Approach Considerations
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.
Reconstruction of the Epiglottis Using a Radial Forearm Free Flap
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).
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.
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).
The flap is sutured into the shape of a normal epiglottis to cover the tracheal inlet.
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).
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).
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]
Tubed Radial Forearm Free Flap
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]
Reconstruction of the Neo-Epiglottis Using the Epiglottic Remnant
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.
The neo-epiglottis (reconstructued from the epiglottis remnant) covers the airway.
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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).
