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Function evaluation of laryngeal reconstruction using infrahyoid muscle after partial laryngectomy in 37 patients
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ARTICLE IN PRESS
ANORL-949; No. of Pages 5
European Annals of Otorhinolaryngology, Head and Neck diseases xxx (2019) xxx–xxx
Available online at
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Original article
Function evaluation of laryngeal reconstruction using infrahyoid muscle after partial laryngectomy in 37 patients O. Vella a,∗ , D. Blanchard b , D. de Raucourt b , J.P. Rame b , E. Babin a a b
Service d’ORL et de chirurgie cervico-faciale, CHU de Caen, Avenue de la Côte de Nacre, 14033 Caen, France Service d’ORL et de chirurgie cervico-faciale, CLCC Franc¸ois-Baclesse, 3, avenue du Général-Harris, 14000 Caen, France
a r t i c l e
i n f o
a b s t r a c t
Keywords: Laryngeal cancer Partial laryngectomy Reconstruction Functional outcome Swallowing
Treatment of small laryngeal cancerous lesions (T1 and T2) is based on partial endoscopic or open surgery and radiotherapy. In addition to the oncological imperative, these techniques must optimally preserve the functions of breathing, swallowing and phonation. Objective: To analyze the above functions in patients treated with supracricoid laryngectomy and reconstruction using infrahyoid muscle. Materials and methods: Breathing, swallowing and phonation were analyzed in 37 patients treated in two institutes between 2005 and 2015. All patients undergoing the above type of reconstruction with a minimum 1 year’s follow-up were included. Respiratory study noted any tracheotomy and measured peak inspiratory flow. Preservation of cricoarytenoid units and nasogastric intubation time, and DHI-30 self-administered questionnaire results were collected to analyze swallowing function. Phonation was assessed on the VHI-30 self-administered questionnaire. Results: The rate of primary surgery without tracheotomy was 64.9% (13 patients), with rapid resumption of oral feeding (mean intubation time, 13 days). Mean VHI score was 28.3 and mean DHI 30 score 2.7. Mean peak inspiratory flow was 203.3 mL/min. Conclusion: Supracricoid laryngectomy with reconstruction using subhyoid muscle is an alternative technique for the treatment of small laryngeal cancerous lesions, providing uncomplicated functional outcome. © 2019 Published by Elsevier Masson SAS.
1. Introduction
frontal laryngectomy (RAFL), cricohyoidoepiglottopexy, or cricohyoidopexy. In 1999, Pignat reported an innovative technique for glottic tumor [2], with a novel approach for laryngoplasty that could be used whenever reconstruction is required, based on subtotal laryngectomy with cricohyoidoepiglottopexy as described by Majer [3] and Piquet [4], modified by Guerrier [5]. The aim of the present study was to analyze functional results in early-stage laryngeal cancer treated by supracricoid laryngectomy with reconstruction by subhyoid muscle approximation.
The larynx is a key organ in relational life, involved in 3 essential functions: breathing, swallowing and phonation. Laryngeal cancer accounts for 1.9% of cancers worldwide [1]. Diagnosis is usually early (T1–T2, N0), as symptoms are evident. Several treatment options are available for these localized tumors: endoscopic laser surgery, external radiation therapy, or open partial laryngeal surgery. Indications for the last of these have diminished with the rise of endoscopy, but it remains part of the therapeutic armamentarium for small laryngeal tumors. Laryngeal reconstruction after open partial laryngeal surgery aims at optimal preservation of breathing, swallowing and phonation. Various reconstruction techniques following supracricoid laryngectomy have been described: reconstructive anterior
∗ Corresponding author. E-mail address: [email protected] (O. Vella).
2. Material and methods All patients in two Head and Neck surgery centers managed between 2005 and 2015, with ≥ 1 year’s follow-up, were included. Patients were identified from the institution database by diagnostic codes GDFA006 (vertical partial laryngectomy), GDFA011 (supracricoid laryngectomy with cricohyoidoepiglottopexy), and GDFA016 (anterior frontal laryngectomy with epiglottoplasty),
https://doi.org/10.1016/j.anorl.2019.09.004 1879-7296/© 2019 Published by Elsevier Masson SAS.
Please cite this article in press as: Vella O, et al. Function evaluation of laryngeal reconstruction using infrahyoid muscle after partial laryngectomy in 37 patients. European Annals of Otorhinolaryngology, Head and Neck diseases (2019), https://doi.org/10.1016/j.anorl.2019.09.004
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according to the French Common Classification of Medical Acts (CCAM). Only patients receiving the Pignat reconstruction variant [2] were eligible. The surgical steps were as follows: • resection: ◦ orotracheal intubation, with nasogastric tube, ◦ bi-mastoid U incision, horizontal at the cricothyroid membrane, ◦ skin flap taken above the hyoid bone, with location of subhyoid muscles, ◦ prelaryngeal neck dissection, with minimal trauma to subhyoid muscles. ◦ exposure of thyroid cartilage and anterior edge of cricoid cartilage, ◦ midline incision of external perichondrium for 2 lateral perichondrial flaps. ◦ sectioning anterior part of cricothyroid membrane along the superior edge of the cricoid cartilage: the anterior cricoid arch can be resected, with sectioning of the cricotracheal membrane at the inferior edge of the cricoid cartilage (in case of wider glottic extension, with precise preoperative endoscopy to check feasibility), ◦ bilateral lateral vertical thyrotomy adapted to tumor extension, always beginning on the less affected side. An oscillating saw is generally used. Sectioning should be gentle and careful, sparing the internal perichondrium, ◦ the paraglottic space and internal perichondrium are retracted inward, ◦ transverse transepiglottic sectioning: horizontal section with level according to tumor extension, but always at least partially sparing the suprahyoid epiglottis, ◦ prearytenoid vertical sectioning from the superior edge of the cricoid up to the aryepiglottic fold or vice-versa, starting from the less affected side, ◦ resection of the whole paraglottic space, ◦ this enables the specimen to be opened and tumor resection to be continued under visual control, ◦ tumor resection continues from the affected side, with vertical sectioning of the aryepiglottic fold up to the superior edge of the cricoid, removing the arytenoid cartilage if necessary, ◦ the specimen is oriented and sent for frozen section histology (preferably transported by one of the surgeons, to explain the margins to the pathologist), ◦ bilateral neck dissection (if performed), during frozen section biopsy;
Fig. 1. Diagram of epiglottic mooring and vertical bracing.
• reconstruction: ◦ the epiglottis is moored by 2 Vicryl® 2.0 sutures to the 2 remaining thyroid wings, to prevent tilting or tubulization (Fig. 1), ◦ the 2 perichondrial flaps are sutured with the remaining laryngeal structures, retensioning the ventricular bands and remaining vocal ligaments, so as to cover the sectioned cartilage, ◦ bracing to join the laryngotracheal axis to the hyoid bone using 3 Vicryl® n◦ 1 or Merseture® sutures through the epiglottis, passing under the inferior side of the cricoid (submucosally if possible) and over the superior side of the epiglottis. No impaction or pexy is performed. There should be no resulting shortening or narrowing of the larynx (Fig. 1), ◦ tight closure by paramedial suture of the subhyoid muscles, forming an overlap (Fig. 2), ◦ performance or preparation of tracheotomy, by an incision other than for the partial laryngectomy. Further non-inclusion criteria concerning prospective functional follow-up assessment comprised second pulmonary or esophageal neoplasia, other upper airway oncologic surgery, complementary postoperative treatment, and recurrence or disease progression. Data were collected on paper or computer files. Respiratory function was assessed in terms of intra- or post-operative tracheotomy with cannulation time, and peak inspiratory flow (highest of 3 consecutive measurements). Conservation of
Fig. 2. Hyoid muscle overlap in 2 planes.
Please cite this article in press as: Vella O, et al. Function evaluation of laryngeal reconstruction using infrahyoid muscle after partial laryngectomy in 37 patients. European Annals of Otorhinolaryngology, Head and Neck diseases (2019), https://doi.org/10.1016/j.anorl.2019.09.004
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O. Vella et al. / European Annals of Otorhinolaryngology, Head and Neck diseases xxx (2019) xxx–xxx Table 1 Patient distribution on pTNM classification. Tumor stage Lymph-node stage
pT1a
No dissection N0 N1
20 patients 3 patients /
pT1b 1 patient 1 patient /
3
Table 2 VHI scores. pT2 6 patients 3 patients 1 patient
pT3
Score
Total
Functional
Physical
Emotional
1 patient / 1 patient
Mean Minimum Maximum Median Standard deviation
28.3 4 62 28 17.5
10.5 0 20 12 5.3
10.9 3 24 12 6.8
6.8 0 26 6 7.4
cricoarytenoid units, nasogastric intubation time and DHI-30 selfadministered questionnaire responses were collated to analyze swallowing function. Phonation was assessed on the VHI-30 selfadministered questionnaire. Statistical analysis using STATISTICA software was performed by the biostatistics and clinical research department. Descriptive analysis was performed for certain qualitative variables, reported as percentage, and quantitative variables, reported as mean, median and standard deviation. For the latter, significance was assessed on Mann – Whitney U – test. The significance threshold was set at 0.05. 3. Results 3.1. Preoperative data The series comprised 37 patients: 26 (70.3%) operated on in a Cancer Center, and 11 (29.7%) in the local university hospital, all during the period 2005–2015. Mean age at surgery was 57.6 ± 7.7 years (range, 44–76 years; median, 56 years). 3.2. Intraoperative data 3.2.1. Cricoarytenoid unit conservation Resection spared the two cricoarytenoid units in 31 cases (83.8%), including 3 patients in whom the vocal apophysis was removed. 3.2.2. Intraoperative tracheotomy Intraoperative tracheotomy was required in 13 cases (35.1%): overweight with short neck (3 patients), large resection (1 patient), underlying chronic obstructive bronchopneumopathy with relative hypoxemia or associated with large resection (2 patients), history of frontolateral laryngectomy (1 patient), balloon rupture during closure (1 patient), operator’s decision without clear explanation (5 patients). The rate of surgery without tracheotomy was 64.9%.
3.3.4. Time to decannulation Twenty-two 22 patients had no tracheotomy (59.4%). In the 13 patients with intraoperative tracheotomy, mean time to decannulation was 10.5 days (range, 4–33 days). Continued cannulation was required for underlying tracheal stenosis. 3.3.5. Time to resumption of oral feeding Analysis concerned 33 patients (4 cases of missing data). Mean time to resumption of oral feeding was 10.4 days (range, 4–27 days). Patients without intra- or post-operative tracheotomy in hospital (21 patients; 1 case of missing data) showed a mean time to resumption of oral feeding of 9.5 days, versus 12 days in case of tracheotomy (12 patients) (P = 0.07). Patients with conserved arytenoid cartilage (27 patients) showed a mean time to resumption of oral feeding of 10.4 days, versus 10.3 days in case of conservation of only 1 cricoarytenoid unit (6 patients) (P = 0.77). 3.3.6. Nasogastric intubation time Analysis concerned 32 patients (5 cases of missing data). Mean time to tube removal was 13 days (range, 5–28 days). Patients without intra- or post-operative tracheotomy (19 patients) showed a mean time to resumption of oral feeding of 11.8 days, versus 14.7 days in case of tracheotomy (13 patients) (P = 0.01). Patients with conserved arytenoid cartilage (26 patients; 1 case of missing data) showed a mean time to resumption of oral feeding of 13.3 days, versus 11.5 days in case of conservation of only 1 cricoarytenoid unit (6 patients) (P = 0.65). Eleven patients (34.4%) were discharged home with enteral feeding by nasogastric tube. 3.4. Functional assessment Seventeen patients (46%) had functional assessment during oncologic follow-up, all with postoperative speech therapy.
3.3. Postoperative data 3.3.1. Tumor staging Table 1 shows tumor staging. Most cases concerned pT1a glottic cancer (23 patients: 62.2%). 3.3.2. Resection quality Margins on definitive pathology were positive in a single case (2.7%), both anteriorly (anterior commissure) and posteriorly; the tumor was staged as pT3 on definitive histology (initially, cT1bN0). 3.3.3. Secondary tracheotomy Twenty-four patients had no primary tracheotomy. Only 2 had secondary tracheotomy, both for postoperative emphysema, at day 1 and day 2, respectively. One patient with primary tracheotomy, removed at day 15, had secondary emergency tracheotomy for respiratory distress with tracheal stenosis at day 42; he had no history of tracheobronchial disease.
3.4.1. Respiratory function Two measurements could not be taken due to insufficient graduation of initial Peak Inspiratory Flow (PIF > 120 mL/mn) with refusal to come back for consultation; analysis concerned 15 patients. Mean PIF was 203.3 ± 72.3 mL/mn (range, 90–300 mL/mn; median, 200 mL/mn). There was no significant difference according to arytenoid conservation (P = 0.54). 3.4.2. Vocal quality Seventeen patients filled out the VHI-30 vocal perception questionnaire. Table 2 shows functional, physical and emotional scores. There was no significant difference according to arytenoid conservation (14 patients with both units and 3 with only 1 unit conserved; P = 0.86). 3.4.3. Swallowing Seventeen patients filled out the DHI-30 questionnaire. Table 3 shows functional, specific and emotional scores.
Please cite this article in press as: Vella O, et al. Function evaluation of laryngeal reconstruction using infrahyoid muscle after partial laryngectomy in 37 patients. European Annals of Otorhinolaryngology, Head and Neck diseases (2019), https://doi.org/10.1016/j.anorl.2019.09.004
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4 Table 3 DHI scores. Score
Total
Functional
Specific
Emotional
Mean Minimum Maximum Median Standard deviation
2.7 0 7 2 2.2
0.6 0 4 0 1.1
1.9 0 7 2 1.7
0.2 0 3 0 0.7
There was no significant difference according to arytenoid conservation (14 patients with both units and 3 with only 1 unit conserved; P = 0.16). 4. Discussion Subtotal laryngeal surgery with reconstruction using subhyoid muscles has a double imperative: to be oncologic, and to optimally conserve function, notably with return to unrestricted solid and liquid oral feeding without false passage and with an adequate calorie balance without symptoms of dysphagia. The technique thus ensures: • 64.9% surgery without the tracheotomy often required by the Tucker technique or cricohyoidoepiglottopexy (CHEP) (Laryngectomies partielles, subtotales et totales, EM Consulte, Techniques chirurgicales); • mean time to decannulation of 10.5 days, shorter than with other reconstruction techniques (19–27 days after CHEP [6,7] and 14–20 days after epiglottoplasty [7,8]); • rapid return to oral feeding, at a mean 13 days, compared to 14, 23 or 22 days after CHEP [6,8,9] or 17 days after epiglottoplasty [7]. The interval was, moreover, overestimated in the present study due to home relay by a service-provider in 11 cases, with tube ablation supervised by the speech therapist and dietician during a short hospital admission. This reconstruction technique using subhyoid muscles theoretically avoids intraoperative tracheotomy, which, however, is still relevant for obese patients with short neck or patients at risk of requiring postoperative assisted respiration, especially in case of chronic obstructive bronchopneumopathy. Compared to Pignat’s study [2], the present series had a similar rate of surgery without tracheotomy (34% and 35.1%, respectively), with similar time to decannulation. Based on Périé’s study [10] of peak inspiratory flow in tracheotomy following oncologic surgery for pharyngolaryngeal tumor, we sought to determine reference values following partial laryngectomy with reconstruction using subhyoid muscles. The lower the PIF, the more likely is a pharyngolaryngeal obstruction [10], which could help clinicians in measuring and grading pharyngolaryngeal stenosis. No comparative data could be found in the literature. Voice quality stabilizes 6 months after endoscopic laser resection [11]. Treatment results and comparison with surgery are not reliable during these first 6 months [11]. The present results at a minimum 1 year’s follow-up allow comparison with the literature. Mean VHI-30 score was 28.3, which is satisfactory compared to results of other reconstruction techniques: 55.58 for CHEP and 52.78 for Tucker [7], or 32.9 for epiglottoplasty and 52.22 for CHEP [12,13]. Voice quality is, however, better after external radiation therapy or laser cordectomy: 8.3 and 12.4 respectively for Tis-T2 tumors [14]. The aim of avoiding pexy is to conserve one anatomic pharyngolaryngeal unit as nearly normal as possible [2]. A posterior vertical portion is conserved at the two thyroid wings, and the pharyngeal
constrictors are not sectioned. Pharyngeal height is thus conserved and the superior laryngeal nerves undergo no intraoperative trauma. Reconstruction uses tight paramedial suture of the subhyoid muscles to form an overlap after joining the laryngotracheal axis to the hyoid bone by vertical bracing. This maintains laryngeal ascension by joining the laryngotracheal axis to the hyoid bone and preventing the sutured muscle being inhaled and inducing laryngeal stenosis or laryngomalacia. Excellent swallowing function is thus achieved, as seen in the present mean 2.7 DHI-30 score. Arytenoidectomy during laryngectomy has discordant impact on swallowing in the literature: some studies reported better functional outcome with conservation of both units [15–18], while others, including the present study, found no significant difference [19–25]. The small sample size in the present series is, however, to be underlined, and larger-scale studies are needed. 5. Conclusion Functional sequelae of glottic carcinoma surgery can have social, psychosocial and mental impact. Surgery should be oncologic while limiting functional consequences. Endoscopic surgery and radiation therapy are to be preferred in first line. Open partial laryngeal surgery is an alternative that surgeons need to be aware of. Reconstruction using subhyoid muscles can be considered organ-sparing, allowing physiological rehabilitation of phonation, swallowing and respiration functions, while usually avoiding tracheotomy. Rigorous and methodical execution is straightforward, without functional complications. Disclosure of interest The authors declare that they have no competing interest. References [1] Succo G, Crosetti E, Bertolin A, et al. Benefits and drawbacks of open partial horizontal laryngectomies, part A: early- to intermediate-stage 11 lottis carcinoma. Head Neck 2016;38(Suppl 1):E333–40. [2] Bolot G, Poupard M, Zroumba P, Herlemont F, Pignat JC. Laryngectomies sub-totales reconstructrices à propos d’une technique personnelle sur une série de 100 patients opérés entre 1990 et 1997. Rev Laryngol Oto. Rhinol 1999;120(2):93–6. [3] Majer H, Rieder A. Technique de laryngectomie permettant de conserver la perméabilité respiratoire: la crico-hyoïdo-pexie. Ann Otolaryngol Chir Cervicofac 1959;76:677–81. [4] Piquet JJ, Desaulty A, Decroix G. La crico-hyoïdo-épiglotto-pexie. Technique opératoire et résultats fonctionnels. Ann Otolaryngol Chir Cervicofac 1974;91:681–6. [5] Guerrier B. L’intervention de Majer-Piquet modifiée selon Bernard Guerrier. Oto-Rhino-laryngol Chir Cervicofac 1994;174:33–4. [6] Ozturk K, Akyildiz S, Gode S, et al. Post-Surgical and Oncologic Outcomes of Supracricoid Partial Laryngectomy: A Single-Institution Report of Ninety Cases. ORL J Otorhinolaryngol Relat Spec 2016;78(2):86–93. [7] Oysu C, Aslan I. Cricohyoidoepiglottopexy vs near-total laryngectomy with epiglottic reconstruction in the treatment of early glottic carcinoma. Arch Otolaryngol Head Neck Surg 2006;132(10):1065–8. [8] Lawson G, Jamart J, Remacle M. Improving the functional outcome of Tucker’s reconstructive laryngectomy. Head Neck 2001;23(10):871–8. [9] Zhang SY, Lu ZM, Chen LS, et al. Supracricoid partial laryngectomy cricohyoidoepiglottopexy (SCPL-CHEP) versus vertical partial laryngectomy for the treatment of glottic carcinoma. Eur Arch Otorhinolaryngol 2013;270:1027–34. [10] Guerlain J, Guerrero JA, Baujat B, St Guilly JL, Périé S. Peak inspiratory flow is a simple means of predicting decannulation success following head and neck cancer surgery: a prospective study of fifty-six patients. Laryngoscope 2015;125(2):365–70. [11] Chu PY, Hsu YB, Lee TL, et al. Longitudinal analysis of voice quality in patients with early glottic cancer after transoral laser microsurgery. Head Neck 2012;34(9):1294–8. [12] Nie C, Shen C, Hu H, et al. Mid-term results of frontovertical partial laryngectomy for early glottic carcinoma with anterior commissure involvement. Acta Otolaryngol 2014;134(4):407–12 [7]. [13] Makeieff M, Venail F, Garrel R, de la Breteque BA, Giovanni A, Guerrier B. Evaluation du handicap vocal après laryngectomie partielle supracricoïdienne. [Voice handicap evaluation after supracricoid partial laryngectomy]. Rev Laryngol Otol Rhinol (Bord) 2004;125(5):313–7.
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[14] Remmelts AJ, Hoebers FJ, Klop WM, et al. Evaluation of laser surgery and radiotherapy as treatment modalities in early stage laryngeal carcinoma: tumor outcome and quality of voice. Eur Arch Otorhinolaryngol 2013;270(7):2079–87. [15] Benito J, Holsinger FC, Perez-Martin A, et al. Aspiration after supracricoid partial laryngectomy: Incidence, risk factors, management, and outcomes. Head Neck 2011;33:679–85. [16] Park JO, Joo YH, Cho KJ, et al. Functional and oncologic results of extended supracricoid partial laryngectomy. Arch Otolaryngol Head Neck Surg 2011;137(11):1124–9. [17] Topaloglu I, Koprucu G, Bal M. Analysis of swallowing function after supracricoid laryngectomy with cricohyoidopexy. Otolaryng Head Neck 2012;146:412–8. [18] Akbas Y, Demireller A. Oncologic and functional results of supracricoid partial laryngectomy with cricohyoidopexy. Otolaryngol Head Neck Surg 2005;132:783–7. [19] Karasalihoglu AR, Yagiz R, Tas A, et al. Supracricoid partial laryngectomy with cricohyoidopexy and cricohyoidoepiglottopexy: functional and oncological results. J Laryngol Otol 2004;118:671–5.
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[20] Pinar E, Imre A, Calli C, et al. Supracricoid partial laryngectomy: analyses of oncologic and functional outcomes. Otolaryngol Head Neck Surg 2012;147:1093–8. [21] Lewin JS, Hutcheson KA, Barringer DA, et al. Functional analysis of swallowing outcomes after supracricoid partial laryngectomy. Head Neck 2008;30: 559–66. [22] Mercante G, Grammatica A, Battaglia P, Cristalli G, Pellini R, Spriano G. Supracricoid partial laryngectomy in the management of t3 laryngeal cancer. Otolaryngol Head Neck Surg 2013;149:714–20. [23] Castro A, Sanchez-Cuadrado I, Bernaldez R, Del Palacio A, Gavilan J. Laryngeal function preservation following supracricoid partial laryngectomy. Head Neck 2012;34:162–7. [24] Lallemant JG, Bonnin P, El-Sioufi I, Bousquet J, Cricohyoepiglottopexy:. longterm results in 55 patients. J Laryngol Otol 1999;113:532–7. [25] Caicedo-Granados E, Beswick DM, Christopoulos A, et al. Oncologic and functional outcomes of partial laryngeal surgery for intermediate-stage laryngeal cancer. Otolaryng Head Neck 2013;148:235–42.
Please cite this article in press as: Vella O, et al. Function evaluation of laryngeal reconstruction using infrahyoid muscle after partial laryngectomy in 37 patients. European Annals of Otorhinolaryngology, Head and Neck diseases (2019), https://doi.org/10.1016/j.anorl.2019.09.004
ARTICLE IN PRESS
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European Annals of Otorhinolaryngology, Head and Neck diseases xxx (2019) xxx–xxx
Available online at
ScienceDirect www.sciencedirect.com
Original article
Function evaluation of laryngeal reconstruction using infrahyoid muscle after partial laryngectomy in 37 patients O. Vella a,∗ , D. Blanchard b , D. de Raucourt b , J.P. Rame b , E. Babin a a b
Service d’ORL et de chirurgie cervico-faciale, CHU de Caen, Avenue de la Côte de Nacre, 14033 Caen, France Service d’ORL et de chirurgie cervico-faciale, CLCC Franc¸ois-Baclesse, 3, avenue du Général-Harris, 14000 Caen, France
a r t i c l e
i n f o
a b s t r a c t
Keywords: Laryngeal cancer Partial laryngectomy Reconstruction Functional outcome Swallowing
Treatment of small laryngeal cancerous lesions (T1 and T2) is based on partial endoscopic or open surgery and radiotherapy. In addition to the oncological imperative, these techniques must optimally preserve the functions of breathing, swallowing and phonation. Objective: To analyze the above functions in patients treated with supracricoid laryngectomy and reconstruction using infrahyoid muscle. Materials and methods: Breathing, swallowing and phonation were analyzed in 37 patients treated in two institutes between 2005 and 2015. All patients undergoing the above type of reconstruction with a minimum 1 year’s follow-up were included. Respiratory study noted any tracheotomy and measured peak inspiratory flow. Preservation of cricoarytenoid units and nasogastric intubation time, and DHI-30 self-administered questionnaire results were collected to analyze swallowing function. Phonation was assessed on the VHI-30 self-administered questionnaire. Results: The rate of primary surgery without tracheotomy was 64.9% (13 patients), with rapid resumption of oral feeding (mean intubation time, 13 days). Mean VHI score was 28.3 and mean DHI 30 score 2.7. Mean peak inspiratory flow was 203.3 mL/min. Conclusion: Supracricoid laryngectomy with reconstruction using subhyoid muscle is an alternative technique for the treatment of small laryngeal cancerous lesions, providing uncomplicated functional outcome. © 2019 Published by Elsevier Masson SAS.
1. Introduction
frontal laryngectomy (RAFL), cricohyoidoepiglottopexy, or cricohyoidopexy. In 1999, Pignat reported an innovative technique for glottic tumor [2], with a novel approach for laryngoplasty that could be used whenever reconstruction is required, based on subtotal laryngectomy with cricohyoidoepiglottopexy as described by Majer [3] and Piquet [4], modified by Guerrier [5]. The aim of the present study was to analyze functional results in early-stage laryngeal cancer treated by supracricoid laryngectomy with reconstruction by subhyoid muscle approximation.
The larynx is a key organ in relational life, involved in 3 essential functions: breathing, swallowing and phonation. Laryngeal cancer accounts for 1.9% of cancers worldwide [1]. Diagnosis is usually early (T1–T2, N0), as symptoms are evident. Several treatment options are available for these localized tumors: endoscopic laser surgery, external radiation therapy, or open partial laryngeal surgery. Indications for the last of these have diminished with the rise of endoscopy, but it remains part of the therapeutic armamentarium for small laryngeal tumors. Laryngeal reconstruction after open partial laryngeal surgery aims at optimal preservation of breathing, swallowing and phonation. Various reconstruction techniques following supracricoid laryngectomy have been described: reconstructive anterior
∗ Corresponding author. E-mail address: [email protected] (O. Vella).
2. Material and methods All patients in two Head and Neck surgery centers managed between 2005 and 2015, with ≥ 1 year’s follow-up, were included. Patients were identified from the institution database by diagnostic codes GDFA006 (vertical partial laryngectomy), GDFA011 (supracricoid laryngectomy with cricohyoidoepiglottopexy), and GDFA016 (anterior frontal laryngectomy with epiglottoplasty),
https://doi.org/10.1016/j.anorl.2019.09.004 1879-7296/© 2019 Published by Elsevier Masson SAS.
Please cite this article in press as: Vella O, et al. Function evaluation of laryngeal reconstruction using infrahyoid muscle after partial laryngectomy in 37 patients. European Annals of Otorhinolaryngology, Head and Neck diseases (2019), https://doi.org/10.1016/j.anorl.2019.09.004
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according to the French Common Classification of Medical Acts (CCAM). Only patients receiving the Pignat reconstruction variant [2] were eligible. The surgical steps were as follows: • resection: ◦ orotracheal intubation, with nasogastric tube, ◦ bi-mastoid U incision, horizontal at the cricothyroid membrane, ◦ skin flap taken above the hyoid bone, with location of subhyoid muscles, ◦ prelaryngeal neck dissection, with minimal trauma to subhyoid muscles. ◦ exposure of thyroid cartilage and anterior edge of cricoid cartilage, ◦ midline incision of external perichondrium for 2 lateral perichondrial flaps. ◦ sectioning anterior part of cricothyroid membrane along the superior edge of the cricoid cartilage: the anterior cricoid arch can be resected, with sectioning of the cricotracheal membrane at the inferior edge of the cricoid cartilage (in case of wider glottic extension, with precise preoperative endoscopy to check feasibility), ◦ bilateral lateral vertical thyrotomy adapted to tumor extension, always beginning on the less affected side. An oscillating saw is generally used. Sectioning should be gentle and careful, sparing the internal perichondrium, ◦ the paraglottic space and internal perichondrium are retracted inward, ◦ transverse transepiglottic sectioning: horizontal section with level according to tumor extension, but always at least partially sparing the suprahyoid epiglottis, ◦ prearytenoid vertical sectioning from the superior edge of the cricoid up to the aryepiglottic fold or vice-versa, starting from the less affected side, ◦ resection of the whole paraglottic space, ◦ this enables the specimen to be opened and tumor resection to be continued under visual control, ◦ tumor resection continues from the affected side, with vertical sectioning of the aryepiglottic fold up to the superior edge of the cricoid, removing the arytenoid cartilage if necessary, ◦ the specimen is oriented and sent for frozen section histology (preferably transported by one of the surgeons, to explain the margins to the pathologist), ◦ bilateral neck dissection (if performed), during frozen section biopsy;
Fig. 1. Diagram of epiglottic mooring and vertical bracing.
• reconstruction: ◦ the epiglottis is moored by 2 Vicryl® 2.0 sutures to the 2 remaining thyroid wings, to prevent tilting or tubulization (Fig. 1), ◦ the 2 perichondrial flaps are sutured with the remaining laryngeal structures, retensioning the ventricular bands and remaining vocal ligaments, so as to cover the sectioned cartilage, ◦ bracing to join the laryngotracheal axis to the hyoid bone using 3 Vicryl® n◦ 1 or Merseture® sutures through the epiglottis, passing under the inferior side of the cricoid (submucosally if possible) and over the superior side of the epiglottis. No impaction or pexy is performed. There should be no resulting shortening or narrowing of the larynx (Fig. 1), ◦ tight closure by paramedial suture of the subhyoid muscles, forming an overlap (Fig. 2), ◦ performance or preparation of tracheotomy, by an incision other than for the partial laryngectomy. Further non-inclusion criteria concerning prospective functional follow-up assessment comprised second pulmonary or esophageal neoplasia, other upper airway oncologic surgery, complementary postoperative treatment, and recurrence or disease progression. Data were collected on paper or computer files. Respiratory function was assessed in terms of intra- or post-operative tracheotomy with cannulation time, and peak inspiratory flow (highest of 3 consecutive measurements). Conservation of
Fig. 2. Hyoid muscle overlap in 2 planes.
Please cite this article in press as: Vella O, et al. Function evaluation of laryngeal reconstruction using infrahyoid muscle after partial laryngectomy in 37 patients. European Annals of Otorhinolaryngology, Head and Neck diseases (2019), https://doi.org/10.1016/j.anorl.2019.09.004
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O. Vella et al. / European Annals of Otorhinolaryngology, Head and Neck diseases xxx (2019) xxx–xxx Table 1 Patient distribution on pTNM classification. Tumor stage Lymph-node stage
pT1a
No dissection N0 N1
20 patients 3 patients /
pT1b 1 patient 1 patient /
3
Table 2 VHI scores. pT2 6 patients 3 patients 1 patient
pT3
Score
Total
Functional
Physical
Emotional
1 patient / 1 patient
Mean Minimum Maximum Median Standard deviation
28.3 4 62 28 17.5
10.5 0 20 12 5.3
10.9 3 24 12 6.8
6.8 0 26 6 7.4
cricoarytenoid units, nasogastric intubation time and DHI-30 selfadministered questionnaire responses were collated to analyze swallowing function. Phonation was assessed on the VHI-30 selfadministered questionnaire. Statistical analysis using STATISTICA software was performed by the biostatistics and clinical research department. Descriptive analysis was performed for certain qualitative variables, reported as percentage, and quantitative variables, reported as mean, median and standard deviation. For the latter, significance was assessed on Mann – Whitney U – test. The significance threshold was set at 0.05. 3. Results 3.1. Preoperative data The series comprised 37 patients: 26 (70.3%) operated on in a Cancer Center, and 11 (29.7%) in the local university hospital, all during the period 2005–2015. Mean age at surgery was 57.6 ± 7.7 years (range, 44–76 years; median, 56 years). 3.2. Intraoperative data 3.2.1. Cricoarytenoid unit conservation Resection spared the two cricoarytenoid units in 31 cases (83.8%), including 3 patients in whom the vocal apophysis was removed. 3.2.2. Intraoperative tracheotomy Intraoperative tracheotomy was required in 13 cases (35.1%): overweight with short neck (3 patients), large resection (1 patient), underlying chronic obstructive bronchopneumopathy with relative hypoxemia or associated with large resection (2 patients), history of frontolateral laryngectomy (1 patient), balloon rupture during closure (1 patient), operator’s decision without clear explanation (5 patients). The rate of surgery without tracheotomy was 64.9%.
3.3.4. Time to decannulation Twenty-two 22 patients had no tracheotomy (59.4%). In the 13 patients with intraoperative tracheotomy, mean time to decannulation was 10.5 days (range, 4–33 days). Continued cannulation was required for underlying tracheal stenosis. 3.3.5. Time to resumption of oral feeding Analysis concerned 33 patients (4 cases of missing data). Mean time to resumption of oral feeding was 10.4 days (range, 4–27 days). Patients without intra- or post-operative tracheotomy in hospital (21 patients; 1 case of missing data) showed a mean time to resumption of oral feeding of 9.5 days, versus 12 days in case of tracheotomy (12 patients) (P = 0.07). Patients with conserved arytenoid cartilage (27 patients) showed a mean time to resumption of oral feeding of 10.4 days, versus 10.3 days in case of conservation of only 1 cricoarytenoid unit (6 patients) (P = 0.77). 3.3.6. Nasogastric intubation time Analysis concerned 32 patients (5 cases of missing data). Mean time to tube removal was 13 days (range, 5–28 days). Patients without intra- or post-operative tracheotomy (19 patients) showed a mean time to resumption of oral feeding of 11.8 days, versus 14.7 days in case of tracheotomy (13 patients) (P = 0.01). Patients with conserved arytenoid cartilage (26 patients; 1 case of missing data) showed a mean time to resumption of oral feeding of 13.3 days, versus 11.5 days in case of conservation of only 1 cricoarytenoid unit (6 patients) (P = 0.65). Eleven patients (34.4%) were discharged home with enteral feeding by nasogastric tube. 3.4. Functional assessment Seventeen patients (46%) had functional assessment during oncologic follow-up, all with postoperative speech therapy.
3.3. Postoperative data 3.3.1. Tumor staging Table 1 shows tumor staging. Most cases concerned pT1a glottic cancer (23 patients: 62.2%). 3.3.2. Resection quality Margins on definitive pathology were positive in a single case (2.7%), both anteriorly (anterior commissure) and posteriorly; the tumor was staged as pT3 on definitive histology (initially, cT1bN0). 3.3.3. Secondary tracheotomy Twenty-four patients had no primary tracheotomy. Only 2 had secondary tracheotomy, both for postoperative emphysema, at day 1 and day 2, respectively. One patient with primary tracheotomy, removed at day 15, had secondary emergency tracheotomy for respiratory distress with tracheal stenosis at day 42; he had no history of tracheobronchial disease.
3.4.1. Respiratory function Two measurements could not be taken due to insufficient graduation of initial Peak Inspiratory Flow (PIF > 120 mL/mn) with refusal to come back for consultation; analysis concerned 15 patients. Mean PIF was 203.3 ± 72.3 mL/mn (range, 90–300 mL/mn; median, 200 mL/mn). There was no significant difference according to arytenoid conservation (P = 0.54). 3.4.2. Vocal quality Seventeen patients filled out the VHI-30 vocal perception questionnaire. Table 2 shows functional, physical and emotional scores. There was no significant difference according to arytenoid conservation (14 patients with both units and 3 with only 1 unit conserved; P = 0.86). 3.4.3. Swallowing Seventeen patients filled out the DHI-30 questionnaire. Table 3 shows functional, specific and emotional scores.
Please cite this article in press as: Vella O, et al. Function evaluation of laryngeal reconstruction using infrahyoid muscle after partial laryngectomy in 37 patients. European Annals of Otorhinolaryngology, Head and Neck diseases (2019), https://doi.org/10.1016/j.anorl.2019.09.004
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4 Table 3 DHI scores. Score
Total
Functional
Specific
Emotional
Mean Minimum Maximum Median Standard deviation
2.7 0 7 2 2.2
0.6 0 4 0 1.1
1.9 0 7 2 1.7
0.2 0 3 0 0.7
There was no significant difference according to arytenoid conservation (14 patients with both units and 3 with only 1 unit conserved; P = 0.16). 4. Discussion Subtotal laryngeal surgery with reconstruction using subhyoid muscles has a double imperative: to be oncologic, and to optimally conserve function, notably with return to unrestricted solid and liquid oral feeding without false passage and with an adequate calorie balance without symptoms of dysphagia. The technique thus ensures: • 64.9% surgery without the tracheotomy often required by the Tucker technique or cricohyoidoepiglottopexy (CHEP) (Laryngectomies partielles, subtotales et totales, EM Consulte, Techniques chirurgicales); • mean time to decannulation of 10.5 days, shorter than with other reconstruction techniques (19–27 days after CHEP [6,7] and 14–20 days after epiglottoplasty [7,8]); • rapid return to oral feeding, at a mean 13 days, compared to 14, 23 or 22 days after CHEP [6,8,9] or 17 days after epiglottoplasty [7]. The interval was, moreover, overestimated in the present study due to home relay by a service-provider in 11 cases, with tube ablation supervised by the speech therapist and dietician during a short hospital admission. This reconstruction technique using subhyoid muscles theoretically avoids intraoperative tracheotomy, which, however, is still relevant for obese patients with short neck or patients at risk of requiring postoperative assisted respiration, especially in case of chronic obstructive bronchopneumopathy. Compared to Pignat’s study [2], the present series had a similar rate of surgery without tracheotomy (34% and 35.1%, respectively), with similar time to decannulation. Based on Périé’s study [10] of peak inspiratory flow in tracheotomy following oncologic surgery for pharyngolaryngeal tumor, we sought to determine reference values following partial laryngectomy with reconstruction using subhyoid muscles. The lower the PIF, the more likely is a pharyngolaryngeal obstruction [10], which could help clinicians in measuring and grading pharyngolaryngeal stenosis. No comparative data could be found in the literature. Voice quality stabilizes 6 months after endoscopic laser resection [11]. Treatment results and comparison with surgery are not reliable during these first 6 months [11]. The present results at a minimum 1 year’s follow-up allow comparison with the literature. Mean VHI-30 score was 28.3, which is satisfactory compared to results of other reconstruction techniques: 55.58 for CHEP and 52.78 for Tucker [7], or 32.9 for epiglottoplasty and 52.22 for CHEP [12,13]. Voice quality is, however, better after external radiation therapy or laser cordectomy: 8.3 and 12.4 respectively for Tis-T2 tumors [14]. The aim of avoiding pexy is to conserve one anatomic pharyngolaryngeal unit as nearly normal as possible [2]. A posterior vertical portion is conserved at the two thyroid wings, and the pharyngeal
constrictors are not sectioned. Pharyngeal height is thus conserved and the superior laryngeal nerves undergo no intraoperative trauma. Reconstruction uses tight paramedial suture of the subhyoid muscles to form an overlap after joining the laryngotracheal axis to the hyoid bone by vertical bracing. This maintains laryngeal ascension by joining the laryngotracheal axis to the hyoid bone and preventing the sutured muscle being inhaled and inducing laryngeal stenosis or laryngomalacia. Excellent swallowing function is thus achieved, as seen in the present mean 2.7 DHI-30 score. Arytenoidectomy during laryngectomy has discordant impact on swallowing in the literature: some studies reported better functional outcome with conservation of both units [15–18], while others, including the present study, found no significant difference [19–25]. The small sample size in the present series is, however, to be underlined, and larger-scale studies are needed. 5. Conclusion Functional sequelae of glottic carcinoma surgery can have social, psychosocial and mental impact. Surgery should be oncologic while limiting functional consequences. Endoscopic surgery and radiation therapy are to be preferred in first line. Open partial laryngeal surgery is an alternative that surgeons need to be aware of. Reconstruction using subhyoid muscles can be considered organ-sparing, allowing physiological rehabilitation of phonation, swallowing and respiration functions, while usually avoiding tracheotomy. Rigorous and methodical execution is straightforward, without functional complications. Disclosure of interest The authors declare that they have no competing interest. References [1] Succo G, Crosetti E, Bertolin A, et al. Benefits and drawbacks of open partial horizontal laryngectomies, part A: early- to intermediate-stage 11 lottis carcinoma. Head Neck 2016;38(Suppl 1):E333–40. [2] Bolot G, Poupard M, Zroumba P, Herlemont F, Pignat JC. Laryngectomies sub-totales reconstructrices à propos d’une technique personnelle sur une série de 100 patients opérés entre 1990 et 1997. Rev Laryngol Oto. Rhinol 1999;120(2):93–6. [3] Majer H, Rieder A. Technique de laryngectomie permettant de conserver la perméabilité respiratoire: la crico-hyoïdo-pexie. Ann Otolaryngol Chir Cervicofac 1959;76:677–81. [4] Piquet JJ, Desaulty A, Decroix G. La crico-hyoïdo-épiglotto-pexie. Technique opératoire et résultats fonctionnels. Ann Otolaryngol Chir Cervicofac 1974;91:681–6. [5] Guerrier B. L’intervention de Majer-Piquet modifiée selon Bernard Guerrier. Oto-Rhino-laryngol Chir Cervicofac 1994;174:33–4. [6] Ozturk K, Akyildiz S, Gode S, et al. Post-Surgical and Oncologic Outcomes of Supracricoid Partial Laryngectomy: A Single-Institution Report of Ninety Cases. ORL J Otorhinolaryngol Relat Spec 2016;78(2):86–93. [7] Oysu C, Aslan I. Cricohyoidoepiglottopexy vs near-total laryngectomy with epiglottic reconstruction in the treatment of early glottic carcinoma. Arch Otolaryngol Head Neck Surg 2006;132(10):1065–8. [8] Lawson G, Jamart J, Remacle M. Improving the functional outcome of Tucker’s reconstructive laryngectomy. Head Neck 2001;23(10):871–8. [9] Zhang SY, Lu ZM, Chen LS, et al. Supracricoid partial laryngectomy cricohyoidoepiglottopexy (SCPL-CHEP) versus vertical partial laryngectomy for the treatment of glottic carcinoma. Eur Arch Otorhinolaryngol 2013;270:1027–34. [10] Guerlain J, Guerrero JA, Baujat B, St Guilly JL, Périé S. Peak inspiratory flow is a simple means of predicting decannulation success following head and neck cancer surgery: a prospective study of fifty-six patients. Laryngoscope 2015;125(2):365–70. [11] Chu PY, Hsu YB, Lee TL, et al. Longitudinal analysis of voice quality in patients with early glottic cancer after transoral laser microsurgery. Head Neck 2012;34(9):1294–8. [12] Nie C, Shen C, Hu H, et al. Mid-term results of frontovertical partial laryngectomy for early glottic carcinoma with anterior commissure involvement. Acta Otolaryngol 2014;134(4):407–12 [7]. [13] Makeieff M, Venail F, Garrel R, de la Breteque BA, Giovanni A, Guerrier B. Evaluation du handicap vocal après laryngectomie partielle supracricoïdienne. [Voice handicap evaluation after supracricoid partial laryngectomy]. Rev Laryngol Otol Rhinol (Bord) 2004;125(5):313–7.
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Please cite this article in press as: Vella O, et al. Function evaluation of laryngeal reconstruction using infrahyoid muscle after partial laryngectomy in 37 patients. European Annals of Otorhinolaryngology, Head and Neck diseases (2019), https://doi.org/10.1016/j.anorl.2019.09.004