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Selective Neck Dissection

Introduction Selective neck dissection (SND) is distinguished by the preservation of lymph node groups and nonlymphatic structures that are removed during radical neck dissection. SND is a generic term that applies to a group of procedures named according to the levels of the neck in which the lymph nodes are removed. SNDs evolved as surgeons developed an understanding of the predictable lymphatic drainage patterns in head…

Superselective Neck Dissection

Introduction The nodal status of the neck remains one of the most important prognostic factors for overall survival in patients with cancer of the head and neck. The lymphatic drainage of the neck is organized into anatomic compartments ( Fig. 63.1 ). The type of neck dissection depends on the nodal levels removed and the extent of nonlymphatic structures preserved ( Table 63.1 ). Over the…

Sentinel Lymph Node Biopsy

Introduction Sentinel lymph node biopsy (SLNB) is primarily used in the head and neck for malignant melanoma and squamous cell carcinoma (SCC) of the oral cavity. The technique is employed to help the surgeon understand the pathologic status of a clinically N0 neck. Multiple prospective randomized trials for melanoma have failed to demonstrate a survival benefit for elective neck dissection in the N0 patient. Similarly, no…

Management of the Unknown Primary Cancer

Introduction Many patients with squamous cell carcinoma of the head and neck (SCCHN) present with metastasis to the cervical lymph nodes. Metastatic carcinoma in the neck without an identifiable primary cancer is defined as a squamous cell carcinoma of the head and neck of unknown primary origin (SCCHNUP). Patients with isolated supraclavicular metastatic carcinoma usually have a primary source from the skin or infraclavicular sites of…

Office-Based Procedures: Fine-Needle Aspiration Biopsy of a Mass in the Head and Neck

Introduction When evaluating a patient with a mass in the head and neck, the fine-needle aspiration biopsy (FNAB) plays a critical role in the initial workup. It can help establish a diagnosis, among a wide variety of pathology, including infectious, benign, and malignant lesions. Needle biopsy, first popularized in the 1920s by Dr. Hayes Martin at Memorial Sloan-Kettering Hospital, has been used for more than 100…

Maxillomandibular Advancement for Obstructive Sleep Apnea

Introduction The fundamental principle of maxillomandibular advancement (MMA) is to move the muscular attachments of the hard palate, tongue, and suprahyoid soft tissue in an anterior direction by advancement of the tooth-bearing segments of the maxilla and mandible. This maneuver enlarges the bony vault, effectively improving retropalatal, lateral wall, and retroglossal airway collapse. MMA has been used effectively for adults with obstructive sleep apnea (OSA) since…

Genioglossus Advancement

Introduction The pathogenesis of obstructive sleep apnea (OSA) is complex and involves many anatomic and physiologic factors. The Fujita system for classifying the level of airway obstruction is often employed as a diagnostic tool. Level 1 indicates obstruction at the retropalatal/oropharyngeal level area. Level 2 indicates obstruction at the retropalatal/oropharyngeal and retroglossal/hypopharyngeal levels. Level 3 indicates obstruction at the retroglossal/hypopharyngeal area only. One of the major…

Hyoid Suspension

Introduction It is estimated that adequate adherence to continuous positive airway pressure (CPAP) may vary from 28% to 80%. For patients with moderate-to-severe obstructive sleep apnea (OSA) who fail CPAP, a variety of surgical procedures are available. To determine the surgical intervention most suitable, the airway is fully evaluated for level, pattern, and degree of airway collapse. In a prospective study of 108 patients, Kezirian et al.…

Hypoglossal Nerve Stimulation Therapy

Introduction The prevalence of obstructive sleep apnea (OSA), its complex pathophysiology, and the suboptimal adherence rates with positive pressure therapy require alternative treatment strategies in many OSA patients. Hypoglossal nerve stimulation (HNS) represents a novel and unique therapeutic approach that combines a surgical implant procedure with a titratable medical device to provide multilevel upper airway improvement via neuromodulation of the hypoglossal nerve. A recent multicenter prospective…

Volumetric Tongue-Base Reduction (Lingual Tonsillectomy, Coblation Midline Glossectomy, Trans Oral Robotic Surgery)

Introduction First-line surgical treatment of obstructive sleep apnea (OSA) in both pediatric and adult patients is adenotonsillectomy and has often been uvulopalatopharyngoplasty in adults. When initial medical or surgical treatment of OSA fails to successfully treat the condition, adjunct surgical treatment may be warranted. Lingual tonsillectomy and tongue-base reduction are two of these surgical techniques that can lead to improved outcomes in patients with OSA. In…

Advanced Palatal Surgery: Expansion Sphincter Pharyngoplasty & Transpalatal Advancement Pharyngoplasty

Introduction Obstructive sleep apnea (OSA) is a state-dependent phenomenon in which the pharyngolarynx undergoes repetitive collapse. Retropalatal obstruction is often the primary site of sleep-disordered breathing. Traditional uvulopalatopharyngoplasty (UPPP) as described by Fujita has important potential limitations, including nonphysiologic modification, residual proximal palatal obstruction, and risk of nasopharyngeal stenosis and velopharyngeal insufficiency. The two techniques discussed in this chapter, expansion sphincter pharyngoplasty (ESP) and transpalatal advancement…

Uvulopalatopharyngoplasty and Related Modifications (Traditional Uvulopalatopharyngoplasty, Uvulopalatal Flap, Anterior Palatoplasty)

Introduction Obstructive sleep apnea (OSA) is a dynamic collapse and obstruction of the upper airway occurring in sleep due to decreased upper airway neuromuscular activity. At least 13% of men and 6% of women aged 30 to 70 years in the United States have moderate-to-severe OSA (apnea-hypopnea index [AHI] ≥ 15/hour), and at least half of this population are likely to be intolerant of the first-line…

Drug-Induced Sedated Endoscopy

Introduction Obstructive sleep apnea (OSA) is a state-dependent phenomenon in which the pharyngolarynx undergoes repetitive obstruction. For the otolaryngologist, the ability to phenotype the specific site(s), anatomic structures, and patterns involved in the upper airway obstruction appears crucial to successful outcomes. Upper airway evaluation in a sedated state was first published by Croft and Pringle in 1991. Since that description, drug-induced sedated endoscopy (DISE) has demonstrated…

Office-Based Snoring Procedures

Introduction “Primary snoring” can be described as a symptomatic, sleep-related, respiration-dependent acoustic phenomenon with an apnea-hypopnea index (AHI) of less than 5 and without complaints of daytime sleepiness. Snoring is common; it is estimated that 35% to 45% of men and 15% to 28% of women snore regularly. Current evidence regarding the medical morbidity of snoring is inconclusive. Population-based studies have been contradictory regarding the effect…

Cancer of the Cervical Esophagus

Introduction Cancer of the cervical esophagus has long been known as one of the most difficult neoplasms to treat and cure surgically. It is relatively uncommon, representing less than 5% of all esophageal cancers, themselves representing 5% of all digestive system cancers. In 2010 in the United States there were an estimated 16,640 new cases of esophageal carcinoma, with 14,500 deaths, thus explaining the paucity of…

Reconstruction of Hypopharyngeal Defects

Acknowledgments I acknowledge Hyunjoo Park for the illustrations in this chapter. Introduction The hypopharynx is a complex anatomic region that begins at the level of the hyoid and terminates at the esophageal inlet. It is adjacent to, but distinct from, the larynx and is the functional conduit that carries food from the oropharynx to the esophagus. Three anatomic subsites are included: paired pyriform sinuses, posterior pharyngeal…

Partial Pharyngectomy

Introduction The hypopharynx is the inferior-most portion of the pharynx, bounded by the oropharynx superiorly and the esophagus inferiorly. The hypopharynx is intimately related to the larynx, both anatomically and functionally. Anatomically, the hypopharynx extends from the base of the vallecula down to the apices of the piriform sinuses and the inferior border of the cricoid cartilage. For purposes of classification, the hypopharynx is divided into…

Penetrating Trauma to the Hypopharynx and Cervical Esophagus

Introduction Penetrating trauma to the hypopharynx and cervical esophagus is a potentially life-threatening injury, which may be the result of iatrogenic injury, accidental impalement, or assault. Multiple routine procedures and surgeries (intubation, nasogastric tube placement, rigid and flexible esophagoscopy with or without dilation/biopsy/foreign body removal, Zenker’s diverticulectomy, cervical spine surgery, and transesophageal echocardiography) carry a risk of visceral perforation, which if not recognized can quickly lead…

Dysfunction of the Upper Esophageal Sphincter

Introduction The cricopharyngeus muscle is the major component of the upper esophageal sphincter (UES). The cricopharyngeus muscle is innervated by the pharyngeal plexus, which is composed of contributions from the vagus and glossopharyngeal nerves. Increasing evidence suggests that contributions from the recurrent laryngeal nerve (RLN) also innervate the cricopharyngeus muscle. The origin of the parasympathetic innervation is vagal, whereas sensory branches are derived from the glossopharyngeal…

Esophagoscopy and Hypopharyngoscopy

Introduction Disorders of the esophagus present a challenge to the otolaryngologist owing to the broad variety of pathology and oftentimes nonspecific nature of patient complaints. Using a mirror, Bozzini in 1809 was credited with the first attempts to evaluate the esophagus. Initially described in 1868 by Kussmaul, the straight esophagoscope underwent multiple refinements until the early 1900s when Chevalier Jackson introduced the technique and instrumentation of…