Master Techniques in Otolaryngology - Head and Neck Surgery: Head and Neck Surgery by Myers Eugene N.;Ferris Robert;

Author:Myers, Eugene N.;Ferris, Robert;
Language: eng
Format: epub
Publisher: Wolters Kluwer

FIGURE 18.1 Involvement of RLN by thyroid cancer.

The growth of the primary cancer or cancer in the lymph nodes in the tracheoesophageal sulcus may invade vital structures such as the RLN, trachea, or esophagus. The surgeon must be prepared to undertake appropriate surgical resection if these surrounding structures are involved by the primary cancer or metastatic lymph nodes. Involvement of the esophagus is quite rare, and most of the time, the cancer is adherent to the esophageal musculature leading to the need for resection of the esophageal muscles rather than the mucosa itself. However, if the cancer involves the esophageal mucosa, a much more radical resection is required and reconstruction may require a microvascular free flap or a gastric pull up. Cancer involving the region of the cricoid cartilage or cricopharyngeal muscles may be difficult to evaluate even intraoperatively on gross evaluation. The management of recurrent cancer involving this region of the cricothyroid area makes for extremely complex surgical decision making as laryngectomy may be necessary for surgical resection with cancer-free margins. Involvement of other vital structures such as the carotid artery, vagus, and phrenic nerves and sympathetic trunk is quite rare.

The majority of these patients will require a multidisciplinary approach with active involvement of specialists in endocrinology, nuclear medicine, and medical oncology with special expertise in the management of thyroid cancer with targeted therapies. The laryngologist and speech language pathologist play an important role in the management of voice problems. The RLN may be directly in contact with cancer, and resection of the RLN or any tedious separation may jeopardize the function of the RLN either temporary or permanently. The superior laryngeal nerve (SLN) is rarely directly involved by the cancer, but surgical intervention may lead to iatrogenic trauma to the SLN, leading to a change in voice and inability to raise the voice, pitch, and tone. The parathyroid glands are adherent to the posterior portion of the thyroid capsule. In locally aggressive thyroid cancer, these glands may be inseparable from the cancer or may be involved in the thyroid capsule leading to unintentional loss of one or more parathyroid glands, resulting in temporary or permanent hypoparathyroidism. Consideration should be given to parathyroid autotransplantation.

Anesthesia Considerations

The anesthesia decisions are also intricate in these complex surgical procedures. Any attempt at awake intubation should be best avoided for the fear of laryngospasm and intralaryngeal trauma. Induction should be smooth with a nontraumatic intubation with a size 6 tube. Larger tubes such as 8 and 9 are not necessary in thyroid surgery. The cuff of the endotracheal tube should be well below the vocal cords. If there is a major concern about a difficult intubation, a fiberoptic nasotracheal intubation may be considered.

Principles of Surgical Management of Locally Invasive Cancer of the Thyroid

The oncologic principles in the management of locally aggressive thyroid cancer dictate that all gross cancer should be removed and clear surgical margins obtained. Pathologists should be readily available for appropriate frozen sections of the lymph node, esophageal musculature, or tracheal wall as necessary.

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