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Dissection for tumors follows a slightly different course. Dissection is begun at a distance away from the tumor, in order not to break into it. The recurrent laryngeal nerves, if they are likely to be involved or are involved, are identified (as in surgery for thyroid neoplasm) at a distance from the tumor and followed up to the area of the tumor. If one of the nerves is clearly involved by tumor, or if the vocal cord is already paralyzed by tumor, it will have to be sacrificed. Dissection is done with great delicacy to avoid bruising injury to a nerve, even if it is not divided. Extensive lymph node dissection is generally not possible, except in the area adjacent to the tumor, since excessive dissection of the paratracheal nodes may injure the blood supply of the trachea. If tracheal tumor invades the thyroid gland, the lobe or a portion of it may be resected en bloc with the trachea. If the tumor involves the anterior esophageal wall, it may be necessary to remove a portion of the muscular wall or, less commonly, a full thickness portion of the wall. In the case of muscular removal, muscular edges are reapproximated with fine interrupted 4-0 silk or Vicryl sutures. Following full thickness removal, the esophagus is closed in two layers, using Sweet's technique of inverting the esophageal mucosa with 4-0 sutures, followed by Lembert sutures of the muscularis.2 A flap of strap muscle should be sutured over the closure so that muscle will be interposed between the esophageal suture

figure 24-12 Management of two separate tracheal stenoses. The proximal lesion is usually due to a stoma and the distal lesion to a cuff. A, The distal stenosis is resected and tracheostomy placed in the proximal lesion. Great care is taken to preserve blood supply, especially of the intervening segment. B, A short T tube provides an airway during healing of the distal anastomosis. C, Final result. The previous anastomosis is indicated by a dotted line.

line and the tracheal suture line to minimize the possibility of a fistula. An esophagus so narrowed usually does not require subsequent dilations.

Frozen sections from margins of resection are essential in all malignant or indeterminate neoplasms and also in case of close resection of a benign neoplasm. Specific tumors present special problems. Thyroid carcinoma, which involves the lower portion of the larynx as well as upper trachea, is dealt with subsequently (see Chapter 25, "Laryngotracheal Reconstruction"). Since adenoid cystic carcinoma often extends for long distances beyond visible pathology, the approach for resection and for appropriate release maneuvers must be carefully planned. It may become necessary to accept microscopic tumor at the margins of resection, in order not to compromise the possibility of healing by excessive anastomotic tension following an extended resection.

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