.4 This form of cancer is most prevalent in
patients who have undergone renal transplantation.5
Other types of cancer occur less commonly on the
lip, including malignant melanoma and malignant
tumors of salivary gland origin, such as adenoid cystic
carcinoma and adenocarcinoma. Basal cell carcinoma
occurs infrequently on the lip.
PATIENT SELECTION
Most patients with squamous cell carcinoma of the
lower lip consult a physician when the tumor is at a
relatively early stage (≤1 cm in diameter) (Fig. 24-1)
and because of nonhealing ulceration or bleeding.
Although small, most of these lesions have been present
in some form for many months, and some have been
treated with antibiotic ointment or skin cream. Patients
seek medical attention when they see no improvement
after this treatment. Some of these cancers have been
preceded or accompanied by whitish plaque, ulcer-
ation, or erythroplasia.
A small number of patients are not initially seen
until later in the course of the disease, at which time
the tumor is characterized by deep invasion of the mus-
culature of the lip (Fig. 24-2), the adjacent skin, the oral
mucosa, or the mandible, especially by way of the mental
nerve.2 This may be due to neglect or to a more aggres-
sive tumor phenotype and lack of optimal immune
function. A small fraction of patients (approximately
2%) with squamous cell carcinoma will demonstrate
perineural involvement. Although occurring infre-
quently, cancer with perineural spread deserves special
attention because it has important therapeutic and
prognostic implications, such as a high incidence of
local recurrence and nodal metastasis and a 5-year sur-
vival rate of 33%, which is strikingly lower than that for
most patients with carcinoma of the lip.
Patient selection begins with a thorough history.
The presence of other skin changes as a result of expo-
sure to ultraviolet radiation should be noted at this
time. The location on the lip, which is highly visible,
usually makes the tumor accessible for inspection and
palpation. Inspection and measurement of the lesion
are important to ensure proper staging. Careful palpa-
tion of the lesion between gloved thumb and forefi nger
is helpful in determining the size and degree of infi ltra-
183

184
Section 2
Oral Cavity/Oropharynx
tion of the tumor, which may extend beyond the visible
ulceration. All patients should be tested for hypoesthe-
sia of the lower lip in the distribution of the mental
nerve because of the possibility of perineural involve-
ment. Even in the absence of cortical bone destruction,
the tumor may grow along the mental nerve into the
medullary portion of the mandible and may even extend
as far as the cranial cavity.2 The neck must be palpated,
particularly in patients receiving chronic immunosup-
pression. Lymphatic drainage of the middle third of the
lower lip is primarily into the submental lymph nodes,
with secondary drainage into the submandibular and
upper internal jugular nodes (Fig. 24-3). Cancer of the
lateral third of the lower lip tends to drain into the
submandibular lymph nodes. Cancer of the upper lip
metastasizes to the submental and submandibular nodal
groups. The incidence of regional nodal metastasis has
been found to be 5% for T1 lesions, 50% for T2 lesions,
and 70% for T3 lesions.2 Although metastasis to neck
nodes has been believed to be related to advanced
stage, deeply ulcerated lesions, and mandibular or peri-
neural involvement, Hosal and coworkers concluded
that the size of the primary cancer does not correlate
closely with predicting the incidence of regional lymph
node metastasis.6 Immunosuppression should lead to
heightened concern and search for regional metastasis
by palpation and imaging studies.
Metastasis from cancer of the upper lip may occur
more frequently than that of the lower lip.4 Likewise,
cancer involving the commissure metastasizes more fre-
quently than that of the midportion of the lip. A com-
plete examination of the head and neck should be
performed to rule out a second primary cancer of the
head and neck.
PREOPERATIVE PLANNING
All lesions suspected of being malignant or premalig-
nant should undergo biopsy. If the lesion is ulcerated,
as with most squamous cell carcinomas, a punch biopsy
under local anesthesia may be performed, preferably
on the edge of the lesion and including some normal
tissue. In lesions manifested as submucosal nodules,
such as salivary gland cancer, an incisional biopsy, again
taking some normal tissue, is necessary for diagnosis.
Cancer of the lip is staged as follows:
• T1—Tumor less than 2 cm in greatest diameter
• T2—Tumor between 2 and 4 cm in greatest diam -
eter
• T3—Tumor larger than 4 cm in greatest diameter
• T4—Tumor larger than 4 cm in greatest diameter
with deep invasion, including muscle, bone, or other
structures
Figure 24-1. Typical appearance of early squamous cell carcinoma
of the lower lip.
Figure 24-2. Advanced cancer of the lip with deep invasion.
Figure 24-3. Lymphatic drainage of the lip.

Chapter 24
Cancer of the Lip
185
Patients who have any history or physical fi nding
suggestive of perineural spread, mandibular involve-
ment, or palpable lymph nodes should undergo imaging
of the neck with computed tomography (CT) or mag-
netic resonance imaging (MRI). This group should also
include any patient who is chronically immunosup-
pressed. These studies should encompass the entire
head and neck because perineural involvement can be
discovered in the mental and inferior alveolar nerves,
as demonstrated by widening of the foramen, or as far
proximal as the intracranial cavity. MRI may demon-
strate tumor involvement of the inferior alveolar nerve
before bone erosion is visible on CT. In more advanced
cases, there is an increased probability of lymph node
metastasis. Imaging is useful in planning treatment by
identifying cervical lymph nodes that meet the criteria
for malignancy. Combined positron emission tomogra-
phy (PET)/CT may be useful in such situations, particu-
larly for evaluating bilateral or contralateral spread to
the neck and for staging purposes before forming a
plan of management.
Modalities that have been used successfully in the
treatment of carcinoma of the lip include surgical exci-
sion alone, radiation therapy alone (external beam,
intensifi ed implants, or both), or combined surgical
excision and radiation therapy.2 The management
program selected usually depends on a number of
factors, including the size and location of the lesion;
the patient’s age, general medical condition, and needs;
and the experience and skill of the surgeon and radia-
tion oncologist.
T1 and T2 invasive squamous cell carcinoma and
the more infrequently occurring basal cell carcinoma
may be treated successfully by either surgery or radia-
tion therapy. The results are cosmetically acceptable
with either technique. In advanced lesions, surgical
excision or a combination of surgery and radiation
therapy is preferred.
Radiation therapy may consist of interstitial, exter-
nal, or contact beam therapy (or any combination).
Application of external beam radiation is disadvanta-
geous to patients who will return to occupations requir-
ing sun exposure because sensitivity of the treated area
to thermal actinic stimuli is said to be increased. Because
many of these patients live in rural or remote areas,
access to radiation therapy over a long period may be
inconvenient or impossible. Radiation is also not useful
in more advanced forms of cancer with deep infi ltra-
tion, perineural involvement, mandibular destruction,
or positive lymph nodes. Although radiation therapy
is not generally as invasive and carries a lower risk of
treatment-related morbidity, it is more time consuming
and expensive in most cases. Even successful radiation
therapy frequently leaves a tissue defect that may need
to be reconstructed or an atrophic scar at the site of the
original primary lesion. It also provides unpleasant side
effect such as xerostomia and loss of taste.
The mainstay of treatment of cancer of the lip is
surgical excision. Radiation therapy is typically reserved
for patients who refuse surgery or those whose physical
or mental condition may not permit surgery. It can also
be used in programs of combined therapy in patients
with advanced lesions.7 Neck dissection should be
undertaken only if palpable nodes are present, if
imaging suggests abnormal nodes meeting the criteria
for malignancy, or for a large or bulky cancer in which
the risk of local metastatic disease is increased. Sentinel
node biopsy may be used to determine the presence
of metastasis and lymphatic drainage patterns to assist
in management of the neck, particularly in high-risk
patients.8
SURGICAL TECHNIQUE
Surgical management of carcinoma of the lip should
accomplish the following objectives:
• Adequate excision of the cancer
• Preservation of lip function (speech, chewing, oral
competence, and retention of saliva)
• Satisfactory cosmetic appearance
• Rapid rehabilitation
• Minimal cost
Because of the low probability of a coexisting
second primary cancer in the upper digestive tract,
routine preoperative panendoscopy is not performed.
However, if the patient has oropharyngeal symptoms,
physical fi ndings on examination of the head and neck,
or abnormal imaging studies, endoscopy is warranted.
The key to the successful treatment of affected patients
is removal of the cancer in its entirety. Surgical margins
are close (5 mm), so pathologic examination is manda-
tory. We systematically perform intraoperative frozen
section examination of surgical margins to decrease the
likelihood of re-excision later.9 If permanent section
reveals positive margins, re-excision is mandatory
because recurrence and often metastasis are distinct
risks related to subtotal excision of the tumor.
Orientation of the specimen can be problematic,
especially if the pathologist is not familiar with head
and neck procedures. We believe that asking the pathol-
ogist to come into the operating room to visualize the
specimen and the defect and to speak with the surgeon
directly is the best method to enhance communication
so that the patient’s chance for cure is not compro-
mised. Debate about whether frozen section margins
should be removed from the tumor specimen or from
the patient is ongoing.
Small Cancers of the Upper or Lower Lip
(Excision of Less Than One Third of
the Lip)
Anatomically, the facial aesthetic unit of the lips is
bounded by the nasal base superiorly and centrally, the
melolabial crease laterally, and the labiomental crease
inferiorly. As much as possible, particularly with smaller
defects, one tries to stay within these anatomic boundar-
ies. Furthermore, the relaxed skin tension lines (RSTLs)
are oriented in radial fashion around the upper and
lower lips, much like the spokes of a wheel. Orienting
incision lines parallel to the RSTLs will ultimately help
provide optimal scar camoufl age.

186
Section 2
Oral Cavity/Oropharynx
The excision is generally performed with the patient
under local anesthesia with intravenous sedation. If the
surgery is performed under general anesthesia, a naso-
tracheal tube should be used to avoid distortion of the
lower lip from an orotracheal tube. Excision margins
should be marked on the patient with methylene blue
or a marking pen before infi ltration of local anesthetic
to prevent distortion of tissues. With the scalpel blade,
the vermilion border is marked on each side of the lip
adjacent to the margins of excision (Fig. 24-4). Included
in the incision, in addition to the cancer, should be
approximately 5 mm of normal-appearing tissue to be
certain that the margins of resection are free of tumor.
We inject 1% lidocaine with 1:100,000 epinephrine
through a no. 30 needle to obtain anesthesia and vaso-
constriction. The injection is carried out along the pre-
viously marked lines of incision so that if the lines are
erased during preparation of the skin, the needle marks
will still provide an accurate line of incision. Mental
(lower lip) or infraorbital (upper lip) nerve blocks can
be helpful for additional anesthesia. The skin of the
entire face is prepared with povidone-iodine (Betadine)
solution, and the entire face is draped into the sterile
fi eld. Ten minutes should elapse after the completion
of infi ltration to obtain maximal vasoconstriction.
The lip is grasped on each side of the line of inci-
sion with a thumb and fi nger (for hemostatic control)
or a Lahey clamp, and the tumor is excised in a wedge
shape. While frozen sections are being carried out,
hemostasis is obtained by electrocautery or ligatures as
needed. A Prolene suture is loosely applied in the area
marking the edges of the vermilion border and the lips
drawn together (Fig. 24-5). A three-layer closure follows,
starting at the apex of the wedge in the mucosal area,
working out with interrupted 3-0 chromic catgut suture,
and ending at the vermilion border. Absorbable suture,
either chromic catgut, Vicryl, or PDS, is used to close
the defect in the orbicularis muscle. The same material
is used for the subcutaneous layer, and the skin is
approximated with either running or interrupted 5-0 or
6-0 nylon or Prolene monofi lament suture. Steri-Strips
are applied over the suture line in such a way that the
area of incision is relaxed and without tension. Patients
are discharged from the hospital the same day and
return to the offi ce in approximately 7 days for removal
of the sutures. Chronically immunosuppressed patients
have delayed wound healing and may require addi-
tional time before the sutures are removed.
When the surface area of the cancer is somewhat
larger (occasionally up to half the lip) but it remains
relatively superfi cial rather than infi ltrating deeply, a
variation of the wedge excision in terms of a W excision
and closure is useful. This incision essentially “inverts”
the V of the wedge to reduce the distance that the inci-
sion must extend below (or above) the lip, thus helping
keep excision lines within the boundaries of the aes-
thetic unit. Preparation, anesthesia, and performance
of this incision are similar to those described earlier.
The closure, however, is somewhat more complex (Fig.
24-6).
Larger Cancers of the Upper and Lower Lips
More extensive cancer involving the upper or lower lip,
in which more than one third of the lip must be excised,
cannot generally be closed primarily. Such defects will
result in unsightly distortion of the oral commissure
and diffi culty with oral intake and articulation if they
are closed primarily. Additional local tissue must be
advanced into the defect. Usually, this takes the form
of simple advancement fl aps with or without some type
of lip switch procedure to achieve a functional unit. The
mucosa under the lip must be incised to release the
tissue and advance the fl aps properly.
Excision of the cancer is carried out in a manner
similar to that described earlier, except that rather than
planning the excision in the shape of a V (see Fig. 24-5),
the rectangular block is shaped to incorporate the inci-
sions required for advancement (Fig. 24-7). The trans-
verse incision must be situated in the sulcus at the
junction between the upper lip and chin to incorporate
this natural skin fold for camoufl age of the scar. Two
through-and-through vertical incisions are made to
encompass the cancer with adequate margins. A hori-
zontal connecting incision is made in the melolabial
crease where the chin and lip intersect. After excision
and confi rmation of adequate margins with frozen
section, relaxing incisions are made laterally. These
incisions permit mobilization of two opposing rectan-
gular advancement fl aps, which can then be advanced.
The wound is once again closed in layers.
Similar advancement fl aps can be created after
block resection of cancer of the median portion of the
Figure 24-4. The incision is marked on the skin, and the vermilion
border is marked with a scalpel to ensure accurate realignment.

Chapter 24
Cancer of the Lip
187
B
C
A
D
Figure 24-5. A, A wedge incision is used for excision of a small cancer
of the lower lip. B, The skin, muscle, and mucosa are closed without
tension. A temporary Prolene suture may be used to approximate the
vermilion or gray line while the deeper layers are closed. C, Closure
includes accurate restoration of the vermilion border. D, Wound is
closed.
upper lip (Fig. 24-8A and B). Flaps similar to those
described earlier are created by removing Burrow’s tri-
angles just lateral to the nasal ala (see Fig. 24-8C and
D). This provides two fl aps that can be advanced to the
midline without producing the unsightly bunching
effect that would otherwise take place (see Fig. 24-8E).
This type of simple reconstruction provides excellent
cosmetic results.
For resection defects up to one half to two thirds
of the lip, closure will generally require a full-thickness
pedicled fl ap from the opposite lip (the “lip switch”
fl aps—Abbé or Estlander) or larger perioral advance-
ment fl aps such as the Karapandzic fl ap.
With the “lip switch” fl aps, tissue is rotated from the
upper to the lower lip or from the lower to the upper
lip, depending on circumstances. These fl aps lend
themselves to satisfying rehabilitation in this area
because the neurovascular supply is retained. They are
preferable because they are local fl aps and afford an
excellent match in skin color and texture and the avail-
ability of vermilion and mucous membrane. The fl aps
should be designed so that the height of the fl ap equals
the height of the defect. The width of the fl ap should
be one half that of the resected segment so that both
lips are reduced in width proportionately.1,9
The Estlander fl ap is based on branches of the
labial artery and is used to reconstruct defects in the
lateral aspect of the lip and oral commissure (Fig.
24-9A). Effort should be made to terminate the incision
at the nasolabial fold to incorporate the scar into this

188
Section 2
Oral Cavity/Oropharynx
A
B
C
D
Figure 24-6. A, The W excision is outlined. B, The defect is shown. C, Wound closure. D, Wound is completely healed with good cosmetic
result.
natural structure. Accurate approximation of the ver-
milion border of the fl ap with that of the defect will
ensure a good cosmetic result (see Fig. 24-9B and C).
The surgeon should recall that the vermilion border is
an important guide, because the labial artery runs just
deep to the muscle at the level of the vermilion border.
The fl ap, once developed, is transposed into the defect,
and after hemostasis is achieved, a four-layer closure is
performed as described earlier, including mucosa,
muscle, subcutaneous tissue, and skin. The only unfor-
tunate aspect of this reconstruction is the creation of a
rounded commissure. Although this does not produce
any functional problems, the patient may request revi-
sion for cosmetic appearance at a later date.
An Abbé fl ap based on the opposite lip is, in prin-
ciple, similar to an Estlander fl ap except that it is used
to reconstruct defects away from the oral commissure.
It may be used if tumor resection includes an area that
is too large for primary closure and yet not large enough
to require Karapandzic advancement fl aps. A wedge-
shaped defect is created by tumor resection, and the
surgeon then makes a full-thickness incision in the
opposite lip in the shape of a wedge, pedicled on
the labial artery on one side. Precautions in dissecting
the labial artery and preserving the pedicle are carried
out as described earlier. The fl ap is transposed into
the defect, and a four-layer closure is carried out (Fig.
24-10). The donor site is also closed in layers. The
patient is fed a liquid diet by straw over the next 14 to
21 days, at which time the pedicle is divided and the
fl aps inset, with special care taken to approximate the
vermilion border on both sides.
The Karapandzic fl ap provides an excellent method
of reconstructing larger defects while still preserving a
functional, albeit smaller oral stoma. This may cause
diffi culty with feeding, oral hygiene, and insertion of
dentures. Bilateral oral commissure revision can be per-
formed at a later date to obtain more defi nition of the
oral commissure. This is not only functionally benefi cial
to the patient but is also an important cosmetic
consideration.
The excision is performed as necessary to accom-
modate the large size of the cancer. In most cases this
will, for all practical purposes, entail sacrifi cing most of
the lower lip (Fig. 24-11A). Incisions are made in the
nasolabial folds and carried down through subcutane-
ous tissue (see Fig. 24-11B). The incisions should be
made sharply through the dermis and subcutaneous

Chapter 24
Cancer of the Lip
189
A
B
C
Figure 24-7. A, The wedge/block excision is shown with the advancement fl aps out-
lined. A central lower lip cancer is removed, with optional relaxing incisions for residual
lip mobilization. B, The defect is shown with the advancement fl aps outlined. C, Wound
closure.
tissue, but the remainder of the dissection must be
carried out bluntly with the use of blunt dissecting scis-
sors to avoid devascularizing and denervating the fl ap
(see Fig. 24-11C). The tissues are spread along the
course of the facial artery and its branches to identify
and preserve these vessels. Soft tissue should be pre-
served around the neurovascular bundle to maintain
the integrity of the vasa vasorum and vasa nervorum.
Dissection should be carried down to but not through
the mucosa. Care must be taken to preserve branches
of the facial nerve if one hopes to maintain a functional
unit. Flaps are mobilized to obtain the desired skin
coverage. As tension is applied to the fl aps, the mucosa
is incised incrementally for a distance suffi cient to allow
the fl aps to come together with suffi cient mucosal cov-
erage. Flaps should be approximated with subcutane-
ous absorbable catgut suture in the mucosa and 4-0
Vicryl or Dexon suture to bring the orbicularis oris
muscles together. The submucosal and dermal layers
can be closed with 4-0 chromic catgut suture, the
mucosa is closed with 3-0 chromic catgut, and the skin
is closed with 5-0 or 6-0 interrupted silk suture (see Fig.
24-11D and E). Steri-Strips are applied to minimize
tension on the suture lines. This technique produces a
functional oral commissure with acceptable, if not out-
standing cosmetic results.
In certain types of defects that do not allow closure
by either straight advancement fl aps or local fl aps, a
combination of fl aps may be necessary. Such a situation
is demonstrated in Figure 24-10. Massive tumors requir-
ing excision of blocks of tissue too large to reconstruct
with local fl aps may require reconstruction with free
fl aps or a regional pedicle fl ap.
POSTOPERATIVE MANAGEMENT
We routinely administer intravenous antibiotics periop-
eratively for 24 hours and then have the patient con-
tinue oral medication for a total of 1 week because these
wounds are technically contaminated by oral cavity
fl ora. Postoperative care includes both local and general
considerations. It is important to keep the suture line
clean and well lubricated. The suture line itself is
cleaned of dried blood and crusts with peroxide two or
Text continues on page 193.

D
A
B
C
H
E
F
G
Figure 24-8. A, Cancer of the upper lip (black arrow). B, The excision is outlined. C, The defect after excision. D, Diagram of reconstruction.
E, Burrow’s triangles outlined. F, Excision of Burrow’s triangles and bilateral advancement fl aps. G, Wound closure. H, Postoperative
appearance.

Chapter 24
Cancer of the Lip
191
B
A
C
C
A
B
D
Figure 24-9. A, Recurrent squamous cell carcinoma of the lower lip.
B, Scheme for an Estlander fl ap. C, Acceptable cosmetic and functional
results at the commissure with an Estlander fl ap.
Figure 24-10. A, Extensive cancer of the upper lip. B, The defect after excision of the cancer. C, The defect reconstructed with an Abbé
fl ap and cheek advancement fl aps facilitated by the use of Burrow’s triangles. D, Appearance after release and inset of the Abbé fl ap.

192
Section 2
Oral Cavity/Oropharynx
B
C
D
E
A
Figure 24-11. A, The defect after excision of a large cancer of the
lower lip. B, The Karapandzic fl aps incised. C, The fl aps incorporate new
vascular components. D, The fl aps are advanced and closed in multiple
layers. E, Good functional and cosmetic results are shown.

Chapter 24
Cancer of the Lip
193
three times a day, and antibiotic ointment, such as baci-
tracin ointment, is applied to the skin of the lip. The
Steri-Strips used to reduce skin tension are removed in
1 week. The sutures are removed in 10 days to 2
weeks.
Consideration must be given to the patient’s diet.
In patients who have undergone only excision and
primary closure, a liquid diet for the fi rst 48 hours,
particularly with use of a straw, is helpful. A soft diet is
prescribed for the following week because it requires
less chewing and therefore less movement of the lips,
thereby preventing tension on the suture line. Patients
with an Abbé fl ap should be maintained on a liquid diet
through a straw until division of the pedicle can be
accomplished.
References
1. Salgarelli AC, Sartorelli F, Cangiano A, et al: Treatment of lower
lip cancer: An experience of 48 cases. Int J Oral Maxillofac Surg
34:27-32, 2005.
2. Bucur A, Stefanescu L: Management of patients with squamous
cell carcinoma of the lower lip and N0-neck. J Craniomaxillofac
Surg 32:16-18, 2004.
3. Busick TL, Uchida T, Wagner RF Jr: Preventing ultraviolet light
lip injury: Beachgoer awareness about lip cancer risk factors and
lip protection behavior. Dermatol Surg 31:173-176, 2005.
4. King GN, Healy CM, Glover MT, et al: Increased prevalence of
dysplastic and malignant lip lesions in renal-transplant recipients.
N Engl J Med 332:1052-1057, 1995.
5. Leigh IM, Buchanan JA, Harwood CA, et al: Role of human papil-
loma viruses in cutaneous and oral manifestations of immuno-
suppression. J Acquir Immune Defi c Syndr 21(Suppl 1):S49-S57,
1999.
6. Hosal IN, Onerci M, Kaya S, et al: Squamous cell carcinoma of the
lower lip. Am J Otolaryngol 13:363-365, 1992.
7. Babington S, Veness MJ, Cakir B, et al: Squamous cell carcinoma
of the lip: Is there a role for adjuvant radiotherapy in improving
local control following incomplete or inadequate excision? Aust N
Z J Surg 73:621-625, 2003.
8. Altinyollar H, Berberoglu U, Celen O: Lymphatic mapping and
sentinel lymph node biopsy in squamous cell carcinoma of the
lower lip. Eur J Surg Oncol 28:72-74, 2002.
9. Gooris PJ, Vermey B, de Visscher JG, Roodenburg JL: Frozen
section examination of the margins for resection of squamous cell
carcinoma of the lower lip. J Oral Maxillofac Surg 61:890-894, dis-
cussion 895-897, 2003.
PEARLS
• Wound infection can be prevented by good local
wound care and the administration of antibiotics.
• Vascular compromise in the pedicle, which may
destroy the viability of the fl ap, can be avoided by
meticulous attention to surgical technique.
• Nonabsorbable sutures should be used for up to
2 weeks, until wound strength is suffi cient to
counteract the strong muscular force exerted by the
oral commissure.
• Uneven bites of tissue must be taken while suturing
the midportion of the lip, which is thick, to the
thinner, lateral portion of the commissure.
• The degree of microstomia is proportional to the
extent of tumor resection, and it is a necessary
tradeoff for using lip tissue for reconstruction after
lip resection.
PITFALLS
• Tension on the pedicle will lead to severe
complications such as tissue necrosis in the cross-lip
and local fl ap operations.
• Not accurately marking the vermilion border before
excision for careful approximation of the vermilion
margins will lead to poor cosmetic results.
• Distortion of the oral commissure may occur,
particularly with use of the Estlander fl ap, and
should be corrected at a revision procedure.
• Drooling may result from injury to the
neuromuscular components of the lip in either
excision or reconstruction of the defect. A secondary
revision procedure in these areas may be required.

Chapter 25
Transoral Removal of Elongated
Styloid Process
Eugene N. Myers
Eagle, in 1937, reported two cases in which he observed
that elongation of the styloid process appeared to be
the cause of pharyngeal and cervical pain.1 Over the
years, little has been written about this syndrome, and
in fact, there is some controversy whether this syndrome
exists at all. Eagle’s syndrome is characterized as a dull,
aching pain localized to either or both sides of the
throat with referred otalgia. Some pain may occur on
swallowing or protrusion of the tongue or on rotating
the head, and some patients complain of a foreign body
sensation in their throat. Eagle’s syndrome occurs more
frequently in women than in men and is usually found
in patients older than 30 years.2 Palpation of the tonsil-
lar fossa will reveal a hard mass3 and reproduce the
patient’s symptoms.
The stylopharyngeus, stylohyoid, and styloglossus
muscles all take their origin from the styloid process
of the temporal bone. Gruber4 measured the styloid
process in 2000 skulls and found that most styloid proc-
esses measured from 3.0 to 5.0 cm. Eagle5 stated that
the normal styloid process is approximately 2.75 cm
and any styloid process beyond that length may be con-
sidered elongated. Elongation of the styloid process
with or without calcifi cation of the stylohyoid ligament
has been reported to occur frequently, but there are
few cases in which they are symptomatic. The pathogen-
esis of an elongated styloid process is unclear. The exact
cause of the pain is unknown, although several mecha-
nisms have been suggested. The mechanism most easily
understood is compression of the glossopharyngeal
nerve as it passes the elongated styloid process, and
the condition may be classifi ed as an entrapment
syndrome.6
The differential diagnosis of this condition includes
cranial nerve neuralgias (e.g., trigeminal, glossopharyn-
geal, sphenopalatine, superior laryngeal, and primary
geniculate neuralgias2), temporomandibular joint
disease, chronic pharyngotonsillitis, unerupted or
impacted molar teeth, and tumors in the oropharynx.
Unlu and colleagues7 assessed elongation of the styloid
apparatus (styloid process and ligament) in degenera-
tive or infl ammatory diseases such as ankylosing
spondylitis, psoriatic arthropathy, and cervical spondy-
loarthrosis, in which cervical spine involvement can be
seen. The authors concluded that an elongated styloid
process might be another manifestation of enthesopa-
thy in the cervical spine.
PATIENT SELECTION
Many patients with Eagle’s syndrome are evaluated
by an otolaryngologist because of the sensation of a
nagging sore throat, usually unilateral. Most have been
treated with multiple courses of antibiotics, and some
have been dismissed as having a functional disorder.
Eagle’s syndrome is characterized by a history of dull,
nagging pain in an area of the throat that becomes
worse during deglutition. Findings on inspection are
normal, but palpation of the tonsillar fossa reveals a
hard mass in the area of the tonsillar fossa and repro-
duces the patient’s symptoms.
The differential diagnosis includes a primary tumor
of the tonsil, a tumor of the parapharyngeal space, or
cervical osteoarthritis. A granular cell tumor manifested
as Eagle’s syndrome was reported recently.8 Nakamaru
and associates studied a series of patients suspected of
having an elongated styloid process with three-dimen-
sional computed tomography (CT) reconstruction.9
They concluded that three-dimensional CT scanning is
useful for diagnosis, explanation to patients, and selec-
tion of treatment in some patients with an elongated
styloid process.
195

196
Section 2
Oral Cavity/Oropharynx
Figure 25-1. Radiograph demonstrating an elongated styloid
process.
A
B
Figure 25-2. A and B, Hurd
retractors tenting the constrictor
muscles over the styloid process
and the incision carried down onto
the styloid process under direct
vision.
An elongated styloid process with or without calci-
fi cation of the stylohyoid ligament can be seen on plain
posteroanterior views of the head and neck (Fig. 25-1).
It is often identifi ed on Panorex fi lms in patients being
evaluated for temporomandibular joint syndrome. A
high index of suspicion on the part of the physician in
evaluating these patients is probably the most impor-
tant step for proper diagnosis and management.
PREOPERATIVE PLANNING
Panorex radiographs or a CT scan of the head and neck
provides valuable confi rmatory information and a
detailed map of the anatomy of the anatomic site and
the relationship of the styloid process to the internal
carotid artery. Infi ltration of lidocaine in an attempt to
abolish the symptoms is a simple test that when confi r-
matory, will provide reassurance to the patient and
surgeon alike.10
SURGICAL TECHNIQUE
With the patient in the Rose position under general
anesthesia, a transoral approach with a self-retaining
tonsil retractor and a ring blade is carried out to be
certain that the endotracheal tube is out of the opera-
tive fi eld. Nasotracheal intubation through the contra-
lateral nasal fossa is an excellent alternative to keep the
tube out of the surgical fi eld.
If the patient has not had a tonsillectomy, one
should be performed (see Chapter 23). Many of these
patients have already had a tonsillectomy, in which case
an incision is made through the mucosa of the tonsillar
fossa down onto the constrictor muscles. Hurd retrac-
tors are placed through the mucosal incision, and the
soft tissues are pushed laterally and posteriorly to
tent the tissues over the styloid process (Fig. 25-2).
The constrictor muscle is then incised. Once the
styloid process is identifi ed (Fig. 25-3), the tendinous
attachments are also incised and the styloid process is
skeletonized with a sharp elevator or a ring curette.
Care must of course be taken to retract the other local
tissues to prevent injury to the underlying carotid artery.
A Kerrison rongeur is then inserted and the styloid
process is removed as far superior as possible
(Fig. 25-4).
Hemostasis is obtained with electrocautery, and the
wound is irrigated. Usually no blood is lost with this
procedure. The constrictor muscles are closed with
interrupted chromic catgut sutures, as is the overlying
mucosa, and no drains are required. Perioperative anti-
biotics are administered.

Chapter 25
Transoral Removal of Elongated Styloid Process
197
Figure 25-3. The styloid process exposed.
Figure 25-4. The styloid process removed piecemeal with
rongeurs.
POSTOPERATIVE MANAGEMENT
Postoperatively, the patient is observed for several hours
and may be discharged the same day. Antibiotics are
given by mouth for the next 5 days and mild analgesics
are prescribed. Half-strength hydrogen peroxide is used
as a gargle for 5 days. Generally, the patient’s original
pain is relieved immediately by removal of the styloid
process.
It is possible to remove the styloid process through
an external procedure; however, the transoral approach
is so direct, simple, and brief that we have not used the
external approach. A description of this surgery may
be found in the excellent article by Strauss and
colleagues.2
PEARLS
• The most diffi cult part of this procedure is
considering the diagnosis in a patient with a chronic
sore throat.
• CT scanning can confi rm the diagnosis and provide
information regarding the surrounding anatomic
structures.
• The transoral approach avoids scar formation and
potential damage to the carotid artery.
• Injury to the carotid artery or glossopharyngeal
nerve may be avoided by careful and limited
dissection directly on the styloid process.
PITFALLS
• Beware of the possibility of an incorrect diagnosis.
• Injury to the carotid artery, which lies just deep to
the styloid process, is a potential complication.
• Injury to the glossopharyngeal nerve is possible as
well.
• Bleeding from the operative site may be
encountered.
• Incomplete removal of the styloid process may result
in the patient’s symptoms not being relieved.
References
1. Eagle WW: Elongated styloid process. Arch Otolaryngol 25:584-
587, 1937.
2. Strauss M, Zohar Y, Laurian N: Elongated styloid process syn-
drome: Intraoral versus external approach for styloid surgery.
Laryngoscope 95:976-979, 1985.
3. Subramaniam S, Majid MD: Eagle’s syndrome. Med J Malaysia
58:139-141, 2003.
4. Gruber W: Über enorm lange Processus styloides der Schläfen-
beinne. Arch Pathol Anat Physiol Klin Med 50:232-234, 1870.
5. Eagle WW: Symptomatic elongated styloid process. Report of two
cases of styloid process–carotid artery syndrome with operation.
Arch Otolaryngol 49:490-503, 1949.
6. Slavin KV: Eagle syndrome: Entrapment of the glossopharyngeal
nerve? Case report and review of the literature. J Neurosurg
97:216-218, 2002.

198
Section 2
Oral Cavity/Oropharynx
7. Unlu Z, Tarhan S, Gunduz K, Goktan C: Relationship between
ossifi cation of the stylohyoid ligament and enthesopathy: A com-
parative study. Clin Exp Rheumatol 20:661-667, 2002.
8. Philipp K, Barnes EL, Carrau RL: Eagle syndrome produced by
a granular cell tumor. Arch Otolaryngol Head Neck Surg
127:1499-1501, 2001.
9. Nakamaru Y, Fukuda S, Miyashita S, Ohashi M: Diagnosis of the
elongated styloid process by three-dimensional computed tomog-
raphy. Auris Nasus Larynx 29:55-57, 2002.
10. Prasad KC, Kamath MP, Reddy KJ, et al: Elongated styloid process
(Eagle’s syndrome): A clinical study. J Oral Maxillofac Surg
60:171-175, 2002.

Chapter 26
Surgery of the Soft Palate
Jonas T. Johnson
Squamous cell carcinoma is the most commonly encoun-
tered neoplasm in the soft palate. These tumors develop
on the surface epithelium.1-3 Epidemiologically, they
are closely associated with the use of tobacco and
alcohol (Fig. 26-1). Patients with squamous cell carci-
noma of the palate are at high risk for the development
of a second primary carcinoma of the aerodigestive
tract, including the lung and esophagus, as well as other
head and neck primaries.4-6 Accordingly, all patients
with squamous cell carcinoma of the palate must be
carefully evaluated for a potential synchronous primary
carcinoma, including thorough imaging and endo-
scopic evaluation.
The next most commonly encountered tumors
originate from the minor salivary glands, which are dis-
tributed in abundance throughout the soft palate. The
most common benign tumor is pleomorphic adenoma.
Adenoid cystic carcinoma is the most frequently encoun-
tered malignant tumor. Mucoepidermoid and low-
grade polymorphous adenocarcinoma (Fig. 26-2A) and
lymphoma (Fig. 26-2B) are encountered less often.
Various studies have estimated that approximately 50%
to 70% of tumors arising in the minor salivary glands
are malignant.7-9 Cancer of the minor salivary glands is
manifested as a submucosal mass that when small, is
almost invariably asymptomatic. These tumors may fi rst
be noticed on routine dental examination. Occasion-
ally, the tumors interfere with the fi t of dental appli-
ances or ulcerate and cause pain, thus bringing the
patient to the dentist. The usual referral route is from
the family dentist to the oral maxillofacial surgeon for
treatment. Referral is then made to a head and neck
surgeon for defi nitive management.
PATIENT SELECTION
In the past, surgical management of squamous cell car-
cinoma of the soft palate was limited to biopsy of the
primary cancer and management of neck disease not
controlled with radiation therapy.10-12 Cure rates of
approximately 30% to 40% were reported.13,14 The rela-
tively poor outcome reported in patients treated with
primary radiation therapy for squamous cell carcinoma
of the soft palate suggests that some of these patients
may benefi t from a combined program of surgery and
postoperative radiation therapy.15 A more recent report
from the University of Florida suggests that for limited
carcinoma of the soft palate, radiation therapy alone or
followed by planned neck dissection results in relatively
high local-regional control and survival rates. For
advanced cancer of the soft palate, local-regional control
and survival rates are low and chemoradiation therapy
is indicated.16,17
The radiation therapist is limited in treating lesions
of the soft palate because of the proximity of the cancer
to the spinal cord. Radiation-induced transverse myeli-
tis may occur if doses in excess of 4500 cGy are admin-
istered to the spinal cord inasmuch as it is generally
accepted that at least 5000 cGy is required to control
microscopic disease. Treatment of the retropharyngeal
lymph nodes is a fundamental part of the treatment
program because of the potential for metastases from
cancer of the soft palate.18,19 This poses a legitimate
practical challenge that has been improved with modern
radiation techniques such as intensity-modulated radio-
therapy (IMRT).
Conversely, the surgeon’s ability to effectively resect
the lymphatics in the retropharyngeal and skull base
areas to which cancer of the palate may spread is techni-
cally limited. In the absence of identifi able metastases,
we recommend wide resection of the primary cancer
with bilateral selective neck dissection in zones 2 and
3. If metastases are palpable or visualized on scan,
more comprehensive neck dissection should be under-
taken, including excision of the retropharyngeal lymph
nodes. Postoperative radiation therapy requires close
199