Epiglottic Reconstruction

Epiglottis reconstruction is mainly and most commonly performed to prevent abnormal swallowing and aspiration.[1, 2]

Malignancies of the head and neck can result in devastating functional and cosmetic deficits that have a significant psychosocial impact on affected patients. In most cases, the ramifications of undergoing treatment for head and neck cancers extend far beyond the psychological and social aspects. Aside from cosmetic deformities of the head and neck, these patients may also develop deficits in their abilities to speak, eat, swallow, and even breathe.

The incidence of head and neck cancers, and thus the need for treatment, has slowly increased,[3] as has the burden of posttreatment management. The morbidity associated with head and neck malignancies has necessitated the evolution of operative techniques and ushered in an era of innovative conservation surgeries and reconstructive procedures in the field of plastic surgery.

Although the 20th century saw substantial progress in the area of head and neck reconstruction, the first plastic surgery dates as far back as 3000 BC, when the first rhinoplasty in the management of facial trauma was described.[1, 4] Since then, the field of reconstructive surgery has made remarkable gains with the use of revascularized flaps, free flaps with autologous skin transplants, pedicled myocutaneous flaps, and osteocutaneous free flaps in reconstructing defects.[5, 6, 7, 8]

These historical landmarks have paved the way for current techniques in epiglottis reconstruction. The review of these techniques first begins with a discussion of the function of the epiglottis.

The epiglottis is an elastic leaf-shaped cartilage that covers the entrance to the larynx. It is important in preventing aspiration of solids and liquids. A competent and functional epiglottis is essential for normal eating and swallowing.[9, 10] Dysfunction of the epiglottis can lead to complications such as chronic aspiration, which, in turn, can cause significant pulmonary damage.[11, 12] Epiglottis dysfunction has multiple etiologies, but, in the field of reconstructive surgery, these dysfunctions typically result from anatomic deficits of the epiglottis, such as after supraglottic (horizontal) laryngectomy.

Relevant Anatomy

During embryologic development, the supraglottic structures (epiglottis, arytenoid cartilages, false vocal folds, ventricle) derive from the buccopharyngeal primordium, which arises from the third and fourth branchial arches. In contrast, the glottis and subglottis are derived from the tracheobronchial primordium of the sixth branchial arch.[11] Because the supraglottis is not embryologically linked to the glottis and subglottis, it derives its blood supply from the superior laryngeal arteries. The lymphatics of the supraglottis travel along the superior laryngeal vessels to the carotid sheath and drain bilaterally into the deep cervical chain nodes in levels II and III of the neck.

The epiglottis is considered to be part of the “supraglottis,” which also includes the arytenoid cartilages, false vocal folds, and ventricle. The epiglottis is divided into the suprahyoid epiglottis (lingual and laryngeal surfaces) and the infrahyoid epiglottis. At its most inferior aspect (petiole), the epiglottis is attached to the inner surface of the thyroid cartilage laminae above the anterior commissure and projects posteriorly into the pharynx. Laterally, it is attached to the quadrangular membrane, an accessory elastic structure that provides support to the supraglottic structures. Along with the thyroepiglottic ligament, the anterior surface of the epiglottic cartilage forms the posterior boundary of the pre-epiglottic space (see images below).

Sensory information is provided to the epiglottis by the internal branch of the superior laryngeal nerve, which also gives off sensory fibers to the base of tongue, the valleculae, pyriform sinus, the aryepiglottic folds, and the vestibule of the larynx down to the level of the glottis. The recurrent laryngeal nerve provides motor innervation to all the intrinsic muscles of the larynx (except the cricothyroid muscle) and sensory innervation to the glottis, subglottis, and trachea (see images below).

No standardized method has been established for reconstruction of the epiglottis; thus, this article is an overview of the various techniques that have been described in the literature.

The most important and common reason for epiglottis reconstruction is to prevent abnormal swallowing and aspiration.[1, 2]

In the case of malignancy, the decision to reconstruct the epiglottis is based on tumor staging and spread and may be influenced by postsurgical treatments such as chemotherapy and radiation therapy.

Beyond malignancy, epiglottic reconstruction may also be indicated in patients recovering from severe penetrating trauma to the larynx and epiglottis or in patients with epiglottic scarring or stenosis, as these can also significantly affect swallowing and speech function.[13]

The main contraindication to epiglottis reconstruction is extensive tumor invasion. In patients who are undergoing total laryngectomy or who require significant tumor resection, epiglottis reconstruction is not performed.

Peripheral vascular disease may also pose a difficulty in the patient undergoing a free flap repair, as this places the flap at risk for necrosis secondary to poor circulation.

Tissue fibrosis in a patient with a history of radiation is another limiting factor in selecting flap donor sites, as is scarring from previous surgical procedures.

Tumor extension

Extension of tumor to the epiglottis often dictates the type of reconstruction that may be performed. If only the suprahyoid aspect of the epiglottis is involved, several different reconstructive techniques may be considered (see Technique), as follows:

• Bilobed radial forearm free flap repair[14]

• Radial forearm free flap with hyoid bone flap[15]

• Tubed radial forearm free flap[16]

• Reconstruction with the remnant epiglottis[17]

If the tumor extends to the infrahyoid portion of the epiglottis, the method of reconstruction is fairly limited and may be accomplished using the hyoid bone as an osteomuscular flap.[16] In all of the techniques listed above, a remnant stump of the epiglottis (at the petiole) is used for reconstruction.

Alternatively, no reconstructive technique may be undertaken, and the laryngeal defect can be closed primarily (closed with suture) or secondarily (allowed to fill in with granulation tissue) or with a local rotational flap.

Nerve preservation

Epiglottic reconstruction is performed in an effort to maintain normal swallowing and voice function. In order to aid this effort, close attention must be paid to the preservation of the superior laryngeal nerve (internal branch) and recurrent laryngeal nerve during supraglottic laryngectomy (see Relevant Anatomy), as the loss of innervation can cause significant sensory and motor deficits, resulting in postoperative aspiration.[18]

Complication Prevention

In patients undergoing a free flap repair, vessel thrombosis is a significant concern because of the risk of flap necrosis. In these patients, it is very important to start anticoagulation therapy in the immediate postoperative period. The specific method of anticoagulation is often dependent on the physician and institution and can include ASA, low molecular weight heparin, and subcutaneous heparin. However, the choice of anticoagulation therapy does not appear to significantly affect the incidence of post-operative free flap complicationsrRef30}[19]

A review of 68 patients with glottic carcinoma who underwent frontal anterior laryngectomy with epiglottic reconstruction showed a 5-year disease-free survival rate of 93.5%.[20]

In one study involving 2 patients who underwent reconstruction with the radial forearm free flap, both patients had excellent swallowing outcomes without any evidence of leak or aspiration.[14]

In another study assessing the use of radial forearm free flap with septal cartilage in reconstruction of the epiglottis, 5 of 7 patients were able to tolerate oral feeds without episodes of aspiration pneumonia.[21] Overall, this technique appears to yield moderate to excellent swallowing results, with most patients able to tolerate oral feeding with few complications of aspiration.[22, 21, 23]

Calcaterra (1985) also achieved excellent results in 14 patients undergoing reconstruction with the epiglottis remnant. The patients all had rapid rehabilitation of deglutition without significant aspiration because of the projection of the neo-epiglottis over the laryngeal inlet, allowing for diversion of food to the pyriform fossae.[17]

Potential complications

Many of the complications associated with epiglottis reconstruction are complications that may be expected with any surgery, while others are associated with the technique used.[24, 22] They are as follows:

• Deep venous thrombosis/pulmonary embolism

• Bleeding

• Infection

• Pain

• Thrombosis/necrosis of the free flap

• Dysphagia/aspiration

• Difficulty speaking (weakness, breathiness)

• Difficulty breathing

• Hematoma

• Salivary fistula

• Numbness

• Cosmetic scarring

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]

• For staging purposes and planning of the surgical procedure

• To search for recurrence of tumor in a previously treated patient

• To obtain tissue samples when lesions are difficult to access

• To search for an unknown primary malignancy (in a patient with cervical metastases without a source)

• 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:

• Size and location of the defect after tumor resection

• Caliber and health of donor vessels

• 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.

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.

Swallowing studies

Patients must undergo postoperative swallowing studies to assess the deglutition process and aspiration risk. Swallowing rehabilitation must be conducted under close supervision to avoid complications of swallowing.[33]

Because of the limited data on epiglottic reconstruction, the various techniques that have been reported in the literature are described below. The descriptions are meant to provide an understanding of the reconstructive portion of the surgery only.

A tracheotomy (or tracheostomy) and NG tube are placed intraoperatively. The decision to remove the tracheotomy and NG tube is based on the postoperative course and results of swallowing studies.

After supraglottic laryngectomy is completed and cancer-free margins are confirmed, the reconstructive portion of the procedure can begin with the raising of the radial forearm free flap.

Once the wound is inspected and the defect is measured, the vascular pedicle is identified and marked on the forearm.

Islands are created to allow for 2 skin paddles (a bilobed flap), which overlie the radial artery.

The distal lobe of the flap is used to reconstruct the defect in the tongue base, while the proximal lobe becomes the neo-epiglottis.

The free flap is raised in the standard fashion (see image below).

A pair of appropriate recipient vessels in the neck are be identified and trimmed for anastomosis with the donor vessels from the free flap.

The size of the free flap is larger than the size of the defect to account for atrophy following anastomosis.

Next, the proximal lobe is folded in on itself to recreate the epiglottis and reinforced with cartilage implants harvested from the excised hyoid bone.

The recipient vessels (artery and vein) are anastomosed to the donor vessels to vascularize the flap.

At this point, some surgeons may opt to place Doppler leads around the newly anastomosed vessels to ensure patency and flow postoperatively.

Following the Doppler lead placement, the distal lobe of the flap is sutured to the defect in the base of the tongue, and the folded neo-epiglottis is sutured to the stump of the epiglottis.

Once the reconstruction is complete, the neck is closed in layers (see image below).

A close variation of this technique uses the radial forearm free flap and hyoid bone flap to recreate the epiglottis. After tumor resection is complete, the hyoid bone is elevated as an osteomuscular flap and sutured to the remaining stump of the epiglottis (see image below).

In order to fit the curvature of the hyoid bone from the epiglottis to the arytenoid cartilage, the authors advocate the creation of a green stick fracture.[15]

The radial forearm flap is then placed on the hyoid bone.

One corner of the flap is sutured to the hyoid bone and the other corner is sutured to the hypopharynx.

In this manner, the elevation of the arytenoid and the paraglottic space are recreated.[15]

After completion of the neck dissection and tumor excision via a supraglottic laryngectomy, the radial forearm free flap is raised.

A microvascular anastomosis of the flap vessels to the recipient vessels in the neck is created (the radial artery and either cephalic or basilic veins are used for the vascular anastomosis).

The forearm free flap is then folded to create a tube that becomes the reconstructed laryngeal tube.

The superior aspect of the flap is sutured closed with an epiglottislike flap that functions as the neo-epiglottis.

The flap is reinforced with an implant of cartilage, and the flap is doubled over the cartilage to re-epithelialize the epiglottis.

The reconstructed laryngeal tube is sutured to the pharynx below the base of the tongue or to the hyoid bone, allowing the tube and reconstructed epiglottis to be pulled up during swallowing.

The inferior aspect of the tube is attached to the trachea.[16]

In this technique, described by Calcaterra in 1985, reconstruction of the epiglottis begins with tumor resection,[17] which involves a portion of the epiglottis necessary to ensure adequate resection but allows for preservation of some epiglottic tissue (see image below).

Once these margins are confirmed to be tumor-free, the remnant epiglottis is mobilized for reconstruction.

First, the epiglottic tissue is detached from the base of the tongue at its muscular attachments.

Next, the lingual mucosal margin of the epiglottis remnant is approximated and sutured to the free mucosal edge of the base of tongue using absorbable sutures.

The epiglottic cartilage at the fixed inferior margin (petiole) may be released submucosally and anchored to the base of the tongue muscles with nonabsorbable sutures, allowing increased flexibility and mobility of the epiglottis. In this fashion, the remnant epiglottis is reconstructed to form a neo-epiglottis or “hood” over the larynx.

Finally, the laryngopharyngeal defect is sutured closed by approximating the laryngeal flap with pharyngeal mucosa and base of tongue mucosa.