This document discusses principles of conservative surgery for head and neck cancers. It covers selective and comprehensive neck dissection techniques for managing cervical lymph nodes. It describes various open and endoscopic surgical procedures to preserve structure and function for cancers of the larynx and hypopharynx, including vertical partial laryngectomy, supracricoid laryngectomy, and transoral laser resection. Complications and oncologic outcomes of these organ preservation techniques are also discussed.

1. Principles of Conservative
Surgery in Head & Neck
Oncology
Dr Zeeshan Ahmad
M.S.(ENT,PGY2)
Department of ENT
NMCH, Patna.29-08-13

2. Introduction
 Surgery on Head and Neck has major impact on swallowing,
speech and aesthetic appearance.
 Organ preserving radiation techniques.
 New chemotherapeutic regimens.
 Greater understanding of tumour biology.
 Introduction of CO2 laser- transoral.
 endoscopes

3. Neck

4. Conservation surgery for Neck
 Single most imp factor for prognosis of SCC of HN – cervical nodes.
 5yr survival rate reduces by 50% if nodes involved.
 Memorial Sloan-Kettering Cancer Center – Levels I to VII.

5. N0 disease – Neck dissection
 N0 – 15-20% risk of occult metastatic disease.
 Selective neck dissection
 Spares all non-lymphatic tissue including SCM, IJV and SpAN.
 Only selected nodes on involved site removed.

6. Types of Selective Neck Dissection
 SupraOmoHyoid Neck Dissection
 Extended SupraOmoHyoid Neck Dissection
 Anterolateral Neck Dissection
 Posterolateral Neck Dissection
 Central compartment Neck Dissection

7. SupraOmoHyoid Neck Dissection
 SCC of Oral Cavity
 Lymph nodes of level I to III
 Submandibular Gland

8. Extended SupraOmoHyoid Neck
Dissection
 SCC of Lateral Tongue
 Small but increased risk of Skip Metastasis to level IV
 Lymph nodes of level I to IV
 Submandibular Gland

9. Anterolateral Neck Dissection
 Also called Jugular Neck Dissection.
 SCC of Larynx or Pharynx
 If primary tumour crosses midline A.N.D. is carried out bilaterally.
 Not required if Radiotherapy planned.
 Lymph nodes of level II to IV

10. Posterolateral Neck Dissection
 Primary cutaneous malignancies of Posterior Scalp.
 Lymph nodes of level II to IV and suboccipital LN.

11. Central compartment Neck Dissection
 Diferentiated Thyroid carcinoma.
 Lymph nodes of level VI to VII and
 Delphian
 Perithyroid
 Tracheo-osophageal groove
 Anterior-superior mediastinum

12. N+ disease - Neck Dissection
 Comprehensive neck dissection – removal of all lymphatic tissue in
lateral neck.
 Classified into Radical and Modified Radical depending upon other
structures removed.
 Gold standard – Radical Neck Dissection.
 Modified Radical Neck Dissection three types

13. Structures removed in RND along
with level I to V LN
 RND
 SSG
 IJV
 SCM
 Sp Acc N

14. Structures removed in MRND along
with level I to V LN
 MRND type I – (Spinal Accessory spared)
 SSG
 IJV
 SCM

15. Structures removed in MRND along
with level I to V LN
 MRND type II –( Spinal Accessory + SCM spared)
 SSG
 IJV

16. Structures removed in MRND along
with level I to V LN
 MRND type III – (Spinal Accessory + SCM + IJV spared)
 SSG

17. N+ Disease post Chemoradiation
 Generally acepted that N0 and N1 disease can be treated by
Chemoradiation alone.
 Insufficient data for N2 and N3
 Brizel et al – reported 4yr disease free survival rate
 75% in RT + ND
 53% in RT only
 Therefore ND is recommended for N2/N3.

18. Larynx

19. Conservation surgery for cancer of
Larynx
 Main aim is to
 Maintain speech
 Maintain swallowing
 Avoid tracheostomy
 Conservation laryngeal surgery may be
 Open
 endoscopic
 securing negative margins is crucial to success of procedure.

20. Crico-arytenoid unit
 It is the basic functional unit of larynx.
 Consists of
 An Arytenoid cartilage
 Cricoid cartilage
 Associated musculature
 Nerve suply
 Allows physiological speech and swallowing without the need for
tracheostomy.

21. Open Partial Laryngeal surgery
 General principles
 Consent for Total Laryngectomy
 Speech rehabilitation – patient and family active
 Good pulmonary function
 No medical problem

22. Types
 Glottic
 Vertical Partial Laryngectomy
 Lateral
 anterolateral
 Supracricoid Partial laryngectomy with Cricohyoidoepiglottopexy.
 Supraglottic
 Horizontal SPL
 Supracricoid Partial laryngectomy with Cricohyoidoepiglottopexy.

23. GLOTTIC

24. Vertical Partial Laryngectomy
 Vertical cuts through laryngeal cartilage
 Removal of majority of
 Ipsilateral thyroid cartilage
 True vocal cord
 Portions of subglottic mucosa
 False cord
 Tracheostomy 3-7 days.

25. Vertical Partial Laryngectomy
 Criteria for selection
 Lesion of mobile cord extending to anterior commissure
 Lesion of mobile cord involving vocal process and anterosuperior arytenoid
 Subglottic extension ≯5mm
 Fixed cord lesion not extending midline
 Anterior commissure/ VC lesion ≯ anterior 1/3 of opposite VC

26. Vertical Partial Laryngectomy
 Oncological results
 T1 glottic cancer
 Recurrence rates are <10%
 If ant comm not invoved 93% local control
 If ant comm invoved 75% local control( subglottic recurrence)
 T2 glottic cancer
 Failure rates of 4-26% ( cricoid and thyroid involvement)
 T3 glottic cancer
 Higher recurrence rates of 11-46%

27. Vertical Partial Laryngectomy
 Functional results
 Some degree of hoarseness
 Most impairment – if no reconstruction
 Least – replacement of glottis with adjacent false cord flap

28. Supracricoid Partial Laryngectomy with
Cricohyoidoepiglottopexy
 Resection of
 Both true cords and Both false cords
 Entire thyroid cartilage and One arytenoid
 Paraglottic spaces bialterally

29. Supracricoid Partial Laryngectomy with
Cricohyoidoepiglottopexy
 Reconstruction is done using
 Hyoid bone, Epiglottis, Cricoid and tongue
 Temporary tracheostomy and feeding tube
 Used for T1b with ant commissure involvement and selected T2 / T3
glottic carcinoma.

30. Supracricoid Partial Laryngectomy with
Cricohyoidoepiglottopexy
 Local recurrence rate
 T2 4.5% (3 of 67)
 T3 10% (2 of 20)
 Temporary dysphagia and aspiration is expected
 Nasogastric feeding tube for 9 to 50 days.
 Hyoid necrosis and neolaryngeal stenosis
 Voice quality is initially poor but improves over several months

31. SUPRAGLOTTIC

32. Horizontal Supraglottic Partial
Laryngectomy
 Parts removed
 Epiglotis and Pre-epiglottic space
 Hyoid bone
 Thyrohyoid membrane
 Upper half of thyroid cartilage
 Supraglottic mucosa

33. Horizontal Supraglottic Partial
Laryngectomy
 Closure is by approximating base tongue to lower half of thyoid
cartilage
 Temporary tracheostomy is required.
 Bilateral selective lymph node dissection is carried out at the same
time
 It is important to identify and preserve internal and external
branches of superior laryngeal nerve

34. Horizontal Supraglottic Partial
Laryngectomy
 Selection criteria
 At least 5mm margin at anterior commissure
 True VC must be mobile
 Only one arytenoid may be removed
 No cartilage invasion by the tumour
 Tongue mobility should be normal
 No extension to interarytenoid or postcricoid area
 Apex of pyriform sinus should be free
 Generally lesions should be <3cm

35. Horizontal Supraglottic Partial
Laryngectomy
 High local control for T1 and T2
 75% for T3 and 67% for T4

36. Other Laryngectomies
 Subtotal Laryngectomy =
supralottic partial laryngectomy+ipsilateral vertical partial
laryngectomy
 Near Total Laryngectomy =
this is a technically complex procedure to create a physiological
voice shunt based around one mobile arytenoid.
Requires permanent stoma

37. Supracricoid Partial Laryngectomy with
Cricohyoidoepiglottopexy
 Supraglottic carcinomas not amenable to supraglottic
laryngectomy due to
 Glottic level involvement through anterior commissure or ventricle
 Pre-epiglottic space invasion
 Decreased cord mobility
 Limited thyroid invasion

38. Supracricoid Partial Laryngectomy with
Cricohyoidoepiglottopexy
 Operation involves resection of
 Both true cords and both false cords
 Entire thyroid cartilage
 Both paraglottic spaces
 Maximum of one arytenoid
 Thyrohyoid membrane
 epiglottis

39. Supracricoid Partial Laryngectomy with
Cricohyoidoepiglottopexy
 Reconstruction using
 Hyoid bone
 Cricoid
 tongue
 Temporary tracheostomy tube and feeding tube is required.

40. Supracricoid Partial Laryngectomy with
Cricohyoidoepiglottopexy
 Indications
 T1 and supraglottic lesions with ventricle extension
 T2 infrahyoid epiglottis or posterior 1/3 of false cord
 Supraglottic lesions extending to glottis or anterior commissure
 T3 transglottic carcinoma
 Selective t4 lesions invading thyroid cartilage

41. Supracricoid Partial Laryngectomy with
Cricohyoidoepiglottopexy
 Contraindications
 Bulky pre-epiglottic space involvement
 Gross thyroid cartilage destruction
 Interarytenoid involvement
 Fixed arytenoids
 Subglottic extension >10mm anteriorly and >5mm posteriorly
 Inadequate pulmonary reserve

42. Supracricoid Partial Laryngectomy with
Cricohyoidoepiglottopexy
 No local recurrence reported by Laccourreye et al
 3.3% reported by chevalier
 Nasogastric feeding is required for 30-365 days
 Total laryngectomy may be required in 10% of cases

43. Transoral Endoscopic LASER Resection
 Outpatient procedure possible
 Shorter operating time
 Less overtreatment
 Better voice quality
 Low morbidity
 No feeding tube
 No tracheostomy
 Similar oncologic results

44. Transoral Endoscopic LASER Resection
 As compared to radiotherapy it has similar oncologic and
functional results, lower cost.
 Radiotherapy is possible after endocopic laser if it fails

45. Hypopharynx

46. Conservation surgery for cancer of
Hypopharynx
 Cancer of hypopharynx includes
 Cancer of pyriform sinus (70%)
 Postcricoid (15%)
 Posterior pharyngeal wall (15%)
 Of all Head and Neck sites Hypopharyngeal Cancer has poorest
prognosis – 5yr survival rate of <20%
 Patients usually present with advanced diseaseAbout 66% of
patients have nodal disease at presentation
 Thus it requires treatment of primary and also of neck

47. Conservation surgery for cancer of
Hypopharynx
 T1 and small volume T2 without neck metastasis
 Usually treated by radiation
 Partial pharyngectomy and bilateral selective neck dissection can also be
performed
 T1 and small volume T2 with neck metastasis
 Comprehensive neck dissection
 Radiation to the primary

48. Conservation surgery for cancer of
Hypopharynx
 Large volume T2 / T3 / T4
 Radical surgery
 Excision of primary tumour
 Reconstruction
 Radiotherapy
 Endoscopic laser
 Excellent functional results
 With synchronous or separate neck dissection

49. Oral cavity

50. Conservation surgery for cancer of the
Oral cavity
 Limited resection of oral cavity is to be condemned
 However it is possible to perform conservative surgery to mandible
 Careful assessment is carried out by bimanual palpation.
 CT is helpful in assessing cortical invasion
 MRI helps to find marrow invasion and inferior alveolar nerve

51.  Segmental mandibulectomy is carried out if
 Gross invasion by cancer
 Tumour close to mandible in irradiated patient
 Invasion of inferior alveolar nerve or canal by tumour
 Massive soft tissue disease adjacent to tumour
 Marginal mandibulectomy is done if
 Superficial aspect of cortical bone is involved

52.  Marginal mandibulectomy is done if
 Superficial aspect of cortical bone is involved
 Marginal mandibulectomy is contraindicated
 Gross invasion into cancellous part
 Irradiated mandible
 Edentulous patient with pipestem mandible

53. Oropharynx

54. Conservation surgery for cancer of
Oropharynx
 Transoral laser resection is an alternatve to chemoradiation and
radical surgery
 With the use of appropriate retractors and distending
pharyngoscopes adequate access is obtained
 Temporary tracheostomy may be required
 Postoperative radiotherapy is recommended
 TORS

55. Nose and PNS

56. Conservation surgery for cancer of
Nose and PNS
 Certainly, endoscopic approach for benign disease has advantage
over open surgical resection
 Better function as well as cosmesis
 Availability of
 real time image guidance,
 neuro-navigation and
 intraoperative MRI has furthur improved the safety and accuracy of endoscopic
resections
 However, malignant disease management is still questionable

57. Conservation surgery for cancer of
Nose and PNS
 Indications
 Midline lesions with limited lateral extension
 Benign tumours – inverted papilloma and angiofibroma
 Low grade malignant tumours
 Palliation
 Medical comorbidity limiting open approach

58. Conservation surgery for cancer of
Nose and PNS
 Contraindications
 Lateral extension of tumour
 Intracranial invasion
 Intraorbital invasion
 High grade malignant tumours

59. Parotid

60. Conservation surgery for Tumours of
Parotid Gland
 Warthin’s tumour excision without parotidectomy
 Preservation of facial nerve unless they are adherent to or directly
invaded by tumour
 If major branches or the main trunk are involved, then immediate
cable grafts should be done using branches of Cervical plexus or
Sural nerve

62. NEXT 
05.09.13 Dr Sonu Kumar Singh
M.S.(ENT,PGY2)
Benign tumours of
mouth and jaw