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Modified frontolateral partial laryngectomy without tracheotomy
Otolaryngology–Head and Neck Surgery (2009) 141, 70-74
ORIGINAL RESEARCH–LARYNGOLOGY AND NEUROLARYNGOLOGY
Modified frontolateral partial laryngectomy without tracheotomy Pin Dong, MD, Xiaoyan Li, MD, Jin Xie, MD, Li Li, MD, and Hongming Xu, MD, Shanghai, China Sponsorships or competing interests that may be relevant to content have been disclosed at the end of this article. ABSTRACT OBJECTIVE: To investigate the feasibility of modified frontolateral partial laryngectomy without tracheotomy for patients with early-stage laryngeal cancer or dysplasia of the true vocal cord. STUDY DESIGN: After frontolateral partial laryngectomy, the inner side of the sternohyoid muscle was drawn into the laryngeal lumen to suture it to the incisal margin of the uninjured side and to the false vocal cord on the side of the lesion to ensure the safety without tracheotomy. A reverted sternohyoid fascial flap was used to cover the anterior area to form a new laryngeal lumen in the shape of a ladder. SUBJECTS AND METHODS: A total of 65 patients with early glottic carcinomas or severe dysplasia of the true vocal cord were treated with modified frontolateral partial laryngectomy without tracheotomy. Ipsilateral false vocal cord flaps and cervical skin flaps were used in 63 patients and two patients respectively to reconstruct the defect. RESULTS: Deglutition and phonation were fully recovered after 7 to 10 days postsurgery. The only postoperative complication was subcutaneous emphysema noted in nine patients. The 1-, 3-, and 5-year survival rates were all 100 percent. CONCLUSION: Modified frontolateral partial laryngectomy without tracheostomy is an effective surgical method for early glottic carcinomas and severe dysplasia of the true vocal cord.
approach without tracheotomy for T1 and T2 glottic and supraglottic cancers in a series of 5 patients. In the case of small primary laryngeal tumors, traditional partial laryngectomy is often considered too aggressive owing to the associated complications of this procedure. In this study, we describe the development of a novel approach, the modified frontolateral partial laryngectomy without tracheotomy, and review the results in 65 patients who underwent this new operation.
PATIENTS
© 2009 American Academy of Otolaryngology–Head and Neck Surgery Foundation. All rights reserved.
We identified 65 patients with primary glottic squamous cell carcinoma or atypical hyperplasia of the larynx who underwent treatment with modified frontolateral partial laryngectomy without tracheotomy between April 2000 and May 2006, at the Department of Otolaryngology Head and Neck Surgery of Shanghai Jiao Tong University Affiliated First People’s Hospital. The patients were all male and ranged in age from 49 to 65 years. The follow-up period ranged between 4 months and 6 years postoperatively. According to the 2002 American Joint Committee on Cancer staging classification system,5 tumor stage was T1a in 53 cases, T2 in 10 cases of lateral true vocal cord lesions, and severe atypical dysplasia of the lateral vocal cord in two cases. None of the patients included had synchronous second primary tumors according to our retrospective analysis.
T
METHODS
he frontolateral partial laryngectomy and laryngofissure for cordectomy are commonly used conservative approaches in the treatment of early laryngeal cancer.1-3 In these procedures, tracheotomy is a standard intervention, used to avoid dyspnea caused by postoperative edema and consequent shrinking of the laryngeal cavity. The goals of oncological surgery of the larynx are to control local disease and to conserve the physiological functioning of the larynx, while preserving quality of life. Therefore, much effort has been made to create optimal approaches that minimize the extent of postoperative morbidity. Rebeiz et al4 reported the successful completion of a combined endoscopic and open
After we obtained approval from the institutional review board, all patients underwent modified frontolateral partial laryngectomy without tracheotomy under general anesthesia. Intubation was performed with an endotracheal tube 6 to 7 mm in internal diameter. A horizontal U- type incision was made, extending from the edge of the cricothyroid membrane to the hyoid bone. The strap muscles were incised along the linea alba cervicalis. The prelaryngeal soft tissue, including the Delphian lymph node, was then resected. The
Received February 4, 2008; revised February 3, 2009; accepted February 3, 2009.
0194-5998/$36.00 © 2009 American Academy of Otolaryngology–Head and Neck Surgery Foundation. All rights reserved. doi:10.1016/j.otohns.2009.02.007
Dong et al
Modified frontolateral partial laryngectomy . . .
prethyroidal muscles were elevated to expose the thyroid cartilage and the cricothyroid membrane was incised horizontally, exposing the bed of the tumor through the incision site (Fig 1). In the case of the anterior commissure involvement, the thyroid lamina was incised vertically along the uninvolved side, 4 to 5 mm from the anterior commissure. The laryngeal mucosa and soft tissue on the tumor-bearing side were also dissected from the tumor bed, achieving separation of at least 5 mm. The area of excision extended superiorly from the ventricle of the larynx or the inferior border of the false vocal cord to the lower border of the true vocal cord, inferiorly. The posterior edge included the vocal process of the ipsilateral arytenoid cartilage, whereas the contralateral edge was defined by the opposite true or false vocal cord. The margins of resection were free of tumor in all cases (Fig 2). An ipsilateral false vocal cord flap6-9 was used in 63 patients to reconstruct the defect after resection of the true vocal cord. The false vocal cord flap was sutured to the inferior margin of the excision site on the interior of the laryngeal lumen. The rotated flap was almost equal in thickness to the true vocal cord. Therefore, during phonation, the flap could directly appose the contralateral side, thus enabling satisfactory vocal function. By preserving a 5-mm striplike defect at the excision site, efforts at phonation caused a slight bulge of the ipsilateral side, resulting in contact between the flap and the contralateral true vocal cord and phonation. Two patients with abnormally large excision defects were instead treated with cervical skin flaps. In this case, the inner side of the sternohyoid muscle was drawn into the laryngeal lumen so that the myofascial flap could be sutured to the incisal margin of the uninjured side and the false vocal cord on the side of the lesion (Fig 3). The unilateral fascial flap of the sternohyoid muscle was turned over and sutured to the contralateral side. Thus, the laryngeal luminal defect could be closed by the muscular fasciae, creating a “ladder” shape with an enlarged intraluminal diameter (Fig 4). Meticulous efforts were made to achieve endolaryngeal hemostasis. The width of the newly con-
Figure 1 The cricothyroid membrane was incised horizontally, exposing the area of the tumor bed for direct observation.
71
Figure 2 The excision range included the superior border: superior edge of the laryngeal ventricle or the inferior border of the false vocal cord; inferior border: inferior edge of the true vocal cord; posterior border: vocal process of the ipsilateral arytenoid cartilage; contralateral border: 3 to 5 mm of the true or false vocal cord. The margins of resection were free of tumor in all cases.
structed glottic area was sufficient to sustain the placement of two endotracheal tubes to ensure normal breathing after extubation, when there was an increased risk of laryngospasm. A frame was not utilized to maintain the laryngeal lumen. The subcutaneous tissue and skin were sutured with a suction-type drain inserted subcutaneously. None of the patients required the placement of a nasogastric feeding tube postoperatively.
RESULTS Respiration was normal in all patients following the operative procedure. Although nine patients had a postoperative
Figure 3 The inner side of the sternohyoid muscle was reverted into the laryngeal lumen so that the sternohyoid myofascial flap could be sutured to the incisal margin of the uninjured side and the false vocal cord on the side of the lesion.
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Otolaryngology–Head and Neck Surgery, Vol 141, No 1, July 2009
Figure 4 A unilateral muscular fascia flap was turned over and sutured to the contralateral, uninvolved side. Thus, the laryngeal lumen defect was closed by the muscular fascia, creating a trapezoidal shape with an increased cross-sectional area.
course complicated by pneumoderma, these wounds eventually healed without requiring additional intervention. Pap feeding was initiated within 24 hours in all patients. The mean duration of hospitalization was 10 days (range 7-15 days). It is markedly less than partial laryngectomy with a tracheotomy (mean 18 days; range 14-36 days). Postoperative tracheotomy was performed only in one patient owing to laryngeal edema sustained after treatment with radiotherapy. The reconstructed vocal cord was smooth and had no evidence of increased secretions when reexamined 6 months after surgery (Fig 5). Areas of granulation were appreciated in the anterior area of the laryngeal lumen. All of the patients had complete neoglottic closure on phonation. The patients with normal movement of the ipsilateral arytenoid cartilage had good phonation, whereas the patients with decreased cartilage mobility had an unsatisfactory result. The follow-up time ranged from 4 to 78 months. The 1-, 3-, and 5-year survival and local control estimates were all 100 percent (41/41, 12/12, 4/4, respectively).
dysplasia of the true vocal cord, radiotherapy has been demonstrated to achieve survival rates comparable to surgical intervention.12,13 Other studies have heralded the efficacy of microendoscopic laser surgery in obtaining success rates in early cancers similar to conventional partial laryngectomy.14,15 However, when the anterior commissure is involved, partial laryngectomy is the optimal treatment option for glottic cancers. This is because the anatomical region is not easily visualized endoscopically and safe excision margins may be compromised. Furthermore, the anterior commissure lacks an anatomical barrier to regional spread like the adjacent perichondrium of the thyroid cartilage. Consequently, the intrinsic vulnerability of this structure may lead to unrecognized micro- or macroinvasion, thus leading to the mistreatment of more progressed T4a cancers that are incorrectly diagnosed as early glottic lesions.2 Therefore, partial laryngectomy is considered superior to laser surgery in the treatment of glottic cancer involving the anterior commissure. Tracheotomy is routinely performed in patients undergoing partial laryngectomy because of the high risk of postoperative dyspnea originating from a narrowed laryngeal lumen or laryngeal edema. Postoperative care for the tracheotomy is cumbersome for the patient and provider, and is associated with a prolonged hospitalization and significant morbidity. Even temporary tracheotomy is associated with increased complication rates, which suggests that prophylactic tracheotomy at the time of surgery is less than ideal. Although Muscatello et al3 and Wolfensberger and Dort16 have reportedly avoided tracheotomy in the treatment of glottic carcinomas with cordectomy via laryngofissure or endoscopic laser surgery, the feasibility of frontolateral partial laryngectomy without tracheotomy remains uncertain. In 2005, Brumund et al11 reported a series of 270 patients with invasive glottic squamous cell carcinomas managed with frontolateral partial laryngectomy without tracheotomy. Our study examined the efficacy of a novel
DISCUSSION Conventionally, laryngofissure and cordectomy have been the primary means of eradicating early and selected invasive glottic squamous cell carcinomas.3 Because frontolateral vertical partial laryngectomy was initially pioneered in Europe by Leroux-Robert10 in the 1970s, the efficacy of the surgery has been confirmed and the technique is widely considered the standard of care.1,2,11 More recently, in the case of early glottic squamous cell carcinoma and severe
Figure 5 Endoscopic pictures taken at the end of the procedure. The left vocal cord was nearly normal and the right anterior area of the laryngeal lumen was enlarged; therefore, the patient had good respiration.
Dong et al
Modified frontolateral partial laryngectomy . . .
surgical approach, the modified frontolateral partial laryngectomy without tracheotomy, in achieving tumor control and restoring proper laryngeal function.17 The feasibility and effectiveness of the modified frontolateral partial laryngectomy are functions of the anatomical relationship between the laryngeal lumen and its surrounding structures. The interior of the larynx in cross-section is triangular in shape owing to the contour of the thyroid cartilage. Geometrically, the area of a triangle is less than that of a trapezoid or rectangle of equivalent base and height. In our approach, we sought to transform the natural triangular contour into a trapezoidal shape to achieve a greater cross-sectional area. To achieve this, we sutured the sternohyoid muscle to the laryngeal lumen and vertically incised the thyroid lamina, which resulted in abduction of the anterior part of thyroid cartilage. In addition, the muscular fascia was retroflexed and sutured to the contralateral side, thus bringing the larynx into the desired trapezoidal or rectangular conformation. To expand the breadth of the laryngeal cavity, we reverted the sternohyoid fascia, covering the anterior larynx and completing the ladder-shaped lumen. Although the anteroposterior diameter of neolarynx is decreased, the cross-sectional area becomes sufficiently enlarged to provide for normal respiration even in the absence of an endotracheal tube. The modified frontolateral partial laryngectomy has many advantages in addition to the avoidance of performing a tracheotomy, including its ability to achieve tight closure of the thyroid cartilage at the midline with the muscular fascia as opposed to the strap muscles. As Brumund et al11 reports, when the anterior commissure is involved or when the tumor stage is higher than T1, a frontolateral partial laryngectomy without tracheotomy is not conventionally considered an appropriate choice. However, in our approach, we modified the technique of the frontolateral partial laryngectomy by abducting the anterior thyroid cartilage. Additionally, the thyroid lamina was vertically incised on the uninjured side 4 to 5 mm from the anterior commissure, extending from its superior border to the inner membrane of thyroid cartilage. The resulting defect was large enough to allow for excision of the tumor tissue and conservation of laryngeal function. Thus, the indications for performing a modified frontolateral partial laryngectomy without tracheotomy are expanded. It may be appropriately applied in T1 or T2 cancer of the glottis, with the tumor limited to one vocal cord (including those involving the anterior commissure or invading less than 1-2 mm of the contralateral vocal cord) and severe dysplasia or carcinoma in situ of the true vocal cord. In this study, 63 cases of excised laryngeal squamous cell carcinoma with exposed glottic defects were treated by a false vocal fold flap. In two cases, the false vocal cords were not able to provide enough soft tissue bulk for the reconstruction. Instead, they were corrected with cervical skin flaps (including the hypoderma and platysma muscle). The cervical skin flap, which was first performed for intraoral
73
reconstruction, has long been used as a simple and effective reconstructive option for head and neck surgical cases because it provides thin and pliable tissue, ideal for filling excisional defects.18-20 The procedure for harvesting the platysma takes a short time with minimal damage to the donor site and virtually no postoperative morbidity in the neck.21 However, this flap is not suitable for patients with thick beards or a large amount of adipose tissue in the neck, or in patients with extensive cervical scar tissue from previous operative procedures. Among our patient population, nine cases of pneumoderma were noted. This was the major postoperative complication, thought to result from repeated bouts of coughing and consequent overextension of the neck. A suction drain was inserted subcutaneously for 3 to 5 days in an attempt to minimize this complication. Wound infection was not observed in any of the patients. By avoiding a tracheotomy, we were also able to substantially reduce the risk of aspiration typically associated with partial laryngectomy. This common complication is thought to be due to laryngeal elevation by the endotracheal tube at the time of swallowing and reduced stimulation of the infraglottic cough receptors.11,22 Following operative intervention, there are several circumstances that may necessitate an emergency tracheotomy. Postoperative dyspnea is considered a life-threatening complication and requires the performance of an immediate tracheotomy. It is also required in any patient undergoing postoperative radiotherapy owing to the high likelihood of radiation-induced dysphagia and an increased risk of aspiration. In this study, only one of three patients undergoing radiotherapy required a secondary tracheotomy because of a complaint of dyspnea. Moreover, tracheotomy remains necessary in the case of excessive postoperative bleeding or subcutaneous hematoma. Theoretically, the modified frontolateral partial laryngectomy without tracheotomy is a more appropriate approach in men because they have a larger larynx and longer vocal cords relative to the female patient. In this series, the patients were all male; however, it is also a feasible option for the carefully selected female patient in which the laryngeal anatomy is more pronounced. During the operation, the application of smaller endotracheal tubes may facilitate the operation by permitting greater visibility in the endolarynx. Finally, the pneumathode should be put below the cricoid cartilage in case of air leakage.
CONCLUSIONS Our data indicate that modified frontolateral partial laryngectomy creates a more spacious neolarynx relative to the traditional partial laryngectomy, thus obviating the need for a prophylactic tracheotomy during the initial operative procedure. This procedure, therefore, represents a new, lessinvasive technique for the treatment of glottic squamous cell carcinoma.
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Otolaryngology–Head and Neck Surgery, Vol 141, No 1, July 2009
ACKNOWLEDGEMENT The authors would like to thank Dr. Daqing Li for critical reading of the manuscript.
AUTHOR INFORMATION From the Department of Otolaryngology–Head and Neck Surgery, Shanghai First People’s Hospital, Shanghai Jiao Tong University. Corresponding author: Pin Dong, Department of Otolaryngology-Head and Neck Surgery, Shanghai First People’s Hospital, Shanghai Jiao Tong University, Shanghai 200080 China. E-mail address: [email protected].
AUTHOR CONTRIBUTIONS Pin Dong, first author, study designer, surgeon; Xiaoyan Li, coauthor, surgeon; Jin Xie, coauthor, operator; Li Li, statistical analysis; Hongming Xu, animal experiment.
DISCLOSURES Competing interests: None. Sponsorships: The study was supported in part by the Foundation of Science & Technology.
REFERENCES 1. Dedivitis RA, Guimaraes AV, Guirado CR. Outcome after partial frontolateral laryngectomy. Int Surg 2005;90:113– 8. 2. Olsen KD, DeSanto LW. Partial vertical laryngectomy—indications and surgical technique. Am J Otolaryngol 1990;11:153– 60. 3. Muscatello L, Laccourreye O, Biacabe B, et al. Laryngofissure and cordectomy for glottic carcinoma limited to the mid third of the mobile true vocal cord. Laryngoscope 1997;107:1507–10. 4. Rebeiz EE, Wang Z, Annino DJ, et al. Preliminary clinical results of window partial laryngectomy: a combined endoscopic and open technique. Ann Otol Rhinol Laryngol 2000;109:123–7. 5. American Joint Committee on Cancer. AJCC staging manual. 6th ed. New York-Berlin-Heidelberg: Springer; 2002.
6. Brasnu D, Laccourreye O, Weinstein G, et al. False vocal cord reconstruction of the glottis following vertical partial laryngectomy: a preliminary analysis. Laryngoscope 1992,102:717–9. 7. Biacabe B, Crevier-Buchman L, Hans S, et al. Vocal function after vertical partial laryngectomy with glottic reconstruction by false vocal fold flap: durational and frequency measures. Laryngoscope 1999;109: 698 –704. 8. Har-El G, Paniello RC, Abemayor E, et al. Partial laryngectomy with imbrication laryngoplasty for glottic carcinoma. Arch Otolaryngol Head Neck Surg 2003;129:66 –71. 9. Biacabe B, Crevier-Buchman L, Hans S, et al. Phonatory mechanisms after vertical partial laryngectomy with glottic reconstruction by false vocal fold flap. Ann Otol Rhinol Laryngol 2001;110:935– 40. 10. Leroux-Robert J. A statistical study of 620 laryngeal carcinomas of the glottic region personally operated upon more than five years ago. Laryngoscope 1975;85:1440 –52. 11. Brumund KT, Gutierrez-Fonseca R, Garcia D, et al. Frontolateral vertical partial laryngectomy without tracheotomy for invasive squamous cell carcinoma of the true vocal cord: a 25-year experience. Ann Otol Rhinol Laryngol 2005;114:314 –22. 12. Small W Jr, Mittal BB, Brand WN, et al. Results of radiation therapy in early glottic carcinoma: multivariate analysis of prognostic and radiation therapy variables. Radiology 1992;183:789 –94. 13. Nguyen C, Naghibzadeh B, Black MJ, et al. Carcinoma in situ of the glottic larynx: excision or irradiation? Head Neck 1996;18:225– 8. 14. Gallo A, de Vincentiis M, Manciocco V, et al. CO2 laser cordectomy for early-stage glottic carcinoma: a long-term follow-up of 156 cases. Laryngoscope 2002;112:370 – 4. 15. Bocciolini C, Presutti L, Laudadio P. Oncological outcome after CO2 laser cordectomy for early-stage glottic carcinoma. Acta Otorhinolaryngol Ital 2005;25:86 –93. 16. Wolfensberger M, Dort JC. Endoscopic laser surgery for early glottic carcinoma: a clinical and experimental study. Laryngoscope 1990;100: 1100 –5. 17. Dong P, Wang J, Jin B, et al. Surgery on laryngeal carcinoma— retrospective analysis of 205 cases [in Chinese]. Zhonghua Er Bi Yan Hou Tou Jing Wai Ke Za Zhi 2005;40:591– 4. 18. Futrell JW, Johns ME, Edgerton MT, et al. Platysma myocutaneous flap for intraoral reconstruction. Am J Surg 1978;136:504 –7. 19. Koch WM. The platysma myocutaneous flap: Underused alternative for head and neck reconstruction. Laryngoscope 2002;112:1204 – 8. 20. Smith MM, Shults S, Waldron DR, et al. Platysma myocutaneous flap for head and neck reconstruction in cats. Head Neck 1993;15:433–9. 21. Dursun G, Ozgursoy OB. Laryngeal reconstruction by platysma myofascial flap after vertical partial laryngectomy. Head Neck 2005;27: 762–70. 22. Sasaki CT, Suzuki M, Horiuchi M, et al. The effect of tracheostomy on the laryngeal closure reflex. Laryngoscope 1977;87:1428 –33.
ORIGINAL RESEARCH–LARYNGOLOGY AND NEUROLARYNGOLOGY
Modified frontolateral partial laryngectomy without tracheotomy Pin Dong, MD, Xiaoyan Li, MD, Jin Xie, MD, Li Li, MD, and Hongming Xu, MD, Shanghai, China Sponsorships or competing interests that may be relevant to content have been disclosed at the end of this article. ABSTRACT OBJECTIVE: To investigate the feasibility of modified frontolateral partial laryngectomy without tracheotomy for patients with early-stage laryngeal cancer or dysplasia of the true vocal cord. STUDY DESIGN: After frontolateral partial laryngectomy, the inner side of the sternohyoid muscle was drawn into the laryngeal lumen to suture it to the incisal margin of the uninjured side and to the false vocal cord on the side of the lesion to ensure the safety without tracheotomy. A reverted sternohyoid fascial flap was used to cover the anterior area to form a new laryngeal lumen in the shape of a ladder. SUBJECTS AND METHODS: A total of 65 patients with early glottic carcinomas or severe dysplasia of the true vocal cord were treated with modified frontolateral partial laryngectomy without tracheotomy. Ipsilateral false vocal cord flaps and cervical skin flaps were used in 63 patients and two patients respectively to reconstruct the defect. RESULTS: Deglutition and phonation were fully recovered after 7 to 10 days postsurgery. The only postoperative complication was subcutaneous emphysema noted in nine patients. The 1-, 3-, and 5-year survival rates were all 100 percent. CONCLUSION: Modified frontolateral partial laryngectomy without tracheostomy is an effective surgical method for early glottic carcinomas and severe dysplasia of the true vocal cord.
approach without tracheotomy for T1 and T2 glottic and supraglottic cancers in a series of 5 patients. In the case of small primary laryngeal tumors, traditional partial laryngectomy is often considered too aggressive owing to the associated complications of this procedure. In this study, we describe the development of a novel approach, the modified frontolateral partial laryngectomy without tracheotomy, and review the results in 65 patients who underwent this new operation.
PATIENTS
© 2009 American Academy of Otolaryngology–Head and Neck Surgery Foundation. All rights reserved.
We identified 65 patients with primary glottic squamous cell carcinoma or atypical hyperplasia of the larynx who underwent treatment with modified frontolateral partial laryngectomy without tracheotomy between April 2000 and May 2006, at the Department of Otolaryngology Head and Neck Surgery of Shanghai Jiao Tong University Affiliated First People’s Hospital. The patients were all male and ranged in age from 49 to 65 years. The follow-up period ranged between 4 months and 6 years postoperatively. According to the 2002 American Joint Committee on Cancer staging classification system,5 tumor stage was T1a in 53 cases, T2 in 10 cases of lateral true vocal cord lesions, and severe atypical dysplasia of the lateral vocal cord in two cases. None of the patients included had synchronous second primary tumors according to our retrospective analysis.
T
METHODS
he frontolateral partial laryngectomy and laryngofissure for cordectomy are commonly used conservative approaches in the treatment of early laryngeal cancer.1-3 In these procedures, tracheotomy is a standard intervention, used to avoid dyspnea caused by postoperative edema and consequent shrinking of the laryngeal cavity. The goals of oncological surgery of the larynx are to control local disease and to conserve the physiological functioning of the larynx, while preserving quality of life. Therefore, much effort has been made to create optimal approaches that minimize the extent of postoperative morbidity. Rebeiz et al4 reported the successful completion of a combined endoscopic and open
After we obtained approval from the institutional review board, all patients underwent modified frontolateral partial laryngectomy without tracheotomy under general anesthesia. Intubation was performed with an endotracheal tube 6 to 7 mm in internal diameter. A horizontal U- type incision was made, extending from the edge of the cricothyroid membrane to the hyoid bone. The strap muscles were incised along the linea alba cervicalis. The prelaryngeal soft tissue, including the Delphian lymph node, was then resected. The
Received February 4, 2008; revised February 3, 2009; accepted February 3, 2009.
0194-5998/$36.00 © 2009 American Academy of Otolaryngology–Head and Neck Surgery Foundation. All rights reserved. doi:10.1016/j.otohns.2009.02.007
Dong et al
Modified frontolateral partial laryngectomy . . .
prethyroidal muscles were elevated to expose the thyroid cartilage and the cricothyroid membrane was incised horizontally, exposing the bed of the tumor through the incision site (Fig 1). In the case of the anterior commissure involvement, the thyroid lamina was incised vertically along the uninvolved side, 4 to 5 mm from the anterior commissure. The laryngeal mucosa and soft tissue on the tumor-bearing side were also dissected from the tumor bed, achieving separation of at least 5 mm. The area of excision extended superiorly from the ventricle of the larynx or the inferior border of the false vocal cord to the lower border of the true vocal cord, inferiorly. The posterior edge included the vocal process of the ipsilateral arytenoid cartilage, whereas the contralateral edge was defined by the opposite true or false vocal cord. The margins of resection were free of tumor in all cases (Fig 2). An ipsilateral false vocal cord flap6-9 was used in 63 patients to reconstruct the defect after resection of the true vocal cord. The false vocal cord flap was sutured to the inferior margin of the excision site on the interior of the laryngeal lumen. The rotated flap was almost equal in thickness to the true vocal cord. Therefore, during phonation, the flap could directly appose the contralateral side, thus enabling satisfactory vocal function. By preserving a 5-mm striplike defect at the excision site, efforts at phonation caused a slight bulge of the ipsilateral side, resulting in contact between the flap and the contralateral true vocal cord and phonation. Two patients with abnormally large excision defects were instead treated with cervical skin flaps. In this case, the inner side of the sternohyoid muscle was drawn into the laryngeal lumen so that the myofascial flap could be sutured to the incisal margin of the uninjured side and the false vocal cord on the side of the lesion (Fig 3). The unilateral fascial flap of the sternohyoid muscle was turned over and sutured to the contralateral side. Thus, the laryngeal luminal defect could be closed by the muscular fasciae, creating a “ladder” shape with an enlarged intraluminal diameter (Fig 4). Meticulous efforts were made to achieve endolaryngeal hemostasis. The width of the newly con-
Figure 1 The cricothyroid membrane was incised horizontally, exposing the area of the tumor bed for direct observation.
71
Figure 2 The excision range included the superior border: superior edge of the laryngeal ventricle or the inferior border of the false vocal cord; inferior border: inferior edge of the true vocal cord; posterior border: vocal process of the ipsilateral arytenoid cartilage; contralateral border: 3 to 5 mm of the true or false vocal cord. The margins of resection were free of tumor in all cases.
structed glottic area was sufficient to sustain the placement of two endotracheal tubes to ensure normal breathing after extubation, when there was an increased risk of laryngospasm. A frame was not utilized to maintain the laryngeal lumen. The subcutaneous tissue and skin were sutured with a suction-type drain inserted subcutaneously. None of the patients required the placement of a nasogastric feeding tube postoperatively.
RESULTS Respiration was normal in all patients following the operative procedure. Although nine patients had a postoperative
Figure 3 The inner side of the sternohyoid muscle was reverted into the laryngeal lumen so that the sternohyoid myofascial flap could be sutured to the incisal margin of the uninjured side and the false vocal cord on the side of the lesion.
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Otolaryngology–Head and Neck Surgery, Vol 141, No 1, July 2009
Figure 4 A unilateral muscular fascia flap was turned over and sutured to the contralateral, uninvolved side. Thus, the laryngeal lumen defect was closed by the muscular fascia, creating a trapezoidal shape with an increased cross-sectional area.
course complicated by pneumoderma, these wounds eventually healed without requiring additional intervention. Pap feeding was initiated within 24 hours in all patients. The mean duration of hospitalization was 10 days (range 7-15 days). It is markedly less than partial laryngectomy with a tracheotomy (mean 18 days; range 14-36 days). Postoperative tracheotomy was performed only in one patient owing to laryngeal edema sustained after treatment with radiotherapy. The reconstructed vocal cord was smooth and had no evidence of increased secretions when reexamined 6 months after surgery (Fig 5). Areas of granulation were appreciated in the anterior area of the laryngeal lumen. All of the patients had complete neoglottic closure on phonation. The patients with normal movement of the ipsilateral arytenoid cartilage had good phonation, whereas the patients with decreased cartilage mobility had an unsatisfactory result. The follow-up time ranged from 4 to 78 months. The 1-, 3-, and 5-year survival and local control estimates were all 100 percent (41/41, 12/12, 4/4, respectively).
dysplasia of the true vocal cord, radiotherapy has been demonstrated to achieve survival rates comparable to surgical intervention.12,13 Other studies have heralded the efficacy of microendoscopic laser surgery in obtaining success rates in early cancers similar to conventional partial laryngectomy.14,15 However, when the anterior commissure is involved, partial laryngectomy is the optimal treatment option for glottic cancers. This is because the anatomical region is not easily visualized endoscopically and safe excision margins may be compromised. Furthermore, the anterior commissure lacks an anatomical barrier to regional spread like the adjacent perichondrium of the thyroid cartilage. Consequently, the intrinsic vulnerability of this structure may lead to unrecognized micro- or macroinvasion, thus leading to the mistreatment of more progressed T4a cancers that are incorrectly diagnosed as early glottic lesions.2 Therefore, partial laryngectomy is considered superior to laser surgery in the treatment of glottic cancer involving the anterior commissure. Tracheotomy is routinely performed in patients undergoing partial laryngectomy because of the high risk of postoperative dyspnea originating from a narrowed laryngeal lumen or laryngeal edema. Postoperative care for the tracheotomy is cumbersome for the patient and provider, and is associated with a prolonged hospitalization and significant morbidity. Even temporary tracheotomy is associated with increased complication rates, which suggests that prophylactic tracheotomy at the time of surgery is less than ideal. Although Muscatello et al3 and Wolfensberger and Dort16 have reportedly avoided tracheotomy in the treatment of glottic carcinomas with cordectomy via laryngofissure or endoscopic laser surgery, the feasibility of frontolateral partial laryngectomy without tracheotomy remains uncertain. In 2005, Brumund et al11 reported a series of 270 patients with invasive glottic squamous cell carcinomas managed with frontolateral partial laryngectomy without tracheotomy. Our study examined the efficacy of a novel
DISCUSSION Conventionally, laryngofissure and cordectomy have been the primary means of eradicating early and selected invasive glottic squamous cell carcinomas.3 Because frontolateral vertical partial laryngectomy was initially pioneered in Europe by Leroux-Robert10 in the 1970s, the efficacy of the surgery has been confirmed and the technique is widely considered the standard of care.1,2,11 More recently, in the case of early glottic squamous cell carcinoma and severe
Figure 5 Endoscopic pictures taken at the end of the procedure. The left vocal cord was nearly normal and the right anterior area of the laryngeal lumen was enlarged; therefore, the patient had good respiration.
Dong et al
Modified frontolateral partial laryngectomy . . .
surgical approach, the modified frontolateral partial laryngectomy without tracheotomy, in achieving tumor control and restoring proper laryngeal function.17 The feasibility and effectiveness of the modified frontolateral partial laryngectomy are functions of the anatomical relationship between the laryngeal lumen and its surrounding structures. The interior of the larynx in cross-section is triangular in shape owing to the contour of the thyroid cartilage. Geometrically, the area of a triangle is less than that of a trapezoid or rectangle of equivalent base and height. In our approach, we sought to transform the natural triangular contour into a trapezoidal shape to achieve a greater cross-sectional area. To achieve this, we sutured the sternohyoid muscle to the laryngeal lumen and vertically incised the thyroid lamina, which resulted in abduction of the anterior part of thyroid cartilage. In addition, the muscular fascia was retroflexed and sutured to the contralateral side, thus bringing the larynx into the desired trapezoidal or rectangular conformation. To expand the breadth of the laryngeal cavity, we reverted the sternohyoid fascia, covering the anterior larynx and completing the ladder-shaped lumen. Although the anteroposterior diameter of neolarynx is decreased, the cross-sectional area becomes sufficiently enlarged to provide for normal respiration even in the absence of an endotracheal tube. The modified frontolateral partial laryngectomy has many advantages in addition to the avoidance of performing a tracheotomy, including its ability to achieve tight closure of the thyroid cartilage at the midline with the muscular fascia as opposed to the strap muscles. As Brumund et al11 reports, when the anterior commissure is involved or when the tumor stage is higher than T1, a frontolateral partial laryngectomy without tracheotomy is not conventionally considered an appropriate choice. However, in our approach, we modified the technique of the frontolateral partial laryngectomy by abducting the anterior thyroid cartilage. Additionally, the thyroid lamina was vertically incised on the uninjured side 4 to 5 mm from the anterior commissure, extending from its superior border to the inner membrane of thyroid cartilage. The resulting defect was large enough to allow for excision of the tumor tissue and conservation of laryngeal function. Thus, the indications for performing a modified frontolateral partial laryngectomy without tracheotomy are expanded. It may be appropriately applied in T1 or T2 cancer of the glottis, with the tumor limited to one vocal cord (including those involving the anterior commissure or invading less than 1-2 mm of the contralateral vocal cord) and severe dysplasia or carcinoma in situ of the true vocal cord. In this study, 63 cases of excised laryngeal squamous cell carcinoma with exposed glottic defects were treated by a false vocal fold flap. In two cases, the false vocal cords were not able to provide enough soft tissue bulk for the reconstruction. Instead, they were corrected with cervical skin flaps (including the hypoderma and platysma muscle). The cervical skin flap, which was first performed for intraoral
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reconstruction, has long been used as a simple and effective reconstructive option for head and neck surgical cases because it provides thin and pliable tissue, ideal for filling excisional defects.18-20 The procedure for harvesting the platysma takes a short time with minimal damage to the donor site and virtually no postoperative morbidity in the neck.21 However, this flap is not suitable for patients with thick beards or a large amount of adipose tissue in the neck, or in patients with extensive cervical scar tissue from previous operative procedures. Among our patient population, nine cases of pneumoderma were noted. This was the major postoperative complication, thought to result from repeated bouts of coughing and consequent overextension of the neck. A suction drain was inserted subcutaneously for 3 to 5 days in an attempt to minimize this complication. Wound infection was not observed in any of the patients. By avoiding a tracheotomy, we were also able to substantially reduce the risk of aspiration typically associated with partial laryngectomy. This common complication is thought to be due to laryngeal elevation by the endotracheal tube at the time of swallowing and reduced stimulation of the infraglottic cough receptors.11,22 Following operative intervention, there are several circumstances that may necessitate an emergency tracheotomy. Postoperative dyspnea is considered a life-threatening complication and requires the performance of an immediate tracheotomy. It is also required in any patient undergoing postoperative radiotherapy owing to the high likelihood of radiation-induced dysphagia and an increased risk of aspiration. In this study, only one of three patients undergoing radiotherapy required a secondary tracheotomy because of a complaint of dyspnea. Moreover, tracheotomy remains necessary in the case of excessive postoperative bleeding or subcutaneous hematoma. Theoretically, the modified frontolateral partial laryngectomy without tracheotomy is a more appropriate approach in men because they have a larger larynx and longer vocal cords relative to the female patient. In this series, the patients were all male; however, it is also a feasible option for the carefully selected female patient in which the laryngeal anatomy is more pronounced. During the operation, the application of smaller endotracheal tubes may facilitate the operation by permitting greater visibility in the endolarynx. Finally, the pneumathode should be put below the cricoid cartilage in case of air leakage.
CONCLUSIONS Our data indicate that modified frontolateral partial laryngectomy creates a more spacious neolarynx relative to the traditional partial laryngectomy, thus obviating the need for a prophylactic tracheotomy during the initial operative procedure. This procedure, therefore, represents a new, lessinvasive technique for the treatment of glottic squamous cell carcinoma.
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Otolaryngology–Head and Neck Surgery, Vol 141, No 1, July 2009
ACKNOWLEDGEMENT The authors would like to thank Dr. Daqing Li for critical reading of the manuscript.
AUTHOR INFORMATION From the Department of Otolaryngology–Head and Neck Surgery, Shanghai First People’s Hospital, Shanghai Jiao Tong University. Corresponding author: Pin Dong, Department of Otolaryngology-Head and Neck Surgery, Shanghai First People’s Hospital, Shanghai Jiao Tong University, Shanghai 200080 China. E-mail address: [email protected].
AUTHOR CONTRIBUTIONS Pin Dong, first author, study designer, surgeon; Xiaoyan Li, coauthor, surgeon; Jin Xie, coauthor, operator; Li Li, statistical analysis; Hongming Xu, animal experiment.
DISCLOSURES Competing interests: None. Sponsorships: The study was supported in part by the Foundation of Science & Technology.
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