ISSN: 2572-4193 Bottini et al. J Otolaryngol Rhinol 2017, 3:032 DOI: 10.23937/2572-4193.1510032 Volume 3 | Issue 2 Journal of Open Access Otolaryngology and Rhinology CASE REPORT Epiglottis Reconstruction with Auricular Free Flap for Re- habilitation of Dysphagia: A Case Study Battista Bottini G1*, Brandtner C1, Rasp G2 and Gaggl A1 1Department of Oral and Maxillofacial Surgery, University Hospital, Private Medical University Paracelsus, Austria 2Department of Ear, Nose and Throat, University Hospital, Private Medical University Paracelsus, Check for updates Austria *Corresponding author: Gian Battista Bottini, MD, DMD, Department of Oral and Maxillofacial Surgery, Uni- versity Hospital, Private Medical University Paracelsus, 48 Muellner Hauptstrasse, 5020 Salzburg, Austria, Tel: +43(0)57255-57230, Fax: +43(0)57255-26499, E-mail: [email protected] and requires a coordinated activity of nerves, muscles, Abstract the hyoid bone and the larynx [1]. The process can be Supraglottic laryngectomy for laryngeal cancer aims to remove divided in stages: oral pharyngeal and oesophageal [1]. cancer of the larynx whilst preserving its functions of airway protection, breathing and voice production. A well-known long- During the pharyngeal stage, the vocal cords adduct term complication of this procedure is aspiration. to seal the glottis and the arytenoid tilt forward to con- We present a case of a delayed epiglottis reconstruction tact the epiglottis base. with auricular free flap for surgical rehabilitation of dyspha- gia. Primarily the patient underwent supraglottic laryngecto- When the hyo-laryngeal complex is pulled in anterior my, bilateral neck dissection and radiotherapy. She had a and superior direction against the base of the tongue, permanent tracheostoma because of a complete paralysis the epiglottis, acting like a shield, tilts backwards and of the right vocal cord and a residual minimal mobility of the covers completely the glottis [1]. The bolus descending left cord. Her main complaint was leakage of liquid from her tracheostomy whenever she was drinking something. The from the oral cavity is deflected laterally on both sides chondrocutaneous auricular free flap was harvested from in the paraglottic space to slide along the piriform fos- the pinna and was based on the superficial temporal artery sae and through the upper oesophageal sphincter [2]. and accompanying vein. The vessels were anastomosed to the superior thyroid artery and vein via a submandibular Supraglottic laryngectomy for laryngeal cancer aims to neck incision. remove a malignancy originating within the larynx crani- The neo-epiglottis helped re-establishing a degree of pro- ally to the vocal cords. The false cords, the epiglottis and tection of the glottis during deglutition of liquids reducing vo- the aryepiglottic folds can be removed; however the vocal cal cords irritation, thereby improving swallowing and voice cords are preserved. The second goal of this procedure is quality. In conclusion this form of reconstruction should be the preservation of the three functions of airway protec- taken in consideration when surgical rehabilitation of swal- tion, breathing and phonation of the larynx. The surgical lowing after supraglottic laryngectomy is indicated. approach can be either through a neck incision or endo- Keywords scopic, depending on the staging. A well-known compli- Supraglottic laryngectomy, Dysphagia, Epiglottis recon- cation is aspiration, due to removal of structures that are struction, Microvascular free flap major players in protecting the tracheal inlet during deglu- tition, such as the false vocal cords and the epiglottis [3]. Introduction According to Logemann vocal cord adduction and Swallowing is the active propulsion of food and liquid laryngeal elevation were the 2 most common dysfunc- starting from the oral cavity and ending in the stomach tions after supraglottic laryngectomy [4]. Citation: Bottini G, Brandtner C, Rasp G, Gaggl A (2017) Epiglottis Reconstruction with Auricular Free Flap for Rehabilitation of Dysphagia: A Case Study. J Otolaryngol Rhinol 3:032.doi.org/10.23937/2572- 4193.1510032 Received: July 06, 2017: Accepted: November 13, 2017: Published: November 15, 2017 Copyright: © 2017 Bottini G, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Bottini et al. J Otolaryngol Rhinol 2017, 3:032 • Page 1 of 6 • DOI: 10.23937/2572-4193.1510032 ISSN: 2572-4193 Aspiration affects as many as 39% of these patients The patient underwent a full course of speech and according to Simonelli [5]. language therapy to improve her swallowing and was Dysphagia can have a huge impact on patients’ life, able to swallow solid or semi-solid food and never need- causing undernutrition dehydration, aspiration, chest ed a percutaneous gastrostomy tube. infections [6] and affecting social interactions making it Since the first operation, over the course of 5 years, difficult to eat in public and reducing overall quality of she had 2 episodes of pneumonia ab ingestis. Her weight life. remained stable. We present a case of epiglottis reconstruction for A videofluoroscopy, 3 years postoperatively, showed surgical rehabilitation of dysphagia after supraglottic normal elevation of the complex hyoid-thyroid cartilage, laryngectomy and radiotherapy. followed by normal transit of the majority of the fluids Case Report along the oesophagus with concomitant silent aspira- tion. Most of the aspirated liquid was leaking through A 62-year-old woman presented complaining of the tracheostomy (Figure 1), however a minimal inha- leakage of liquid from her tracheostomy whenever she lation of contrast medium was also evident in the right was drinking something. She had no dysphagia for solid inferior lobe of the lung. food. The patient had a whispered voice, however quality She had been already treated for a squamous cell and volume were acceptable and she kept working as a carcinoma of the glottic and supraglottic area staged as teacher. She had to change shirts several times perday, as pT2 pN2c M0 at another institution. these would become completely wet and she was uncom- Five years previously she underwent horizontal su- fortable eating and drinking in the presence of others. praglottic laryngectomy extended to the right aryte- Preoperative workup noid, together with bilateral functional neck dissection and tracheostomy followed by a cycle of adjuvant RT. The preoperative evaluation included an assessment of the residual swallowing function by means of a vid- She was cured from her cancer, however suffered eofluoroscopy and a Functional Endoscopic Evaluation from dysphagia and dyspnoea and needed a short tra- of Swallowing (FEES). The latter confirmed the presence cheostomy tube to keep her tracheostomy open be- of aspiration and demonstrated a complete paralysis cause of a severe stenosis at the level of the vocal cords. Figure 1: Videofluoroscopy: Aspiration and leakage of fluid through the tracheostomy. Bottini et al. J Otolaryngol Rhinol 2017, 3:032 • Page 2 of 6 • DOI: 10.23937/2572-4193.1510032 ISSN: 2572-4193 Figure 2: Submandibular incision with isolated neck vessels ready for the microvascular anastomosis. Right hand side. Figure 3: Preauricular incision, temporal vessels and flap design. Right hand side. of the right vocal cord in a paramedian position and a A platysma skin flap was raised and the upper border residual minimal mobility of the left vocal cord with ab- of the thyroid cartilage exposed. Following blunt dissec- sent closure during coughing and phonation. The glottis tion and under endoscopic control, the hypopharynx opening was estimated to be approximately 3 mm in was opened at the level of the tongue base to allow for length and 1 mm in the transversal dimension during the passage of the flap pedicle. inspiration. Applying a nerve stimulator to the hypoglossal nerve, A Computed Tomography Angiography (CTA) and a it was possible to pinpoint the best position for the trans- CT with contrast medium ruled out tumours and lymph plant. The superior thyroid artery and vein were identified node metastasis and showed adequate vascularity for and trimmed on the right hand side of the neck (Figure 2). microvascular anastomosis. The flap harvest began after ultrasound identifica- Surgical procedure tion of the superficial temporal artery on the right hand Under general anaesthesia, after endotracheal intu- side. Access was gained using a preauricular incision with bation via the existing tracheostoma, a submandibular hockey stick extension in the temporal region. The Super- incision was performed along the old scaron the right ficial Temporal Artery (STA) and venae comitantes were hand side. followed along their superior course. Two branches for the helix could be identified and the STA and accompany- Bottini et al. J Otolaryngol Rhinol 2017, 3:032 • Page 3 of 6 • DOI: 10.23937/2572-4193.1510032 ISSN: 2572-4193 ing veins were further dissected in cranial direction for a py (Figure 5) and the transplant was always vital, however, length of approximately 5 cm (Figure 3). over the course of the first week, the patient developed a tracheitis with crusting. In view of these findings her tra- A triangular flap was raised from the superior aspect cheostomy tube was provided with a heat moisture ex- of the right pinna including the upper fourth of the helix changer