Pharyngotomy

PHARYNGOTOMY (from Greek pharynx-throat and tomia-incision), the operation of incising the pharynx. There are distinguished: 1) subhyoid Ph. (pharyngotomia subhyoidea), proposed still by Vidal and Malgaigne and perfected by Langenbeck and Kocher; 2) suprahyoid Ph. (Hoifmann-Hacker-Yeremich) (ph. suprahyoidea); 3) median Ph. (ph. transhyoidea) with incision of the hyoid bone and if necessary with an additional incision of the thyroid cartilage; 4) lateral Ph. (ph. lateralis) (Kronlein). All operations provide access to the epiglottis, the entrance to the larynx (aditus laryngis) and the lower part of the pharynx and partially the nasopharynx. Operations are indicated for removing tumors and foreign bodies from these areas. The smallest access is provided by ph. subhyoidea, a larger one by ph. lateralis. Ph. suprahyoidea due to the small access and large number of complications (postoperative pneumonias) at present is performed rarely (as an approach to the root of the tongue). Before Ph. usually preliminary tracheotomy is performed (although Bergmann, Kilster and others advise not doing it) and insertion of a probe into the esophagus through the nose for feeding patients for the first time after the operation. Pharyngotomia subhyoidea. A skin incision 7-8 cm long in the space between the thyroid cartilage and the hyoid bone, through platysma to complete exposure of the hyoid bone. At the lower edge of the latter, close to the bone, the attachments of mm. sterno-, oto- and thyreo-hyoidei are cut. In the lateral part of the wound it is necessary to carefully preserve the n. laryngeus sup., damage to which causes insensitivity of the larynx and the possibility of developing aspiration pneumonia. Then the membrana hyo-thyreoidea and the pharyngeal mucosa are incised. By pulling the hyoid bone upward and the thyroid cartilage downward and extracting the epiglottis, sufficient access is obtained to the middle part of the pharynx, the entrance to the larynx and adjacent parts. Subsequently the mucosa is sutured with catgut and the skin with silk, inserting drains on the sides of the wound. Pharyngotomia transhyoidea. A vertical skin incision along the median line, beginning 2 cm above the hyoid bone, to the upper edge of the thyroid cartilage or lower to the cricoid cartilage, in order to insert a tracheotomy tube into the incision lig. crico-thyreoidei. Layer by layer they reach the hyoid bone and the upper notch of the thyroid cartilage, incise membr. hyo-thyreoidea and cut the hyoid bone and the pharyngeal mucosa. The access obtained is smaller than with ph. subhyoidea. Pharyngotomia lateralis. A skin incision along the anterior edge of m. sterno-cleido-mastoideus from the angle of the lower jaw to the level of the cricoid cartilage. Platysma and m. omohyoideus are incised; above the submaxillary gland capsule is opened and the latter together with the surrounding lymph glands and connective tissue is dissected out; a. maxillaris externa is ligated. By blunt exposure the v. facialis ant. and a. lingualis are exposed and ligated, and below a. thyreoidea sup. The posterior belly of m. biventeris and m. stylo-hyoideus are cut close to the hyoid bone. After this the lateral wall of the pharynx freely lies, which is incised above and below n. laryngei sup. or, if necessary, throughout its entire length with cutting of the nerve. If a wider access is required, the incision according to Krenlein is continued to the angle of the mouth, a temporary incision of the lower jaw is made or the ascending part of the lower jaw is disarticulated by twisting. After this mm. styloglossus and stylopharyngeus are cut. N. hypoglossus is displaced upward. After removal of the tumor within healthy tissues the mucosa, as much as possible, is sutured, and the wound is kept mainly open. Besides the typical operations listed, a whole series of combinations of the described methods with other operations in this area for the purpose of gaining access to the larynx, esophagus and root of the tongue is possible. To the methods of lateral Ph. also belong the methods of operations proposed by Seiffert: Seiffert I-for removing tumors on the posterior wall of the pharynx-a two-stage operation. With a lateral incision they reach the posterior wall and separate the pharynx from the soft tissues of the anterior surface of the spine. A plate of epithelium according to Thiersch is transplanted onto the exposed surface of the spine. After the latter takes, the tumor is removed together with the posterior wall of the pharynx, and the edges of the resulting defect are sutured to the engrafted epithelium. Seiffert IV-for tumors occupying a large part of the lower part of the pharynx. From the lateral incision the entire lower part of the pharynx is removed. From an additional transverse incision the trachea is cut below the larynx and sutured to the skin of the fossa jugularis. The larynx is sutured to the remaining lower part of the pharynx. Thus the larynx will serve as the beginning of the esophagus.