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Epiglottoplasty technique in endoscopic partial laryngectomy
G Model
ARTICLE IN PRESS
ANORL-728; No. of Pages 3
European Annals of Otorhinolaryngology, Head and Neck diseases xxx (2017) xxx–xxx
Available online at
ScienceDirect www.sciencedirect.com
Technical note
Epiglottoplasty technique in endoscopic partial laryngectomy M. Moulin a , C.A. Righini a,b,c , P.F. Castellanos d , I. Atallah a,b,c,d,∗ a
Otolaryngology-Head and Neck Surgery Department CS 10217, Grenoble Alpes University Hospital, 38043 Grenoble cedex 9, France Grenoble Alpes University, School of Medicine, Grenoble, France c UGA/UMR/CNRS 5309/Inserm 1209, Albert-Bonniot Institute, Grenoble, France d Division of Otolaryngology, Department of Surgery, University of Alabama, Birmingham, AL, USA b
a r t i c l e
i n f o
Keywords: Endoscopic laser surgery of the larynx Epiglottoplasty Swallowing Reconstructive transoral laser microsurgery
a b s t r a c t The main advantage of endoscopic laser surgery for laryngeal cancer is to allow tumour resection, while limiting functional sequelae, thereby improving the postoperative course. In this type of surgery, the epiglottis is often partially resected, leaving a raw zone without any reconstruction. The surgical technique described here involves endoscopic reconstruction of the epiglottis after partial resection. The sectioned edge of the epiglottis is sutured to the base of the tongue to create a neoepiglottis and to reconstruct the vallecula, thus resembling preoperative anatomy, allowing improvement of postoperative swallowing. © 2017 Elsevier Masson SAS. All rights reserved.
1. Introduction
2. Technique
Unlike open surgery for laryngeal cancer, endoscopic surgery requires resection of healthy tissues to provide access to the tumour. For example, resection of the vestibular fold provides excellent exposure of the paraglottic space. Resection of the base of the epiglottis is necessary to expose and to resect tumours arising from or involving the anterior commissure. Resection of part of the suprahyoid epiglottis may be necessary to expose some tumours of the glottis and the lateral epilarynx. In the absence of adequate exposure, another surgical approach has to be performed. Endoscopic partial laryngectomy techniques described in the literature focus on tumour resection without discussing the problem of reconstruction, which has a considerable impact on functional results [1,2]. During supraglottic partial laryngectomy, the epiglottis is often partially resected (Fig. 1a) and allowed to heal by secondary wound healing. Only few teams have studied reconstruction of the epiglottis following resection [3]. We describe an endoscopic reconstruction technique on the residual portion of the epiglottis that could be performed following any type of endoscopic partial laryngeal surgery in order to restore the anatomy and physiology of swallowing.
The surgical technique described here can be performed at the same time of endoscopic tumour resection surgery or during a deferred procedure. The objective of this technique is to attach the free edge of the sectioned epiglottis to the base of the tongue (Fig. 1b). Surgical positioning is identical to that during endoscopic tumour resection by suspension microlaryngosopy, allowing the use of both hands. Instruments used are those of reconstructive transoral laser microsurgery [4]. Interrupted sutures using a 4/0 monofilament synthetic ® absorbable surgical suture (Monocryl , Ethicon, Johnson and Johnson) are performed between the base of the tongue at the level of the resection zone and the free edge of the sectioned epiglottis to achieve lateral rotation of the residual epiglottis in order to reconstruct the missing part of the epiglottis which is resected during supraglottic partial laryngectomy. The proximal part of the resection margin is sutured to the most lateral part of the resection zone at the base of the tongue. The rest of the mucosa is then sutured contiguously (Fig. 1c). The stitches are secured by clipping to avoid tying knots through the laryngoscope which can be time-consuming. The excess suture is cut by CO2 laser or microinstruments (Fig. 1d).
3. Discussion ∗ Corresponding author. Otolaryngology-Head and Neck Surgery Department CS 10217, Grenoble Alpes University Hospital, 38043 Grenoble cedex 9, France. E-mail address: [email protected] (I. Atallah).
The epiglottis plays an essential role in swallowing by ensuring dynamic functions during swallowing consisting of tilting during laryngeal elevation and during horizontal and vertical hyoid motion
https://doi.org/10.1016/j.anorl.2017.12.003 1879-7296/© 2017 Elsevier Masson SAS. All rights reserved.
Please cite this article in press as: Moulin M, et al. Epiglottoplasty technique in endoscopic partial laryngectomy. European Annals of Otorhinolaryngology, Head and Neck diseases (2017), https://doi.org/10.1016/j.anorl.2017.12.003
G Model ANORL-728; No. of Pages 3 2
ARTICLE IN PRESS M. Moulin et al. / European Annals of Otorhinolaryngology, Head and Neck diseases xxx (2017) xxx–xxx
Fig. 1. Endoscopic epiglottoplasty surgical technique: a: intraoperative view showing the vallecula, larynx and epiglottis after supraglottic partial laryngectomy. Arrow showing the potential lateral rotation that could be performed on the residual part of the epiglottis in order to reconstruct the resected portion; b: lateral rotation of the residual right part of the epiglottis showing its future position; c: suture of the sectioned edge of the epiglottis to the left vallecular mucosa; d: final result after securing sutures with clips. Excess suture material will be cut by laser + mucosa of the left vallecula; *: sectioned edge of the epiglottis; #: remaining right part of the epiglottis after resection; ¤: base of tongue.
Fig. 2. Relations of the neoepiglottis with the larynx: a: intraoperative appearance; b: long-term appearance after complete healing (12 weeks after surgery).
[5]. The epiglottis ensures laryngeal closure during food bolus passage. Incomplete tilting of the epiglottis is one of the main causes of aspiration [6,7]. The epiglottis also ensures a static function during swallowing, as it acts as a border to slow down the movement of liquids through the pharynx, allowing time to ensure laryngeal elevation and protective adduction of the vocal folds [8]. The epiglottis
could therefore diverts liquids into pyriform sinuses even before the swallowing reflex is triggered, thereby avoiding direct flow into the glottis. Epiglottoplasty following supraglottic partial laryngectomy seems to be useful to restore almost normal anatomy in order to prevent swallowing disorders by recreating a functional
Please cite this article in press as: Moulin M, et al. Epiglottoplasty technique in endoscopic partial laryngectomy. European Annals of Otorhinolaryngology, Head and Neck diseases (2017), https://doi.org/10.1016/j.anorl.2017.12.003
G Model ANORL-728; No. of Pages 3
ARTICLE IN PRESS M. Moulin et al. / European Annals of Otorhinolaryngology, Head and Neck diseases xxx (2017) xxx–xxx
swallowing organ. The midline position of the neoepiglottis and its posterior tilting to ensure closure of the larynx would therefore prevent aspiration. By preserving laryngeal anatomy, this technique has no impact on airway (Fig. 2) and, based on our experience, patients undergoing epiglottoplasty after partial supraglottic laryngectomy do not experience postoperative aspirations, more specifically to liquids. This surgical technique does not require any specific instrumentation or specific surgical skills, making it accessible to all experienced laryngologists. Reconstruction could be performed during the same surgery of tumour resection without any change in surgical positioning. 4. Conclusion Epiglottoplasty following endoscopic partial laryngectomy is an accessible technique for experienced surgeons familiar with reconstructive transoral laser microsurgery. It restores almost normal anatomy, preventing the risks of postoperative swallowing disorders.
3
Disclosure of interest The authors declare that they have no competing interest. References [1] Sandulache VC, Kupferman ME. Transoral laser surgery for laryngeal cancer. Rambam Maimonides Med J 2014;5:e0012. [2] Rubinstein M, Armstrong WB. Transoral laser microsurgery for laryngeal cancer: a primer and review of laser dosimetry. Lasers Med Sci 2011;26:113–24. [3] Grajek M, Maciejewski A, Oles K, et al. An experience with auricular free flap epiglottis reconstruction after supraglottic laryngectomy. J Reconstr Microsurg 2016;32:164–8. [4] Atallah I, Manjunath MK, Omari AA, et al. Reconstructive transoral laser microsurgery for posterior glottic web with stenosis. Laryngoscope 2017;127:685–90. [5] Seo HG, Oh BM, Leigh JH, et al. Correlation varies with different time lags between the motions of the hyoid bone, epiglottis, and larynx during swallowing. Dysphagia 2014;29:591–602. [6] Barbiera F, Fiorentino E, D’Agostino T, et al. Digital cineradiographic swallow study: our experience. Radiol Med 2002;104:125–33. [7] Pearson Jr WG, Taylor BK, Blair J, et al. Computational analysis of swallowing mechanics underlying impaired epiglottic inversion. Laryngoscope 2016;126:1854–8. [8] Logemann JA, Rademaker AW, Pauloski BR, et al. Normal swallowing physiology as viewed by videofluoroscopy and videoendoscopy. Folia Phoniatr Logop 1998;50:311–9.
Please cite this article in press as: Moulin M, et al. Epiglottoplasty technique in endoscopic partial laryngectomy. European Annals of Otorhinolaryngology, Head and Neck diseases (2017), https://doi.org/10.1016/j.anorl.2017.12.003
ARTICLE IN PRESS
ANORL-728; No. of Pages 3
European Annals of Otorhinolaryngology, Head and Neck diseases xxx (2017) xxx–xxx
Available online at
ScienceDirect www.sciencedirect.com
Technical note
Epiglottoplasty technique in endoscopic partial laryngectomy M. Moulin a , C.A. Righini a,b,c , P.F. Castellanos d , I. Atallah a,b,c,d,∗ a
Otolaryngology-Head and Neck Surgery Department CS 10217, Grenoble Alpes University Hospital, 38043 Grenoble cedex 9, France Grenoble Alpes University, School of Medicine, Grenoble, France c UGA/UMR/CNRS 5309/Inserm 1209, Albert-Bonniot Institute, Grenoble, France d Division of Otolaryngology, Department of Surgery, University of Alabama, Birmingham, AL, USA b
a r t i c l e
i n f o
Keywords: Endoscopic laser surgery of the larynx Epiglottoplasty Swallowing Reconstructive transoral laser microsurgery
a b s t r a c t The main advantage of endoscopic laser surgery for laryngeal cancer is to allow tumour resection, while limiting functional sequelae, thereby improving the postoperative course. In this type of surgery, the epiglottis is often partially resected, leaving a raw zone without any reconstruction. The surgical technique described here involves endoscopic reconstruction of the epiglottis after partial resection. The sectioned edge of the epiglottis is sutured to the base of the tongue to create a neoepiglottis and to reconstruct the vallecula, thus resembling preoperative anatomy, allowing improvement of postoperative swallowing. © 2017 Elsevier Masson SAS. All rights reserved.
1. Introduction
2. Technique
Unlike open surgery for laryngeal cancer, endoscopic surgery requires resection of healthy tissues to provide access to the tumour. For example, resection of the vestibular fold provides excellent exposure of the paraglottic space. Resection of the base of the epiglottis is necessary to expose and to resect tumours arising from or involving the anterior commissure. Resection of part of the suprahyoid epiglottis may be necessary to expose some tumours of the glottis and the lateral epilarynx. In the absence of adequate exposure, another surgical approach has to be performed. Endoscopic partial laryngectomy techniques described in the literature focus on tumour resection without discussing the problem of reconstruction, which has a considerable impact on functional results [1,2]. During supraglottic partial laryngectomy, the epiglottis is often partially resected (Fig. 1a) and allowed to heal by secondary wound healing. Only few teams have studied reconstruction of the epiglottis following resection [3]. We describe an endoscopic reconstruction technique on the residual portion of the epiglottis that could be performed following any type of endoscopic partial laryngeal surgery in order to restore the anatomy and physiology of swallowing.
The surgical technique described here can be performed at the same time of endoscopic tumour resection surgery or during a deferred procedure. The objective of this technique is to attach the free edge of the sectioned epiglottis to the base of the tongue (Fig. 1b). Surgical positioning is identical to that during endoscopic tumour resection by suspension microlaryngosopy, allowing the use of both hands. Instruments used are those of reconstructive transoral laser microsurgery [4]. Interrupted sutures using a 4/0 monofilament synthetic ® absorbable surgical suture (Monocryl , Ethicon, Johnson and Johnson) are performed between the base of the tongue at the level of the resection zone and the free edge of the sectioned epiglottis to achieve lateral rotation of the residual epiglottis in order to reconstruct the missing part of the epiglottis which is resected during supraglottic partial laryngectomy. The proximal part of the resection margin is sutured to the most lateral part of the resection zone at the base of the tongue. The rest of the mucosa is then sutured contiguously (Fig. 1c). The stitches are secured by clipping to avoid tying knots through the laryngoscope which can be time-consuming. The excess suture is cut by CO2 laser or microinstruments (Fig. 1d).
3. Discussion ∗ Corresponding author. Otolaryngology-Head and Neck Surgery Department CS 10217, Grenoble Alpes University Hospital, 38043 Grenoble cedex 9, France. E-mail address: [email protected] (I. Atallah).
The epiglottis plays an essential role in swallowing by ensuring dynamic functions during swallowing consisting of tilting during laryngeal elevation and during horizontal and vertical hyoid motion
https://doi.org/10.1016/j.anorl.2017.12.003 1879-7296/© 2017 Elsevier Masson SAS. All rights reserved.
Please cite this article in press as: Moulin M, et al. Epiglottoplasty technique in endoscopic partial laryngectomy. European Annals of Otorhinolaryngology, Head and Neck diseases (2017), https://doi.org/10.1016/j.anorl.2017.12.003
G Model ANORL-728; No. of Pages 3 2
ARTICLE IN PRESS M. Moulin et al. / European Annals of Otorhinolaryngology, Head and Neck diseases xxx (2017) xxx–xxx
Fig. 1. Endoscopic epiglottoplasty surgical technique: a: intraoperative view showing the vallecula, larynx and epiglottis after supraglottic partial laryngectomy. Arrow showing the potential lateral rotation that could be performed on the residual part of the epiglottis in order to reconstruct the resected portion; b: lateral rotation of the residual right part of the epiglottis showing its future position; c: suture of the sectioned edge of the epiglottis to the left vallecular mucosa; d: final result after securing sutures with clips. Excess suture material will be cut by laser + mucosa of the left vallecula; *: sectioned edge of the epiglottis; #: remaining right part of the epiglottis after resection; ¤: base of tongue.
Fig. 2. Relations of the neoepiglottis with the larynx: a: intraoperative appearance; b: long-term appearance after complete healing (12 weeks after surgery).
[5]. The epiglottis ensures laryngeal closure during food bolus passage. Incomplete tilting of the epiglottis is one of the main causes of aspiration [6,7]. The epiglottis also ensures a static function during swallowing, as it acts as a border to slow down the movement of liquids through the pharynx, allowing time to ensure laryngeal elevation and protective adduction of the vocal folds [8]. The epiglottis
could therefore diverts liquids into pyriform sinuses even before the swallowing reflex is triggered, thereby avoiding direct flow into the glottis. Epiglottoplasty following supraglottic partial laryngectomy seems to be useful to restore almost normal anatomy in order to prevent swallowing disorders by recreating a functional
Please cite this article in press as: Moulin M, et al. Epiglottoplasty technique in endoscopic partial laryngectomy. European Annals of Otorhinolaryngology, Head and Neck diseases (2017), https://doi.org/10.1016/j.anorl.2017.12.003
G Model ANORL-728; No. of Pages 3
ARTICLE IN PRESS M. Moulin et al. / European Annals of Otorhinolaryngology, Head and Neck diseases xxx (2017) xxx–xxx
swallowing organ. The midline position of the neoepiglottis and its posterior tilting to ensure closure of the larynx would therefore prevent aspiration. By preserving laryngeal anatomy, this technique has no impact on airway (Fig. 2) and, based on our experience, patients undergoing epiglottoplasty after partial supraglottic laryngectomy do not experience postoperative aspirations, more specifically to liquids. This surgical technique does not require any specific instrumentation or specific surgical skills, making it accessible to all experienced laryngologists. Reconstruction could be performed during the same surgery of tumour resection without any change in surgical positioning. 4. Conclusion Epiglottoplasty following endoscopic partial laryngectomy is an accessible technique for experienced surgeons familiar with reconstructive transoral laser microsurgery. It restores almost normal anatomy, preventing the risks of postoperative swallowing disorders.
3
Disclosure of interest The authors declare that they have no competing interest. References [1] Sandulache VC, Kupferman ME. Transoral laser surgery for laryngeal cancer. Rambam Maimonides Med J 2014;5:e0012. [2] Rubinstein M, Armstrong WB. Transoral laser microsurgery for laryngeal cancer: a primer and review of laser dosimetry. Lasers Med Sci 2011;26:113–24. [3] Grajek M, Maciejewski A, Oles K, et al. An experience with auricular free flap epiglottis reconstruction after supraglottic laryngectomy. J Reconstr Microsurg 2016;32:164–8. [4] Atallah I, Manjunath MK, Omari AA, et al. Reconstructive transoral laser microsurgery for posterior glottic web with stenosis. Laryngoscope 2017;127:685–90. [5] Seo HG, Oh BM, Leigh JH, et al. Correlation varies with different time lags between the motions of the hyoid bone, epiglottis, and larynx during swallowing. Dysphagia 2014;29:591–602. [6] Barbiera F, Fiorentino E, D’Agostino T, et al. Digital cineradiographic swallow study: our experience. Radiol Med 2002;104:125–33. [7] Pearson Jr WG, Taylor BK, Blair J, et al. Computational analysis of swallowing mechanics underlying impaired epiglottic inversion. Laryngoscope 2016;126:1854–8. [8] Logemann JA, Rademaker AW, Pauloski BR, et al. Normal swallowing physiology as viewed by videofluoroscopy and videoendoscopy. Folia Phoniatr Logop 1998;50:311–9.
Please cite this article in press as: Moulin M, et al. Epiglottoplasty technique in endoscopic partial laryngectomy. European Annals of Otorhinolaryngology, Head and Neck diseases (2017), https://doi.org/10.1016/j.anorl.2017.12.003