1. Conservation laryngeal surgery

2. Reference Cummings otolaryngology head and neck surgery, 5 th edition, chapter 110 ; conservation laryngeal surgery P. 1539-1562 Cummings otolaryngology head and neck surgery, 5 th edition, chapter 110 ; conservation laryngeal surgery P. 1539-1562 Cummings otolaryngology head and neck surgery, 4 th edition Cummings otolaryngology head and neck surgery, 4 th edition Bailey BJ. Atlas of Head & Neck Surgery Otolaryngology Otolaryngology. 4 th Edition. Bailey BJ. Atlas of Head & Neck Surgery Otolaryngology Otolaryngology. 4 th Edition. Bailey BJ. Head & Neck Surgery – Otolaryngology. 5 th Edition Bailey BJ. Head & Neck Surgery – Otolaryngology. 5 th Edition Atlas of head and neck surgery. 2 nd edition; 1999 Atlas of head and neck surgery. 2 nd edition; 1999 Cummings otolaryngology head and neck surgery, 5 th edition, chapter 110 ; conservation laryngeal surgery P. 1539-1562 Cummings otolaryngology head and neck surgery, 5 th edition, chapter 110 ; conservation laryngeal surgery P. 1539-1562 Cummings otolaryngology head and neck surgery, 4 th edition Cummings otolaryngology head and neck surgery, 4 th edition Bailey BJ. Atlas of Head & Neck Surgery Otolaryngology Otolaryngology. 4 th Edition. Bailey BJ. Atlas of Head & Neck Surgery Otolaryngology Otolaryngology. 4 th Edition. Bailey BJ. Head & Neck Surgery – Otolaryngology. 5 th Edition Bailey BJ. Head & Neck Surgery – Otolaryngology. 5 th Edition Atlas of head and neck surgery. 2 nd edition; 1999 Atlas of head and neck surgery. 2 nd edition; 1999

3. IntroductionIntroduction Conservation laryngeal surgery  Preserve speech and swallow function without permanent tracheostomy  high local control rate same total laryngectomy Conservation laryngeal surgery  Preserve speech and swallow function without permanent tracheostomy  high local control rate same total laryngectomy

4. First principle: Local control First principle: Local control Second principle: Accurate assessment of three-dimensional extent of tumor Second principle: Accurate assessment of three-dimensional extent of tumor Third principle: Cricoarytenoid unit is basic functional unit of larynx (swallowing, Respiration,Phonation and airway protection) Third principle: Cricoarytenoid unit is basic functional unit of larynx (swallowing, Respiration,Phonation and airway protection) Fourth principle: Resection of normal tissue to achieve an expected functional outcome Fourth principle: Resection of normal tissue to achieve an expected functional outcome First principle: Local control First principle: Local control Second principle: Accurate assessment of three-dimensional extent of tumor Second principle: Accurate assessment of three-dimensional extent of tumor Third principle: Cricoarytenoid unit is basic functional unit of larynx (swallowing, Respiration,Phonation and airway protection) Third principle: Cricoarytenoid unit is basic functional unit of larynx (swallowing, Respiration,Phonation and airway protection) Fourth principle: Resection of normal tissue to achieve an expected functional outcome Fourth principle: Resection of normal tissue to achieve an expected functional outcome Principles of organ preservation surgery

5. Laryngeal framework

6. Only complete skeletal ring of airway Only complete skeletal ring of airway compare with signet ring Allow for decanulation after conservation laryngeal surgery

7. Cricoarytenoid unit fundamental functional unit of the larynx one arytenoid cartilage with its associated cricoarytenoid musculature and recurrent and superior laryngeal nerves Preservation of one cricoarytenoid unit with the associated cricoid ring allows for speech and swallowing without a permanent tracheostomy. Cricoid, Arytenoid Muscle: PCA, LCA, interarytenoid Nerve: SLN, RLN

8. Petiole เกาะกึ่งกลางของ thyroid cartilage โดยมี fibrous tissue ประสานไป กับ Broyles’ ligament. Suprahyoid Infrahyoid  fenestration CA supraglottic CA supraglottic may invade preepiglottic space through the fenestration

9. Condensations of fibrous tissue of larynx

10. Arise from sup. portion of cricoid cartilage to join with inferomedial part of vocal ligament of vacal cord

11. Condensations of fibrous tissue of larynx temporary barrier for the spread of early glottic carcinoma But for larger cancer,gateway to subglottic and extralaryngal spreading

12. Sup. border of membrane is free and oblique and thickening to form aryepiglottic fold. Inf. ; extend from infr point of epiglottis this attach to thyroid cartilage to insert arytenoid Inf. border are thickening to form vestibular fold; a part of false vocal cord

13. Broyles ligament: or anterior commissure tendon, devoid of perichondrium Thyrohyoid membrane: extension out of the larynx through the thyrohyoid membrane alone is rare, typically seen when cancer exit larynx through upper portion of thyroid cartilage

14. Hyoepiglottic ligament Resilient barrier to malignant spread from the supraglottis to BOT When cancer confined to laryngeal membranes does not clinically invade the suprahyoid epiglottis

15. Ant. surface; thyrohyoid m. Sup. surface; hyoepiglottic ligament,valleculae Post. surface; epiglottis Inf. surface; thyroepiglottic ligament Contain lymphatic tissue, vessels, fat. CA supraglottis invasion to this space through fenestration of epiglottis

16. Inferomedial ; conus elasticus Anterolateral ; thyroid ala, abut preepiglottic space Superomedial ; quadrangular membrane Posterior ;medial wall of pyriform Inferior ; adjacent to cricothyroid m. Tumor invade to extralarynx through cricothyroid m.

18. Lymphatic drainage Lymphatic drainage sparse anteriorly and at glottis Rich lymphatics in supraglottis, subglottis, posterior half Barriers to spread 1)Conus Elasticus inferiorly 2)Quadrangular Membrane laterally 3)Thyrohyoid Membrane superiorly Lymphatic drainage sparse anteriorly and at glottis Rich lymphatics in supraglottis, subglottis, posterior half Barriers to spread 1)Conus Elasticus inferiorly 2)Quadrangular Membrane laterally 3)Thyrohyoid Membrane superiorly

19. Preoperative evaluation 1)Assess oncologic of primary site, regional nodes, and distant sites (TNM staging) 2)Assess patient's ability (medical undergo surgery and postop.) 3)Patient and family insight, emotional state, and ability and willingness to postop. Rehab. 1)Assess oncologic of primary site, regional nodes, and distant sites (TNM staging) 2)Assess patient's ability (medical undergo surgery and postop.) 3)Patient and family insight, emotional state, and ability and willingness to postop. Rehab.

20. Degree of airway impairment and voice quality Arytenoid and vocal cord mobility – Glottic CA : Impaired mobility TVC may be result of superficial TA invasion or bulk on surface of cord in exophytic lesion Fixed TVC most common results from extensive invasion of TA m. Oncologic assessment

21. – Supraglottic CA : Pseudofixation : arytenoid motion impaired superiorly causing from "weight impact" of tumor Actual fixation : malignant involvement of intrinsic laryngeal muscle, cricoarytenoid joint, or both

22. Oncologic assessment Extensions out of endolarynx : – Palpate thyroid cartilage for irregularities – Areas directly above and below thyroid cartilage Bulge or mass at level of thyrohyoid membrane may indicate massive preepiglottic space invasion Mass at level of cricothyroid ligament may indicate delphian lymph node, which indicates subglottic extension of malignancy

23. AJCC Staging Glottic cancer

24. AJCC Staging Supraglottic cancer

25. Assessment of patient's ability Aging and chronic lung obstructive disease increase risk of postoperative atelectasis/pneumonia Lung function test  controversy – Some authers: routinely for all patients – FEV-1 < 50-60% of expected for age predicts high risk of pulmonary complications – Ability to walk up 2 flights of stairs without getting short of breath better predictor of post-op complications  good candidates for conservation sx Good cognitive function, consent for intra-op TLG Aim: Good life activity, Good control local Aging and chronic lung obstructive disease increase risk of postoperative atelectasis/pneumonia Lung function test  controversy – Some authers: routinely for all patients – FEV-1 < 50-60% of expected for age predicts high risk of pulmonary complications – Ability to walk up 2 flights of stairs without getting short of breath better predictor of post-op complications  good candidates for conservation sx Good cognitive function, consent for intra-op TLG Aim: Good life activity, Good control local

26. Conservation laryngeal surgery Endoscopic Surgery Open Surgery

27. Glottic cancer Vertical hemilaryngectoym Extended FRONTOLATERAL VERTICAL HEMILARYNGECTOMY Anterior frontal vertical hemilaryngectomy POSTEROLATERAL VERTICAL HEMILARYNGECTOMY. EXTENDED VERTICAL HEMILARYNGECTOMY. Extended FRONTOLATERAL VERTICAL HEMILARYNGECTOMY Anterior frontal vertical hemilaryngectomy POSTEROLATERAL VERTICAL HEMILARYNGECTOMY. EXTENDED VERTICAL HEMILARYNGECTOMY. Horizontal Partial Laryngectomies Supracricoid Partial Laryngectomy with Cricohyoido-Epiglottopexy (SCPL with CHEP) Supracricoid Partial Laryngectomy with Cricohyoido-Epiglottopexy (SCPL with CHEP) EXTENDED PROCEDURES. Transoral laser microsurgery Vertical partial laryngectomy

28. Supraglottic cancer Supraglottic Laryngectomy EXTENDED PROCEDURES ARYTENOID, ARYEPIGLOTTIC FOLD, OR SUPERIOR MEDIAL PYRIFORM INVOLVEMENT FROM SUPRAGLOTTIC CARCINOMA. BASE OF TONGUE EXTENSION FROM SUPRAGLOTTIC CARCINOMA. EXTENDED PROCEDURES ARYTENOID, ARYEPIGLOTTIC FOLD, OR SUPERIOR MEDIAL PYRIFORM INVOLVEMENT FROM SUPRAGLOTTIC CARCINOMA. BASE OF TONGUE EXTENSION FROM SUPRAGLOTTIC CARCINOMA. Supracricoid Laryngectomy with Cricohyoidopexy (CHP) EXTENDED PROCEDURES. Transoral laser microsurgery Horizontal Partial Laryngectomies

30. Principles Endoscopic laser resection can encompass smaller lesions without transgressing tumor Larger tumors are best managed with controlled resection in several pieces Image B: Microscopic evaluation of the cut surface C, Small vocal fold lesions can be resected as a single specimen with care to keep a 1- to 3-mm distance about the lesion and to mark it appropriately to confirm clear margins histologically Ref: Cumming Figure 100-10

31. Classification by European laryngological society 2007

32. Type I Type II Type III Type IV

33. Type Va Type Vb Type Vc Type Vd

34. Cordectomy type VI

35. Classification by European laryngological society for supreglottic CA

37. Endoscopic cordectomy Reference : www. medscape.com

39. TLM for T1 glottic cancer

40. Endoscopic laser surgery for T2 supraglottic cancer Pre-treatmentPost-resection

42. IndicationsIndications Early glottic cancer (T1 and T2 stages) Select cases T3 lesions Not be appropriate in cases of recurrent glottic carcinomas

43. ContraindicationsContraindications Large T3 or any T4 lesions Large T3 or any T4 lesions Arytenoid fixation (CA joint) Arytenoid fixation (CA joint) Interarytenoid, postcricoid invasion Interarytenoid, postcricoid invasion Cricoid invasion (subglottic extension >10 mm anteriorly; >5 mm posteriorly) Cricoid invasion (subglottic extension >10 mm anteriorly; >5 mm posteriorly) Bulky transglottic lesion Bulky transglottic lesion Massive Pre-epiglottic space invasion Massive Pre-epiglottic space invasion Lesions extending beyond external thyroid perichondrium Lesions extending beyond external thyroid perichondrium Large T3 or any T4 lesions Large T3 or any T4 lesions Arytenoid fixation (CA joint) Arytenoid fixation (CA joint) Interarytenoid, postcricoid invasion Interarytenoid, postcricoid invasion Cricoid invasion (subglottic extension >10 mm anteriorly; >5 mm posteriorly) Cricoid invasion (subglottic extension >10 mm anteriorly; >5 mm posteriorly) Bulky transglottic lesion Bulky transglottic lesion Massive Pre-epiglottic space invasion Massive Pre-epiglottic space invasion Lesions extending beyond external thyroid perichondrium Lesions extending beyond external thyroid perichondrium

44. Laryngofissure & cordectomy For midcord mobile For midcord mobile T 1 CA glottic T 1 CA glottic cannot resect endoscopic because of anatomic constraint preventing adequate laryngoscopic exposure cannot resect endoscopic because of anatomic constraint preventing adequate laryngoscopic exposure For midcord mobile For midcord mobile T 1 CA glottic T 1 CA glottic cannot resect endoscopic because of anatomic constraint preventing adequate laryngoscopic exposure cannot resect endoscopic because of anatomic constraint preventing adequate laryngoscopic exposure

45. Laryngofissure & cordectomy Advantages Excellent exposure, which permits precise tumor removal and accurate sampling of adjacent tissue for F/S analysis Excellent exposure, which permits precise tumor removal and accurate sampling of adjacent tissue for F/S analysis Can be extended to include resection of adjacent structures (e.g., underlying thyroid cartilage). Can be extended to include resection of adjacent structures (e.g., underlying thyroid cartilage).Advantages Excellent exposure, which permits precise tumor removal and accurate sampling of adjacent tissue for F/S analysis Excellent exposure, which permits precise tumor removal and accurate sampling of adjacent tissue for F/S analysis Can be extended to include resection of adjacent structures (e.g., underlying thyroid cartilage). Can be extended to include resection of adjacent structures (e.g., underlying thyroid cartilage).Disadvantages Need for tracheotomy Need for tracheotomy Potential problems with healing may compromise airway, voice, and swallowing Potential problems with healing may compromise airway, voice, and swallowing Relies on secondary intention healing to create a neocord : breathy voice commonly results Relies on secondary intention healing to create a neocord : breathy voice commonly resultsDisadvantages Need for tracheotomy Need for tracheotomy Potential problems with healing may compromise airway, voice, and swallowing Potential problems with healing may compromise airway, voice, and swallowing Relies on secondary intention healing to create a neocord : breathy voice commonly results Relies on secondary intention healing to create a neocord : breathy voice commonly results

46. Surgical technique

47. Surgical technique (2)