Ebook An atlas of head and neck surgery (Vol II- 4/E): Part 1

John M. Lore, Jr., M.D.
Distinguished Member (Clinical Research) Medical Staff, Roswell Park Cancer Institute.
Professor Emeritus, School of Medicine, State University of New York at Buffalo.
Medical Director Emeritus, John M. Lore, Jr., Head and Neck Center, Sisters of Charity Hospital.
Former Head, Department of Otolaryngology-Head
and Neck Surgery, Sisters of Charity Hospital.
University Chief, Department of Otolaryngology,
Buffalo Children's Hospital and Erie County Medical Center.
Consultant, Veterans Administration
Medical Center
Consultant, Roswell Park Cancer Institute
Director of Surgery, Good Samaritan Hospital, Suffern, New York.

Jesus E. Medina, M.D.
University

Paul and Ruth Jonas Professor and Chair, Department of Otorhinolaryngology,
of Oklahoma Health Sciences Center College of Medicine, Oklahoma City, Oklahoma.

Illustrated by

Robert Wabnitz
Director Emeritus

of Medical Illustration,

University of Rochester
and

Medical Center, Rochester,

Margaret Pence
M.F.A. in Medical Illustration, Rochester Institute of Technology
Adjunct Professor, School of Fine Art, College of Imaging Arts and Sciences,
Rochester, New York.

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AN ATLAS OF HEAD AND NECK SURGERY, FOURTH EDITION
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NOTICE
Surgery is an ever-changing field. Standard safety precautions must be followed, but as new
research and clinical experience broaden our knowledge, changes in treatment and drug therapy
may become necessary or appropriate. Readers are advised to check the most current product infor-

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2


CONTRIBUTORS

AHMED ABDEHALlM, M.D.

ANGELA BONTEMPO,

Clinical Assistant Professor of Diagnostic Radiology,
State University of New York at Buffalo School
of Medicine and Biomedical Sciences;
Neuroradiologist,
Roswell Park Cancer Institute;
Neuroradiologist,
Women and Children's Hospital
of Buffalo (Kaleida Health System), Buffalo,
New York
Advanced Techniques for CT in the Head and Neck
(Chapter 1)

President and CEO, Saint Vincent Health System,
Erie, Pennsylvania
A Comprehensive, Interdisciplinary Head and Neck
Service (Chapter 3)

F.A.C.H.E.

DANIEL BRODERICK, M.D.
Assistant Professor of Radiology, Mayo Clinic,
Jacksonville, Florida
Bone Imaging and Pathology (Chapter 3)

RONALD A. ALBERICO, M.D.

DANiEl SETTE CAMARA, M.D.

Associate Professor of Radiology and Assistant
Clinical Professor of Neurosurgery, State University
of New York at Buffalo School of Medicine and
Biomedical Sciences; Director of Neuroradiology
and Head and Neck Imaging, Roswell Park Cancer
Institute; Director of Pediatric Neuroradiology,
Women and Children's Hospital of Buffalo
(Kaleida Health System), Buffalo, New York
Advanced Techniques for CT in the Head and Neck
(Chapter 1)

Clinical Associate Professor of Medicine,
State University of New York at Buffalo School
of Medicine and Biomedical Sciences;
Gastroenterology
Service, Sisters of Charity Hospital,
Buffalo, New York
Percutaneous Endoscopic Gastrostomy (Chapter 21)

JOSEPH M. ANAIN, M.D.
Assistant Clinical Professor, Otolaryngology,
State University of New York at Buffalo School
of Medicine and Biomedical Sciences; Chief,
Division of Vascular Surgery, Sisters of Charity
Hospital, Buffalo, New York
Vascular Procedures (Chapter 22)

DAVID M. CASEY, D.D.S., M.S.
Clinical Professor, Department of Restorative Dentistry,
State University of New York at Buffalo School
of Dental Medicine; Head, Maxillofacial Prosthetic
Section, John M. Lore, Jr., M.D. Head and Neck
Center, Sisters of Charity Hospital; Maxillofacial
Prosthodontist,
Department of Dentistry,
Maxillofacial Prosthetics, Roswell Park Cancer
Institute, Buffalo, New York
Dental and Prosthetic Considerations in Head and
Neck Surgery (Chapter 3); Maxillofacial Prostheses
(Chapter 3)

SHIRLEY A. ANAIN, M.D.
Assistant Clinical Professor, State University
of New York at Buffalo School of Medicine
and Biomedical Sciences, Buffalo, New York
Facial Paralysis (Chapter 7)

GREGORY J. CASTIGLIA, M.D.
Neurosurgeon,
Buffalo Neurosurgical Group, Amherst,
New York
Supraorbital Approach to the Orbit and Paranasal
Sinuses (Chapter 23)

JOHN E. ASIRWATHAM, M.D.
Clinical Associate Professor of Pathology,
State University of New York at Buffalo School

of Medicine and Biomedical Sciences;
Department of Pathology, Sisters of Charity
Hospital, Buffalo, New York
Bone Imaging and Pathology (Chapter 3); Pathology
of the Parathyroid Glands (Chapter 18)

v


CONTRIBUTORS

NIEVA B. CASTILLO, M.D.
Assistant Clinical Professor of Pathology,
State University of New York at Buffalo School
of Medicine and Biomedical Sciences; Associate
Chief of Pathology, Department of Pathology,
Sisters of Charity Hospital, Buffalo, New York
Malignant Mixed Tumor (Chapter 17); Endocrine
Surgery (Chapter 18); Vascular Procedures
(Chapter 22)
KANDALA CHARY, M.D.
Medical Oncology, Sisters of Charity Hospital,
Buffalo, New York
Preoperative Chemotherapy, Uncompromised Surgery,
and Selective Radiotherapy in the Management
of Advanced Squamous Cell Carcinoma of the
Head and Neck (Chapter 3)
SCOTT CHOLEWINSKI, M.D.
Director, Department of Magnetic Resonance Imaging,
Sisters of Charity Hospital, Buffalo, New York

CT and MRI (Chapter 1); Bone Imaging and Pathology
(Chapter 3)
KEITH F. CLARK, M.D., Ph.D.
Clinical Professor, Department of Otorhinolaryngology,
University of Oklahoma Health Sciences Center
College of Medicine, Oklahoma City, Oklahoma
Endoscopic Sinus Surgery (Chapter 5)
ERNESTO A. DIAZ-ORDAZ, M.D.
Assistant Professor of Otolaryngology and Assistant
Professor of Communicative
and Speech Disorders,
State University of New York at Buffalo School
of Medicine and Biomedical Sciences; Acting Chair,
Department of Otolaryngology, Sisters of Charity
Hospital, Buffalo, New York
Infratemporal Approach to the Skull Base (Chapter 23)
ROBERT W. DOLAN, M.D.
Surgeon, Department of Otolaryngology, Head and Neck
Surgery, Lahey Clinic, Burlington, Massachusetts
Microvascular Surgery (Chapter 24)
MEGAN FARRELL,M.D.
Endocrinologist, John M. Lore, Jr., M.D. Head and
Neck Center, Sisters of Charity Hospital, Buffalo,
New York
Endocrine Surgery (Chapter 18)

DAVID F. HAYES, M.D.
Assistant Clinical Professor of Radiology,
State University of New York at Buffalo School
of Medicine and Biomedical Sciences;

Chair, Department of Diagnostic Imaging,
Sisters of Charity Hospital, Buffalo, New York
CT and MRI (Chapter 1); Ultrasound (Chapter 1)
l. NELSON HOPKINS, M.D.
Chief of Neurosurgery, State University of New York
at Buffalo School of Medicine and Biomedical
Sciences, Buffalo, New York
Vascular Procedures (Chapter 22)
R. LEE JENNINGS, M.D.
Assistant Clinical Professor of Surgery,
University of Colorado Health Sciences Center
School of Medicine; Colorado Surgical Oncology
Associates, Denver, Colorado
Preoperative and Postoperative Care (Chapter 3)
CONSTANTINE P. KARAKOUSIS, M.D., PH.D.
Professor of Surgery, State University of New York
at Buffalo School of Medicine and Biomedical
Sciences; Millard Fillmore Hospital
(Kaleida Health System), Buffalo, New York
Malignant Melanoma (Chapter 3); Soft Tissue
Sarcoma (Chapter 3)
SOL KAUFMAN, Ph.D.
Research Assistant Professor of Otolaryngology,
State University of New York at Buffalo School
of Medicine and Biomedical Sciences; Consultant,
Biostatistics, Buffalo, New York
Preoperative Chemotherapy, Uncompromised Surgery,
and Selective Radiotherapy in the Management
of Advanced Squamous Cell Carcinoma of the
Head and Neck (Chapter 3)

DOUGLAS W. KLOTCH, M.D.
Surgeon in Private Practice, Tampa, Florida
Fractures of Facial Bones (Chapter 13)
ASHOK KOUL, M.D.
Clinical Assistant Professor of Pathology,
State University of New York at Buffalo School
of Medicine and Biomedical Sciences;
Director of Pathology and Laboratory Medicine,
Sisters of Charity Hospital, Buffalo, New York
Commonly Used Terminology for Squamous Epithelium
(Chapter 3)


CONTRIBUTORS

JOHN LAURIA, M.D.

DOUGLAS B. MORELAND, M.D.

Professor and Chair Emeritus, Department of
Anesthesiology, State University of New York
at Buffalo School of Medicine and Biomedical
Sciences and Sisters of Charity Hospital, Buffalo,
New York
Venous Air Embolism (Chapter 2); Malignant
Hyperthermia (Chapter 2)

Director, Buffalo Neurosurgery Group;
Chief of Neurosurgery, Sisters of Charity Hospital;
Co-Director, Gamma Knife Center,

Roswell Park Cancer Institute, Buffalo, New York
Endoscopic Endonasal Transsphenoidal Approach to
the Pituitary Gland (Chapter 23)

WILLIAM M. MORRIS, M.D.
KEUN Y. LEE, M.D.
Assistant Clinical Professor, Department of
Otolaryngology, State University of New York
at Buffalo School of Medicine and Biomedical
Sciences; Attending in Otolaryngology-Head
and
Neck Surgery, Sisters of Charity Hospital; Buffalo
Otolaryngology Group, Buffalo, New York
Posterior Neck Dissection (Chapter 16)

Buffalo, New York
Cardiopulmonary Resuscitation (Chapter2)

WILLIAM R. NElSON,

M.D.

Clinical Professor Emeritus of Surgery,
University of Colorado Health Sciences Center
School of Medicine, Denver, Colorado
Preoperative and Postoperative Care (Chapter 3)

JOHN S. LEWIS, M.D.

ROBERT J. PERRY, M.D.

Associate Clinical Professor Emeritus of Otolaryngology,
Columbia University College of Physicians and
Surgeons, New York, New York
Temporal Bone Resection (Chapter 23)

Clinical Associate Professor of Surgery (Plastic),
State University of New York at Buffalo School
of Medicine and Biomedical Sciences;
Chief, Division of Plastic Surgery, Women and
Children's Hospital of Buffalo (Kaleida Health
System), Buffalo, New York
Cleft Lip and Palate (Chapter 10)

THOM R. LOREE, M.D.
Chief, Department of Head and Neck Surgery,
Roswell Park Cancer Institute, Buffalo, New York
Management of Salivary Gland Tumors (Chapter 17)

JOACHIM PREIN, M.D., D.M.D.

Senior Vice President, Medical Affairs,
Sisters Healthcare System, Buffalo,
New York
A Comprehensive, Interdisciplinary Head and Neck
Service (Chapter 3)

Professor of Maxillofacial Surgery and Chair,
Clinic for Reconstructive Surgery,
Unit for Maxillofacial Surgery, University Clinics

of Basel; Chair, European Maxillofacial Education
Committee, Basel, Switzerland
Compression Plating for Ireatment of Mandibular
Fractures (Chapter 13)

JESUS E. MEDINA, M.D.

ALLEN M. RICHMOND,

Paul and Ruth Jonas Professor and Chair,
Department of Otorhinolaryngology,
University of Oklahoma Health Sciences Center
College of Medicine, Oklahoma City, Oklahoma
The Neck (Chapter 16)

Clinical Instructor, Department of Otolaryngology,
State University of New York at Buffalo School
of Medicine and Biomedical Sciences; John M. Lore,
Jr., M.D. Head and Neck Center, Sisters of Charity
Hospital; Staff, Buffalo Hearing and Speech Center,
Inc., Buffalo, New York
Voice, Speech, and Swallowing Rehabilitation of the
Head and Neck Patient (Chapter 3)

A. CHARLES MASSARO, M.D.

ROBERT S. MILETICH, M.D., Ph.D.
Associate Professor of Clinical Nuclear Medicine,
Department of Nuclear Medicine,
State University of New York at Buffalo School

of Medicine and Biomedical Sciences; Staff Physician,
Veterans Affairs Western New York Healthcare
System, Buffalo, New York; Staff Physician,
Dent Neurologic Institute, Amherst, New York
Positron Emission Tomography (Chapter 1)

PH.D.

ARTHUR J. SCHAEFER, M.D.t
Clinical Professor of Ophthalmology
and Clinical
Assistant Professor of Otolaryngology,
State University of New York at Buffalo School
of Medicine and Biomedical Sciences, Buffalo,
New York
Blindness and Ophthalmic Complications of Surgery
of the Head and Neck (Chapter 2)
t Deceased.


CONTRIBUTORS

DANIEL P. SCHAEFER, M.D.

MONICA B. SPAULDING,

Director of Oculoplastic, Facial, Orbital,
and Reconstructive Surgery; Clinical Professor
of Ophthalmology;
Clinical Assistant Professor

of Otolaryngology, State University of New York
at Buffalo School of Medicine and Biomedical
Sciences, Buffalo, New York
Blindness and Ophthalmic Complications of Surgery
of the Head and Neck (Chapter 2); Thyroid-Related
Orbitopathy (Chapter 3); Supraorbital Approach to
the Orbit and Paranasal Sinuses (Chapter 23)

Associate Professor of Medicine and Otolaryngology,
State University of New York at Buffalo School
of Medicine and Biomedical Sciences; Chief,
Oncology Section, Veterans Affairs Western
New York Healthcare System, Buffalo, New York
The Place for Chemotherapy in Management
of Squamous Cell Carcinoma of the Head and Neck
(Chapter 3)

DHIREN K. SHAH, M.D.
Medical Director, Cancer Treatment Services;
Assistant Clinical Professor, State University
of New York at Buffalo School of Medicine and
Biomedical Sciences, Buffalo, New York
Radiation Therapy for Laryngeal Cancer
(Chapter 20)

DONALD P. SHEDD, M.D.
Professor Emeritus, Department of Head and Neck
Surgery, Roswell Park Cancer Institute, Buffalo,
New York
Common Departures from Sound Management

(Chapter 3)

M.D.

MAUREEN SULLIVAN, D.D.S.
Chief, Department of Dentistry and Maxillofacial
Prosthetics, Roswell Park Cancer Institute,
Buffalo, New York
Osseointegrated Implants in Head and Neck
Reconstruction (Chapter 3)

NAN SUNDQUIST,

R.N.

Formerly Chief Nurse, Department of Otolaryngology,
State University of New YQrk at Buffalo School
of Medicine and Biomedical Sciences, Buffalo,
New York
Preoperative Chemotherapy, Uncompromised Surgery,
and Selective Radiotherapy in the Management
of Advanced Squamous Cell Carcinoma of the
Head and Neck (Chapter 3)


IN

MEMORIAM

Dr. John M. Lore, Jr., passed away on January 12,2004. He continued active medical

practice and cared for his patients until shortly before his death. Dr. Lore was world
renowned as a head and neck surgeon. After receiving his medical degree from New
YorkUniversity, he completed residencies in both otolaryngology and general surgery.
He was the Chairman of the Department of Otolaryngology-Head and Neck Surgery
at the State University of New York at Buffalo School of Medicine, 1966 to 1991. He
later joined the Department of Head and Neck Surgery at Roswell Park Cancer Institute.
Dr Lore was one of the founders of the American Society of Head and Neck Surgery.
He was a past president of that society as well as of the Society of Head and Neck
Surgeons. He contributed to the early efforts to combine the two Head and Neck
Societies. He was also a founding member, and former chairman of the Joint Council
for Advanced Training in Head and Neck Oncologic Surgery, which was instrumental
in establishing the fellowship programs in advanced Head and Neck Surgical Oncology,
accredited by the American Head and Neck Society. During his long and distinguished
career, Dr. Lore received many honors and awards recognizing his many contributions to the specialty of Head and Neck Oncology. He was passionate and tenacious
in the practice of his profession; he was an early pioneer and champion of the use
of adjuvant chemotherapy in the treatment of head and neck cancer.
Jack was equally passionate and tenacious in his many nonprofessional interests
and pursuits. He was an avid and accomplished skier, sailor, and photographer.
Professionally, his most enduring and cherished attribute was his compassion and
his dedication to his patients. When I first met Dr. Lore, he was one of the leading
members of our specialty. I then became one of his collaborators and colleagues.
Eventually, 1 came to know Jack as my friend. He will be greatly missed. An Atlas
of Head and Neck Surgery, 4th edition, serves as a legacy and tribute to his memory.
Thom R. Loree, M.D.

IX


Recognition by
The Board of Managers of St. Vincent's Hospital, New York,

New York, at the time of his death.


To My FATHER
JOHN M. LORE, M.D., F.A.C.S.

1892-1950
whose energy and devotion both in his chosen field in medicine-otolaryngologyand in his dedicated aim in medical education-a new medical center for his
medical school, New York University-were and still are an inspiration.
His desire for cooperation in and plans for a consolidated surgical training program
in the field of head and neck surgery provided the impetus for this Atlas.

Dr Lore, Sr. was born in Caleane, Sicily, and came to the United States of
America at age 5. He was a naturalized citizen of the United States and served in
World War I as an officer in the United States Navy.

XI



PREFACE

Over 40 years have passed since the publication of the
first edition of An Atlas of Head and Neck Surgery,
including three English editions and one Spanish
edition. This Fourth Edition has further broadened its
background-an
increased scope of each chapter with
an additional number of contributors.
Jesus E. Medina, M.D., is welcomed as an associate

editor to this Fourth Edition. He has been instrumental
in a number of facets, namely in obtaining Robert W.
Dolan, M.D., Department of Otolaryngology, Head and
Neck Surgery, Lahey Clinic, to author the new chapter
on Microvascular Surgery, and Keith F. Clark, M.D.,
Ph.D., for the addition of Endoscopic Sinus Surgery to
Chapter 5. Dr. Medina also has contributed to a number
of other areas.
The additions, it is believed, cover items that hit the
highlights of a number of aspects of head and neck
surgery, which are available to the surgeon as up-tothe-minute help. It is not a cookbook of surgery, however. This could be an inherent danger in an atlas. The
surgeon must be experienced with the various procedures and modifications thereof. No dabblers.! The
choice of the surgical procedure must not be based on
the easiest and quickest minimum resection but rather
must be aggressive'> There is a danger of preserving
soft tissue and bone with disease-free minimum margins
and even no margins.
Reference is made to Dr. Murray F. Brennan's presidential address to the Society of Surgical Oncologists
in 1996.3 There should be no such attitude as "leave
disease right up to the line of resection." It appears that
widespread use of radiotherapy as a routine postoperative modality is fraught with the misconception for
the surgeon that if a little tumor is left behind it is
really no worry since routine radiotherapy is the catchall. Margins in this methodology mean little since ionizing radiation will handle all that the surgeon neglects.
Radiotherapy, as well as chemotherapy, plays an important part in the management of head and neck squamous cell carcinoma, Stage III and Stage IV, but is not
meant to give a false sense of security to the surgeon.
Hence, it is believed that radiotherapy should not be
routinely used postoperatively but rather selectively. This
spares the patient of the side effects of radiotherapy, as
well as making radiotherapy available during the entire

follow-up period if indicated. With the use of chemotherapy, the surgeon must not compromise the scope of
surgical resection when there is a favorable response to
the chemotherapy. Please confer preoperative chemotherapy in Chapter 3.
As more tissue and bone are removed, the reconstructive measures must be further improved and expanded
from a cosmetic and a functional point. A caveat that
must be emphasized is that wherever possible or practical the reconstructive measures should not mask early
or late recurrence of disease. At times this is not possible.
As an expansion of the reference to microvascular
surgery in the preface of the Third Edition, a new
Chapter 24 has been added. The indication for microvascular surgery has broadened and has served well in
a number of reconstructive problems, especially free skin
flaps for major skin defects of the cheek, as well as muscle
and bone transfers. This new chapter by Dr. Dolan serves
two purposes: (1) to demonstrate to the head and neck
oncologic surgeon what can be achieved by microvascular surgery and (2) to present the techniques involved.
These techniques are not for the dabblers-only
for
experienced microvascular surgeons.
Take time to evaluate and record the extent of disease
utilizing tattoo, when possible, prior to any management plan. Do not depend on the site evaluation at the
time of the initial surgical procedure. This admonition
is an absolute with the use of preoperative chemotherapy
or, for that matter, radiotherapy, especially if salvage
surgery becomes necessary following any recurrence
after the radiotherapy.
Regular careful and thorough follow-up of patients
must be carried out to the best possible degree. Followup must be done by the surgeon and by those expert in
the field of head and neck examination and knowledge
of the natural history of the disease. The primary responsibility is the surgeon's and not the primary care physician's. Keep records, which will be valuable as an evaluation of outcome-not only the physical examination,
but also the quality of life. When evaluating the quality

of life, take into account the family support or lack
of support.
It may be worthwhile at different times to have
different physicians in other allied disciplines involved
in the search for early recurrence. For example, the
XIII


PREFACE

reconstructive surgeon, the prosthodontist, the radiation oncologist and the medical oncologist, and the
specially trained nurse clinicians all should be involved
in evaluation. This approach is time consuming both
for the medical professionals as well as the patient,
and sometimes it's shattering for the HMOs. These
follow-up examinations should be based on a regular
schedule-usually one time per month for the first year
and then every two months for the second year and so
on up to five years. They continue every 5 to 6 months,
as enumerated later. There is some indication or recurrence following preoperative chemotherapy. New primaries may appear between the seventh and the tenth
year. Follow-up should not be more than every 5 to
6 months; sooner if there appears to be a predisposing
factor to squamous cell carcinoma.
Follow-up is for life. A patient who continues to smoke
or who has an indication of field carcinogenesis is an
example. Frequencies may be increased or decreased,
depending on the anticipated natural history of the
disease. This is time consuming yet most important.
Review all images-not just reports. CT, MRl, MRA,
angiograms, and PET scans, when appropriate, must

be reviewed by the surgeon. It is not unusual to spend
upwards of one hour in this type of preoperative evaluation. Postoperative examination, especially long-term,
likewise involves considerable time and effort. This is
another problem for those from the HMOs to comprehend even though they may be physician consultants.
One HMO recognized this "unique specialty practice"
involving training in both otolaryngology and general
surgery. All this is a significant and tremendous responsibility for the surgeon and all those concerned.
In the Preface of the Third Edition, the concept of
centers of excellence was introduced in the management of neoplasms of the head and neck. In 1993, this
concept was initiated at Sisters of Charity Hospital in
Buffalo, NY. The following is a description of such a
center. It has flourished well and its weekly tumor
conferences with surgery, medical oncology, radiation
oncology, and endocrinology, as well as with its specialized nurses and support personnel, has attracted local
physicians from other hospitals in the Buffalo area. Since
its inception, it has trained fellows with backgrounds
in otolaryngology, general surgery, and plastic surgery.
The center supports the concept of excellence in patient
care plus the important addition of academia and ecumenism. The academia in itself is desirable, and when
joined in a single service including all of the disciplines
involved becomes a sine qua non in the management
of head and neck neoplasms, including thyroid diseases.
A dedicated interest in academia produces interest
in newer concepts-for
example, molecular biology
with gene therapy-which
may well become the basis
of future treatment of head and neck squamous cell
carcinoma.

Description of Head and Neck Services
at Sisters Hospital4
Over the years, management of neoplastic disease as well
as other diseases has crossed time-honored established
disciplines. In head and neck neoplasia, including thyroid malignancy; surgical, medical, and radiation oncology; and endocrinology, other supportive disciplines
and services are involved. The input from these disciplines is usually achieved by multidisciplinary conferences. To further develop this ecumenical approach, to
avoid "turf battles," and to further enhance cooperative
and close exchange of ideas regarding diagnosis and
management of head and neck neoplasia, a Head and
Neck Oncology Service within the John M. Lore, Jr.,
M.D., Head and Neck Center at Sisters Hospital, Buffalo,
NY, was established 8 years ago. This service encompasses the aforementioned disciplines plus all other
germane disciplines and services, including General
Otolaryngology, Reconstructive Surgery, Vascular Surgery, Microvascular Surgery, Neuro-otology, Skull Base
Surgery, Oncologic Ophthalmology, Diagnostic Imaging, Head and Neck Pathology, Nuclear Medicine,
Psychiatry, Maxillofacial Prosthetics, Dental Pathology,
Swallowing and Speech Pathology, Nutrition and
Biostatistics.
The main purpose is to render the best possible
patient care, to attract the best qualified physicians and
other professionals (thus sifting out the dabblers), and
to promote an academic atmosphere. This oncology
service functions as an autonomous service with the
cooperation and support of the Chairman of the Department of Surgery and the Chairman of the Department
of Internal Medicine. The Service is responsible for
its own quality review data, which is supplied to the
Quality Review hospital committee. Outpatient; inpatient; speech and swallowing professionals with laboratory staff, physicians, fellows, and nurse clinicians;
as well as oncologic dentistry, conference rooms, library
and nutritional offices are all contiguous and on the
same floor of the hospital.

On the same floor is the Pathology Department and
up one flight are the OR and ICU. Down one flight is
Diagnostic Imaging and Nuclear Medicine. On another
floor is the Microsurgical Laboratory.
It appears that this approach to head and neck neoplasia, including thyroid and parathyroid tumors, truly
improves patient care without the stigma of "treatment
by committee." We may agree or disagree yet each individual is free to treat the patient as he or she sees fit.
This type of service avoids the wasted time involved in
turf conflicts. The Head and Neck Oncology Service is
a complete system where the sum of all the components
is much better for patient care than any independent
part. At the very beginning of this project was and still
is Robert E. Rich, the founder of Rich Products, who


PREFACE

gave me the impetus to go ahead with this idea. He
produced the wherewithal to start basically a "onestep" facility, which minimizes "wasted time" in the
diagnosis and management of head and neck neoplastic disease.
There are four team players who helped in the inauguration of this multiple discipline service: Kenneth
Eckhert, M.D., Chief of Surgery; Nelson Torre, M.D.,
Chief of Medicine; Sister Angela Bontempo, Administrator at Sisters of Charity Hospital; and Charles Massaro,
M.D., Vice President of Medical Affairs at Sisters of
Charity Hospital. Without the cooperation of these individuals this service could never have been developed.
It had previously been proposed when I was Chairman
of the Department of Otolaryngology at the State
University of New York at Buffalo to the dean, and
twice he turned this concept down saying, "We are not
ready for anything like that just yet." Hence, the medical

school was bypassed in this endeavor.
The amalgamation of the Society of Head and Neck
Surgeons, founded by Hayes Martin and Grant Ward
in 1954, and the American Society for Head and Neck
Surgeons, established in 1958 by the hard work of George
Sisson, M.D., along with other dedicated head and neck
surgeons, was a great step forward. Among the other
dedicated surgeons as founders of the American Society
for Head and Neck Surgery was Edwin W Cocke, M.D.,
John S. Lewis, M.D., W. Franklin Keim, M.D., William
M. Trible, M.D., and John M. Lore, Jr., M.D. This amalgamation in 1999 united the two societies into one
society, now known as The American Head and Neck
Society. This joined the disciplines of otolaryngology,
general surgery, and plastic surgery into one endeavor.
There are many benefits to this amalgamation, not the
least of which, of course, is improvement of patient
care by the sharing of various ideas among the various
disciplines all present at the same meeting.
The main downside as I see it is the fact that the
larger the society is, the less discussion there is from
the floor and membership. I would strongly suggest
that adequate time be allowed in meetings for this type
of discussion, because this enhances the exchange of
different ideas and different methodologies of treatment.
There is an interesting and laudable result of this
amalgamation in that it should and will eliminate the
striving of one society to have more members than the
other. This inherent danger, which previously existed,
should be eliminated once and for all. This attempt at
getting more members led to the admission of surgeons

regardless of background who were not fully qualified
in the field of head and neck oncology. There is no need
for an unlimited supply of head and neck surgeons
since, to quote from the Third Edition, "There are only
about 50,000 new patients each year with head and neck
cancer, and only approximately 35 to 75 new, well-trained
head and neck oncologic surgeons are necessary each

year to maintain an adequate workforce of some 400
to 1,000 head and neck oncologic surgeons to manage
this number of patients. Thus, we must minimize the
number of 'dabblers.'] There is simply no reason to
accept physicians who are not well-trained in this field.
Quality and not quantity is the objective.
There is no doubt that, except in the rare case, the
residents interested in this field must be dedicated to it
and spend extra time in a fellowship, preferably approved
by the American Head and Neck Society. This would
help them reach near perfection in their chosen field as
best as possible. This concept in medicine has been
useful in the training of hand surgeons, since it involves
the disciplines of general surgery, orthopedic surgery,
and plastic surgery. In hand surgery, this has been recognized by the three boards as an important facet in the
training of a hand surgeon. Unfortunately, in head and
neck surgery, the three boards involved, namely, otolaryngology, general surgery, and plastic surgery, have not
seen fit to endorse this concept. Unless the individual
is a genius, there is simply no way to adequately train a
resident in the various facets of head and neck oncology
and endocrinology in a residency training program,
since the training in that particular specialty involves a

number of other aspects over and above head and neck
oncology. As Harvey Baker, M.A.,s discussed in his
presidential address to the Society of Head and Neck
Surgeons entitled Head and Neck Surgery: The Pursuit
of Excellence in 1971 and pointed out that to be active,
for example in general otolaryngology, simply does
not afford the time and effort needed to become a welltrained and practicing and active head and neck oncologic surgeon.
Logical conclusion to these standards is the active
participation in one of the approved fellowships. Having
been the originator of this additional fellowship training plus having the position of president of both head
and neck societies, I have had, and I say this with
humility, experience in the endeavor. Changes in the
fellowship curriculum were made from time to time
and rightly so. The latest one of admitting graduates of
well-trained foreign programs is strongly commended.
Remember, American surgeons at the time of the late
1800s and early 1900s were afforded the benefits of
learning from their European counterparts. We have
the same obligation and advantage today to share all
our ideas and techniques with our European colleagues.
We learn from one another.
Some flexibility is worthy of implementation, namely,
possibly one or two types of fellowships. The one-year
fellowship would primarily focus on the clinical aspects
of head and neck oncology but would also include a
reasonable amount of clinical research. The two-year
fellowship would involve basic research along with
clinical exposure in a suitable institution where the
candidate's desires can be realized. Selected arrange-

PREFACE

ments for rotation of fellows from one parent institution to one or two other institutions-for one monthwould afford the fellow an excellent exposure to other
methodologies in the overall management of head and
neck neoplasia.
Again, it is my strong admonition that two years
of basic surgical training in an approved general surgical training program is highly recommended for those
who wish to pursue a head and neck oncologic fellowship. The exposure to basic surgical principles cannot
be achieved, I believe, in a single discipline-oriented
program. I can attest to this again by personal experience, having completed the approved residency in the
American Board of Otolaryngology and the American
Board of Surgery. I am not inferring that double boards
are necessary. But otolaryngology residents would certainly benefit from two years of general surgery. The
reverse, namely, dedicated training in otolaryngology,
is also true for the general surgery and plastic surgery
residents. Ideally, another year of plastic surgery would
be fortuitous.
The next step in the joint venture of all three disciplines, namely, general surgery, otolaryngology, and
plastic surgery, would be the recognition by the three
boards concerned relative to an approval of this fellowship. To attempt to achieve this objective, plans were
modeled after the three boards of general surgery, plastic
surgery, and orthopedic surgery, agreeing on a postresidency hand training program. Dr. George Omer,
from Albuquerque, New Mexico, was the driving force
in this venture. It appears that they have succeeded
with the cooperation of the three boards recognizing an
acceptable fellowship in hand surgery.
Following this concept that was developed in hand
surgery, an attempt was made to achieve the same type
of recognition by the three boards involved in training

of head and neck oncologic surgeons. The initial datagathering trip was made by Dr. William Nelson and me
going to Albuquerque to review with Dr. George Omer
how he achieved the cooperation of the three boards.
Following his ideas, Dr. Elliott Strong and I developed
a similar concept for the recognition of head and neck
oncologic surgery by the American Boards of Otolaryngology, Surgery, and Plastic Surgery as "added qualifications." Unfortunately, we failed despite our efforts at
the board level and at the American College of Surgeons
level and it was then that we simply gave up the
endeavor. I decided then to take the next step and that
was to develop a center of excellence in our particular
field and, hence, the development of the Head and Neck
Oncologic Service at Sisters of Charity Hospital.
Another aspect that is most important in the development of our field is the realization that we are a profession and not a business. This is aptly referred to in
Dr. Robert M. Beyers's presidential address to the Society
of Head and Neck Surgeons in 1996 entitled, Barberpoles,

and Wounds that Will Not Heal.6 I quote
him as follows: "If we act like a trade or business rather
than a profession, we shouldn't complain about words
used to describe us such as healthcare providers and
our patients as clients." Dr. Beyers goes on to quote
Simon H. Rifkind, a lawyer, who expressed his views
about how a profession loses its professionalism. It is
recommended that Dr. Beyers's presidential address be
read in its entirety.

Battlefields,

And Now a Few Caveats
Insecurity is the main stumbling block for a joint venture.

For management with the best overall survival for
advanced squamous cell carcinoma of the head and
neck, aggressive surgery is the mainstay.2 Radiation
Oncology and Medical Oncology are ancillary and
required fine-tuning. Molecular Biology may alter this
sequence in years ahead.
For organ preservation in advanced squamous cell
carcinoma of the head and neck, chemotherapy and
radiotherapy are the primary modalities with salvage
surgery for failures and backup. Patients must be aware
of the complications and effect on survival and quality
of life, specifically the significant complications of salvage surgery. These complications were experienced
some 40 to 50 years ago when radiation was the first
treatment modality followed by surgery. Because of
these complications, the sequence of treatment was
changed to surgery followed by radiotherapy.
Physicians must be the real leaders in medicine.
Unfortunately, from time to time, physicians have abrogated this responsibility and opportunity. Do not admit
physicians into the American Head and Neck Society
who are not adequately and completely trained. Quality
and not quantity is the objective. Our prime objective
is the best of care, the highest quality for patients, regardless of the pressures of paperwork and other limitations
by insurance companies and government. Closely related
to the prime objective is evaluation of each and every
service's end results, performance data, and quality of
life- "evaluate your track record." Just because a procedure can be done, that is not the reason to do it.
Develop the atmosphere of academia, which stimulates
intellectual curiosity and improves quality of patient
care.
Randomization-Is

this always necessary? Does it
make any and every presentation valid? Review the pros
and cons of randomized study techniques when you
report your end results.8 (Suggest review of this reference by Drs. Fung and Lore.)
There are shadows that surround us. Namely, the
insurance companies, the paperwork, and the loss of
valuable time in the encountering and fighting of these
obstacles. In any event, we must not be complacent
and discouraged. We must not lose the main objective


PREFACE

of our calling in life. We must not be dabblers. I We
must assume our responsibilities.? We must return to
the philosophy of the founding fathers of our country
and Constitution when they saw fit to engrave on our
coins In God We Trust.
Recommendations
It is recommended that the head and neck surgeon,
especially the younger ones who are not aware of the
background of this entire field, review a number of
excellent resumes and books. They are as follows:
The Head and Neck Story, by George A. Sisson, M.D.,
1983, published by the American Society for Head
and Neck Surgery, produced by Kascot Media,
Chicago, IL.
The Making of a Specialty, Hayes Martin Lecture, by
Jatin P. Shah, M.D., American Journal of Surgery,
Vol. 176, Nov. 1998, pp 398-403.

History of Head and Neck Surgery,by Jerome C. Goldstein,
M.D., and George A. Sisson, M.D., Otolaryngology
Head and Neck Surgery, Vol. 1, US, #5, 1996.

Donald P. Shedd, Historical Landmarks in Head and
Neck Cancer Surgery, 2000, American Head and
Neck. Society.
REFERENCES
1. Lore, JM, Jr: Dabbling in head and neck oncology (a plea for
added qualifications). Arch Otolaryngology Head Neck Surg 1987;
113:1165-1168
2. Forastiere, A, Koch, W, Trotti, A, Sidransky, D: Head and neck
cancer. N Engl J Med 2001; 345:1890-1900.
3. Brennan. MF: The enigma of local recurrence. Ann Surg Oncol
1997; 4:1-12.
4. Lore, JM, Jr., Massaro, M: Description of Head and Neck Services
at Sisters Hospital Abstract submitted.
5. Baker, HW: Head and neck surgery: The pursuit of excellence. Am
J Surg 1971; 122:433-436.
6. Beyers. RM: Barber poles. battlefields and wounds that will not
heal. Am J Surg 1996; 172:613-617.
7. Lore. JM, Jr: Bill of responsibility. The Hayes Martin Lecture. Am
J Surg 1992; 164:556-562.
8. Fung E, Lore, JM, Jr: Randomized control studies for evaluating
surgical questions. Accepted for publication Arch Otolaryngol In
press.



ACKNOWLEDGEMENTS

First, I wish to once again thank my wife, Chalis, for all
the ancillary work she did as well as her quiet support
despite the mess of "paper" that I managed to disperse
throughout our home during these more than five years
of work on this Fourth Edition.
Shortly after deciding to go ahead with the Fourth
Edition, Robert Wabnitz, our master illustrator, suffered
a stroke, which to everyone, especially his wife, Sue,
was a terrible shock. He could no longer continue on
with this venture. Fortunately, he had taught medical
illustration at the University of Rochester Medical Center.
Margaret Pence, one of his students, took over for Robert.
She uses the same style that her teacher taught her, and
she has done an excellent and professional job. Not only
for her expertise as an illustrator are we all grateful, but
also her pleasant cooperation in anything and everything we asked of her in her chosen field. She is a
superb Medical Illustrator.
I wish to also thank Jesus E. Medina, our associate
editor, and all of our contributors-in
the previous
editions and in this edition-for
their time, interest,
and expertise. They are all detailed in the list of contributors. Many, many thanks. The extent of their contributions is noted in the various chapters. These included
contributions for an entire chapter, for example, Chapter
24, to major portions, inserts, and commentaries.
To a very grateful patient, supporter, and sponsor of
the John M. Lore, Jr., M.D., Head and Neck Center at
Sisters Hospital-Robert
E. Rich. He recognized

the
importance of an ecumenical approach in the development of a medical and surgical service to achieve quality
of patient care. The center is a byproduct of this atlas,
and I am deeply appreciative of Bob's involvement and
support.
The next expression of gratitude goes to the two
transcriptionists:
Lauri L. Hess, of Dr. Medina's office,
who, in dedicated
fashion, transcribed
my illegible
inserts onto the disks, and Leslie Berry, a freelance
transcriber
par excellence, who, under considerable
pressure, completed the final draft. Dottie Kane, who
did most of the transcribing for the Third Edition, helped
us with initial note-taking relative to this Edition of An

Atlas of Head and Neck Surgery.

Other acknowledgements
go to the staff of our Head
and Neck Service at Sisters of Charity Hospital in Buffalo,
NY: Karen Stawiasz, MS, RN, NP, OCN (Oncology
Certified Nurse), an incredible person who is Jill-of-alltrades and master of all and, specifically, our Oncology
Clinical Nurse Specialist and Nurse Practitioner. To all
our specially trained head nurses, who tolerated my
idiosyncrasies during this protracted period, to complete
this edition: Joyce Clemons, our patient coordinator,
Jennifer Feltz, Maureen Heatley and Nancy Wojtulski,

Kathleen Killion, RN, OCN, Tracy Trifilo, RN, Jean
Errington, RN, Elizabeth Gryzybowski, RN, and James
Sped ding, a key helper and patient. Thanks to Barbara
Lowe, MS, RD, our nutritionist. Thanks goes to a number of other transcribers: Becky Lonczak, Sandra Ochs,
and Linda Eick. To the office secretaries and administrative assistants over the years, I'm indebted to Dottie,
and Linda Runfola. My deepest appreciation
goes to
Sharon Eagles who bridged the gap from one Hospital
to another, Sisters of Charity Hospital to Roswell Park
Cancer Institute.
Many thanks to Elsevier Saunders,
especially to
Rebecca Schmidt Gaertner, Stephanie Smith-Donley,
Christian Elton, and Arlene Chappelle, who were of
exceptional help in manuscript review, as well as all
the previous medical editors and associates, for without them this publication
could not have existed.
Among these are John Dusseau, Robert Rowan, and
Sam Mink.
My condolences to the families of William Bukowski
and Paul Milley-both
contributors
who have passed
away since the Third Edition. Their contributions were
valued. Bill was my personal primary care physician.
Paul was an excellent head and neck pathologist.
(I
remember when he examined 137 sections of a thyroid
gland for the primary tumor in a patient who had an
incidental finding of metastatic papillary carcinoma of

the thyroid in a radical neck dissection, which was
done for squamous cell carcinoma.)
Many thanks to all and to all Ave atque Vale.
JOHN M. LORE,JR.

XIX



PREFACE
TO THE THIRD EDITION

Twenty-six years have elapsed since the first edition of
this atlas, and 15 years since the second edition. This
third edition has in some respects departed from the
original concept of being simply an atlas. It contains
much more information, with background material in a
number of subjects, such as endocrine surgery of the
head and neck and chemotherapy. This background
material is most important if the surgeon is not to be
relegated to the position of being solely a technician,
which, sad to say, is occurring in a number of surgical
disciplines. This is not to say that diagnosis and management of problems such as endocrine diseases involving
the head and neck are to be performed solely and independently by the head and neck surgeon. The endocrinologist, specialists in nuclear medicine, and imaging
and surgical pathologists are all necessary, integral members of the management team. It does mean, however,
that the surgeon operating on, for example, the thyroid
gland and parathyroid glands must have more than just
a superficial knowledge of these endocrine organs.
The third edition has been expanded in a number of
facets. The number of chapters has been increased

from 21 to 23 with the addition and further clarification
of Emergency Procedures (Chapter 2) and Base of the
Skull Surgery (Chapter 23). Although both these new
chapters include some procedures that were covered in
the previous editions, this material has now been significantly revised and relegated to these two new chapters.
Virtually every chapter has been enlarged with new
and other time-proven procedures, encompassing additional text and plates. The reader has simply to refer
to the table of contents to see the increased amount
of material. To emphasize these additions, examples
include the following: expanded listing of complications
following most procedures along with air embolism and
blindness and pitfalls; adjuvant chemotherapy; carbon
dioxide laser surgery; myocutaneous and myomucosal
flaps; updated management of cleft lip and palate;
compression plates in the management of facial fractures; various types of neck dissections and their applications; expansion of thyroid and parathyroid surgery;
rehabilitation following laryngectomy; expansion of
various reconstructive procedures related to the pharynx
and esophagus; and updated vascular procedures and

tissue expanders that lead to interesting possibilities for
reconstruction. The number of contributors has also
increased.
The anatomic sectional x-ray plates in Chapter 1 have
been related to the newer techniques of imaging. These
reproductions can be of great aid in the correlation
with both CT scans and MRI.
The comments in the preface of the previous editions
are still valid for the most part. Progress has been made
in the training of head and neck oncologic surgeons by
the formation by the American Society for Head and

Neck Surgery and the Society of Head and Neck
Surgeons of a Joint Council for Approval of Advanced
Training in Head and Neck Oncologic Surgery. This was
accomplished during 1976 to 1977 with the result being
the formation of a carefully structured fellowship following the completion of a residency in otolaryngology,
general surgery, or plastic surgery. This fellowship is the
only one of its kind in head and neck surgery having a
carefully structured evaluation system, site visits, and
review by the executive councils of both head and neck
surgical societies. A diploma is awarded by these two
societies to those candidates who follow the rigid criteria
and successfully complete the fellowship. The fellowship encompasses three phases: Phase [-basic surgical
training involving 1 or 2 years; Phase II-residency in
one of the aforementioned disciplines; and Phase [[[the fellowship portion of 1 or 2 yeats. Details of this
fellowship have been previously reported (Lore, J.M.,
Jr.: Head and neck oncologic training: Where we have
been and where we are going. Am. J. Surg. 142:504-505,
1981). Sixteen programs are now approved for this type
of training-IS in the United States and one in Canada.
The term head and neck oncology might be the better
term applied to this fellowship, since it involves not
only surgical training but also a knowledge of radiotherapy, chemotherapy, and, where applicable, the future
of immunotherapy. This facet of head and neck oncology is only one of five categories involved in head and
neck surgery, with the others being congenitallesions,
cosmetic surgery, and infectious disease. Likewise
involved in head and neck surgery is reconstructive
surgery, which relates to both head and neck oncologic
surgery and cosmetic surgery.

xxi

PREFACETO THE THIRD EDITION

Head and Neck Oncologic Surgery
The concept of regional surgery appears to be well
established. Stumbling blocks still remain, one of them
being the cliche "fragmentation" of the parent disciplines. Interestingly enough, it all depends on one's
biases as to whether the changes of a specific aspect of
a major discipline are termed "fragmentation" or "specialization." Regardless, it is the marketplace that sets
the pace-specifically, the number of patients available.
To borrow the words of James Humphreys, M.D., "surgery was fragmented when the surgeon left the barber
shop." The bottom line, however, is the search for
excellence in patient care and physician training. These
two aspects must not be compromised.
The thrust of head and neck oncologic surgery is a
cooperative and joint venture encompassing all disciplines that can and should contribute to this endeavor.
The initial step has been made with the two head and
neck surgical societies setting up the guidelines, site
evaluations, approval, and awarding of a diploma. The
next step is the formal implementation and recognition
of these postresidency fellowships by the residency review
committees and the specialty boards involved, an examination, and board recognition. Currently, it appears that
this recognition could be achieved by "added qualifications" in head and neck oncology by the boards. These
"added qualifications" could then be affixed to the existing certificate of each board. It is hoped that this would
be accomplished by the three boards jointly agreeing
on the same guidelines and examination. An excellent
example of this type of joint venture is the solution of
education in hand surgery, which has been worked out
by the two hand societies and the three boards of orthopedics, general surgery, and plastic surgery. George

Omer, after many years of dedicated work developing
articles of agreement, is to be congratulated on its fruition.
I hope that a similar modus operandi will be achieved
in head and neck oncology.
To date, this concept of added qualifications has
been stalled by the concern of the three boards and the
three residency review committees as well as a number
of practicing surgeons in the three disciplines. Their
fears surround the worry of fragmentation of their
disciplines as well as the misgivings that such added
qualifications will lead to "a special club" of head and
neck oncologic surgeons and thus restrict their practice. It must be remembered that there are only about
50,000 new patients each year with head and neck
cancer and that only approximately 35 to 75 new welltrained head and neck oncologic surgeons are necessary each year to maintain an adequate work force of
some 400 to 1000 head and neck oncologic surgeons to
manage this number of patients. Thus, we must minimize the number of "dabblers." No one who requires
coronary artery bypass surgery would seek treatment

by a surgeon and team who perform only a few such
procedures a year. We as surgeons must seek the solution, rather than have nonmedical forces outline the
solution for us. Yet with all this protectionism, general
surgery has in fact been fragmented. Otolaryngologists
are going down the same course with the fear of fragmentation. Hence, it appears that this concern only
enhances fragmentation rather than alleviating it. The
basic problem is that the profession of medicine and
its physicians and specialty societies react to obvious
changes that are in the making, rather than acting.
Physicians must be the leaders in this change, rather
than the followers. They must shape these changes,
since they are the ones who know the problem and can

best suggest and initiate the changes best suited to
excellency in patient care and physician training.
Unless this is achieved, a number of legitimate concerns that exist will become aggravated. Following is
a list of such concerns (from Lore, J.M., Jr.: Issues in
community hospital or cancer center care of head and
neck cancer patients. In Myers, E. N., Barofsky, I., and
Yates, J. W. [eds.]: Rehabilitation and Treatment of Head
and Neck Cancer. Washington, D.C., U.S. Department
of Health and Human Services, Public Health Service,
National Institutes of Health [NIH Publication No.
86-2762], 1986, pp. 155-165).

1. The occasional patient manager or "dabbler."
2. Loss of expertise and proficiency for even the welltrained physician.
3. Marginal and then inadequate treatment for head
and neck cancer patients.
4. Loss of concentration of training clinical material.
5. Loss of any significant number of patients for evaluation as to treatment methods, old and new.
6. Increased morbidity, mortality, and cost of medical
care.
To achieve the solution to these problems, it appears
that the three boards and the three residency review
committees should pursue the concept of added qualifications and recognize the additional training beyond
the residency years so necessary to achieve the desired
excellency. In other words, support the fellowship concept and officially recognize the fellowship concept.
To aid in the solution to these problems in a recognized manner, several additional steps are suggested.
Training

1. The American Board of Surgery should develop recognized training in basic surgery that might encompass 2 years, with examination and certification for
the trainee.

2. The trainee then completes the standard residency
in general surgery, otolaryngology, or plastic surgery.


PREFACETO THE THIRD EDITION

3. The trainee enrolls in a fellowship approved by the
three boards. An alternate route could be a similarly
approved preceptorship.
Centers of Excellence

Centers of excellence in head and neck oncology can
either be achieved in a university or community hospital
center with adequate patient load, professional personnel, and support staff. The interested reader is referred
to the aforementioned NIH publication as well as the
author's Presidential Address at the annual meeting
of the American Society for Head and Neck Surgery
(Dabbling in head and neck oncology-A plea for
added qualifications. Arch. Otolaryngol. 113:1165-1168,
1987).

Controversial

Items

There are a number of controversial items quite apart
from the preceding that this author wishes to enumerate.
Correct and Exact Terminology

In the evaluation of statistics relative to survival with

or without disease, a distinction should be made at the
onset of treatment as to whether a patient is "operable"
and whether the lesion is "resectable" for cure or
palliation. Operability refers to whether the patient can
safely undergo a major surgical procedure, whereas
resectability refers to whether a neoplasm can in fact
be totally removed by the surgeon. Nonresectability
distinctly implies advanced disease and actually further
implies a stage beyond stage IV, namely a stage V
disease. This concept has been previously suggested in
a publication entitled Head and Neck Cancer; Proceedings of the First International Conference, The Society
of Head and Neck Surgeons (Chretien et aI., St. Louis,
C.V. Mosby, 1985, p. 434).
Another point of contention are the words partial,
subtotal, near total, and total in regard to the various
surgical procedures, especially thyroidectomy. Granted,
there are fine lines that separate these terms and defy
total exactness, but regardless a more accurate designation of the surgical procedure is warranted as well as a
close adherence to the exact implication of these terms.
The same goes for the terms referring to the various
types of neck dissections, e.g., radical neck dissection,
classical neck dissection, modified radical neck dissection, functional neck dissection, and conservation neck
dissection.
Indications for Surgical Procedure

As for indications for surgery, my bone of contention is
a fundamental philosophical and, for that matter,

practical problem, which can best be summarized as
follows: Just because a procedure can be technically

performed, that is not the indication to perform the
procedure. Advances in medicine and surgery require
the development and trial elfnew procedures. Nevertheless, these trials must be tempered to a certain degree
by past as well as present experience. Again, there
is the "gray zone." Specifically, a number of techniques
and procedures come to mind, for example, microvascular surgery. These procedures have a selected place
in head and neck surgery relative to the following
surgical problems:
1. Augmentation of soft tissue with microvascular anastomosis, e.g., involving massive defects of the top of
the scalp that cannot easily be reached by a myocutaneous flap (tissue expanders may have a significant application in closing such defects).
2. Certain congenital lesions in which a transposed flap
or myocutaneous flap is not indicated.
On the other hand, microvascular techniques do not
appear routinely warranted in, for example, the
following:
1. Reconstruction of the mandible (associated with
ablative surgery) with an iliac bone graft and overlying skin. The added time necessary to accomplish
these procedures must be taken into account when
ablative surgery has already consumed a significant
number of hours of operating time. These microvascular techniques on the other hand are applicable to
massive defects resulting from trauma.
2. Reconstruction of the laryngopharynx with a free
jejunal graft or gastric pull-up. The latter procedure
or colon interposition is definitely indicated when a
total esophagectomy is necessary.
Often, a much simpler reconstructive procedure does
in fact achieve the same end results related to the
reconstructive surgery. For example:
1. Mandibular resection that is reconstructed with the
simple use of a bent Kirschner wire with tie wires.

2. Total laryngectomy with total hypopharyngeal, oropharyngeal, and partial nasopharyngeal resection
reconstructed with a myomucosal tongue flap with
dermal graft or pectoralis major flap with dermal
graft. These simpler forms of reconstructive surgery make total hypopharyngectomy a very feasible
and relatively easy procedure. These techniques are
believed to afford a much better chance of resecting
the entire structure, thus leading to improved survival
rates. Preserving a narrow strip of posterior hypopharyngeal mucosa for reconstruction of the gullet
hardly seems justified.


PREFACETO THE THIRD EDITION

Other Suggestions
1. TNM classification. It is suggested that in the initial
evaluation of the patient basic information should
be tabulated along with the appropriate drawings,
and, if possible, photographs, which at any time can
then be transferred into virtually any TNM classification that may be developed in the future (Kaufman,
S., and Lore, J.M. Jr.: TNM classification and disease
description in head and neck cancer. Am. J. Surg.
136:469-473, 1978).

2. Prevention and treatment of premalignant lesions.
Head and neck oncologic surgeons must face the
fact that to help achieve improved survival rates for
patients with head and neck cancer they should be
actively involved and cognizant of the premalignant
lesion as well as the management of "condemned
mucosa." This concept applies to the high-risk patients

and those with mucosal atypism and dysplasia.
Obviously, the avoidance of tobacco and exposure to
carcinogens is foremost. Next in line is the use of the
retinoic acids-vitamin A-as a dietary supplement,
recognizing, of course, the possible toxic side effects,
particularly of overdosage of vitamin A. This leads
to the establishment of, or at least involvement by,
head and neck surgeons in basic research.
3. Adjuvant chemotherapy. Another consideration is the
admonition that adjuvant chemotherapy be relegated
to organized protocols rather than the haphazard
use of chemotherapeutic agents in the management
of head and neck cancer.
4. Violation of the "Virgin Neck." Many years ago Hayes
Martin emphasized that limited surgical procedures
should be avoided in the unoperated neck, since this
could very well mask future metastatic disease. This
admonition is still true for the most part. For exam-

pIe, I shudder when I see and hear about the use of
the sternocleidomastoid muscle for solely a reconstructive procedure in a patient with a surgical defect
following ablative surgery for intraoral cancer.
5. Randomized studies evaluating treatment and end
results. Although randomized protocols certainly have
definite advantages, there are a number of drawbacks. When multiple institutions are included, variations in technique among the surgeons involved
cause inevitable problems. In addition, these studies
may not be as valid as they are supposed to be if the
number of patients is small or if a study lacks adequate stratification of the various factors involved.
In one recent study (Corey, J.P., et al.: Surgical complications in patients with head and neck cancer
receiving chemotherapy. Arch. Otolaryngol. 112:

437-439, 1986) evaluating surgical complications in
patients receiving chemotherapy, the patients were,
I believe, incorrectly stratified as follows:
Patients

Stage II
Stage 1Il
Stage IV

Control
5
8
6

Chemotherapy
1
12
10

The control group is overweighted with stage II
disease, and underweighted for stage 1Iland IV disease,
a form of incorrect stratification that places the chemotherapy group at a disadvantage.
In short, when a trial is randomized, care should be
taken regarding possible imbalance of results.
In summary, it is hoped that the preceding philosophical comments and suggestions as well as the
expansion of this third edition will be of interest to the
head and neck surgeon.
JOHNM. LORE,JR.

ACKNOWLEDGEMENTS
IN THE THIRD EDITION

During the years taken to expand this atlas many
friends have contributed-some as formal contributors,
others in ways and at times unknown to them either
in the sharing or exchanging of knowledge, others in
technical help, and still others in the various phases of
patient care, which in effect has had significant bearing
on this revision and expansion.
My wife, Chalis, has tolerated this third episode with
exceptional calm and has also helped in selective typing.
For the third time, Bob Wabnitz has joined me as the
one and only medical artist and illustrator of all the
editions of this atlas, demonstrating his skill par excellence. Working with Bob is actually a pleasure. His skill
in his chosen profession as well as his knowledge of
anatomy and surgical procedures is only surpassed by
his humor and cooperative attitude. I repeat, "without
him, the atlas would not be."
For the bulk of the stenographic labor, I am deeply
indebted to Dottie Kane, who like Bob Wabnitz simply
smiled when I asked that more had to be done, and of
course, done yesterday.
In the patient care arena, which is so important to
a surgeon and the success of patient management, I
extend gratitude in a special way to those primarily
associated with the Sisters of Charity Hospital of Buffalo.
This includes in administration Sister Mary Charles and
Sister Eileen, and more recently, Sister Angela and her
staff; in the operating room, Sister Thomasine, and after

her, Pat Archambault, R.N., and on the special head
and neck nursing unit, the head nurse, Diane Smeeding,
R.N., and her staff of devoted and skilled nurses, practical nurses, aides and our floor secretary, Beth Powalski.
Along with patient care and many of the facets related
to this endeavor, I am grateful to my office staff, especially Nan Sundquist, R.N. and Debbie Foschio, and
also to Joan Bilger, R.N., who is our nurse clinician at
the Erie County Medical Center.
I have picked the brains of many physicians, especially my former associate, Duck Kim, M.D., and my
current associate in practice, Keun Lee, M.D. They
filled in for me while I struggled along with this revision. Also in this aspect I am grateful to the Pathology
Department of Sisters Hospital. To Paul Milley, M.D., I
am deeply grateful for his contributions both in his
section and in the chapter on endocrine surgery and for

his time, which he afforded me in the numerous problems associated with surgical pathology. John Sheffer,
M.D., and Ashok Koul, M.D., likewise were helpful in
this phase of surgical pathology, which is reflected in
hidden ways in many of the surgical procedures. These
three surgical pathologists are placed among the best
in the field of head and neck surgical pathology, especially related to frozen section, cytology, and recuts and
searching through many surgical specimens. This is
specifically applicable not only to carcinoma hidden in
those specimens that had a complete clinical response
to chemotherapy but also in thyroid specimens where
there has been a search for primary tumors as well as
C-cell hyperplasia.
I am indebted to Martha Schmidt, M.D., the expert
in nuclear medicine, especially that related to thyroid
scanning, as well as to Joseph Prezio, M.D., who is
chairman of the Department of Nuclear Medicine at the

School of Medicine, State University of New York at
Buffalo and Kwang Joo, M.D., who covers Sisters
Hospital. Gratitude is also extended to their technicians,
who are most important in this particular phase of
diagnostic imaging.
In a similar vein, Monica Spaulding, M.D., and
Kandala Chary, M.D., our medical oncologists are a
great help in the management of patients with advanced
neoplastic disease.
Included on our team is William Bukowski, M.D.,
our internist, and David Casey, D.D.S., our maxillofacial
prosthodontist, who have contributed significantly to
the team approach in the management of our patients.
Without the expert contribution of the Department
of Diagnostic Radiology and Imaging under the direction of David Rowland, M.D., and the person who I
pester the most, David Hayes, M.D., many of the surgical procedures would not have been brought to a successful conclusion.
When speaking of "brain picking," the participants
in our endocrine conferences contributed much to my
understanding of thyroid and parathyroid disease. The
"regulars," Robert LaMantia, M.D., Donald Rachow,
M.D., Jack Cukierman, M.D., and James Kanski, M.D.,
are the stalwarts. However, I must say if there are
differences of opinion in the endocrine chapter, these
are my responsibility, not theirs. Contributing in this

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