Central Annals of Otolaryngology and Rhinology

Research Article *Corresponding author

Nermin Başerer, Department of Otolaryngology, İstanbul University, Valikonağı Caddesi, 149/11, Horizontal Vertical Laryngectomy 34365, Şişli-Istanbul, Turkey, Tel:+90 212 2313005; Email: in Transglottic Laryngeal Cancer Submitted: 30 June 2017 Accepted: 21 September 2017 Nermin Başerer* Published: 25 September 2017 Department of Otolaryngology, İstanbul University, Turkey ISSN: 2379-948X Copyright Abstract © 2017 Başerer Organ preservation surgery in the larynx cancer started with cordectomy technique in OPEN ACCESS 1850s. Leading laryngologists have described alternative techniques to total laryngectomy (TL). But the extent of their indications, resection limits and reconstruction problems led to oncological Keywords and functional failure. Therefore, these techniques were forgotten until 1950s. Studies on the • Horizontal vertical laryngectomy embryology, surgical anatomy of the larynx and biologic behavior of squamous cell cancer • Transglottic cancer provided surgical return. In the organ preservation surgery vertical partial laryngectomy (VPL), • Selected T3 cord fixation horizontal supraglottic partial laryngectomy (SGPL) and their extended modifications were • Laryngostoma technique developed by the pioneer laryngologists. Adoption and application of any new technique usually • Larynx reconstructive surgery take some time. However, the important problem is that when a technique becomes popular it is being used instead of other techniques. In this article, I would like to introduce our horizontal vertical laryngectomy (HVL) technique that we have been using successfully in unilateral selected T2-T3 transglottic cancer since 1977. In this 3/4 laryngectomy, SGPL and VPL are applied together. Reconstruction with restoration of glottis is performed with two stage Cevanşir’s laryngostoma technique. Early decanulation (from 4-5 days) and aspiration free swallowing (from 7-10 days) are the important advantages along with its oncological safety.

ABBREVIATIONS described rather the procedures without functional and oncologic TL: Total Laryngectomy; VPL: Vertical Partial Laryngectomy; long term outcomes. Comparative publications containing years SGPL: Horizontal Supraglottic Partial Laryngectomy; SCPL: Subracricoid Partial Laryngectomy; NTL: Near Total Glottic or supraglottic laryngeal cancer that crosses the ventricle of experiences of larynx cancer surgery centers are not sufficient. Laryngectomy; FLL: Frontolateral laryngectomy; FAL: Frontal is called transglottic carcinoma. These cancers invade laryngeal anterior laryngectomy; PGS: Paraglottic Space; PES: Preepigllottic framework in high percentage (76%) and carry big risk of cervical Space metastases [5]. In the limited thyroid cartilage involvement SCPL techniques that remove the entire of thyroid cartilage became a INTRODUCTION very useful alternative to TL [6-8]. However, the framework of The laryngologist surgeon should have a broad spectrum from cancer crosses only behind the posterior of ventricle [5]. Besides, cordectomy to supracricoid subtotal partial laryngectomy (SCPL) glotticlarynx usually and transglottic is not being cancers invaded have if the unilateral unilateral developmental transglottic of conservation laryngectomy techniques. All speech methods tendencies. Forth is reason, alternative techniques that do not including near total laryngectomy (NTL) should be added to this spectrum. Key of successful oncological results regarding any indications in unilateral transglottic cancers have been technique is the appropriate indication and patient selection. described.require excessive In the literature tissue removal there arein the various presence techniques of appropriate for HVL Until 1970s, immobility of vocal cord T3without discrimination [6-8]. However, these techniques have not been popularised, and almost forgotten. In Figure (1) [9], right transglottic carcinoma for conservation surgery. In these years selected T3concept of the cause of fixation was considered absolute contraindication convenient for HVL technique is given. cord is due to invasion oftyro-arytenoid muscle in paraglottic spacewas unanimously (PGS), crico-arytenoid accepted. In selected joint and T3, musclesthe fixation should of vocal be VHL and HVL procedure by modifying very old laryngostoma intact. Since these years selected T3 has not been accepted a techniqueOur leading of Gluck-Sorensen laryngologist [10] Cevanşir for reconstruction described in in1965 unilateral a new contraindication for conservation surgery [1-4]. This concept led glottic and transglottic cancer surgery [11-14]. In the Department to the development of new conservative techniques for advanced of Ear Nose and Throat in the Medical Faculty of Istanbul University these techniques have been used successfully in the laryngectomy procedures have begun to be described. However, oncologic and especially functional aspect. For the oncologic therelaryngeal were cancer. no large Already series since of these 1960s techniques. more extensive The reports partial safety of HVL technique, with appropriate indication of unilateral

Cite this article: Başerer N (2017) Horizontal Vertical Laryngectomy in Transglottic Laryngeal Cancer. Ann Otolaryngol Rhinol 4(7): 1190. Başerer (2017) Email: Central

Indication of HVL technique

intact crico-arytenoid joint and muscles) transglottic cancer. TheHVL anterior is indicated commissure, in unilateral contralateral T2-T3 true (cord and false fixation cord withand both crico- arytenoid joint, cricoid region with thyroid cartilage should be intact. Contraindications for HVL Crico-arytenoid joint invasion, anterior commissure involvement or its suspicion, cricoid and/or thyroid cartilage invasion, subglottic extension of cancer more than 10 mm anteriorly, 5mm posteriorly, pharyngeal extension to the apex of pyriform sinus, massive invasion of PES. Figure 1 Right transglottic carcinoma, convenient for HVL technique, Contraindication outside the larynx treated with total laryngectomy [9]

the lung (FEV1<50%), poor health condition, physiologic and selected T2-T3 transglottic cancer is very important. In all the chronologicIncurable old neck age. metastases, insufficiency of vital capacity of conservative surgery techniques of the larynx, invasion of the thyroid cartilage in theT4 stage, subglottic extension of the Preoperative and intraoperative careful assessments of cancer to cricoid and/or crico-arytenoid joint involvement are the tumoral extension are essential for the strict indication absolute contraindications. of conservation surgery. Preoperative routine laryngoscopic examinations are video-laryngoscopy and micro-laryngoscopy for HVL technique is indicated in the selected T2-T3 unilateral biopsy and mapping of tumor. For the clear evaluation of anterior transglottic carcinoma. In the cases of transglottic cancers that commissure and subglottic area is performed with 0°, 70°, 120° reach over the anterior commissure and/or thyroid cartilage telescopes, under general anesthesia without intubation at 100% involvement in T3 stage, HVL technique is contraindicated, in oxygenation. MRI/CT, and in the suspicion of distant metastases these cases SCPL is an alternative to TL. The presence of an intact PET/CT are imaging methods. In all cases of transglottic cancer hyoid region is essential for the application of cricohyoidopexy according to the state of the neck, the elective or curative neck in SCPL. In the involvement of the hyoid region near total dissection is performed. Preoperative and postoperative view of laryngectomy (NTL) technique can be successfully used [15-17]. the larynx in the HVL technique is presented in Figure (2). Skin NTL is a dynamic musculomucosal-cartilaginous shunt technique. It is described for speech in larynx or laryngopharyngeal cancer requiring TL or laryngo-pharyngectomy [18-20]. This partial incision of Cevanşir’s flap is schematically illustrated in laryngectomy cannot be accepted as conservative surgery of the hyoid bone to the incisura thyroid. Flap pedicle is in the because the patient must carry a permanent tracheostomy Figure (3). The first incision extends from lower middle cannula. In all partial laryngectomy techniques including NTL subglottic extension should be contraindicated. Our experience theside height of involved is between hemyglottis. incisura Rectangular thyroid and flap thyroid is prepared cartilage in has shown that subglottic extension with cricoid involvement bottom.front of intact The third hemyglottis. vertical The incision width extends of the flap between is only the 7-8 lower mm, and pharyngeal extension to the apex of pyriform sinus is a very middle tip of the thyroid and the lower middle tip of the cricoid. important risk factor of recurrence for partial laryngectomy [21].

MATERIAL AND METHODS andLaryngofissure delineation withof the median tumor is thyrotomy given in Figure is performed (5). Endolaryngeal in Figure (4). After laryngofissure thyrotomy intraoperative exploration Laryngologist surgeon should be able to recognize and apply resection, control of margins and assessment of intact thyroid all surgical techniques. There should be other alternatives at the limit of any technique. HVL technique described in this article is based on our experience of over 30 years in larynx cancer surgery. The material of this study consists of 349 cases of HVL technique (including 30 HVLF) applied between 1977 and 2009. In this period, a total of 3128 cases treated with the different techniques are reported respectively according to the case numbers: 1307 total laryngectomy, 528 supraglottic laryngectomy, 349 endoscopic), 189 NTL, NTLF, 185 laryngopharyngectomy, 93 HVL (including 30 HVLF), 326 cordectomy (laryngofissure, technique, Calaero-Teatini’s horizontal glottectomy technique), (a) Preoperative view of T3 left transglottic cancer,(b) FLL-FAL (L. Robert’s technique, Cevanşir’s technique, Tucher’s Figure 2 79 SCPL, and 72 VHL. postoperative endoscopic view of HVL in this case.

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RESULTS AND DISCUSSION Postoperative early rehabilitation is the major advantage of this technique. Laryngostoma permits early decannulation from 4-5 days, and the patients begin speaking with digital closure of laryngostoma, swallowing without aspiration is also regained after 7-10 days. All of the patient’s early decannulation and removal of the naso-gastric tube were provided. Likewise, there was no evidence of late stenosis. The purpose of designing this reconstruction technique with two stage laryngostoma has been to prevent stenosis as a consequence of secondary healing of the

survival is 89%. Adjuvant radiotherapy was applied in principle Figure 3 inendolaryngeal the presence bare of neck field. metastases. Overall survival is 82%, disease free Incision of Cevanşir’s flap of the right transglottic cancer. The disadvantages of the HVL technique can be summarized as follows: HVL is actually a technique in which 3/4 laryngectomy is applied, and has more limited indications than the subtotal laryngectomy. It is a two-stage technique, and there is a need for

the reconstruction of the hemiglottis. In the recent years, there hasrepeated been epilation a tendency of hair to growth adopt subtotalon the neck laryngectomy skin flap applied instead in of standard conservation surgery techniques, or non-surgical organ preservation with chemo radiotherapy. Nevertheless, in experienced centers of laryngeal cancer surgery TL decreased until 30% [18]. It is also possible that the organ preservation

surgery, anterior commissure involvement is a very important issuesurgery that is often needs the first to bechoice considered. in larynx cancer. Anterior In conservation commissure Figure 4 techniques applied with partial thyroid cartilage resection are thyrotomy. (a) Laterally pedicle flap, (b) Laryngofissure with median cartilage may be the focus for recurrence. Our experiences led oncologically inadequate. Because remaining ossified thyroid ala with subperichondral dissection, in the necessity of frozen us to apply SCPL instead of FAL and FLL techniques in cancer section, is performed in Figures (5a,b)). Specimen of the HVL reaching the anterior commissure and/or in limited T3 stage procedure contains supraglottis (epiglottis with PES), and lesion thyroid cartilage invasion. side of glottis (false and true vocal cord, arytenoid with PGS In the larynx conservation surgery, some lesions can be treated and subglottis up to cricotracheal membrane) (Figures 6a,b). with two different procedures. Controversies exist concerning Ipsilateral intact thyroid ala is removed for facilitation of glottis which is the most appropriate technique for the patient. There reconstruction, thus strap muscles approach more easily to intact are a wide range of conservation surgery techniques smallest hemyglottis. Resection limits of HVL technique are illustrate in Figure (7). In the HVL technique reconstruction is performed with of the resected hemyglottis is performed by the replacement oftwo the staged prelaryngeal laryngostoma. strap In muscles the first instead stage of of the hemiglottic reproduction soft uncoveredtissue and area.the flap Absence skin instead of the bare of resected endolaryngeal mucosa. area The is entire a key incised mucosa is stitched to the flap skin in order not to leave absorbable 0000 is preferable as the suture material (Figure 8).factor Prevention in preventing of bare postoperative endolaryngeal stenosis. area by Monofilament stitching mucosa non- postoperativeand flap skin isstenosis a prerequisite is the most for commonavoiding problemstenosis. forThis other is a immediateprincipal benefit reconstruction of HVL techniques with laryngostoma of the larynx technique. conservation The surgery. Gauze pad tamponade for 2-3 days is applied to reshape

This laryngostoma technique permits early decannulation (after Figure 5 (a) Border evaluation of the tumor subperichondral control, 4-5the neo days), larynx and lumen swallowing after the without first reconstruction aspiration after stage 7-10 of HVL. days (b) Removal of intact thyroid ala of involved glottis for facilitation of glottic reconstruction, thus strap muscles approached more easily to (Figure 8). From 3th week, laryngostoma is closed with the local intact hemyglottis. anesthesia in two layers simple suture (Figure 9).

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to largest from cordectomy to subtotal laryngectomy. Laryngeal surgeon should be able to apply the most appropriate technique. Each technique has its own indications and limits of resection. Rehabilitation and quality of functions depend on the size of the resected endolaryngeal tissue and especially the adequate

technique described by Gluck-Soerensen for reconstruction in VPLreconstruction and HVL. technique. Reconstruction Cevanşir with has laryngostoma modified the layngostoma provided to be successful for hemiglottic replacement and glottic sphincter compensation. Supraglottic sphincter is preserved with intact hyoid bone and strap muscles, and particularly unchanging larynx position and antero-superior suspension in swallowing. Figure 6 (a) En block resection of transglottic tumor, (b) Specimen of the HVL resection. In the selectedT2-T3 transglottic cancers, advanced conservation techniques such as HVL (3/4) and SCPL (subtotal laryngectomy) can be successfully applied. In cases where the conservation surgery cannot be applied, new total laryngectomy can be an alternative to total laryngectomy. Dynamic shunt technique NTL, which is described for speech, may be an alternative to TL [18-20]. In the crico-hyoidopexy (SCPL) reconstruction is an end to end anastomosis; therefore noninvolved glottic part must be removed. Consequently, restoring laryngeal function, especially swallowing without aspiration, is a problem and requires postoperative rehabilitation training. Preservation of uninvolved portion of the larynx and adequate reconstruction is a key of functional success in organ preservation surgery. In our two stage technique, reconstruction is done with laryngostoma Figure 7 Resection limits of the HVL technique, (a) Axial view, (b) for restoration of glottis. As a result, early decannulation and Frontal view. especially postoperative period without aspiration is ensured. Consequently, as stated by Biller [22], the appropriately designed laryngostoma technique promises future in the functional

satisfiedCONCLUSION outcomes. Each technique can be sustained wits its successful results. Any procedure should be discussed in terms of functional outcomes and especially its oncologic safety. Replacement of resected tissue, particularly of hemiglottis, is the key to success for glottic competence, and for regaining swallowing function without aspiration. Supraglottic competence was regained by maintaining the position of the reconstructed larynx and Figure 8 (a) View of laryngostoma after resection and suturing bare ensuring antero-superior suspension in the swallow. It is always surface,(b) Early decannulation (after 4 -5 days). necessary to be open to all options for a higher surviving rate and better quality of life. REFERENCES 1. Laryngoscope. 1971; 81: 1029-1044. Kirchner JA, Som ML. Clinical significance of fixed vocalcord. 2. cord) epidermoid carcinoma of larynx. Laryngoscope. 1976; 86: 1563- 1571.Lesinski SG, Bauer WC, Ogura JH. Hemilaryngectomy for T3 (fixed 3. Kessler DJ1, Trapp TK, Calcaterra TC. The treatment of T3 glottic carcinoma with vertical partial laryngectomy. Arch Otolaryngol Head Neck Surg. 1987; 113: 1196-1199. 4.

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Cite this article Başerer N (2017) Horizontal Vertical Laryngectomy in Transglottic Laryngeal Cancer. Ann Otolaryngol Rhinol 4(7): 1190.

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