Head, Neck and Thyroid Surgery An Introduction and

Practical Guide - 1st Edition

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CONTENTS
Preface vii
Editors ix
Contributors xi
Abbreviations xiii

1 Anatomy and differential diagnosis in head and neck surgery 1

Neeraj Sethi and Neil de Zoysa
2 Imaging in head and neck surgery 11
Salman Qureshi
3 Perioperative issues 23
Gordon A. G. McKenzie and David J. H. Shipway
4 Congenital neck lumps 51
Jarrod J. Homer and Laura Warner
5 Cervical lymphadenopathy 65
Neil de Zoysa
6 Thyroid disease 85
R. James A. England
7 Parathyroid disease 101
R. James A. England
8 Oral cavity 107
Jiten D. Parmar and Nick Brown
9 Oropharynx 119
Emma King and Neil de Zoysa
10 Hypopharynx 137
Patrick J. Bradley and Neeraj Sethi
11 Larynx 155
James Moor and Amit Prasai
12 Nasopharynx 173
Jay Goswamy
13 Sinonasal tumours 181
Yujay Ramakrishnan and Shahzada Ahmed

Contents v
14 The salivary glands 199
Giri Krishnan and Neeraj Sethi
15 Paediatric neck lumps 215
Mat Daniel
16 Reconstruction in head and neck surgical oncology 225
Kishan Ubayasiri and Andrew Foreman

Index 237

vi Contents
PREFACE
When searching the marketplace for books to help It is vital to acknowledge the contribution of all
prepare the trainee attempting to manage patients the authors who have given selflessly of their time
with head and neck pathology in the clinic or ward and expertise. The driving enthusiasm and endless
we found a dearth of accessible texts. All the authors patience of the publishing team have kept this proj-
have, at some point in their lives, found themselves ect moving forward towards a final product. Most
struggling to find easy-to-follow guidance and importantly our families provide the love and sup-
knowledge on the investigation, work-up and fol- port to be able to produce a worthy book.
low-up of patients with head and neck disease. With
this in mind we set out to avoid an impenetrable, This book is very much an introduction and practical
encyclopaedic tome and provide an easy-to-read, guide. It will be invaluable for the trainee at the coal-
evidence-based introduction to this topic. face, developing their approach for these patients. It
should serve as a gateway to more heavyweight ref-
We have tried to set the scene for each subsite with erence texts and in-depth literature searches, whilst
a background of the clinically relevant anatomy and equipping the trainee with confidence and practical
physiology before presenting the clinical manifesta- knowledge.
tions of the more common head and neck patholo-
gies in each area. In addition to evidence-based
guidance on the work-up and management, we were Neeraj Sethi
determined to impart experience-based knowledge R. James A. England
and tips on the same to help the trainee. Neil de Zoysa

Preface vii
EDITORS
Neeraj Sethi has had a passion for head and neck sur- thyroidectomies and 80 parathyroidectomies annu-
gery throughout his career. During his higher surgi- ally. His main research interest is in the translational
cal training in otolaryngology, he completed a PhD potential of microfluidic technologies in the person-
in molecular biology in head and neck cancer, and alised management of thyroid disease.
has published and presented widely on many aspects
of otolaryngology and head and neck surgery. After Neil de Zoysa trained at University College London
completing a fellowship in advanced head and neck and completed his higher specialist training at Guy’s
surgical oncology and robotic surgery in Adelaide, and St George’s Hospitals. He completed dual fellow-
he took up a consultant head and neck surgeon post ships in Head & Neck Surgery as part of the Royal
at Queen Medical Centre, Nottingham. This book College of Surgeons Interface Training Programme at
highlights his ongoing commitment to education Hull Royal Infirmary. He then went on to complete a
and training in head and neck surgery. fellowship in head, neck and skull base surgery at the
Princess Alexandra Hospital in Brisbane, Australia.
R. James A. England has been a Consultant ENT After having children, he moved to his wife’s home-
Surgeon in Hull University Teaching Hospitals town in Poole, UK. He has an interest in thyroid can-
Trust for 20 years. His main interest is in thyroid/ cer and HPV associated SCC. He also has an active
parathyroid surgery, and he is lead of the regional interest in the career development and training of
Thyroid MDT. He p ­ erforms approximately 140 future surgeons.

Editors ix
CONTRIBUTORS

Shahzada Ahmed Jay Goswamy

Consultant ENT and Skull Base Surgeon Consultant Surgeon in Otorhinolaryngology
University Hospitals Birmingham NHS Trust and
Birmingham, United Kingdom Clinical Lead for ENT Surgery
Manchester University NHS Foundation Trust
Patrick J. Bradley Manchester, United Kingdom
Emeritus Professor Head and Neck Oncologic
Surgery Jarrod J. Homer
Nottingham, United Kingdom Consultant Head and Neck/Thyroid Surgeon and
Otolaryngologist
Nick Brown Manchester Royal Infirmary
Consultant Oral and Maxillofacial Surgeon Manchester, United Kingdom
York Teaching Hospital NHS Trust
York, United Kingdom Emma King
Consultant ENT Head and Neck Surgeon
Mat Daniel Cancer Research UK Senior Lecturer Head and
Consultant ENT Surgeon and Honorary Senior Neck Surgery
Lecturer Poole Hospital
Nottingham University Hospitals NHS Trust Poole, United Kingdom
Nottingham, United Kingdom
Giri Krishnan
Neil de Zoysa Surgical Registrar and Clinical Associate Lecturer
Consultant Otolaryngologist Head and Neck Surgeon University of Adelaide
Poole Hospital Adelaide, South Australia
Dorset, United Kingdom Gordon A. G. McKenzie
Academic Clinical Fellow in Otolaryngology Hull
R. James A. England
Teaching Hospitals NHS Trust
Consultant Otolaryngologist Head and
and
Neck Surgeon
Honorary Senior Clinical Lecturer
and
University of Bristol
Honorary Senior Lecturer
Bristol, United Kingdom
Hull and East Yorkshire NHS Hospitals Trust
and James Moor
Hull University Consultant ENT Surgeon
Hull, United Kingdom Leeds Teaching Hospitals NHS Trust
Leeds, United Kingdom
Andrew Foreman
Consultant Otolaryngologist and Reconstructive Jiten D. Parmar
Head and Neck Surgeon Department of Oral and Maxillofacial Surgery
Royal Adelaide Hospital Leeds Teaching Hospitals NHS Trust
Adelaide, South Australia Leeds, United Kingdom

Contributors xi
Amit Prasai David J. H. Shipway
Consultant ENT Surgeon Consultant Physician and Perioperative
Leeds Teaching Hospitals NHS Trust Geriatrician
Leeds, United Kingdom North Bristol NHS Trust
and
Salman Qureshi Honorary Senior Clinical Lecturer
Consultant Head and Neck/Neuro Radiologist University of Bristol
Hamad Medical Corporation Bristol, United Kingdom
Doha, Qatar
Kishan Ubayasiri
Yujay Ramakrishnan Consultant Otolaryngologist/Head and Neck
Consultant ENT and Skull Base Surgeon Surgical Oncologist
Queen’s Medical Centre Nottingham University Hospitals NHS Trust
Nottingham University Hospitals NHS Trust Nottingham, United Kingdom
Nottingham, United Kingdom
Laura Warner
Neeraj Sethi Consultant Otolaryngologist, Head and Neck
Consultant Otolaryngologist Head and Neck Surgeon
Surgeon Newcastle upon Tyne Hospitals NHS Foundation
Queen’s Medical Centre Trust
Nottingham University Hospitals NHS Trust Newcastle upon Tyne, United Kingdom
Nottingham, United Kingdom

xii Contributors
ABBREVIATIONS
AJCC American Joint Committee on Cancer MEN multiple endocrine neoplasia
CT computerised tomography or computed MRI magnetic resonance imaging
tomography PET positron emission tomography
EBV Epstein–Barr virus RT radiotherapy
ENT ear, nose and throat SCC squamous cell carcinoma
FBC full blood count TNM tumor, node, metastasis
FDG fluorodeoxyglucose UADT upper aerodigestive tract
HPV human papillomavirus UICC Union for International Cancer Control
IJV internal jugular vein US ultrasound
IMRT intensity-modulated radiotherapy USS ultrasound scan
MDT multidisciplinary team

Abbreviations xiii
 1 ANATOMY AND DIFFERENTIAL
DIAGNOSIS IN HEAD AND
NECK SURGERY
Neeraj Sethi and Neil de Zoysa

INTRODUCTION
When assessing patients it is vital to formulate a dif- This is often the case and makes sense in the setting
ferential diagnosis based on the initial history and of a patient with a sore throat, altered voice and a
examination. This guides decision-making in inves- neck lump, where a differential diagnosis including
tigating patients swiftly and appropriately. Lack hypopharyngeal carcinoma explains all symptoms.
of investing thought into a differential diagnosis However, Hickam’s dictum must be remembered
will lead to delays and unnecessary anxiety for the which states ‘a man can have as many diseases as he
patient. Knowledge of the anatomy is essential to damn well pleases’, and there will always be patients
understanding what the pathology could possibly be. with multiple pathologies.
Whilst primary malignancy in neck lumps can occur
(e.g. lymphoma, thyroid cancer or salivary gland Whilst the anatomy for each subsite of the upper
cancer), the majority of malignant neck lumps are aerodigestive tract is considered in more detail in
metastatic and immediate thought must be given to each specific chapter, here an overview will be pro-
identifying the source of the primary tumour (which vided to ‘set the scene’ for a general assessment of the
is likely to be in the upper aerodigestive tract). patient referred to a head and neck surgery clinic. As
well as anatomy, the patient’s age, associated symp-
Additionally, Occam’s razor suggests a unifying toms and risk factors for specific illnesses will guide
diagnosis to be the most likely correct diagnosis. differential formulation.

ANATOMY
Triangles and levels For the purposes of clinical medicine and sur-
gery, the neck can be broken down into triangles
The neck is an anatomically complex but quite beau- which are defined by palpable landmarks. This
tiful arrangement of vessels, cranial nerves, periph- aids in both clinical examination and surgical
eral nerves, muscles and fascia. planning.

Anatomy and differential diagnosis in head and neck surgery 1

From an operative point of view however it is equally cricoid cartilage, the sternal notch, the clavicle and
important to understand the fascial planes of the neck. the anterior border of the trapezius muscle.
Generally speaking, these planes and their boundaries
can be followed during surgery. By doing this, a clean Using these landmarks, the neck can be divided into
operative field can be obtained ensuring complete and triangles as shown in Figure 1.1. The submandibular
safe surgery via the relative ease at which important triangle has its superior border at the lower border
anatomy can be identified and preserved. of the mandible. It is then made up by the digastric
muscle, which has two bellies running from the
Important palpable bony landmarks are identified lesser cornu of the hyoid, one to the mastoid tip and
in Figure 1.1. These include the lower border of one towards the digastric fossa of the mandible, just
the mandible, the mastoid tip, the hyoid bone, the lateral to the symphysis (midpoint of the mandible).

Anatomical triangles of the neck

Submandibular triangle
Suprahyoid (Submental) triangle
Carotid triangle
Muscular triangle
Occipital triangle
Body of the mandible
Subclavian triangle

Anterior belly of diagastric

Mylohyoid Stylohyoid
Hyoid
Anterior belly of omohyoid Posterior belly of digastric
Thyroid cartilage
Mastoid process
Median line of the neck
Internal jugular vein
Carotid artery
Splenius capitis
Levator capitis
Accessory nerve
Thyroid gland
Scalenes

Anterior margin of trapezius

Sternum

Posterior belly of omohyoid

Trapezius

Clavicle

Sternocleidomastoid muscle (SCM)

Figure 1.1 Triangles of the neck.

2 Head, neck and thyroid surgery

Between the two anterior bellies of the digastric a line can be made from the lower two-thirds of the
muscle and the body of the hyoid is the suprahyoid sternomastoid muscle to the lesser cornu of the hyoid.
(submental) triangle.
The muscular triangle runs below this line (the omo-
The carotid triangle runs from the posterior belly of hyoid), the remaining sternomastoid muscle and the
the digastric muscle to its insertion at the mastoid tip, midline.
then down the posterior border of the sternomastoid
muscle, then up along the omohyoid muscle towards The occipital triangle is bordered by the posterior
the lesser cornu of the hyoid. The omohyoid muscle is border of the sternomastoid muscle towards the
palpable in slim or muscular patients. As a surrogate, mastoid tip, then along the anterior border of the

Posterior boundary of
submandibular gland Jugular fossa

IB
IIA
Lower border IIB
of hyoid IA

Lower margin
of cricoid cartilage
III
Left common
carotid artery VA

VB
VI
IV

Top of Internal jugular

manubrium vein

Figure 1.2 Levels of the neck. Level IA corresponds to the suprahyoid (submental) triangle. Level IB corresponds
to the submandibular triangle. Level II corresponds to the upper half of the carotid triangle. Level III corresponds
to the lower half of the carotid triangle. Level IV corresponds to the lateral half of the muscular triangle (lateral to
the infrahyoid strap muscles or common carotid artery). Level V corresponds to the occipital triangle (it is divided
into VA and VB by the spinal accessory nerve). Level VI is a rectangle in most patients, as it is in the midline,
technically the area from inferior to the hyoid to the sternal notch, medial to the common carotid arteries. Level
VII is mediastinal level relevant to thyroid and subglottic pathology. It is bordered by the sternal notch and the
carotid arteries joining to the innominate or aortic arch.

Anatomy and differential diagnosis in head and neck surgery 3

trapezius, along the clavicle back to the sternomas- For the purposes of oncological description and
toid. The subclavian (or supraclavicular triangle) is axial imaging, the triangles are replaced by lev-
found within the posterior triangle, bounded by the els (see Figure 1.2 and Table 1.1). Levels are a
inferior belly of omohyoid, the posterior border of more reproducible way of describing the location
sternocleidomastoid and the clavicle [1]. of pathology and should be used in preference to

Table 1.1 Levels of the neck and contents.

Level Contents
IA Lymph nodes draining from the floor of mouth and lower lip. Thyroglossal and dermoid cysts
can also be located here.
IB Submandibular gland.
Lymph nodes which drain the oral cavity, tongue and floor of mouth.
Superficial to the submandibular gland; runs the marginal mandibular branch of the facial
nerve.
Deep to the gland lies the distal portion of the hypoglossal nerve, the mylohyoid muscle and
deep to this the lingual nerve. The submandibular gland is supplied with blood by the facial
artery, which can bleed briskly after trauma in this location.
II Accessory nerve
Upper end of internal jugular vein (IJV), both internal and external carotid arteries.
The hypoglossal nerve crosses the external carotid artery here. The area is encircled by lymph
nodes which drain the pharynx, larynx, face and skin. The internal jugular vein receives its
major tributary, the common facial vein.
III The internal jugular and common carotid artery (this bifurcates at the border of level II/III).
The carotid sheath spans levels II to IV and contains the IJV and the carotid artery. The vagus
nerve lies intimately with the carotid artery thus making its identification and preservation
routine during neck dissection.
Lymph nodes.
Cervical plexus branches run along the floor of this level.
IV Corresponds to the lateral half of the muscular triangle (lateral to the infrahyoid strap muscles
or common carotid artery). It contains the roots of the carotid and internal jugular vein. At a
variable height the subclavian vein and internal jugular vein form the origin of the superior
vena cava. In some patients this can be just above the clavicle. In the left-hand side, the
thoracic duct inserts posteriorly into the IJV which can be commonly injured in this location.
Care should be taken in this area during neck dissection to avoid chylous leak.
Cervical plexus branches also run through this level and the transverse cervical vessels.
V Corresponds to the occipital triangle (it is divided into VA and VB by the spinal accessory
nerve). This contains lymph nodes which drain the parotid area, the thyroid and skin of the
face and neck. Transverse cervical vessels.
VI This is a rectangle in most patients as it is in the midline, technically the area from inferior to
the hyoid to the sternal notch, medial to the common carotid arteries. It contains the recurrent
laryngeal nerves, thyroid and parathyroid glands, and trachea as well as vessels feeding and
draining the thyroid.
VII This is a mediastinal level relevant to thyroid and subglottic pathology. It is bordered by the
sternal notch and the carotid arteries joining to the innominate or aortic arch. It is often
cleared in cases of medullary thyroid cancer.
It contains lymph nodes and thymus gland.

4 Head, neck and thyroid surgery

Table 1.2 Lymphatic levels drainage. triangles in documentation, correspondence and
discussion. In addition, the lymphatic drainage at
Level Regions of drainage specific levels can help clinically identify the pos-
sible location of primary disease in the case of met-
IA Floor of mouth, lower alveolus/
astatic carcinoma.
gingiva, anterior and ventral
tongue
The contents of these levels are shown in Table 1.1
IB Tongue, oral cavity, buccal mucosa, and the region of echelon drainage is shown in
lower alveolus/gingiva Table 1.2.
II Pharynx, larynx, posterior oral cavity
III Oropharynx, larynx, hypopharynx, Fascial layers
nasopharynx
A key area of understanding of applied surgical anat-
IV Hypopharynx, subglottis omy is of the deep cervical fascial planes (summarised
V Skin, parotid by Figure 1.3). Note how the investing layer of cervi-
cal fascia is deep to the platysma. This is why subpla-
VI Thyroid, subglottis
tysmal skin flaps are elevated. This keeps skin flaps

Thyroid gland Oesophagus Trachea Pretracheal Recurrent Sternomastoid

fascia laryngeal
nerve Sternothyroid
Sternohyoid
Carotid sheath
Platysma
Internal
jugular vein Omohyoid

Vagus
Deep cervical nerve
lymph chain Longus
cervicis
Common
carotid artery Scalenus
anterior
Investing
layer of Scalenus
superficial medius
fascia

Prevertebral
layer of fascia Trapezius

Vertebral artery

Ligamentum Semispinalis
Spinal nerve nuchae capitis Splenius capitis Levator scapulae

Figure 1.3 Summary of fascial layers and planes in neck.

Anatomy and differential diagnosis in head and neck surgery 5