Supracricoid Laryngectomy for Laryngeal Cancer

OPEN ACCESS ATLAS OF OTOLARYNGOLOGY, HEAD & NECK OPERATIVE SURGERY

SUPRACRICOID LARYNGECTOMY Alejandro Castro, Javier Gavilán

Supracricoid laryngectomy consists of en and glottic regions. One arytenoid can also bloc resection of both vocal cords, the be resected. However combined resection paraglottic spaces and the thyroid cartilage of the epiglottis and one arytenoid usually (Figure 1). It was first described by Majer results in poor functional outcomes and in 1959 1 and Piquet in 1974 2. It is used increases the chance for aspiration and for the treatment of selected early and delayed decannulation. locally advanced glottic and transglottic carcinoma in an oncologically safe Types of supracricoid operations manner, while preserving laryngeal function i.e. swallowing (airway protection), With supracricoid laryngectomy the hyoid breathing and phonation. bone is approximated directly to the cricoid with three sutures (Figures 2a-c). Types of supracricoid laryngectomy are illustrated below i.e. cricohyoidoepiglottopexy (CHEP), cricohyoidopexy (CHP), and tracheocricohyoidoepiglottopexy (Fig- ures 2a-c). With tracheocricohyoidoepiglottopexy the anterior cricoid is resected for an additional tumour margin anteriorly.

Figure 1: Typical supracricoid laryngectomy specimen c Indications and limitations

Supracricoid laryngectomy is used to treat glottic carcinoma affecting one/both vocal cords, including cancers with deep invasion of the paraglottic space and altered vocal cord mobility. The epiglottis and Figure 2: Cricohyoidoepiglottopexy (a), pre-epiglottic space can be included in the cricohyoidopexy (b), and tracheocrico- specimen, allowing for resection of trans- hyoidoepiglottopexy (c) glottic tumours that invade the supraglottic Function cricoarytenoid units; sacrificing one unit increases the chance of disabling aspiration Key functional outcomes are airway, pho- in the cases where the epiglottis is nation and swallowing without aspiration. resected. Phonation and swallowing depend on the arytenoids being able to tilt forwards and make contact with the base of the tongue; to breathe the arytenoids tilt posteriorly to open the airway (Figures 3, 4).

Base of a tongue a

Figure 5: Anatomy of the cricoarytenoid Figure 3: Arytenoids tilt forwards and unit and the course of the recurrent backwards for phonation, swallowing and laryngeal nerve (yellow arrow) directly breathing behind the articular facet of the inferior

cornu of the thyroid cartilage

Figure 4: Arytenoids tilt backwards and forwards for breathing, phonation, swallowing

Cricoarytenoid unit (Figures 5, 6)

An intact cricoarytenoid unit is critical for function. It comprises the arytenoid moun- ted on an intact posterior cricoid ring, with a functioning recurrent laryngeal nerve and Figure 6: Right side illustrates the lateral and posterior cricoarytenoid mus- situation after supracricoid laryngectomy cles. Ideally one should preserve both with preserved cricoarytenoid unit

2 Preoperative Evaluation superior border of the cricoid cartilage. Some authors describe partial or com- Careful selection of candidates is the key plete resection of the anterior cricoid to success of supracricoid laryngectomy. arch 3, 4. Although this might be oncolo- Both tumour and patient factors must be gically safe, in our hands it compro- taken into account to ensure satisfactory mises the functional results and should oncologic and functional outcomes. be performed only in very carefully selected cases (Figure 2c) 1. Tumour factors • Superiorly: Epiglottis or tongue base, depending on the upper extent of the TNM classifications were not developed tumour: The epiglottis and pre-epiglot- to guide the indications for different surgi- tic space can be included in the resec- cal techniques; other factors should be tion (Figure 2b). Although limited ex- taken into account when considering tension to the base of the tongue can be supracricoid laryngectomy. In general, excised, resection should not extend supracricoid laryngectomy is indicated for beyond the circumvallate papillae as the T1 and selected T2-3 glottic as well as base of the tongue plays a critical role selected T2-4a supraglottic cancers. Never- with laryngeal closure during swallow- theless supracricoid laryngectomy is ing (Figures 3, 4) usually appropriate, for example, for vir- • Laterally: Pyriform sinus: Limited re- tually any T2 glottic cancer but it is con- section of the medial wall of the pyri- traindicated for those rare T2 glottic can- form sinus can be accomplished. How- cers with extensive subglottic extension. ever, wide resection which includes the lateral wall may compromise swallow- Two types of vocal cord immobility should ing be taken into account when considering • Posteriorly (midline): The interaryte- supracricoid laryngectomy noid space must be free of tumour: It is • Tumours that invade the paraglottic strongly recommended to preserve both space and “fix” the vocal cord, but arytenoids when the epiglottis is inclu- with some preserved mobility of the ded in the resection. At least one mobile arytenoid: These tumours can usually arytenoid must always be preserved be resected by supracricoid laryngecto- • Thyroid cartilage: As the paraglottic my as resection of the arytenoid is spaces and thyroid cartilage are resected likely to produce a negative margin en bloc, involvement of only the inner • Cricoarytenoid joint invasion: This perichondrium is not a contraindication must be suspected when the arytenoid However, more extensive invasion of is “frozen”. Supracricoid laryngectomy the thyroid cartilage is a contraindica- is not recommended as even resecting tion to supracricoid laryngectomy. Yet the arytenoid is unlikely to yield a cancers of the anterior commissure in- negative margin vading thyroid cartilage in the midline may be considered for supracricoid The extent of the tumour relative to the laryngectomy. resection limits of supracricoid laryngectomy must be considered Careful preoperative evaluation should be • Inferiorly: Superior border of cricoid undertaken to ensure that the primary cartilage: Routine intraoperative frozen tumour falls within these abovementioned section is strongly recommended to limits. As a rule, indirect (fiberoptic) and/ ensure negative mucosal margins at the or direct laryngoscopy are adequate for this

3 purpose. CT scan or other imaging techni- with age as does a patient’s ability to learn ques may help in some cases, particularly new swallowing techniques. Classically, to determine extralaryngeal extension 65-70yrs is considered the cut-off for open through thyroid cartilage. partial laryngectomy. However, a patient’s general status is more important than age Extending the resection beyond the itself, and successful results have been abovementioned parameters reduces the reported in older patients 5, 6. chance of functional success (aspiration and/or inability to be decannulated) and Careful evaluation of comorbidities is im- should be performed only in very carefully portant to ensure successful functional out- selected patients. Employing supracricoid comes. The cough reflex is of critical im- laryngectomy with too advanced tumours portance to deal with aspiration. In our or relying on postoperative radiotherapy to series, up to 15% of patients developed treat positive margins is unacceptable as it pneumonia 7. Pulmonary and cardiac re- increases recurrence rates and reduces serve is crucial to overcome this compli- survival. cation. Some authors recommend routine preoperative pulmonary function tests 8, 9. Frozen section should always be used with We believe that a detailed clinical history any type of open partial laryngectomy. is adequate, focusing attention on symp- With supracricoid laryngectomy, it should toms relating to chronic obstructive pul- be obtained to confirm oncologic safety of monary disease e.g. dyspnoea when walk- every close margin, and routinely at the ing up a flight of stairs and types of level of the cricoid. Patients should agree medication. preoperatively that total laryngectomy will be performed if negative margins cannot Supracricoid laryngectomy operation be obtained. The operation is done under general anaes- Neck dissection can be performed simul- thesia with the patient in a supine position. taneously. T1-2 glottic cancer without Antibiotics are given perioperatively. evidence of neck metastases can be treated with supracricoid laryngectomy without 1. Surgical approach neck dissection. Elective ipsilateral neck dissection is advocated for locally advan- • A U-shaped cervical incision is made. ced, purely glottic tumours (vocal cord The vertical limbs of the incision start fixation). Bilateral neck dissection is a few centimetres above the hyoid bone recommended in all patients with tumour and run along the anterior borders of invading the supraglottis regardless of T the sternocleidomastoid muscles. The and N stage. horizontal limb passes 2-3cms above the sternal notch 2. Patient factors • If neck dissection is planned, the U- shaped incision runs from mastoid-to- Patients need to learn new ways to swal- mastoid close to the posterior border of low after removal of part of the larynx. the sternocleidomastoid muscle to Every patient undergoing supracricoid create a broader flap. Neck dissections laryngectomy will experience aspiration of are done before the laryngectomy varying degrees during the initial post- • A superiorly based subplatysmal apron operative days. Age is an important consi- flap is elevated to expose the supra- deration as the brain’s plasticity decreases

4 and infrahyoid muscles of the neck (Figures 7, 8)

Figure 9: Divide sternohyoid muscle

Figure 7: Infra- and suprahyoid muscles

Figure 10: Retract omohyoid and divide thyrohyoid muscle

Figure 8: Infra- and suprahyoid muscles

• Detach the sternohyoid muscles from the hyoid bone and reflect them inferiorly to the level of the 1st tracheal ring (Figure, 9) • Retract the omohyoid muscles laterally (Figure 10) • Detach the thyrohyoid muscles from the hyoid and reflected them inferiorly to their insertions on the thyroid cartilage (Figure 10) • Section the sternothyroid muscles at Figure 11: Divide sternothyroid muscle the inferior border of the thyroid cartilage (Figure 11) • Exposed, ligate and divide the isthmus of the thyroid gland

5 • Dissect both thyroid lobes off the larynx and trachea to expose the thyroid and cricoid cartilages, as well as the first tracheal rings (Figure 12) • Stop the dissection posteriorly at the level of the inferior cornu of the thyroid cartilage to avoid injuring the recurrent laryngeal nerves (Figure 5)

Figure 13: Divide superior laryngeal vessels • Rotate the larynx with a hook placed at the posterior border of the thyroid cartilage (Figure 14) • Identify and divide the lateral thyrohyoid ligament (Figure 14)

Figure 12: Surgical view of exposed larynx with strap muscles reflected. Thyroid lobes have been dissected and retracted laterally exposing the larynx and the first tracheal rings. Note that the anterior wall of the trachea has been dissected to facilitate cricohyoidopexy at the end of the surgery Figure 14: (Right side) Rotate the larynx • Identify, ligate and divide the superior with a hook placed at the posterior border laryngeal artery and vein over the of the thyroid cartilage and divide the thyrohyoid membrane (Figure 13) lateral thyrohyoid ligament at its insertion • One may preserve the internal branch on the superior cornu of the thyroid of the superior laryngeal nerve when cartilage the epiglottis and pre-epiglottic space are preserved (Some authors report • Divide the inferior constrictor muscle better swallowing when supraglottic along the posterior border of the sensation is preserved, but in our thyroid cartilage (Figures 15a, b) opinion preservation of the internal • When reaching the inferior cornu, branch of the superior laryngeal nerve direct this cut obliquely in an does not improve swallowing) anteroinferior direction to follow the anterior border of the cornu in order to protect the recurrent laryngeal nerve 6 which lies close to the posterior aspect der of the right thyroid ala exposing the of the inferior cornu (Figure 15a) submucosa of the pyriform sinus • Expose the pyriform sinus submucosa after cutting the inferior constrictor • Place a submucosal stitch in the muscle and dissect it from the inner pyriform sinus without violating the perichondrium of the thyroid lamina mucosa, and leave it in place; this (Figure 15b) stitch is used later during reconstruction (Figures 16, 31)

Figure 15a: Divide the inferior constrictor muscle. Traction on the muscle is genera- Figure 16: A suture is passed through the ted by rotating the larynx with a hook pyriform sinus submucosa placed at the posterior border of the thyroid cartilage. The dotted red line marks • Separate the thyroid and cricoid carti- the course of the cut. Note that the cut lages. The recurrent laryngeal nerve is turns anteriorly as it approaches the infe- close to the cricothyroid joint and may rior cornu to protect the recurrent larynx- be injured at this point. We recom- geal nerve mend transecting the inferior cornu of the thyroid cartilage at its base with scissors while the assistant steadies the thyroid and cricoid cartilages to avoid the blades slipping (Figure 17).

Figure 17: The larynx is rotated with a Figure 15b: The inferior constrictor mus- hook. The inferior cornu of the thyroid cle has been divided over the lateral bor- cartilage is divided with scissors taking the 7 course of the recurrent laryngeal nerve (yellow line) into consideration

• Repeat the same surgical steps on opposite side either simultaneously or sequentially • Free the thyroid cartilage from its attachments so that it can be easily displaced in any direction

2. Resecting the larynx

The supracricoid laryngectomy specimen is resected by means of two horizontal and Figure 19a: Surgical view of the inferior two vertical cuts (Figure 18) horizontal cut. Note that the endotracheal tube is still in place

Figure 18: Horizontal and vertical cuts Figure 19b: Inferior horizontal cut (cricothyrotomy); the orotracheal tube is remov- Inferior horizontal cut ed and a new tube is inserted through the cricothyrotomy • Make a wide cricothyrotomy at the level of the superior border of the Superior horizontal cut anterior cricoid arch, extending from one inferior thyroid cartilage cornu to This can be made at two different levels, the other (Figures 19 a) depending on the superior extension of the • Retract the cricothyroid membrane and tumour directly inspect the inner surface of the cricoid cartilage • Tumours not invading epiglottis • Obtain frozen sections of this margin (cricohyoidoepiglottopexy) (Fig 20a-e)

• Remove the orotracheal tube and insert o Make the cut at the level of the a new tube through the cricothyrotomy; superior border of the thyroid lami- this facilitates the subsequent steps of na through the thyrohyoid mem- the operation (Figures 19b) brane and epiglottis

8 o Place a #11 scalpel in the midline, perpendicular to the larynx o Stab the scalpel through the epiglottic cartilage into the pharyngeal lumen taking care not to injure the posterior pharyngeal wall o Cut laterally first to one side, then the other to create a clean horizontal cut above the ventricular bands and the epiglottic petiole, which are included in the specimen (Figures 20a-e) Figure 20c: The cut is completed on the o Obtain frozen section at this margin contralateral side if needed

Figure 20a: Superior horizontal cut for epiglottis-preserving approach. Scalpel is Figure 20d: Surgical view of the superior inserted in the midline immediately above horizontal cut. The mucosa is opened in the superior border of the thyroid cartilage the midline before the cut is completed

Figure 20b: A cut is been made to one side Figure 20e: Arytenoids visible through superior horizontal cut

9 • When the entire epiglottis and pre- epiglottic space need to be resected (cricohyoidopexy) (Figures 21a-c)

o Make a superior infrahyoid horizontal cut (not into the pharynx) o Using sharp dissection with scissors, remove tissue from the pre- epiglottic space until the submucosa of the valleculae is reached o Make an opening in the mucosa of the vallecula on one side, as far from tumour as possible Figure 21b: The submucosa of the vallecu- o Introduced a blade of the scissors la (arrow) is exposed. The fat of the pre- inside the pharynx through the epiglottic space is included in the resection opening, with the other blade re- (asterisk) maining outside o Cut across both valleculae from side-to-side o Introduce a finger into the pharynx through the mucosal opening to palpate the tumour, or directly inspect the tumour to assure a macro- scopically free margin o Obtain frozen sections whenever the tumour approaches the resection margins

Figure 21c: The cut runs across both valleculae to expose the lingual surface of the epiglottis. Note the fat of the pre-epiglottic space (asterisk), the lingual surface of the epiglottis (+), and the posterior pharyngeal wall and free margin of the epiglottis (red arrow).

1st Vertical cut (Figures 22a, b)

Figure 21a: Superior horizontal cut for a • The 1st vertical cut is made on the side supracricoid laryngectomy with removal of opposite to the tumour; it connects the epiglottis. The hyoid is retracted superiorly lateral ends of the superior and inferior (red arrow) and traction with forceps horizontal cuts (black arrow) is applied to the pre- • The surgeon moves to the head of the epiglottic fat. The pre-epiglottic space is patient to look inside the larynx dissected by cutting with scissors against through the superior horizontal cut the inner aspect of the hyoid bone

10 • Identify all structures by direct vision vocal cord is still in place. The right side and/or palpation before cutting remains untouched • Introduce one blade of the scissors through the opening of the superior • Cut the vocal ligament where it horizontal cut, while the other blade attaches to the vocal process crosses over the lateral soft tissues of • Cut vertically through the subglottis the larynx (Figure 22a) and along the superior aspect of the • Cut through the aryepiglottic fold (if cricoid up to the lateral edge of the epiglottis is included in the specimen) cricothyrotomy • Cut along the anterior surface of the arytenoid (Figure 22b) 2nd Vertical cut

• The surgeon then moves back to the patient’s side • Grip the thyroid laminae with the fing- ers of both hands, fracture the thyroid cartilage down the midline and open the larynx like a book to expose the endolarynx and the tumour (Figure 23a)

A A

Figure 22a: (View from head of table). The VC surgeon moves to the head of the patient to st perform the 1 vertical cut through the Cr superior horizontal cut. One blade of the scissors is inside the larynx and the other VC over the lateral laryngeal soft tissues

Figure 23a: Thyroid cartilage has been fractured in midline to expose arytenoids (A), cricoid (Cr) and vocal cords (VC)

• Make the 2nd vertical cut as on the 1st (non-tumour) side using a #15 scalpel under direct vision, ensuring free mar- A gins (Figures 23b, c, d) • If needed, the arytenoid is resected, providing that the epiglottis has been preserved • Frozen section of the margins is en- Figure 22b: Surgical view of the larynx couraged from the head of the table. The first verti- • This completes the resection, leaving in cal cut has been made along the anterior place the cricoid cartilage, hyoid bone, surface of the left arytenoid (A). The left arytenoid cartilages and epiglottis de-

11 pending on the extent of the resection still retaining the larynx in place (A = (Figure 24). arytenoid)

A A VC VC Cr

Figure 23b: The endotracheal tube is inserted through the cricothyrotomy. The 2nd vertical cut is being made with a scalpel; Arytenoids (A), cricoid (Cr) and vocal cords (VC) Figure 24: Surgical view of the remaining larynx: Preserved epiglottis (red arrow); vocal processes of arytenoids (asterisks); A A and cricoid arch (black arrow) VC VC The resected specimen includes the “voice box”: thyroid cartilage, both vocal cords, Cr Cr and both ventricular bands (Figures 1, 25). One arytenoid or the epiglottis may also be included depending on tumour extension.

Figure 23c: Final stage of vertical cut

A A

Figure 23d: Surgical view of the larynx before completing the resection. The verti- Figure 25: The surgical specimen includes cal cut on the left side has been completed. the thyroid cartilage with both vocal cords The right vocal cord is the only structure and ventricular bands

12 3. Tracheostomy and feeding tube • Resite the endotracheal tube into the new tracheostoma (Figure 28) • To allow one to pull the cricoid up to • Insert a nasogastric feeding tube under the level of the hyoid bone, mobilise direct vision of the hypopharynx to the trachea by dissecting bluntly with a ensure its proper positioning finger along the anterior tracheal wall taking care not to disturb the tracheal vasculature that enters through its lateral walls (Figure 26)

Figure 28: Resiting the endotracheal tube into the new tracheostoma

4. Reconstruction

Figure 26: Dissecting bluntly with a finger Arytenoids along the anterior tracheal wall • Place two 3-0 vicryl sutures between • While maintaining the cricoid in this the superior aspects of the arytenoids position, create a tracheostomy at the and the cricoid arch (Figures 2, 29) level of the suprasternal skin incision (usually 4th/5th tracheal rings) (Figure 27)

A A

Cr Cr

Figure 29: Sutures (red arrows) are placed between each vocal process and the cricoid (Cr) to pull the arytenoids (A) forwards. Do not tie them too tightly as Figure 27: With cricoid abutting hyoid, their role is simply to prevent posterior create a tracheostomy at the level of the rotation of the arytenoids during healing suprasternal skin incision

13 • Do not tie the sutures too tightly • The sutures avoid posterior rotation of Hyoid the arytenoid and allow healing to occur in the correct position; by maintaining the arytenoids in a more ante- A A rior position, closure of the laryngeal entry during deglutition is improved 10

Closing the airway Cricoid

• Cricohyodopexy/CHP (epiglottis resec- CTL ted) or cricohyoidoepiglottopexy / CHEP (epiglottis preserved) is used to close the airway Figure 30b: The needle is passed through • Pass three #1 vicryl sutures around the the cricotracheal ligament (CTL), runs cricoid arch and the body of the hyoid submucosally on the posterior surface of • One suture is placed in the midline and the cricoid arch, and exits at its superior the other two are placed 0.5 cm to each border; note sutures pulling arytenoids (A) side (Figures 2, 30a-e) forwards

Hyoid

Figure 30a: Cricohyoidoepiglottopexy Figure 30c: The same needle re-enters between the epiglottic cartilage and pre- • The needle is passed from outside epiglottic fat, runs a few cm parallel to the through the cricotracheal membrane anterior surface of the epiglottis, and exits and is directed submucosally through through the epiglottic fat below the hyoid the posterior surface of the cricoid arch (Figure 30b) • Finally, it surrounds the posterior and • It re-enters again through the inferior superior aspect of the body of the border of the sectioned epiglottis, runs hyoid bone and exits above the bone 1-2 cm between the epiglottic cartilage through the suprahyoid musculature and the pre-epiglottic fat and exits (Figure 30d) through the pre-epiglottic fat (Figure 30c)

14 Hyoid

Figure 30d: Finally, the needle re-enters Figure 30e: Surgical view of the 3 pexy and passes behind the hyoid body, and stitches after being tied exits through the suprahyoid muscles Pyriform sinuses • If the epiglottis has been preserved, it is important that the suture runs 1-2cm • With loss of support of the thyroid parallel to the epiglottic cartilage in laminae, the pyriform sinuses lose their order to prevent inversion of the epi- shape and collapse glottis that may compromise the out- • Sutures were earlier inserted into the come11. If the epiglottis has been submucosa of the pyriform sinuses du- resected, the sutures are passed around ring the approach stage of the operation the cricoid cartilage and hyoid bone (Figure 16) submucosally in a similar manner • To restore the shape of the sinuses, use • The 1st throw of the knots of the two these sutures to hitch the outer surfaces lateral sutures are tightened simulta- of the pyriform sinuses to each side of neously by the surgeon and the assis- the pexy (Figure 31) tant • Tighten the midline suture; while maintaining tension on the two other sutures, throw at least 3 knots on every suture to avoid dehiscence of the pexy (Figure 30e) • Align the anterior borders of the cricoid and the hyoid; if this is not done then the size of the neoglottis is reduced and the functional outcome may be compromised

Figure 31: After performing the cricohyoido(epiglotto)pexy the pyriform sinuses are pulled forwards by suturing the stitches (red arrows) to the anterior tracheal wall

15 o The sooner that the cuff can be left deflated, the quicker the recovery will be o An uncuffed fenestrated tracheostomy tube is inserted as soon as the patient tolerates the cuff deflated for 24-48 hours o The tube is plugged as soon as it is comfortably tolerated o The tracheostomy tube is removed when the patient tolerates a plugged tube for 24-48hrs continuously Figure 32: The strap muscles are sutured (including at night). This usually over the cricohyoidoepiglottopexy. The happens 7-14days after surgery tracheostomy is secured in its final o The tracheostomy wound is occlu- position ded with a dressing while it heals by second intention • Suture the strap muscles to the hyoid • Swallowing bone with vicryl to cover the pexy o Provide nutrition by nasogastric (Figure 32) feeding tube • Insert a single suction drain that cross- o If no complications have occurred, es the midline; bilateral drains are in- attempt oral nutrition on Day 10 serted if neck dissections have been o Use “supraglottic swallow” and the done “chin tuck” techniques, starting • Suture the skin, leaving a gap in the with yogurt or custard consisten- lower midline to introduce a cuffed cies. The patient takes a deep tracheostomy tube breath and holds it, lowers the head until the chin touches the chest, Postoperative Care introduces a small volume of food and swallows twice while maintain- • A slightly compressive dressing is ing this position, elevates the head and coughs immediately after the placed around the neck and changed nd every day for 5-7 days 2 swallow, and subsequently breathes normally. After 2-3 at- • Drains are maintained for 2-3 days tempts a significant cough will be • Some surgeons use prophylactic anti- noted. The patient then rests for 1-2 biotics during the 1st postoperative hours and tries again days, but we do not think it necessary o As swallowing is progressively bet- unless there are factors that may favour ter tolerated, the supraglottic swal- infection low and chin tuck techniques are • Tracheostomy tube abandoned o The cuff is deflated 24hrs after o A noticeable improvement in swal- surgery lowing occurs when the tracheos- o Significant coughing is guaranteed tomy tube is removed for 5-10min o Thicker and more liquid consis- o If the cough persists after a few tencies are gradually introduced minutes, the cuff is reinflated and o Once oral intake is adequate to the manoeuvre is repeated 24hrs ensure correct nutrition, the feeding later 16 tube is removed (usually 10-20 Comparison with other treatments days after surgery) o This process is prolonged following The indications for supracricoid laryngec- resection of the epiglottis or one tomy overlap with those of vertical partial arytenoid laryngectomy and its permutations. How- ever, while voice after vertical laryngec- Radiotherapy tomy is very breathy, patients undergoing supracricoid laryngectomy preserve a If required, postoperative radiotherapy is rough but powerful voice with excellent commenced when the healing process is phonation times. For this reason, supra- complete i.e. 3-4 weeks after surgery. The cricoid laryngectomy has displaced vertical authors used to leave the tracheostomy laryngectomy techniques in the authors’ tube in situ until the end of radiotherapy as standard surgical armamentarium. Supra- many patients develop oedema that re- glottic carcinoma without glottic invasion quires endoscopic resection (e.g. with CO2 is more properly treated with horizontal laser) prior to definitive decannulation. supraglottic laryngectomy, as voice quality Swallowing rehabilitation is also retarded is much better than after supracricoid by radiotherapy, and some patients need a laryngectomy. However, the latter allows new feeding tube during this period. one to treat supraglottic tumours with glottic invasion with open partial laryngec- Outcomes tomy. In recent decades, transoral endoscopic laser resection of early and advan- Several large series 12-16 have demonstrated ced carcinoma has been described. The that the oncologic results of supracricoid main advantages of endoscopic procedures laryngectomy are equivalent to those of are the avoidance of tracheostomy in some total laryngectomy, providing that candi- patients and quicker swallowing rehabili- dates are properly selected and negative tation. However, limited exposure may margins are obtained on frozen section. compromise a surgeon’s ability to obtain The authors previously reported a 5-year negative margins in bulky tumours, where- actuarial local control rate of >90% for T1- as long-term functional results do not 17 T2 tumours, and ca. 70% for T3 tumours . differ from those of open partial laryngectomy. Moreover, the cost of a laser or a Laryngeal function is maintained in a large robot limits its application in many proportion of patients. Decannulation and developing countries. Chemoradiation is adequate oral intake are achieved in >90% often considered to be a more sophisticated of patients 7, 12, 13, 18. treatment for laryngeal cancer. Although the overall survival is considered similar to Quality of life has been shown to be better total laryngectomy, local recurrence than that of patients submitted to total generally requires salvage surgery. The laryngectomy with tracheoesophageal local control reported by the largest series puncture 16. In a previous study, the of supracricoid laryngectomies for locally authors reported excellent voice and advanced carcinoma is superior to that swallowing in a group of patients as reported by the main studies of nonsurgical measured by the Voice Handicap Index treatment 19, 20. Moreover, chemoradiated and the MD Anderson Dysphagia Inven- patients experience late toxicity that tory 7. worsens their quality of life. Finally, the cost of chemoradiation is far higher than that of supracricoid laryngectomy. Total

17 laryngectomy has been the classic treat- comparable to transoral procedures in the ment for laryngeal carcinoma for many treatment of T1-T2 glottic tumours, and to years. While total laryngectomy patients chemoradiation protocols in T3-T4 glottic experience excellent swallowing and voice and transglottic tumours. However, careful can be successfully restored by different selection of candidates is mandatory to procedures 21, the presence of a permanent achieve these results. tracheostoma is an unavoidable handicap that worsens their quality of life16, 22, 23. References

Summary of authors’ routine practice 1. Majer EH, Rieder W. [Technic of laryngectomy permitting the conservation • Unilateral vocal cord cancers with pre- of respiratory permeability (cricohyoido- served mobility and minimal invasion pexy)]. Ann Otolaryngol. 1959; 76:677-81 of the contralateral cord and/or ventri- 2. Piquet JJ, Desaulty A, Decroix G. [Crico- cular band are treated by endoscopic hyoido-epiglottopexy. Surgical technic and resection (or laryngofissure if adverse functional results]. Ann Otolaryngol Chir anatomical features exist) Cervicofac. 1974;91 (12):681-6 • More advanced glottic cancers are re- 3. Laccourreye O, Ross J, Brasnu D, Chabardes E, Kelly JH, Laccourreye H. sected by supracricoid laryngectomy Extended supracricoid partial laryngec- • Supraglottic cancers without glottic in- tomy with tracheocricohyoidoepiglotto- vasion are managed by horizontal su- pexy. Acta Otolaryngol. 1994;114-(6):669- praglottic laryngectomy (only small 74 supraglottic tumours are endoscopically 4. Yang H, Shen W, Xiong X. [Extended resected) supracricoid partial laryngectomy with • Supracricoid laryngectomy is used for tracheocricohyoidoepiglottopexy and supraglottic cancer that invades the tracheocricohyoidoglottopexy]. Lin Chung glottis Er Bi Yan Hou Tou Jing Wai Ke Za Zhi. 2008;22(18):840-1 • Chemoradiotherapy is offered to pa- 5. Allegra E, Franco T, Trapasso S, tients that cannot be managed with any Domanico R, La Boria A, Garozzo A. form of partial laryngectomy due to Modified supracricoid laryngectomy: on- tumour or patient factors cological and functional outcomes in the • Total laryngectomy is currently consi- elderly. Clin Interv Aging. 2012; 7:475-80 dered a first line treatment for laryngeal 6. Schindler A, Favero E, Capaccio P, Albera and hypopharyngeal cancer when a R, Cavalot AL, Ottaviani F. Supracricoid tumour exceeds the limits of partial laryngectomy: age influence on long-term laryngectomy and presents with adverse functional results. Laryngoscope. 2009; factors for chemoradiation (bulky, carti- 119(6):1218-25 7. Castro A, Sanchez-Cuadrado I, Bernal-dez lage invasion), or when the patient’s age R, Del Palacio A, Gavilan J. Laryngeal or comorbidities contraindicate other function preservation fol-lowing surgical or non-surgical treatments supracricoid partial laryngec-tomy. Head Neck. 2012;34(2):162-7 Conclusions 8. Joo YH, Sun DI, Cho JH, Cho KJ, Kim MS. Factors that predict postoperative Supracricoid partial laryngectomy is a ver- pulmonary complications after supracri- satile technique for the treatment of glottic coid partial laryngectomy. Arch Otolaryn- and transglottic carcinoma. The oncologic gol Head Neck Surg. 2009; 135(11):1154- results are supported by several long-term 7 series. Long-term functional results are 9. Chow JM, Block RM, Friedman M. Preoperative evaluation for partial laryn-

18 gectomy. Head Neck Surg. 1988; 18. Cho KJ, Joo YH, et al. Supracricoid 10(5):319-23 laryngectomy: oncologic validity and 10. Seino Y, Nakayama M, Okamoto M, functional safety. Eur Arch Otorhino- Hayashi S. Three-dimensional computed laryngol. 2010;267(12):1919-25 tomography analysis of neoglottis after 19. Forastiere AA, Goepfert H, Maor M, et al. supracricoid laryngectomy with crico- Concurrent chemotherapy and radiothera- hyoidoepiglottopexy. J Laryngol Otol. py for organ preservation in advanced 2012;126(4):385-90 laryngeal cancer. N Engl J Med. 2003; 11. Nakayama M, Okamoto M, Seino Y, 349(22):2091-8 Miyamoto S, Hayashi S, Masaki T, et al. 20. Wolf GT. Induction chemotherapy plus ra- Inverted epiglottis: a postoperative compli- diation compared with surgery plus radia- cation of supracricoid laryngec-tomy with tion in patients with advanced laryngeal cricohyoidoepiglottopexy. Auris Nasus cancer. The Department of Veterans Larynx. 2010;37(5):609-14 Affairs Laryngeal Cancer Study Group. N 12. Chevalier D, Laccourreye O, Brasnu D, Engl J Med. 1991; 324(24):1685-90 Laccourreye H, Piquet JJ. Cricohyoido- 21. Torrejano G, Guimaraes I. Voice quality epiglottopexy for glottic carcinoma with after supracricoid laryngectomy and total fixation or impaired motion of the true laryngectomy with insertion of voice vocal cord: 5-year oncologic results with prosthesis. J Voice. 2009; 23(2):240-6 112 patients. Ann Otol Rhinol Laryngol. 22. Herranz J, Gavilan J. Psychosocial adjust- 1997;106(5):364-9 ment after laryngeal cancer surgery. Ann 13. Mercante G, Grammatica A, Battaglia P, Otol Rhinol Laryngol. 1999; 108(10):990- Cristalli G, Pellini R, Spriano G. 7 Supracricoid Partial Laryngectomy in the 23. Singer S, Danker H, Guntinas-Lichius O, Management of T3 Laryngeal Cancer. Oeken J, Pabst F, Schock J, et al. Quality Otolaryngol Head Neck Surg. 2013 Aug 6. of life before and after total laryngectomy: [Epub ahead of print] Results of a multicenter prospective cohort 14. Page C, Mortuaire G, Mouawad F, Ganry study. Head Neck. 2014 Mar;36(3):359-68. O, Darras J, Pasquesoone X, et al. doi: 10.1002/hed.23305 Supracricoid laryngectomy with cricohyoidoepiglottopexy (CHEP) in the Clinical practice guidelines management of laryngeal carcinoma: oncologic results. A 35-year experience. • Cancer of Glottis Eur Arch Otorhinolaryngol. 2013;270(6):- https://developingworldheadandneckcance 1927-32 rguidelines.com/index-page-glottic- 15. Pinar E, Imre A, Calli C, Oncel S, Katilmis cancers/ H. Supracricoid partial laryngectomy: • Cancer of Supraglottis analyses of oncologic and functional https://developingworldheadandneckcance outcomes. Otolaryngol Head Neck Surg. rguidelines.com/index-page-supraglottic- 2012;147(6):1093-8 cancers/ 16. Weinstein GS, El-Sawy MM, Ruiz C, • Cancer of Hypopharynx Dooley P, Chalian A, El-Sayed MM, et al. https://developingworldheadandneckcance Laryngeal preservation with supracricoid rguidelines.com/index-page- partial laryngectomy results in improved hypopharyngeal-cancers/ quality of life when compared with total

laryngectomy. Laryngoscope. 2001; 111(2):191-9 Authors 17. Sanchez-Cuadrado I, Castro A, Bernaldez R, Del Palacio A, Gavilan J. Oncologic Alejandro Castro, MD outcomes after supracricoid partial laryn- Department of Otolaryngology gectomy. Otolaryngol Head Neck Surg. La Paz University Hospital 2011;144(6):910-4 Madrid, Spain [email protected] 19 Javier Gavilán, MD Professor and Chairman Department of Otolaryngology La Paz University Hospital Madrid, Spain [email protected]

Editor

Johan Fagan MBChB, FCS(ORL), MMed Professor and Chairman Division of Otolaryngology University of Cape Town Cape Town, South Africa [email protected]

THE OPEN ACCESS ATLAS OF OTOLARYNGOLOGY, HEAD & NECK OPERATIVE SURGERY www.entdev.uct.ac.za

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