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Supracricoid Laryngectomy for Laryngeal Cancer

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Supracricoid Laryngectomy for Laryngeal Cancer CC-BY-NC 3.0 SUPRACRICOID LARYNGECTOMY Alejandro Castro & Javier Gavilán Supracricoid laryngectomy consists of en cord mobility. The epiglottis and pre-epi- bloc resection of both vocal cords, the para- glottic space can be included in the speci- glottic spaces and the thyroid cartilage (Fig- men, allowing for resection of transglottic ure 1). It was first described by Majer in tumours that invade the supraglottic and 1959 1 and Piquet in 1974 2. It is used for the glottic regions. One arytenoid can also be treatment of selected early and locally ad- resected. However combined resection of vanced glottic and transglottic carcinoma in the epiglottis and one arytenoid usually re- an oncologically safe manner, while pre- sults in poor functional outcomes and in- serving laryngeal function i.e. swallowing creases the chance for aspiration and de- (airway protection), breathing and phona- layed decannulation. tion. Types of supracricoid operations With supracricoid laryngectomy the hyoid 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 tra- cheocricohyoidoepiglottopexy (Figures 2a- c). With tracheocricohyoidoepiglottopexy the anterior cricoid is resected for an addi- tional tumour margin anteriorly. Figure 1: Typical supracricoid laryngectomy speci- men 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 http://openbooks.uct.ac.za/ENTatlas 15-1 Open Access Atlas of Otolaryngology, Head & Neck Operative Surgery a Base of a tongue a b Figure 3: Arytenoids tilt forwards and backwards for phonation, swallowing and breathing c Figure 2: Cricohyoidoepiglottopexy (a), cricohy- oidopexy (b), and tracheocricohyoidoepi-glottopexy Figure 4: Arytenoids tilt backwards and forwards for (c) breathing, phonation, swallowing Function Cricoarytenoid unit (Figures 5, 6) Key functional outcomes are airway, pho- An intact cricoarytenoid unit is critical for nation and swallowing without aspiration. function. It comprises the arytenoid Phonation and swallowing depend on the mounted on an intact posterior cricoid ring, arytenoids being able to tilt forwards and with a functioning recurrent laryngeal make contact with the base of the tongue; to nerve and lateral and posterior cricoaryte- breathe the arytenoids tilt posteriorly to noid muscles. Ideally one should preserve open the airway (Figures 3, 4). both cricoarytenoid units; sacrificing one unit increases the chance of disabling aspi- ration in the cases where the epiglottis is re- sected. http://openbooks.uct.ac.za/ENTatlas 15-2 Alejandro Castro & Javier Gavilán 1. Tumour factors TNM classifications were not developed to guide the indications for different surgical techniques; other factors should be taken into account when considering supracri- coid laryngectomy. In general, supracricoid laryngectomy is indicated for T1 and se- lected T2-3 glottic as well as selected T2-4a su- praglottic cancers. Nevertheless supracri- coid laryngectomy is usually appropriate, for example, for virtually any T2 glottic can- cer but it is contraindicated for those rare T2 glottic cancers with extensive subglottic ex- tension. Figure 5: Anatomy of the cricoarytenoid unit and the Two types of vocal cord immobility should course of the recurrent laryngeal nerve (yellow arrow) be taken into account when considering su- directly behind the articular facet of the inferior cornu of the thyroid cartilage pracricoid laryngectomy • Tumours that invade the paraglottic space and “fix” the vocal cord, but with some preserved mobility of the arytenoid: These tumours can usually be resected by supracricoid laryngectomy as resec- tion of the arytenoid is likely to produce a negative margin • Cricoarytenoid joint invasion: This must be suspected when the arytenoid is “fro- zen”. Supracricoid laryngectomy is not recommended as even resecting the ar- ytenoid is unlikely to yield a negative margin Figure 6: Right side illustrates the situation after su- The extent of the tumour relative to the re- pracricoid laryngectomy with preserved cricoarytnoid unit section limits of supracricoid laryngectomy must be considered Preoperative Evaluation • Inferiorly: Superior border of cricoid car- Careful selection of candidates is the key to tilage: Routine intraoperative frozen sec- success of supracricoid laryngectomy. Both tion is strongly recommended to ensure tumour and patient factors must be taken negative mucosal margins at the superior into account to ensure satisfactory onco- border of the cricoid cartilage. Some au- logic and functional outcomes. http://openbooks.uct.ac.za/ENTatlas 15-3 Open Access Atlas of Otolaryngology, Head & Neck Operative Surgery thors describe partial or complete resec- or direct laryngoscopy are adequate for this tion of the anterior cricoid arch 3, 4. Alt- purpose. CT scan or other imaging tech- hough this might be oncologically safe, niques may help in some cases, particularly in our hands it compromises the func- to determine extralaryngeal extension tional results and should be performed through thyroid cartilage. only in very carefully selected cases (Fig- ure 2c) Extending the resection beyond the above- • Superiorly: Epiglottis or tongue base, de- mentioned parameters reduces the chance pending on the upper extent of the tu- of functional success (aspiration and/or in- mour: The epiglottis and pre-epiglottic ability to be decannulated), and should be space can be included in the resection performed only in very carefully selected (Figure 2b). Although limited extension patients. Employing supracricoid laryngec- to the base of the tongue can be excised, tomy with too advanced tumours, or relying resection should not extend beyond the on postoperative radiotherapy to treat pos- circumvallate papillae as the base of the itive margins is unacceptable as it increases tongue plays a critical role with laryngeal recurrence rates and reduces survival. closure during swallowing (Figures 3, 4) • Laterally: Pyriform sinus: Limited resec- Frozen section should always be used with tion of the medial wall of the pyriform si- any type of open partial laryngectomy. With nus can be accomplished. However, wide supracricoid laryngectomy, it should be ob- resection which includes the lateral wall tained to confirm oncologic safety of every may compromise swallowing close margin, and routinely at the level of • Posteriorly (midline): The interarytenoid the cricoid. Patients should agree preoper- space must be free of tumour: It is atively that total laryngectomy will be per- strongly recommended to preserve both formed if negative margins cannot be ob- arytenoids when the epiglottis is in- tained. cluded in the resection. At least one mo- bile arytenoid must always be preserved Neck dissection can be performed simulta- • Thyroid cartilage: As the paraglottic neously. T1-2 glottic cancer without evidence spaces and thyroid cartilage are resected of neck metastases can be treated with su- en bloc, involvement of only the inner pracricoid laryngectomy without neck dis- perichondrium is not a contraindication. section. Elective ipsilateral neck dissection However, more extensive invasion of is advocated for locally advanced, purely thyroid cartilage is a contraindication to glottic tumours (vocal cord fixation). Bilat- supracricoid laryngectomy. Yet cancers eral neck dissection is recommended in all of the anterior commissure invading patients with tumour invading the supra- thyroid cartilage in the midline may still glottis regardless of T and N stage. be considered for supracricoid laryngec- 2. Patient factors tomy. Patients need to learn new ways to swallow Careful preoperative evaluation should be after removal of part of the larynx. Every pa- undertaken to ensure that the primary tu- tient undergoing supracricoid laryngec- mour falls within these abovementioned tomy will experience aspiration of varying limits. As a rule, indirect (fiberoptic) and/ http://openbooks.uct.ac.za/ENTatlas 15-4 Alejandro Castro & Javier Gavilán degrees during the initial postoperative • If neck dissection is planned, the U- days. shaped incision runs from mastoid-to- mastoid close to the posterior border of Age is an important consideration as the the sternocleidomastoid muscle to cre- brain’s plasticity decreases with age as does ate a broader flap. Neck dissections are a patient’s ability to learn new swallowing done before the laryngectomy techniques. Classically, 65-70yrs is consid- • A superiorly based subplatysmal apron ered the cut-off for open partial laryngec- flap is elevated. This exposes the supra- tomy. However, a patient’s general status is and infrahyoid muscles of the neck (Fig- more important than age itself, and success- ures 7, 8) ful results have been reported in older pa- tients 5, 6. Careful evaluation of comorbidities is im- portant to ensure successful functional out- comes. The cough reflex is of critical im- portance to deal with aspiration. In our se- ries, up to 15% of patients developed pneu- monia 7. Pulmonary and cardiac reserve is crucial to overcome this complication. Some authors recommend routine preoper- 8, 9 ative pulmonary function tests . We be- Figure 7: Infra- and suprahyoid muscles lieve that a detailed clinical history is ade- quate, focusing attention on symptoms re- lating to chronic obstructive pulmonary
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