- Email: [email protected]
A simple technic for laryngeal suspension after partial or complete resection of the hyomandibular complex
A Simple Technic for Laryngeal Suspension after Partial or Complete Resection of the Hyomandibular Complex MAJ. MICHAEL E. JABALEY, MC, El Paso, Texas JOHN E. HOOPES, M.D., St. Louis, Missouri
Survival data alone no longer accurately reflect the effectiveness of treatment of cancer. “The quantity of life is a measure of the adequacy of extirpation while the quality of life is a reflection of the adequacy of reconetruction” [I]. The tragedy of extirpating a normal larynx because of inability to reconstruct this anatomic area, rather than for reasons of cancer control, has been long recognized by surgeons responsible for treating cancer of the head and neck. Aspiration pneumonia frequently marred the attempts at reconstruction by the nineteenth century surgeons [Z], and continues to be a dreaded complication today. In the absence of adequate reconstruction, there is little question that serious consideration should be given to elective laryngectomy to prevent aspiration if it has been necessary to sacrifice the superior laryngeal nerves, epiglottis, and hyoid bone [3,4]. The morbidity and mortality associated with chronic aspiration and pneumonia are of sufficient magnitude to warrant any feasible attempts, either primary or secondary, to prevent or control this complication. The hyomandibular complex has been deFrom the Departments of Plastic Surgery, William Beaumont General Hospital, El Paso, Texas (Dr. Jabaley). and The Barnes and Allied Hospitals and the St. Loui’s Children’s Hospital, Washington University School of Medicine, St. Louis. Missouri (Dr. Hoop&. This work was supported by a U. S. Public Health Service Traineeshi#p No. CST 523(A67) to Dr. Jabaley from the Cancer Control Program, U. S. Public Health Service. Reprint requests should be addressed to Dr. Hoopes. Presented at the Fifteenth Annual Meeting of The Society of Head and Neck Surgeons, Mexico City, Mexico, March 1619, 1969.
Vol.
118, November 1969
fined by Edgerton and McKee [5] as “the closely connected unit of larynx and hyoid bone and its supporting muscles leading to the mandibular, mastoid, and styloid processes.” The following case reports illustrate three technics which have proved useful in the prevention or treatment of the consequences of loss of the hyomandibular complex.
Case Reports CASE I. The patient (J.A.C., JHH No. 119 26 23), a fifty-nine year old white man, had an ulcerated 2 cm. primary lesion of the left lateral margin of the tongue at the junction of the anterior and middle thirds. Composite resection, consisting of incontinuity hemiglossectomy and left radical neck dissection, was performed on March 22, 1966, utilizing a mandiblesplitting approach. Histologic examination of the specimen revealed a moderately well differentiated squamous cell carcinoma; the margins of resection were negative for tumor, and all nodes were benign. Resection of a recurrence in the region of the left submaxillary triangle was performed on January 11, 1967, and entailed sacrifice of the left hemihyoid bone, the hypoglossal, lingual, and superior laryngeal nerves, marginal resection of the mandibular body and ramus, and substantial excision of lateral pharyngeal musculature and mucosa. A nasogastric feeding tube was left in place for five days postoperatively. Upon its removal, the patient was unable to tolerate either a liquid or semisolid diet without aspiration ; frequent expectoration was required to prevent aspiration of saliva. Aspiration pneumonia developed, manifested by consolidation of the left lower lobe and daily temperature eleva685
Jabaley and Hoopes
Fig. 1.
Case I//. Primary lesion was 4 cm. in diameter, the anterior floor of the mouth, mandible, and tongue.
Frg. 2. mouth, radical Juty 13,
and invaded
Case 111.Composite resection, consisting of resection of the floor of the the anterior third of the tongue, the mandible from angle to angle, right neck dissection, and left supraomohyoid dissection, was performed on 1967.
tions to 102 to 103” F. which persisted despite antibiotic therapy. Laryngeal suspension was performed on February 1, 1967 with the patient under local anesthesia. Transverse incisions of 2 cm. were placed over the thyroid cartilage and mandibular symphysis, and a doubled No. 1-O chromic traction suture was placed transversely through the thyroid cartilage immediately inferior to the incisura; the traction suture was anchored to the mandibular symphysis, maximally elevating the larynx into a superior and anterior position. The patient’s temperature returned to normal twenty-four hours postoperatively and he was able to consume a pureed regular diet without difficulty. He was discharged from the hospital on the fourth postoperative day after the laryngeal suspension. Six weeks after discharge, the patient had returned to work, was eating a regular diet (except for bread) without difficulty, and had gained six pounds. Subsequent metastases in the right submental region, the right neck, and the base of tongue were treated with Coeo followed by composite resection. (M.J.B., JHH No. CASE II. The patient 11’7 10 60), a sixty-one-year old white man, had a large ulcerated primary lesion involving the anterior floor of the mouth. It infiltrated deeply and restricted tongue motion. There were palpable lymph nodes in both submaxillary triangles. Composite resection, consisting of excision of the anterior floor of the mouth, 40 per cent glossectomy, resection of the symphysis, right radical neck dissection, and left supraomohyoid dissection, was performed OII November 686
ulcerated,
11, 1965. Histologic examination of the specimen revealed a poorly differentiated squamous cell carcinoma with positive nodes at levels I, III, and IV on the right; all lymph nodes on the left were negative for tumor. Immediate reconstruction of the floor of the mouth was accomplished with a forehead flap. A rib graft to the mandibular symphysis, performed in August 1966 failed because of nonunion and resorption of the graft. A subsequent iliac crest corticaleancellous bone graft was successful. On follow-up evaluation, the patient complained of difficulty with speaking, dysphagia, and a subjective feeling of fullness in the hypopharynx (“my tonque is in my throat”), particularly when he was supine. Examination revealed immobility and marked posterior displacement of the tongue. The speech was unintelligible. Correction of the lingua1 ptosis was attempted by an operation similar to the Routledge procedure for Pierre Robin syndrome [S], performed with the patient under local anesthesia on September 29, 1967. A No. 22 stainless steel wire suture was secured over a button at the base of the tongue and passed on either side of the bone graft to be secured at the skin with a second button. Immediate subjective and objective improvement led to replacement of the suture with fascia lata. The patient’s speech has remained good, the sensation of pharyngeal fullness has disappeared, and deglutition presents no problems. He has remained free of tumor. CASE III. The patient (E.M.M., JHH No. 124 82 03), a sixty-eight year old white man, had an ulcerated primary lesion 4 cm. in diameter invading the anterior floor of the mouth, The
American
Journal of
Surgery
Laryngeal Suspension
Fig. 3. technic
Case III. Immediate reconstruction of Edgerton and McKee.
Case Ill. A cervical apron Fig. 4. graft was applied to the neck.
utilizing
flap provided
after Resection of Hyomandibular
a rib graft was performed,
coverage
for the bone graft,
Complex
using the “bone and bar” and a split-thickness
skin
Case Ill. At the time of division of the cervical apron flap, the hyoid bone was suspended from Fig. 5. the bone graft with a single suture of heavy chromic catgut (note the vertical ridge superior to the skin graft). mandible, and tongue. (Fig. 1.) There was severe trismus (the patient was able to eat only food prepared in a blender and had lost twenty pounds). The left submaxillary salivary gland was enlarged; and there were palpable lymph nodes in the right side of the neck. Composite resection, consisting of resection of the floor of the mouth, the anterior third of the tongue, the mandible from angle to angle, right radical neck dissection, and left supraomohyoid dissection, was performed on July 13, 1967. (Fig. 2.) Histologic examination of the specimen revealed squamous cell carcinoma with all margins free of tumor and with all lymph nodes exhibiting inflammatory changes only. Immediate reconstruction utilizing a rib graft was performed, using the “bone and bar” technic of Edgerton and McKee [S]. (Fig. 3.) A cervical apron flap provided coverage for the bone graft, and a split thickness skin graft was applied to the neck. (Fig. 4.) On August 31, 1967, the cervical apron flap was divided and the floor of the mouth reconstructed; at the same time, the hyoid bone was suspended from the bone graft with a single suture of heavy chromic catgut. (Fig. 6.) The patient has achieved an excellent functional and cosmetic result. (Fig. 6.) His speech is good, he does not drool, and he is able to eat Vol. 118, November 1969
a regular diet. A denture has been fitted to the reconstructed mandible. There has been no suggestion of aspiration. The patient was free of disease and employed as a grounds keeper at a state hospital until late 1968, when a recurrence developed in the base of the tongue.
Comments Repeated
aspiration
as a cause of morbidity
Fig. 6. Case III. The patient has achieved cellent functional and cosmetic result.
an ex-
687
Jabaley and Hoopes
-Agpi
B
A Loss of hyomandibular supporting structures (through Fig. 7. sis of the larynx, compression of the esophagus, and aspiration.
and mortality in patients who have undergone resection of portions of the hyomandibular complex has been acknowledged by many authors [5,7-g], but little specific information is available regarding the incidence, prevention, or treatment of this complication. Considerable effort has been addressed to the development of improved reconstructive technics. The use of bone grafts (either primarily or secondarily) and local flaps (from the forehead, neck, or deltopectoral regions) is now widely accepted and applied in the rehabilitation of patients undergoing major resections. Sufficient attention has not been directed toward preservation of laryngeal function. Aspiration of food and oral secretions may be insidious and may not be recognized. Staple, Ragsdale, and Ogura [lo], although studying a different group of patients (supraglottic laryngectomy), discovered a 50 per cent incidence of aspiration and a 33 per cent incidence of pneumonia. Many patients either developed or underwent progression of emphysema. The patients are described as frequently being asymptomatic. The study illustrates the subtle nature of chronic aspiration ; unfortunately, similar data are not available regarding aspiration after resection of intraoral carcinoma. Loss of hyomandibular support produces other serious, although not di688
either denervation
or resection)
leads to pto-
rectly life-threatening, symptoms which account for the great personal discomfort, social withdrawal, and depression frequently characterizing these patients. Dysphagia, dysarthria, puddling of saliva in the floor of the mouth, and drooling cannot be disregarded. utilizing cineradiography, Investigations pressure determinations, and electromyography have yielded precise information regarding the critical role of the hyomandibular supporting structures in speech and deglutition [11-131. The surgical implications of this information have been discussed in a number of publications [6,7,14,.25]. Conley [3] has provided an excellent review of the physiology of deglutition. Shedd, Scatliff, and Kirchner [IS] on -*MANDIBLE
Fig. 8. Hyomandibular of DesPrez and Kiehn.
suspension
The American
by the technic
Journal
of Surgery
Laryngeal
mry ‘e
Laryngeal suspension by means of a heavy Fig. 9. chromic catgut suture between the thyroid cartilage and mandibular symphysis is predicated on the premise that the main vector of force required to support the larynx is anterior and superior in the midline.
the basis of detailed cineradiographic analysis clearly defined the role of forward and upward movement of the hyoid-larynx column in protecting the larynx and opening the pharynx to receive a bolus. Interference with this highly integrated neuromuscular activity leads to ptosis of the larynx with resultant aspiration. (Fig. 7.) The anatomic location of the larynx obviously is a crucial factor in the production of aspiration. Specific attention must be directed to laryngeal support, as reported by Edgerton and McKee [5], DesPrez and Kiehn [I71 (Fig. 8), and others. Only limited laryngeal support is provided by attempts to suture the hyomandibular musculature [18] or as a consequence of fibrosis in the anterior floor of the mouth. The surgeon is likely to face one of three situations in the patient undergoing primary reconstruction after major resection of the hyomandibular complex: (1) an intact mandible, (‘2) a primary bone graft, or (3) a temporary space maintainer; together with loss of all or parts of the geniohyoid, genioglossus, mylohyoid, and digastric muscles. In these situations, the larynx should be suspended in the midline rather than being allowed to assume a ptotic position. The technic presently proposed (Fig. 9) seems to offer several attractive features: Vol. 118, November 1969
Suspension
after Resection of Hyomandibular
Complex
(1) simplicity, (2) versatility, (3) availability as a primary or secondary procedure, and (4) ready accomplishment with the patient under local anesthesia. The method is predicated on the premise that the main vector of force required to support the larynx is anterior and superior in the midline, that is, toward the symphysis of the mandible. It appears that the larynx will retain the new position once having been stabilized for a period of time. On this basis, heavy catgut sutures are preferred to wire which may “cut through” the thyroid cartilage and persist as functionless foreign material [19]. Occasionally, as in case II, the local anatomy may be such that the presenting problem is lingual ptosis rather than laryngeal ptosis. In such circumstances, the procedure may be modified and applied to the tongue. Optimal application of the principle of laryngeal support is demonstrated in case III. The benefits to be derived from a direct approach to the problem are of inestimable value in such patients.
Summary Ptosis of the larynx and/or base of the tongue resulting from extirpation on the hyomandibular complex is a major factor in the production of chronic aspiration. A simple technic of laryngeal su,spension, equally applicable in primary reconstruction or as a secondary procedure, is described. A modification of the method can be adapted for glossoptosi’s. References 1.
2.
MCGREGOR,I. A. Educational Foundation, Society of Plastic and Reconstructive Surgery, Symposium on Head and Neck Surgery, Pittsburgh, December 2-4, 1968. ABSOLON, K. B., ROGERS, W., and AUST, J. B. Some historical developments of the surgical therapy of tongue cancer from the 17th to the 19th century. Am. J. Surg., 104:
3.
4.
5.
686, 1962.
CONLEY,J. J. Swallowing dysfunctions associated with radical surgery of the head and neck. Arch Surg., 80: 602, 1960. DARGENT,M. Treatment of advanced tongue cancer by suprahyoid total glossectomy and excision of floor of the mouth. Am. Surgeon, 102: 793, 1961. EDGERTON,M. T. and MCKEE, D. M. Reconstruction with loss of the hyomandibular complex in excision of large cancers. Arch. Surg., 78: 425, 1959. 689
Jabaley and Hoopes 6.
ROUTLEDGE,R. T. The Pierre Robin synemergency in the drome: a surgical neonatal period. Brit. J. Plast. Surg., 13: 204, 1960: 7. HARROLD,C. C. Surgical treatment of cancer of the base of the tongue. Am. J. Swrg.. - I 114: 493, 1967. 8. PHILLIPS, C. M. Primary and secondary reconstruction of the mandible after ablative surgery. Am. J. Surg., 114: 601, 1967. 9. SPIRO, R. H. and FRAZELL,E. L. Evaluation of radical surgical treatment of advanced cancer of the mouth. Am. J. Surg., 116: 571, 1968. 10. STAPLE, T. W., RAGSDALE,E. F., and OGURA, J. H. The chest roentgenogram following supraglottic subtotal laryngectomy. Am. J. Roentgenok, 100: 583, 1967. 11. ATKINSON, M., KRAMER, P., WYMAN, S. M., and INGELFINGER,F. J. The dynamics of swallowing. I. Normal pharyngeal mechanisms. J. C&z. Invest., 36: 581, 1957. 12. SAUNDERS,J. B., DAVIS, C., and MILLER, E. R. The mechanism of deglutition (second stage) as revealed by cineradiography. Ann. Otol. Rhinol. & Laryng., 60: 897,195l.
690
13.
14. 15.
16.
17.
18.
19.
SUZUKI, M. and KIRCHNER, J. A. Afferent nerve fibers in the external branch of the superior laryngeal nerve in the cat. Ann. Otol. Rhinol. & Laryng., 77: 1059, 1968. DONALDSON, R. C., SKELLY,M., and PALETTA, F. X. Total glossectomy for cancer. Am. J. Surg., 116: 585, 1968. KIRCHNER, J. A. Physiology of the gullet. In Cancer of the Head and Neck. Papers presented at the International Workshop, New York City, May 10-14, 1965. Washington, D.C., 1967. Butterworths. SHEDD, D. P., SCATLIFF,J. A., and KIRCHNER, J. A. A cineradiographic study of post-resectional alterations in oral pharyngeal physiology. Surg. Gvnec. & Obst., 110: 69, 1960. DESPREZ, J. D. and KIEHN, C. L. Methods of reconstruction following resection of anterior oral cavity and mandible for malignancy. Plast. & Reconstruct. Surg., 24: 238, 1959. RAPPAPORT,I., SWIRSKYA, and CHIU, S. C. Functional considerations after resection of the hyomandibular complex. Am. J. Surg., 116: 681, 1968. CHAMBERS,R. G. Personal communication.
The
American
Journal
of
Surgery
Survival data alone no longer accurately reflect the effectiveness of treatment of cancer. “The quantity of life is a measure of the adequacy of extirpation while the quality of life is a reflection of the adequacy of reconetruction” [I]. The tragedy of extirpating a normal larynx because of inability to reconstruct this anatomic area, rather than for reasons of cancer control, has been long recognized by surgeons responsible for treating cancer of the head and neck. Aspiration pneumonia frequently marred the attempts at reconstruction by the nineteenth century surgeons [Z], and continues to be a dreaded complication today. In the absence of adequate reconstruction, there is little question that serious consideration should be given to elective laryngectomy to prevent aspiration if it has been necessary to sacrifice the superior laryngeal nerves, epiglottis, and hyoid bone [3,4]. The morbidity and mortality associated with chronic aspiration and pneumonia are of sufficient magnitude to warrant any feasible attempts, either primary or secondary, to prevent or control this complication. The hyomandibular complex has been deFrom the Departments of Plastic Surgery, William Beaumont General Hospital, El Paso, Texas (Dr. Jabaley). and The Barnes and Allied Hospitals and the St. Loui’s Children’s Hospital, Washington University School of Medicine, St. Louis. Missouri (Dr. Hoop&. This work was supported by a U. S. Public Health Service Traineeshi#p No. CST 523(A67) to Dr. Jabaley from the Cancer Control Program, U. S. Public Health Service. Reprint requests should be addressed to Dr. Hoopes. Presented at the Fifteenth Annual Meeting of The Society of Head and Neck Surgeons, Mexico City, Mexico, March 1619, 1969.
Vol.
118, November 1969
fined by Edgerton and McKee [5] as “the closely connected unit of larynx and hyoid bone and its supporting muscles leading to the mandibular, mastoid, and styloid processes.” The following case reports illustrate three technics which have proved useful in the prevention or treatment of the consequences of loss of the hyomandibular complex.
Case Reports CASE I. The patient (J.A.C., JHH No. 119 26 23), a fifty-nine year old white man, had an ulcerated 2 cm. primary lesion of the left lateral margin of the tongue at the junction of the anterior and middle thirds. Composite resection, consisting of incontinuity hemiglossectomy and left radical neck dissection, was performed on March 22, 1966, utilizing a mandiblesplitting approach. Histologic examination of the specimen revealed a moderately well differentiated squamous cell carcinoma; the margins of resection were negative for tumor, and all nodes were benign. Resection of a recurrence in the region of the left submaxillary triangle was performed on January 11, 1967, and entailed sacrifice of the left hemihyoid bone, the hypoglossal, lingual, and superior laryngeal nerves, marginal resection of the mandibular body and ramus, and substantial excision of lateral pharyngeal musculature and mucosa. A nasogastric feeding tube was left in place for five days postoperatively. Upon its removal, the patient was unable to tolerate either a liquid or semisolid diet without aspiration ; frequent expectoration was required to prevent aspiration of saliva. Aspiration pneumonia developed, manifested by consolidation of the left lower lobe and daily temperature eleva685
Jabaley and Hoopes
Fig. 1.
Case I//. Primary lesion was 4 cm. in diameter, the anterior floor of the mouth, mandible, and tongue.
Frg. 2. mouth, radical Juty 13,
and invaded
Case 111.Composite resection, consisting of resection of the floor of the the anterior third of the tongue, the mandible from angle to angle, right neck dissection, and left supraomohyoid dissection, was performed on 1967.
tions to 102 to 103” F. which persisted despite antibiotic therapy. Laryngeal suspension was performed on February 1, 1967 with the patient under local anesthesia. Transverse incisions of 2 cm. were placed over the thyroid cartilage and mandibular symphysis, and a doubled No. 1-O chromic traction suture was placed transversely through the thyroid cartilage immediately inferior to the incisura; the traction suture was anchored to the mandibular symphysis, maximally elevating the larynx into a superior and anterior position. The patient’s temperature returned to normal twenty-four hours postoperatively and he was able to consume a pureed regular diet without difficulty. He was discharged from the hospital on the fourth postoperative day after the laryngeal suspension. Six weeks after discharge, the patient had returned to work, was eating a regular diet (except for bread) without difficulty, and had gained six pounds. Subsequent metastases in the right submental region, the right neck, and the base of tongue were treated with Coeo followed by composite resection. (M.J.B., JHH No. CASE II. The patient 11’7 10 60), a sixty-one-year old white man, had a large ulcerated primary lesion involving the anterior floor of the mouth. It infiltrated deeply and restricted tongue motion. There were palpable lymph nodes in both submaxillary triangles. Composite resection, consisting of excision of the anterior floor of the mouth, 40 per cent glossectomy, resection of the symphysis, right radical neck dissection, and left supraomohyoid dissection, was performed OII November 686
ulcerated,
11, 1965. Histologic examination of the specimen revealed a poorly differentiated squamous cell carcinoma with positive nodes at levels I, III, and IV on the right; all lymph nodes on the left were negative for tumor. Immediate reconstruction of the floor of the mouth was accomplished with a forehead flap. A rib graft to the mandibular symphysis, performed in August 1966 failed because of nonunion and resorption of the graft. A subsequent iliac crest corticaleancellous bone graft was successful. On follow-up evaluation, the patient complained of difficulty with speaking, dysphagia, and a subjective feeling of fullness in the hypopharynx (“my tonque is in my throat”), particularly when he was supine. Examination revealed immobility and marked posterior displacement of the tongue. The speech was unintelligible. Correction of the lingua1 ptosis was attempted by an operation similar to the Routledge procedure for Pierre Robin syndrome [S], performed with the patient under local anesthesia on September 29, 1967. A No. 22 stainless steel wire suture was secured over a button at the base of the tongue and passed on either side of the bone graft to be secured at the skin with a second button. Immediate subjective and objective improvement led to replacement of the suture with fascia lata. The patient’s speech has remained good, the sensation of pharyngeal fullness has disappeared, and deglutition presents no problems. He has remained free of tumor. CASE III. The patient (E.M.M., JHH No. 124 82 03), a sixty-eight year old white man, had an ulcerated primary lesion 4 cm. in diameter invading the anterior floor of the mouth, The
American
Journal of
Surgery
Laryngeal Suspension
Fig. 3. technic
Case III. Immediate reconstruction of Edgerton and McKee.
Case Ill. A cervical apron Fig. 4. graft was applied to the neck.
utilizing
flap provided
after Resection of Hyomandibular
a rib graft was performed,
coverage
for the bone graft,
Complex
using the “bone and bar” and a split-thickness
skin
Case Ill. At the time of division of the cervical apron flap, the hyoid bone was suspended from Fig. 5. the bone graft with a single suture of heavy chromic catgut (note the vertical ridge superior to the skin graft). mandible, and tongue. (Fig. 1.) There was severe trismus (the patient was able to eat only food prepared in a blender and had lost twenty pounds). The left submaxillary salivary gland was enlarged; and there were palpable lymph nodes in the right side of the neck. Composite resection, consisting of resection of the floor of the mouth, the anterior third of the tongue, the mandible from angle to angle, right radical neck dissection, and left supraomohyoid dissection, was performed on July 13, 1967. (Fig. 2.) Histologic examination of the specimen revealed squamous cell carcinoma with all margins free of tumor and with all lymph nodes exhibiting inflammatory changes only. Immediate reconstruction utilizing a rib graft was performed, using the “bone and bar” technic of Edgerton and McKee [S]. (Fig. 3.) A cervical apron flap provided coverage for the bone graft, and a split thickness skin graft was applied to the neck. (Fig. 4.) On August 31, 1967, the cervical apron flap was divided and the floor of the mouth reconstructed; at the same time, the hyoid bone was suspended from the bone graft with a single suture of heavy chromic catgut. (Fig. 6.) The patient has achieved an excellent functional and cosmetic result. (Fig. 6.) His speech is good, he does not drool, and he is able to eat Vol. 118, November 1969
a regular diet. A denture has been fitted to the reconstructed mandible. There has been no suggestion of aspiration. The patient was free of disease and employed as a grounds keeper at a state hospital until late 1968, when a recurrence developed in the base of the tongue.
Comments Repeated
aspiration
as a cause of morbidity
Fig. 6. Case III. The patient has achieved cellent functional and cosmetic result.
an ex-
687
Jabaley and Hoopes
-Agpi
B
A Loss of hyomandibular supporting structures (through Fig. 7. sis of the larynx, compression of the esophagus, and aspiration.
and mortality in patients who have undergone resection of portions of the hyomandibular complex has been acknowledged by many authors [5,7-g], but little specific information is available regarding the incidence, prevention, or treatment of this complication. Considerable effort has been addressed to the development of improved reconstructive technics. The use of bone grafts (either primarily or secondarily) and local flaps (from the forehead, neck, or deltopectoral regions) is now widely accepted and applied in the rehabilitation of patients undergoing major resections. Sufficient attention has not been directed toward preservation of laryngeal function. Aspiration of food and oral secretions may be insidious and may not be recognized. Staple, Ragsdale, and Ogura [lo], although studying a different group of patients (supraglottic laryngectomy), discovered a 50 per cent incidence of aspiration and a 33 per cent incidence of pneumonia. Many patients either developed or underwent progression of emphysema. The patients are described as frequently being asymptomatic. The study illustrates the subtle nature of chronic aspiration ; unfortunately, similar data are not available regarding aspiration after resection of intraoral carcinoma. Loss of hyomandibular support produces other serious, although not di688
either denervation
or resection)
leads to pto-
rectly life-threatening, symptoms which account for the great personal discomfort, social withdrawal, and depression frequently characterizing these patients. Dysphagia, dysarthria, puddling of saliva in the floor of the mouth, and drooling cannot be disregarded. utilizing cineradiography, Investigations pressure determinations, and electromyography have yielded precise information regarding the critical role of the hyomandibular supporting structures in speech and deglutition [11-131. The surgical implications of this information have been discussed in a number of publications [6,7,14,.25]. Conley [3] has provided an excellent review of the physiology of deglutition. Shedd, Scatliff, and Kirchner [IS] on -*MANDIBLE
Fig. 8. Hyomandibular of DesPrez and Kiehn.
suspension
The American
by the technic
Journal
of Surgery
Laryngeal
mry ‘e
Laryngeal suspension by means of a heavy Fig. 9. chromic catgut suture between the thyroid cartilage and mandibular symphysis is predicated on the premise that the main vector of force required to support the larynx is anterior and superior in the midline.
the basis of detailed cineradiographic analysis clearly defined the role of forward and upward movement of the hyoid-larynx column in protecting the larynx and opening the pharynx to receive a bolus. Interference with this highly integrated neuromuscular activity leads to ptosis of the larynx with resultant aspiration. (Fig. 7.) The anatomic location of the larynx obviously is a crucial factor in the production of aspiration. Specific attention must be directed to laryngeal support, as reported by Edgerton and McKee [5], DesPrez and Kiehn [I71 (Fig. 8), and others. Only limited laryngeal support is provided by attempts to suture the hyomandibular musculature [18] or as a consequence of fibrosis in the anterior floor of the mouth. The surgeon is likely to face one of three situations in the patient undergoing primary reconstruction after major resection of the hyomandibular complex: (1) an intact mandible, (‘2) a primary bone graft, or (3) a temporary space maintainer; together with loss of all or parts of the geniohyoid, genioglossus, mylohyoid, and digastric muscles. In these situations, the larynx should be suspended in the midline rather than being allowed to assume a ptotic position. The technic presently proposed (Fig. 9) seems to offer several attractive features: Vol. 118, November 1969
Suspension
after Resection of Hyomandibular
Complex
(1) simplicity, (2) versatility, (3) availability as a primary or secondary procedure, and (4) ready accomplishment with the patient under local anesthesia. The method is predicated on the premise that the main vector of force required to support the larynx is anterior and superior in the midline, that is, toward the symphysis of the mandible. It appears that the larynx will retain the new position once having been stabilized for a period of time. On this basis, heavy catgut sutures are preferred to wire which may “cut through” the thyroid cartilage and persist as functionless foreign material [19]. Occasionally, as in case II, the local anatomy may be such that the presenting problem is lingual ptosis rather than laryngeal ptosis. In such circumstances, the procedure may be modified and applied to the tongue. Optimal application of the principle of laryngeal support is demonstrated in case III. The benefits to be derived from a direct approach to the problem are of inestimable value in such patients.
Summary Ptosis of the larynx and/or base of the tongue resulting from extirpation on the hyomandibular complex is a major factor in the production of chronic aspiration. A simple technic of laryngeal su,spension, equally applicable in primary reconstruction or as a secondary procedure, is described. A modification of the method can be adapted for glossoptosi’s. References 1.
2.
MCGREGOR,I. A. Educational Foundation, Society of Plastic and Reconstructive Surgery, Symposium on Head and Neck Surgery, Pittsburgh, December 2-4, 1968. ABSOLON, K. B., ROGERS, W., and AUST, J. B. Some historical developments of the surgical therapy of tongue cancer from the 17th to the 19th century. Am. J. Surg., 104:
3.
4.
5.
686, 1962.
CONLEY,J. J. Swallowing dysfunctions associated with radical surgery of the head and neck. Arch Surg., 80: 602, 1960. DARGENT,M. Treatment of advanced tongue cancer by suprahyoid total glossectomy and excision of floor of the mouth. Am. Surgeon, 102: 793, 1961. EDGERTON,M. T. and MCKEE, D. M. Reconstruction with loss of the hyomandibular complex in excision of large cancers. Arch. Surg., 78: 425, 1959. 689
Jabaley and Hoopes 6.
ROUTLEDGE,R. T. The Pierre Robin synemergency in the drome: a surgical neonatal period. Brit. J. Plast. Surg., 13: 204, 1960: 7. HARROLD,C. C. Surgical treatment of cancer of the base of the tongue. Am. J. Swrg.. - I 114: 493, 1967. 8. PHILLIPS, C. M. Primary and secondary reconstruction of the mandible after ablative surgery. Am. J. Surg., 114: 601, 1967. 9. SPIRO, R. H. and FRAZELL,E. L. Evaluation of radical surgical treatment of advanced cancer of the mouth. Am. J. Surg., 116: 571, 1968. 10. STAPLE, T. W., RAGSDALE,E. F., and OGURA, J. H. The chest roentgenogram following supraglottic subtotal laryngectomy. Am. J. Roentgenok, 100: 583, 1967. 11. ATKINSON, M., KRAMER, P., WYMAN, S. M., and INGELFINGER,F. J. The dynamics of swallowing. I. Normal pharyngeal mechanisms. J. C&z. Invest., 36: 581, 1957. 12. SAUNDERS,J. B., DAVIS, C., and MILLER, E. R. The mechanism of deglutition (second stage) as revealed by cineradiography. Ann. Otol. Rhinol. & Laryng., 60: 897,195l.
690
13.
14. 15.
16.
17.
18.
19.
SUZUKI, M. and KIRCHNER, J. A. Afferent nerve fibers in the external branch of the superior laryngeal nerve in the cat. Ann. Otol. Rhinol. & Laryng., 77: 1059, 1968. DONALDSON, R. C., SKELLY,M., and PALETTA, F. X. Total glossectomy for cancer. Am. J. Surg., 116: 585, 1968. KIRCHNER, J. A. Physiology of the gullet. In Cancer of the Head and Neck. Papers presented at the International Workshop, New York City, May 10-14, 1965. Washington, D.C., 1967. Butterworths. SHEDD, D. P., SCATLIFF,J. A., and KIRCHNER, J. A. A cineradiographic study of post-resectional alterations in oral pharyngeal physiology. Surg. Gvnec. & Obst., 110: 69, 1960. DESPREZ, J. D. and KIEHN, C. L. Methods of reconstruction following resection of anterior oral cavity and mandible for malignancy. Plast. & Reconstruct. Surg., 24: 238, 1959. RAPPAPORT,I., SWIRSKYA, and CHIU, S. C. Functional considerations after resection of the hyomandibular complex. Am. J. Surg., 116: 681, 1968. CHAMBERS,R. G. Personal communication.
The
American
Journal
of
Surgery