Pre-Procedure Planning
Because reconstruction of the epiglottis follows tumor resection, much of the workup for this procedure is performed in preparation for partial laryngectomy. However, some preoperative studies and tests may be particularly helpful in planning the reconstructive technique.
Flexible laryngoscopy
In patients with laryngeal cancers, a flexible laryngoscopy is helpful in evaluating the gross appearance and size of the tumor and the function of the vocal folds. Flexible laryngoscopy is a simple and safe procedure that can be performed in the clinic setting and is usually performed with a flexible laryngoscope. The laryngoscope is inserted through the nose into the nasopharynx and then travels into the pharynx and larynx. It allows real-time assessment of vocal-fold mobility and speech production and may help estimate the size of the defect prior to surgery.
Panendoscopy
Panendoscopy (direct laryngoscopy, bronchoscopy, esophagoscopy) may be considered for several reasons, as follows: [12, 25, 2, 14]
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For staging purposes and planning of the surgical procedure
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To search for recurrence of tumor in a previously treated patient
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To obtain tissue samples when lesions are difficult to access
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To search for an unknown primary malignancy (in a patient with cervical metastases without a source)
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To search for other malignant lesions
Modified barium swallow
Barium swallow studies may be performed preoperatively or postoperatively to assess epiglottis function. They are particularly useful in postoperative or postchemoradiation patient to evaluate or monitor swallowing function and severity of aspiration. [11, 25]
Computed tomography
A preoperative CT scan with contrast is a critical part of the workup of a head and neck cancer. It is usually performed to evaluate the extent of disease and involvement of the lymphatic system. [26] CT is particularly valuable because of its ability to reveal extracapsular spread and lymphadenopathy that may not be identified during the clinical examination. [27] However, it has significant limitations, such as the inability to distinguish between reactive lymph nodes and malignant lymphadenopathy and its overall lower sensitivity and specificity compared with positron emission tomography (PET) with CT scanning. [27, 28]
MRI
Along with CT, MRI is also an appropriate initial imaging choice. MRI is able to better define tumor extent (with contrast) than CT and is also able to reveal metastatic neck lymphadenopathy. [27] Overall, MRI has comparable accuracy to CT in evaluating the head and neck. [29]
Positron emission tomography with CT scanning
PET with CT scanning is quickly becoming a critical component of the evaluation of a suspected malignancy. It is useful in staging malignancies prior to surgery and in detecting recurrences during and after treatment. It is particularly advantageous in detecting distant metastases and has been shown to be more accurate than PET alone. [30, 31, 32]
Flap choice
In deciding the type of flap to use, several factors must be considered, as follows:
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Size and location of the defect after tumor resection
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Caliber and health of donor vessels
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Potential exposure of vital structures at the recipient and donor sites (nerves, major vessels)
The clinical status of the patient must also be taken into account when considering reconstruction with a free flap. Several patient factors may influence the health and survival of the flap, including age, nutritional status, comorbid conditions (peripheral vascular disease, diabetes mellitus, cardiovascular disease), coagulopathies, and tobacco use.
Patient Preparation
Anesthesia
The patient is placed under general anesthesia and may be intubated orally or nasally, depending on the surgical approach.
Intubation
If the tumor extends into the oral cavity, the patient is usually intubated nasally to facilitate the approach and resection and to allow maximal exposure for the surgeon. Because the size or site of the tumor may alter the anatomy of the airway, it is important to discuss the possibility of a difficult intubation with the anesthesiologist. Administration of appropriate antibiotics prior to skin incision is also recommended.
Positioning
The patient is placed in the supine position with a shoulder roll to extend the head and maximize exposure. The table is turned 180° to allow adequate space for the surgeon, surgical assistants, and scrub nurse to maneuver around the surgical site. The head of bed is elevated to decrease bleeding.
Marking
Prior to preparing the patient, the surgeon carefully marks the surgical site, making sure to label the proper site(s) and side(s) on the neck. The donor site of the flap is also be marked with the estimated size of the flap. The donor vessels are identified and labeled.
Preparation
Once the patient has been properly positioned and the surgical site and donor site adequately marked, the patient is prepared. Once the preparation is complete, the donor site is covered with sterile drapes until the flap is ready to be raised. The patient is then covered with sterile drapes from head to toe, creating a sterile surgical field, leaving the site of incision exposed. Once the tumor resection is complete, the defect is inspected and measured to ensure adequate size of the reconstructive flap.
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Laryngoscopic view of the larynx. Note the following supraglottic structures: epiglottis, aryepiglottic folds, arytenoids, and false folds.
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Ligaments of the larynx, posterior view.
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empty para to satisfy content model
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empty para to satisfy content model
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Example of a bilobed radial forearm free flap. The proximal stump "B" will be used to re-create the epiglottis, while the distal stump "A" will be used to reconstruct the base of tongue and other structures of the supraglottis.
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The flap is sutured into the shape of a normal epiglottis to cover the tracheal inlet.
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Tumor involvement of the epiglottis and the proposed margins for resection.
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The neo-epiglottis (reconstructued from the epiglottis remnant) covers the airway.
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Reconstruction of the epiglottis using a hyoid bone osteomuscular flap. The blue arrow shows the attachment of the hyoid bone to the remaining stump of the epiglottis, while the black arrow indicates the muscular portion of the flap (sternohyoid muscle).
