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Lingual Release Approach to the Oral Cavity and Pharynx

last modified on: Fri, 12/01/2017 - 15:20

Lingual Release Approach to the Oral Cavity and Pharynx

 

  • 1Lingual Release Approach to the Oral Cavity and Pharynx
    • 1.1GENERAL CONSIDERATIONS
    • 1.2PREOPERATIVE PREPARATION
    • 1.3NURSING CONSIDERATIONS
    • 1.4ANESTHESIA CONSIDERATIONS
    • 1.5OPERATIVE PROCEDURE
    • 1.6POSTOPERATIVE CARE
    • 1.7SUGGESTED READING

 

  1. GENERAL CONSIDERATIONS
    1. Indications
      1. Large anterior, lateral, or posterior tumors of the oral cavity
      2. Tumors of the lateral or posterior oropharynx and selected tumors of the lateral wall of the hypopharynx
      3. Tumors of the tongue base
      4. Mandibular bone involvement, involvement of the maxillary tuberosity, and extension of tumors to involve the lower nasopharynx are not contraindications
      5. An alternative to lip-split for patients with cosmetic concerns. This approach avoids damage to the buccal/labial periosteum and the inferior alveolar vessels of the mandible, thus maintaining blood supply to the lower jaw, which is important if radiotherapy is planned.
    2. Contraindications
      1. Tumor extension to involve the chin skin that is best resected in conjunction with a lip-split procedure
      2. Prior lip-split procedure
      3. Reconstruction with an innervated osteocutaneous flap is a relative contraindication to this approach because of the difficulty associated with "layering in" the various components of the flap
    3. Pertinent Anatomy
      1. If only one side of the neck is to be dissected, the facial artery on the side contralateral to the tumor should be preserved.
      2. Unless segmental mandibulectomy is performed, this procedure does not call for elevation of the periosteum from the lateral surface of the mandible. When segmental resection of the mandible is performed with this procedure, only the lateral periosteum over the section of mandible to be removed is elevated.
  2. PREOPERATIVE PREPARATION
    1. Evaluation
      1. Determine management plan for the dentition. If the dentition requires extraction, this should be done at the time of surgery prior to the lingual release. Removal of the teeth facilitates the mandibular arch incision and closure.
      2. Ensure that tumor clearance will not require excision of chin skin.
    2. Potential Complications
      1. Complications common to all oral and pharyngeal surgery including infection with or without fistula formation and wound breakdown.
  3. NURSING CONSIDERATIONS
    1. Room Setup
      1. See Basic Soft Tissue Room Setup
      2. Mayfield headrest
    2. Instrumentation and Equipment
      1. Standard
        1. Major Instrument Tray 1, Otolaryngology
        2. Major Instrument Tray 2, Otolaryngology
        3. Tracheotomy Tray
        4. Bipolar Forceps Trays
        5. Hall Micro Sagittal Saw Tray (Pneumatic)
        6. Bien Otologic Electric Drill Tray
      2. Special
        1. Sterile anesthesia breathing circuit, adult
        2. Roush Laryngoflex 7 mm endotracheal tube
        3. KLS Free Flap Implant - Instrument Tray or
        4. KLS Locking Reconstruction Threadlock Instrument Tray or
        5. KLS Oto Trauma Implant - Instrument Tray or
        6. KLS mandible tray
        7. KLS maxillectomy tray
        8. Corpak feeding tube
        9. Nerve stimulator control unit and instrument
        10. Varidyne vacuum suction controller
    3. Medications (specific to nursing)
      1. Antibiotic ointment
      2. 2% lidocaine with 1:100,000 epinephrine
    4. Prep and Drape
      1. Standard prep, 10% providone iodine; dilute betadine oral prep
      2. Drape
        1. Head drape
        2. Towels to square off face (above nose), neck bilaterally, and chest
        3. Split sheet
    5. Drains and Dressings
      1. Antibiotic ointment to suture line
      2. Varidyne vacuum suction: 7 mm or 10 mm
    6. Special Considerations
      1. Tracheotomy may be done as part of the procedure or initially under local if there is a concern that the airway is compromised.
      2. Dental extraction instrumentation may be needed and extractions should be done prior to the lingual release (see Dental protocols).
    7. Preoperative Medications
      1. Perioperative antibiotics (see Antibiotic Prophylaxis in Head and Neck Surgery
        protocol)
      2. Decadron 8 to 10 mg if not contraindicated
  4. ANESTHESIA CONSIDERATIONS
    1. General
      1. Most of these patients will require a tracheostomy, which can be done following induction with oral endotracheal anesthesia or with local anesthesia prior to induction if the tumor size or location preclude safe intubation.
      2. The table will be turned 180° with the head away from the anesthesiologist.
    2. Specific
      1. No paralysis until after the mandibular branch of facial nerve is identified.
  5. OPERATIVE PROCEDURE
    1. Incision
      1. Transverse incision from a point below the ipsilateral mastoid tip curved down and across neck at hyoid level carried well across midline, extending nearly to an equivalent point on the contralateral side for more posterior lesion (this is a frequent reason for inadequate exposure). If bilateral necks are planned, the incision is mastoid to mastoid.
      2. Vertical limb as needed for neck dissection
    2. Raise Upper Flap to Lower Mandibular Border
      1. Facial artery and vein are not transected on contralateral side if neck dissection is not planned on that side.
      2. Mandibular branch is identified and reflected superiorly.
    3. Neck Dissection Done at This Time
      1. Submandibular triangle contents or entire neck specimen can be left in continuity with oral or pharyngeal tumor.
    4. Periosteum Incised Sharply Along Inferior Border of Mandible
      1. Do not incise or elevate periosteum over lateral surface of the mandible.
      2. Detach digastric, genioglossus, and hyoglossus muscle attachment to mandible.
      3. Elevate periosteum off of inner cortex of mandible from below up to floor of mouth. If segmental mandibulectomy is planned, do not elevate periosteum away from the mandible in that area. This section of the mandible will remain attached to the floor of mouth and be released with the tongue and floor of mouth contents for removal en bloc with the tumor.
      4. If segmental mandibulectomy is planned, elevate lateral mandibular periosteum only off of that segment. This will detach that segment of mandible so that it will be released in continuity with the tongue and floor of mouth.
    5. Intraoral Releasing Incision
      1. From ipsilateral retromolar trigone to contralateral retromolar trigone
      2. If mandibulectomy is being done, releasing incision joins mucosal incisions over bone cuts.
      3. Place incision on superior gingival crest for edentulous patients. This incision needs to precisely divide the keratinaceous tissue along the alveolar crest.
      4. If patient is dentate, incise at gingival margin of dentomucosal interface, preserving interdental papillae.
      5. The contralateral posterior releasing incision may be "back cut" along the lateral floor of mouth to prevent tearing in this area and to increase exposure. This back cut should be through mucosa only to avoid injury to the contralateral lingual nerve.
      6. Release remaining periosteum from inner cortex of mandible.
    6. Perform Bone Cuts for Segmental Resection at This Time
    7. Drop Released Tongue (and tumor if anteriorly located) Out into Neck Below Mandible
      1. Perforating towel clip in the anterior tongue may be helpful.
      2. Do not pull on the tumor or segment of mandible attached to tumor.
      3. Adequate delivery allows access to the entire oral cavity, tongue, and pharynx below the mandible. Segmental mandibulectomy should relax into neck with tongue.
    8. Tumor Is Excised
    9. Closure
      1. Releasing incision is closed with interrupted 3-0 vicryl as for flap.
      2. In dentate patients, circumdental 3-0 vicryl sutures are used to secure the interdental papillae back into their normal anatomic position.
      3. Restoration of the oral diaphragm is necessary. The digastric, genioglossus, and geniohyoid muscles can be reattached to the anterior mandibular arch using vicryl sutures through drill holes in the mandible.
      4. If flap reconstruction is employed, the posterior aspect of the flap is sutured in place beginning through the neck. This will allow all but the mandibular arch aspect of the closure to be done through the neck.
      5. At least one suction drain should extend up under the floor of mouth.
  6. POSTOPERATIVE CARE
    1. Antibiotics (see Antibiotic Prophylaxis in Head and Neck Surgery
      protocol)
    2. On postoperative day 2, the patient should begin daily rinse and spit peroxide normal saline 1:1 solution QID.
    3. Remove drains when output is less than 30 cc per 24 hours.
    4. Begin oral liquids on postoperative day 7 if there no evidence of breakdown or fistula. Oral feeds begin on postoperative day 14, if the patient has had prior radiation.
  7. SUGGESTED READING
    1. Stanley RB. Mandibular lingual releasing approach to oral and oropharyngeal carcinomas. Laryngoscope 1984;94:596-600.
    2. Stringer SP, Jordan JR, Mendenhall WM, et al. Mandibular lingual releasing approach. Otolaryngol Head Neck Surg. 1992;107:395-398.