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4 Oral Cavity Procedures
4 Oral Cavity Procedures
4 Oral Cavity Procedures
Preoperative Evaluation
Oral cavity procedures are commonly performed to treat malignancies. Tumors should be assessed preoperatively to allow accurate staging of the disease and to facilitate planning of definitive
treatment. In most cases, an examination under anesthesia with
endoscopy and biopsy is required to stage the primary tumor and
to look for synchronous second primary tumors. Except in the
case of very superficial lesions, computed tomography plays an
important role in preoperative planning. In selected cases, plain
radiographs (e.g., Panorex views) may be useful in evaluating the
mandible.When the lesion is located in the tongue, magnetic resonance imaging may provide additional information about the
extent of the primary tumor.
Wide surgical margins are necessary for adequate treatment of
primary squamous cell carcinoma of the head and neck. A margin of 1 to 2 cm should be achieved whenever possible, ideally
with frozen-section control. Current evidence clearly indicates
that overall patient outcome improves when clear margins are
obtained.
Nodal metastases are common with oral cavity tumors. Accordingly, patients should be assessed for cervical adenopathy both
clinically and radiographically. A chest x-ray should be obtained in
all cases. CT or MRI can provide valuable information regarding
the nodal status of the neck. In patients with advanced disease, a
more extensive search for distant metastases should be conducted,
including a CT scan of the chest. In some circumstances, combining CT with positron emission tomography (PET) may be
useful.
Operative Planning
Surgical management of the neck is an evolving field. In general, if the risk of occult metastasis is greater than 20% to 25%, a
selective neck dissection [see 2:6 Neck Dissection] is recommended, particularly if postoperative radiation therapy is not planned.
Whenever there is clinical evidence of nodal disease, treatment of
the neck must be included in operative planning.
The oral cavity is a major component of a number of important functions, including speech and swallowing. Reconstruction
of the anticipated surgical defect must be carefully planned to
achieve the best results. Several basic considerations must be kept
in mind. Tongue mobility and sensation must be maintained to
the extent possible. Maintenance of mandibular continuity (especially in the anterior segment of the mandible) is vital for ensuring postoperative oral competence. Separation of the nasal cavity
from the oral cavity is critical for the oral phase of swallowing and
speech. Maintenance of the gingivobuccal and gingivolabial sulcus is important for oral function and the fitting of dentures.
As a rule, oral cavity defects should be closed primarily whenever possible. Primary closure has the advantage of using sensate
tissue similar in form to the tissue that was excised. With experience and careful judgment, the surgeon can usually determine
when a defect is too large for primary closure or when primary
closure is likely to cause distortion and tethering of adjacent tis-
Either orotracheal or nasotracheal intubation may be appropriate, depending on the surgical approach and the extent of the
planned resection. A tracheostomy should be performed whenever significant postoperative swelling or airway compromise is
anticipated.
The depth of the excision and the size of the anticipated defect
determine the optimal reconstructive approach. Defects that
connect to the neck, unless they are small and can easily be
closed primarily, usually necessitate creation of a flap for optimal
reconstruction. When the excision extends down to the underlying musculature but there is no connection to the neck, a skin
graft may be used. If a postoperative dental splint is planned to
hold a skin graft in place, a dental consultation must be obtained
before operation.
The patient should be supine in a 20 reverse Trendelenburg
position. Turning the table 180 may facilitate access and positioning for the surgeon.
OPERATIVE TECHNIQUE
Palpation of the lesion is critical for obtaining adequate deep surgical margins.
Resection may be performed with a monopolar electrocautery,
with the cutting current used to incise the mucosa and the coagulation current used to cut the muscle. Alternatively, resection
may be performed with a scalpel and a scissors. Hemostasis is
achieved with a monopolar or bipolar electrocautery. Larger vessels are ligated with chromic catgut or Vicryl ties.
Lesions of the lateral tongue should be wedge-excised in a
transverse (rather than horizontal) fashion to facilitate closure
and enhance postoperative function. With larger lesions, for
which either flap reconstruction or healing by secondary intention is typically indicated, the shape of the defect is contoured so
as to obtain wide margins around the lesion, and the flap is
designed to fill the contoured defect.
Step 3: Reconstruction
After negative margins are confirmed by frozen section examination, repair of the surgical defect is initiated. Careful preoperative
assessment of the anticipated defect lays the groundwork for optimal reconstruction. Many defects can be either repaired primarily
or allowed to heal by secondary intention. Free tissue transfer is an
excellent reconstructive option in many cases, allowing the maintenance of tongue mobility and the separation of the tongue from the
mandible and making sensate reconstruction possible.
In many patients with wedge-excised lateral tongue lesions, primary closure of the defect yields good results.The deep muscle is
carefully reapproximated with long-lasting absorbable sutures.The
mucosa is also closed with absorbable sutures. Care should be taken not to strangulate tissues by making the sutures too tight.When
complete primary closure is not possible or desirable, the tongue
may be allowed to granulate and heal by secondary intention. Splitthickness skin grafts, though useful for relining the floor of the
mouth, generally do not take well on the tongue.
For large defects of the tongue and those involving the floor of
the mouth, flap reconstruction is appropriate. Defects that connect to the neck, unless they are small and can be closed primarily, should also be closed with a flap. Free tissue transfer is frequently the optimal reconstructive approach. Free fasciocuta-
neous flaps from the radial forearm, the anterior lateral thigh, or
the lateral arm are well suited to reconstruction in this area.
Pedicled flaps (e.g., myocutaneous flaps from the pectoral muscle) are also used in this setting, but they are bulkier and harder
to contour to the defects.
If a mandibulotomy was made, it is repaired with the previously contoured plate. The lip-splitting incision is closed in three
layers (mucosa, muscle, and skin). Great care must be taken to
ensure accurate realignment of the vermilion border and the
orbicularis oris muscle.
Alternative Procedure: Laser Vaporization
Very superficial and premalignant lesions of the tongue may be
vaporized by using a CO2 laser. The desired depth of tissue
destruction for leukoplakia is approximately 1 to 2 mm.
TROUBLESHOOTING
Larger excisions may lead to airway edema.Whenever this possibility is a concern, a tracheostomy should be performed. A single intraoperative dose of steroids may reduce postoperative
tongue edema without adversely affecting wound healing. Using
a stair-step incision for the lip-splitting incision facilitates accurate reapproximation of the vermilion border. Excessive tongue
movement may result in dehiscence of the closure. Voice rest for
3 to 5 days after operation may be beneficial.
POSTOPERATIVE CARE
Figure 3 Anterior glossectomy. As an alternative to a lip-splitting incision with mandibulotomy, a visor flap may be employed
for exposure.
Postoperative care of patients undergoing excision of floor-ofmouth lesions is virtually identical to that of patients undergoing
anterior glossectomy [see Anterior Glossectomy, Postoperative
Care, above].
COMPLICATIONS
Planning for excision of a superficial or plunging ranula resembles that for glossectomy. A Ring-Adair-Elwyn (RAE) tube is inserted orally and taped to the contralateral cheek. Cervical exploration is usually unnecessary, because the cervical component of
the ranula resolves after removal of the ipsilateral sublingual gland.
In select cases, especially those involving disease recurrence after a
previous attempt at excision, a transcervical approach should be
considered.
OPERATIVE TECHNIQUE
Cyst
Gland
The patient should be maintained on a soft diet postoperatively. Meticulous oral hygiene is important. Oral rinses and flushes
with normal saline or half-strength hydrogen peroxide should be
performed at least four times daily and after meals.
The most significant potential complication of hard palate resection is oral antral or oronasal fistula; careful tissue reconstruction
and the use of an obturator can prevent this complication.
Maxillectomy
OPERATIVE PLANNING
sal flap that is wrapped over the cut bony edge of the palate. The
mucosal cut is connected around the maxillary tuberosity to the
gingivolabial sulcus incision that was made earlier.
The hard palate is then cut with a power saw. Once all the bone
cuts are complete, an osteotome may be used to connect them if
necessary.The remaining soft tissue attachments are divided along
the posterior hard palate with curved Mayo scissors. The surgical
defect is packed to control bleeding. Bleeding from the internal
maxillary artery is controlled by ligatures or ligating clips.
Step 3: Reconstruction
All sharp spicules of bone are debrided.The flap of hard palate
mucosa is brought up over the cut bony edge of the palate and held
in place with several Vicryl sutures.The anterior and posterior cut
edges of the soft palate are reapproximated with absorbable sutures.
A split-thickness skin graft, 0.014 to 0.016 in. thick, is harvested and used to line the raw undersurface of the cheek flap.
The skin graft is sutured to the mucosal edge of the cheek flap
with 3-0 chromic sutures. Superiorly, the graft is not sutured but
draped into position and retained by a layer of Xeroform packing
and strip gauze coated with antibiotic ointment. Gentle pressure
is applied to the packing so that it conforms to the defect. The
previously fabricated dental obturator is placed to support the
packing and to close the oral cavity from the nasal cavity. In a
dentulous patient, the obturator may be wired to the remaining
Figure 6 Maxillectomy. Radiographic assessment helps determine the required extent of resection. Depicted
are (a) medial maxillectomy, (b) subtotal maxillectomy without orbital exenteration, and (c) total maxillectomy
with orbital exenteration.
mucosa area. The graft is sutured to the cut edge of the buccal
mucosa with 4-0 chromic catgut. Xeroform and strip gauze coated with antibiotic ointment are gently packed into the defect to
secure the skin graft. The previously fabricated dental obturator
is wired to the remaining teeth to hold the packing in place.
TROUBLESHOOTING
If a lip-splitting incision is planned, lip contraction can be reduced and vermilion border realignment improved by employing a
stair-step lip incision and a Z-plasty. A single intraoperative steroid
dose reduces facial edema without compromising wound healing.
Retention of the obturator is aided by the band of scar tissue that
forms at the junction of the mucosa and the skin graft. Covering the
cut edge of the hard palate bone with mucosa eliminates pain
caused by pressure from the obturator on thinly covered bone.
If more than a small area of the floor of the orbit is resected, it
should be repaired to prevent enophthalmos. Epiphoria is uncommon; when it occurs, it is related to scarring of the nasolacrimal duct. Identifying the duct and transecting it obliquely should
reduce the incidence of this complication.
POSTOPERATIVE CARE
OPERATIVE TECHNIQUE
Step 1: Exposure
Wide exposure for access to primary tumors of the oral cavity
and the mandible may be achieved by means of either a lowercheek flap or a visor flap.The former is often preferable, in that it
allows resection of the primary and ipsilateral lymph nodes.
To create a lower-cheek flap, a lip-splitting incision is made
through the full thickness of the lower lip and carried down through
the chin tissues to the periosteum of the anterior mandible [see Figure
7].This incision may be made straight through the mental subunit
with a Z-plasty placed at the mental crease; alternatively, it may be
made around the mental subunit.The incision is continued vertically
to approximately the level of the thyrohyoid membrane, then extended laterally to the mastoid along a skin crease.The transverse component of the incision should be made at least two fingerbreadths below
the mandible to prevent injury to the marginal mandibular nerve.
The cheek flap is fully developed by incising the oral mucosa along
the gingivolabial sulcus while maintaining adequate surgical margins
around the lesion.The periosteum of the mandible is then elevated
and the cheek flap retracted to expose the mandible.
A visor flap [see Figure 3] has the advantage of not requiring a
lip-splitting incision, and it provides adequate exposure for lesions
of the anterior oral cavity. However, it is inadequate for exposing
lesions posterior to the middle third of the tongue or in the area of
most patients will need to be fed through this tube until their incisions are healed. A soft diet should be continued for 6 weeks. Oral
rinses and flushes with normal saline or half-strength hydrogen peroxide should be performed at least four times a day and after meals.
Facial incisions are cleaned twice a day and coated with antibiotic ointment. Facial sutures are removed 5 to 7 days after
operation.
TROUBLESHOOTING
Selected Readings
Acknowledgment
Figures 1 through 8
Alice Y. Chen.