Management of Ca. Larynx

Md Shafiuddin MazharPost Graduate, Dept of ENT & HN surgery

NMCH&RC Raichur

Treatment decisions in laryngeal Ca.

Glottic cancer

T1 / T2 SUBGLOTTIC CA.

• No scope for voice conservation sx.• EBRT = manstay of treatment• LN mets= combined chemo + radiation

T3 CA. OF THE LARYNX

• Factors which influence the treatment– The site and extent of the lesion– Mobility of the VC vs fixity of the VC vs fixity of the

hemilarynx– Lateralised lesion vs b/l involvement– Degree of airway obstruction; functional

incometence– Age, general health, pulm status.

T4 CA. OF LARYNX

• T4a= surgery F/B radiotherapy = mainstay.• N0= I/L thyroid lobectomy + LN 2 3 4 B/L cleared.• N1=LN 2 to 5• Subglottic disease= paratracheal LN are also cleared.

• T4b = symptomatic treatment.• Chemotherapy may be considered for palliation.

PRINCIPLES OF OPEN PARTIAL LARYNGECTOMY

• Preserve speech and nasal respiration.• Barriers for the spread provides oncologically

safe compartmental resection.• Present indications in early lesions-– Inadequate transoral access for laser resection– Post radiation salvage– Bulky lesions with impaired cord mobility– Pt. Unsuitable for radiotherapy

PRINCIPLES OF OPEN PARTIAL LARYNGECTOMY

• SCPL is designed for ca. that have spread across the regional barriers and become glottosupraglottic.

• Preservation of an intact cricoid ring and an intact functioning arytenoid are the most imp. Prerequisite for an OPL.

SURGICAL PRINCIPLES OF OPLpreservation of the essential functions of the larynx, ie., phonation. nasal respiration and protection of the airway.

• Embryological Compartments:

• Cricoarytenoid Unit

• Cricoid Ring:

• Innervation

RECONSTRUCTION

The aim is to ensure that

• Anteroposterior diameter of the larynx– Anterior commissure-a silicone keel is placed, temporarily

separating the two sides.

• The posterior glottic bulk– The resected arytenoid is generally replaced with either a piece

of thyroid cartilage or with the strap muscles to provide the posterior glottic bulk.

EXTENDED PARTIAL LARYNGECTOMY– the tumour extent > assessed preoperatively.– surgeon undertaking voice conservation surgery must be adept at the full range of

procedures so that an alternative, more extended procedure is done.– written consent for total laryngectomy

SALVAGE PARTIAL LARYNGECTOMY– Preoperative evaluation must confirm – that the initial lesion prior to radiation therapy was suitable for a conservation

procedure, – recurrence on the same site as before – recurrence fulfils all the eligibility criteria required for the particular conservation to be

performed.– rest of the laryngeal tissues are supple and devoid of post radiation oedema.

PROCEDURESGlottic cancer

vertical plane across the glottis.

• Cordectomy through laryngofissure

• Vertical partial laryngectomy

• Supracricoid partial laryngectomy with crico- hyoido-epiglottopexy (SCPL-CHEP).

Early supraglottic cancer

horizontal plane above the glottis.

• Supraglottic partial laryngectomy

• Extended supraglottic partial laryngectomies.– (+Pyriform/base of the

tongue/arytenoid).

Glotto-supraglottic cancer

combination of the vertical and the horizontal partial laryngectomies.

• Supracricoid partial laryngectomy (SCPL) with Crico-Hyoido-Pexy (CHP)

• Three -Quarter laryngectomy.

PROCEDURES FOR GLOTTIC CA.• Early glottic cancer spreads superficially, and in the vertical direction can be

resected in the vertical plane.

– Laryngofissure and cordectomy• mid-cord lesions with freely mobile cords. (tolr)

– Vertical Partial Laryngectomy (VPL)• includes resection of the involved cord along with overlying thyroid cartilage and paraglottic

tissue. Despite the availability of TOLR, VPL has a very definite place in voice conservation surgery. In fact, it is probably the most frequently.

– supracrioid partial laryngectomy with crico-hyoido-epiglottopexy (SCPL with CHEP) • In glottic cancers with either impaired cord mobility and paraglottic fullness or minimum

supraglottic spread.• offers superior oncologic safety, but VPL is physiologically safer.

• adequate and functional laryngeal aditus is essential after open partial laryngeal procedures.

• SCPL with CHEP is contraindicated in elderly patients and in those with compromised lung function or with existing tracheostomy.

• Voice quality with OPL < TOLR and XRT.

LARYNGOFISSURE WITH CORDECTOMY

• oldest open surgical procedure

• Gordon Buck in 1853

• excellent local control rates in T1 glottic cancer confined to the mid-cord.

• most lesions suitable for a cordectomy are now approached endoscopically and resected using the CO2 laser.

• Is it still a useful procedure?– “Yes”– Inadequate endoscopic exposure/No facilities for CO2 laser.

Indications• mid-cord lesion, confined to the membranous

vocal cord without extension to the anterior commissure with no impairment in vocal cord mobility as this signifies lateral spread into the underlying soft tissue which renders this procedure inadequate.

ProcedureUnder general anaesthesia administered through a tracheostomy,

a midline vertical thyrotomy is performed from the thyroid notch superiorly to the lower border of the thyroid cartilage inferiorly.

The larynx is entered through the cricothyroid membrane.

Cordectomy entails removal of only the soft tissues

• The thyroid cartilage and the perichondrium are approximated.

• The mucosal defect is allowed to heal by granulation.

• In a matter of a few weeks a dense fibrous pseudocord forms.

• The tracheotomy is decannulated within a week and allowed to close.

• Since neither the laryngeal nerve supply nor the pharyngeal musculature is disturbed by this procedure, it does not cause aspiration and is very well tolerated even in the elderly.

Results

• Local control rates following cordectomy 84-98%.

• In properly selected cases, control rates upwards of 90% are consistently obtained.

• The quality of voice following laryngofissure and cordectomy is inferior to that following an endoscopic laser cordectomy (TOLR).

• Voice quality is best following successful radiation therapy.

• Carefully planned TOLR (chapter XIV) resulting in either type I (subepithelial resection — utilised in dysplasia or in-situ cancers) or type II (subligamental) cordectomy gives very good quality voice.

VERTICAL PARTIAL LARYNGECTOMY (VPL)

Aka vertical hemilaryngectomyBillroth in 1875.number of modifications described in surgical literature, the most notable being those described by Norris, Som, Ogura and Biller.

Hemilanyngectomy (without involvement of the anterior commissure or the arytenoid)

Frontal laryngectomy (anterior commissure lesion)

Frontolateral laryngectomy (extension across the anterior commissure)

Extended hemilaryngectomy (involving the arytenoid)

These adaptations of VPL give the procedure a very wide scope.

cancers with impairment of cord mobility, select cases o f cord fixity; involvement of the anterior commissure, and even the contralateral cord; extension to the anterior surface of the arytenoids; limited involvement of the false cord or the

subglottis can all be resected with a VPL

Indications• Involvement of anterior commissure (AC)

– Radiotherapy may fail to deliver an adequate dose at the AC, resulting in higher failure rates.

– Microlaryngoscopic exposure to the AC may be very difficult.

• Impaired mobility of the vocal cord– infiltrating vocalis muscle or the paraglottic

space.Failure rates with RT are higher with such deep infiltration of disease.

– TOLR for such lesions may necessitate type IV cordectomy with resultant poor quality of voice and yet not give very satisfactory tumour free margins.

• Subglottic extension of disease – Limited subglottic extension (< lOmm anteriorly and

<5 mm posteriorly) can be resected effectively with VPL

• Inadequate exposure: – Lesion where there is inadequate exposure on

microlaryngoscopy and yet surgery is strongly indicated e.g.

– a) Verrucous cancer – b) Cancer in the very young – c) Previous radiation therapy to the neck.

• Salvage of post-RT Recurrence– For partial laryngectomy to be feasible in post RT

recurrent / residual disease the following criteria need to be satisfied

– a) The lesion prior to radiotherapy was amenable to VPL

– b) The recurrence is in the same area and has not progressed.

– c) The rest of the laryngeal tissues are supple and non-oedematous.

• Select T3 glottic cancers

LimitationsVPL is not feasible when a glottic cancer has the following:

i. Subglottic extension of disease more than 10 mm anleriorly or more than 5 mm posteriorly.

ii. Paraglottic disease extending superiorly above the level of the ventricle or inferiorly up to the cricothyroid level.

iii. Extension across the anterior commissure involving more than one-third of the contralateral vocal cord.

iv. Cord fixity associated with fixation of the arytenoid.

Procedure• Vertical Partial Laryngectomy involves a full thickness en-

bloc resection of the involved segment of the glottis along with the overlying segment of the thyroid cartilage and the intervening paraglottic tissues.

• The upper margin of mucosal resection includes a segment of the false cord.

• The lower margin of resection is above the cricoid cartilage

Surgery is performed under general anaesthesia administered through a tracheotomy.

• After reflecting the external perichondrium on both sides of the thyroid cartilage, two vertical cartilage cuts (fig)are placed depending on the site of the lesion within the glottis

• Entry into the larynx is via the cricothyroid membrane.

• The first vertical cut across the glottis and the paraglottic tissues is made on the less involved side.

• As the larynx unfolds to allow exposure inside, the remaining mucosal and soft tissue cuts are made under vision to complete the resection.

• The epiglottis is not removed.• Both superior laryngeal nerves are preserved.

Reconstructionprovide an adequate laryngeal aditus which is functional and prevents aspiration.

Three important steps.• Reattachment of the remnant vocal cord:

– The contralateral true vocal cord must be anchored anteriorly to the adjoining thyroid cartilage or to the soft tissue. This helps in keeping the vocal cord taut which results in a better quality of voice.

• The Mucosal Defect – silastic keel.– vertical flange of the keel-separate the two sides from each other horizontal flanges -anchored to the remnant thyroid cartilages

on both sides.– After 2-3 weeks,keel is removed endoscopically.

• Reconstruction of the Resected arytenoid: – It is Important to reconstitute the posterior glottic bulk. (muscle, tendon, fat, cartilage and the

epiglottis.)– The authors prefer to use the remnant of the ipsitateral thyroid cartilage(based on the inferior constrictor muscle )

Postoperative management

• POD 1– Ryle's tube feeding is started

• POD 2-3– The tracheostomy tube is blocked

• POD 5– the tracheostomy tube can be removed and oral feeds

started. – Once this is well tolerated, the Ryle's tube is removed

and oral feeds are gradually stepped up to a regular diet.

Complications• When a very large segment of the glottis, including the

anterior commissure is resected there is a possibility of laryngeal stenosis and delayed decannulation.

• When the arytenoid is included in the resection, chances of aspiration are high.

• Prior radiotherapy can predispose to cartilage necrosis.

Results

For T1 lesions of the glottis, the VPL yields local control rates similar to those following radiotherapy, which is upwards of 90 per cent.

In 12 and select T3 glottic cancers, surgery (VPL) yields better cure rates than radiotherapy.

SUPRACRICOID PARTIAL LARYNGECTOMY WITH CRICO-HYOIDO-EPIGLOTTOPEXY (SCPL-CHEP)

1959 and was refined and presented later by Labayle and Piquet.

It deals essentially with glotto-supraglottic tumours.

involves removal of the entire thyroid cartilage bilaterally along with the paraglottic spaces.

It involves removal of the infrahyoid epiglottis.

This procedure, more radical than vertical partial laryngectomy and achieving better cure rates was widely practised in France and is now accepted globally as a useful addition to the range of voice conservative procedures .

SUPRACRICOID PARTIAL LARYNGECTOMY WITH

CRICO-HYOIDO-EPIGLOTTOPEXY (SCPL-CHEP)

• While the procedure of SCPL-CHEP is oncologically sound, it is physiologically much more stressful in the early post-operative period mainly because of the problems of aspiration.

• Hence it should be offered only to very fit patients.

• Frail individuals or those with chronic obstructive pulmonary disease or any chronic respiratory problem are not candidates for SCPL-CHEP

Indications• T1b, glottic cancer

– Bilateral early glottic cancer (T1b) with involvement of more than half the vocal cord on either side;

• T2a glottic cancer: – Glottic cancer with extension of the disease to the false cord or to the base of the epiglottis but

with freely mobile vocal cords. (glotto supraglottic cancer)

• T2b glottic cancer – (cord mobility impaired)

• T3 glottic cancer – fixed vocal cord with freely mobile arytenoids:

• Even gross invasion of the paraglottis or erosion of the inner aspect of the thyroid cartilage is compatible with this procedure.

Limitations• Fixed hemilarynx

– fixity of the arytenoid indicates subglottic spread involving the cricoanirtenoid joint.

• subglottic spread – Anterior > 10 mm and posterior > 5 mm.– Such a spread would not allow preservation of the cricoid cartilage.

• Glotto-supraglottic disease– above the level of the false cord either along the mucosa or along the paraglottis.– Such a spread has a tendency for extension into the pre epiglottic space.

• Prior tracheostomy.– CHEP entails mobilisation of the cervicomediastinal trachea which moves up to meet the hyoid, after which the

tracheostome is positioned.– Prior tracheostomy will interfere with this.

• Respiratory impairment – either due to frail health or due to chronic respiratory disease.

Technique of Resection• SCPL-CHEP is performed under general anaesthesia administered through an orotracheal tube.

• The approach is through a subplatysmal apron flap.

• The sternohyoid and the thyrohyoid muscles are divided on both sides at the level of the upper border of the thyroid cartilage.

• The sternothyroid muscle is divided at the level of the lower border of the thyroid cartilage.

• The inferior constrictor muscles are divided at the posterolateral edge of the thyroid cartilage taking care not to injure the superior laryngeal nerve, which may at times overly the superior cornu of the thyroid cartilage.

• The internal thyroid perichondrium and pyriform sinus is released from the inner surface of the thyroid cartilage for a short distance. This must not be overdone, because it may transgress the paraglottic space.

Technique of Resection• The cricothyroid joints are disarticulated

– stay absolutely close to the edges of the thyroid cornu and preventing damage to the soft tissues posterior to the joint.

– This is an extremely important step in the procedure to prevent injury to the recurrent laryngeal nerves.

• The isthmus of the thyroid gland is divided

• cervico-mediastinal fascia is released over the anterior wall of the trachea, right down to the carina.This mobilization is necessary to facilitate the crico-hyoidopexy.

• In order to prevent devascularisation of the trachea, the dissection is restricted to the anterior surface and not carried laterally.

Technique of Resection• in case of T3 glottic cancer

– Ipsilateral thyroid lobectomy paratracheal node clearance is carried out.– Once again, damage to the recurrent laryngeal nerve must be prevented.

• crico-thyrotomy

– at this stage to introduce an armoured endotracheal tube to continue the general anaesthesia.

– if resectability with a SCPL is at all in doubt, this step should be performed at a much earlier stage to judge the subglottic extent of the disease.

• Superiorly horizontal incision in the thyrohyoid membrane– at the level of the upper border of the thyroid cartilage, deepening it to transect the

epiglottis and leaving its superior portion attached to the base of the tongue.– care is taken to preserve the superior laryngeal trunk, its internal division and the posterior

descending branch in order to preserve the sensory supply to the laryngeal remnant.

Technique of Resection• Anterior traction on the thyroid notch facilitates visualisation of the endolarynx.

• Vertical resection cuts are now made first along the side with less tumour involvement.

• incision is made anterior to the arytenoid cartilage and resecting the entire false vocal fold, the ventricle and the true vocal cord.

• This cut is carried anteriorly through the cricothyroid musculature and the subglottic mucosa to connect

with the anterior horizontal cricothyroid opening.

• With the larynx opening up like a book, the vertical cut on the involved side is made from below upwards under vision.

• If the arytenoid cartilage needs to be resected, this is done preserving the mucosa over its posterior surface.

• Frozen section examination is carried out from the inferior and posterior cut margins to judge the adequacy of resection.

Reconstruction (Securing the glottic aditus)

• the remaining arytenoid and the posterior arytenoid mucosa is loosely approximated to the cricoid with 3-0 vicryl sutures.– This prevents it from flopping in and out of the laryngeal inlet, like a ball valve causing respiratory

obstruction. • The Pexy:

– Three 1-0 vicryl sutures are placed 1 cm apart for the crico-hyoidopexy. – Each suture is placed submucosally around the cricoid and through the epiglottis. – It is then passed through the preepiglottic space around the hyoid bone, base of the tongue and the

suprahyoid musculature.– the 3 sutures are tied tightly to ensure that the cricoid abuts the hyoid snugly.

• Tracheotomy:– is positioned in line with a separate skin incision. – Anaesthesia is now continued through the tracheotomy

• Muscular Buttress:– The cut edges of the inferior constrictor muscles are approximated over the impaction.– The sternohyoid muscles are resutured.– The skin flaps are sutured taking care to isolate the tracheostome and prevent air leaking into the main

wound.

Post-operative management• The airway is maintained through a non-cuffed tracheostomy tube with

suction performed as required.

• Tube feeding either through a nasogastric tube or a feeding gastrostomy is commenced on POD1.

• Intermittent blockage of the tracheostomy tube is encouraged after 3-4 days.

• If well tolerated, the tube is uncorked only when suction is required to be done.

• Depending on the progress after surgery, tracheostomy tube is removed in about 1-2 weeks.

Complications

• pneumonia due to aspiration

• dehiscence of the crico-hyoido-epiglottopexy and laryngeal stenosis

• The incidence of – persistent aspiration necessitating a permanent

gastrostomy is 14% and – intractable aspiration requiring conversion to a total

laryngectomy is 6%

ResultsOncologic

Overall survival rates - range from 68 to 84%.Local recurrence rate - between 0 -16%.

Speech

On phonation (as also on swallowing) the arytenoids abut against the base of the tongue and remnant epiglottis, occluding the larynx and generating sound.

The voice quality after SCPL is harsh but is nevertheless a "lung powered" speech and the patient satisfaction level is very high.

Supraglottic Ca.• Early Supraglottic disease is limited to the superior compartment of the

larynx above the ventricle and is suitable for Horizontal Partial Laryngectomy.

• Bilateral neck nodes should be addressed -potential occult mets>40%.

• lnfrahyoid epiglottic lesions early +pre-epiglottic space & >occult neck node metastasis.

• Aspiration following supraglottic resection should be managed actively. – Elderly patients /compromised lung function-not likely candidates.

• Supraglottic partial laryngectomy and its extensions are rarely performed, today being replaced by TOLR or chemo-radiation.

Procedures for supraglottic Ca.

TYPES OF HPL • 1) Horizontal supraglottic

partial laryngectomy• resection includes • the false cords, • the epiglottis, • the pre epiglottic space • the upper third of the

thyroid cartilage.• hyoid is included in the

resection when the pre

epiglottic space +

• 2) Extended Horizontal Partial Laryngectomy

• ipsilateral arytenoid, • the vallecula with the

adjacent base of the tongue,

• or the pyriform.

Horizontal Supraglottic partial laryngectomy

INDICATIONS • Open supraglottic partial

laryngectomy is indicated in those cases of early supraglottic cancer with freely mobile vocal cords(T1, 12 and select T3) where surgery is the preferred option and transoral laser resection is not feasible.

Where is Surgery preferred over radiation therapy/chemo-radiotherapy?

• Cancer of the infrahyoid epiglottis. – high propensity for invasion of the pre-epiglottic space -relatively

poor blood supply -response to radiotherapy is poor. – Supraglottic cancer with invasion of the pre epiglottic space (T3) is

amenable to supraglottic partial laryngectomy if the vocal cords are freely mobile.

• Early supraglottic primary with N2/N3 neck disease. – The large lymph node metastases respond poorly to radiotherapy.

• Early supraglottic cancer in very young individuals.– It is preferable to avoid radiotherapy in the young.

CONTRAINDICATIONSvery stressful in the post-operative period-aspiration. This is more so with the extended supraglottic partial laryngectomy.

• Poor pulmonary reserve– Elderly patients, frail individuals and those with poor pulmonary reserve are not suitable for this

procedure as even minor degrees of aspiration are not tolerated.

• Impaired cord mobility– Tumour extension to the glottis or the paraglottis causing impaired cord mobility converts the lesion

into a transglottic carcinoma making supraglottic laryngectomy inadequate.

• Thyroid cartilage erosion – is a rare feature in early supraglottic cancers and rules out a horizontal partial laryngectomy

• Involvement of the pyriform sinus up to its apex– Involvement of the interarytenoid or postcricoid region; or Significant involvement of the base tongue.

In all these situations, supraglottic laryngectomy is not feasible.

PROCEDURE

Conventional supraglottic laryngectomy.

Division of thyroid cartilage

Clearance of pre epiglottic space

Resection of the tumourReconstruction

If necessary, a preliminary tracheostomy is performed.

horizontal incision - at the level of the thyroid cartilage.

The sternohyoid and sternothyroid muscles-transected (sup border)

The perichondrium of the cartilage is incised along the upper border and reflected downwards over the upper half of the thyroid cartilage (it helps in the closure.)

The inferior constrictor muscle is divided on dominant side of the tumour.

Don’t damage superior laryngeal nerve along the neurovascular pedicle.

The perichondrium from the inner surface of the thyroid cartilage is elevated only postero-laterally to free the pyriform mucosa if there is no tumour extension to this site.

Division of the thyroid cartilage• The thyroid cartilage cuts are made.

• prevent injury to the anterior commissure since this will result in permanent impairment in the quality of speech.

• The anterior commissure is located at – the junction of the upper 1/3 and lower 2/3 female.– halfway between the thyroid notch and the inferior margin in the male.

• The cartilage cut is made at least 1 mm above the estimated level of the anterior commissure.

Clearance of the pre-epiglottic space

• In early tumours– entire hyoid can be preserved by subperiosteal dissection of the pre epiglottic space.– Preserving the hyoid allows a more secure closure and early rehabilitation.

• With gross infiltration of the space– at least the body of the hyoid or the entire hyoid is resected to allow satisfactory

clearance of the pre epiglottic space.– preserve the sensory supply, particularly over and around the arytenoids– Aspiration-turbulent post—operative period. – For this, it is vital that the superior laryngeal nerve and the posterior descending branch

of its internal division are preserved on both sides.(Rassekh et al.)

Resection of the tumour• If a prior tracheostomy has not been performed, it is undertaken at this stage.

• Entry into the larynx– transvallecular, – except in extended resections where the vallecula is involved by tumour.

• After the pharynx is entered, – the epiglottis is grasped in retracted downwards. – The pharyngostome is enlarged giving an excellent view of the tumour– The aryepiglottic folds are now divided well anterior to the arytenoids on both sides.– Resection is continued inferiorly through the ventricles, preserving the true vocal cords,

while removing both false cords with the specimen.

• The entire specimen is thus removed under direct vision with an adequate tumour free margin.

Resection of the tumour• In lateralized lesions, – there is often a tendency to preserve the uninvolved

supraglottic tissue on the contralateral side. – This is in fact detrimental and leads to a more difficult

post-operative course.

• It is recommended that resection in supraglottic horizontal partial laryngectomy should be more on anatomical lines with an endeavour to preserve only the arytenoids.

Reconstruction• Following excision,a cricopharyngeal myotomy may be

performed to facilitate post-operative swallowing. • Closure of the defect

– by suturing the cut edges of the pyriform mucosa below, to the oropharyngeal mucosa above.

– starting laterally and progressing towards the centre.– This is not necessary if a classical supraglottic laryngectomy is done

with preservation of the pyriform sinus.

• As the region of the resected supraglottis is approached, primary mucosal apposition is no longer possible.

Reconstruction• Closure is now obtained by approximating the upper end of the

remaining thyroid cartilage to the base of the tongue.

• This is achieved by using three 1-0 sutures that are passed through the thyroid cartilage inferiorly and the base tongue musculature superiorly.

• If the hyoid is preserved during the pre epiglottic space clearance, the sutures pass around the hyoid superiorly to give a more secure closure.

• The thyroid perichondrium which was preserved is now sutured to the base of tongue musculature as the second layer of closure.

Extended Supraglottic Laryngectomy

The horizontal supraglottic laryngectomy can be extended to include resection of the involved

arytenoid,

the pyriform,

the vallecula with the adjacent base of the tongue.

Arytenoid Resectiontotally/partially.

Gently dislocate the cricoarytenoid joint and prevent damage to the underlying recurrent laryngeal nerve.

After resection, posterior glottic bulk is defecient , the ipsilateral remnant of the vocal cord must be medialised by anchoring it in the midline to the superior border of the cricoid cartilage using a strong non-absorbable suture. adequacy- checked by initiating a cough reflex and glottic closure.

Arytenoid Resection

The raw area of the posterior glottis is resurfaced by advancing the adjoining mucosa of the pyriform fossa.

If extensive endolaryngeal tissue is excised, the posterior glottic bulk may have to be replaced(using muscle/cartilage)

Resection of the base tongue/ vallecula

• tumours that involve the lingual surface of the epiglottis.

• vallecula and adjacent portions of the base of the tongue along with the supraglottic larynx.

• At least one half of the base tongue along with its blood supply must be preserved in such a resection. Should direct closure of the defect be difficult due to the loss of significant amount of soft tissue, a pectoralis major myocutaneous(PMM) flap is used.

• Resection of the lateral wall of the pyriform fossa along with involved portions of the lateral and posterior pharyngeal wall is compatible with the extended supraglottic laryngectomy.

• Closure of the defect however requires a myocutaneous flap.

COMPLICATIONS• Aspiration

– is the most common complication following a supraglottic laryngectomy. – The degree of aspiration varies from patient to patient and

proportionately with the extent of resection. – This complication can be prevented in part, by saving at least the

posterior descending branch of both the superior laryngeal nerves. When the arytenoid is included in the resection, cricovocal approximation on the ipsilateral

• Pharyngocutaneous fistula is an infrequent complication following the procedure.– an increased incidence in the case of extended supraglottic laryngectomy– in patients who have had prior radiotherapy.

POSTOPERATIVE CARE

• Nasogastric tube feeds are begun 24-48 hours following surgery.

• Tracheotomy Care: After 4-5 days, once the tissue oedema is less, the tracheostomy is corked and nasal respiration is encouraged.Once this is well tolerated, the tracheostomy tube is removed.

• Oral Feeds: After wound healing is complete, (usually at the end of the first week) and there are no signs of a salivary leak, the patient is encouraged to start oral intake. The initial diet consists of semisolids, pureed foods or soft diet.Should aspiration be severe, a temporary feeding gastrostomy is performed and oral feeding withheld for a few days.

RESULTS

• Following supraglottic laryngectomy,

• Local recurrence rates <2% in properly selected cases and are comparable to those following total laryngectomy.

• The most common site of failure is in the cervical lymph nodes.

Procedure for glottosupraglottic ca.

• Concept of glotto-supraglottic disease • Supracricoid Partial Laryngectomy with Crico Hyoido-

Pexy (SCPL — CHP) – Indications – Contraindications – Procedure – Reconstruction – Post-Operative Management – Complications – Results

CONCEPT OF GLOTTO-SUPRAGLOTTIC DISEASE

• Glotto-supraglottic (transventricular) cancers with mobile VC are T2 cancers.

• Tumours that involve the glottis as well as the supraglottis and cause fixity of the true vocal cord are defined as transglottic cancers/transventricular cancers.

• Hence by definition transglottic cancer is stage T3 cancer because of cord fixity.

• Fixity of vocal cord - infiltration of the vocalis muscle and the paraglottic space,The arytenoids in these cases are mobile.

• neither amenable to the HSPL nor to the VPL.

• supracricoid partial laryngectomy is the most widely accepted partial laryngectomy procedure for transglottic cancers.

• Fixity of the vocal cord in transglottic cancer may also be due to extension of disease subglottically to involve the cricoarytenoid joint.

• Clinically, not only the vocal cord but also the arytenoid is immobile (fixed hemilarynx). These transglottic cancers are not amendable to any partial laryngectomy procedure and will necessitate either total or near-total laryngectomy.

• The SCPL may be utilised for those patients with– fixed cords (but mobile arytenoids) and – also for those lesions with mobile cords (T2) but where the extent of the

disease or inadequate exposure prohibits the safe use of TOLR.

• Depending on the extent of resection, two types of reconstruction are needed after an SCPL.– crico-hyoido-epiglottopexy (CHEP) for predominantly glottic tumours.– crico-hyoidopexy (CHP) for tumours with significant supraglottic disease.

CHEP CHP 3 QUARTER LAR.

PREDOMINANTLY GLOTTIC TUMOURS

SIGNIFICANT SUPRGLOTTIC DISEASE

HORIZONTAL PARTIAL LARYNGECTOMY+HEMILARYNGECTOMY

EPIGLOTTIS PARTIALY REMOVED

ENTIRE EPIGLOTTIS INFREQUENTLY DONE

LOCALLY ADVANCED GLOTTIC CA. WITH DEEP PARAGLOTTIC INFILTRATION

CLEARANCE OF PRE EPIGLOTTIS SPACE

IndicationsI. Spread to the anterior

commissure or across the ventricle to the vocal cord.

II. Impaired cord mobility or cord fixity due to paraglottic spread but with mobile arytenoids.

III. Early thyroid cartilage erosion. The external perichondrium must be intact.

ContraIndicationsi.Fixed Hemilarynx

Fixity of the arytenoid indicates involvement of the cricoarytenoid joint and is not compatible with SCPL.

ii. Subglottic extensiongreater than 10 mm anteriorly and 5 mm posteriorly, which makes preservation of the cricoid oncologically unsafe.

iii. Involvement of the base of tongue, or vallecula or massive involvement of the pre-epiglottic space, where saving the hyoid bone is oncologically unsafe.iv. Involvement of the pyriform sinus is not compatible with this procedure since the resultant pharyngeal defect will not close with a crico-hyoidopexy.

v. Involvement of the postcricoid and interarytenoid regions. Such spread makes it impossible to preserve at least one arytenoid.

vi. Prior tracheostomy is technically incompatible with the procedure, since the tracheostome needs to be positioned after the trachea and cricoid have moved up for the pexy.

vii. Poor pulmonary reserve

Procedure• Anaesthesia is administered through an

oro-tracheal tube. Prior tracheostomy must be avoided.

• Approach The larynx is approached through a superiorly based subplatysmal apron flap, the apex of which is about two finger breadths above the suprastemal notch where the final tracheostomy would be positioned. The incision is carried up to the mastoid on the side where neck is carried up to the mastoid on the side where neck dissection is planned.

• The subplatysmal flap=2 cm above the hyoid bone.

• The sternohyoid and thyrohyoid muscles are divided.– In order to ensure a secure crico-hyoidopexy at the end, it is important that the muscles are

not divided too close to the hyoid bone.

• The sternothyroid is divided – at the level of the lower border of the thyroid cartilage.

• The inferior constrictor muscle along with the perichondrium of the thyroid cartilage is incised along the posterior border of the thyroid cartilage.

• dislocation of the cricothyroid joint.

• The procedure is repeated on the opposite side .

Mobilisation of the cervicomediastinal trachea

• The isthmus of the thyroid gland is divided. Pre-tracheal fascia is opened and with blunt finger dissection the entire anterior surface of the cervicomediastinal trachea is freed from the fascia right up to the carina. – This will enable the trachea to move up during the

pexy. Care is taken not to strip the fascia from the lateral aspects of the trachea in order to preserve its vascularity.

Dissection of the pre-epiglottic space

– The periosteurn along the inferior border of the hyoid bone is incised and stripped off its posterior surface.

– This facilitates dissection of the underlying soft tissue and the pre-epiglottic space which will be excised with the specimen.

Reconstruction

• The arytenoid cartilage (or the posterior arytenoid mucosa) is pulled forward.

• A 4-0 vicryl suture anchors the vocal process or the arytenoid mucosa to the upper border of the cricoid cartilage. This will prevent a flip-flop movement, at times blocking the airway like a ball-valve during inspiration.

• It also prevents posterior prolapse of the arytenoid.

The crico-hyoido-pexy• in order to minimize the post-operative complications of

dehiscence, aspiration on swallowing, & stenosis. • i. A portion of the strap muscles must be left attached to

the hyoid bone in order to maintain its viability & to ensure a secure pexy.

• ii. The disarticulation of the cricothyroid joint must be done very carefully staying absolutely close to the thyroid cornu.

• iii. The posterior descending branch of the internal division of the superior laryngeal nerve must be preserved to ensure a sensate laryngeal remnant.

• iv. The entire length of the true and false cords must be excised bilaterally even if uninvolved, so that there is no redundant tissue, and the larynx is well occluded during swallowing and during phonation by the arytenoids abutting against the base of the tongue.

• v. The cut edges of the inferior constrictor muscle are sutured anteriorly to reposition the pyriform sinuses to a physiologic position so as to improve the swallowing function.

Postoperative Management• Extension of the neck is avoided for a few days to prevent dehiscence of the crico-hyoidopexy.

• Postoperative period is marked by problems of aspiration for several days. The patient is encouraged not to swallow saliva for few days.

• Decannulation is attempted after a week or two depending on how well the patient tolerates occlusion of the tracheostomy tube.

• Swallowing is encouraged gradually. Tube feeding supplements are continued until adequate oral intake is possible. Restoration of normal swallowing and removal of the feeding tube may take a few weeks.

• A small percentage requires permanent gastrostomy. Inability to decannulate is reported in less than 10% in most series.

Complications• aspiration pneumonitis,

• dehiscence of the crico-hyoidopexy and

• laryngeal stenosis

• The incidence of persistent aspiration necessitating a permanent gastrostomy is reported to be as high as 14% and intractable aspiration requiring conversionto a total laryngectomy is reported to be 6 %

Results

The 3 to 5 year overall survival rates 68 to 84%.

Local recurrence rate is up to 16%.

Near total laryngectomy• Principle

• Indications

• Contraindications

• Technique & Results – Resection – Construction of shunt – Pharyngeal Closure

• Post-operative management & Complications

• Speech

• Advantages over TL+TEP

• In 1981 by dr. Bruce pearson from mayo

• Utilising a dynamic myomucosal shunt for voicing utilising lung powered speech.

• A natural biological shunt which is self-maintaining and avoids doctor dependence is suitable in advanced lateralised laryngopharyngeal lesions.

• Uninvolved interarytenoid and post cricoid mucosa, two-third of contralateral vocal cord and an intact contralateral recurrent laryngeal nerve are pre-requisites of this procedure.

• Oncologic safety of this procedure is proven with global literature supporting its reproducibility.

• Neck Dissection and Adjuvant Treatment can be used as suitable for the stage of disease.

• Voicing is similar if not better than Tracheo-Esophageal Prosthesis and is successful in more than 90% of patients.

• 1. PRINCIPLE • where the vertical extent of the lesion is such

that a segment of the cricoid ring has to be resected and yet one arytenoid is supple and free of disease, a NTL can be performed.

INDICATIONS• 1) T3/T4 lateralised transglottic lesion of the larynx, with no extension to the inter arytenoid

region.• 2) T3/T4 lateralised cancer of the pyriform sinus with involvement of its apex and causing

fixity of the hemilarynx or even thyroid cartilage erosion.

CONTRAINDICATIONS• Interarytenoid or postcricoid

involvement which makes preservation of the contralateral arytenoid oncologically unsafe.

• Mucosal involvement of more than one-third the length of the contralateral cord

• Prior radiation therapy is a relative contraindication to NTL if the tissues are oedematous.

• The perichondrium over the contralateral thyroid cartilage is stripped from medial to lateral side.

• A vertical segment of the thyroid cartilage is resected to inspect the paraglottis on the normal side, and confirm its suppleness.

• Suprahyoid muscles are divided to skeletonize the hyoid bone.

• After a transvallecular entry into the larynx as in a total laryngectomy, the epiglottis is caught in an Allis forceps and refracted downwards.

• Thereafter the mucosa of the interarytenoid region and that over the posterior cricoid lamina is incised.

• The posterior cricoid lamina is now fractured or cut, care being taken to avoid damage to the postcricoid mucosa.

• The resection is now completed, preserving the opposite arytenoid and the posterior tracheal wall between the arytenoid and the tracheotome.

Construction of the shunt • A myomucosal shunt is created from the

laryngotracheal remnant.

• resection of excess cricoid is performed, sparing the posterior segment of the cartilage on which the functioning arytenoid rests.

• The shunt is now formed by tubing the laryngotracheal remnant with 3-0 interrupted vicryl sutures.

• Some surgeons prefer to stent the shunt temporarily using 14 no. Foley's or a No.6 red rubber catheter.

• Subglottic pressure studies have indicated that the diameter of the shunt must be at least 6 mm (14R) to enable the patient to speak at physiological airway pressures without straining.

• If the mucosa of the laryngeal remnant is inadequate, it must be augmented using the uninvolved hypopharyngeal mucosa.

• The stent also helps the surgeon's

orientation for pharyngeal closure, which is the next step.

Pharyngeal closure• The neopharynx is closed as in a total

laryngectomy.

• Closure , with particular care at the point where the pharynx is closed over the neoglottis i.e. the voice shunt, to avoid pharyngocutaneous fistula postoperatively.

• In case extensive resection,patch

pharyngoplasty should be performed using a pectoralis major myocutaneous flap.

• If a stent was used for the voice shunt, it is pulled out from the tracheostome end once the pharyngeal closure is complete.

Stomal Maturation• The Tracheostome in a near-total laryngectomy is a side stoma unlike a

total laryngectomy which is an end stoma.

• The tracheostoma should be made at 3rd or 4th ring to ensure a longer shunt.

• The cartilage at the site of the stoma is removed - wide stoma.

• The skin flaps are matured to the tracheal rings above and below.

• Tracheostomy tube may be required for a few months to prevent it from stenosis.

POSTOPERATIVE MANAGEMENT• A tracheostomy tube is usually not required unless the stoma shows a

tendency for stenosis.

• Feeding is commenced through the nasogastric tube on POD1.

• Oral feeds are started once the wound is healed and there are no signs of salivary leak, which is usually by the 10th postoperative day.

• Most patients are on a regular diet within three weeks.

• In case of a pharyngeal leak, oral feeding will need to be postponed until the leak has ceased.

RESULTS

Speech • A great advantage of NTL is the simplicity and ease with which

patients acquire good, intelligible, lung powered speech.

• Almost every patient will speak following this procedure unless there is a shunt breakdown or stenosis, which is uncommon and is usually technique related and can be minimised with experience.

COMPLICATIONS• Pharyngeal leak

– The incidence of pharyngeal leak is higher than that following total laryngectomy, mainly due to tension on the suture line as the pharynx is closed over the voice shunt. If need be, patch pharyngoplasty should be done using the pectoral myocutaneous flap, to minimize the incidence of leak.

• Shunt stenosis– This can result in failure to develop speech. The complication is almost completely avoidable.

During the formation of the shunt, the size can be augmented, if necessary, by using the adjacent pyriform mucosa. Shunt stenosis can also be a complication of post operative radiotherapy, though rarely.

• Aspiration– The incidence of significant aspiration following near total laryngectomy is extremely low

unlike that following supraglottic or supracricoid partial laryngectomy. Rarely does one need to convert the procedure to a total laryngectomy because of problems of aspiration. Most patients are on regular diet including liquids within 2-3 weeks.

ADVANTAGES OF NTL OVER TEPNTL TEP

quality of voice following NTL is superior require the services of a speech therapist initially.

maintenance free biological shunt which stays so for life.

silicone voice prosthesis .Rs.20,000/per piece

lung powered with a success rate more than 83%.

sensitive stoma, making postoperative radiotherapy very difficult to tolerate.

speech shunt is constructed at the same time as the resection of the primary.

secondary procedure, it requires a second hospital admission and anaesthesia

Thank you…

Previous questions

Multiple primary cancers

Lymph node grading

Imaging for recurrent tumour= fdg pet

Microinvasion vs carcinoma in situ

• There are 4 main lymph node stages in cancer of the larynx. N2 is divided into N2a, N2b and N2c. The important points here are whether there is cancer in any of the nodes and if so, the size of the node and which side of the neck it is on.

• N0 means there are no lymph nodes containing cancer cells• N1 means there are cancer cells in one lymph node on the same side of the neck as the

cancer, but the node is less than 3cm across• N2a means there is cancer in one lymph node on the same side of the neck and it is

between 3cm and 6cm across• N2b means there is cancer in more than one lymph node, but none are more than 6cm

across. All the nodes must be on the same side of the neck as the cancer• N2c means there is cancer in lymph nodes on the other side of the neck from the tumour,

or in nodes on both sides of the neck, but none is more than 6cm across• N3 means that at least one lymph node containing cancer is larger than 6cm across