A Modified Frontolateral Partial Laryngectomy with Laryngeal Framework Reconstruction, the Voice Outcomes Better: preliminary report

Motohiro Sawatsubashi, Toshiro Umezaki, Kazuo Adachi, Shizuo Komune Dept. of Otorhinolaryngology-Head and Neck Surgery, Kyushu University, Fukuoka, JAPAN

INTRODUCTION

RESULTS

Table 1. Patients and post operative GRBAS scale. T; according to 2010 TNM

Fig. 10. One year post operative endoscopic Findings (Patient 2, modified method)

Fig. 9. One year post operative endoscopic Findings (Patient 7, conventional method)

ABSTRACT

METHODS AND MATERIALS

DISCUSSION & CONCLUSIONS

REFERENCES

CONTACT

Objectives: Endoscopic resection and radiotherapy are organ-preservation strategies for glottic cancer because of the high local control and quality of voice after the therapy. However, frontolateral partial laryngectomy is still needed in some cases. This procedure has the complication of hoarseness. Therefore, we applied the theories of laryngeal framework surgery to partial laryngectomy with reconstruction using strap muscles and skin flap in order to improve postoperative voice qualities. Methods: We performed a modified frontolateral partial laryngectomy in three selected cases (rT1a, T3 cases). The retrospective analysis of voice qualities (PPQ, APQ, NHR, MPT) was performed in 10 frontolateral partial laryngectomy cases (7 conventional and 3 modified methods). Surgical procedure: Frontolateral vertical partial laryngectomy with tumor-free margin was performed via laryngofissure approach. After tumor resection, approximation laryngoplasty was performed using sternothyroid muscle flap that was inserted into posterior dead space to gain better contact of the posterior vocal fold on the reconstructed vocal ridge. After these procedures, a reverted sternohyoid muscle was placed inside the preserved outer perichondrium to reduce dead space and externally medialize cervical skin flap, which shaped new vocal fold. Results: No recurrence was observed in any case. No aspiration and laryngeal stenosis were observed in any case. The postoperative voice qualities were improved over pretreatment qualities in modified cases. PPQ after modifying this method was better than conventional methods. Conclusions: It is better for voice quality to treat selected glottic cancers with this modified frontolateral partial laryngectomy.

No recurrence was observed in any case. No aspiration and laryngeal stenosis were observed in any case. The reconstructive vocal folds were in good shapes in modified method cases, (Fig.10, 12) Breathiness, MPT, PPQ, APQ and NHR of modifying method cases were better than those of conventional method cases in the post-operative voice qualities (Table 1, Fig.13 -15).

Patients: We performed a novel modified frontolateral partial laryngectomy in three selected cases (rT1a, T3 cases) in 2012. We also compared the results to the seven patients (T3 or T2 cases) with conventional frontolateral partial laryngectomy between 2007 and 2011. All patients were radiation therapy (RT) failure or poor RT responders. Voice Evaluation We evaluated the patient’s voice with GRBAS, maximum phonation time (MPT), pitch perturbation (PPQ), amplitude perturbation quotient (APQ), noise to harmonic ration (NHR). The GRBAS scale was classified according to the Japan Society of Logopedics and Phoniatrics. Surgical procedure A novel modified frontolateral partial laryngectomy: Frontolateral vertical partial laryngectomy with tumor-free margin was performed via laryngofissure approach.

Primary treatments for glottic cancer are endoscopic laser surgical resection or RT , radiochemotherapy (CRT). Non- responders or poor responders for the RT,CRT are selected surgery. The frontolateral partial laryngectomy is used for organ preservation salvaged surgery after RT or CRT. This conventional procedure has the complication of voice quality, especially hoarseness after surgery. This modified frontolateral partial laryngectomy can get adequate glottic closure during phonation in order to obtain a good voice quality after glottic reconstruction.

Endoscopic resection and radiotherapy are organ-preservation strategies for glottic cancer because of the high local control and quality of voice after the therapy. However, frontolateral partial laryngectomy is still needed in some cases. This procedure has the complication of hoarseness. Therefore, we applied the theories of laryngeal framework surgery to partial laryngectomy with reconstruction using strap muscles and skin flap in order to improve postoperative voice qualities.

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3.  Calcaterra TC: Sternohyoid myofascial flap reconstruction of the larynx for vertical partial laryngectomy. Laryngoscope. 1983 Apr;93(4):422-4.

4.  Hirano M, Kurita S, Matsuoka H: Vocal function following hemilaryngectomy. Ann Otol Rhinol Laryngol. 1987 Sep-Oct;96(5):586-9.

5.  Biacabe B, Crevier-Buchman L, Laccourreye O, et al: Phonatory mechanisms after vertical partial laryngectomy with glottic reconstruction by false vocal fold flap. Ann Otol Rhinol Laryngol 2001; 110:935-940.

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<Motohiro Sawatsubashi MD, PhD> <Kyushu University, JAPAN> Email: motohiro@med.kyushu-u.ac.jp Phone: +81-92-462-5668 FAX: +81-92-462-5685

Fig 13. Pre and one year post operative MPT (conventional method)

Fig 14. . Pre and one year post operative MPT (modified method)

After tumor resection, approximation laryngoplasty was performed using sternothyroid muscle flap that was inserted into posterior dead space to gain better contact of the posterior vocal fold on the reconstructed vocal ridge. After these procedures, a reverted sternohyoid muscle was placed inside the preserved outer perichondrium to reduce dead space and externally medialize cervical skin flap, which shaped new vocal fold.

Fig 1. Make the skin incision.

Fig. 3. After Resected tumor of left vocal fold (arrow head)

Fig. 5. The upper portion of both sternohyoid and sternothyroid muscles are inserted into the intralaryngeal wound so as to make a large bulge of the vocal folds.

Fig. 7. Reconstruction of vocal fold surface using

the cutaneous skin flaps.

Fig. 8. Close the skin with drains.

Fig. 11. CT findings one year after surgery, (Patient 7, conventional method)

Fig. 12. CT findings one year after surgery, (Patient 2, modified method)

　 　 　 　 　 　 　 　 　 　 　 　

Group Patient Age T 　 Post operative GRBAS scale (12 months) 　 Surgical time Follow-up

　 　 　 　 　 Grade Roughness Breathiness Asthenicity Strain (minute) (month)

Modified method 　 　 　 　 　 　 　 　 　 　

　 1 66 r1 　 1 1 1 0 1 272 17

　 2 61 3 　 3 3 1 0 2 189 13

　 3 64 1a 　 　 　 　 　 　 208 7

　 　 　 　 　 　 　 　 　 　 　 　

Conventional method 　 　 　 　 　 　 　 　 　 　

　 4 65 3 　 3 0 3 3 0 NA 76

　 5 50 3 　 2 1 2 0 2 292 41

　 6 63 3 　 3 2 3 0 2 193 38

　 7 59 3 　 2 1 1 1 0 305 36

　 8 51 3 　 3 2 3 0 3 189 32

　 9 58 2 　 3 2 3 1 1 203 30

　 10 56 3 　 2 2 2 0 1 159 20

　 　 　 　 　 　 　 　 　 　 　 　

Fig 2. Separate strap muscles in the Midline and elevated the muscle flaps .

Fig. 6. showing the strap muscle and skin flaps and cartilage

PPQ APQ NHR

Figure 15. One year post operative voice qualities

Sternohypod muscle flap

Sternothyroid muscle flap

denudation

Denuded skin

Rt. Vocal fold

Reconstructive right vocal fold Reconstructive right vocal fold