Supracricoid Laryngectomy Treatment & Management

Patients must be assessed for their willingness and motivation to undergo intensive speech and swallowing rehabilitation postoperatively. Because age impairs oropharyngeal motor control and laryngopharyngeal sensitivity and esophageal motility, elderly patients are at increased risk for postoperative swallowing impairment. ^[4] A percutaneous endoscopic gastrostomy (at time of staging endoscopy) or an intraoperatively placed nasogastric feeding tube may be useful if rehabilitation of swallowing is expected to be difficult or longer than usual.

Precise evaluation of the extent of the laryngeal tumor depends upon findings on clinical examination (see Clinical), direct laryngoscopy (see Diagnostic Procedures), and imaging studies (see Imaging Studies). A precise understanding of the superficial and deep extent of the lesion is necessary to determine if surgical ablation of the lesion is possible.

Despite careful preoperative workup, the final decision concerning the suitability of a particular OPS procedure cannot be made until the time of surgery. Always obtain permission to perform a total laryngectomy with or without voice prosthesis insertion preoperatively in case tumor extent precludes organ preservation surgery.

Careful selection of patients should result in less postoperative morbidity and mortality and less need for a completion TL or permanent gastrostomy.

The following section describes the SCPL-CHEP and SCPL-CHP techniques. The descriptions are meant to provide broad overviews. Details of the procedures are discussed elsewhere (see Bibliography).

In both SCPL-CHEP and SCPL-CHP, a subplatysmal apron flap is elevated in line with the planned position of the future tracheostomy site. The strap muscles are divided, and the constrictors are transected at the posterior aspect of the thyroid cartilage. The cricothyroid joints are disarticulated, with care taken to avoid damaging either the superior laryngeal nerve (SLN) or the recurrent laryngeal nerve (RLN). The internal thyroid perichondrium is elevated from the inner aspect of the thyroid cartilage. A transverse cricothyrotomy is performed at the superior level of the cricoid, and a flexible armored endotracheal tube is placed. ^[5]

Supracricoid partial laryngectomy with cricohyoidoepiglottopexy reconstruction

The larynx is entered with scissors just above the thyroid notch. The entry above the false cords spares essentially the whole epiglottis and preepiglottic space. The arytenoid is preserved on the noninvolved side. With one scissor blade between the inner aspect of the thyroid cartilage and the internal thyroid perichondrium, the false cord is transected where it meets the arytenoid. The excision is extended posterior to the ventricle and through the vocal process of the true cord to the level of the cricoid.

The transection continues anteriorly through the cricothyroid musculature and along the top of the cricoid cartilage to the level of the previously made cricothyrotomy. The larynx is cracked open on itself like a book, and the resection on the involved side is performed along the cricoid, taking the involved arytenoid as necessary. The posterior arytenoid mucosa must be spared on the involved side. The remaining arytenoid and posterior arytenoid mucosa are sutured anteriorly to the level of the cricoid.

Closure is performed with 3 pexy sutures placed around the cricoid and passed through the epiglottis, preepiglottic space, around the hyoid, and deep into the tongue base. The sutures are initially placed and held tightly to approximate the cricoid and hyoid so that the tracheostomy can be performed in line with the original neck skin incision. The sutures are securely tied, and the strap muscles are closed over the reconstruction.

Supracricoid partial laryngectomy with cricohyoidopexy reconstruction

Scissors enter below the hyoid bone into the vallecula. Transection is performed along the lateral edges of the epiglottis almost to the level of the corniculate cartilages where the false cords come into view. The arytenoid is spared on the noninvolved side. With one scissor blade between the inner aspect of the thyroid cartilage and the internal thyroid perichondrium, the transection is made through the false cord where it meets the arytenoid and is continued just posterior to the ventricle and through the vocal process of the true cord to the level of the cricoid.

The transection is brought anteriorly through the cricothyroid musculature and along the top of the cricoid cartilage to the level of the previously made cricothyrotomy. The larynx is cracked open on itself like a book, and the resection of the involved side is performed along the cricoid, taking the involved arytenoid if necessary. The posterior arytenoid mucosa must be spared on the involved side. The remaining arytenoid and posterior arytenoid mucosa are sutured anteriorly to the level of the cricoid.

Closure is performed with 3 sutures placed around the cricoid, around the hyoid, and deep into the tongue base. The sutures are initially placed and held tightly to approximate the cricoid and hyoid so that the tracheostomy can be performed in line with the original neck skin incision. The sutures are securely tied and then the strap muscles are closed over the reconstruction.

Two points are worth particular attention. All of the vallecula mucosa should be resected and not utilized in the closure. This mucosa is not sufficiently vascularized and has a high risk of necrosis. Additionally, the entire ventricle must be resected to ensure that a postoperative laryngocele does not form and cause airway obstruction.

Management of neck disease

Bilateral modified neck dissection is the standard of care for all carcinoma invading the supraglottic larynx. Radical neck dissection may be required for all clinically palpable nodes that are larger than 2 cm.

Key surgical points

See the list below:

• Elevate the superiorly based platysma flap to 2 cm above the hyoid bone to prevent tethering of the skin in the impaction during reconstruction.

• Incise the infrahyoid muscles at the superior border of the thyroid cartilage. Resection close to the hyoid bone precludes muscular reconstruction. The suprahyoid muscles must be spared because transection of these muscles threatens the blood supply of the hyoid bone.

• Blunt finger dissection along the anterior wall of the cervicomediastinal trachea reduces tension at the suture line at the time of closure and reduces risk of potential rupture of the pexy.

• Be careful to preserve an intact mobile cricoarytenoid unit on the noninvolved side of the larynx because this structure is the basis for laryngeal function postoperatively. Always take care to spare the cricoarytenoid joint.

• Spare the main trunks of both SLNs to ensure sensation of the remaining larynx postoperatively. Care must be taken when transecting the inferior constrictor muscles.

• A mobile arytenoid is necessary postoperatively for laryngeal closure during deglutition and for the best possible voice quality. Subperichondrial disarticulation of the cricothyroid joint always protects the RLN where the nerve enters the larynx.

• If the arytenoid is removed on the tumor-bearing side of the larynx, preserve the posterior arytenoid mucosa. This flap provides additional posterolateral mass that enhances recovery of swallowing function.

• Do not preserve the posterior third of the false and true vocal cords on the noninvolved side of the larynx. This additional tissue compromises the apposition of the arytenoid and the base of the tongue, compromising the functional efficiency of the neoglottis.

• Suturing the vocal process of the arytenoids anteriorly to the cricoid creates a narrow T-shaped larynx. This prevents the backward prolapse of the arytenoids cartilage and mucosa into the posterior pharynx. When only one arytenoid is preserved, the repositioning suture should be directed more anteriorly and towards the midline. The vertical portion of the T between the arytenoid cartilages and/or mucosa serves as the posterior respiratory glottis. The horizontal portion of the T between the arytenoid cartilage and the laryngeal surface of the epiglottis acts as the phonatory glottis.

• Pyriform repositioning improves swallowing function and reduces the risk of postoperative aspiration. Two sutures are placed through the transected interior constrictor muscles, which are positioned over the completed pexy (CHEP or CHP), bringing the pyriform sinuses into closer approximation than normal.

• Prior to impaction, a cricopharyngeal myotomy should be performed if palpation of the upper esophageal sphincter reveals hypertonia. However, a history of gastroesophageal reflux might be a contraindication.

• Only 3 pexy sutures are placed, and they should be precisely 1 cm apart. They should be placed deeply into the tongue base to allow for proper propulsion of the food bolus during swallowing and airway protection. Additional sutures only flatten the tongue, reducing swallowing efficiency.

• In SCPL-CHEP, the epiglottis is included in the impaction to avoid posterior dislocation of the epiglottic cartilage that would result in airway compromise postoperatively.

• Avoid rotation of the laryngeal skeletal structures at the time of impaction. The anterior border of the cricoid cartilage and the hyoid bone must be carefully aligned to reduce postoperative aspiration.

• Care must be taken when tying the pexy sutures to avoid fracture of the cricoid arch. If a fracture occurs, the pexy must be performed using the first 2 tracheal rings.

• The tracheostomy site is made in line with the neck incision to facilitate replacement of the tracheostomy tube if it becomes dislodged in the perioperative period. If the tracheostomy tube becomes dislodged, air could potentially track above the tracheostomy site, forming a dead space. Several steps are taken intraoperatively to prevent this occurrence. To obliterate the space anterior to the trachea above the tracheostomy site, the thyroid isthmus is resutured and a portion of the thyroid tissue is included within the vertical midline closure of the strap muscles. To separate the tracheostomy site from the remainder of the wound, a running 3-0 Vicryl suture is placed in a semicircular fashion above the tracheostomy site between the inferior portion of the upper skin flap and the strap muscles.

The goal is to discharge patients within the first postoperative week. The wound is cleaned with saline and treated with antibiotic ointment. In patients with no history of head and neck radiation therapy, staples or sutures are removed on postoperative day 6. Typically, a number 10 Jackson-Pratt drain is placed above the strap muscles and left on bulb suction. This drain is usually removed when output has decreased to less than 20 mL per 24 hours.

At present, tracheostomy management is based on late decannulation of the patient that permits early hospital discharge between day 3 and day 5 postoperatively. The tracheostomy cuff is deflated on postoperative day 1. The tracheostomy tube is changed to a cuffless tube on approximately postoperative day 3. Visualization of the airway by indirect laryngoscopy should not demonstrate any evidence of significant edema or granulation tissue. Either a 4 or 5 tracheostomy tube is put into place, and the patient is taught tracheostomy care. The tracheostomy is capped if the airway is sufficient, or a Passy-Muir valve is put into place instead. The date of hospital discharge is based on patients' ability to manage their tracheostomy and gastrostomy tube feeds.

Temporary postoperative dysphagia is to be expected, but long-term dysphagia is rare. Patients typically require swallowing therapy to facilitate adequate excursion of the neoglottis. If placed intraoperatively, the nasogastric tube is removed based upon the speed at which the patient recovers swallowing ability. The median time for removal of feeding tube in one study of SCPL-CHP was 16 days (range 9-40 d).

Finally, patients are able to communicate with lung-powered speech and engage in normal social interactions. The quality of the voice is breathy and permanently hoarse, as in chronic laryngitis. This improves somewhat as the mobility of the arytenoid improves. Speech and swallow rehabilitation should commence immediately to maximize postoperative laryngeal function.

A 1998 study of SCPL-CHEP in a series of 190 patients by Naudo et al reported a postoperative mortality rate of 1% and a morbidity rate of 11.7%. ^[6] The postoperative mortality rate for SCPL-CHP is 2.6% in the literature, with a similar morbidity rate to that for SCPL-CHEP. These mortality and morbidity rates are similar to those reported for VPL and SGL.

Complications can include the following:

• Aspiration pneumonia (most common complication in a number of outcomes studies)

• Neck wound infection

• Hematoma

• Laryngocele, symptomatic

• Ruptured pexis

• Laryngeal chondronecrosis

• Laryngeal stenosis

• Local recurrence of carcinoma

Long-term functional complications (0.5-2.5% of all patients) can include the following:

• Completion laryngectomy

• Permanent gastrostomy

• Permanent tracheostomy

Intraoperative steps to prevent many of these complications were described earlier in this article (see Key surgical points).

Oncologic rationale and results

Successful application of supracricoid partial laryngectomy-cricohyoidoepiglottopexy (SCPL-CHEP) and supracricoid partial laryngectomy-cricohyoidopexy (SCPL-CHP) to laryngeal carcinoma requires careful preoperative selection of patients and meticulous surgical technique. Local control rates for these procedures are comparable to those achieved with TL.

SCPL-CHEP is applied to selected glottic carcinomas that are invading the anterior commissure, ventricle, or thyroid cartilage or that manifest with impairment or fixation of the true vocal cord. Surgical resection involves the true and false vocal cords, the entire thyroid cartilage, both paraglottic spaces, the inferior portion of the epiglottis, and a maximum of one arytenoid. Local control rates are excellent. In a study in 1991 by Piquet and Chevalier, the local failure rate was 5% among 104 patients with glottic carcinoma. ^[7] The 5-year actuarial local control was 94.4% with T2 glottic carcinoma.

SCPL-CHP is indicated for selected supraglottic and transglottic carcinomas, especially those lesions that are not amenable to SGL because of glottic involvement, invasion of the preepiglottic space, impaired cord mobility, or limited thyroid cartilage invasion. The resection is more extensive than in the SCPL-CHEP and involves removal of the entire epiglottis and preepiglottic space. Appropriate use of this technique also results in excellent local control. In one 1990 study in Laryngoscope by Laccouraeye, et al, no local failure occurred among 68 patients with at least 18 months of follow-up. ^{[8, 9]} Another study had a low 3.3% local failure rate. ^[10] The 5-year survival rate is 75%, a rate that is comparable to survival following SGL.

The organ preservation surgery techniques of supracricoid partial laryngectomy-cricohyoidoepiglottopexy (SCPL-CHEP) and supracricoid partial laryngectomy-cricohyoidopexy (SCPL-CHP) are increasingly gaining acceptance around the world for the treatment of selected laryngeal cancers. Both SCPL-CHP and SCPL-CHEP achieve local control rates that are comparable to TL for selected laryngeal cancers. Furthermore, they achieve the functional goals of speech and swallowing without a permanent tracheostomy. These techniques also avoid the stigma of the permanent stoma that remains the primary detractor from quality of life for patients who have undergone a TL. Because both SCPL-CHP and SCPL-CHEP have standard resection boundaries and closure techniques, functional outcomes are predictable and reproducible.

Proper patient selection and preoperative evaluation remain the keys to successful functional and oncologic outcome. SCPL has become a valuable alternative to TL for surgical salvage of patients with residual or recurrent disease following other treatment modalities. Recent clinicopathological analysis has also demonstrated that SCPL is safe for the resection of glottic SCC with subglottic extension of up to 15 mm. Additional studies will be required to verify the effective use of SCPL in these clinical settings.