© Borgis - New Medicine 2/2001, s. 28-30
Mirosława Pietniczka1, Andrzej Kukwa1, Romuald Krajewski1, Wojciech Adach1, Barbara Lisowska2, Lechosław P. Chmielik1
The possibilities of surgical treatment of tumours of the head and neck in children
1 Department of Otolaryngology, Stomatology Division the Medical Academy School in Warsaw
Head of Department.: Prof. Andrzej Kukwa MD.
2 Department of Anaesthesia and Intensive Care Unit, Czerniakowski Hospitalin Warsaw
Head of Department.: Dr hab. Henryk Kwiatkowski MD.
Summary
Background:Treatment of malignant tumours, especially in children, needs a complex procedure. From the initial diagnosis, which as other physicians they derive from the results of histopathology and investigation, the treatment should be settled by a team including the surgeon and specialists in chemo – and radiotherapy. Additionally, the treatment of malignant tumours in children differs considerably from that in adults, which is most often diagnosised empirically. The authors work in co – operation with several Departments of Paediatric Oncology in the country. They confirm on the basis of results from operated patients, the necessity for complex co – operation between oncologists, chemo – and radiotherapists, and surgeons, suggesting that the link between them should be a highly specialised histopathologist.
They discuss the possibility of and methods for surgical procedures and general anaesthesia for neurosurgery.
Methods:52 patients underwent surgery for neck and head tumours under general anaesthesia. There were 74 operative procedures. There were 10 diagnostic biopsies and 64 treatment procedures.
Our material was composed mainly of benign neoplasms, numbering 41, and in 11 cases we had malignant neoplasm. Depending on the size and the location of the tumours, the authors used different types of surgical access.
Results:Observation periods lasted from 2 months to 6 years. All children remained under the control of our Clinic Out – Patient department. We did not observe deaths or any recurrence of illness. Children operated on for RMS, NHL, olfactory neuroblastoma and histiocytosis X were subjected to postoperative chemotherapy. Cosmetic results after the reconstructions were good. Side effects, such as liquorrhoea and otorrhoea, were not recorded in any of the cases.
Conclusion:Treatment of child malignant neoplasm requires complex action and should be effected in close co – operation between the surgeon – oncologist, radio – and chemotherapist. Such treatment significantly increases the child´s chances of cure.
General anaesthesia with controlled ventilation, which is associated with stable blood pressure, adequate ventilation and full muscle relaxation makes it possible to decrease the risk of intraoperative complications and to satisfy the surgeon´s requirements.
INTRODUCTION
Primary neck and brain malignant tumours in children constitute 25-27% of all malignant cancers that appear in this age group. The most frequently encountered are: lymphomas (59%), rhabdomyosarcoma (17.5%), thyroid carcinoma (10%) and neuroblastoma (5%). Nasal pharynx tumors and salivary gland cancers appear in a small percentage (1, 7, 8). Thanks to constantly improved operating methods, progress in reconstruction techniques and in anaesthesia, the possibilities of a cure reach as much as 70% in this group of patients.
Development of diagnostic research, including computer tomography and magnetic resonance, has contributed to the measurable success in the struggle against neoplasm conditions. The results of computer tomography can decide the final diagnosis and procedure (5). Exact definition of a diagnosis frequently requires an electron microscope, immunocytochemical examinations, and cytochemical examination.
Anaesthesia for neurosurgery may cause many problems coupled with the presence of intracranial hypertension, the risk of airway obstruction, hypotension, specific cranial nerve stimulation, and vital sign changes due to brain stem manipulation. The factors in selection of anaesthetic drugs are multiple. The effects of agents on intracranial pressure, cerebral blood flow, cerebral perfusion pressure and promptness of return to consciousness are major considerations. Secondary considerations include drug – related protection from ischaemia or oedema, blood pressure control, and compatibility with neurophysiological monitoring techniques (2).
A well – performed general anaesthesia with controlled ventilation makes possible lowering of the intracranial pressure, and maintaining of cerebral perfusion pressure, avoiding hypoxia, hypercapnia, cough and pain reflexes. After the operation the patient should be conscious as quickly as possible.
The patient´s position depends on the tumour locatien, especially with reference to the tentorium of the cerebrum. When the lateral and prone position is used the extremities and the neck must be supported, with attention paid to avoid injuring peripheral nerves or kinking the airway (3). Circulation and respiration parameters and body temperature, diuresis and loss of fluids are controlled during the operation. Measurement of intracranial pressure may be useful.
MATERIALS AND METHODS
In the Otolaryngology Clinic of the Oral Medicine Faculty of the Medical Academy in Warsaw, in 6 years (1995-2000), 52 patients underwent surgery for neck and head tumours.
The analyzed group of patients was mainly boys – 31 persons (61%), and 21 girls (39%). The youngest patient was 1.5 years old, the oldest 18 years; the average age was 11 years. The observation period varied from 2 months to 6 years.
Preliminary diagnosis, indications and type of treatment were defined on the basis of: subjective and objective examination, of thin – needle biopsy or of histopathologic examination of an extracted tumour fragment, of imaging examinations such as CT, MRI, angiography, and ultrasonic examination, Doppler examination, and endoscopic examinations. In 6 cases decisions about the area and depth of the operation were taken as a result of a mid – operation examination.
The final diagnosis is determined on the basis of the result of histopathological examination of the postoperative specimen.
Our material was composed mainly of benign neoplasms (41), and in 11 cases we had malignant neoplasm (tables 1, 2).
Table 1. shows the kind of malignant neoplasm and the number of patients diagnosed.
| Type of malignant neoplasm | Number of patients |
| RMS | 7 |
| Olfactory neuroblastoma | 1 |
| Ca adenoides cysticum (cylindroma) | 1 |
| B - cell non - Hodgkin´s lymphoma (NHL) | 1 |
| Histiocytosis X | 1 |
| Total | 11 |
Table 2. Shows the type of non-malignant neoplasm, and the number of patients diagnosed.
| Type of non-malignant neoplasm | Number of patients |
| Juvenile angiofibroma | 12 |
| Type II neurofibromatosis | 6 |
| Adenoma pleomorphe | 4 |
| Haemangioma | 3 |
| Lymphangioma | 3 |
| Epithelioma Malherbe´s | 2 |
| Choroid cyst | 2 |
| Osteoma | 2 |
| Mucoepidermoidal tumour | 1 |
| Fibromatosis ossificans | 1 |
| Schwannoma | 1 |
| Tu epithelialis monomorphus | 1 |
| Osteoclastoma | 1 |
| Myxoma | 1 |
| Lipoma | 1 |
| Total | 41 |
Seventy – four operative procesures were performed. There were 10 diagnostic biopsies and 64 treatment procedures. All operations were performed under general anaesthesia with controlled ventilation.
Patients with parotid gland tumours (8 cases) had partial parotidectomy with the removal of the frontal lobe (6 cases) and the remainder had total parotidectomy with preservation of the facial nerve (2 cases).
Depending on the size and area of the juvenile angiofibroma, and of its location and propagation, different types of surgical access were used:
through the palate in 1 case,
through enlarged lateral rhinotomy in 4 cases,
temporal – zygomatic access in 1 case,
through the joint access from the palate side and rhinotomy in 2 cases,
by the joint access: temporal zygomatic and from enlarged lateral rhinotomy in 3 cases,
by triple access: temporal – zygomatic, lateral rhinotomy, frontal and orbital cavity craniotomy, in 1 case.
For RMS patients the following approaches were used:
temporal – zygomatic access in 1 case,
enlarged lateral rhinotomy in 4 cases,
frontal – temporal – orbital cavity – zygomatic craniotomy in 1 case.
All patients with neurofibromatosis were scheduled for several operations and the following approaches were used:
frontal – temporal – orbital cavity – zygomatic craniotomy,
hemilaminectomy C1 – C2, Th 12 – L1,
through ear and neck access,
through lateral pharyngotomy,
labyrinth and retro – mastoid access
Reconstructive operations were performed in cases of the removal of large neoplasms (RMS, juvenile angiofibroma, NFT 2). The principle of action was separation of the intracranial area from the nose and nasal pharynx areas with at least two layers of tissue (4, 6).
Seven patients underwent reconstruction of the facial nerve.
During the postoperative period, respiratory, haemodynamic parameters, level of consciousness, and temperature were monitored in all patients. The aim of the postoperative treatment was to maintain correct cerebral perfussion and the prevention of intracranial hypertension.
RESULTS
The observation period lasted from 2 months to 6 years. All children remained under the control of our Clinic Out – Patient department. We did not observe deaths or any recurrence of illness. Children operated on for RMS, NHL, olfactory neuroblastoma and histiocytosis X were subjected to postoperative chemotherapy.
A girl, after salivary gland neoplasm (sialoma) removal, underwent Co – therapy. No child who had an operation for salivary gland neoplasm had any deficiency in the facial nerve functions. Cosmetic results after the reconstructions were good. Side effects, such as liquorrhea and otorrhea, were not recorded in any of the cases.
PRESENTATION
We have presented a relatively large amount of material on child neoplasm. Malignant neoplasm of the head and neck, especially those penetrating into the cranium, have the most difficult procedures, both for diagnosis and for treatment. As other authors (1, 5, 8, 9), we have stated that insufficient oncologic vigilance on the part of first – contact physicians, and excessive time spent on diagnosis lead to significant development of the neoplasm, and in consequence complicate its treatment and reduces the chance of healing. Effective evaluation before the operation and preparation for the operation are as important as an adequate anaesthetic technique, in order to guarantee safety for the patient and good conditions for the surgeon.
CONCLUSIONS
1. The treatment of child malignant neoplasm requires complex action and should be effected with close co – operation between the surgeon – oncologist and the radio- and chemo-therapist. Such treatment significantly increases the chance of a cure.
2. The diagnosis should be precisely defined by a group of specialists: clinician, imaging specialist, USG expert, and histopathologist.
3. The main method of treatment for malignant head and neck neoplasm in children and young people is surgical resection of the tumour, together with chemotherapy before and after the operation.
4. The great effectiveness of modern chemo – therapy schemes means that many tumours, which originally were „non – operational”, may now be removed radically after preliminary chemotherapy.
5. The principle in neoplasm surgery is reconstruction of tissues and damaged nerves during the same operation.
6. General anaesthesia with controlled ventilation, which is associated with stable blood pressure, adequate ventilation, and full muscle relaxation, makes it possible to decrease the risk of intra – operation complications and to satisfy the surgeon´s requirements.
Piśmiennictwo
1.Bożek J.: Nowotwory wieku dziecięcego. (Child neoplasm) PZWL, Warsaw, 1989. 2.Cucchiara R.F et al.: Anaesthesia for Intracranial Procedures from Barash P.G. et al.: Clinical Anesthesia. J.B. Lippincott Company.; 1989, 849-876. 3.Hannedouche A., Mann Ch., Murat I., Ecoffey C.: Podręcznik anestezjologii pediatrycznej. (Manual of pediatric anesthesia) Ossolineum; 1994, 245-252. 4.Janecka I.P., Sekhar L.N.: Reconstruction of Skull Base Surgical Defects. in Surgery of Skull Base Tumours, edited by Jackson C.G., Churchill Livingstone, NY, Edinburgh, London, 1991, 251. 5.Komorowska A., Makowska-Piontek A.: Rhabdomyosarcoma ucha środkowego u dzieci. (Child middle ear rhabdomyosarcoma) Otolaryngol. Pol. (Polish Otolaryngology) 1999, LIII, 4, 417-421. 6.Kukwa A. et al.: Metody rekonstrukcji w chirurgii podstawy czaszki. (Reconstruction Methods in the Skull Base Surgery) Neur. Neurochir. Pol. (Polish Neurosurgery) 1998, T.32 (XLVIII), Nr 4. 7.Mueller-Malesińska M.: Guzy złośliwe głowy i szyi u dzieci. Część I – poglądowa. (Child malignant tumours of head and neck. 1st Part – Demonstrative) Otolaryngol. Pol. (Polish Otolaryngology), 1992, XLVI, 4, 419-425. 8.Lanzkowsky P.: Hematologia i onkologia dziecięca. (Child hematology and oncology) PZWL, Warsaw 1994, 300-313.
