Surgical Atlas of pediatric otolaryngology - part 7 pdf

Congenital Malformations of the Neck 507
FOURTH BRANCHIAL POUCH SINUS
The fourth branchial pouch sinus is an uncommon congenital anomaly
with two characteristic clinical presentations:
1. Neonatal neck mass. A neonate presents with a lateral neck cyst or
abscess associated with actual or impending airway compromise. The
mass mimics a cystic hygroma, and may contain air or increase in size
during crying or Valsalva.
2. Recurrent deep neck infection. A child, adolescent, or occasionally an
adult, presents with recurrent deep neck abscess or suppurative thy-
roiditis, despite several attempts at drainage or neck exploration.
The fourth branchial pouch sinus is not a complete fistula, but rather a
brief, internal tract originating in the piriform sinus. After exiting the pyri-
form apex, caudal to the superior laryngeal nerve (Figure 22–9), the tract
descends translaryngeally under the thyroid ala to emerge beneath the infe-
rior constrictor muscle, and exit the larynx near the cricothyroid joint.
Nearly all reported sinuses have been left sided.
Indications
• Fourth branchial pouch sinus diagnosed by barium swallow, sinogram
(when an external fistula exists), or hypopharyngoscopy
• Suspected fourth branchial pouch sinus based on clinical history, particu-
larly unexplained recurrent deep neck infection or suppurative thyroiditis
Figure 22–9 Fourth branchial
pouch sinus originating in the
piriform apex (dashed lines),
caudal to the superior laryngeal
nerve (SLN), and terminating as
a small cyst in the superior pole
of the thyroid gland. The sinus
tract is near the recurrent laryn-

geal nerve (RLN) at the
cricothyroid joint.
508 Surgical Atlas of Pediatric Otolaryngology
Preparation
• Acutely infected sinuses are treated with antibiotics, and incision and
drainage if necessary; definitive excision is delayed several weeks until
inflammation has resolved.
• Perioperative antibiotics are given routinely.
• Equipment is available for direct microlaryngoscopy to examine the ipsi-
lateral piriform apex for a sinus tract.
Anesthesia and Preparation
• General anesthesia with orotracheal intubation is required.
• The patient’s neck is extended and draped from the clavicle to the chin.
Procedure
• Direct laryngoscopy is performed and the ipsilateral piriform apex is
inspected for a sinus tract opening. If a distinct opening is found, two
options exist:
1. Endoscopic cauterization. The sinus tract is obliterated by endoscopic
cauterization using an insulated needlepoint electrocautery, and the
procedure is concluded. Preliminary results with limited follow-up
have been favorable. Cauterization is at low power and limited to the
superficial mucosal layer, which leads to scarring and closure of the
sinus tract with low risk of perforation.
2. Open surgical excision. The sinus tract is excised retrograde, beginning
with complete exposure of the piriform fossa. Recurrence has not
been reported with this approach, but morbidity is higher than with
cauterization. In contrast, excising only the extralaryngeal portion of
the tract almost guarantees recurrence.
• External excision begins by exposing the thyroid ala and carotid sheath,
which allows the operation to begin in a region relatively free of postin-

flammatory fibrosis.
1. An incision is made along the anterior border of the sternocleido-
mastoid muscle, from superior aspect of the thyroid cartilage to the
level of the cricoid cartilage (Figure 22–10).
2. The sternocleidomastoid muscle is retracted, exposing the posterior
edge of the lateral thyroid cartilage, with the attached inferior con-
strictor muscle.
3. If a tract is discovered exiting from the thyrohyoid membrane, rostral
to the superior laryngeal nerve, the diagnosis of a third pouch sinus is
confirmed and exposure of the piriform fossa is not required. The
tract is ligated and dissected retrograde.
4. If a tract or fibrosis is not apparent near the thyrohyoid membrane, a
fourth pouch sinus is likely, and the piriform fossa is exposed as
described below.
• To expose the piriform fossa, a vertical incision is made along the poste-
rior edge of the lateral thyroid cartilage and inferior cornu down to and
through the perichondrium. The inferior constrictor is separated poste-
510 Surgical Atlas of Pediatric Otolaryngology
riorly, hugging the cartilage closely and elevating the perichondrium
around the posterior edge and on the medial side sufficiently to detach
the inferior constrictor muscle.
• A tracheal hook distracts the posterior edge of the thyroid ala anteriorly
(Figure 22–11), and the facet-like joint between the inferior cornu and
the cricoid cartilage is separated. To avoid recurrent laryngeal nerve
injury, the joint is divided as close to the inferior cornu as possible.
• The thyroid perichondrium is elevated anteriorly to expose the posteri-
or thyroid cartilage. A 1-cm strip of posterior thyroid ala is excised,
exposing the underlying piriform sinus.
• The fourth pouch sinus tract is ligated from its origin at the piriform apex
and any pharyngeal defect is repaired with pursestring closure. Recur-

rence is likely if the pharyngeal connection is incompletely ligated.
• The sinus tract is then excised retrograde, ending with a surrounding
ellipse of skin if a fistula was present.
♦
Part of the superior pole of the thyroid gland may be included if nec-
essary (see Figure 22–11), but the superior parathyroid gland should
be preserved.
♦
If the tract descends paratracheally, exposure of the recurrent laryn-
geal nerve is necessary to prevent injury. When the nerve cannot be
identified because of inflammation or scarring, the excision should
end at the cricothyroid region to prevent nerve injury.
• A Penrose rubber drain is inserted and the incision is closed in layers.
Postoperative Care
• Perioperative antibiotics are continued for 24 hours.
• The drain is removed on the first postoperative day unless drainage is
excessive.
512 Surgical Atlas of Pediatric Otolaryngology
FIBROMATOSIS COLLI
Fibromatosis colli (sternomastoid tumor of infancy) is thought to represent
an injury to the sternomastoid muscle, incurred either in utero or during
delivery. The deformity is usually noted at birth or within the first 10 days
of life, and may be associated with congenital hip dislocation. A firm mass
becomes palpable in the muscle and progresses to a maximal size (1-3 cm),
generally within 1 month. The head is usually tilted toward the side of the
shortened muscle, and the chin rotates toward the opposite (normal) side.
Fine needle aspiration aids in diagnosis.
If left untreated, the condition may cause developmental asymmetry of
the face and ocular imbalance. Conservative management, which consists
of range of motion exercises, is generally successful in resolving the prob-

lem; however, surgery may be necessary in rare cases. Other evidence of
injury should be looked for, such as a fracture of the clavicle or cervical
spine injury or abnormality.
Indications
• A mass within the body of the sternomastoid muscle that does not
resolve with aggressive physical therapy, consisting of passive range of
motion exercises performed by the parent three to four times daily
• Long standing torticollis in older children may benefit from tenotomy
or release of the shortened sternomastoid muscle. Evaluation of the
underlying cervical spine should be performed to detect any abnormal-
ities.
Anesthesia and Preparation
• General endotracheal anesthesia is necessary.
• The patient’s neck is extended, and the head is rotated away from the
side of the torticollis to make the mass as prominent as possible.
• The neck is prepped from the clavicle to the chin.
Procedure
• A horizontal incision is created over the mass and carried through the
subcutaneous tissue (Figure 22–12).
• The greater auricular nerve is preserved if possible.
• The mass can generally be separated from normal muscle fiber with
preservation of the portion of the sternomastoid muscle that is not
involved with the fibrosis. The accessory branch to the sternomastoid
muscle should also be preserved.
• The incision is closed immediately in the standard fashion.
Postoperative Care
• Postoperatively, the patient performs range of motion exercises to main-
tain the release that has been surgically created.
514 Surgical Atlas of Pediatric Otolaryngology
Kennedy TL. Cystic hygroma-lymphangioma: a rare and still unclear entity. Laryngoscope 1989;99

Suppl:1–10.
Landing BH, Farber S. Function of the cardiovascular system. In: Atlas of tumor pathology, Wash-
ington (DC): Armed Forces Institute of Pathology; 1956. p.
May J, D’Angelo AJ Jr. The facial nerve and the branchial cleft surgical challenge. Laryngoscope
1989;99:564–5.
Mickel RA, Calcaterra TC. Management of recurrent thyroglossal duct cysts. Arch Otolaryngol
Head Neck Surg 1983;109:34–6.
Prasad S, Grundfast G, Milmoe G. Management of congenital preauricular pit and sinus tract in
children. Laryngoscope 1990;100:320–1.
Ricciardelli EJ, Richardson MA. Cervicofacial cystic hygroma: patterns of recurrence and manage-
ment of the difficult case. Arch Otolaryngol Head Neck Surg 1991;117:546–53.
Riechelmann H, Muehlfay G, Keck T, et al. Total, subtotal, and partial surgical removal of cervico-
facial lymphangiomas. Arch Otolaryngol Head Neck Surg 1999;125:643–8.
Rosenfeld RM, Biller HF. Fourth branchial pouch sinus: diagnosis and treatment. Otolaryngol Head
Neck Surg 1991;105:44–50.
Sedwick CE, Walsh JF. Branchial cysts and fistulas: a study of seventy-five cases relative to clinical
aspects and treatment. Am J Surg 1952;83:3–8.
Simpson RA. Lateral cervical cysts and fistulas. Laryngoscope 1969;79:30–58.
Sistrunk WE. The surgical treatment of cysts of the thyroglossal tract. Ann Surg 1920;71:121–4.
Tom LW, Handler DS, Wetmore RF, Potsic WP. The sternocleidomastoid tumor of infancy. Int J
Pediatr Otorhinolaryngol 1987;13:245–55.
Tom LW, Rossiter JL, Sutton LN, et al. Torticollis in children. Otolaryngol Head Neck Surg
1991;105:1–5.
Woodman D. A modification of the extralaryngeal approach to arytenoidectomy for bilateral abduc-
tor paralysis. Arch Otolaryngol 1946;43:63–5.
Work WP. Newer concepts of first branchial cleft defects. Laryngoscope 1972;82:1581–93.
CHAPTER 23
SALIVARY GLAND SURGERY
Michael J. Cunningham, MD
PAROTIDECTOMY

During childhood, the parotid glands and paraparotid lymph nodes are
subject to infection, inflammation, and neoplasia. Vasoformative and con-
genital cystic lesions often are clinically apparent. Conversely, chronic
inflammation may present as an indolent firm mass indistinguishable from
a benign or malignant neoplasm. Serology, skin tests, and radiologic imag-
ing (contrast sialography, ultrasonography, computed tomography, or mag-
netic resonance imaging) may suggest, but typically cannot confirm, the
specific underlying disease process.
Fine-needle aspiration (FNA) biopsy has a limited role in diagnosing
solid parotid masses. If the child needs general anesthesia for needle biop-
sy, then excisional biopsy will yield greater histopathologic information.
More importantly the definitive treatment of many inflammatory and neo-
plastic causes of solid parotid masses in children is surgical excision. Exci-
sional biopsy, or superficial parotidectomy, is therapeutic and diagnostic in
such circumstances. As in adults, neither incisional biopsy nor the isolated
enucleation of solitary parotid lesions is recommended. Total parotidecto-
my is rarely necessary in children.
Indications
• Solid parotid mass of unknown or uncertain etiology
• Chronic recurrent parotitis
• First and second branchial system anomalies
• Vasoformative lesions
Anesthetic Considerations and Preparation
• The procedure is performed under general anesthesia.
• Paralytic agents are avoided to allow for intraoperative facial nerve stim-
ulation.
• Informed consent regarding the risk of facial nerve injury is an absolute
necessity.
516 Surgical Atlas of Pediatric Otolaryngology
• The child is positioned supine with the head turned toward the unin-

volved side. The operative field is draped with sterile transparent plastic
sheeting to provide exposure of the entire face on the involved side,
including the corners of the eye and mouth (Figure 23–1). This allows
for the intraoperative assessment of facial nerve function.
Procedure
• The planned incision is infiltrated with 1% lidocaine and 1:100,000
epinephrine solution for local hemostasis.
♦
In older children and adolescents, an S-shaped face lift–type incision is
used (Figure 23–2
A). This incision begins in the preauricular crease,
runs under the lobule, continues up and over the mastoid process,
and extends in a curvilinear fashion down into the neck approxi-
mately two finger breadths below the angle of the jaw. A Y-shaped
incision with a retroauricular extension is an alternative approach
(Figure 23–2
B).
♦
In infants and very young children, a single curved incision, beginning
1.5 to 2 cm below the mandible and extending posterior and superi-
or over the mastoid prominence, reportedly protects the superficially
located facial nerve (Figure 23–2
C).
Figure 23–1 The patient is posi-
tioned so that facial nerve func-
tion can be assessed.
518 Surgical Atlas of Pediatric Otolaryngology
• The skin flaps are elevated in a plane of dissection deep to the subcuta-
neous tissues and superficial to the investing fascia of the parotid gland.
The anterior margin of elevation is the parotid gland’s anterior border to

avoid inadvertent transection of small facial nerve branches emerging
from the gland over the masseter muscle (Figure 23–3).
• Posteroinferior flap dissection is performed in the subplatysmal plane
until the anterior border of the sternocleidomastoid muscle is clearly
identified.
♦
Care is particularly necessary in infants and young children because
limited posterior development of the parotid gland may expose a
large portion of the facial nerve (Figure 23–4).
♦
In older children, the tail of the parotid gland often needs to be separat-
ed from the sternocleidomastoid muscle. Both the greater auricular
nerve and the posterior facial (retromandibular) vein are typically
encountered and need to be sacrificed for gland retraction and exposure.
• Using both superior traction on the earlobe and anterior traction on the
parotid gland, blunt dissection along the tragal cartilage and adjacent
mastoid bone allows separation of the small fibrous bands that attach the
posterior border of the parotid gland to these structures (Figure 23–5).
Figure 23–3 Elevation of the anterior and posteroinferior flaps.
520 Surgical Atlas of Pediatric Otolaryngology
♦
The goal of progressive medial dissection in this fashion is to identi-
fy the main trunk of the facial nerve as it emerges from the stylomas-
toid foramen.
♦
In older children and adolescents, the location of the facial nerve can be
anticipated approximately halfway between the tip of the mastoid
process and a triangular extension of the cartilaginous external ear
canal, the so-called pointer.
1. Immediately before encountering the facial nerve, the tem-

poroparotid fascia often arises from the tympanomastoid fissure as
a firm band extending into the parotid gland.
2. Conservative use of the nerve stimulator during this portion of the
procedure helps to distinguish fascia from nerve.
3. Hemostasis is crucial for visualization purposes; bipolar cauteriza-
tion in a moist field is advocated to decrease the likelihood of
cautery-induced neural damage.
♦
In infants and young children, limited mastoid development results in
less well-defined bony landmarks for facial nerve identification (Fig-
ures 23–6
A and B). In addition, some of the inflammatory condi-
tions necessitating parotidectomy in children pathologically involve
the external auditory canal, creating scarring in this region and plac-
ing the main trunk of the facial nerve in further jeopardy.
1. An alternative method of finding the facial nerve in such circum-
stances is to follow the anterior border of the sternocleidomastoid
muscle superiorly to its temporal bone insertion and to locate the
posterior belly of the digastric muscle just deep to this insertion site.
2. Using blunt dissection and working anteriorly, the facial nerve
trunk typically can be found within the triangle formed by these
two muscles and the cartilaginous ear canal (Figure 23–7).
• In revision surgical procedures with extensive cervical scarring, an alter-
native approach is to use the retroauricular extension of a Y-shaped skin
incision (see Figure 23–2
B). A limited mastoidectomy is then per-
formed to provide access to the facial nerve in the descending portion of
the fallopian canal prior to its skull base exit.
• Once the main trunk of the facial nerve is clearly identified, it is fol-
lowed anteriorly to the pes anserinus.

♦
In adolescents and older children, this requires dissection into the
parotid gland.
♦
In infants, the pes may actually be in the retromandibular region out-
side of the parotid gland proper (see Figure 23–4).
522 Surgical Atlas of Pediatric Otolaryngology
• A plane of cleavage through the parotid gland is developed as proximal
to distal dissection of both the upper zygomaticotemporal and lower cer-
vicofacial divisions of the facial nerve is performed (Figure 23–8).
♦
Branches of the posterior facial (retromandibular) vein require liga-
tion during this portion of the procedure, as does the parotid duct if
identified and transected.
♦
Once the temporal, zygomatic, buccal, and mandibular branches of
the facial nerve have been followed completely to the point of turning
deeply toward the facial musculature, the remaining portions of the
parotid gland can be separated from the investing fascia (Figure 23–9).
♦
This separation completely mobilizes the superficial lobe of the
parotid gland. The so-called deep lobe of the parotid gland is the sali-
vary tissue that remains undisturbed under the preserved facial nerve.
• A superficial parotidectomy is adequate treatment for virtually all super-
ficially located parotid masses; it allows the complete operative dissec-
tion of first and second congenital branchial anomalies.
• A total parotidectomy may prove necessary if the mass in question is
located within the deep lobe, or if the pathology involves the entire
gland, as is the case in some vasoformative lesions and chronic inflam-
matory processes.

♦
In such circumstances, the main trunk and individual branches of the
facial nerve can be retracted gently with rubber vascular loops to
allow access to the underlying parotid tissue (Figure 23–10).
Figure 23-8: Dissection along the facial nerve develops a plane of cleavage through the parotid gland. (Adapted from Welch KJ,
Randolph JC, editors. Pediatric surgery. Vol. I. Chicago: Year Book Medical Publishers; 1986. p. 500.)
524 Surgical Atlas of Pediatric Otolaryngology
♦
The deep parotid tissue is separated from the underlying facial mus-
culature, temporomandibular joint, and mandible.
♦
Ligation of the medially adjacent maxillary and superficial temporal
arteries may be necessary. Deep parotid lobe dissection exposes the
parotid duct.
• Neoplastic invasion of the facial nerve is extremely infrequent in pedi-
atric parotid malignancies.
♦
In the rare case of a resectable undifferentiated or sarcomatous malig-
nancy, total parotidectomy with facial nerve resection is performed in
conjunction with a modified neck dissection and perhaps a partial
mandibulectomy.
♦
The proximal aspect of the facial nerve typically is identified within
the vertical segment of the fallopian canal; the peripheral facial nerve
branches are likewise identified and tagged (Figure 23–11).
♦
Frozen section histopathology is used to determine healthy neural
margins.
♦
Immediate reconstruction by free autogenous nerve grafting is advo-

cated using either the sural nerve or the greater auricular nerve from
the opposite side of the neck; the harvesting of the former allows a
two-team approach.
♦
Microanastomotic technique increases the likelihood of graft success.
• When the facial nerve has been preserved in parotid surgery, the main
trunk, divisions, and individual branches of the nerve should be stimu-
lated prior to wound closure to determine neural integrity. If the facial
muscles do not twitch briskly with stimulation, the nerve must be
inspected along its entire course for possible disruption. A transected
nerve should be repaired immediately. Stretching or compression may
have injured an anatomically intact nerve.
• Following hemostasis and irrigation, suction drainage is recommended.
The drain typically leaves the skin through a separate stab incision (Fig-
ure 23–12).
♦
A Jackson-Pratt drain is appropriate in older children and adolescents.
♦
In infants and young children, a Brent butterfly drain using a large test
tube for vacuum purposes works well.
• Closure is performed in two layers using interrupted absorbable sutures
subcutaneously, and either nylon or absorbable sutures in an interrupt-
ed or running fashion in the skin.
• A pressure dressing completes the procedure.
Complications
• Facial paresis may be observed on the side of the operation for days or
even weeks postoperatively, depending on the extent of nerve mobiliza-
tion. If gentle retraction was performed and no significant branches of
the facial nerve have been severed, complete recovery is the rule.
526 Surgical Atlas of Pediatric Otolaryngology

• Gustatory sweating (Frey’s syndrome) occurs secondary to the regrowth of
parasympathetic motor fibers from the auriculotemporal nerve, which pre-
operatively innervated the parotid gland, into the skin. Efferent impulses
that had induced salivation now stimulate the cutaneous sweat glands.
• Hypoesthesia of the earlobe is commonly present for up to several
months. Permanent hypoesthesia can occur if the greater auricular nerve
has been sacrificed.
• Hemorrhage with secondary hematoma or seroma formation reflects
inadequate hemostasis or drainage.
• Salivary fistula formation may occur if the parotid duct has not been
identified and ligated prior to transection.
SUBMANDIBULAR GLAND EXCISION
Submandibular gland neoplasms are extremely rare in children. Vasofor-
mative lesions, especially lymphatic vascular malformations, can arise with-
in the submandibular space. The inflammatory processes that afflict the
paraparotid lymph nodes can likewise involve the submandibular lymph
nodes. The submandibular gland itself is also susceptible to a higher rate of
stone formation (sialolithiasis) and secondary inflammation (sialoadenitis).
Excision of the submandibular gland in children is infrequently necessary.
Indications
• Chronic sialoadenitis with or without sialolithiasis
• A persistent firm submandibular mass of unknown or uncertain etiology
• Elective removal in an attempt to decrease salivary secretions in children
with excessive drooling secondary to cerebral palsy and other neuro-
muscular disorders
Anesthetic Considerations and Preparation
• The procedure is performed under general anesthesia.
• Paralytic agents are avoided to allow for intraoperative marginal
mandibular nerve stimulation.
• Informed consent regarding the risk of marginal mandibular nerve

injury is necessary.
• The child is positioned supine with the head turned toward the unin-
volved side. The operative field is draped with sterile transparent plastic
sheeting to provide exposure of the corner of the mouth on the involved
side (Figure 23–13). This allows for the intraoperative assessment of
marginal mandibular nerve function.
Procedure
• A horizontal skin incision is made in a neck crease two finger breadths
inferior and parallel to the angle and body of the mandible (Figure
23–14).
• The incision is infiltrated with 1% lidocaine and 1:100,000 epinephrine
solution for hemostasis.
528 Surgical Atlas of Pediatric Otolaryngology
• The skin, subcutaneous tissues, and platysma muscle are divided down
to the investing fascia of the submandibular gland. The mylohyoid mus-
cle anteriorly, the sternocleidomastoid muscle posteriorly, and the digas-
tric muscle inferiorly are exposed (Figure 23–15).
• The fascia over the submandibular gland is divided at its inferior aspect
and elevated toward the mandible. The anterior facial vein is sought
because the marginal mandibular branch of the facial nerve usually
crosses this vein; ligation and elevation of this vessel with the fascia helps
to shield the marginal mandibular nerve from injury (Figures 23–16
A
and B). Direct identification of the marginal mandibular nerve with the
use of a nerve stimulator is the best way to protect and preserve the nerve
during elevation of the fascia.
• Mobilization of the submandibular gland is begun along its inferior
aspect. The plane between the intermediate tendon of the digastric mus-
cle and the submandibular gland is opened (Figure 23–17).
♦

The hypoglossal nerve will be encountered deeply in the digastric tri-
angle.
♦
The external maxillary (facial) artery enters the posterior aspect of the
submandibular gland; this vessel is double-ligated before transection.
♦
Branches of the posterior facial (retromandibular) vein also require
careful ligation.
Figure 23–15 Exposure of the mylohyoid, sternocleidomastoid, and digastric muscles.
(Adapted from Montgomery WW. Surgery of the upper respiratory system. Vol. II.
Philadelphia: Lea & Febiger; 1989. p. 263.)
530 Surgical Atlas of Pediatric Otolaryngology
• Anterior retraction of the mylohyoid muscle and gentle downward trac-
tion on the submandibular gland allow identification of the lingual
nerve, its attached submandibular ganglion, and the submandibular
(Wharton’s) duct (Figure 23–18).
♦
The duct is ligated and divided. The efferent fibers arising from the
ganglion to the submandibular gland also are divided, freeing the lin-
gual nerve from the gland.
♦
The submandibular gland is now completely mobilized by blunt dis-
section. The superior end of the external maxillary (facial) artery, if
not previously ligated, should be identified and secured.
• After removal of the specimen, the submandibular space is explored
carefully (Figure 23–19). The marginal mandibular nerve, if previously
identified, should be stimulated to determine neural integrity.
• Following hemostasis and irrigation, a Penrose drain is placed through
the operative incision (Figure 23–20).
• Closure is performed in two layers using interrupted absorbable sutures

for platysma muscle and subcutaneous tissue approximation, and either
interrupted or a single subcuticular nylon suture in the skin.
• A pressure dressing completes the procedure.
Complications
• Paresis or paralysis of the lower lip may occur secondary to injury to the
marginal mandibular branch of the facial nerve. If the anatomic integri-
ty of the nerve is operatively preserved, complete recovery is the rule.
• Because the platysma muscle aids in depressing the lower lip, there may be
transient unilateral lip weakness secondary to its intraoperative division.
Figure 23–18 Complete mobi-
lization of the submandibular
gland.
532 Surgical Atlas of Pediatric Otolaryngology
RANULA EXCISION
Ranulas are cystic lesions of sublingual gland origin. Simple ranulas are true
retention cysts appearing as transparent thin-walled cysts, typically unilat-
eral, within the floor of the mouth. The cervical or plunging ranula is a
mucous extravasation pseudocyst that arises as mucus escapes through a
ruptured sublingual duct. Plunging ranulas may extend through the gap
between the posterior edge of the mylohyoid muscle and the anterior edge
of the hyoglossus muscle into the superior cervical neck. The presence of a
cystic floor-of-mouth swelling on the same side as a cystic swelling in the
submental and/or submandibular space is suggestive of the diagnosis.
Computed tomography or magnetic resonance imaging can distinguish a
ranula from a lymphatic vascular malformation, the clinical entity with
which it is most commonly confused.
Ranulas localized to the floor of the mouth are managed with intraoral
marsupialization or complete excision. Plunging ranulas require complete
excision, typically via a transcervical approach.
PLUNGING RANULA EXCISION

Indications
• Plunging ranula associated with
♦
Dysphagia, speech impediment, or respiratory distress manifestations
♦
Recurrent infection
♦
Progressive enlargement
• Diagnostic confirmation of a cervical lesion
Anesthetic Considerations and Preparation
• The procedure is performed under general anesthesia.
• Paralytic agents are avoided to allow for intraoperative marginal
mandibular nerve stimulation.
• Nasotracheal intubation is preferable to allow intraoral access if necessary.
• Informed consent regarding the risk of marginal mandibular nerve
injury is necessary.
Procedure
• The transcervical approach described for submandibular gland resection
is also used for surgical access to this lesion. The submandibular duct
passes through the same muscle cleft through which the ranula typical-
ly extends. The submandibular duct empties into the floor of the mouth
medial to the sublingual gland; it provides a direct pathway to the site of
ranula origin (Figure 23–21).
• The anatomic proximity of these glandular structures often dictates the
removal of the submandibular gland with ligation of its duct to allow
complete removal of the plunging ranula cyst. The cervical approach
provides greater exposure and protection of the lingual nerve than is pos-
sible transorally (Figure 23–22).
534 Surgical Atlas of Pediatric Otolaryngology
• Gloved intraoral palpation on the ipsilateral floor of the mouth can help

to deflect the sublingual gland into the operative field (Figure 23–23).
Complete removal of the sublingual gland, ideally in continuity with the
ranula cyst, is necessary.
• Cervical wound closure is performed as described above–see
Sub-
mandibular Gland Excision
.
♦
If the floor-of-mouth mucosa has been disrupted, closure by inter-
rupted absorbable sutures is recommended.
♦
If the submandibular gland is not removed and the submandibular
duct is transected, the proximal end of the duct must be brought out
through the mucosa of the floor of the mouth for salivary drainage
(Figure 23–24).
Complications
• The same postoperative sequelae described for submandibular gland
excision can occur following the transcervical excision of a ranula.
• A ranula may recur if the sublingual gland is not operatively removed.
• Submandibular sialoadenitis may occur if the submandibular gland is
left in place and the submandibular duct is injured intraoperatively.
Figure 23–23 Gloved intraoral
palpation displaces the ranula
and attached sublingual gland
into the cervical operative field.
536 Surgical Atlas of Pediatric Otolaryngology
INTRAORAL RANULA EXCISION
Indications
• Intraoral ranula associated with
♦

Dysphagia, speech impediment, or respiratory distress manifestations
♦
Recurrent infection
♦
Progressive enlargement
Anesthetic Considerations and Preparation
• The procedure is performed under general anesthesia.
• Nasotracheal intubation is preferable to facilitate intraoral access.
• The patient is positioned supine with the neck extended.
Procedure
• A mouth retractor without a tongue blade is placed.
• A silk suture placed in the midline of the tongue facilitates tongue
retraction.
• The orifice of the ipsilateral submandibular gland duct should be can-
nulated with a Teflon catheter or metal lacrimal probe; this procedure
identifies the location of the submandibular duct so that it can be pro-
tected from injury during dissection of the ranula cyst (Figure 23–25).
• A wide elliptical incision is outlined over the dome of the cyst (see Fig-
ure 23–25).
• Lidocaine 1% with 1:100,000 epinephrine is infiltrated submucosally
for hemostasis. Care must be taken not to puncture the cyst.
• If solely marsupialization or exteriorization of the ranula is planned, the
entire dome of the cyst is removed, leaving an exposed bed to heal by
secondary intention; however, the rate of recurrence is high. The more
definitive procedure is complete excision of the ranula and the ipsilater-
al sublingual gland from which it arises.
• When complete ranula excision is anticipated, no attempt is made to sep-
arate the overlying adherent mucosa from the underlying cyst: they are
removed together to facilitate ranula dissection ideally without disruption.
• Using primarily blunt and limited sharp dissection, the ranula cyst is

separated from the mucosal margins and deeper floor-of-mouth struc-
tures (Figure 23–26).
♦
Care is taken not to injure the lingual nerve or the cannulated sub-
mandibular duct, both of which should be identifiable on the surface
of the floor-of-mouth musculature (Figure 23–27).
♦
The sublingual gland ideally is removed in continuity with the ranu-
la cyst.
• Hemostasis is achieved by bipolar cauterization of numerous small lin-
gual veins. Drains typically are not used.
• The mucosal edges are closed using interrupted absorbable sutures (Fig-
ure 23–28).
538 Surgical Atlas of Pediatric Otolaryngology
Complications
• Postoperative edema of the floor of the mouth can potentiate airway
obstruction. Intravenous dexamethasone during surgery may decrease
this risk. Monitored postoperative observation is recommended;
overnight nasotracheal intubation is a consideration in selected cases.
• Postoperative hematoma of the floor of the mouth can likewise potenti-
ate airway obstruction; this can be prevented by meticulous intraopera-
tive hemostasis.
• Ranula recurrence is a possibility if the sublingual gland is not removed.
BIBLIOGRAPHY
Batsakis JG, Sneige N, El-Naggar AK. Fine needle aspiration of salivary glands; its utility and tissue
effects. Ann Otol Rhinol Laryngol 1992;101:185–8.
Camacho AE, Goodman ML, Eavey RD. Pathologic correlation of the unknown solid parotid mass
in children. Otolaryngol Head Neck Surg 1989;101:566–71.
Crysdale WS, Mendelsohn JD, Conley S. Ranulas—mucoceles of the oral cavity: experience in 26
children. Laryngoscope 1988;98:296–8.

Farrior JB, Santini H. Facial nerve identification in children. Otolaryngol Head Neck Surg
1985;93:173–6.
Loré JM Jr. Excision of ranula. In: Loré JM. An atlas of head and neck surgery. Philadelphia: WB
Saunders; 1988. p. 628–9.
Loré JM Jr. The parotid salivary glands. In: Loré JM. An atlas of head and neck surgery. Philadel-
phia: WB Saunders; 1988. p. 708–25.
Loré JM Jr. Resection of the submandibular salivary gland for benign disease. In: Loré JM. An atlas
of head and neck surgery. Philadelphia: WB Saunders; 1988. p. 678–81.
Luna MA, Batsakis JG, El-Naggar AK. Salivary gland tumors in children. Ann Otol Rhinol Laryn-
gol 1991;100:869–71.
Matt BH, Crockett DM. Plunging ranula in an infant. Otolaryngol Head Neck Surg
1988;99:330–3.
May M, D’Angelo AJ Jr. The facial nerve and the branchial cleft: surgical challenge. Laryngoscope
1988;99:564–5.
Montgomery WW. Surgery of the salivary glands. In: Montgomery WW. Surgery of the upper res-
piratory system. Vol. II. Philadelphia: Lea & Febiger; 1989. p. 225–69.
Seligman I, Lusk R. Excision of a ranula in a child. In Bailey BJ. Surgery of the oral cavity. Chica-
go: Year Book Medical Publishers; 1989. p. 209–14.
Welch KJ. The salivary glands. In: Welch KJ, Randolph JC. Pediatric surgery. Chicago: Year Book
Medical Publishers; 1986. p. 487–502.
CHAPTER 24
THYROIDECTOMY
Michael J. Cunningham, MD
PREOPERATIVE EVALUATION
• Blood tests [serum thyroxine (T4), triiodothyronine (T3), thyroid-stim-
ulating hormone (TSH), antithyroglobulin antibodies, and antimicro-
somal antibodies] may be necessary for complete evaluation, but rarely
prove diagnostic for solitary thyroid masses. The exception is an elevat-
ed serum calcitonin level for medullary thyroid cancer.
• Ultrasonography is useful in evaluating the size, position, and multiplicity

of thyroid lesions, as well as determining their cystic or solid character.
•
Thyroid scanning compliments ultrasonography, particularly in the eval-
uation of solid thyroid masses. Thyroid malignancies frequently appear
“cold” on thyroid scanning; nonsuppressible “warm” and “hot” masses
can also prove to be malignant.
•
Radiologic evaluation of children and adolescents with suspected thyroid
neoplasms should also assess the remainder of the neck and chest. Thy-
roid cancer in this age group often presents in an advanced stage with
regional lymph node metastases and distant extrathyroidal disease, par-
ticularly to the lungs. Documenting regional or systemic metastases sig-
nificantly influences initial surgical management, but does not necessar-
ily imply a poor prognosis.
Thyroidectomy is an infrequent procedure in children, performed most often for a poten-
tially malignant thyroid mass. The differential diagnosis of a thyroid mass in a child or ado-
lescent includes congenital anomalies (thyroglossal duct cyst, ectopic thyroid, unilateral
thyroid lobe agenesis), thyroid abscess, colloid nodule, Hashimoto’s thyroiditis, benign ade-
nomas, and malignant neoplasms. Clinical factors suspicious for malignancy include large
size or rapid growth of the mass, fixation of the mass to surrounding structures, associated
vocal fold paralysis or ipsilateral cervical lymphadenopathy, bring exposure to radiation
therapy, or a familial predisposition to thyroid tumors.
540 Surgical Atlas of Pediatric Otolaryngology
• Fine-needle aspiration (FNA) biopsy with cytopathologic examination is
a valuable tool in the diagnostic work-up of thyroid masses, given the
high specificity and ease and safety of this technique in experienced
hands. Positive FNA results can help further select the appropriate thy-
roid surgical procedure.
• Open surgical biopsy is indicated for a solitary thyroid mass, which despite
extensive preoperative evaluation, cannot be definitively determined to be

benign or malignant. A total thyroid lobectomy (hemithyroidectomy) is
performed initially, with more extensive surgery, if needed, dictated by
intraoperative frozen section histopathologic tissue diagnosis.
THYROIDECTOMY
Indications
• A solitary thyroid mass, especially a solid mass for which a definitive
benign diagnosis cannot be made on the basis of preoperative evaluation
Anesthetic Considerations
• The procedure is performed under general anesthesia.
• Paralytic agents are avoided to allow for intraoperative recurrent laryn-
geal nerve (RLN) stimulation and monitoring.
Preparation
• Preoperative evaluation of vocal fold function is mandatory. From a
diagnostic standpoint, documentation of impaired vocal fold mobility at
presentation is a clinical criterion suggestive of an underlying malignant
etiology. The presence of overt vocal fold paralysis may be important in
dictating the surgical course.
• When there is normal vocal fold function, informed consent regarding
the risk of RLN injury is necessary.
• Consideration should be given to intraoperative RLN monitoring.
♦
In older children and adolescents, the Xomed NIM II EMG endo-
tracheal tube can be used for this purpose (Figure 24–1). This endo-
tracheal tube has exposed electrodes which come in contact with the
luminal surface of the true vocal folds, allowing passive and evoked
electromyogram (EMG) monitoring of the thyroarytenoid muscle
during thyroid surgery.
♦
Unfortunately, the smallest EMG endotracheal tube (outer diameter
8.8 mm, inner diameter 6.0 mm) is too large for most children, but

is applicable in adolescents.
♦
A surface electrode which monitors posterior cricoarytenoid muscle
activity can alternatively be used in younger children; this electrode
requires placement against the posterior cricoid lamina by intraoper-
ative laryngoscopy before the child is positioned for the definitive
thyroid procedure (Figure 24–2).
542 Surgical Atlas of Pediatric Otolaryngology
• The child is placed in the thyroid position, supine with the neck in full
extension (Figure 24–3).
Procedure
• A transverse collar incision is outlined in the lower neck.
1. The exact position of the incision must take into account the rela-
tionship between the palpable portions of the laryngeal skeleton, the
sternum, and the thyroid gland.
2. The thyroid isthmus is situated immediately inferior to the cricoid
cartilage. A natural skin crease is chosen within 1-2 cm of this level
(Figure 24–4).
3. In young children, the laryngeal structures may not be obviously pal-
pable, and may be considerably more cephalad relative to the sternal
notch than anticipated (Figure 24–5).
• The planned incision is infiltrated with 1% lidocaine with 1:100,000
epinephrine solution to provide hemostasis.
Figure 24–3 Thyroidectomy operative position.
544 Surgical Atlas of Pediatric Otolaryngology
• The skin, subcutaneous tissues, and platysma muscle are transected. The
anterior borders of the sternocleidomastoid muscle serve as the lateral
margins (Figure 24–6).
• The incision should be wide enough to allow adequate vertical exposure.
A superior flap is elevated in the subplatysmal plane to the level of hyoid

bone, and an inferior flap is elevated to the level of the sternal notch
(Figure 24–7).
• The midline raphe between the strap muscles is incised, and the ster-
nohyoid and sternothyroid muscles are separated from one another and
from the underlying thyroid gland (Figure 24–8).
♦
Dividing the strap muscles is infrequently necessary in the pediatric
population.
♦
When required for operative exposure, the muscles should be divided
high in the neck, above the cricoid cartilage to preserve ansa cervicalis
innervation.
Figure 24–6 Transection of the
skin, subcutaneous tissues, and
platysma muscle. (Adapted from
the Loré JM. An atlas of head
and neck surgery. 3
rd
ed.
Philadelphia: WB Saunders;
1988. p.759.)
546 Surgical Atlas of Pediatric Otolaryngology
Identifying the recurrent laryngeal nerves
• Once the strap musculature is separated or divided, the sternocleido-
mastoid muscle on the side of the lesion is retracted to identify the
carotid sheath structures (Figure 24–9).
• The thyroid lobe is retracted medially, and blunt dissection is care-
fully performed in the superior thoracic inlet just caudal to the infe-
rior thyroid pole to identify the recurrent laryngeal nerve (RLN).
• When searching for the RLN, it is preferable to identify the inferior

thyroid artery. The nerve typically passes under this vessel, but may
be superficial (Figure 24–10).
• The right RLN normally recurs beneath the right subclavian artery;
the left RLN recurs beneath the aortic arch (Figure 24–11
A). Both
recurrent nerves ascend toward the larynx in the tracheoesophageal
groove.
♦
The left nerve ascends in a straight longitudinal direction parallel
to the lateral border of the trachea. The right nerve follows a short-
er course, approaching the larynx at a right angle, coursing medi-
ally as it ascends. Both nerves pass posterior to the thyroid lobes as
they approach the cricoid cartilage.
♦
A nonrecurrent right RLN can arise from the vagus nerve as a
direct medial branch in the neck in approximately 0.5 to 1% of
individuals (Figure 24–11
B). A nonrecurrent left RLN is rare, typ-
ically occurring only with transposition of the great vessels.
Figure 24–9 Retraction of the
sternocleidomastoid muscle for
carotid sheath exposure.
548 Surgical Atlas of Pediatric Otolaryngology
Thyroid mobilization
• Once the RLN is identified inferiorly, dissection proceeds cephalad. The
inferior and middle thyroid veins on the side of the lesion will need to
be ligated and divided for adequate gland mobilization (Figure 24–12).
• Ligating the main trunk of the inferior thyroid artery should be
avoided to preserve the blood supply to the parathyroid glands; small-
er medial branches of this artery may be ligated close to the capsule

of the thyroid.
• The superior pole of the thyroid lobe is mobilized next by transecting
the superior vascular pedicle (Figure 24–13).
1. Care must be taken during this portion of the procedure to avoid
damage to the external branch of the superior laryngeal nerve. This
nerve can sometimes be identified between the superior pole ves-
sels and the laryngeal structures.
2. If the plane of the superior pole dissection continues bluntly along
the presenting portion of the cricothyroid muscle, the likelihood
of superior laryngeal nerve (SLN) injury is small.
3. Ligation without clamping of the superior pole vessels further
decreases the likelihood of SLN injury.
Figure 24–12 Ligation and divi-
sion of the inferior and middle
thyroid veins. (Adapted from
Silver CE. Atlas of head and
neck surgery. New York:
Churchill Livingstone; 1986.
p. 265.)