tional iatrogenic spinal accessory nerve injury, which in about 60% ... (1) and ultrasound and mammography in women over the ... of fibroadenoma of the breast.
Letters and Comment References 1 Jones PF. Approaches to orchidopexy. Br J Urol 1995; 75: 693-6. 2 La Roque GP. A modification of Bevan's operation for undescended testicle. Ann Surg 1931; 94: 314-17. 3 Nassar A. Laparoscopic operations in paediatric surgery. Br J Surg 1993; 80: 537. 4 Gaur DD, Agarwal DK, Purohit KC, Darshane AS. Laparoscopic orchiopexy for the intra-abdominal testis. J Urol 1995; 153: 479-81. S Nassar AHM. Laparoscopic assisted orchidopexy: a new approach to the impalpable testis. J Pediatr Surg 1995; 30: 39-41. 6 Jones PF, Bagley FH. An abdominal extraperitoneal approach for the difficult orchidopexy. Br J Surg 1979; 66: 14-18.
Iatrogenic accessory nerve injury We were interested to read the article of Ms London et al. (Annals, March 1996, vol 78, p146) regarding unintentional iatrogenic spinal accessory nerve injury, which in about 60% (1) of cases leads to the deforming and disabling condition known as the 'shoulder syndrome' (2,3). The reason for this figure not being higher is as a result of contributions to the motor supply of the trapezius by branches from the cervical plexus (2). The surface anatomy of the spinal accessory nerve in the posterior triangle, though useful should only be regarded as a rough guide, and a detailed appreciation of both its course and depth is necessary. The course of the nerve may be located in the posterior triangle by identifying 'Erb's point', that is where the greater auricular nerve curves anteriorly around the posterior border of sternocleidomastoid; the accessory nerve lies in a variable position between 1 cm and 2 cm superior to this point. It also does not run a straight course across the posterior triangle, as just before passing beneath the trapezius the nerve runs parallel to the muscle for a short distance. Conceming the depth of the nerve in the posterior triangle, it lies within the middle cervical fascia which is surgically indistinct from the superficial cervical fascia, thus the only guide to avoiding the nerve is to keep in the subplatysmal plane (4). However, in the posterior aspect of the posterior triangle the platysma is often absent and therefore the only plane of dissection which is certain to avoid the nerve lies between the dermis and the globular subcutaneous fat layer. When operating in the region of the accessory nerve we recommend identifying it, particularly as lymphadenopathy distorts the local anatomy. We should also like to add to the proposed management options, that in established cases of the 'shoulder syndrome' reconstructive operations, particularly dynamic procedures such as those described by Eden and Lange, should be considered (5). J S ALMEYDA FRCS(CSiG) FRCS(Otol) SHO in Otolaryngology-Head and Neck Surgery P Q MONTGOMERY FRCS(ORL) Senior Registrar in Otolaryngology-Head and Neck Surgery N S TOLLEY MD FRCS Consultant in Otolaryngology-Head and Neck Surgery St Mary's Hospital
London
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References 1 Leipzig B, Suen JY, English JL, Barnes J, Hooper H. Functional evaluation of the spinal accessory nerve after radical neck dissection. Am i Surg 1983; 146: 526-30. 2 Soo K-C, Hamlyn PJ, Pegington J, Westbury G. Anatomy of the cervical accessory nerve and its cervical contributions in the neck. Head Neck Surg 1986; 9: 111-15. 3 Nahum AM, Mullally W, Marmor L. A syndrome resulting from radical neck dissection. Arch Otolaryngol 1961; 74: 4248. 4 Kahle W, Hardt L, Platzer. Colour Atlas and Textbook of Human Anatomy, 3rd Edition, Volume 1. Georg Thieme. S Bigliani L, Perez-Sanz J, Wolfe I. Treatment of trapezius paralysis. J Bone joint Surg 1985, 67A: 871-7.
The treacherous fibroadenoma: a 'mighty mouse' Mr Benson (Annals, March 1996, vol 78, p154) makes a number of comments about the management of fibroadenomas which cannot go unchallenged. Firstly, regardless of whether a clinical fibroadenoma is to be excised or not, it is important that it is investigated by cytology and radiological imaging which should be ultrasound alone in women under the age of 35 years (1) and ultrasound and mammography in women over the age of 35 years. The advantage of this approach comes when one plans removal of peripheral fibroadenomas through central incisions. While this is not an operation for the unsupervised trainee, there is no reason why, when this operation is performed by an experienced individual, it should involve loss of more tissue than an incision directly over the lesion or that there should be an increased risk of haematoma formation. Lighted retractors are available to see down long subcutaneous tunnels and in the United States endoscopes are being used rather like lighted retractors to ensure accurate removal of these lesions and to visualise any bleeding vessels and so prevent haematoma formation. My experience is that one achieves a much better cosmetic outcome by removing peripheral fibroadenomas through these circumareolar incisions, particularly when the lesion is in the upper inner quadrant. In relation to leaving solid discrete lumps in the breast, we have recently published an assessment of acceptability of conservative management of fibroadenomas (2). Over 90% of our patients with fibroadenomas opted for a conservative approach and we were able to show that conservative management of fibroadenomas in patients under the age of 40 years appears safe. J MICHAEL DIXON FRCS FRCSEd Hon Senior Lecturer in Surgery and Consultant Surgeon Edinburgh Breast Unit
References 1 Dixon JM. Techniques of and indications for breast biopsy. Curr Pract Surg 1993; 5: 142-8. 2 Dixon JM, Dobie V, Lamb J, Walsh JS, Chetty U. Assessment of the acceptability of conservative management of fibroadenoma of the breast. Br J Surg 1986; 83: 264-5.
An audit of one surgeon's experience of oral squamous cell carcinoma using a computerised malignancy database I read with some interest the letter from Mr Cliff Bierne (Annals, March 1996, vol 78, pl54), regarding the above
