VERTICAL PARTIAL LARYNGECTOMY Jonas Johnson

OPEN ACCESS ATLAS OF OTOLARYNGOLOGY, HEAD & NECK OPERATIVE SURGERY

Management of small tumours involving involvement of the arytenoids and the the true vocal folds can be contentious. posterior commissure, and those in whom Tumour control is achieved in over 95% of poor health compromises suitability for patients presenting with T1 glottic cancer surgery may be better served with external employing external beam radiation thera- beam irradiation. py, vertical hemilaryngectomy, or transoral endoscopic resection. Given adequate re- Preoperative Planning sources, the weight of evidence favours endoscopic transoral resection as the most When considering surgical intervention for cost-effective approach with very high cancer involving the true vocal cords, rates of tumour control. precise staging and patient selection are crucial for good outcomes. High resolution Patient Selection fine-cut CT compliments microlaryngosco- py and examination under anaesthesia. Young patients presenting with involvement of the anterior commissure or partial In the setting of failed prior irradiation the- impairment of motion (T2) and those who rapy, the surgeon must be aware of the have failed attempts at curative irradiation potential for multifocal persistent cancer. therapy for small glottic lesions may be In general, the entire field of the original suitable candidates for vertical partial tumour should therefore be considered for laryngectomy. removal.

When the tumour requires removal of the Careful preoperative tumour mapping em- anterior commissure, the proper term for ploying flexible fiberoptic endoscopy and this procedure is frontolateral partial fine cut CT allows the surgeon to estimate laryngectomy. Frontolateral vertical hemi- the extent of resection and the reconstruc- laryngectomy can be accomplished to tive needs of each individual patient. For include one arytenoid and, when necessa- instance, patients requiring frontolateral ry, both true vocal folds. Under these cir- hemilaryngectomy in which both aryte- cumstances, some surgeons may choose noids are intact and 80% of one vocal cord supracricoid partial laryngectomy with can be maintained will require no added cricohyoidoepiglottopexy to manage ex- tissue for reconstruction. Conversely, if an tensive cancer of the anterior commissure arytenoid is resected or if more than 20% involving both vocal cords and the para- of the contralateral vocal fold must be re- glottic space. moved, some reconstruction must be undertaken to afford good swallowing with- Vertical partial laryngectomy is not suita- out aspiration and to allow adequate dia- ble for tumours involving the supraglottic meter of the lumen for respiration. larynx and the paraglottic space. Similarly, it is not appropriate for patients with Operative steps greater than 10mm of subglottic extension. Involvement of both arytenoids is also a The procedure is undertaken under general strict contraindication. anaesthesia. Perioperative prophylactic an- tibiotics are administered. Tracheotomy is Patients presenting with multifocal lesions, accomplished through a separate incision. diffuse dysplasia and carcinoma in situ, A second horizontal incision is made at approximately the level of the thyroid notch (Figure 1).

Figure 1: Incision for vertical partial laryngectomy. Care should be taken to en- sure separation of the tracheostomy incision from that required for the partial laryngectomy Figure 3: Elevation of the perichondrium with the overlying strap muscles Skin flaps are elevated superiorly to the hyoid and inferiorly to the cricoid cartila- Vertical cuts are then made through the ge. The strap muscles are then elevated, thyroid cartilage, maintaining as much of exposing the thyroid lamina. the posterior lamina of the cartilage as basic oncologic principles will allow (Fig- The external perichrondrium of the thyroid re 4). cartilage is incised at the midline and a posteriorly-based perichrondrial flap is elevated bilaterally (Figures 2 & 3). The extent of the elevation should reflect the intended thyroid cartilage resection.

Figure 4: The vertical cartilage cuts are Figure 2: Incision of the perichondrium to designed to correspond with soft tissue expose the thyroid ala resection margins within the larynx

2 It is essential that the cartilage cuts be proximated in the midline as the second made perpendicular to the plane of the layer of closure. cartilage and that soft tissue cuts be made with a knife (not with a saw) (Figure 5). A Penrose drain is inserted. Suction drains should be avoided because they will tend to pull secretions through the wound. The skin is reapproximated in layers and a cuffed tracheotomy tube is introduced.

Figure 5: The cartilage cuts must be perpendicular to the cartilage to allow for corresponding soft tissue cuts in the larynx

A wide cricothyrotomy allows access to the subglottis such that the surgeon work- Figure 6: Reattachment of the vocal cord ing with a headlight and a knife can vis- remnant to the thyroid ala ualize the undersurface of the vocal cords and to place the initial cut to allow a 2mm margin from the tumour without unneces- sarily removing uninvolved vocal fold. The thyrotomy is then opened widely such that the cut across the posterior aspect of the involved vocal fold can be accomplished with a 2mm margin and the specimen removed. New margins from both sides of the vocal cord should be submitted for frozen section assessment. A nasogastric tube is introduced and fixed to the nasal septum with a suture.

When two-thirds or more of one vocal fold has been preserved, no extra soft tissue reconstruction is required. The free end of the residual vocal fold must be fixed anteriorly to the residual thyroid cartilage with a vicryl suture (Figure 6). Figure 7: The remaining larynx after the Reconstruction is accomplished by closing specimen has been removed. Closure is the external perichondrium in the midline initiated by suturing the external peri- (Figure 7). The strap muscles are reap- chondrium in the midline

3 Reconstruction Considerations struction invariably have prolonged reco- very and temporary dysphagia. When more than 80% of the contralateral vocal fold cannot be maintained, some form of tissue reconstruction is required to reconstitute the lumen to maintain an adequate airway. I prefer employing an epiglottopexy. The petiole of the epiglottis is grasped with an Allis forceps, and the hyoepiglottic ligament freed such that the epiglottis can be mobilized and pulled inferiorly and fixed to the superior surface of the cricoid cartilage (Figures 8 & 9).

Figure 9: Epiglottopexy: The epiglottis is pulled inferiorly

Postoperative Care

At completion of the procedure, the patient should have a cuffed tracheotomy tube in place with the balloon inflated. Antibiotic administration is terminated on the first Figure 8: Epiglottopexy: The lingual sur- postoperative morning. The patient’s nutri- face of the epiglottic cartilage is under- tional needs are supported by feeding mined in the subperichondrial plane to through a nasogastric tube. divide the hyoepiglottic ligament The dressing supporting the Penrose drain When tumour considerations require re- should be changed for good hygiene. The moval of the body of the arytenoid, it, too, drain can be removed when it is no longer must be reconstructed. The critical aspect producing mucoid secretions. Ordinarily is to re-establish the height of the arytenoid that occurs on the third or the fourth post- to prevent secretions from flowing directly operative day. from the pharynx into the larynx. A multi- tude of techniques have been reported em- Routine tracheotomy care is provided. The ploying cartilage, muscle or just fat. The tracheotomy cuff should be maintained tissue needs to be fixed to the top of the inflated for 4-5 days to divert coughed cricoid and then covered by advancing secretions through the tracheotomy tube mucosa from the medial wall of the pyri- rather than into the newly reconstructed form sinus over the reconstructive mate- wound. rials. Patients requiring arytenoid recon-

4 On the fifth postoperative day, the tracheo- that multifocal tumour is overlooked and tomy cuff can be deflated. This allows the if not completely removed, will recur. treatment team to determine if the patient can protect his own airway without aspira- All patients having open partial laryngec- tion. Patients who have previously been tomy have dysphonia postoperatively. The treated with radiation therapy may have a overwhelming majority of patients do delayed decannulation process. If the pa- however have a serviceable voice. tient tolerates deflating the cuff on the tracheotomy tube, the treatment team can Longstanding dysphagia and aspiration change the tracheotomy tube to a smaller, are unusual if both arytenoids are preser- uncuffed tube. The adequacy of the recon- ved or, when one arytenoid has been re- structed airway can be tested by plugging moved, it has been appropriately recon- the tracheotomy tube. Patients who tolerate structed. this overnight are candidates for decannulation. Soft foods are reintroduced, and the Failure to properly reconstruct the glottis patient can be discharged. after resection of most of both vocal folds will result in laryngeal stenosis. Preven- Salvage following radiation: Special tion is the key to relief of this problem. considerations and problems The treatment team must recognise the need for extra soft tissue and incorporate The most common call for frontolateral the reconstruction at the time of resection. partial hemilaryngectomy in the era of Reconstructing the stenotic larynx is be- transoral endoscopic technology is to treat yond the scope of this chapter. patients with persistent cancer after having had radiation therapy. Such patients have Useful reference increased oedema, slower healing, and a high incidence of chondritis. The drain fre- AfHNS Clinical Practice Guidelines quently needs to be maintained beyond the for Glottic Cancers in Developing first week. Antibiotic administration Countries and Limited Resource Settings should be instituted for cellulitis and ery- thema. Return to oral eating is often de- Author layed and the nasogastric tube may need to be maintained for 2-3 weeks. Under these Jonas T. Johnson, M.D. circumstances, most patients can be dis- Eugene N. Myers Professor & Chairman charged to home with home nursing and Department of Otolaryngology care of the tracheotomy and nasogastric Eye and Ear Institute tube until the wound has stabilized, oede- 200 Lothrop Street ma has resolved, at which time the treat- Suite 500, Pittsburgh, PA 15213, USA ment team can proceed with the decannu- [email protected] lation and oral feeding process. Editor Therapeutic Expectations Johan Fagan MBChB, FCS (ORL), MMed Partial vertical hemilaryngectomy is highly Professor and Chairman effective (>90%) in properly selected pa- Division of Otolaryngology tients. Surgical removal of previously irra- University of Cape Town diated tumours always has the potential Cape Town, South Africa [email protected]

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