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Chapter 31
Resection of the Floor of the Mouth
251
A
C
D
B
E
Figure 31-16. A tooth is extracted adjacent to the tooth to be preserved,
and the osteotomy is placed in the extraction site.
Figure 31-17. A, Advanced cancer of the ﬂ oor of the mouth with destruction of
the mandible and inﬁ ltration of the skin of the chin. B, Surgical specimen, including
the ﬂ oor of the mouth, mandible, and skin. C, Reconstruction with a bivalved ﬁ bular
osseocutaneous free ﬂ ap. D, Good intraoral healing (including implants). E, Replace-
ment of the skin of the chin with the same ﬂ ap.

252
Section 2
Oral Cavity/Oropharynx
have skin paddles that can be bivalved to provide exter-
nal coverage in patients requiring excision of the skin
of the chin (see Fig. 31-17D).
POSTOPERATIVE MANAGEMENT
Postoperative management in these cases is similar to
that described for transoral excision of limited lesions
and includes the usual care of the tracheostomy. Suction
drains are always necessary in these cases, similar to
neck dissections (see Chapter 78). Patients are fed
through a nasogastric tube once bowel sounds are
audible. Intraoral management of the patient is similar
to that described earlier. Monitoring and care of the
ﬂ aps are described in the chapters on reconstruction
(see Chapter 81).
References
1. McGuirt WF Jr, Johnson JT, Myers EN, et al: Floor of mouth car-
cinoma: The management of the clinically negative neck. Arch
Otolaryngol Head Neck Surg 121:278-282, 1995.
2. Myers EN, Cunningham MJ: Treatments of choice for early car-
cinoma of the oral cavity. Oncology 2:18-36, 1988.
3. Muñoz Guerra MF, Naval Gías L, Rodríguez Campo F, Sastre
Pérez J: Marginal and segmental mandibulectomy in patients with
oral cancer: A statistical analysis of 106 cases. J Oral Maxillofac
Surg 61:1289-1296, 2003.
4. Pauloski BR, Logemann JA, Colangelo L, et al: Surgical variables
affecting speech in treated patients with oral and oropharyngeal
cancer. Laryngoscope 108:908-916, 1998.
5. Massengill R, Maxwell S, Pickrell K: An analysis of articulation
following partial and total glossectomy. J Speech Hear Disord
35:170-173, 1970.
6. Skelly M: Glossectomy Speech Rehabilitation. Springﬁ eld, IL,
Charles C Thomas, 1973.
7. Rentschler GJ, Mann MB: The effects of glossectomy on intelligi-
bility of speech and oral perceptual discrimination. J Oral Surg
38:348-354, 1980.
8. LaBlance GR, Kraus K, Steckol KF: Rehabilitation of swallowing
and communication following glossectomy. Rehabil Nurs 16:266-
270, 1991.
9. Zieske LA, Johnson JT, Myers EN, et al: Composite resection
reconstruction: Split thickness skin graft—a preferred option.
Otolaryngol Head Neck Surg 98:170-173, 1988.
10. Allison GR, Rappaport I, Salibian AH, et al: Adaptive mechanisms
of speech and swallowing after combined jaw and tongue recon-
struction in long-term survivors. Am J Surg 154:419-422, 1987.
11. Schramm FL, Johnson JT, Myers EN: Skin grafts and ﬂ aps in oral
cavity reconstruction. Arch Otolaryngol 109:175-177, 1983.
12. Baek S, Lawson W, Biller H: An analysis of 133 pectoralis major
myocutaneous ﬂ aps. Plast Reconstr Surg 69:460-467, 1982.
13. Haribhakti V, Kavarana NM, Tibrewala AN: Oral cavity recon-
struction: An objective assessment of function. Head Neck 15:119-
124, 1993.
14. Logemann JA, Pauloski BR, Rademaker AW, et al: Speech and
swallow function after tonsil/base of tongue resection with
primary closure. J Speech Hear Res 36:918-926, 1993.
15. Teichgraeber J, Bowman J, Goepfert H: New test series for the
functional evaluation of oral cavity cancer. Head Neck Surg 8:9-
20, 1985.
16. Schliephake H, Rüffert K, Schneller T: Prospective study of the
quality of life of cancer patients after intraoral tumor surgery. J
Oral Maxillofac Surg 54:664-669, 1996.
17. Spiro RH, Strong EW: Epidermoid carcinoma of the oral cavity
and oropharynx. Elective versus therapeutic radical neck dissec-
tion as treatment. Arch Surg 107:383-384, 1973.
18. Silver CE, Moisa II: Elective treatment of the neck in cancer of
the oral tongue. Semin Surg Oncol 7:14-19, 1991.
PEARLS
• Transoral excision of early squamous cell carcinoma
of the ﬂ oor of the mouth plus reconstruction with a
split-thickness skin graft results in excellent survival
and normal or nearly normal speech and
articulation.
• Successful healing of the skin graft depends on
proper thickness of the skin graft, meticulous
hemostasis, and immobilization of the graft by
proper suturing and application of the gauze bolus.
• Despite advances in imaging modalities, palpation
of the mandible is the most accurate method of
determining whether cancer of the ﬂ oor of the
mouth has inﬁ ltrated into the mandible.
• It is not necessary to reconstruct submandibular
salivary ducts because these glands may be removed
during selective neck dissection.
• Extensive inﬁ ltration of the ﬂ oor of the mouth and
tongue may require total glossectomy with excision
of the ﬂ oor of the mouth. If this seems likely from
clinical evaluation and imaging studies, the patient
should be counseled accordingly.
• The quality of life of patients with extensive cancer
of the ﬂ oor of the mouth can be maximized with
the use of free ﬂ ap reconstruction and early
intervention by a speech pathologist experienced in
swallowing therapy for head and neck cancer
patients.
• Thorough clinical assessment and imaging studies
are necessary for evaluating whether the cancer has
inﬁ ltrated the mandible. If the mandible is involved
and segmental resection is necessary, proper
preoperative plans have to be made for
reconstruction of the mandible.
• Soft tissue specimens must be properly marked for
frozen section evaluation, which should be carried
out systematically. On-site discussion with the
pathologist will reduce the likelihood of error
because of miscommunication.
• Because frozen section is not available for bone
margins, generous margins of bone must be resected
to obtain adequate tumor clearance.
PITFALLS
• Thorough clinical evaluation and imaging studies are
necessary to determine the depth of inﬁ ltration in
squamous cell carcinoma of the ﬂ oor of mouth so
that the proper surgical procedure can be planned.
Performing too large a procedure for a limited
cancer is almost as bad as performing too small a
procedure for a deeply inﬁ ltrative cancer.

Chapter 31
Resection of the Floor of the Mouth
253
19. Dias FL, Kligerman J, Matos de Sá G, et al: Elective neck dissec-
tion versus observation in stage I squamous cell carcinomas of the
tongue and ﬂ oor of the mouth. Otolaryngol Head Neck Surg
125:23-29, 2001.
20. Medina JE: A rational classiﬁ cation of neck dissections. Otolaryn-
gol Head Neck Surg 100:169-176, 1989.
21. Rodgers LW Jr, Stringer SP, Mendenhall WM, et al: Management
of squamous cell carcinoma of the ﬂ oor of mouth. Head Neck
15:16-19, 1993.
22. Schramm VL, Myers EN, Sigler BA: Surgical management of early
epidermoid carcinoma of the anterior ﬂ oor of the mouth. Laryn-
goscope 90:207-215, 1980.
23. Brown B, Barnes L, Mazariegos J, et al: Prognostic factors in
mobile tongue and ﬂ oor of mouth carcinoma. Cancer 64:1195-
1202, 1989.
24. Schramm VL, Myers EN: Skin grafts in oral cavity reconstruction.
Arch Otolaryngol Head Neck Surg 106:528-531, 1980.
25. Maurer P, Eckert AW, Schubert J: Functional rehabilitation fol-
lowing resection of the ﬂ oor of the mouth: The nasolabial ﬂ ap
revisited. J Craniomaxillofac Surg 30:369-372, 2002.
26. Lopez R, Dekeister C, Sleiman Z, Paoli JR: The temporal fascio-
cutaneous island ﬂ ap for oncologic oral and facial reconstruc-
tion. J Oral Maxillofac Surg 61:1150-1155, 2003.
27. Zhao YF, Zhang WF, Zhao JH: Reconstruction of intraoral defects
after cancer surgery using cervical pedicle ﬂ aps. J Oral Maxillofac
Surg 59:1142-1146, 2001.
28. Wolff KD, Hölze F, Nolte D: Perforator ﬂ aps from the lateral
lower leg for intraoral reconstruction. Plast Reconstr Surg
113:107-113, 2004.

Chapter 32
Marginal Mandibulectomy
Eugene N. Myers
The therapeutic goals in the management of cancer of
the oral cavity are eradication of the cancer and restora-
tion of form and function. Crile1 ﬁ rst described the
marginal mandibulectomy in 1923 as an incision that is
“carried down to the underlying bone, and thence into
the bone by a sharp chisel or saw, so that a slice of bone
can be split off in one piece, bearing the undisturbed
cancer off as on a bone platter.” Greer and colleagues,2
in 1953, also described the marginal mandibulectomy
in a study of 21 patients in whom he resected a part of
the mandible in the treatment for intraoral cancer.
Marginal resection of the mandible can be used to
obtain adequate exposure for resection of certain
lesions in the oral cavity, as well as to obtain additional
margins of resection that otherwise would not have
been pos sible by leaving the bone in place. The three
most common locations of cancer of the oral cavity in
which marginal mandibulectomy plays a role include
the ﬂ oor of the mouth, the gingival ridge, and the ret-
romolar trigone.
Squamous cell carcinoma in the oral cavity and
oropharynx often abuts or invades the mandible. In
1951, Ward and Robben3 advocated segmental man-
dibulectomy for tumors that involved or were close to
bone for adequate oncologic resection. The philosophy
of the authors was based on the understanding that
cancers of the tongue and ﬂ oor of mouth drained
through lymphatic channels in the periosteum into the
mandible. However, segmental mandibulectomy pro-
duced severe functional and cosmetic defects. At that
time, reliable reconstructive techniques had not been
developed.
Marchetta and colleagues4 later demonstrated that
mandibular involvement with tumor occurred only with
direct invasion of the periosteum. This eliminated the
mandate for segmental mandibulectomy. Marginal
mandibulectomy is now accepted as an oncologically
sound approach in the management of cancer adjacent
to or involving the periosteum of the mandible.5-11
The advantage of the marginal mandibulectomy is
that it encompasses only a portion of the mandible,
either the alveolar process or the lingual cortex, while
leaving the mandibular arch intact. A segmental rather
than a marginal resection of the mandible is necessary
for tumor clearance if physical examination or imaging
reveals that the bone is invaded by cancer or that the
bone of a tooth socket is invaded. Guerra and associ-
ates12 analyzed a series of 106 patients with cancer of
the oral cavity who required either a marginal or seg-
mental resection of the mandible. The authors found
that patients having marginal mandibulectomy had
cancers smaller than those of patients undergoing seg-
mental mandibulectomy.
I frequently use marginal mandibulectomy in the
surgical management of early squamous cell carcinoma
of the ﬂ oor of the mouth. Schramm and colleagues13
described this procedure in 12 of 26 patients undergo-
ing transoral resection of cancer and split-thickness skin
graft reconstruction. McGuirt and associates,14 in a
more extensive series, reported the use of marginal
mandibulectomy with transoral excision of cancer of
the ﬂ oor of the mouth in 92 of 135 patients to obtain
tumor-free margins.
Petruzzelli and colleagues15 reported the use of
posterior marginal mandibulectomy in the surgical
treatment of cancer of the retromolar trigone or
oropharynx. Good oncologic results were achieved
without signiﬁ cant changes in the patient’s appearance
(Fig. 32-1).
The following are indications for the use of this
technique:
• Inability to obtain an adequate anterior margin of
resection without removing the alveolar process of
the mandible (Fig. 32-2A). This is particularly true in
dentulous patients.
• Attachment of the lesion to the lingual aspect of the
periosteum of the mandible (see Fig. 32-2B).
255

256
Section 2
Oral Cavity/Oropharynx
• In the edentulous patient, tumor that crosses the
alveolus and involves the gingivobuccal sulcus (see
Fig. 32-2C).
A striking advantage of this technique is that mar-
ginal mandibulectomy with split-thickness skin graft
does not eliminate the possibility of dental rehabilita-
tion. After adequate healing, patients can be ﬁ tted with
complete (Fig. 32-3) or partial removable dentures
(Fig. 32-4) or dental implants.
Care must be taken preoperatively to make certain
that there is no bone invasion to avoid local recurrence.
McGregor and MacDonald16 pointed out that when the
tumor originates in the gingival ridge mucosa, the vas-
cular channels in the tooth roots in the alveolar bone
permit early invasion of bone. Dubner and Heller
report that tumors invading deeply into the bone from
cancer of the ﬂ oor of the mouth require segmental
mandibulectomy and that “superﬁ cially invasive cancer
and those cancers arising close to the bone may some-
times be treated with marginal mandibulectomy.”6 They
studied the patterns of recurrence and local tumor
control following mandibulectomy for treatment of
squamous cell carcinoma of the oral cavity and orophar-
ynx. Fifteen of 79 patients (19%) who underwent mar-
ginal mandibulectomy had local recurrence. In our
series,14 only 5 of 130 patients (4%) undergoing trans-
oral resection of squamous cell carcinoma of the ﬂ oor
of the mouth developed local failure, all of which devel-
oped within soft tissue not bone. We believe that our
good results were due to adhering to the concept of
never using the marginal mandibulectomy when man-
dibular bone has been invaded, even superﬁ cially.
Similar results were reported by Ord and associates.5
Muñoz Guerra and colleagues12 believe that the ﬁ nal
decision of which mandibulectomy technique should
be used should be based on clinical judgment in the
operating room. The authors studied their patients and
found that a positive surgical margin and bone invasion
have a signiﬁ cant negative inﬂ uence on survival (Figs.
32-5 and 32-6).
Using a similar concept, Lore17 described a mar-
ginal mandibulectomy including the removal of the
entire inner cortex and alveolar ridge of the hemiman-
dible to resect the tumor and preserve the continuity
of the mandibular arch. Our experience with this type
of procedure is limited, because most tumors approach
but do not actually involve the bone along the body of
the mandible. These tumors may be successfully sepa-
rated from the mandible by undermining the muco-
periosteum off the lingual plate of the mandible and
excising the tumor. If the bone of the mandible is
involved by deep invasion, a segmental resection is
indicated.
Brown and colleagues18 showed that larger tumors
are more likely to have a more aggressive pattern of
invasion of the bone. In these cases, segmental resec-
tion is a safer oncologic option. Marginal mandibulec-
tomy can provide not only good oncologic outcome but
also greatly improves the patient’s postoperative func-
tion and cosmesis by preserving a viable segment of
mandible.11 To maintain the long-term viability of the
remnant mandibular rim and prevent pathologic frac-
tures, it is important to be aware of the blood supply to
the mandible.8
In contrast, a series by Song and Har-El11 included
four pathologic fractures—two associated with osteora-
dionecrosis and two secondary to technical error. The
authors strongly recommend preservation of the facial
artery, if oncologically possible, in patients undergoing
neck dissection with marginal mandibulectomy. This
goal is certainly achievable during elective neck dissec-
tion for the N0 neck. The authors’ results conﬁ rm that
marginal mandibulectomy provides an oncologically
sound approach to tumors abutting the mandible, with
very good local control rates. Attention should be given
to the preservation of the periosteum of the remaining
segment, as well as the facial artery, to prevent the
immediate postoperative morbidity of mandibular
fractures. When postoperative radiation is given, the
surgeon should take into account the potential long-
term complication of osteoradionecrosis.
A
B
Figure 32-1. A, Schematic repre-
sentation
of
retromolar
trigone
lesion amenable to resection with
posterior marginal mandibulectomy.
B, Diagram of surgical defect after
posterior marginal mandibulectomy.
(Reprinted with permission from Petruz-
zelli GJ, Knight FK, Vandevender D, et al:
Posterior marginal mandibulectomy in the
management of cancer of the oral cavity
and oropharynx. Otolaryngol Head Neck
Surg 129:713-719, 2003.)

Chapter 32
Marginal Mandibulectomy
257
A
B
C
Figure 32-2. A, Cancer of the ﬂ oor of the mouth too close to the
mandible to resect without marginal mandibulectomy. B, A tumor
adherent to the mandibular periosteum. C, A tumor crossing but not
invading the mandible.
A
B
Figure 32-3. Complete dentures
(B) in a patient following marginal
mandibulectomy excision of the
cancer and a split-thickness skin
graft (A).
PATIENT SELECTION
Surgical extirpation can have signiﬁ cant functional and
cosmetic implications, but failure to resect a mandible
invaded by cancer leads to progression of disease.19
Patients who are to undergo resection of the ﬂ oor of
the mouth with the indications described above may
beneﬁ t from marginal mandibulectomy. Marginal man-
dibulectomy may also be used safely in patients who fail
radiation therapy for carcinoma of the anterior ﬂ oor of
the mouth. Reconstruction with a split-thickness skin
graft in such cases is contraindicated, however, because
of the possibility of graft failure, exposed bone, and
subsequent osteoradionecrosis. Defects that expose
irradiated bone to oral cavity secretions should be
covered by full-thickness vascularized tissue. My prefer-
ence is a radial forearm free ﬂ ap.
PREOPERATIVE PLANNING
Physical examination remains the mainstay in decision
making. In a patient with an ulcerative lesion overlying
the mandible or adjacent to the lingual cortex of the
mandible, the mandible must be palpated to determine
whether there is exposed bone. Topical anesthesia
or analgesia may be required to facilitate evaluation.
Occasionally, bone invasion can be felt even when it
cannot be seen. Lesions that are adjacent to the man-
dible or attached to the mandibular periosteum can
be identiﬁ ed by bimanual palpation demonstrating
that the tumor is mobile. If the tumor appears to be
ﬁ xed to the bone, it is suggestive of bone invasion.
Modern imaging with computed tomography (CT) or
magnetic resonance imaging (MRI) still lacks the
sensitivity to identify subtle bone invasion. The best
technique to detect bone invasion is the periapical
radiograph. A CT scan can identify gross invasion of
bone as well as perineural involvement, whereas MRI
can identify tumors invading bone marrow. Gomez

258
Section 2
Oral Cavity/Oropharynx
A
B
Cumulative survival
Surgical margin
Affected
Censored
Free
Censored
Time (months)
0
0.0
.1
.2
.3
.4
.5
.6
.7
.8
.9
1.0
1.1
100
200
300
log-rank test-p = 0.0001
Figure 32-4. Partial removable
dentures (B) in a patient following
marginal mandibulectomy and a
split-thickness skin graft (A).
Figure 32-5. Kaplan-Meier estimate of survival by surgical margin
status. Tumor inﬁ ltration beyond the margin of resection had a nega-
tive effect on survival. (Reprinted with permission from Muñoz Guerra MF,
Naval Gías L, Rodríguez Campo F, Sastre Pérez J: Marginal and segmental
mandibulectomy in patients with oral cancer: A statistical analysis of 106
cases. J Oral Maxillofac Surg 61:1293, 2003.)
Cumulative survival
Bone invasion
Free
Censored
Affected
Censored
0.0
.1
.2
.3
.4
.5
.6
.7
.8
.9
1.0
1.1
Time (months)
0
100
200
300
log-rank test-p = 0.0003
Figure 32-6. Kaplan-Meier estimate of survival related to bone inva-
sion. Tumor inﬁ ltration beyond the margin of resection had a nega-
tive effect on survival. (Reprinted with permission from Muñoz Guerra MF,
Naval Gías L, Rodríguez Campo F, Sastre Pérez J: Marginal and segmental
mandibulectomy in patients with oral cancer: A statistical analysis of 106
cases. J Oral Maxillofac Surg 61:1293, 2003.)
and colleagues20 observed that clinical evaluation and
Panorex radiographs (87% sensitivity) remain their
most reliable methods in evaluation of bone invasion.
Weisman and Kimmelman21 have stressed that one third
of the cases of histologically proven invasion of the
mandible do not show clinical signs of bone invasion
preoperatively. A new diagnostic method known as mul-
tiplanar re-formation (Dentascan) CT is now becoming
more popular for assessing the mandible in cancer of
the oral cavity.22,23
Perhaps the most accurate method of clinical assess-
ment of invasion of the mandible involves undermining
the periosteum and directly inspecting the area sus-
pected as invasion of the mandible. Studies in the last
10 years generally agree that direct intraoperative
inspection after periosteal stripping has a high degree
of sensitivity.19
Perineural invasion has been reported as being sig-
niﬁ cantly inﬂ uenced by the presence of dentition.24,25
Neoplastic spread related to the inferior alveolar nerve
was four times greater in the edentulous mandible than
in the partially dentate mandible. This appeared to be
related to the resorption of the alveolar ridge, which
places the inferior alveolar nerve in a more superﬁ cial
position making it more susceptible to invasion by
cancer.19
Preoperative counseling must include a discussion
of the postoperative requirement for a temporary tra-
cheostomy, and placement of a nasogastric tube, and
the different types of reconstructive techniques.
SURGICAL TECHNIQUE
The patient is placed under general anesthesia, and
perioperative antibiotics are administered intrave-
nously. Following direct laryngoscopy, esophagoscopy,
and tracheotomy, right-angled retractors are employed
to provide exposure. A silk suture is placed in the
midline of the tongue approximately 1 cm posterior to
the tip to retract the tongue. The lesion is identiﬁ ed,
the mucosa is dried with gauze, and the extent of the
resection is marked with methylene blue or marking

Chapter 32
Marginal Mandibulectomy
259
pen. The marginal mandibulectomy is always in conti-
nuity with the soft tissue excision, and the anterior
incision is placed in the gingivobuccal sulcus. I have
occasionally encountered superﬁ cial tumors that cross
the alveolar process and extend into the mucosa of the
gingivobuccal sulcus and even onto the buccal surface
of the lower lip (see Fig. 32-2C). In such cases, the inci-
sion must be extended to encompass this area.
Incisions are made with the coagulating current
using a needle tip electrode. A black silk suture is placed
in the anterior margin of the specimen before remov-
ing it to orient the pathologist who will be examining
the specimen with frozen sections. Anteriorly, the inci-
sion is carried down through periosteum to bone. A
broad, sharp periosteal elevator is used to elevate the
mucoperiosteum off the anterior mandible, thereby
exposing the alveolar process (Fig. 32-7).
If the patient has full, or almost full, lower denti-
tion, the osteotomies for an anterior marginal mandib-
ulectomy will usually include the central and lateral
incisors. In such cases, both of the canine teeth should
be extracted and the osteotomy made in the middle of
the tooth socket (Fig. 32-8A) This preserves bone
around the remaining adjacent tooth, which will later
allow application of partial removable dentures with
clasps. If the osteotomy is made just next to the remain-
ing tooth, bone support for this tooth will be weakened.
Eventually, the tooth will become loose and require
removal, thereby losing the support for a partial
denture. If the incisor teeth are removed with the speci-
men, the residual bone must be inspected for the pres-
ence of residual tooth roots, which will interfere with
healing if not removed.
An oscillating saw with a right-angle blade is used
for both the vertical osteotomies and the transverse
osteotomy (see Fig. 32-8B). During the transverse oste-
otomy, the bone must be cut through until the tip of
the blade is felt in the soft tissues of the ﬂ oor of the
mouth. This is an important step, because trying to pry
the alveolar process off of the lingual cortex instead of
completing the osteotomy may lead to fracture of the
mandible. Once free of the mandible, the bone frag-
ment is left attached to the soft tissues of the ﬂ oor of
the mouth, and excision of the cancer by sharp and
blunt dissection is carried deep to the sublingual glands
and up onto the ventral surface of the tongue and then
delivered.
While the frozen sections of the soft tissues are
being examined by the pathologist, hemostasis is
obtained and any sharp edges surrounding the osteoto-
mies are smoothed with a bone ﬁ le or a drill. Closure
is carried out in the appropriate manner, either with a
split-thickness skin graft (Fig. 32-9A) in an unirradiated
case or a radial forearm ﬂ ap in an irradiated case (see
Chapter 31). A split-thickness skin graft will heal on this
bone, because most of the cut surface is cancellous
rather than cortical bone and provides an adequate
Figure 32-7. An incision in soft tissue with dissection of the perios-
teum off the bone.
A
B
Figure 32-8. A, Teeth are extracted and osteotomies are placed in
the tooth sockets to avoid eventual loss of support to the remaining
teeth. B, Vertical and horizontal osteotomies are made with an oscil-
lating saw.

260
Section 2
Oral Cavity/Oropharynx
B
A
Figure 32-9. A, A split-thickness skin graft is sewn into place over
the defect. B, The skin graft overlying soft tissue and bone.
blood supply to the graft (see Fig. 32-9B). Pogrel and
associates26 describe the use of the split-thickness skin
graft and introduce the idea of using bilateral inferiorly
based nasolabial ﬂ aps and island platysma ﬂ aps in
reconstruction of ﬂ oor of the mouth defects. Galati and
Myers27 have also described their good outcome with
the use of platysma ﬂ aps for this purpose.
POSTOPERATIVE MANAGEMENT
Postoperative care for the remainder of the procedure
can be found in the description of transoral resection
of the ﬂ oor of the mouth (see Chapter 31).
COMPLICATIONS
The major complication that must be considered is
fracture of the mandible. Fracture can occur with an
excessive vertical osteotomy even if the transverse oste-
otomy is in proper position. The edentulous mandible
with its decreased vertical height is particularly vulner-
able to this injury. The second possibility is failure to
complete the osteotomies with the saw, then trying to
pry up and fracture off the alveolar process and the
lingual cortex of the bone. In such cases, the bone must
be repaired with a compression plate or wires to ensure
proper healing. Mandibulotomy in conjunction with
marginal mandibulectomy is to be avoided so that bone
is not devascularized.
PEARLS
• Every effort should be made to rule out invasion of
the mandible by preoperative imaging studies to
have the most accurate preoperative planning.
• Osteotomies must be planned, in a detailed
manner, in advance of the surgery.
• In dentate patients, extraction of appropriate teeth
with osteotomies carried out through the tooth
sockets is important in providing long-term
preservation of the residual teeth for prosthetic
rehabilitation.
• The systematic use of intraoperative frozen section
analysis should be used to prevent recurrence in the
soft tissues.
• The use of the split-thickness skin graft is the
mainstay of reconstruction in cases in which
marginal mandibulectomy is used.
PITFALLS
• Invasion of bone may be underestimated and
positive bone margins may occur.
• If intraoperative frozen section control of soft tissue
margin is not practiced systematically, the incidence
of positive margins and recurrence will be
unacceptably high.
• Osteotomies placed adjacent to the remaining tooth
rather than in extraction sites in dentate patients will
weaken the bone and lead to loss of the tooth.
• Fracture of the mandible from prying the fragment
off the bone may occur if the horizontal osteotomy
is not carried out completely.
References
1. Crile GW: Carcinoma of the jaws, tongue, cheek, and lips. Surg
Gynecol Obstet 36:159-162, 1923.
2. Greer DB, Smith RR, Klopp CT: A surgical method of treatment
of carcinoma of the ﬂ oor of the mouth. Surgery 34:279-287,
1953.
3. Ward GE, Robben JO: A composite operation for radical neck
dissection and removal of cancer of the mouth. Cancer 4:98-109,
1951.
4. Marchetta FC, Sako K, Murphy JB: The periosteum of the man-
dible and intraoral carcinoma. Am J Surg 122:711-713, 1971.
5. Ord RA, Sarmadi M, Papadimitrou J: A comparison of segmental
and marginal bony resection for oral squamous cell carcinoma
involving the mandible. J Oral Maxillofac Surg 55:470-477,
1997.
6. Dubner S, Heller KS: Local control of squamous cell carcinoma
following marginal and segmental mandibulectomy. Head Neck
15:29-32, 1993.
7. Randall CJ, Eyre J, Davies D, et al: Marginal mandibulectomy for
malignant disease: Indications, rationale, and results. J Laryngol
Otol 101:676-684, 1987.

Chapter 32
Marginal Mandibulectomy
261
8. Komisar A, Barrow HN: Mandible preservation in cancer of the
ﬂ oor of the mouth: Anatomical and oncological considerations.
Arch Otolaryngol Head Neck Surg 120:1197-1200, 1994.
9. Wald RM Jr, Calcaterra TC: Lower alveolar carcinoma. Segmental
vs marginal resections. Arch Otolaryngol 109:578-582, 1983.
10. Barttelbort SW, Ariyan S: Mandible preservation with oral cavity
carcinoma: Rim mandibulectomy versus sagittal mandibulec-
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11. Song CS, Har-El G: Marginal mandibulectomy: Oncologic and
nononcologic outcome. Am J Otolaryngol 24:61-63, 2003.
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Pérez J: Marginal and segmental mandibulectomy in patients with
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13. Schramm VL, Myers EN, Sigler BA: Surgical management of early
epidermoid carcinoma of the anterior ﬂ oor of the mouth. Laryn-
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Otolaryngol Head Neck Surg 121:278, 282, 1995.
15. Petruzzelli GJ, Knight FK, Vandevender D, et al: Posterior mar-
ginal mandibulectomy in the management of cancer of the oral
cavity and oropharynx. Otolaryngol Head Neck Surg 129:713-719,
2003.
16. McGregor IA, MacDonald DG: Spread of squamous cell carci-
noma to the nonirradiated edentulous mandible. A preliminary
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17. Lore JM Jr: An Atlas of Head and Neck Surgery, 3rd ed. Philadel-
phia, WB Saunders, 1988, pp 586-595.
18. Brown JS, Lowe D, Kalavrezos N, et al: Patterns of invasion and
routes of tumor entry into the mandible by oral squamous cell
carcinoma. Head Neck 24:370, 2002.
19. Politi M, Costa F, Robiony M, et al: Review of segmental and
marginal resection of the mandible in patients with oral cancer.
Acta Otolaryngol 120:569-579, 2000.
20. Gomez D, Faucher A, Picot V, et al: Outcome of squamous cell
carcinoma of the gingiva: A follow-up study of 83 cases. J Cranio-
maxillofac Surg 28:331-335, 2000.
21. Weisman RA, Kimmelman CP: Bone scanning in the assessment
of mandibular invasion by oral cavity carcinomas. Laryngoscope
92:1-4, 1982.
22. King JM, Caldarelli DD, Petasnick JP: DentaScan: A new diagnos-
tic method for evaluating mandibular and maxillary pathology.
Laryngoscope 102:379-387, 1992.
23. Talmi YP, Bar-Ziv J, Yahalom R, et al: DentaCT for evaluating
mandibular and maxillary invasion in cancer of the oral cavity.
Ann Otol Rhinol Laryngol 105:431-437, 1996.
24. McGregor AD, MacDonald DG: Reactive changes in the mandible
in the presence of squamous cell carcinoma. Head Neck Surg
10:378-386, 1988.
25. McGregor AD, MacDonald DG: Patterns of spread of squamous
cell carcinoma within the mandible. Head Neck 11:457-461,
1989.
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dibulectomy. Atlas Oral Maxillofac Surg Clin North Am 5:37-54,
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reconstruction of the ﬂ oor of mouth. Rev Bras Cir Cabeça Pescoço
24:67-69, 2000.

Chapter 33
Segmental Mandibulectomy
David E. Eibling
Segmental mandibulectomy describes removal of a
segment of mandible and thereby interrupting its con-
tinuity. Segmental mandibulectomy may be performed
in the setting of a composite resection, that is, resection of
a segment of mandible in continuity with a cancer of
the oral cavity or oropharynx or a primary cancer of the
alveolar ridge. Excision of bone, as commonly per-
formed today, was reported by Slaughter and colleagues
and then Ward and Robben half a century ago,1,2 and
the fundamental concepts of extirpation have not
changed in the interval. An exception is that uninvolved
mandible is no longer removed to provide adequate
exposure to remove the cancer. Unless the bone is
involved, an osteotomy is now carried out by retraction
of the bone fragments, which provides adequate expo-
sure to remove the cancer without removing the
bone.
What has changed signiﬁ cantly in the half-century
interval are the techniques of reconstruction, selection
of which is the most problematic decision-making
dilemma facing the operating surgeon. Resection of the
alveolar ridge with maintenance of continuity of the
mandible is termed marginal mandibulectomy (Table
33-1) and is discussed in Chapter 32. Segmental man-
dibulectomy should be performed for cancers that actu-
ally invade the bone without soft tissue involvement, in
which case reconstruction is less problematic. Segmen-
tal resection of the mandible is also performed in
patients with advanced osteoradionecrosis (ORN) that
cannot be treated medically.
Postoperative radiotherapy is required for most
patients because of their advanced stage at initial evalu-
ation. Patients with bone involvement are staged T4,
and many patents will also have clinical evidence of
cervical adenopathy. Recent reports suggest that con-
current adjuvant chemoradiation therapy is beneﬁ cial
in this high-risk group.3,4 Surgical extirpation should be
performed with the intention of complete excision of
the cancer, as well as expeditious healing to avoid
untoward delays in initiating adjuvant treatment.
The use of primary or adjunctive radiation therapy
has become a standard of treatment in the manage-
ment of advanced cancer of the head and neck. Unfor-
tunately, one of the devastating complications resulting
from this therapy is mandibular ORN. Its incidence
ranges between 2% and 25% and it varies in severity.
Mandibular ORN has proved to be a difﬁ cult condition
to manage. The use of conservative treatments such as
antibiotics, local débridement, and hyperbaric oxygen
therapy has been advocated for lower grades of ORN,
as well as for early ORN. For advanced ORN, segmental
resection of the mandible along with reconstruction
with vascularized bone-containing free ﬂ aps harvested
from the ﬁ bula, iliac crest, and scapula is emerging as
a mainstay of therapy for ORN. Militsakh and associ-
ates5 described the role of an osseocutaneous radial
forearm free ﬂ ap in the treatment of mandibular ORN.
The authors reported excellent postoperative outcomes
when ORN was managed with an osseocutaneous radial
forearm free ﬂ ap, even in the setting of heavily irradi-
ated tissue.
PATIENT SELECTION
Cancer arising in the oral cavity and oropharynx may
invade the mandible. Bone invasion is usually associ-
ated with a large cancer arising on the ﬂ oor of the
mouth, on the alveolar ridge, or in the retromolar
trigone region (Fig. 33-1). If the cancer is adjacent to
bone or ﬁ xed to the periosteum without invasion, mar-
ginal mandibulectomy is adequate to ensure a safe
margin of resection (Fig. 33-2). If the bone is involved
by cancer, marginal mandibulectomy is inappropriate
for adequate tumor excision because of the high rate
of recurrence associated with insufﬁ cient resection of
bone. Histologic whole-organ studies have demon-
263

264
Section 2
Oral Cavity/Oropharynx
Table 33-1 DEFINITIONS OF MANDIBULECTOMY
Mandibulotomy
Osteotomy of the mandible to
permit exposure, no bone resected;
bone is reapproximated at the
completion of the procedure
Marginal
mandibulectomy
A portion of the mandible, typically
the alveolus or lingual plate, is
resected while leaving the continuity
of the mandible intact
Segmental
mandibulectomy
A portion of mandible is resected,
with disruption of condyle-to-
condyle continuity
Ramus
Angle
Body
Parasymphysis
B
D
C
A
Figure 33-1. A, A squamous cell carcinoma arising from the alveolar ridge and invading the bone of the mandible. B, Patient after segmental
resection and reconstruction with a ﬁ bular osseocutaneous free ﬂ ap. C, Donor site for a ﬁ bular ﬂ ap. D, Fibular ﬂ aps are wide enough to accom-
modate dental implants.
Figure 33-2. Squamous cell carcinoma of the anterior ﬂ oor of the
mouth adjacent to the mandibular alveolus. In these cases, unin-
volved bone must be resected to ensure an adequate margin. This is
an ideal situation for a marginal mandibulectomy rather than seg-
mental mandibulectomy.
strated that once cancer gains access to marrow spaces,
tumor cells can spread beyond the apparent gross
margins and involve not only the marrow cavity but also
the neurovascular bundle.6 Gross tumor involvement by
cancer results in bone resorption, as well as osteoblastic
activity, and may cause pathologic fractures (Fig. 33-3).
Marginal mandibulectomy, if performed in these situa-
tions, leads to a high rate of local recurrence.
Preoperative determination of the presence or
extent of involvement of the mandible can be challeng-
ing. Palpation of the tumor with determination of
mobility of the tumor relative to the mandible is often
more accurate than radiologic imaging. More than 60%
to 70% of bone mineral must be lost before radio-
graphic changes become evident (Fig. 33-4). Even axial

Chapter 33
Segmental Mandibulectomy
265
computed tomography (CT) scans often cannot reliably
demonstrate the presence or extent of tumor invasion
into bone, although with extensive involvement the loss
of bone is apparent (Fig. 33-5). This lack of reliability
is even more troublesome in patients who have previ-
ously undergone treatment, either surgery or radio-
therapy. A study by Tsue and associates suggested that
ﬁ ndings on CT are conﬁ rmed histologically in only
73% of patients.7 The use of a computer software
program that permits cross-sectional imaging of the
mandible may improve the sensitivity somewhat.
However, correlation between radiographic evidence of
bone involvement and histologic evidence of cancer
involvement is, at this time, inadequate.
Imaging techniques such as technetium-99m bone
scanning or positron emission tomography may provide
some beneﬁ t in selected patients. Unfortunately, the
local inﬂ ammatory response to the adjacent cancer and
the poor resolution combine to reduce the clinical
utility of these studies.
Magnetic resonance imaging (MRI) may help
detect cancer involving the marrow spaces because it
does not rely on changes in bone density.8 MRI occa-
sionally helps in preoperatively determining the extent
of bone resection required to assist in planning recon-
structive techniques (Fig. 33-5). Unfortunately, a study
has suggested that MRI may have an excessive rate of
false-positive results.9 McGregor and MacDonald dem-
onstrated that bone involvement typically occurs
through the alveolus rather than through either the
lingual or buccal cortical plates in an edentulous man-
dible.10 This axiom does not hold true in patients who
have undergone radiation therapy, however. Decision
making regarding mandibulectomy after previous treat-
ment is problematic and relies heavily on physical
examination and the surgeon’s clinical judgment.6,10
Figure 33-3. Pathologic fracture caused by invasion and partial
destruction of the mandible by squamous cell carcinoma.
Figure 33-4. Panorex view of the mandible demonstrating bone
erosion from carcinoma invading the mandibular alveolus (arrow)
adjacent to the molar tooth.
A
B
Figure 33-5. A and B, Com-
puted tomography scans of a
patient with retromolar squamous
cell carcinoma that eroded the
mandible and enveloped the molar
tooth (arrows).

266
Section 2
Oral Cavity/Oropharynx
The mainstay of patient selection remains physical
examination, with careful attention to bimanual palpa-
tion of the mandible and estimation of the probability
of involvement of the bone by cancer. Unfortunately,
preoperative evaluation does not reliably correlate with
histologic ﬁ ndings at the time of surgery: rates of false-
positive and false-negative results approach 50%. Deter-
mination of adequate margins is difﬁ cult because of the
complex three-dimensional anatomy of the resected
specimen. Frozen section cannot be performed on
bone biopsy samples, but it may be useful on samples
taken from the neurovascular bundle or bone
marrow.
In past years, excision of cancer in the posterior
oral cavity usually included bone removal, even in the
absence of deﬁ nite involvement of bone with tumor.
Mandibulectomy was performed routinely to facilitate
exposure of the tumor and postoperative soft tissue
closure. Alternative approaches such as mandibulotomy
provide excellent exposure while retaining the continu-
ity of the mandibular arch. This technique is recom-
mended when the mandible is not involved directly by
the cancer.
Selection of the proper location for osteotomies is
sometimes problematic. Once bone involvement has
been demonstrated either clinically or radiographically,
the extent of invasion of cancer into bone is not easily
determined. A marrow cavity that appears uninvolved
on CT scan may be found on histologic evaluation
to include cancer cells, hence the requirement for
generous bone margins. The ﬁ nding of cancer involve-
ment in bone margins after decalciﬁ cation is even more
problematic and typically requires reoperation for
tumor control because positive margins essentially guar-
antee recurrence and death.11 Wide margins of at least
2 cm beyond the visible extent of bone involvement
should be the rule. This is true not only for invasive
squamous cell carcinoma but also for primary bone
malignancies such as osteogenic sarcoma and chondro-
sarcoma, which present individual problems in
management.
Reconstruction of the Mandible
The most difﬁ cult decision making regarding segmen-
tal resection of the mandible is that involving recon-
struction of the mandible. These decisions must be
made preoperatively to prepare for the reconstructive
portion of the procedure. Loss of continuity of the
mandible is associated with signiﬁ cant morbidity. As a
U-shaped structure hinged only at the open ends to the
skull base, the mandible is rotated and translated by
coordinated muscular pull at various points and vectors.
Interruption of continuity of the mandibular arch
results in difﬁ culty positioning the remaining mandi-
ble, as well as the obvious effects of loss of the frame-
work for the soft tissue and teeth. With the advent of
modern free tissue transfer, there have been great
advances in mandibular reconstruction after resection
for cancer. Nonetheless, substantial morbidity accom-
panies these reconstructive procedures, so the surgeon
must decide not “what is best” but “what is best for this
patient.”
Various techniques for mandibular reconstruction
have evolved over the years12,13 and are listed in Table
33-2. The techniques most commonly used today are
free vascularized bone or a metal reconstruction plate
covered by a free vascularized or pedicled soft tissue
ﬂ ap. The ﬁ rst technique provides optimal long-term
results because even with adequate muscle coverage,
metal plates still tend to become exposed.13 Although
reconstruction adds to the operative morbidity of the
procedure, most patients, even in the older age group,
appear to tolerate these long procedures quite well.
Defects after segmental resection of the mandible
can be divided into lateral and anterior defects because
their indications and morbidity vary accordingly. Con-
troversy surrounds reconstruction of defects involving
the mandible posterior to the mental foramen. Komisar14
demonstrated that these patients do not beneﬁ t func-
tionally from the reconstructive efforts that are required
to reconstitute bone continuity. Urken and coworkers15
noted that in their hands reconstruction is warranted
not only to restore continuity of the mandibular arch
but also to facilitate dental prosthetic rehabilitation
with osseointegrated ﬁ xation devices placed in the vas-
cularized bone. They also routinely reconstruct the
inferior alveolar nerve to restore sensation in the lower
lip. Lateral bone defects are not in and of themselves
debilitating, but function is more likely to be impaired
by the associated soft tissue loss (or tethering) and
dental loss. Decisions regarding reconstruction should
be based on the patient’s age, dentition, and expecta-
tions, as well as on the anticipated soft tissue defect.
Occasionally, a patient who is an exceptionally poor risk
can be reconstructed with soft tissue only, such as a
pectoralis major myocutaneous or split-thickness skin
graft. If immediate reconstruction of these defects is
elected, a free vascularized bone graft performed at the
time of surgery is the optimal strategy.
There is no controversy regarding reconstruction
of mandibular defects anterior to the mental foramen.
Mandibular continuity in this central region is critical
for maintenance of tongue protrusion, cosmetic reasons,
including chin contour, and oral cavity competence.
Table 33-2
METHODS OF RESTORATION OF
MANDIBULAR CONTINUITY
Soft tissue only
Regional pedicle ﬂ ap
Skin graft
Reconstruction plate
Plate and screw with a regional pedicle ﬂ ap
Plate and bone-anchored post with a titanium hollow-
screw reconstruction plate (THORP)
Microvascular free ﬂ aps with bone (preferred option)
Radius
Fibula
Scapula
Iliac crest

Chapter 33
Segmental Mandibulectomy
267
Loss of the anterior segment of bone results in severe
deformity with associated loss of function of the oral
cavity, including mastication, oral competence, drool-
ing, and swallowing ability (Fig. 33-6). In addition, loss
of anterior support for the tongue may result in airway
difﬁ culty for these patients. For these reasons, recon-
struction of anterior mandibular defects is mandatory,
particularly with the current widespread availability of
surgeons skilled in microvascular reconstructive tech-
niques. Reconstruction should be performed at the
time of resection. The details of reconstruction are dis-
cussed in Section 9 of this text.
Distraction Osteogenesis
A novel means of mandibular reconstruction via distrac-
tion osteogenesis as popularized by Ilizarov in long
bones has been applied to hypoplastic mandibles.16 It
seems feasible that this technique may ﬁ nd utility in
mandibular reconstruction. This technique involves
dividing the bone and leaving the periosteum intact. As
the two ends of the bone are slowly separated by an
external apparatus ﬁ xed to both bone segments, new
bone is deposited by the remaining periosteum. Its use
in mandibular reconstruction has been demonstrated
recently by several investigators.17,18 It seems unlikely
that this technique will replace free ﬂ ap mandibular
reconstruction, however, because of the time required
to replace a mandibular segment with this technique.
PREOPERATIVE PLANNING
All patients must undergo tracheotomy because post -
operative oral disability will result in aspiration. Edema
may lead to airway obstruction. The tracheotomy should
be performed at the beginning of the procedure to
allow removal of the endotracheal tube from the oral
cavity to facilitate excision of the cancer. Although a
tracheostomy is routine in such cases, it may not be
viewed as such by the patient and requires preoperative
discussion. A discussion of the tracheostomy, feeding
tubes, Foley catheter, and drains is mandatory during
the preoperative counseling.
Complete dental evaluation and extractions when
necessary are important in the management of oral
cavity cancer. Postoperative radiotherapy or chemora-
diotherapy is often required, and retention of teeth that
are in poor condition will probably lead to substantial
postoperative and postradiation morbidity. A large
cancer of the oral cavity is most likely to be encountered
in patients who have had less than adequate dental
care. We believe that dental extractions should be the
rule in this patient population and that only teeth that
are in excellent condition and may play a role in dental
rehabilitation should be saved. The teeth in the involved
section of bone do not require removal preoperatively
because they will be resected in continuity with the
tumor.
Perioperative antibiotics are indicated and must be
administered before the procedure begins. Antibiotics
effective against oral ﬂ ora, including anaerobes, must
be selected. It is useful for surgeons to establish a
routine so that they do not neglect to order these anti-
biotics and to ensure that they are given at the appropri-
ate time. Failure to use antibiotics in clean-contaminated
cases such as these will result in an unacceptable high
rate of postoperative wound infection.
As previously noted, plans for reconstruction of the
mandible must be ﬁ nalized before the procedure. Pre-
operative vascular studies to deﬁ ne the donor vascular
anatomy is routine in some centers, and preoperative
discussion with the reconstructive team (particularly if
from another department) is mandatory.
Communication with the operating room nursing
staff is necessary to ensure that all are aware of the
planned procedure. Appropriate instruments and
powered tools should be available, including both saws
and drills with appropriate blades and bits. Frequently,
two teams are operating at the same time, so preopera-
tive planning will reduce the disorder often found in
such busy two-team rooms. Nevertheless, one surgeon
must be designated as the primary surgeon, with all
signiﬁ cant decisions being referred to that person. The
site of the mandibulectomy, the donor site, and any
planned neck dissection should be marked on the skin
to prevent any possibility of “wrong-side” or “wrong-site”
surgery.
The choice of incisions varies with the site of the
cancer and the skill of the surgeon. Usually, mandibu-
lectomy can be performed through an upper neck inci-
sion 2 to 4 cm below the mandible. It is usually
incorporated into a half-H or similar incision because
neck dissection is typically performed as part of the
procedure (Fig. 33-7). A lip-splitting incision dramati-
cally improves visualization during resection of the
primary cancer and mandible and contributes little
additional postoperative morbidity. Such an incision
may not be required for mandibulectomy in some
Figure 33-6. This severe deformity is due to resection of the antero-
lateral segment of the mandible with failed bone reconstruction.
Pectoralis myofascial ﬂ aps were used to reconstruct the soft tissue
defect.

268
Section 2
Oral Cavity/Oropharynx
patients, however, if adequate mucosal incisions are
made to facilitate degloving of the mandible (visor
ﬂ ap). Because the ipsilateral inferior alveolar nerve will
be sacriﬁ ced, the contralateral mental nerve must be
preserved. Unfortunately, preservation of the contralat-
eral mental nerve often creates signiﬁ cant technical
difﬁ culties in exposure when a visor ﬂ ap is used. Marking
the proposed incision and then halting the neck inci-
sions just inferior to the chin will permit extension into
a lip-splitting incision should additional visualization be
desired intraoperatively.
Neck Dissection
Squamous cell carcinoma that is of sufﬁ cient size to
warrant segmental mandibulectomy will require neck
dissection. Patients with no palpable adenopathy on
clinical examination (N0) and with negative preopera-
tive imaging results should undergo selective neck dis-
section in levels I through III. Removal of level IV is
necessary in patients with or without squamous cell car-
cinoma of the lateral tongue because such patients may
have “skip lesions” in level IV without involvement of
levels II and III. In the face of palpable adenopathy,
either selective neck dissection for N1 and N2c or
radical or modiﬁ ed neck dissection (with preservation
of the spinal accessory nerve) for more advanced stage
N2/N3 is advocated. For patients undergoing segmen-
tal mandibulectomy for cancer of other histologic types,
neck dissection should be based on the biologic char-
acteristics of the tumor.
Care must be taken during neck dissection to
remove level I nodes adjacent to the facial artery (i.e.,
prevascular and postvascular nodes). The surgeon may
be tempted to leave these nodes in situ to reduce the
possibility of injury to the marginal mandibular nerve.
Unfortunately, they may contain metastases from
primary cancer involving the alveolus and mandible
and hence must be removed. Neck dissection usually
precedes mandibulectomy and excision of the cancer.
The superior dissection is performed last, and the speci-
men can be left attached to the periosteum of the
mandible.
Decisions regarding the contralateral neck may be
difﬁ cult. In the presence of cancer-free nodes and a lat-
erally located posterior oral cavity lesion, contralateral
neck dissection may not be necessary. However, if the
primary cancer has involved the base of the tongue, if
the tumor approaches or crosses the midline, or if large
nodes are present in the ipsilateral neck, the likelihood
of contralateral adenopathy is increased and bilateral
neck dissection is indicated. In most cases this will
involve selective neck dissection of levels I through III.
Prosthetic Rehabilitation
Many patients undergoing segmental resection of a
mandible in continuity with oropharyngeal cancer will
require prosthetic rehabilitation to improve postopera-
tive deglutition and speech function. The goal of such
rehabilitation is not replacement of resected bone but
obturation of the soft tissue defect resulting from tumor
excision. Rehabilitation can begin shortly after the
bolus is removed in patients who have undergone
reconstruction with a skin graft and once healing has
been completed in patients in whom a muscle or skin-
muscle ﬂ ap has been used to close the defect. This
process is facilitated by preoperative consultation with
a maxillofacial prosthodontist before surgical excision
if the patient is able to tolerate oral examination and
trismus is minimal. Prosthetic rehabilitation with osseo-
integrated ﬁ xation devices may be appropriate in
selected patients. Because of the requirement for post-
operative radiotherapy in the majority of these patients,
other surgeons elect to not use these techniques out of
concern for the long-term effects of radiotherapy-
induced bone complications.
TECHNIQUE
In most instances a preliminary tracheotomy is per-
formed to provide maximal exposure of the tumor and
to prevent accidental extubation during the mandibu-
lectomy and intraoral tumor excision. Dental extrac-
tions may be performed at the beginning of the
procedure or at the time of tumor excision. If done by
the oral surgical team, it is usually easier to perform the
extractions ﬁ rst for scheduling reasons, provided that
the patient does not have severe trismus.
Once the neck dissection has been completed, the
specimen may be removed or left attached superiorly
Figure 33-7. Among the incisions used for composite resection is
the lip-splitting modiﬁ ed half-H. This incision provides excellent visi-
bility of posterior oral cavity lesions. It can be used for bilateral neck
dissection by the formation of a submental trifurcation.

Chapter 33
Segmental Mandibulectomy
269
to the periosteum of the mandible. Dissection is carried
over the periosteum of the buccal plate of the mandible
anterior to the masseter muscle, and the marginal
branch of the facial nerve is elevated with the skin ﬂ ap.
The periosteum is incised inferior to the attachment of
the masseter muscle, which is then elevated from the
angle of the mandible, depending on the extent of
cancer lateral to the mandible (Fig. 33-8). If the tumor
has invaded the soft tissue lateral to the mandible or if
the prevascular and postvascular nodes are grossly
involved with cancer, it may be necessary to sacriﬁ ce the
facial artery and associated marginal mandibular nerve
to widely encompass the cancer. If these nodes are not
clinically involved, the marginal nerve must be identi-
ﬁ ed and then isolated and elevated to prevent injury.
The lip is divided in the midline and the skin ﬂ ap
is elevated in continuity with the superiorly based ﬂ ap.
An intraoral degloving incision will have to be made
anterolateral to the cancer in the buccogingival sulcus
as the cheek ﬂ ap is elevated (Fig. 33-9). The incision
must be tailored to leave an adequate margin (at least
1 cm) as it approaches the tumor. The mental nerve will
have to be divided as the skin ﬂ ap is elevated. This does
not increase the morbidity associated with the proce-
dure because the ipsilateral inferior alveolar nerve will
be sacriﬁ ced at the time of mandibulectomy. A lip-
splitting incision results in wide exposure of the man-
dible, preserves the contralateral mental nerve, and is
preferred by most surgeons (Fig. 33-10).
When a degloving approach is planned, intraoral
incisions must be made before entering the oral cavity
to ensure appropriate placement of the mucosal inci-
sions. This step requires adequate light and wide
opening of the oral cavity with retractors (Fig. 33-11).
A suture placed in the tip of the tongue or along the
lateral margin of the tongue anterior to the cancer will
assist in stretching out the mucosa, thereby easing
placement of these incisions. Extending the incision
into the contralateral gingivolabial sulcus will be neces-
sary to ensure exposure, and the contralateral mental
nerve must be identiﬁ ed and preserved. The neck inci-
sion is then connected with the intraoral incision via
blunt dissection (if this was not already performed) and
carefully extended along the previously made mucosal
incision. Care must be taken to not compromise resec-
tion of the margins. One or two Penrose drains can be
passed through the oral cavity, brought out through the
neck incision, and used for retraction of the ﬂ ap to
improve visualization at this point in the procedure.
The reconstruction team may wish to preplate the
mandible before mandibulectomy. If this is the case,
the reconstruction plate is shaped and screw holes are
placed at either end to register the planned residual
bone. Because there is usually considerable soft tissue
remaining, some adjustment may be necessary. The
plate is then removed and must be sterilized to elimi-
nate all cancer cells before reuse at the time of
reconstruction.
The anterior position for the mandibular osteot-
omy is then marked on the mandible. Care must be
taken to ensure adequate margins; at the very minimum
Figure 33-8. Dissection of the mandibular periosteum and masse-
ter muscle lateral to the mandible. Care must be taken to avoid
exposing the cancer by excessive dissection superiorly.
Figure 33-9. A lip-splitting incision with extension along the buc-
cogingival sulcus to permit retraction of the cheek ﬂ ap. Care must be
taken to avoid compromising the tumor margin of resection
laterally.

270
Section 2
Oral Cavity/Oropharynx
the mental foramen should be included. This will
require bimanual palpation, as well as direct inspection
of the tumor.
The osteotomy is then performed with a reciprocat-
ing power saw (Fig. 33-12) and continuous irrigation.
Face shields are always required by all at the operating
table, but they are even more critical when using power
saws with irrigation. Appropriate soft tissue retraction
helps prevent excessive soft tissue injury. The osteotomy
can be facilitated by removal of a tooth from the line
of the planned excision. Care should be taken during
osteotomy to ensure that adequate bone is left around
any remaining dentition. It may be necessary to remove
one or more additional teeth to ensure adequate
mucosal coverage of the remaining bone. Most of these
patients have poor dentition, and typically all the
remaining teeth have been removed before tumor exci-
sion. It is a grave error to leave poor teeth in place at
the time of tumor excision because access to the oral
cavity will be severely compromised by the reconstruc-
tion, thus making later extraction challenging at best
and perhaps even impossible.
Excision of the cancer is facilitated by sectioning
the ramus of the mandible before excision of the cancer
(Fig. 33-13). Lateral retraction of the mandibular
segment is limited by the presence of an intact mandi-
ble and temporomandibular joint. Depending on the
extent of the cancer, this may be performed either
below the notch of the mandible, through the notch
with section of the coronoid process and a portion of
the tendon of the temporalis muscle, by disarticulation
of the mandible from the glenoid fossa, or vertically
with preservation of the angle and posterior aspect of
the ramus. Division of the tendon of the temporalis
muscle will be required if the coronoid process is left
Figure 33-10. Reﬂ ection of the cheek ﬂ ap provides excellent visu-
alization of the cancer.
Figure 33-11. A buccogingival incision without a lip-splitting inci-
sion to permit elevation of the cheek ﬂ ap as a “visor.” If this incision
is selected, care must be taken to avoid sacriﬁ cing the contralateral
mental nerve.
Figure 33-12. An anterior osteotomy is made with a reciprocating
power saw. If the patient is dentate, the osteotomy is made through
an extraction site.

Chapter 33
Segmental Mandibulectomy
271
on the specimen. Disarticulation is somewhat more
technically challenging, compromises mandibular
reconstruction, and is not generally required. Section
of the mandible in the midramus is often associated
with signiﬁ cant bleeding because of interruption of the
inferior alveolar artery or, occasionally, the internal
maxillary artery. Once the osteotomy is completed, any
bleeding can usually be controlled expeditiously; there-
fore, one should not stop midway through the bone cut
in an attempt to control the bleeding. Placing the oste-
otomy near the coronoid notch will minimize bleeding
from the inferior alveolar artery.
When both osteotomies have been completed, the
mucosal incision can more easily be made around the
tumor in the posterior oral cavity. The mucosal incision
is extended along the mucosa of the mouth to further
expose the tumor (Fig. 33-14). Overexuberant retrac-
tion of bone must be avoided to prevent tearing the
specimen at this time. Although the lingual nerve can
usually be preserved anteriorly, cancer of the posterior
oral cavity involving the mandible typically involves or
closely approaches the lingual nerve, thereby preclud-
ing routine preservation. The inferior alveolar canal is
transected at the time of anterior osteotomy, and the
inferior alveolar nerve must be sectioned proximally
and in the soft tissue incision inferior to the skull
base.
Adequate margins must be ensured, particularly
posteriorly and superiorly toward the eustachian tube,
which tends to be a difﬁ cult region to visualize. Spend-
ing the extra time to obtain hemostasis before comple-
tion of the resection is often valuable in that it aids
visualization of the cancer and ensures adequate three-
dimensional margins (as well as limits unnecessary
blood loss). Care must be taken to avoid tearing the
specimen because tearing can make determination of
the adequacy of margins difﬁ cult for the pathologist,
even if the torn specimen is marked by suture.
Excision of the cancer may require resection of a
portion of the soft palate. Placement of a suture in the
cut end of the soft palate before tumor excision aids
retraction and assists in identifying this portion later
and orienting the specimen for the pathologist (Fig.
33-15). The excision extends superiorly and laterally,
and the medial pterygoid muscles and branches of the
mandibular nerve (V3) are divided. This is facilitated
by placing a ﬁ nger behind the specimen to elevate the
soft tissue to be cut and to protect the carotid artery
Figure 33-13. An oscillating saw is used for osteotomy of the neck
of the mandibular condyle. The osteotomy could also be made
through the midramus. If oncologically feasible and reconstruction
is planned, a vertical osteotomy provides more bone, thereby improv-
ing ﬁ xation of the graft.
Figure 33-14. The mandible is retracted laterally, and a suture is
placed in the tongue to help in retraction and maintenance of an
adequate margin around the tumor as it is excised.
Figure 33-15. Retraction of the soft palate with a suture placed in
the uvula will help make precise cuts through the mucosa of the soft
palate. It is also advisable to place a suture through the specimen to
facilitate orientation by the pathologist.

272
Section 2
Oral Cavity/Oropharynx
posteriorly (Fig. 33-16). It is usually easiest to work cir-
cumferentially and gradually narrow the pedicle attach-
ing the tumor to the skull base. Adequacy of excision
must be ensured because growth of cancer will typically
parallel the branches of V3. Branches of the maxillary
artery will be encountered and must be ligated.
When the tumor has been excised, it must be exam-
ined carefully by both the surgeon and the pathologist.
Orientation of the specimen may be difﬁ cult or impos-
sible for the pathologist without the assistance of the
surgeon (Fig. 33-17) because of the complex three-
dimensional anatomy. Frozen sections are obtained to
ensure adequacy of the margins of resection, especially
the neurovascular pedicle. Failure to adequately excise
the cancer results in recurrent disease and death in
essentially all patients.12 It is preferable to completely
excise the cancer at the initial attempt rather than
return in several weeks for additional attempts at exci-
sion after histologic demonstration of cancerous
margins.
Close cooperation between the surgeon and pathol-
ogist cannot be overemphasized. We have found that
asking the pathologist to come into the operating room
to discuss the case and to examine not only the speci-
men but also the surgical defect is helpful in selecting
speciﬁ c areas for frozen section evaluation. Frozen sec-
tions may be taken from either the patient or the speci-
men, but they must be accurately registered and labeled.
When margins are excised from the patient, care must
be taken to ensure that the correct portion of the tumor
bed is sampled and labeled. The adequacy of bone
margins cannot be determined on frozen section
because bone must be decalciﬁ ed before sectioning.
Biopsy of the proximal and distal neurovascular bundle
Figure 33-16. The carotid artery is protected by placing a ﬁ nger
posteriorly and amputating the specimen through the pterygoid
muscle. Care must be taken to ensure that any tumor extension along
the path of V3 is included in this specimen.
may be helpful as a surrogate for adequate bone exci-
sion, depending on the location of the tumor.
Reconstruction
After the cancer has been excised and hemostasis
ensured, the wound is irrigated and reconstruction can
begin. Smoothing the cut end of the bone to prevent
sharp edges and allow mucosal coverage is important
in preventing postoperative bone exposure, osteomyeli-
tis, and other wound complications. Although smooth-
ing can be performed with a rasp, a rotating burr will
speed bone removal. The defect can then be recon-
structed as previously planned.
Primary Closure
Primary closure was the traditional, time-honored tech-
nique used for many years when bone reconstruction
was not performed. Although this technique is not dif-
ﬁ cult, particularly when excision of soft tissue is minimal,
it carries with it the risk of ﬁ xation of oral cavity struc-
tures. The resultant tethering of the tongue results in
a decrease in postoperative swallowing and speaking
ability. Consequently, this technique is used only in
unusual circumstances.
Split-Thickness Skin Graft
We prefer a split-thickness skin graft for reconstruction
of defects in which bone reconstruction is not planned
(Figs. 33-18 and 33-19). The technique is described in
detail in Chapter 32. The graft is taken at a thickness
of 0.16 inch and sewn in position in a pie crust manner.
A bolus of antibiotic-impregnated gauze, typically Xero-
Figure 33-17. Specimen from a composite resection. Identiﬁ cation
of margins is difﬁ cult because of the complex three-dimensional
nature of the resection. Close cooperation between the pathologist
and surgeon is mandatory.

Chapter 33
Segmental Mandibulectomy
273
form, is placed and tied over with long silk sutures.
Watertight closure must be ensured because the skin
graft not only resurfaces the defect but also separates
the oral cavity from the interstices of the neck during
the healing phase. In addition, during placement of
suction drains in the neck, the skin graft must not
contact the drain or a ﬁ stula will result. This error can
be prevented by suturing the platysma muscle of the
upper ﬂ ap directly to the digastric sling superior to the
drains to reinforce the closure and prevent graft-drain
contact.
Myocutaneous or Myofascial Flap
Pedicle muscle ﬂ aps with or without attached skin are
commonly used for closure of soft tissue defects (see
Chapter 82). Muscle ﬂ aps provide additional bulk and
result in a somewhat improved cosmetic appearance, as
well as increased protection for the carotid artery.
Unfortunately, this increased bulk may cause dimin-
ished tongue mobility and decreased oral cavity func-
tion, with adverse effects on swallowing and speaking
function postoperatively. Nevertheless, this ﬂ ap tech-
nique remains the mainstay of closure in many centers.
The ﬂ ap most commonly used is the pectoralis major
based on the thoracoacromial artery. The ﬂ ap may be
used with overlying chest wall skin or as a muscle-fascial
ﬂ ap. The latter technique is preferable when less bulk
is desirable because a thin mucosal lining forms over
the muscle rapidly. It is best to avoid suturing the ﬂ ap
to the mucosa of the tongue to prevent restriction of
tongue mobility. A split-thickness skin graft may be used
to re-create a sulcus between the ﬂ ap and the remaining
tongue musculature to avoid tethering. This ﬂ ap will
pivot directly into the defect if the sternocleidomastoid
muscle is either resected as part of the neck dissection
or disconnected from its inferior attachment to the
sternum and clavicle and rotated posteriorly to the
muscle ﬂ ap. Closure should be done in at least two
layers to ensure adequate separation of the oral cavity
from the neck structures, primarily the carotid artery.
Suturing of the ﬂ ap into position is facilitated by ini-
tially placing the ﬂ ap in position and then rotating it
inferiorly and beginning the closure inferiorly. This
technique helps ensure complete, sequential closure,
thereby avoiding missed areas that result in postopera-
tive leaks.
Mandibular Reconstruction
Mandibular reconstruction has been discussed in the
section on patient selection and will not be repeated
here. We have favored the radial forearm ﬂ ap for recon-
struction of the mandible (see Chapter 81). The ﬁ bular
ﬂ ap has been reserved for cases in which long segments
of the mandible must be replaced. The segmental blood
supply enhances the ability to fashion the bone by sub-
periosteal osteotomy and plating to permit reshaping
for cosmetic contouring of the graft (Figs. 33-20 and
33-21).19 Adequate soft tissue is available for reconstruc-
tion of soft tissue loss associated with bone excision.
This graft has been highly reliable, especially for patients
who must undergo removal of the anterior segment of
the mandibular arch (Fig. 33-22). Appropriate testing
of the blood supply of the lower extremities, such as
Doppler studies and arteriography, is essential in
patients with a history of peripheral vascular disease.
POSTOPERATIVE MANAGEMENT
The patient is observed postoperatively in an intensive
care unit for 24 to 48 hours. Careful nursing manage-
ment of the drains and tracheal suctioning are neces-
sary. If a free ﬂ ap has been used, monitoring of its
Figure 33-18. A split-thickness skin graft is a satisfactory means of
closure. It is usually easiest to begin suturing the graft in position in
the most posterior aspect of the wound. Every other suture is left long
to tie over the bolus.
Figure 33-19. A split-thickness skin graft (arrow) for resurfacing a
defect after composite resection for cancer of the retromolar
trigone.

274
Section 2
Oral Cavity/Oropharynx
blood supply with Doppler ultrasound by the nursing
staff is critical for success. Oral care should be minimal
in the initial stages to preclude traumatization of the
closure or disruption of the skin graft bolus. Immobili-
zation of the skin graft bolus by an external compressive
dressing is warranted and helpful in ensuring “take” of
the skin graft. We use such a compressive dressing in
all patients who undergo reconstruction with a skin
graft unless bilateral neck dissection has been per-
formed. We do not use a dressing in patients who have
undergone ﬂ ap reconstruction (either pedicled or free
microvascular) for fear that the dressing could lead to
venous congestion of the ﬂ ap and result in tissue is -
chemia and necrosis.
Perioperative antibiotics are continued for 24
hours. Continuation of antibiotics beyond 24 hours has
not been shown to be efﬁ cacious and may lead to colo-
nization with resistant organisms.20 The single most
important factor in prevention of postoperative wound
Figure 33-20. Free ﬁ bular ﬂ ap being harvested. Note the multiple
osteotomies and the mandibular reconstruction plate used to contour
the ﬁ bular graft. This can be performed before dividing the vessels.
Figure 33-21. Free ﬁ bular graft in place. Adequate soft tissue is
available to reconstruct the intraoral defect.
B
A
Figure 33-22. A, Postoperative Panorex view demonstrating inte-
gration of the ﬁ bular reconstruction. B, A patient with anterior seg-
mental mandibulectomy and reconstruction with a free ﬁ bular ﬂ ap.
infections is assurance of a watertight seal during
wound closure—hence the emphasis on reconstructive
techniques.
If reconstruction with a skin graft was performed,
the bolus is removed in 5 days. The entire bolus must
be removed. Counting the number of pledgets of
packing placed within the bolus at the time of the surgi-
cal procedure and then recording this number in the
operative note helps avoid inadvertently leaving a
portion of the bolus within the defect.
Decannulation can begin when the bolus has been
removed from the oral cavity or the ﬂ ap is healing well.
We do not begin oral feeding until the decannulation
process is complete and the tracheostomy has closed.
SUMMARY
Cancer of the oral cavity involving bone requires seg-
mental mandibulectomy to ensure adequate ablation.
Margins must be adequate, or local recurrence of
tumor is inevitable. Mandibular continuity can be re-
established with the use of various vascularized bone
grafts, of which the radial forearm is the preferred
choice. Isolated lateral defects may not require recon-
struction; however, anterior defects should be recon-
structed to facilitate rehabilitation and postoperative
oral cavity function. A novel means of mandibular
“reconstruction” involving the use of distraction osteo-
genesis may offer patients improved reconstructive
options.

Chapter 33
Segmental Mandibulectomy
275
References
1. Slaughter DP, Roeser EH, Smejkal WF: Excision of the mandible
for neoplastic disease: Indications and techniques. Surgery
26:507-522, 1949.
2. Ward GE, Robben JO: A composite operation for radical neck
dissection and removal of cancer of the mouth. Cancer 4:98-109,
1951.
3. Cooper J, Pajak T, Forastiere A, et al: Postoperative concurrent
radiotherapy and chemotherapy for high-risk squamous-cell car-
cinoma of the head and neck. N Engl J Med 350:1937-1944,
2004.
4. Bernier J, Domenge C, Ozsahin M, et al: Postoperative irradiation
with or without concomitant chemotherapy for locally advanced
head and neck cancer. N Engl J Med 350:1945-1952, 2004.
5. Militsakh ON, Wallace DI, Kriet JD, et al: The role of the osteo-
cutaneous radial forearm free ﬂ ap in the treatment of mandibu-
lar osteoradionecrosis. Otolaryngol Head Neck Surg 133:80-83,
2005.
6. McGregor AD, MacDonald DG: Patterns of spread of squamous
cell carcinoma within the mandible. Head Neck Surg 11:457-461,
1989.
7. Tsue TT, McCulloch TM, Girod DA, et al: Predictors of carcino-
matous invasion of the mandible. Head Neck Surg 16:116-126,
1994.
8. Weber AL, Bui C, Kaneda T: Malignant tumors of the mandible
and maxilla. Neuroimaging Clin North Am 13:509-524, 2003.
9. van den Brekel MW, Smeele LE, Tiwari RM, et al: Assessment of
tumour invasion into the mandible: The value of different
imaging techniques. Eur Radiol 8:1552-1557, 1998.
10. McGregor AD, MacDonald DG: Routes of entry of squamous cell
carcinoma to the mandible. Head Neck Surg 10:294-301, 1988.
11. Zieske LA, Johnson JT, Myers EN, Thearle PB: Squamous cell
carcinoma with positive margins. Arch Otolaryngol Head Neck
Surg 112:863-866, 1986.
12. Haller JR, Sullivan MJ: Contemporary techniques of mandibular
reconstruction. Am J Otolaryngol 16:19-23, 1995.
13. Mehta RP, Deschler DG: Mandibular reconstruction in 2004: An
analysis of different techniques. Curr Opin Otolaryngol Head
Neck Surg 12:288-293, 2004.
14. Komisar A: The functional result of mandibular reconstruction.
Laryngoscope 100:364-374, 1990.
15. Urken ML, Buchbinder D, Weinberg H, et al: Functional evalua-
tion following microvascular oromandibular reconstruction of
the oral cancer patient: A comparative study of reconstructed and
nonreconstructed patients. Laryngoscope 101:935-950, 1991.
16. Kuriakose MA, Shnayder Y, DeLacure MD: Reconstruction of
segmental mandibular defects by distraction osteogenesis for
mandibular reconstruction. Head Neck 25:816-824, 2003.
17. Costantino PD, Johnson CS, Friedman CD, Sisson GA: Bone
regeneration within a human segmental mandible defect: A pre-
liminary report. Am J Otolaryngol 16:56-65, 1995.
18. Imola MJ, Hamlar DD, Thatcher G, Chowdhury K: The versatility
of distraction osteogenesis in craniofacial surgery. Arch Facial
Plast Surg 4:8-18, 2002.
19. Hidalgo DA: Aesthetic improvements in free-ﬂ ap mandibular
reconstruction. Plast Reconstr Surg 88:574-585, 1991.
20. Simons JP, Johnson JT, Yu VL, et al: The role of topical antibiotic
prophylaxis in patients undergoing contaminated head and neck
surgery with ﬂ ap reconstruction. Laryngoscope 111:329-335,
2001.
PEARLS
• Marginal mandibulectomy is preferred over
segmental mandibulectomy whenever oncologically
feasible.
• Not all lateral segmental resections need to be
replaced, and the decision regarding reconstruction
of the lateral mandible should be made on a case-
by-case basis.
• All anterior mandibular segmental defects must be
reconstructed to avoid major cosmetic and
functional defects.
• Preplating the mandible before resection can assist
in accurate reconstruction and occlusion.
• The success of free ﬂ ap reconstruction depends on
excellent nursing care.
PITFALLS
• Failure to achieve negative margins is usually due to
underestimating tumor extent preoperatively.
• Tumor can extend into soft tissue at the site of the
mental foramen. Biopsy of this region should be
considered in cases in which the inferior mandibular
neurovascular canal is involved with tumor.
• Skin grafts will not adhere to cortical bone.
• Osteoradionecrosis may occur if all diseased teeth
are not removed.
• Frozen section analysis of bone margins is not a
possibility, so a generous margin of bone must be
taken to avoid positive margins.

Chapter 34
Mandibular Osteotomy Approaches
Jonas T. Johnson
MANDIBULOTOMY
Mandibulotomy is undertaken to facilitate exposure for
extirpation of oral and oropharyngeal lesions. The use
of mandibulotomy to allow an anterior approach to the
parapharyngeal space and skull base has also been
proposed.1,2
The site of the mandibulotomy may vary from
patient to patient. Lateral mandibulotomy, performed
through the body of the mandible, has largely been
abandoned because the rate of complications was high
when the procedure was performed in patients who
subsequently required postoperative radiation therapy
and because anesthesia of the lip was unavoidable.
Accordingly, most surgeons today perform mandibu-
lotomy anterior (mesial) to the mental foramen.
PATIENT SELECTION
Preoperative assessment is a critical component of
patient care. Assessment begins with the history and
physical examination. Inspection and palpation are fre-
quently the most accurate means of assessing the dimen-
sion and depth of inﬁ ltration of the tumor in the oral
cavity or oropharynx. Lesions involving the soft palate
and tonsil and the retromolar trigone, the posterior
third of the mobile tongue, and the adjacent tongue
base and those involving the posterior aspect of the
ﬂ oor of the mouth and the ventral surface of the tongue
may be best suited for a mandible-sparing procedure if
the periosteum of the mandible is not involved with
cancer. Adequate exposure is critical to ensure that the
margins of resection are adequate. Additionally, recon-
struction is greatly facilitated and healing enhanced if
the repair is performed with comfortable surgical
exposure.
Mandibulotomy is ideally suited to facilitate expo-
sure for surgical management of tumors of the oral
cavity, the oropharynx, and occasionally the parapha-
ryngeal space.3,4 It is performed when a transoral pro-
cedure would be compromised by lack of exposure.
Mandibulotomy is not appropriate in patients who
require removal of a portion of the mandible because
of involvement with tumor.5-8 The evolution of head
and neck surgery has been accompanied by an appre-
ciation of the severe cosmetic and functional deformi-
ties that accompany mandibulectomy. Accordingly,
mandibulectomy is reserved for patients who require
resection of bone because of inﬁ ltration by or proximity
to tumor rather than for exposure of the tumor.
Evaluation of bone involvement is a clinical chal-
lenge. Bone scanning, computed tomography (CT),
and magnetic resonance imaging (MRI) have all been
advocated.9-12 Invasion of the mandibular cortex is often
best studied with CT scans. Spread through the medul-
lary space may be better identiﬁ ed with MRI. Unfortu-
nately, these imaging techniques may miss subtle
involvement of bone by tumor. There is no replace-
ment for good clinical judgment. If a rim of normal
tissue exists between the tumor and bone, the mandible
may be spared. If the periosteum is involved, marginal
or rim mandibulotomy should be considered.13,14 When
the mandibular cortex or marrow space is involved by
tumor, we recommend segmental mandibulectomy.
If a satisfactory margin of soft tissue can be obtained
without removal of bone, continuity of the mandible
should be preserved for both functional and cosmetic
reasons. Nevertheless, exposure for resection and sub-
sequent reconstruction may be limited by the mandible.
In these circumstances, mandibulotomy enhances the
exposure needed to appropriately perform the resec-
tion and reconstruction.
PREOPERATIVE EVALUATION
Preoperatively, it is important to determine whether the
surgical exposure would be inadequate if the procedure
were performed transorally. The presence of intact
277

278
Section 2
Oral Cavity/Oropharynx
dentition, trismus, and a posterior location of the lesion
to be resected are features suggesting that mandibulot-
omy would be appropriate to enhance exposure.
In general, edentulous ectomorphic persons are
best suited for transoral removal of limited lesions
(T1 to T2). In contrast, fully dentulous mesomorphic
persons may present a surgical challenge that would
compromise adequate tumor excision if the surgeon is
limited to a transoral approach.
Palpation of the lesion is an important component
of the preoperative evaluation. Lesions that cannot be
fully encompassed digitally in the ofﬁ ce may be rela-
tively inaccessible at the posterior limits in the operat-
ing room. Fixation to the mandible is a contraindication
to this approach. If the mandible is grossly invaded, we
prefer segmental mandibulectomy. The area of bone to
be removed is determined preoperatively, and osteoto-
mies are created during surgery to facilitate exposure.
If the tumor is ﬁ xed to the periosteum, marginal
mandibulectomy is preferred. A combination of mar-
ginal mandibulectomy and anterior mandibulotomy is
to be avoided because it is frequently associated with
mandibular fracture postoperatively. Exposure in
patients requiring marginal mandibulectomy may be
improved by using a midline lip- and chin-splitting inci-
sion and elevation of the facial ﬂ ap. This technique is
appropriate in patients in whom the transoral approach
is inadequate for marginal mandibulectomy and exci-
sion of the tumor.
Most patients are imaged preoperatively to better
assess the extent of the lesion and the status of the cervi-
cal lymphatics. MRI clearly enhances the soft tissue
interfaces, whereas CT perhaps better delineates the
interface between bone and soft tissue. Neither imaging
technique, however, can detect subtle amounts of bone
involvement. Accordingly, physical evaluation remains
the critical assessment tool.
SURGICAL APPROACHES
Mandibulotomy is almost always undertaken as a part
of another surgical procedure. General anesthesia is
established as required. Tracheotomy should be carried
out at the onset of the procedure to remove the endo-
tracheal tube from the oral cavity and thus improve
exposure. Usually, the cutaneous incision is developed
in the midline and oriented vertically. The vermilion is
marked to facilitate reapproximation of the lip at the
completion of the case, and the lip is split (Fig. 34-1).
The incision is then carried laterally in the gingivobuc-
cal sulcus, and a 5- to 8-mm cuff of vestibular mucosa is
left to facilitate closure at the completion of the proce-
dure. At the site of the intended mandibulotomy, the
mucosal incision is carried to the mandible. Periosteum
is not elevated but is incised sharply.
An alternative to a lip-splitting incision is a visor
ﬂ ap. In this circumstance, a horizontal incision is made
in a submandibular skin crease and carried across the
midline to the contralateral angle of the mandible.
Then, working in a subplatysmal plane, the soft tissue
is elevated up to the labial mandibular sulcus. The
mucosa is divided and the oral cavity entered, with a
rim of approximately 5 mm of mucosa left on the
surface of the mandible to facilitate closure at the com-
pletion of the procedure. This technique avoids a
midline skin incision, but the mental nerve must be
divided bilaterally to afford adequate retraction of the
visor ﬂ ap during surgical extirpation. Some patients
may regain sensation, but the long-term functional
effect of denervating the lower lip has not been quan-
titated. We believe that the morbidity associated with
bilateral mental nerve sacriﬁ ce justiﬁ es the performance
of a midline lip-splitting incision.
The mandibulotomy should be performed anterior
to the mental foramen. In an edentulous patient, the
exact site of osteotomy is not critical. In patients with
intact dentition, a tooth should be extracted and the
mandibulotomy performed through the middle of the
tooth socket (Fig. 34-2). If the mandibulotomy is per-
formed immediately between two intact teeth, both may
be lost. Incisor teeth are rarely extracted for this purpose
because the cosmetic affect of missing this anterior
tooth is too noticeable. Accordingly, mandibulotomy is
performed lateral to the midline through the site of the
extracted ﬁ rst bicuspid tooth or at the point where a
tooth has previously been lost. In general, mandibulot-
omy should not be performed in the body of the man-
dible posterior to the mental foramen, especially in
patients who may require postoperative radiation
therapy. The combination of radiation therapy and loss
of blood supply to the bone secondary to division of the
artery in the mental canal frequently results in ischemic
necrosis of the body of the mandible.
Figure 34-1. The vermilion is marked horizontally with a knife
blade before dividing the lip. This facilitates approximation of the
vermilion at the conclusion of the procedure.

Chapter 34
Mandibular Osteotomy Approaches
279
With today’s rigid ﬁ xation techniques, almost any
type of mandibulotomy may be undertaken. A straight
vertical mandibulotomy can be adequately ﬁ xed, but we
continue to favor a stair-step mandibulotomy. When
plates are used, we place the ﬁ xation plate and drill the
screw holes before actual performance of the osteotomy
to ensure proper alignment of the bone fragments
during the reconstruction phase (Fig. 34-3). The mucosa
of the ﬂ oor of the mouth is then incised, and the man-
dible is retracted laterally (Fig. 34-4). Exposure of
tumors in the posterior oral cavity and oropharynx is
improved when the mylohyoid muscle is divided while
the submandibular gland and its associated duct are
retracted medially with the tongue.
After excision and reconstruction, the mandible is
once again brought into anatomic position. The plate
is ﬁ xed to bone through the screw holes previously
drilled. A variety of plates and screws are available. The
soft tissues are reapproximated, and the wound is
drained as necessary.
POSTOPERATIVE MANAGEMENT
The patient may be returned to a liquid or soft diet as
soon as healing of the soft tissue allows use of the oral
cavity. Intermaxillary ﬁ xation is not necessary. Chewing
of solid food should be postponed until approximately
the sixth postoperative week. The integrity of the
healing mandibulotomy can be ascertained clinically
through direct inspection and evaluation of the man-
dibulotomy site. The decision to use postoperative radi-
ation therapy in patients undergoing resection of
malignant tumors is based on established criteria and
protocol. Mandibulotomy is to be considered a surgical
approach that facilitates tumor resection and recon-
struction. When radiation therapy is needed, it may be
undertaken without undue risk. Various investigators
Figure 34-2. The mandibulotomy is undertaken through the socket
of an extracted tooth.
Figure 34-3. The plate is placed over the site of the proposed
mandibulotomy, and holes are drilled before actually dividing the
bone.
Figure 34-4. The mandible is retracted laterally as the mucosa of
the ﬂ oor of the mouth is incised. Care is taken to maintain the
mucosa along the alveolus to facilitate closure.
have indicated that a mandible-stabilizing plate has
minimal effect on the tissue dose of radiation. The plate
may minimally reduce the dose in some areas, as well
as cause some “hot spots.” Neither of these observa-
tions, however, signiﬁ cantly affects the efﬁ cacy or safety
of postoperative radiation therapy, and dose adjust-
ments are not required. Similarly, patients who have
previously undergone radiation therapy may be at
increased risk for postoperative osteonecrosis.

280
Section 2
Oral Cavity/Oropharynx
Midline labiomandibuloglossotomy (LMG) affords
the surgeon exposure to the tongue base, the posterior
wall of the oropharynx, the posterior wall of the hypo-
pharynx, and the nasopharynx, as well as the cervical
space, clivus, and basiocciput. This approach combines
a mandibulotomy with a midline tongue-splitting
approach. To achieve maximal exposure, most surgeons
split the lip as well.1-11 Midline LMG is performed
through an incision that gives wide exposure without
jeopardizing
the
laterally
placed
neurovascular
structures.
MIDLINE
LABIOMANDIBULOGLOSSOTOMY
PATIENT SELECTION
Midline LMG should be considered as an approach
when excising a tumor that cannot be appropriately
removed transorally. This technique is especially appro-
priate for tumors of the posterior oropharyngeal wall
in which transhyoid or lateral pharyngotomy would
provide inadequate exposure. Similarly, midline LMG
may be considered when treating tumors of the tongue
base that cannot be reliably removed via transhyoid
pharyngotomy. Midline LMG is one way to gain expo-
sure to the inferior aspects of the nasopharynx and
clivus; in these circumstances, however, the palate must
also be split and retracted anteriorly.
PREOPERATIVE EVALUATION
The mandibulotomy portion of this procedure need
not be made directly in the midline. The mandibulot-
omy site should be somewhere between the midline and
the mental foramina in an edentulous portion of the
mandible. If the patient has full dentition, a tooth may
need to be extracted and the mandibulotomy per-
formed through the tooth socket to leave an appropri-
ate cushion of bone on either side of the adjacent teeth.
Leaving this bone improves the stability of the teeth,
which should be preserved to act as posts for removable
partial dentures. We prefer to extract the ﬁ rst bicuspid
in these circumstances. Tracheostomy is performed as
an associated procedure in most cases.
SURGICAL APPROACHES
General anesthesia is administered through the trache-
ostomy. A vertical midline skin incision is carried
through the lip and subcutaneous tissue. The vermilion
is marked sharply to facilitate closure at the completion
of the procedure (Fig. 34-5). The soft tissue incision is
carried directly onto the anterior face of the mandible
unless the mandibulotomy is to be carried out lateral
to the midline, in which case the incision through the
mucosa of the labial sulcus should be carried laterally.
Approximately 5 to 8 mm of mucosa should be main-
tained on the labial side of the mandible to provide
ample mucosa for closure. The incision is then carried
up onto the alveolus, and the periosteum is elevated
(Fig. 34-6). A four-screw miniplate should be sized and
bent, and screw holes should be drilled before the man-
dibulotomy to facilitate reconstruction. We prefer
either a deep V or a stair-step mandibulotomy, either of
which facilitates ﬁ rm ﬁ xation at the completion of the
procedure.
The soft tissue incision is now carried through the
midline to separate the submandibular ducts so that
they may be preserved bilaterally. The tongue is grasped,
and great care is taken to divide it exactly in the midline
to minimize bleeding. An off-center glossotomy is to be
avoided because it may compromise the vasculature of
the tongue. Hemostasis is achieved with suture ligatures
as needed. At this point the intended resection and
reconstruction can be carried out.
The surgical defect is reconstructed as needed.
Small defects limited to the posterior pharyngeal wall
may be allowed to heal by secondary intention. The
deep musculature of the tongue is then reapproximated
with 3-0 Vicryl in at least two layers, after which the
mucosa is closed in a posterior-to-anterior direction.
The mandible is returned to its anatomic position, and
a plate is applied with two screws on either side of the
mandibulotomy (Fig. 34-7). After drains have been
inserted according to the nature of the procedure, the
soft tissues of the lip and chin are closed in three
layers.
POSTOPERATIVE MANAGEMENT
LMG invariably results in contamination of the surgical
site by oral secretions. Accordingly, perioperative pro-
phylactic antibiotics should be administered. The
patient is maintained on nothing by mouth, with tube
feeding for 5 to 7 days or until healing of the oral cavity
is satisfactory. At this point the patient can be started
on a liquid or soft diet as dictated by the primary surgi-
cal procedure (Fig. 34-8).
Figure 34-5. Midline labiomandibuloglossotomy requires a man-
dibulectomy. As the bone is retracted, an incision is carried between
Wharton’s ducts and directly through the midline of the tongue.

Chapter 34
Mandibular Osteotomy Approaches
281
B
A
Figure 34-6. A, In most circumstances it is necessary to divide the
tongue back into the vallecula. This affords adequate exposure of the
posterior hypopharyngeal wall. Small lesions of the tongue base can
be satisfactorily removed in this way as well. B, Exposure afforded on
the posterior wall of the oropharynx.
Figure 34-7. After reapproximation of the tongue and other soft
tissues, the mandibular plate is applied with two screws on either
side.
A
B
Figure 34-8. A, This man under-
went midline mandibulotomy 4
years previously. The scar is accept-
able. B, The patient demonstrates
good oral function 4 years after
surgery.

282
Section 2
Oral Cavity/Oropharynx
References
1. Kumins NH, Tober JC, Larsen PE, Smead WL: Vertical ramus
osteotomy allows exposure of the distal internal carotid artery to
the base of the skull. Ann Vasc Surg 15:25-31, 2001.
2. Smith GI, Brennan PA, Webb AA, Ilankovan V: Vertical ramus
osteotomy combined with a parasymphyseal mandibulotomy for
improved access to the parapharyngeal space. Head Neck 25:1000-
1003, 2003.
3. Petruzzelli GJ, Knight FK, Vandevender D, et al: Posterior mar-
ginal mandibulectomy in the management of cancer of the oral
cavity and oropharynx. Otolaryngol Head Neck Surg 129:713-719,
2003.
4. Pan WL, Hao SP, Lin YS, et al: The anatomical basis for mandibu-
lotomy: Midline versus paramidline. Laryngoscope 113:377-380,
2003.
5. Muller H, Slootweg PJ: Mandibular invasion by oral squamous
cell carcinoma. J Craniomaxillofac Surg 18:80-84, 1990.
6. Wax MK, Bascom DA, Myers LL: Marginal mandibulectomy vs
segmental mandibulectomy: Indications and controversies. Arch
Otolaryngol 128:600-603, 2002.
7. Brown J: Mechanisms of cancer invasion of the mandible. Curr
Opin Otolaryngol Head Neck 11:96-102, 2003.
8. McGregor IA, MacDonald DG: Spread of squamous cell carci-
noma to the nonirradiated edentulous mandible—a preliminary
report. Head Neck Surg 9:157-161, 1987.
9. Bolzoni A, Cappiello J, Piazza C, et al: Diagnostic accuracy of
magnetic resonance imaging in the assessment of mandibular
involvement in oral-oropharyngeal squamous cell carcinoma: A
prospective study. Arch Otolaryngol Head Neck Surg 130:837-
843, 2004.
10. Brockenbrough JM, Petruzzelli GJ, Lomasney L: DentaScan as an
accurate method of predicting mandibular invasion in patients
with squamous cell carcinoma of the oral cavity. Arch Otolaryngol
Head Neck Surg 129:113-117, 2003.
11. Schaefer SD, Maravilla KR, Suss RA, et al: Magnetic resonance
imaging vs computed tomography: Comparison in imaging oral
cavity and pharyngeal carcinomas. Arch Otolaryngol 111:730-734,
1985.
12. Ator GA, Abemayor E, Lufkin RB, et al: Evaluation of mandibular
tumor invasion with magnetic resonance imaging. Arch Otolar-
yngol Head Neck Surg 116:454-459, 1990.
13. Randall CJ, Eyre J, Davies D, Walsh-Waring GP: Marginal man-
dibulectomy for malignant disease: Indications, rationale, and
results. J Laryngol Otol 101:676-684, 1987.
14. Barttelbort SW, Bahn SL, Ariyan S: Rim mandibulectomy for
cancer of the oral cavity. Am J Surg 154:423-428, 1987.
PEARLS
• The osteotomy is always performed anterior to the
mental foramen to maximize blood ﬂ ow to the bone
and facilitate postoperative healing.
• Accurate reapproximation of the lip is the key to
improved cosmesis with mandibulotomy. The lip
should be closed in three layers: the orbicularis
muscle, the mucosa, and the skin.
• Perfect bone realignment and ﬁ xation are enhanced
by placing the plate and drill holes before
performance of the mandibulotomy. Use of a
stepped osteotomy, in our experience, facilitates
ﬁ xation.
• Postoperative application of a bulky supportive
dressing tends to reduce facial edema and enhance
immobilization, both of which augment rapid
healing and good cosmesis.
• A tracheotomy is necessary to provide an airway
during the early postoperative phase. The
tracheotomy can be removed as soon as
oropharyngeal function has resumed.
PITFALLS
· Failure to provide adequate soft tissue coverage and
water-tight closure at the completion of the
procedure may result in contamination of the
osteotomy by saliva. Contaminated plating materials
may need to be removed. Should drainage persist
beyond 2 months postoperatively, the surgeon may
recommend a minor procedure in which the labial
sulcus is opened and the plate is removed.
• Osteotomy performed posterior to the mental
foramen may be associated with ischemic necrosis
of the mandible, especially in patients who have
previously undergone radiation therapy or in those
who require postoperative adjuvant radiation
therapy.
• Patients who have previously undergone radiation
therapy may be at increased risk for postoperative
wound-healing difﬁ culty. This is especially true if
inadequate soft tissue closure fails to prevent soilage
of the osteotomy with saliva during the healing
phase.
• Failure to achieve complete stabilization of the
mandibulotomy site may result in painful nonunion.
The patient should be returned to the operating
room for appropriate ﬁ xation. In patients who have
been previously treated with radiation therapy,
nonunion may result in osteoradionecrosis and
sequestration. Bone débridement with bone grafting
and reﬁ xation may be required to achieve an
appropriate union.
• Combining marginal resection of the mandible with
mandibulotomy may result in a weak devascularized
segment and subsequent pathologic fracture.

Chapter 35
Transoral Excision of Oropharyngeal
Malignancy
David E. Eibling and Eugene N. Myers
More than half of patients with cancer of the orophar-
ynx are initially found to have stage III or IV disease.
Either primary surgery or an organ-sparing approach
with either radiotherapy alone for early-stage disease/
cancer or concurrent chemoradiotherapy for late-stage
cancer can be used for treatment. A high percentage of
patients with cancer of the tonsil will have cervical ade-
nopathy, so management of the neck is of utmost
importance. Cancer with local extension into the naso-
pharynx, parapharyngeal space, or carotid artery or
metastasis to the retropharyngeal lymph nodes is con-
sidered inoperable, and nonoperative therapy is the
only option available. Surgical management of advanced
cancer results in postoperative oropharyngeal dysfunc-
tion, primarily swallowing disorders. In an attempt to
avoid this problem, most advanced cancers are now
managed with nonoperative organ-sparing protocols.
Despite preservation of the “organ,” these patients also
suffer from post-treatment swallowing disability that
rivals that of surgical extirpation.1
A small subset of patients have early-stage cancer
that may be successfully managed by surgery alone.
Management of early cancer by transoral resection and
elective neck dissection may spare the patient the
adverse effects of radiotherapy. The surgeon must also
be alert to the possibility of a lymphoma (Fig. 35-1)
arising in either the base of the tongue or the tonsil.
These lesions may look alike, but their management
could be different. Rarely, a cancer can metastasize to
the tonsil or the base of the tongue from a distant site
(Fig. 35-2).
Selected cancers of the oropharynx, including
those arising in the tonsil, soft palate (Fig. 35-3), or
posterior wall of the oropharynx, may be resectable via
a transoral approach. Cancers involving the base of the
tongue, lateral or posterior wall of the hypopharynx, or
supraglottic larynx have traditionally been considered
unresectable through this route. However, with recent
innovations in endoscopic instrumentation and with
new paradigms for resection, some of these cancers are
now being managed in this manner.
The decision to attempt transoral resection is the
most critical part of the preoperative assessment. If the
appropriate surgical approach is chosen, the actual
excision is not difﬁ cult, whereas if the excision seems
unduly difﬁ cult, it must be suspected that the wrong
approach was selected. Attempting transoral resection
of a tumor that cannot be adequately visualized or
manipulated will result in a high probability of inade-
quate cancer excision with potential recurrence and, all
too often, untimely demise of the patient.
The probability of occult neck metastases is sufﬁ -
ciently high with primary cancer in oropharyngeal sites
to warrant elective management of the neck in all cases.
Selective neck dissection should be performed in an
at-risk but clinically negative neck. Sentinel node biopsy,
which is still investigational, may in the future reduce
the number of patients subjected to elective neck dis-
section. The goal of these strategies is to avoid radiation
therapy and thereby spare the patient the xerostomia
and ﬁ brosis that downgrade swallowing function and
quality of life. If the patient has palpable cervical ade-
nopathy, adjunctive treatment with radiotherapy will be
required either as primary treatment or in the adjuvant
setting. Most of our patients with cancer of the orophar-
ynx are now managed with nonoperative protocols, and
hence the number of patients actually undergoing
transoral resection with the intent of surgical cure is
small. However, as these chemoradiation protocols con-
tinue to produce major problems with swallowing, there
may be renewed interest in primary surgical treatment
of early lesions of the oropharynx.
Cancer of the oropharynx may metastasize early to
the retropharyngeal nodes. These nodes are not part of
routine neck dissection because they lie medial to the
carotid artery (Fig. 35-4). Some head and neck sur-
geons routinely recommend postoperative radiation
therapy for these nodes after resection of tumors of the
283

284
Section 2
Oral Cavity/Oropharynx
is another alternative to open procedures for cancer of
the base of the tongue. Small cancers of the posterior
wall of the oropharynx can be excised if the inferior
aspect of the tumor does not extend beyond the tip of
the epiglottis. For most lesions of the posterior wall of
the oropharynx, a transhyoid or lateral pharyngotomy
provides more exposure (see Chapters 29 and 30).
Physical examination must include visualization of
all the mucosal surfaces of the upper aerodigestive
tract, usually via transnasal ﬁ beroptic examination.
Careful palpation of the oral cavity and oropharynx, as
well as palpation of the tumor, is mandatory. Not only
must the size and “third dimension” of the tumor be
assessed, but its attachment to underlying structures
and the proximity of the tumor to vital structures, such
as the carotid artery or the mandible, must also be
assessed.
Absolute contraindications to transoral excision
include trismus, deep invasion by the tumor, and poor
accessibility. A high tooth proﬁ le, macroglossia, thick
lips, or microstomia all interfere with adequate expo-
sure and are therefore relative contraindications that
must be considered. Preoperative palpation of the neck
should be routine to help assess the requirement for
and selection of the appropriate neck dissection.
Computed tomography (CT) or magnetic reso-
nance imaging (MRI) is not usually helpful in assessing
Figure 35-1. Lymphoma of the tonsil must be considered in the
differential diagnosis.
Figure 35-2. Malignant melanoma metastatic from the lower
extremity to the tonsil.
A
B
Figure 35-3. A, Squamous cell carcinoma arising on the soft palate.
B, Reconstruction with a split-thickness skin graft after excision of a
T1 lesion of the tonsil.
soft palate and oropharyngeal walls, regardless of the
status of the sampled neck nodes. In such instances it
may be more reasonable to treat the primary as well.
Salvage surgical extirpation of residual disease after
nonoperative treatment is not uncommon. In most
instances this involves salvage neck dissection for
advanced-stage neck metastasis. Persistence of the
primary tumor after treatment may require excision,
and some of these patients may be suitable for transoral
excision.
PATIENT SELECTION
Proper patient selection is the most critical aspect in
planning transoral excision. Not only must the cancer
be appropriate for resection by a transoral route, but
the surgeon must also be able to adequately visualize
the tumor throughout the procedure. This require-
ment effectively limits these procedures to those involv-
ing the oral cavity and oropharynx. Cancer of the base
of the tongue is not usually amenable to the transoral
approach. The transhyoid pharyngotomy approach to
these tumors has been well described.2 The transoral
approach to the base of the tongue with laser ablation

Chapter 35
Transoral Excision of Oropharyngeal Malignancy
285
the extent of a small primary cancer. Occasionally,
imaging provides some clinically useful information
regarding the depth of invasion, but CT or MRI is gen-
erally less reliable than palpation of the lesion. However,
imaging of the neck is valuable in detecting suspicious
adenopathy, particularly the presence of metastasis to
the retropharyngeal lymph nodes (Fig. 35-4). The pres-
ence of enlarged or otherwise suspicious nodes may
change treatment decisions because the intent of trans-
oral resection of the primary tumor is usually to avoid
radiation therapy.
PREOPERATIVE EVALUATION
All patients who are candidates for transoral excision
should undergo endoscopy of the larynx, pharynx, and
esophagus. This may be performed at the same time as
the deﬁ nitive procedure, before the actual excision and
neck dissection. If the patient will be treated by nonsur-
gical means, endoscopy and biopsy should be done at
the same time. Planning such multiple procedures in a
single operation carries with it the risk of identifying
unexpected tumor extension or a second primary
malignancy. Such unexpected ﬁ ndings may require
aborting the planned procedure and rescheduling for
another time after further discussion with the patient.
For this reason, many surgeons prefer to routinely
perform endoscopy at a separate setting, typically several
days before the planned excision. It is usually efﬁ ca-
cious to perform the transoral excision before the neck
dissection because more extensive transoral resection
may extend into the neck. Performing the neck dissec-
tion after the primary resection has been carried out
allows reconstruction of the intraoral wound, if neces-
sary, and facilitates immediate re-resection in the same
operative setting if necessary.
Preoperative dental evaluation is required for
patients with residual dentition. Many patients have
poor oral hygiene, periodontal disease, and multiple
caries. Some of these patients will require postoperative
radiotherapy, which will result in considerable risk for
radiation caries and osteoradionecrosis if diseased teeth
are present. The safest and most efﬁ cient approach is
to have the patient evaluated by an oral surgeon preop-
eratively so that any necessary dental extractions can be
scheduled at the time of excision of the cancer or
endoscopy and the extraction sites can heal before
radiation therapy. Extraction of diseased teeth, particu-
larly those with severe periodontal disease, also helps
with wound healing. Healthy teeth, especially if they
play a role in dental rehabilitation, should be
preserved.
Speech and swallowing will be signiﬁ cantly impaired
in patients who require partial removal of the palate.
These functional defects can be ameliorated with the
use of an intraoral speech appliance fashioned by a
maxillofacial prosthodontist. Preoperative impressions
are essential in planning the fabrication of a temporary
postoperative prosthesis. Therefore, if partial palatec-
tomy is planned, preoperative consultation with a max-
illofacial prosthodontist must be obtained to establish
dental records and make impressions for a surgical
prosthesis to be used at the completion of surgery.
Determination of the need for postoperative airway
support must be made preoperatively. A tracheostomy
may occasionally be required, even for smaller lesions
amenable to transoral excision. When tumor excision
requires skin grafting or reconstruction, in which case
swelling is likely, or when tongue mobility will be dimin-
ished or a large intraoral gauze bolus is present, elective
tracheostomy should be performed at the onset of the
procedure. Other cancers may be appropriate for exci-
sion by the transoral route under orotracheal or naso-
tracheal intubation with planned extubation at the
completion of the procedure. Tracheostomy is pre-
ferred instead of delayed postoperative weaning because
emergency reintubation in an uncontrolled setting can
lead to airway catastrophe. Moreover, the sedation and
paralysis required for prolonged intubation increase
the likelihood of associated (and often unnecessary)
perioperative morbidity.
Because antibiotics have been shown to be beneﬁ -
cial in tonsillectomy, most head and neck surgeons
routinely administer antibiotics to these patients peri-
operatively. Antibiotics appear to not only decrease the
amount of postoperative wound contamination but also
decrease oral odor and pain in the postoperative
period.
Preoperative counseling of the patient must include
the possibility of tracheostomy, as well as frank discus-
sion regarding resectability of the cancer by transoral
means. The patient and family must understand what
functional problems are likely to result from the proce-
dure, especially those of speech and swallowing, as well
as the length of time expected for rehabilitation.
Figure 35-4. Computed tomography scan demonstrating an
enlarged necrotic retropharyngeal lymph node (arrow).

286
Section 2
Oral Cavity/Oropharynx
SURGICAL TECHNIQUE
Proper lighting and retraction are mandatory for the
transoral excision of tumor. Though typically viewed as
“easy cases,” many of these smaller cancers can present
a daunting surgical challenge because of the require-
ment for adequate exposure throughout the entire
tumor excision.
Cancer involving the tonsillar fossa and soft palate
can be exposed by using an oral mouth gag such as the
Crowe-Davis gag used in tonsillectomy. Suspending
the mouth gag from a Mayo stand plus operating in the
Rose position as for tonsillectomy (see Chapter 23) is
often the easiest approach and permits the familiar
hand-eye coordination similar to that required for ton-
sillectomy. In this manner, the endotracheal tube is
held anteriorly by the tongue blade and is not likely to
obstruct the surgeon’s view or be involved in the surgi-
cal excision. Appropriate cuffed endotracheal tubes
must be chosen and protected if excision by either laser
or electrocautery is planned. Laser strike against the
oral portion of the tube can ignite a ﬁ re, and high
concentrations of oxygen accumulating in the oral
cavity from a leaking or uncuffed endotracheal tube
may support combustion of the tube, even if not actu-
ally contacted by the cautery unit. Visualization of
tumors of the posterior oropharyngeal wall is often
obstructed by the soft palate. Exposure can be improved
with retraction of the soft palate either by placing red
rubber catheter tubing through the nose and out the
mouth or by placing a suture through the uvula and out
through the nose.
The margin of resection should be carefully pal-
pated and identiﬁ ed. Margins should maintain a width
of at least 1 cm around the tumor and should be marked
with a marking pen or methylene blue before the initia-
tion of excision. If electrocautery is being used, “dots”
can be made with the electrocautery to mark the exci-
sion line. Some surgeons choose to tattoo the planned
excision with India ink or methylene blue on a needle.
Those electing to use the hand-held laser can use it for
marking. The initial mucosal incision should be made
as far posterior or inferior as feasible because this portion
of the mucosa will be the most difﬁ cult to visualize as the
tumor is being elevated. The mucosal incision is then
carried around both sides of the cancer to the most
anterior or superior portion and then deepened (Fig.
35-5). Before delivering the specimen, a suture should
be placed that can serve not only for traction but also as
a marker to orient the pathologist (Fig. 35-6). Maintain-
ing an adequate margin in the third dimension is critical
in this portion of the procedure and requires not only
good visualization and retraction but also periodic pal-
pation. A surgical error in technique occurs when there
is insufﬁ cient depth of excision, which results in difﬁ -
culty obtaining cancer-free margins because the site at
which the cancer was transected frequently cannot be
readily identiﬁ ed in the tumor bed (Fig. 35-7).
Once the cancer is excised, it should be carefully
examined by the surgeon and reviewed with the pathol-
ogist. Orientation is critical because positive or close
margins cannot be re-resected unless their position is
known. A sketch or photo is often very useful, but the
most effective means of communication with the pathol-
ogist is face to face while examining the specimen and
surgical defect! Surgical margins should be taken from
the tumor bed, the tumor, or both; proper orientation
of the margins must be ensured before they are removed
from the patient. A typical error at this stage is removal
of additional margins from the tumor bed with inaccu-
rate registration to the excised tumor specimen. If
during excision the line of dissection appears to be too
close to the tumor, the surgeon should take an addi-
tional margin (Fig. 35-8). At the completion of the
procedure, the ﬂ ap that has been raised from the speci-
men should be sutured into position to demonstrate to
the pathologist that the affected area did not represent
a true margin.
Figure 35-5. The portion of the mucosal incision that
is most difﬁ cult to visualize (usually inferior) should be
made ﬁ rst to reduce the likelihood that blood from the
more anterior or superior portion will obscure the
planned incision site.

Chapter 35
Transoral Excision of Oropharyngeal Malignancy
287
Figure 35-6. A suture is placed for retraction, as well as for orienta-
tion of the specimen for the pathologist.
Figure 35-7. A grave error is allowing insufﬁ cient depth of excision,
which results in cutting across the tumor (arrow). Attempting to com-
plete the excision and then re-excise the base often produces an
inadequate excision.
A
B
Figure 35-8. A, If it is recognized that the deep margin is insufﬁ -
cient, the surgeon should “back up” and include an additional
margin. B, The “ﬂ ap” thus created is sutured down to facilitate proper
orientation of the specimen and ensure accurate assessment of the
additional margin of resection.
Once clear margins have been obtained, the wound
can be closed. Defects of the posterior pharyngeal wall
may be resurfaced with a split-thickness skin graft (Fig.
35-9) or simply left to heal by secondary intention by
suturing the margins of the mucosa to the prevertebral
fascia. Lesions of the tonsillar fossa and palate can be
left open to heal as with a tonsillectomy. If the defect is
large and the neck spaces are exposed, a split-thickness
skin graft will help seal the oral cavity from the neck
and prevent scar contracture during the postoperative
healing phase, which may result in trismus or decreased
tongue mobility.
Resurfacing oropharyngeal defects following trans-
oral excision of residual tumor after primary radiation
therapy is problematic. The tumor often extends deeper
than may be anticipated preoperatively, thereby result-
ing in opening into deeper planes of the neck or even
leading to exposure of the carotid artery. Healing by
secondary intention is not an option in these cases, and
another modality, such as a vascularized free ﬂ ap,
should be used to ensure coverage of the irradiated
carotid artery.
Nearly all cases will require elective neck dissection,
which can be performed at the same procedure. The
goal of neck dissection in an N0 neck is for purposes of
staging. If the patient has an N1 or N2a or N2c neck,
selective neck dissection is appropriate. Higher-stage
neck disease will require a modiﬁ ed or radical neck
dissection. In most oropharyngeal sites this would
include levels II to IV. As previously noted, the retro-
pharyngeal nodes are not sampled by routine neck dis-
section and, if identiﬁ ed on imaging studies, should be
excised during the neck dissection.
A more extensive procedure for carcinoma of the
tonsil has recently been described by Holsinger and
colleagues.3 This is also carried out by the transoral
approach and is a wider, more extensive resection of
the tonsil and lateral pharyngeal wall.
POSTOPERATIVE MANAGEMENT
Postoperative management of patients undergoing
resection of a small cancer is similar to that of patients
undergoing tonsillectomy. Patients should be given a
soft or liquid diet until they can tolerate solids and must
be evaluated for the risk of aspiration, especially
if tongue mobility has been compromised. Silent
aspiration may occur, particularly in more elderly,

288
Section 2
Oral Cavity/Oropharynx
A
B
C
D
Figure 35-9. A, Squamous cell carcinoma on the posterior wall of the oropharynx. B, Specimen demonstrating grossly adequate margins of
resection. C, Diagram of a split-thickness skin graft sewn into the defect in the posterior pharyngeal wall. D, Split-thickness skin graft sewn into
the prevertebral fascia.
debilitated patients, and can lead to serious postopera-
tive pulmonary morbidity, so careful observation and
involvement of the dysphagia team is necessary.1 Intra-
venous antibiotics are discontinued after 24 hours, but
many surgeons maintain oral antibiotics for 7 to 10
days. Rinsing the mouth with normal saline solution or
mixtures of saline solution and peroxide is helpful
in decreasing oral cavity odor. If a tracheostomy is
required, decannulation can begin as soon as the
patient can tolerate plugging of the tracheostomy
tube or removal of the bolus from a skin graft. Patients
who have had a split-thickness skin graft for tonsil
cancer may have the bolus removed safely in the ofﬁ ce.
Patients with a bolus on a site in the posterior pharyn-
geal wall will need to have the bolus removed in the
operating room to provide proper relaxation and
exposure.
Speech and swallowing function is severely impaired
in patients in whom a portion of the soft palate has
been removed. Fabrication of a speech appliance pros-
thesis (Fig. 35-10) to assist in closing the defect is usually
helpful in restoring oral-nasal separation. Preoperative
impressions should be made so that a temporary pros-
thesis can be available in the early postoperative period.
Many months are required for adequate healing before
a ﬁ nal prosthesis can be fashioned. Fabricating plus
ﬁ tting these devices requires considerable expertise,
and patients should be referred to a maxillofacial
prosthodontist experienced in these techniques.
Postoperative management must include careful
review of the permanent pathologic report. If tumor
margins are found to be involved with cancer, re-
excision is necessary because it is unlikely that radiation
therapy alone will control positive margins.

Chapter 35
Transoral Excision of Oropharyngeal Malignancy
289
A
B
C
Figure 35-10. A, Patient with an extensive defect in the soft palate and
tonsillar pillar after transoral resection of squamous cell carcinoma.
B, A speech appliance restores oral-nasal separation and aids speech and
swallowing after partial palatectomy. C, Patient with a speech appliance
in place.
PEARLS
• Some early oropharyngeal cancers are easily
accessible and may be amenable to transoral
excision.
• Accurate assessment of tumor extent is critical when
planning a transoral resection.
• Adequate visualization is essential for successful
transoral excision.
• Dissecting the deep margin requires three-
dimensional knowledge of the anatomy and should
proceed slowly to facilitate frequent reassessment of
the anatomic relationships.
• A decision regarding treatment of the neck must be
made early because the choice of treatment will
have an impact on decision making for management
of the primary cancer.
• Failure to excise positive retropharyngeal lymph
nodes will result in treatment failure.
• Postoperative hemorrhage, similar to that seen
after tonsillectomy, can occur after transoral
excision.
• Failure to accurately register additional margins with
the resected specimen may be a cause of recurrent
cancer.
• Failure to address the neck in patients at risk for
neck metastasis will result in a high incidence of
recurrent cancer in the neck.
References
1. Simental A, Carrau R: Assessment of swallowing function in
patients with head and neck cancer. Curr Oncol Rep 6:162-165,
2004.
2. Ferris RL, Myers EN: Suprahyoid pharyngotomy. Oper Tech Oto-
laryngol Head Neck Surg 16:49-54, 2005.
3. Holsinger FC, McWhorter AJ, Menard M, et al: Transoral lateral
oropharyngectomy for squamous cell carcinoma of the tonsillar
region: I. Technique, complications and functional results. Arch
Otolaryngol Head Neck Surg 131:583-591, 2005.
PITFALLS
• The choice of an inappropriate approach to a
cancer that cannot be adequately managed through
a transoral route can lead to failure of treatment.

section 3
Larynx
Chapter 36
Ofﬁ ce-Based Laryngeal Procedures
Priya Krishna and Clark A. Rosen
Ofﬁ ce-based laryngeal procedures are quickly gaining
popularity. These procedures are cost effective and
provide an important alternative in patients who
are not good candidates for operative direct laryngos-
copy. Included are those patients with contraindica-
tions to general anesthesia or who have anatomic
variations that result in poor exposure when direct
laryngoscopy is attempted. Advantages of procedures
performed on an awake patient in the ofﬁ ce include
the performance of intraoperative assessment of
vocal quality without interference from sedation or
an endotracheal tube. Described in this chapter are
several procedures that can be successfully and rela-
tively easily undertaken in the ofﬁ ce setting under local
anesthesia.
PATIENT SELECTION
Patient selection for ofﬁ ce-based laryngeal procedures
is critical. Because a hyperactive gag reﬂ ex can lead to
aborting a procedure prematurely, the ideal patient
should be able to tolerate an examination with a ﬂ exi-
ble ﬁ beroptic laryngoscope (FFL) without excessive
gagging or undue anxiety. It should be kept in mind
that gagging during the mirror examination should
not be a contraindication to FFL. The patient
should have an adequate interincisal distance (at least
20 mm) for optimal transoral exposure and manipula-
tion.1 The patient who has severe torticollis or a head
tremor may not be suitable candidate for these ofﬁ ce
procedures.
Indications for ofﬁ ce-based laryngeal procedures
vary. The use of botulinum toxin is indicated in patients
who have spasmodic dysphonia, certain types of essen-
tial voice tremor, and vocal fold granuloma. Transoral
vocal fold augmentation is indicated in patients with
symptomatic glottal incompetence or insufﬁ ciency due
to unilateral vocal fold paralysis or paresis, vocal fold
atrophy, vocal fold scar, sulcus vocalis, or loss of the soft
tissue of the vocal folds.
Contraindications to ofﬁ ce-based laryngeal proce-
dures include unstable cardiopulmonary status, allergy
to any injectable materials including local anesthetic,
poor exposure of the endolarynx due to a prolapsing
arytenoid or severe supraglottic constriction, and the
use of anticoagulants or antiplatelet agents (nonsteroi-
dal anti-inﬂ ammatory drugs, aspirin, warfarin). Relative
contraindications to vocal fold augmentation in the
ofﬁ ce include a large posterior glottal gap or large
interarytenoid defects that require laryngeal framework
surgery. Speciﬁ c contraindications to the use of botuli-
num toxin (Botox) are pregnancy, breast-feeding,
impaired abduction of vocal fold for PCA injection
(relative), any neuromuscular condition such as myas-
thenia gravis, as well as concurrent aminoglycoside
treatment. Speciﬁ c contraindications to percutaneous
procedures for vocal fold augmentation include poorly
deﬁ ned anatomic landmarks of the neck.
291

292
Section 3
Larynx
PREOPERATIVE PLANNING
The following is a list of recommended equipment and
medications for the performance of most ofﬁ ce laryn-
geal procedures (Fig. 36-1):
• Flexible ﬁ beroptic laryngoscope with distal chip (the
ﬁ beroptic image clarity makes these procedures more
difﬁ cult) for a two-person approach, with a channel
for passage of a ﬂ exible catheter for anesthetic or
ﬂ exible needle passage (or rigid 70-degree telescope
for a one-person approach)
• C-mount camera (attaches to the laryngoscope)
• Video monitor for visualization
• Curved Abraham cannula for delivery of topical lido-
caine and vocal fold palpation, as needed
• Orotracheal injection device for transoral injection
approach (Medtronic-Xomed, Jacksonville, FL)
• 23-, 25-, or 27-gauge 1.5-inch needles for percutane-
ous injection (when required)
• Flexible ﬁ ne-gauge injection needle for use with
working channel in ﬂ exible laryngoscope
• Injectable material
• Alcohol prep pad or topical prep solution (povidone-
iodine) for percutaneous injections
• Cetacaine spray (benzocaine/tetracaine topical)
• Oxymetazoline and/or 2% Pontocaine for nasal
decongestion and anesthesia
• Cotton pledgets
• 4% lidocaine (topical)
Speciﬁ c to Botox injection:
• Electromyographic (EMG) device (The AccuGuide
[Medtronic-Xomed, Jacksonville, FL] is a hand-held
device that offers principally acoustic output that may
be used as a lower cost alternative to more expensive
traditional EMG machines)
• Botulinum toxin
• Insulated 26-gauge needle electrode, which is also
used to simultaneously administer Botox
• Ground and reference electrodes
• Tuberculin syringe
• Local anesthetic for skin (1% lidocaine with 1:100,000
epinephrine)—optional
SURGICAL TECHNIQUE
Botulinum Toxin Injection in the Ofﬁ ce via
Percutaneous and Transoral Approaches
Botulinum toxin is a naturally occurring clostridial neu-
rotoxin that reversibly inhibits release of acetylcholine
into the synaptic cleft of the neuromuscular junction,
thereby causing ﬂ accid paralysis. Clinically, this results
in a reversible, dose-dependent weakening of injected
muscles. Botulinum toxin also may have an effect on
efferent feedback to the central nervous system. This
efferent effect may explain the broad success of botuli-
num toxin in the treatment of dystonia, particularly in
comparison with surgical denervation. Botulinum toxin
is or can be used for the treatment of spasmodic dys -
phonia, essential tremor of the larynx, and vocal fold
granuloma.
There are seven different serotypes of botulinum
toxin, only two of which are available for clinical use:
type A (Botox, Allergan, Irvine, CA, and Dysport;
Ipsen Ltd, Slough, UK) and type B (Myobloc; Elan
Pharmaceuticals, Dublin, Ireland). Type A has been
most widely used in laryngology. Dose is expressed in
mouse units (U) and differs substantially among the
commercial preparations. All dosages discussed in this
chapter refer to Botox. For a more in-depth description
of the pharmacology of botulinum toxin, refer to “Phar-
macology of Botulinum Neurotoxins” by Aoki.2
Botulinum Toxin Reconstitution and Dilution
Botox is supplied as a freeze-dried powder in 100-unit
vials and is reconstituted with preservative-free saline.
The product insert provides dilution instructions to
achieve a wide variety of concentrations (1.25 units to
10 units/0.1 mL). Injection volume should be limited
to minimize diffusion. Preferable volume is 0.1 mL
per vocal fold; however, a volume of 0.2 mL is also
acceptable to minimize airway difﬁ culty from vocal fold
engorgement. A larger than 21-gauge needle should be
used for reconstitution, dilution, and transfer from vial
to injection syringe.
There are two basic injection approaches to deliver
botulinum toxin to the larynx. Percutaneous injection
with EMG guidance is the traditional approach, but the
percutaneous technique with laryngoscopic guidance is
an alternative. Each approach has advantages and dis-
advantages. Selection of the best approach is related to
the experience of the surgeon, availability of proper
equipment, characteristics of the disease being treated
and patient preference (Fig. 36-2).
Although percutaneous injection under EMG guid-
ance is the quickest and most precise method of deliv-
Figure 36-1. Common equipment used for ofﬁ ce laryngeal proce-
dures. 1—ﬂ exible wire sheath with 27-gauge needle; 2—Xomed
orotracheal injector device; 3—Bioform malleable 25-gauge orotra-
cheal needle; 4—3-mL syringe attached to Abraham cannula; 5—end
of ﬂ exible endoscopic catheter for administration of topical anes-
thetic; 6—nasal pledgets.
1
2
3
4
6
5

Chapter 36
Ofﬁ ce-Based Laryngeal Procedures
293
ery of botulinum toxin into the larynx, this technique
has a learning curve and takes time and practice to
master. The technique also requires the purchase of an
EMG machine and familiarity with EMG interpretation.
Those surgeons who perform injections of laryngeal
botulinum toxin relatively infrequently should consider
the alternative method of percutaneous injection tech-
nique using direct visual guidance with a laryngoscope.
These approaches without EMG guidance are less
precise and often the toxin dose of Botox used is
higher than when EMG-guided percutaneous injection
is used.
Spasmodic Dysphonia
The most common treatment for adductor spasmodic
dysphonia (SD) is EMG-guided bilateral percutaneous
injections of the thyroarytenoid–lateral cricoarytenoid
muscle complex (TA-LCA) using equal amounts of
botulinum toxin. This procedure is based on the under-
standing that the motor control disorder is bilateral and
symmetrical.3-5 In patients with abductor spasmodic dys-
phonia, both posterior cricoarytenoid muscles are
treated, although injections are staggered for reasons
of airway safety. For both forms of SD, the dose is
adjusted based on the initial severity of the disease and
on the response to treatment. Unilateral injection may
provide essentially equivalent symptomatic relief in
patients with adductor spasmodic dysphonia, although
the dose is usually increased and the duration of beneﬁ t
may not be as long.
A reasonable initial dose in adductor spasmodic
dysphonia is 1.25 units of Botox per side, which is a
low-average dose. The dose used at subsequent treat-
ments is adjusted based on the patient’s response. For
abductor spasmodic dysphonia, the ﬁ rst posterior cri-
coarytenoid (PCA) muscle is injected with 5 units of
Botox. Improvement in the voice and vocal fold mobil-
ity are evaluated 2 weeks after the injection. The con-
tralateral dose is determined based on the above, so
that the dose is inversely proportional to the degree of
muscle weakness observed. Asymmetrical dosing is the
rule in abductor spasmodic dysphonia. Botulinum toxin
treatment results in an initial period of marked muscle
weakness with transient breathy dysphonia lasting for
several days, followed by a 3- to 4-month-long plateau
of milder weakening that constitutes the principal ther-
apeutic effect. In general, the length of the period of
breathiness and the length of the therapeutic effect are
approximately proportional, so that attempts to shorten
the breathiness may compromise the duration of thera-
peutic effect. Naturally, patients prefer to minimize the
frequency of their injections, but each will have a dif-
ferent tolerance for the initial breathy voice phase of
their treatment and the subsequent duration of effect.
Dyspnea is the equivalent early treatment effect fol-
lowing the injection for abductor SD. Because this may
be life-threatening, only one side is treated at a time to
allow partial recovery before chemical denervation of
the contralateral side. Injections into the PCA muscle
are technically more difﬁ cult than the TA-LCA injec-
tions and may be less satisfactory in patients with abduc-
tor SD because (1) the PCA muscle injection is more
difﬁ cult to access and/or (2) some patients believed to
have abductor SD have mixed SD, a combination of
adductor and abductor SD.
Essential Voice Tremor
Essential voice tremor (EVT) is typically treated with
bilateral symmetrical muscle injections of Botox into
the TA-LCA muscle complex similar to adductor SD.
Essential voice tremor often involves a variety of muscles
of the upper aerodigestive tract. Many of the muscles
such as the straps and pharyngeal constrictors cannot
be treated due to the negative impact on swallowing
function. When the tremor is found to be predomi-
nantly at the level of the true and false vocal folds,
injection of botulinum toxin into the TA-LCA muscles
and/or the supraglottis can be very effective. If the
tremor is predominantly located in the soft palate, base
of tongue, pharyngeal walls, and/or extrinsic laryngeal
muscles, then Botox will not be effective.6 EVT patients
are more likely to be troubled by prolonged post-
treatment breathiness, thus a lower dose is preferred by
most patients.
Vocal Fold Granuloma
Vocal fold (or vocal process) granulomas (Fig. 36-3) are
associated with three inciting conditions: gastroesopha-
geal reﬂ ux disorder (GERD), intubation trauma, and
vocal abuse. GERD-related granulomas are usually seen
in adult males in the fourth to ﬁ fth decades of life.
Adult women with granulomas usually have had a
history of endotracheal intubation in the recent past.
Habits such as forceful throat clearing or coughing may
also lead to the development of granulomas. The main-
stay of treatment is voice therapy, including vocal rest,
antireﬂ ux medication, and lifestyle modiﬁ cations.7 Bot-
ulinum toxin injection has been advocated by some in
more refractory cases to weaken the vocal adductor
force of the arytenoid to allow better healing and reso-
lution of vocal fold granuloma. Botulinum toxin is
injected into the ipsilateral or bilateral TA-LCA muscle
Figure 36-2. Percutaneous electromyographically guided Botox
injection. Note landmarks and needle position.

294
Section 3
Larynx
complexes in doses ranging from 1.25 to 20 units. Most
often, 5 units injected unilaterally is adequate. In most
cases, a single application, either alone or in conjunc-
tion with surgical removal, has been sufﬁ cient to allow
for resolution of the granuloma. Patients treated in this
fashion will have a signiﬁ cantly breathy, weak voice for
several months, which they must be told may have major
functional impacts on their voice capacity (work and
social).
Percutaneous Electromyographically Guided
Botulinum Toxin Injection
Connecting Electromyogram Electrodes
A ground and a reference electrode are coated with a
conducting gel and attached to the patient’s skin at a
convenient site so as not to obstruct the injection
pathway. The insulated injection needle (26 gauge),
which serves as a monopolar sampling electrode during
the injection, is attached to an EMG recording device.
Thyroarytenoid–Lateral Cricoarytenoid Muscle
Complex Localization and Injection
The patient is positioned in a semirecumbent position
with the chin elevated and the head extended. If the
patient’s neck is thin and laryngeal landmarks are easily
palpable, a shoulder roll may be omitted. If the patient
has a short and stocky neck, or if the larynx is canted
forward, a shoulder roll is helpful. Alternatively, the
head piece of the chair can be positioned to allow
extension of the neck. The patient is asked to breathe
quietly and to try not to swallow during the procedure.
Local anesthetic may be injected into the skin. The use
of local anesthesia is highly variable among experienced
clinicians. Some surgeons argue that the discomfort to
the patient from the anesthetic injection is approxi-
mately equivalent to that from the injection of the toxin
itself, whereas others believe that the skin injection
(30-gauge needle using 1% lidocaine with 1:100,000
epinephrine and sodium bicarbonate) is justiﬁ ed
in ameliorating discomfort or pain of the procedure.
Bending the needle upward approximately 30 to 45
degrees is helpful, especially when injecting the female
larynx, because the shorter anteroposterior distance
requires a more acute angle of entry under the inferior
rim of the thyroid cartilage.
The EMG needle is inserted through the cricothy-
roid membrane approximately 2 to 3 mm off of the
midline toward the side to be injected and advanced
superiorly and laterally. This lateral entry point is used
to avoid the airway, because traversing endolaryngeal
mucosa is uncomfortable for the patient and may cause
coughing or even laryngospasm during the procedure.
If it is possible to remain entirely submucosal, the
patient ﬁ nds the procedure much less painful and stim-
ulating to airway reﬂ exes. Entry into the airway pro-
duces a characteristic “buzz” in the EMG signal that
should alert the surgeon to redirect the needle more
laterally or even start again. The location where the
needle penetrates the cricothyroid membrane from a
superior-inferior perspective is determined by the sur-
geon’s preference. Some surgeons enter the larynx at
the junction of the inferior border of the thyroid carti-
lage and the membrane, whereas others prefer to be at
the halfway point of the membrane.
The needle is maneuvered within the tissue until
the tip lies in an area of crisp motor unit potentials
found by EMG. The patient is asked to phonate, and
when a brisk recruitment and a full interference pattern
conﬁ rm placement, the botulinum toxin is injected
(Fig. 36-4). It is especially good to see a characteristic
prephonatory burst of EMG activity for optimal localiza-
tion of the injection.
Posterior Cricoarytenoid Muscle Localization
and Botox Injection
The patient is seated upright, and the surgeon who will
inject the Botox places his or her thumb at the posterior
border of the thyroid cartilage on the side to be injected.
Using counterpressure on the opposite side of the
thyroid cartilage from the other four ﬁ ngers, the larynx
is gently rotated to expose its posterior aspect (poste-
rior plate of the cricoid cartilage). The needle pierces
the skin along the lower one half of the posterior border
of the thyroid cartilage, and is advanced until it stops
against the posterior surface of the cricoid. The needle
is then pulled back slightly and the patient is asked to
sniff to conﬁ rm placement. When this produces brisk
recruitment, the toxin is injected.
Figure 36-3. Vocal fold granuloma (arrow). (Reprinted with permission
from Leonard R, Kendall K: Effects of voice therapy on vocal process granu-
loma: A phonoscopic approach. Am J Otolaryngol 26:101-107, 2005.)

Chapter 36
Ofﬁ ce-Based Laryngeal Procedures
295
Botulinum Toxin Injection with
Laryngoscopic Guidance (Two-Person)
A puncture through the cricothyroid membrane is per-
formed for administration of local anesthesia, instilling
approximately 3 mL of 4% lidocaine into the airway.
The nasal cavity is anesthetized and a ﬂ exible laryngo-
scope, attached to a video monitor, is inserted through
the nasal cavity and advanced to a level slightly above
the vocal folds. An assistant keeps the scope in position
to provide exposure and visual feedback during the
procedure. A 1-mL syringe ﬁ lled with botulinum toxin
is attached to a 27-gauge needle, and the needle is
placed through the cricothyroid membrane near the
midline while under visualization by video monitoring
to conﬁ rm the location of the needle tip in the subglot-
tic airway. The needle is angled toward the posterior
aspect of the vocal fold, piercing the infraglottic mucosa,
and advancing the needle laterally into the musculature
of the vocal fold. The posterior one third of the mem-
branous vocal fold is targeted for Botox placement. A
similar injection is then performed on the opposite
vocal fold through the same approach. Using ﬂ exible
laryngoscopic visualization to conﬁ rm correct place-
ment is a precise technique that ensures that inadver-
tent “loss” of the Botox does not occur.
Transoral Vocal Fold Injection and Other
Transoral Procedures
Transoral (or per oral) vocal fold augmentation (Fig.
36-5) in the ofﬁ ce is indicated in the treatment of symp-
tomatic glottic insufﬁ ciency as previously described.
This technique can also be used for temporary or per-
manent correction of the patient’s glottic insufﬁ ciency.
A typical case is a patient with idiopathic unilateral
vocal fold paralysis who presents early (1 to 3 months
after onset) in the course of this condition. Temporary
augmentation is an excellent option in treating the
patient who aspirates and has signiﬁ cant dysphonia and
vocal demands. The procedure addresses the patient’s
vocal/swallowing needs, while allowing for spontaneous
recovery of function without having to have a surgical
procedure in the hospital or a general anesthesia. Vocal
fold augmentation can also be offered to a patient
as a minimally invasive opportunity to evaluate their
voice after correction of glottic insufﬁ ciency. This
may help the patient decide whether a permanent
treatment option for glottic insufﬁ ciency is desirable.
This approach is referred to as a trial vocal fold
augmentation.
Topical Anesthesia Nasal/Oropharynx
Topical oxymetazoline/Pontocaine 2% is sprayed into
nasal cavities (medication-soaked cotton pledgets
placed intranasally are an alternative). Topical Ceta-
caine spray is also administered to the palate and pha-
ryngeal walls.
Video Monitoring/Topical Anesthesia
of the Larynx
A video camera is attached to a ﬂ exible ﬁ beroptic laryn-
goscope or a distal chip ﬂ exible laryngoscope system,
which is inserted through the nasal cavity (typically the
side opposite the intended vocal fold to be injected) by
an assistant, employing a “videocart system.” The laryn-
goscope is generally maintained slightly below the
palate so that the tongue base and larynx can be easily
viewed on the video monitor.
Four percent lidocaine is then dripped onto the
larynx under ﬂ exible laryngoscope guidance (3 to
5 mL).8 The patient is bent forward at the waist with
the neck extended in a “snifﬁ ng” position to maximize
exposure of the larynx. The tongue is grasped with
gauze with the surgeon’s left hand. An Abraham cannula
attached to a 3-mL syringe of 4% lidocaine is passed
from the oral cavity into the pharynx under ﬂ exible
laryngoscopy guidance. Approximately 1 mL of lido-
caine is deposited over the tongue base, and 2 to 4 mL
are dripped onto the vocal folds during phonation (sus-
tained “i”), producing the characteristic “laryngeal
gargle.” NOTE: The maximum recommended dose of
4% lidocaine is approximately 7 to 8 mL (4.5 mg/kg;
approximately 300 mg in 70-kg patient).
The initial dose is usually followed by a brisk cough
as the anesthetic is aspirated and then distributed over
the laryngotracheal mucosa. Absence of the laryngeal
gargle and cough may indicate that the patient has
swallowed the anesthetic, and additional topical
Figure 36-4. Electromyographic recording during “ee” maneuver
for thyroarytenoid muscle localization. (Reprinted with permission from
Munin M, Murry T, Rosen CA: Laryngeal electromyography: Diagnostic and
prognostic applications. Otolaryngol Clin N Am 33:759-770, 2000.)
Figure 36-5. Transoral vocal fold augmentation with endoscopic
guidance placement of Abraham cannula. Note positioning of
patient.

296
Section 3
Larynx
applications may be indicated until topical anesthesia
has been obtained.
Alternative Methods of Topical Anesthesia
Nebulization
An alternative method of obtaining anesthesia of the
larynx involves nebulization of lidocaine using a simple
disposable nebulization device (e.g., those used by
respiratory therapy) and an external source of pressur-
ized air (i.e., from an oxygen tank) (Fig. 36-6). Four
percent lidocaine can be nebulized and inhaled by
mouth by the patient. This method of anesthesia pro-
vides a simple and less physician-involved method
for obtaining laryngeal anesthesia. Typically, 6 mL of
4% plain lidocaine is nebulized over a 5- to 10-minute
time period, achieving excellent anesthesia of the
larynx. After the nebulization process, a curved Abraham
cannula can be used to supplement any additional need
for laryngeal anesthesia on an as-needed basis and to
test for complete anesthesia of the larynx and, speciﬁ -
cally the vocal folds.
Flexible Catheter
Another technique of delivering the anesthetic agent
to the larynx is by using a small silastic, ﬂ exible cannula
through the working channel of the ﬂ exible laryngo-
scope or an EndoSheath with a working channel
(Medtronic-Xomed, Jacksonville, FL). This silastic cath-
eter (Olympus America, PW-2L-1.B, Center Valley, PA)
passes through the working channel of the ﬂ exible
laryngoscope and is used to deliver 4% plain lidocaine
to the endolarynx during sustained phonation to
achieve the “laryngeal gargle” as described earlier. This
catheter allows direct application of the anesthesia to
the speciﬁ c areas intended for the vocal fold injection
and is very well tolerated by most patients.
Transoral Passage of the Needle into the
Endolaryngeal Region
The two most commonly used needles for transoral
vocal fold augmentation in the ofﬁ ce are the orotra-
cheal injector device (Medtronic-Xomed, Jacksonville,
FL) and the injection needle developed by Bioform
Medical (Bioform Medical, San Mateo, CA). Each of
these injection devices is ﬁ ne-gauge (27- and 25-gauge,
respectively.) The former device is precurved for trans-
oral injection and the latter is malleable and must be
bent to the appropriate dimensions and curvature
needed for transoral vocal fold augmentation. In prepa-
ration for vocal fold injection, the intended injection
material should be attached to the injection needle and
the needle “primed” to eliminate the dead space within
the needle. The orotracheal injector is designed to
inject thin liquids and not thick, viscous augmentation
materials.
Preferably, patients hold their own tongue with a
gauze pad, or the surgeon grasps the patient’s tongue
with the left hand. The needle is passed through the
oral cavity and then advanced into the oropharynx
under direct visualization with the ﬂ exible laryngo-
scope. The patient is instructed to say “a” as the needle
enters the oral cavity, which results in palatal elevation,
providing visualization into the oropharynx. The assis-
tant should position the ﬁ beroptic scope just above
the palate, until the needle is visualized in the
oropharynx.
The needle is then guided into the oropharynx and
the endolarynx under endoscopic visualization as the
assistant follows closely behind with the ﬂ exible laryn-
goscope. The assistant must be facile with manipulating
the ﬂ exible scope. Consistent visualization of the needle
is especially important in a narrow airway with copious
secretions. The ﬂ exible scope should be positioned a
few millimeters above the true vocal folds, providing a
clear, well-illuminated view before, during, and imme-
diately after the injection.
Vocal Fold Injection
For unilateral VF paralysis, the injection should be
placed at two sites: the posterior aspect (lateral to the
vocal process) and the mid-membranous vocal fold
(Fig. 36-7). The initial injection should be at the poste-
rior aspect of the vocal fold, where, typically, the most
correction is needed. The depth of injection should be
into the substance of the vocal fold lateral to the body
of the TA muscle. Great care should be taken to avoid
superﬁ cial placement into Reinke’s space, which results
in a stiff vocal fold and poor voice quality. If the subglot-
tis begins to bulge during injection, the needle should
be withdrawn slightly. Once the posterior vocal fold is
adequately medialized, a smaller additional amount can
be deposited at the mid vocal fold, if needed. If the
injected substance extrudes from the puncture hole,
patients can clear this themselves with a gentle cough
or throat clear (this rarely is a problem when a ﬁ ne-
gauge needle is used). The patient’s vocal quality should
be checked periodically during the procedure to deter-
mine the optimal volume of injected material. Only
when a steroid injection for superﬁ cial scar is per -
formed is the injection performed superﬁ cially along
the medial surface of the vocal fold into the lamina
Figure 36-6. Equipment needed for nebulization.

Chapter 36
Ofﬁ ce-Based Laryngeal Procedures
297
propria (Reinke’s space). Steroid injection is best done
via the transoral or transnasal approach.9
For most injectable substances, the medialized
vocal fold should be overinjected (past midline) to a
variable degree depending on the speciﬁ c nature of the
material and the primary goal of the procedure (long
duration of the temporary agent versus immediate need
for optimal voice function). In general, the vocal fold
is medialized until the voice is maximally improved, and
then an additional 0.1 to 0.2 mL is injected to achieve
overcorrection. Overcorrection is necessary because all
injectables have a small aqueous component that will
be absorbed 3 to 5 days after injection leading to loss
of volume. The total amount necessary for unilateral
augmentation is typically less than 1 cm3, but the
amount injected should be determined visually and
audioperceptually.
For patients with a bowed vocal fold due to atrophy
or paresis, the injection differs slightly from the previ-
ous technique. These cases typically require injection
principally in the midportion of the vocal fold, where
the maximal glottal gap usually occurs. In severe cases
of muscular atrophy, the posterior vocal fold can be
augmented to ﬁ ll in the atrophy that occurs just ante-
rior to the vocal process. Again, overcorrection is the
rule, even in the case of bilateral injections. Airway
compromise should not be a concern, because the pos-
terior respiratory glottis remains patent and in cases of
vocal fold atrophy both vocal folds are usually fully
mobile.
Percutaneous (Transcervical) Vocal
Fold Injection
Vocal fold augmentation using a percutaneous
approach in the ofﬁ ce or at the bedside has been suc-
cessfully performed with a number of different materi-
als and can be performed with either temporary or
permanent augmentation materials (Fig. 36-8). There
are multiple percutaneous vocal fold augmentation
approaches, including transthyroid cartilage, transcri-
cothyroid membrane, and transthyrohyoid membrane.
All of these approaches require anesthesia of the
overlying skin, a skilled endoscopist as an assistant, and
a 23- to 25-gauge needle (1.5 inches long). The trans-
thyroid cartilage and cricothyroid membrane approaches
are similar. Ossiﬁ cation of the thyroid cartilage can
prevent passage of the injection needle through the
thyroid cartilage and thus a cricothyroid (subthyroid)
or thyrohyoid approach is required.
The thyrohyoid approach can be used for VF aug-
mentation as well as for injection of therapeutic sub-
stances, such as cidofovir and Botox (Fig. 36-9).10,11 The
transthyrohyoid approach is an excellent alternative
to transoral or traditional percutaneous approaches
(transthyroid cartilage and cricothyroid approach).
This technique is as well tolerated as other percutane-
Figure 36-7. Proper placement of the needle lateral to the vocal
fold for augmentation using ﬂ exible endoscopy. (Reprinted with per-
mission from Andrade FP, Carrau R, Buckmire R: Safety and cost-effectiveness
of intra-ofﬁ ce ﬂ exible video-laryngoscopy with transoral vocal fold injection in
dysphagic patients. Am J Otolaryngol 27:319-322, 2006.)
Figure 36-8. Percutaneous vocal fold augmentation procedure.
(Reprinted with permission from LifeCell Corporation.)

298
Section 3
Larynx
ous approaches and provides good visualization and
precision.
Percutaneous vocal fold augmentation in the clinic
setting has the same indications as transoral vocal fold
augmentation. These are unilateral vocal fold paresis or
paralysis, vocal fold atrophy, vocal fold scar, sulcus
vocalis, and soft tissue loss of the vocal folds. Injection
can be performed as trial, temporary, or permanent for
augmentation as described in the section on transoral
augmentation. With the percutaneous approach,
interincisal opening and gag reﬂ ex are not concerns.
Percutaneous Vocal Fold Augmentation in
the Ofﬁ ce
1. The area overlying the injection site is swabbed with
an alcohol prep pad or povidone-iodine prep.
2. The patient is positioned in the sitting position but
slightly reclined with the neck in neutral position
and the head slightly extended on the neck.
3. It is important to anesthetize both the skin over the
area to be injected as well as the upper airway in
preparation for ﬂ exible laryngoscopy. To anesthe-
tize the skin and subcutaneous tissues, approxi-
mately 0.5 mL of local anesthetic (1% lidocaine
with 1:100,000 epinephrine) is sufﬁ cient. The skin
and subcutaneous tissues overlying the cricothyroid
membrane are injected as well as the area over the
inferior aspect of the thyroid cartilage on the side(s)
intended for injection. The surgeon must avoid
overinjection of this area with anesthetic because
this may transiently impair cricothyroid function,
thus clouding the picture of paresis/paralysis at the
time of injection.
4. The nasal cavity is anesthetized and decongested as
is customary for the surgeon. Topical anesthesia to
the endolarynx is helpful per the surgeon’s prefer-
ence but is rarely necessary for the percutaneous
procedure.
5. Flexible laryngoscopy is performed by the assistant
and the preprocedure diagnosis/diseases are con-
ﬁ rmed. Ideally, the tip of the scope is maintained
over the contralateral arytenoid, as posteriorly as
possible to avoid stimulating the supraglottic struc-
tures. This position allows for some visualization of
the infraglottic surface of the vocal fold to be
injected.
6. The cricothyroid membrane is palpated by the
injecting surgeon. In many patients, it is possible to
see (endoscopically) the depression of the underly-
ing mucosa during this maneuver. This is very
helpful in estimating the height of the vocal fold
relative to the cricothyroid membrane. If the
impression from the palpating ﬁ nger is not seen,
this maneuver may be performed with the injection
needle without penetrating into the airway.
7. The vertical and horizontal distances from this
point to the midpoint of the membranous vocal
fold are estimated by the surgeon. The needle (23-
or 25-gauge, 1.5 inches long) is placed along a verti-
cal line approximately 6 to 12 mm from the midline;
this distance depends on the size of the larynx. The
needle should be oriented perpendicularly in rela-
tion to the thyroid ala.
8. The needle is placed against the thyroid ala at the
desired vertical level along this line. In most females
and younger males, gentle steady pressure will
allow the needle to pass through the cartilage. The
surgeon should avoid “past pointing” as the needle
is passed through the thyroid cartilage to avoid
entering the airway. If the needle meets signiﬁ cant
resistance, the needle is kept in the same line and
“walked” down the thyroid ala until the inferior
aspect of the thyroid cartilage is reached.
9. The needle is then advanced medially, again per-
pendicularly to the thyroid ala for approximately 3
to 4 mm through the junction of the thyroid ala
and the cricothyroid membrane. At this point, the
tip of the needle is in the infraglottic vocal fold and
needs to be directed nearly straight up vertically.
All attempts should be made to avoid entering
the airway. The needle may be seen indenting the
infraglottic mucosa or penetrating the ﬂ oor of the
ventricle with the image from the ﬂ exible
laryngoscope.
10. To facilitate identifying where the needle has
entered into the endolarynx, the needle can be
Figure 36-9. Thyrohyoid approach in cadaver larynx. (Reprinted
with permission from Getz AE, Schar J, Amin M: Thyrohyoid approach to
cidofovir injection: A case study. J Voice 19:501-503, 2005.)

Chapter 36
Ofﬁ ce-Based Laryngeal Procedures
299
moved back and forth rapidly several times over a
short distance.
11. The tip of the needle is then redirected to the main
bulk of the vocal fold if found not to be located in
the membranous vocal fold.
12. Once the needle location is conﬁ rmed, vocal fold
injection is started slowly. Good visualization of the
vocal fold is essential at this stage. As the material
is injected, the vocal fold will swell. The end point
for injection will be determined by the endoscopic
appearance of the vocal fold as well as by the
patient’s voice. Depending on the nature of the
substance injected, modest to moderate overcorrec-
tion is often desirable. The patient may immedi-
ately notice the improvement in the voice—it is
important in most cases to overcorrect past this
point, if possible, to allow for a longer duration
of overall beneﬁ t for temporary augmentation
materials.
13. If the contour is not ideal (focally overinjected)
immediately following injection, a hard cough may
“straighten out” the vocal fold as seen during the
endoscopy. In the case of bilateral vocal fold pathol-
ogy, there is generally no limitation to treating both
sides at the same setting.
Thyrohyoid Approach to the Larynx
1. The surgeon ﬁ rst sprays (topical 50:50 mix of oxy-
metazoline/lidocaine) into the nasal cavities.
2. Skin and subcutaneous tissues overlying the thyro-
hyoid notch are injected using a 25-gauge needle
and 1% lidocaine.
3. The patient should be positioned sitting upright
with neck extended to expose the thyrohyoid
notch.
4. An assistant passes the ﬂ exible laryngoscope
through the nasal cavity (usually left side) and posi-
tions the scope so the tongue base and larynx are
clearly visualized.
5. A 25-gauge needle (1.5 inches long) and syringe
with topical 4% lidocaine is passed into the airway
above the vocal folds via the thyrohyoid mem -
brane. The needle is passed immediately above the
thyroid notch and directed acutely downward until
the needle enters the airway in the area of the
petiole.
6. Proper positioning is conﬁ rmed by ﬁ beroptic guid-
ance and the ability to draw back air into the syringe.
Note that absence of a laryngeal gargle or cough
suggests the patient swallowed the anesthetic and
additional 4% lidocaine may be needed. Adequate
anesthesia is achieved after 3 to 5 minutes. Alterna-
tively, topical laryngeal anesthesia may be adminis-
tered through a working channel of the ﬂ exible
laryngoscope if this is available.
7. The implant/injectable material is prepared in an
appropriate syringe attached to a 25- or 23-gauge,
1.5-inch needle.
8. The needle is passed in the midline just above the
thyrohyoid notch in a downward, acute angle just
under the patient’s chin. If the patient turns his or
her head slightly away from the surgeon, this will
help establish the optimal angle.
9. The tip of the needle passes through the pre-
epiglottic space and enters the larynx at the petiole
of the epiglottis.
10. Under direct guidance on the monitor, the assis-
tant advances the ﬂ exible scope to follow the needle
as it is guided to the appropriate injection site(s).
11. Bilateral VF injection may be achieved by backing
out the needle slightly (without removing it) and
redirecting the needle tip under direct visualization
to the other side (see Fig. 36-9).
POSTPROCEDURE CARE/COMPLICATIONS
Botox
Patients may leave the ofﬁ ce immediately after the
injection. Patients receiving TA-LCA injections should
be cautioned regarding an initial period of (1) breathi-
ness and (2) dysphagia, especially to liquids, as dis-
cussed earlier. Patients receiving their second posterior
cricoarytenoid injection should be advised regarding
the possibility of dyspnea and stridor.
Vocal Fold Injection or Augmentation
Immediately following vocal fold injection in the ofﬁ ce,
patients should be observed for 20 to 30 minutes to
monitor for any complications of the vocal fold injec-
tion, particularly airway distress. Patients need to be
instructed that they should not take anything orally for
approximately 2 hours following vocal fold injection to
allow adequate time for the local anesthesia to wear off.
In addition, patients should take care as they resume
oral intake to be sure that any residual anesthetic effects
have dissipated. The use and duration of strict voice rest
following vocal fold injection are not standardized and
are often determined by the size of the vocal fold injec-
tion needle and surgeon preference. Because most
vocal fold injections are now performed with ﬁ ne-gauge
needles, prolonged voice rest (exceeding 24 hours) is
usually not indicated. Some surgeons do not suggest the
use of voice rest, whereas others use a 24-hour period
of voice rest. The rationale for voice rest following vocal
fold injection is to minimize loss of the injected mate-
rial being extruded through the injection site(s) if
immediate phonation is allowed. Antibiotics and ste-
roids are not typically indicated for this procedure.
Patients should be instructed that, because of the vocal
fold edema and overinjection of the augmentation
material, optimal voice quality is typically not achieved
for 1 to 2 weeks following vocal fold injection.
Complications of transoral vocal fold injection
include inappropriate placement of the vocal fold
injection material: too superﬁ cially into Reinke’s space,
very lateral into the paraglottic space (this can cause
increased pain), and inferior into the subglottis. If these
inappropriate locations of vocal fold injection are rec-
ognized during the procedure, often the material can
be “milked” out of the vocal fold with the use of an

300
Section 3
Larynx
Abraham cannula, applying gentle lateral pressure to
the vocal fold. If this is not possible, it is advisable that
the vocal fold material, if permanent in nature (e.g.,
calcium hydroxylapatite), be removed under microlar-
yngoscopy with general anesthesia in the near future.
Injection should be aborted with the ﬁ rst sign of airway
embarrassment, laryngeal spasm, or unexpected vocal
fold swelling. Dramatic swelling may occur if air is inad-
vertently injected. Complications unique to the percu-
taneous approaches include plugging of the needle
with cartilage (transthyroid approach) and bleeding
into the airway. Bleeding is typically minimal, although
when it leads to coughing, the endolarynx may be
covered with a thin ﬁ lm of blood, which limits visibility.
The patient is asked to gargle (if possible) and the
procedure may be continued. A hematoma in the skin
overlying the injection site may occur also but it is
usually self limited.
In-Ofﬁ ce Laryngeal Biopsy Using EndoCDx
This procedure uses surface exfoliative cytology as its
basis. The indications for this procedure are epithelial
lesions that are preneoplastic or of uncertain behavior.
This brush biopsy technique can be used both for initial
diagnosis and pathologic surveillance. The contraindi-
cations are as mentioned previously for any in-ofﬁ ce
procedure.12
1. The endolarynx should be anesthetized as for any
transoral or transnasal vocal fold injection through
the working channel of a ﬂ exible laryngoscope.
Instillation of 2 mL of 4% lidocaine one to three
times while the patient’s vocal folds are in adduction
appears to be adequate but the amount is left to the
discretion of the surgeon.
2. The EndoCDx brush (Fig. 36-10) is guided through
the working channel of the ﬂ exible laryngoscope.
Alternatively, it can be guided via indirect rigid
endoscopy using an alligator or cup forceps to hold
the brush.
3. The EndoCDx brush should be placed against the
lesion while maintaining pressure by angulating the
laryngoscope. The brush is rotated against the lesion
unless pinpoint bleeding is observed. A vigorous up
and down direction should be used while rotating
the brush.
4. Care must be taken to not contaminate the sample
by touching other sites during withdrawal/retrac-
tion. The brush is retracted into its sheath and
removed, and the material (cells) is spread evenly
onto the bar-coded side of an enclosed glass slide.
Care must be taken to not contaminate the sample
by touching other sites during withdrawal/retrac-
tion. A ﬁ xative packet is emptied onto the slide
and should saturate the material on the slide. The
slide should be set aside to dry for 15 minutes and
then placed in the slide holder supplied by the
company.
5. The bristle end of the brush is clipped off into a
supplied vial. The vial is closed and is then sent to
the CDx laboratories. The brush and slide are ana-
lyzed both by a trained cytopathologist and a propri-
etary computerized program. The only signiﬁ cant
complication to be aware of is bleeding because the
procedure itself is short in duration. This can be
avoided by paying particular attention before the
procedure to the patient’s coagulation status, medical
history, and medications.
Figure 36-10. EndoCDx brush. (Reprinted with permission from CDx
Laboratories, Inc.)
PEARLS
• Percutaneous EMG-guided injection provides
effective administration of botulinum toxin,
minimizes diffusion to neighboring muscles, and
conﬁ rms placement of needle during EMG by
muscle activation during appropriate activity.
• Percutaneous injection of Botox under ﬂ exible (or
rigid) laryngoscopic guidance is ideal for
practitioners who perform laryngeal injections
infrequently because it is easier to master and relies
on visual conﬁ rmation of the target rather than on
blind needle placement.
• Percutaneous vocal fold augmentation in the ofﬁ ce
is an alternative for patients who prefer not to
undergo general anesthesia or will not tolerate
transoral vocal fold augmentation in the ofﬁ ce.

Chapter 36
Ofﬁ ce-Based Laryngeal Procedures
301
References
1. Simpson CB, Amin MR: Ofﬁ ce-based procedures for the voice.
ENT J 83(7 Suppl 2):6-9, 2004.
2. Aoki KR: Pharmacology of botulinum neurotoxins. Op Tech Oto-
laryngol 15:81-85, 2004.
3. Blitzer A, Brin MF, Stewart CF: Botulinum toxin management of
spasmodic dysphonia (laryngeal dystonia): A 12-year experience
in more than 900 patients. Laryngoscope 108:1435-1441, 1998.
4. Blitzer A, Sulica L: Botulinum toxin: Basic science and clinical
uses in otolaryngology. Laryngoscope 111:218-226, 2001.
5. Sulica L, Blitzer A: Botulinum toxin treatment of spasmodic dys-
phonia. Op Tech Otolaryngol 15:76-80, 2004.
6. Bové M, Daamen N, Rosen C, et al: Development and validation
of the vocal tremor scoring system. Laryngoscope 116:1662-1668,
2006.
7. Devaney KO, Rinaldo A, Ferlito A: Vocal process granuloma of
the larynx-recognition, differential diagnosis and treatment. Oral
Oncol 41:666-669, 2005.
8. Simpson CB, Amin MR, Postma GN: Topical anesthesia of the
airway and esophagus. ENT J 83(7 Suppl 2):2-5, 2004.
9. Tateya I, Omori K, Kojima H, et al: Steroid injection for Reinke’s
edema using ﬁ beroptic laryngeal surgery. Acta Otolaryngol
123:417-420, 2003.
10. Amin MR: Thyrohyoid approach for VF augmentation. Ann Otol
Rhinol Laryngol 155:699-702, 2006.
11. Getz AE, Scharf J, Amin MR: Thyrohyoid approach to cidofovir
injection: A case study. J Voice19:501-503, 2005.
12. Woo P: Ofﬁ ce-based laryngeal procedures. Otolaryngol Clin N
Am 39:111-133, 2006.
• Proper patient positioning, skilled endoscopy by the
assistant, the skill of the surgeon, and knowledge of
multiple approaches to the vocal fold provide the
highest chance of success for vocal fold
augmentation in the ofﬁ ce.
• In-ofﬁ ce brush biopsy can be used for diagnostic
and pathologic surveillance of suspicious lesions on
the vocal fold.
PITFALLS
• Patients who have a hyperactive gag reﬂ ex, anxiety,
or copious secretions are poor candidates for an in-
ofﬁ ce laryngeal procedure.
• Patients with essential tremor that is not conﬁ ned to
the glottis and supraglottis do poorly with Botox
injections compared with those with focal laryngeal
essential tremor.
• Multiple injection sites during vocal fold
augmentation and early phonation may cause
premature extrusion of the injected substance.
• Too superﬁ cial injection of material into the vocal
fold (into Reinke’s space) during augmentation
procedures causes stiffness and decreased vibration
of the vocal fold, leading to a less than optimal
voice result. Too much overinjection during
augmentation may cause airway obstruction, which
is a potentially disastrous complication.

Chapter 37
Phonomicrosurgery for Benign Vocal
Fold Lesions
Libby J. Smith and Clark A. Rosen
Patients complaining of hoarseness, vocal fatigue,
diminished vocal range, strain, or other vocal issues
require a complete laryngeal examination. Based on
ﬁ ndings of the laryngeal examination, several treat-
ments may be indicated, including surgery. Phonomi-
crosurgery encompasses a variety of elective operations
whose primary goal is to improve the quality of the
voice. These procedures focus on precision microsurgi-
cal techniques to remove benign vocal fold lesions,
which usually occur in the subepithelial space. Hirano’s
body cover theory of vocal vibration is paramount in the
design of current microsurgical principles and surgical
procedures.1 The delicate interface between the mucosa
and superﬁ cial lamina propria (cover) and the deeper
lamina propria layers and muscle (body) guides surgi-
cal advancements in phonomicrosurgery (Fig. 37-1).
Wound healing is optimized by preserving the mucosal
superﬁ cial lamina propria whenever possible and limit-
ing surgery to the vocal fold layers involved with pathol-
ogy (staying as superﬁ cial in the vocal fold as possible).
This is believed to result in better postoperative mucosal
wave vibration, thereby probably improving vocal
outcomes.
PATIENT SELECTION
Phonomicrosurgery is an elective procedure. The risks
and beneﬁ ts of surgery should be clearly delineated to
the patient. The patient’s vocal limitations (speaking
and singing) should be thoroughly reviewed, especially
in relation to the vocal requirements of jobs and
hobbies. This review process is often conducted over a
period of several weeks and involves the patient, the
family, a speech therapist, and possibly a singing voice
specialist. Once all nonsurgical therapies have been
exhausted and even more is required of the patient’s
voice, only then is it appropriate to proceed with
phonomicrosurgery.
Types of Benign Vocal Fold Lesions2
Nodules
Nodules are benign bilateral masses, not always sym-
metrical, located within the lamina propria. They are
typically located at the midpoint of the musculomem-
branous vocal fold. Breathy dysphonia is the result of
incomplete vocal fold closure. Nodules tend to occur
in patients who use their voices aggressively (children,
cheerleaders). After phonotraumatic behavior is elimi-
nated, these lesions almost always resolve on their own.
Accordingly, surgery and exploratory cordotomy are
rarely indicated.
Fibrous Masses
Fibrous masses are composed of irregular ﬁ brous mate-
rial without clearly deﬁ ned borders and can occur in
either the subepithelial space or near the ligament of
the vocal fold. These masses are often located in the
midmembranous vocal fold, either unilateral or bilat-
eral, and therefore incomplete vocal fold closure is
common. Unilateral lesions are frequently associated
with a contralateral reactive lesion. Development of a
ﬁ brous mass is often associated with chronic phono-
trauma or hemorrhage. Reduced and proper voice use
is the initial treatment. If this fails, surgical excision with
a microﬂ ap technique is indicated.
Ligamentous ﬁ brous masses are located deeper in
the vocal fold and are often attributed to chronic pho-
notrauma or hemorrhage. They may be unilateral or
bilateral, frequently with a contralateral reactive com-
ponent. Microﬂ ap surgery is indicated. Because of the
303

304
Section 3
Larynx
deep dissection required, the risk of worse postopera-
tive voice quality is higher than with more superﬁ cial
masses.
Cysts
Vocal fold cysts, both subepithelial and ligamentous,
are often unilateral and located at the leading (medial)
edge of the midmusculomembranous portion of the
vocal fold. These encapsulated structures are attributed
to glandular duct blockage or phonotrauma or may be
congenital. Hoarse voice from an hourglass closure
pattern, vocal fatigue, and altered pitch control are
common. Proper voice use is the initial treatment. If
this is not adequate to meet the vocal demands of the
patient, microﬂ ap excision is performed.
Reactive Lesions (Secondary Lesions)
Reactive lesions are believed to result from altered
contact forces from a primary contralateral lesion, such
as a polyp, cyst, or ﬁ brous mass. Rigid videostroboscopy
will demonstrate a convex lesion (primary lesion) that
ﬁ ts into a concave lesion (secondary lesion). Surgical
excision of a reactive lesion is not generally necessary.
Voice rest, reduced voice use, or voice therapy is often
all that is required. In addition, after the primary lesion
is addressed therapeutically, the reactive lesion usually
reduces in size or resolves. If these measures fail, micro-
ﬂ ap excision is performed.
Polyps
Polyps are located in the superﬁ cial lamina propria, at
the midpoint of the musculomembranous vocal fold.
They are generally unilateral, sometimes with a contra-
lateral reactive lesion. Polyps can be sessile (broadly
attached to a vocal fold) or pedunculated (hanging
from a stalk). These lesions are believed to be the
product of intense phonotrauma or vocal fold hemor-
rhage. Inﬂ ammatory agents, dehydration, hormone
treatment, and anti-inﬂ ammatory medications may be
predisposing factors. Acute polyps are treated by
reduced voice use. If this is unsuccessful, microﬂ ap
excision with preservation of normal mucosa is per-
formed for sessile polyps. Truncation (excision) is per-
formed for pedunculated polyps.
Reinke’s Edema (Polypoid Degeneration, Diffuse
Polyposis, Chronic Polypoid Corditis)
Reinke’s edema signiﬁ es the chronic presence of
increased gelatinous material in the superﬁ cial lamina
propria. It is usually bilateral but may be asymmetrical
or unilateral. The patient’s voice is lower in pitch and
dysphonic. Women are affected more often by Reinke’s
edema; however, this is probably due to selection bias
because women are more bothered by lower vocal pitch
and roughness. Interestingly, many women employed in
traditionally male-dominated ﬁ elds (lawyer, newscaster,
etc.) have Reinke’s edema. In this patient population,
eradication of Reinke’s edema could be detrimental to
their professional livelihood, because a lower pitch voice
is often desired. The largest risk factor is smoking, in
addition to environmental toxins, reﬂ ux, and phono-
trauma. When the pathologic accumulation is severe,
airway obstruction can occur. Primary treatment is to
remove the offending agents that led to the develop-
ment of Reinke’s edema. Smoking cessation is abso-
lutely necessary. Voice therapy can occasionally be
helpful if the probable cause is phonotrauma. Only after
several months of compliance with smoking cessation
and other conservative treatments (medical reﬂ ux
therapy, avoidance of toxins, and speech therapy)
should surgery be considered. Conservative removal of
a portion of the gelatinous material is achieved through
a small access incision on the superior aspect of the
vocal fold, followed by minimal suctioning and milking
of material from the superﬁ cial lamina propria. Removal
of too much superﬁ cial lamina propria will lead to scar-
ring and permanent hoarseness.
PREOPERATIVE EVALUATION
A thorough history plus physical examination is para-
mount in evaluating a patient with voice problems. Not
only complete examination of the head and neck but
also an extensive history on vocal demands, employ-
ment, and singing is required. Laryngeal examination
with ﬂ exible nasopharyngeal laryngoscopy is the best
way to evaluate gross vocal fold motion, as in the case
of vocal fold paresis or paralysis. Rigid stroboscopy plays
a major role in examination of the vocal folds. It allows
superior evaluation of the vibratory margin so that the
vibratory effects of the lesion can be determined. Alter-
ation or diminution of the mucosal wave (vibration
along the medial/vibratory margin) leads to hoarse-
ness. This view also allows the clinician to look for asso-
ciated vocal fold scars, which may be an important
comorbidity with various vocal fold lesions.
Epithelium
Superficial
layer
Intermediate
layer
Deep layer
Muscle
Lamina
propria
Figure 37-1. Cross-sectional view of a vocal fold demonstrating
layers of the vocal fold lamina propria. (Reprinted with permission from
Hirano M: Clinical Examination of Voice. New York, Springer-Verlag, 1981,
p 5.)

Chapter 37
Phonomicrosurgery for Benign Vocal Fold Lesions
305
Sound is the product of subglottic airﬂ ow forcing
closed vocal folds to open, thereby leading to the gen-
eration of a mucosal wave along the medial edge of the
vocal fold. Closure of the vocal folds during this vibra-
tory cycle is achieved by the inherent elastic recoil of
the vocal fold and the Bernoulli effect. This is called
the myoelastic aerodynamic theory of phonation. This
cycle usually occurs 100 to 800 times per second, as
determined by the patient’s pitch. A vocal fold mass can
disrupt this normal process and lead to hoarseness and
other vocal complaints. Depending on the patient’s
history and laryngeal examination, either ﬂ exible naso-
laryngoscopy (gross vocal fold motion abnormalities),
rigid stroboscopy (lesions), or both may need to be
performed to fully evaluate the larynx. Such laryngeal
examinations will provide the surgeon with an idea of
the depth and type of the lesion. Although all vocal fold
lesions are sent to pathology for evaluation, it is difﬁ cult
for pathologists to distinguish between nodules, cysts,
and polyps based on histologic characteristics. Precise
classiﬁ cation of benign vocal fold lesions is therefore
based on the surgeon’s evaluation in the operating
room, including magniﬁ cation with the operating
microscope, palpation of the vocal fold, and identiﬁ ca-
tion of the physical features of the lesion or lesions,
such as a cystic or ﬁ brous mass.
Preoperative voice therapy is very important in pre-
paring the patient for surgery. One to two sessions are
often scheduled if the patient did not receive voice
therapy before the decision to undergo surgery. Anti-
coagulant medications should be avoided preopera-
tively if medically possible. Smoking cessation is critical
for improved postoperative healing. The patient should
also avoid vocal abuse and misuse preoperatively. These
guidelines will prepare the patient and vocal folds for
surgery.
Absolute voice rest (≈7 days) and reduced voice use
(additional 7 to 10 days) after surgery should be dis-
cussed with the patient preoperatively. The amount of
voice rest is determined by the extent of surgery along
the vibratory margin of the vocal fold (the medial
portion of the musculomembranous vocal fold that
makes contact with the other vocal fold during vibra-
tion). The patient should make the appropriate sched-
ule changes to comply with the prescribed postoperative
voice restrictions. If the patient has any laryngopha-
ryngeal reﬂ uxsymptoms (globus, throat clearing, exces-
sive mucus, cough, heartburn3) or signs (infraglottic
edema, ventricular obliteration, laryngeal erythema,
vocal fold edema, diffuse laryngeal edema, posterior
laryngeal hypertrophy, granuloma, or thick endolaryn-
geal mucus4), proper reﬂ ux medications should
be started at least 4 weeks before surgery. This will
decrease the risk for postoperative wound-healing
complications.
Discussion of consent for phonomicrosurgery
should include the risks associated with general anes-
thesia, infection, bleeding, dental injury, injury to the
temporomandibular joint, and injury to the lingual
nerve.5 A serious discussion between the patient and
surgeon involving the small but real risk of no voice
improvement or worsening of vocal function must take
place before surgery. Keeping in mind the elective
nature of these surgeries, the patient must accept these
risks.6
SURGICAL APPROACHES
Anesthesia
Close communication between the surgeon and anes-
thesia team is important for successful phonomicrosur-
gery. These procedures require general anesthesia, with
complete relaxation of the patient throughout the pro-
cedure. Preoperative intravenous administration of
steroids and glycopyrrolate (Robinul) (unless contrain-
dicated) will make the surgical environment better by
minimizing swelling and secretions. A small endotra-
cheal tube (size 5.0 to 5.5) should be placed without
the aid of a stylet. Not only does the smaller tube
improve visualization for the surgeon, but it also dimin-
ishes the chance of injury to the vocal fold on intuba-
tion. If the vocal fold is injured during intubation, the
surgery may need to be cancelled. Stressing the impor-
tance of careful intubation is often facilitated by discuss-
ing the planned surgery with the anesthesiologist before
the procedure and by the surgeon being present during
intubation. If an endotracheal tube will obscure ade-
quate visualization, jet ventilation can be used. Tracheal
jet ventilation is preferred over supraglottic jet ventila-
tion because there is no vibration of the operative site
or desiccation of the vocal fold tissues and it enables
the anesthesia team to monitor CO2 levels.
Patient Positioning
Patient positioning is critical to obtain the best visualiza-
tion of the larynx. The optimal position is supine with
the neck ﬂ exed and the head extended (Fig. 37-2).
Trendelenburg positioning will often aid in providing
Neck flexed
on the body
Head extended
on the neck
Figure 37-2. Patient positioning for microsuspension laryngoscopy:
neck ﬂ exion and head extension.