CORRESPONDENCE: LETTERS
128 Correspondence
Biopsy of the difficult anterior commissure glottic lesion using an AirTraqâ intubation device and flexible bronchoscopy 14 January 2014
Sir, The management of the elusive anterior commissure lesion is a familiar dilemma to most laryngologists and head and neck surgeons. Often, a variety of methods are sought to overcome difficult access to the lesion. Fortunately, in most circumstances, these endeavours prove successful. Occasionally, this is not the case. We report a patient with an original diagnosis of T1N0M0 squamous cell carcinoma to the right vocal cord initially treated with radiotherapy due to inadequate access for laser treatment. He recurred 10 months later and was subsequently treated with an open partial laryngectomy. On follow-up, a new suspicious lesion was visualised at the anterior commissure requiring biopsy. This was attempted using an anterior commissure scope and 70° Hopkins rod but unfortunately, although the anterior glottis area could be visualised, it could not be biopsied. Ultimately, the patient was biopsied using the novel method illustrated above. Following intubation, an AirTraqâ (Fannin Ltd, Wellingborough, UK) device most familiar to anaesthetists for optic-assisted intubations in difficult airways was used to visualise the posterior aspect of the larynx. Through its side port, normally used to deliver an endotracheal tube, a flexible bronchoscope was introduced to identify the lesion directly, and flexible pulmonary biopsy forceps were used (via the bronchoscope) to successfully retrieve multiple biopsies Fig. 1. We believe that this method represents a unique and industrious manner of accessing lesions placed in challenging anatomical areas in the larynx. The tools used are familiar to most hospitals in the UK and hence the technique should
Fig. 1. AirTraqâ device supporting a flexible bronchoscope and pulmonary biopsy catheter.
prove easy to replicate. Consideration should also be made of transnasal oesophagoscopy, itself an extremely useful instrument, which although is not universally accessible, presents an excellent alternative in such scenarios. Conflict of interest
None declared. Mirza, A.H., Stevens, P., King, E.V. & Loew, C. Department of Head and Neck Surgery, Poole Hospital NHS Foundation Trust, Poole, UK E-mail: [email protected]
A new method to identify the hypoglossal nerve 21 January 2014
Sir, The hypoglossal nerve (HN) is a motor cranial nerve that plays a critical role in speech and swallowing. Its injury during surgery may negatively impact the patient’s quality of life. Preservation of the HN must be taken into account
during several surgical procedures, including neck dissection,1 carotid endarterectomy,2 anterior approaches to the cervical spine3 and external carotid artery ligation. Surgical landmarks to find the HN have been described, but the position of each of them varies significantly.4 Rather than © 2014 John Wiley & Sons Ltd Clinical Otolaryngology 39, 127–133
Correspondence
(a)
129
(b)
Fig. 1. Intraoperative (a) and schematic (b) anatomical representation of the triangular area where the extracranical portion of the HN constantly passes through. CFV, common facial vein; IJV, internal jugular vein; PBDM, posterior belly of digastric muscle; 1, hypoglossal nerve; 2, descendens hypoglossi; 3, vagus nerve; 4, carotid bifurcation; 5, mylohyoid muscle; 6, anterior belly of digastric muscle; 7, hyoid bone; 8, inferior lobe of the parotid gland.
using one single landmark, it is possible to improve the ability in recognising and preserving the HN by identifying a specific anatomical region. We hereby suggest a practical way to rapidly and safely identify the extracranial tract of the HN during surgery. Anatomical description
Internal jugular vein laterally, common facial vein inferiorly and posterior belly of digastric muscle (PBDM) superiorly are considered the boundaries of a superficial triangle where the HN passes through on a deeper level (Fig. 1). By dissecting into this area along the inferior margin of the PBDM, the surgeon can identify the nerve underneath a thin fascial layer. Discussion
The anatomical relationships between the HN and the adjacent structures (sternocleidomastoid artery, carotid bifurcation, descendens hypoglossi, PBDM and common facial vein) have been described separately in previous papers.2,4 However, the frequent variability of these landmarks may lead to difficulty in finding the HN, raising the rate of iatrogenic injury to this nerve.4 It is common daily practice, particularly for head and neck surgeons, vascular surgeons and neurosurgeons, to deal with the challenge of preserving the HN. We describe an easily recognisable anatomic triangle where the extracranical portion of the HN constantly passes through, which allows the surgeon to directly identify the HN, without needing to previously expose deeper structures such as the carotid artery or its branches. Fewer injuries of the HN could be expected using this new anatomic triangle.
© 2014 John Wiley & Sons Ltd Clinical Otolaryngology 39, 127–133
The same anatomical-oriented philosophy was adopted in the past when describing the so called ‘Farabeuf triangle (FT)’ which is useful in identifying the external carotid artery.5 However, the superior side of the FT is the HN that lies on a deeper plane compared to the other two sides. This may explain the high risk of damage of the HN during that procedure. In this perspective, we think that the triangle here reported could be helpful also for the FT delimitation. Conflict of interest
None to declare. Battaglia, P., Mercante, G., Turri-Zanoni, M., Pellini, R. & Spriano, G. Department of Otolaryngology – Head and Neck Surgery, Regina Elena National Cancer Institute, Rome, Italy E-mail: [email protected]
References 1 Prim M.P., De Diego J.I., Verdaguer J.M. et al. (2006) Neurological complications following functional neck dissection. Eur. Arch. Otorhinolaryngol. 263, 473–476 2 Aldoori M.I. & Baird R.N. (1988) Local neurological complication during carotid endarterectomy. J. Cardiovasc. Surg. 29, 432– 436 3 Sengupta D.K., Grevitt M.P. & Mehdian S.M. (1999) Hypoglossal nerve injury as a complication of anterior surgery to the upper cervical spine. Eur. Spine J. 8, 78–80 4 Kim T., Chung S. & Lanzino G. (2009) Carotid artery-hypoglossal nerve relationships in the neck: an anatomical work. Neurol. Res. 31, 895–899 5 Farabeuf L.H. (1872) Precis de manuel operatoire. Masson, Paris
128 Correspondence
Biopsy of the difficult anterior commissure glottic lesion using an AirTraqâ intubation device and flexible bronchoscopy 14 January 2014
Sir, The management of the elusive anterior commissure lesion is a familiar dilemma to most laryngologists and head and neck surgeons. Often, a variety of methods are sought to overcome difficult access to the lesion. Fortunately, in most circumstances, these endeavours prove successful. Occasionally, this is not the case. We report a patient with an original diagnosis of T1N0M0 squamous cell carcinoma to the right vocal cord initially treated with radiotherapy due to inadequate access for laser treatment. He recurred 10 months later and was subsequently treated with an open partial laryngectomy. On follow-up, a new suspicious lesion was visualised at the anterior commissure requiring biopsy. This was attempted using an anterior commissure scope and 70° Hopkins rod but unfortunately, although the anterior glottis area could be visualised, it could not be biopsied. Ultimately, the patient was biopsied using the novel method illustrated above. Following intubation, an AirTraqâ (Fannin Ltd, Wellingborough, UK) device most familiar to anaesthetists for optic-assisted intubations in difficult airways was used to visualise the posterior aspect of the larynx. Through its side port, normally used to deliver an endotracheal tube, a flexible bronchoscope was introduced to identify the lesion directly, and flexible pulmonary biopsy forceps were used (via the bronchoscope) to successfully retrieve multiple biopsies Fig. 1. We believe that this method represents a unique and industrious manner of accessing lesions placed in challenging anatomical areas in the larynx. The tools used are familiar to most hospitals in the UK and hence the technique should
Fig. 1. AirTraqâ device supporting a flexible bronchoscope and pulmonary biopsy catheter.
prove easy to replicate. Consideration should also be made of transnasal oesophagoscopy, itself an extremely useful instrument, which although is not universally accessible, presents an excellent alternative in such scenarios. Conflict of interest
None declared. Mirza, A.H., Stevens, P., King, E.V. & Loew, C. Department of Head and Neck Surgery, Poole Hospital NHS Foundation Trust, Poole, UK E-mail: [email protected]
A new method to identify the hypoglossal nerve 21 January 2014
Sir, The hypoglossal nerve (HN) is a motor cranial nerve that plays a critical role in speech and swallowing. Its injury during surgery may negatively impact the patient’s quality of life. Preservation of the HN must be taken into account
during several surgical procedures, including neck dissection,1 carotid endarterectomy,2 anterior approaches to the cervical spine3 and external carotid artery ligation. Surgical landmarks to find the HN have been described, but the position of each of them varies significantly.4 Rather than © 2014 John Wiley & Sons Ltd Clinical Otolaryngology 39, 127–133
Correspondence
(a)
129
(b)
Fig. 1. Intraoperative (a) and schematic (b) anatomical representation of the triangular area where the extracranical portion of the HN constantly passes through. CFV, common facial vein; IJV, internal jugular vein; PBDM, posterior belly of digastric muscle; 1, hypoglossal nerve; 2, descendens hypoglossi; 3, vagus nerve; 4, carotid bifurcation; 5, mylohyoid muscle; 6, anterior belly of digastric muscle; 7, hyoid bone; 8, inferior lobe of the parotid gland.
using one single landmark, it is possible to improve the ability in recognising and preserving the HN by identifying a specific anatomical region. We hereby suggest a practical way to rapidly and safely identify the extracranial tract of the HN during surgery. Anatomical description
Internal jugular vein laterally, common facial vein inferiorly and posterior belly of digastric muscle (PBDM) superiorly are considered the boundaries of a superficial triangle where the HN passes through on a deeper level (Fig. 1). By dissecting into this area along the inferior margin of the PBDM, the surgeon can identify the nerve underneath a thin fascial layer. Discussion
The anatomical relationships between the HN and the adjacent structures (sternocleidomastoid artery, carotid bifurcation, descendens hypoglossi, PBDM and common facial vein) have been described separately in previous papers.2,4 However, the frequent variability of these landmarks may lead to difficulty in finding the HN, raising the rate of iatrogenic injury to this nerve.4 It is common daily practice, particularly for head and neck surgeons, vascular surgeons and neurosurgeons, to deal with the challenge of preserving the HN. We describe an easily recognisable anatomic triangle where the extracranical portion of the HN constantly passes through, which allows the surgeon to directly identify the HN, without needing to previously expose deeper structures such as the carotid artery or its branches. Fewer injuries of the HN could be expected using this new anatomic triangle.
© 2014 John Wiley & Sons Ltd Clinical Otolaryngology 39, 127–133
The same anatomical-oriented philosophy was adopted in the past when describing the so called ‘Farabeuf triangle (FT)’ which is useful in identifying the external carotid artery.5 However, the superior side of the FT is the HN that lies on a deeper plane compared to the other two sides. This may explain the high risk of damage of the HN during that procedure. In this perspective, we think that the triangle here reported could be helpful also for the FT delimitation. Conflict of interest
None to declare. Battaglia, P., Mercante, G., Turri-Zanoni, M., Pellini, R. & Spriano, G. Department of Otolaryngology – Head and Neck Surgery, Regina Elena National Cancer Institute, Rome, Italy E-mail: [email protected]
References 1 Prim M.P., De Diego J.I., Verdaguer J.M. et al. (2006) Neurological complications following functional neck dissection. Eur. Arch. Otorhinolaryngol. 263, 473–476 2 Aldoori M.I. & Baird R.N. (1988) Local neurological complication during carotid endarterectomy. J. Cardiovasc. Surg. 29, 432– 436 3 Sengupta D.K., Grevitt M.P. & Mehdian S.M. (1999) Hypoglossal nerve injury as a complication of anterior surgery to the upper cervical spine. Eur. Spine J. 8, 78–80 4 Kim T., Chung S. & Lanzino G. (2009) Carotid artery-hypoglossal nerve relationships in the neck: an anatomical work. Neurol. Res. 31, 895–899 5 Farabeuf L.H. (1872) Precis de manuel operatoire. Masson, Paris
