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Chapter 102 – CONSERVATION LARYNGEAL SURGERY Department Of Oto-rhino-Laryngology Of Isfahan Medical Science.

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1 Chapter 102 – CONSERVATION LARYNGEAL SURGERY Department Of Oto-rhino-Laryngology Of Isfahan Medical Science

2 These techniques allow for the maintenance of physiologic speech and swallowing without the need for a permanent tracheostoma. Horizontal or vertical ?:innitial entry in to the laryngeal lumen

3 PRINCIPLES OF ORGAN PRESERVATION SURGERY direct our focus away from the vocal fold and concentrate on the cricoarytenoid unit as the essential functional unit of the larynx

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6 First Principle: Local Control Local control is the most important principle. Early detection of the primary site recurrence may be difficult. Medical and surgical organ preservation modalities alter the topography of the larynx and make definitive evaluation of recurrent cancer difficult.symptoms may be attributed to the treatment intervention or recurrent tumor, although increasing pain, persistent ear pain, and dysphagia are ominous signs. Repeat endoscopy and biopsy of the original primary site is warranted.

7 Second Principle: Accurate Assessment of the Three-Dimensional Extent of Tumor Third Principle: Cricoarytenoid Unit is the Basic Functional Unit of the Larynx The cricoarytenoid unit is the basic functional unit of the larynx. The cricoarytenoid unit consists of an arytenoid cartilage, the cricoid cartilage, the associated musculature, and the superior and recurrent laryngeal nerves for that unit. Fourth Principle: Resection of Normal Tissue to Achieve an Expected Functional Outcome

8 PREOPERATIVE EVALUATION includes an oncologic assessment of the primary site, regional nodes, and distant sites. In addition, it includes an assessment of the patient's ability to medically undergo the surgery and postoperative treatment. Finally, patient and family insight, emotional state, and ability and willingness to undergo the postoperative rehabilitation should be considered.

9 Clinical Evaluation of the Primary Site Glottic carcinomas cause hoarseness; supraglottic cancers cause a muffled "hot potato" voice Hoarseness from a supraglottic carcinoma may indicate impairment of cord mobility as a result of arytenoid involvement or glottic level involvement. A bulge or mass at the level of the thyrohyoid membrane may indicate massive preepiglottic space invasion. A mass at the level of the cricothyroid ligament may indicate a delphian lymph node, which indicates subglottic extension of the malignancy.

10 Mobility of the vocal cord itself, is adequate when planning for management that is directed to the entire organ, such as total laryngectomy or radiotherapy Impaired mobility from glottic carcinoma may be a result of superficial thyroarytenoid invasion or bulk on the surface of the cord in an exophytic lesion

11 glottic carcinoma associated with a fixed vocal cord most commonly results from extensive invasion of the thyroarytenoid muscle In some patients, subglottic extension with fixation to the cricoid cartilage and lateral extension with adherence to the thyroid cartilage resulted in fixation of the cord and invasion of the lateral cricoarytenoid musculature and the cricoarytenoid joint At the supraglottic level, cancer invasion into the thyroarytenoid musculature at the glottic level is less likely, and the most common cause of cord fixation, was deep arytenoid cartilage invasion superiorly

12 two types of impairment in arytenoid mobility—namely the "weight impact" of the tumor—in which the arytenoid motion seems impaired superiorly causing "pseudofixation" vs actual fixation from the malignant involvement of the intrinsic laryngeal musculature, the cricoarytenoid joint, or both it is unlikely that a larynx with a "pseudofixed" arytenoid has cricoarytenoid joint and musculature involved, whereas these areas are involved in more than two-thirds of patients when "true fixation" of the arytenoid is present. Palpation of the vallecula with a finger and of the posterior floor of mouth provides a critical assessment of submucosal extent of disease in these areas from supraglottic carcinoma.

13 Radiologic Evaluation of the Primary Site Limitations when evaluating particularly small lesions or the superficial extension of a large lesion, CT or MRI may demonstrate little abnormality.. with large exophytic lesions. When lesions have large extensions into the airway, they may sit up against adjacent mucosal sites, such as the pyriform sinus, tongue base, floor of mouth, the lateral pharyngeal wall, or the ventricle or saccule. Although the point of the attachment of the cancer may be small and discrete, the scan may deceptively indicate that all mucosal surfaces are involved.

14 Key point in CT and MRI valsalva maneuver performed during the CT scan may be useful. Occasionally, tumors may be isodense (CT) or isointense (MRI) with the surrounding tissues, which at times may overestimate or underestimate the size of the lesion noted on the clinical examination. sclerotic changes on CT are indications of perichondrial or direct arytenoid cartilage involvement.

15 loss of calcification of the cartilage on CT is an unreliable indicator of tumor extension. MRI has been shown to be highly sensitive to cartilage invasion, particularly if fat-suppressed and post-gadolinium scans are performed. Enhancement into cartilage on post-gadolinium fat- suppressed scans is highly sensitive to invasion, but it suffers from reduced specificity because inflammation and chondronecrosis will show similar findings. questionable isolated involvement of the superior aspect of the thyroid cartilage may represent random calcification patterns within the cartilage

16 Some Choices in MRI views Sagittal MRI has been shown to be a sensitive and specific test for varying degrees of preepiglottic space invasion Coronal T1-weighted MRI scans are particularly elegant in demonstrating submucosal transglottic spread The cricoarytenoid area is best evaluated with axial scans T1:infiltrative tomur T2:tomur in mocusal and mascular layer

17 T Stage T-staging system is useful when comparing modalities that encompass the entire larynx it lacks the precision necessary to determine whether conservation laryngeal surgery may be performed at all and, if so, which particular procedure is indicated The factors that are clinically important include the precise extent of mucosal involvement, the depth of invasion of the malignancy, and the vocal cord and arytenoid mobilities it has frequently been stated that millimeter margins are adequate for conservation laryngeal surgery,

18 Overall Clinical Assessment ability to successfully tolerate the general anesthesia ? severe systemic medical problems? patient's pulmonary reserve ? Systemic illnesses that may predispose to poor wound healing include severe nutritional depletion, medications associated with organ transplantation, diabetes mellitus, and gastroesophageal reflux? Vertical hemilaryngectomy sparing arytenoid typically causes little impact on swallowing function, whereas extensions of standard or extended supraglottic laryngectomy may result in increased dysphagia and aspiration risk.

19 percutaneous gastrostomy tube has been useful for patients who require long periods of no nutrition by mouth Patients with sever pulmonary status : not recommend conservation laryngeal surgery. An important factor in patient selection is the patient's insight and active role of him. patient's overall constitution is more important than the chronologic age

20 Indication for total laryngectomy Indications 1. Advanced tumors with cartilage destruction and anterior extralaryngeal spread; particularly presenting initially with laryngeal dysfunction (including vocal cord paralysis) that includes airway obstruction or severe aspiration (these patients are not good candidates for "organ preservation," because the organ already has been damaged and will not likely function even if preserved anatomically). 2. Posterior commissure or bilateral arytenoid tumor involvement. 3. Circumferential submucosal disease with or without bilateral vocal cord paralysis. 4. Subglottic extension to involve the cricoid cartilage. 5. Completion laryngectomy for failed conservation or extensive endoscopic surgery. 6. Hypopharyngeal tumor originating at or spreading to the postcricoid mucosa.

21 7. Massive neck metastases or thyroid tumors (usually recurrent) invading both sides of the larynx from outside the laryngeal skeleton. 8. Advanced tumors of certain histologic types that are incurable by endoscopic resection, chemotherapy, or radiotherapy (e.g., adenocarcinoma, spindle cell carcinoma, soft tissue sarcomas, minor salivary gland tumors, and large cell neuroendocrine tumors); chondrosarcomas of the thyroid cartilage. 9. Extensive pharyngeal or tongue base resections in patients who are at high risk for aspiration problems. 10. Radiotherapy or chemoradiation failures; including those who have also had partial laryngectomy fail. 11. Radiation necrosis of the larynx, despite tumor control, unresponsive to adequate antibiotic and hyperbaric oxygen management. 12. Severe irreversible aspiration, with the laryngectomy used for complete separation of the air and food passages.

22 Conservation Laryngeal Surgery for the Lesions Originating in the Glottic Level Vertical Partial Laryngectomies excellent : for T1 glottic carcinomas Caution : antrior commissure is involved or if there is extension beyond the glottis or impaired cord mobility. not recommend : advanced T2 lesions or any T3 or T4 glottic carcinomas included only T2 lesions with impaired mobility and excluded lesions that extended beyond the midventricle (only five patients) or beyond 5 mm into the subglottis because of the known high local failure rate for these lesions When the anterior commissure is involved, the most common site of recurrence is the subglottis local recurrence rates for T1 lesions ranged from 0% to 11%

23 Supracricoid Partial Laryngectomy with Cricohyoido-Epiglottopexy for selected T2 and T3 carcinomas of the glottis, it has been reported that it was used for T1b and selected T4 glottic carcinomas Why low local recurrence ? the complete resection of the entire thyroid cartilage and the bilateral en bloc resection of the paraglottic spaces. In one study there were no local recurrences among nine patients with T1 glottic carcinomas (one T1a and eight T1b). The local control for T2 lesions is 4.5% (3 of 67). The local recurrence for selected T3 glottic carcinomas was 10%

24 Conservation Laryngeal Surgery for Lesion Originating in the Supraglottic Level Supraglottic laryngectomy high local control for selected T1 and T2 lesions an extremely variable success rate for those with T3 and T4 lesions, with local recurrence rates as high as 75% for the former and 66.7% for the latter improved local control among intermediate-sized supraglottic carcinomas with the addition of postoperative radiotherapy after supraglottic laryngectomy extension below the false cord and impaired cord mobility are contraindications for supraglottic laryngectomy

25 Supracricoid laryngectomy with cricohyoidopexy Contraindications to the procedure include: (1) subglottic extension > 10 mm anteriorly and 5 mm posteriorly because of the potential for cricoid cartilage involvement; (2) arytenoid fixation; (3) massive preepiglottic space invasion with involvement of the vallecula; (4) extension to the pharyngeal wall, vallecula, base of tongue, postcricoid region, and interarytenoid region; and (5) cricoid cartilage invasion. the incidence of spread of supraglottic carcinoma to the glottic level was between 20% and 54% Glottic level invasion should be suspected when there is either impaired cord mobility or extension of carcinoma to the ventricle

26 Other manage ment in early glottic cancer Only radiation:T1,T2a Laser:Tis,T1 whit out ant commisure Contravercy inT2a,poor in T2b Endoscopic cordectomy:T1 Laryngo fissur and cordectomy:T1 Vertical:T1 mid memberano vocal cord Supra cricoid:selected T1,T2,T3

27 Surgical technique (vertical partiel) 1.A tracheostomy routinely is performed 2.A horizontal skin incision is used that is separate from the tracheostomy site. 3.strap muscles is dissected from the cricoid cartilage to just above the superior aspect of the thyroid cartilage. 4.The external thyroid perichondrium is scored in the midline with a blade, and the perichondrium is elevated as a single flap in continuity with the strap musculature. 5.midline thyrotomy 6.varying amounts of ipsilateral thyroid cartilage is excised, ranging from no cartilage to the entire ipsilateral ala 7.the resected cartilage begins approximately 5 mm above the inferior aspect of the thyroid cartilage, and the resected portion is approximately 1.5 cm in height.It extends from the midline to the posterior aspect of the thyroid cartilage 8.A No. 15 blade is used to make a midline vertical cricothyrotomy. 9.At this point, the patient is paralyzed, the cords are held apart from below with a mosquito clamp, and a No. 12 blade is used to gently transect the anterior commissure 10.The true and false cords are separated sharply up to the level of the petiole of the epiglottis 11.The cancer is visualized. The soft-tissue resection is accomplished with a No. 15 blade for the anterior and posterior cuts

28 Frontolateral vertical hemilaryngectomy has been used for lesions that approach or involve the anterior commissure or opposite true vocal cord anteriorly. In this case, the vertical thyrotomy is made through the thyroid lamina of the less involved side, allowing for removal of the anterior angle of the thyroid cartilage, anterior commissure, and a portion of the contralateral true vocal cord. Posterolateral vertical hemilaryngectomy is used for cancers that extend posteriorly to involve the ipsilateral arytenoid mucosa. The thyrotomy approach is the same as the standard operation, and the modification lies in the posterior extension of the resection to encompass part or all of the ipsilateral arytenoid cartilage and mucosa A variety of reconstructive options exist, including no replacement of the glottic level allowing healing to occur by secondary intention, strap muscle flap with thyroid cartilage preservation and skin flaps. In imbrication laryngoplasty, the authors elevate a composite flap that includes the superior portion of the thyroid cartilage and the undermined false cord

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30 Extended vertical hemilaryngectomy Common characteristics include resection of the entire ipsilateral hemilarynx with the option of resecting the superior aspect of the cricoid cartilage. A variety of reconstructions : a posterior strip of the ipsilateral thyroid cartilage and fashioning a new hemilarynx, strap muscle reconstruction or pyriform sinus mucosal flap advancement into the hemilaryx

31 Functional outcome some degree of permanent hoarseness, which varies with the reconstructive technique. A more impaired voice tends to accompany no reconstruction, whereas the best voice was associated with replacement of the glottis with an adjacent false cord flap Chronic dysphagia is not associated with the standard vertical hemilaryngectomy with or without resection of the vocal process, and 92% (11 of 12) of patients resumed a normal postoperative diet within 1 month.

32 Key surgical points always tack the petiole of the epiglottis back into position with a 3-0 Vicryl stitch so that the epiglottis will not prolapse posteriorly postoperatively suture the anterior commissure on the noninvolved side anteriorly at the external thyroid perichondrium with a 4-0 Vicryl stitch so that the cord will be in normal position and so the vocal tendon will have proper tension Complications. seroma or hematoma might occur fistula is uncommon In extended procedures, there is a higher incidence of complications, including delay in decannulation, stenosis, and long-term dysphagia

33 Epiglottic Laryngoplasty The term epiglottic laryngoplasty refers to the reconstruction, which is done by undermining the epiglottis and advancing it inferiorly and laterally to reconstruct the larynx after vertical hemilaryngectomy or anteroinferiorly to reconstruct after a bilateral vertical partial laryngectomy 1.A tracheostomy is performed 2. The midline raphe of the strap muscles is identified. The thyroid perichondrium is incised in the midline. The perichondrium is elevated in continuity with the overlying strap musculature. 3.The vertical thyrotomies are made 3 to 4 mm anterior to the posterior aspect of the thyroid cartilage on the more involved side and placed more anteriorly on the less involved side 4.. A transverse cricothyrotomy is performed 5.Right-angled scissors are used to transect the soft tissue of the paraglottic space on the less involved side through the previously made thyrotomy 6.The resection on the involved side can resect the arytenoid, taking care to preserve the posterior arytenoid mucosa. 7.The epiglottis is undermined to the level of the vallecula, which is not transgressed It is advanced inferiorly and sutured to the cricothyroid membrane or cricoid cartilage and laterally to the thyroid cartilage remnants 8.The external thyroid perichondrial flap and strap muscles then are sewn across the midline.

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35 Extended procedures One extension of the epiglottic laryngoplasty has combined the procedure of the supracricoid partial laryngectomy with cricohyoidoepiglottopexy Functional outcome all patients were taking food by mouth from 1 to 18 days after decannulation, although as in all conservation laryngeal procedures in which one arytenoid is resected, some degree of temporary dysphagia is to be expected. Other authors have encountered increased degrees of postoperative aspiration and an extremely breathy voice, which they attributed to the wide anterior posterior dimension of the airway that prevents appropriate sphincteric function of the posterior glottis

36 Surgical technique (supra cricoid…) 1.a U-shaped incision in line with the tracheostomy site 2.the superior flap is elevated to approximately 2 cm above the hyoid bone 3.the sternothyroid and the thyrohyoid muscles are transected individually, from medial to lateral, along the superior aspect of the thyroid cartilage. 4.The sternohyoid muscle is elevated inferiorly, allowing for the exposure of the sternothyroid muscle. 5. The sternothyroid muscle is then carefully is transected along the inferior edge of the thyroid cartilage. Care is taken at this point not to cut the underlying thyroid gland. 6.The constrictor muscles then are transected along the posterior and superior- lateral aspect of the thyroid cartilage 7. the pyriform sinus mucosa is elevated off of the internal surface of the thyroid cartilage bilaterally 8. A Freer elevator is used to disarticulate the cricoarytenoid joint bilaterally, taking care to protect the recurrent laryngeal nerves 9.The isthmus of the thyroid gland is transected and ligated. At this point, a blunt finger dissection of the cervicomediastinal trachea is done to the level of the carina,

37 10.A transverse cricothyrotomy is performed just above the cricoid cartilage 11. endotracheal tube is removed from above and placed into the cricothyrotomy 12 The larynx then is entered through a transverse transepiglottic laryngotomy. 13 The scissors are oriented obliquely and inferiorly to allow transection of the epiglottis at the level of the petiole 14 The endolaryngeal excision now is performed on the non-tumor-bearing side first, and the incision is brought down in the sagittal plane with a scissors at the junction between the false cord and arytenoid 15. The transection is carried inferiorly just posterior to the ventricle and then through the vocal process of the arytenoid. Special care is taken to avoid entering the cricoarytenoid joint with the scissors. 16Just above the cricoid cartilage, the orientation of the scissors changes to allow connection of this incision, through the cricothyroid muscle, to the previously made cricothyrotomy. 17 The larynx is opened up on its anterior spine like a book The cut on the tumor- bearing side may be made through just posterior to the ventricle again or may transect all or part of the arytenoid cartilage 18 This incision can be done by cutting the subglottic mucosa with a No. 15 blade and following posteriorly and superiorly to the level of the arytenoid. Nonetheless, the posterior arytenoid mucosa should be spared

38 reconstruction 1.pulling the arytenoid cartilages forward with 3-0 Vicryl suture material by placing a stitch just at or just above the vocal process and sewing them (or the posterior arytenoid mucosa in the case of unilateral arytenoid resection) anterolaterally to the cricoid cartilage 2.Impaction of the cricoid to the hyoid is performed with three centrally placed 2- 0 Vicryl sutures on a 65-mm round needle. The first stitch is placed circumferentially, submucosally around the cricoid cartilage, in the midline. The stitch then is passed through a few millimeters of inferior epiglottic cartilage, submucosally, so that when the stitch is tied down, the epiglottic mucosa will be approximated to the cricoid mucosa 3.the same first stitch is passed back into the preepiglottic fat and up around the hyoid bone and deep into the tongue base 4.Before tightening the sutures, the two lateral sutures are pulled taut, which places the trachea in its postoperative position, and the tracheostomy is performed in line with the skin incision 5.With the two lateral cricohyoidoepiglottopexy sutures under tension, the central pexy stitch is tied, followed by the two lateral stitches 6.The strap muscles are closed as a second layer closure with 3-0 Vicryl 7.A cuffed tracheostomy tube is put into place 8.The skin wound is closed in two layers, taking special care to separate the tracheostomy site from the remainder of the wound

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40 Key surgical points When disarticulating the cricoarytenoid joint, be careful not to injure the recurrent laryngeal nerve When making the vertical prearytenoid incision just posterior to the ventricle, be careful not to enter the cricoarytenoid joint. Always save the posterior arytenoid mucosa in the case of a transected arytenoid cartilage, and sew this mucosa anteriorly to the cricoid cartilage during the closure The three tongue base sutures should be placed precisely 1 cm apart and arched up deeply into the tongue base. The authors use a 2-0 Vicryl on a 65-mm needle Perfect alignment between the cricoid cartilage and the hyoid bone should be created to reduce the risk of dysphagia postoperatively Gentle internal palpation of the upper esophageal sphincter with a finger will allow for assessment of hypertonia, which should prompt the consideration of cricopharyngeal myotomy except in the presence of gastroesophageal reflux The dissected inner thyroid perichondrium should be gently sewn anteriorly with one 3-0 Vicryl stitch after the creation of the cricohyoidoepiglottopexy to reposition the pyriform sinus in a closer approximation to normal

41 Extended procedures Extensions of the basic technique include resection of one arytenoid. Anterior subglottic extension may be managed with resection of the anterior arch of the cricoid, which is closed with a pexy between the first two tracheal rings and the hyoid or a tracheohyoidoepiglottopexy Functional outcome Temporary dysphagia immediately postoperatively is to be expected, but long-term dysphagia is rare a range of days to removal of nasogastric tube postoperatively from 9 to 50 days by the sixth month, speech parameters of phrase grouping and number of words per minute were similar to normal speakers, although the mean fundamental frequency was lower and wider than normal the degree of voicelessness parameters increased, suggesting difficulties in achieving consistent neoglottic closure during speech.

42 Surgical technique (supra glottic …) 1.apron incision in line with the tracheostomy 2.routinely perform bilateral modified neck dissection 3.The fascia between the strap muscles at the level of the superior aspect of the thyroid cartilage is divided. In addition, the fascia between the strap muscles is divided inferiorly 4.thyroid isthmus is transected and ligated routinely 5.The sternohyoid and the thyrohyoid muscles at the superior border of the thyroid cartilage are divided, 6.The constrictor muscles are sharply cut at the posterior and superior edge of the thyroid cartilage laterally all the way to the top of the superior cornua 7.The external thyroid cartilage perichondrium is elevated halfway down the cartilage from the superior edge to allow for the transverse thyrotomy to be made at the level just above the anterior commissure 8.The pyriform sinuses then are freed up bilaterally for endolaryngeal tumors

43 9. A tracheostomy is then performed 10. If the tumor has not involved the vallecular mucosa and if it was not palpable beneath the vallecula mucosa in the preepiglottic space, then it is oncologically sound to spare the hyoid bone, and it is skeletonized from below with an electrocautery 11. horizontal thyrotomy is made through the thyroid cartilage at the appropriate level with a sagittal saw 12.The vallecula is entered, and the epiglottis is pulled externally with an Allis clamp 13. The cut is made anterior to the arytenoid cartilage bilaterally in a superior-to-inferior direction with one scissor blade in the laryngeal lumen and one scissor blade between the thyroid cartilage and the previously elevated internal thyroid perichondrium 14.The cut is brought down to the level of the ventricle, at which point the transection is made through the ventricle at right angles to the previously made transection in front of the arytenoid 15 The reconstruction is accomplished by first sewing either the remnant of false cord mucosa or the lateral aspect of the floor of the ventricle to the external perichondrium at the corresponding level of the remaining thyroid cartilage …

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46 Key surgical points The authors locate the main trunk of the internal and external branches of the superior laryngeal nerve routinely at the time of bilateral modified neck dissection This is accomplished by dissection of the fat pad, which is anterior to the carotid artery, inferior to the hypoglossal nerve, and lateral to the superior laryngeal nerves. The superior thyroid artery runs through this fat pad and is transected proximally and distally to perform this dissection. This procedure also requires removal of the lymphatics, which travel adjacent to the larynx, allowing the main trunk of the superior laryngeal nerves to be spared bilaterally. The superior aspects of the arytenoid are spared, unless the malignancy is directly involving this area The hyoid bone is not spared when the malignancy involves the vallecula or tongue base The greater cornua of the hyoid is resected in those with marginal lesions. The tongue base sutures are placed in the midline and 1 cm off of the midline, avoiding damaging the hypoglossal nerves and the lingual arteries

47 Extended procedures There are two basic extensions of the supraglottic laryngectomy, including: (1) resection of one arytenoid or the upper part of the pyriform sinus; and (2) resection of a portion of the tongue base Arytenoid, aryepiglottic fold, or superior medial pyriform involvement from supraglottic carcinoma 1. Skeletonize the hyoid bone 2. free up the lateral cornua of the hyoid if it is to be resected 3. Only free up the internal thyroid perichondrium on the uninvolved side. 4.Enter the endolarynx through the vallecula on the uninvolved side or through the thyrotomy inferiorly if the vallecula is involved 5.Cut anterior to the uninvolved arytenoid and through the false cord. Bring the resection around the upper pyriform on the involved side, which is transected at the level of the ipsilateral true vocal cord. 6.When the pharyngoepiglottic fold is involved, resect a generous margin of the posterior tonsillar pillar and a portion of the ipsilateral tongue base. If the posterior tonsillar pillar and tongue base have been unilaterally resected, close this portion of the defect separately

48 Base of tongue extension from supraglottic carcinoma 1.Enter inferiorly through the thyrotomy 2.Do not skeletonize the hyoid bone 3.If necessary, free up the twelfth nerves and move them out of the line of resection 4.Make the tongue base resection under direct visualization from below with a 2-cm margin. 5.The resection should leave at least 1 cm of tongue base posterior to the circumvallate papillae to allow for adequate function postoperatively Functional outcome normal vibration of the cords and normal vibration amplitudes, and results of sonographic evaluations are normal, with some abnormalities related to removal of the resonance space above the cords 87% of patients had normal-to-mild breathiness and that 67% had mild or no evidence of hoarseness. Impaired swallowing function has been associated with extended supraglottic laryngectomy

49 Complications. The reported fistula rate after supraglottic laryngectomy has been 0% to 12.5% aspiration pneumonia (0%–10.8%),inability to decannulate the tracheostomy (0%–5.5%),and tracheocutaneous fistula.

50 Surgical technique ( Supracricoid laryngectomy with cricohyoidopexy ) The approach and many of the steps are the same as in supracricoid laryngectomy with cricohyoidoepiglottopexy, although in this procedure, the entire epiglottis and preepiglottic space is resected Extended procedures resection of one arytenoid Functional outcome duration of tube feedings with a range from 13 days to 365 days The percent of patients undergoing functional laryngectomy for intractable aspiration varied from 0% to 10.8% Dysphagia is more common after supracricoid laryngectomy with cricohyoidopexy when one arytenoid is resected although the average F0 among the supracricoid laryngectomy group was within normal range, the operated group was significantly less efficient in jitter, shimmer, maximum phonation time, and phase grouping The authors attributed these findings to the instability of the neoglottis

51 Intraoperative Conversion to Total Laryngectomy avoid intraoperative conversion to total laryngectomy do not perform randommicroscopic biopsies of normal appearing mucosa, The area in glottic carcinoma for which involvement may result in intraoperative conversion to total laryngectomy is invasion of the cricoarytenoid joint. Fixation of the joint is an indication that the joint capsule, the joint itself, or the surrounding musculature is involved by carcinoma. do not advocate conversion from one type of conservation laryngeal surgery intraoperatively to another to avoid total laryngectomy. patient understanding that in rare instances, removal of the entire larynx may be necessary

52 Current Organ Preservation Paradigm for Laryngeal Cancer induction chemotherapy followed by radiation was able to preserve the larynx while not affecting survival concurrent chemotherapy and radiation was superior to both induction chemotherapy followed by radiation and radiation alone for larynx preservation in patients with stage III and stage IV disease (T2, T3, or T4 not extending to tongue base or through cartilage

53 Conservation Laryngeal Surgery and Radiotherapy The loss of functional anatomy usually manifests as permanent hoarseness when the glottis is resected and as temporary dysphagia when the supraglottis is resected. The conservation laryngeal approach to organ preservation accepts decreased laryngeal function for the entire population of patients to decrease the morbidity and mortality associated with local recurrence.

54 ANATOMY, PHYSIOLOGY, AND TUMOR SPREAD The extension of cancer into the thyroid cartilage tends to occur in areas of ossification of the cartilage. The mode of invasion into the ossified bone has been attributed to osteoclast formation extension along collagen bundles, or through areas of high vascularity.

55 The perichondrium provides an excellent barrier to invasion, and once the carcinoma is within the cartilage, the cancer can extend throughout the cartilage behind an intact perichondrium patients with T3 glottic cancers, any combination of two factors including significant degree of calcification of the cartilage, tumor length >2 cm, and anterior commissure involvement resulted in a higher incidence of cartilage invasion (71%–92%) The cricoid cartilage is the only circumferential ring in the airway, and preservation or reconstruction of its ring-shaped structure allows for decannulation after conservation laryngeal surgery. The most common site of cricoid cartilage invasion by carcinoma is at its posterior superior border most common site of arytenoid invasion is at the points of attachment of the joint capsule

56 The most common site of invasion of the thyroid cartilage was at the angle,although other sites of predilection for carcinoma invasion are the points of attachment of the cricothyroid membrane and the anterior origin of the thyroarytenoid musculature. The perichondrium provides an excellent barrier to invasion, and once the carcinoma is within the cartilage, the cancer can extend throughout the cartilage behind an intact perichondrium

57 carcinoma on the infrahyoid surface of the epiglottis readily extends through the fenestrations of the epiglottic cartilage through blood vessels and the ducts of the seromucinous glands The hyoid bone is almost never involved by supraglottic carcinoma Preservation of the hyoid bone helps with swallowing postoperatively. Understanding this concept is essential and makes it possible to perform supracricoid laryngectomy with cricohyoidopexy in selected transglottic tumors. preserve the hyoid bone in cases without palpable submucosal vallecula carcinoma or vallecula mucosal involvement The conus elasticus provides a temporary barrier for the spread of early glottic carcinoma, but ultimately, for larger cancers, it serves as the gateway to the subglottic and extralaryngeal spread of carcinoma

58 the anterior commissure tendon is a point of dense adhesion of fibrous tissue, and it is rare for an early glottic cancer with anterior commissure involvement to erode into the thyroid cartilage here the anterior commissure tendon provides access to cartilage invasion for larger cancers, which spread superiorly or inferiorly. Anteriorly, there is a superior inferior condensation of the conus elasticus called the cricothyroid ligament, which is a central structure and does not spread out laterally to provide a connective tissue barrier along the circumference of the cricoid Extension out of the larynx through the thyrohyoid membrane alone is rare and typically is seen when cancer exits the larynx through the upper portion of the thyroid cartilage

59 The hyoepiglottic ligament to be a resilient barrier to malignant spread from the supraglottis to the tongue base when the cancer is confined to the laryngeal membranes and does not clinically invade the suprahyoid epiglottis carcinoma tends to invade within the preepiglottic space with a "pushing edge," which is almost "encapsulated" after it reaches the elastic tissue membranes in the preepiglottic space, contributing to the oncologic safety in saving the hyoid bone during supraglottic surgery. The paraglottic space traverses the supraglottis, glottis, and subglottis laterally within the larynx. Rather than having a distinct barrier to superior- inferior spread, cancer seems to be impeded in its course through the paraglottic space to varying degrees by the hourglass shape of the space, which is made by the indentation of the ventricle and saccule

60 One additional space is Reinke's space, which actually is a potential space under the true vocal cord mucosa and provides no barrier to invasion. supraglottic carcinomas that overlie the epiglottic cartilage have a tendency (9 of 10 cases) to extend into the preepiglottic space, at least microscopically, through the fenestrations in the epiglottic cartilage. seromucinous tubuloalveolar glands extend through the fenestrations and provide a route of spread of cancer into the preepiglottic space incidence of spread of supraglottic carcinoma to the glottic level is between 20% to 54%.

61 there was a statistically significant relationship between the presence of abnormal cord mobility or involvement of carcinoma below the false cord and glottic level extension, most commonly through the paraglottic space Carcinomas at the glottic level tend to begin at the junction of the anterior one-third and posterior two-thirds of the vocal cord. They readily pass through Reinke's space to the tissues below For early lesions, the conus elasticus provides a barrier to extension; as the lesion enlarges, this barrier becomes less pertinent. the main trunks of the superior and recurrent laryngeal nerves and the hypoglossal nerves, bilaterally, should be preserved during conservation laryngeal surgery.

62 50% to 65% of the entire adult airway is located posterior to the tips of the vocal processes and concluded that the posterior larynx is the respiratory airway and the anterior portion is the phonatory airway loss of one or both vocal cords results in hoarseness, but preservation of at least one arytenoid and an intact circumferential ring at the level of the cricoid is sufficient for speech and swallowing without a tracheostomy


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