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Partial Laryngopharyngectomy for Piriform Sinus Carcinoma. Technique and Preliminary Results
Auris · Nasus · Larynx (Tokyo) 15, 129-136 (1988)
PARTIAL LARYNGOPHARYNGECTOMY FOR PIRIFORM SINUS CARCINOMA. TECHNIQUE AND PRELIMINARY RESULTS Minoru HIRANO, M . D., Shigejiro KURITA, M. D ., Tetsuji YOSHIDA, M. D., Hisashi TANAKA, M. D., and Yoshiaki TAl, M. D.* Department of Otolaryngology-Head and Neck Surgery, Kurume University, Kurume, Japan *Department of Plastic Surgery, Kurume University, Kurume, Japan
This paper presents a technique for partial laryngopharyngectomy followed by a one-stage reconstruction and its preliminary results. This surgery is indicated for carefully selected cases in which the lesion is confined to the ipsilateral piriform sinus, aryepiglottic fold, arytenoid eminence and paraglottic space at the level of the false fold. The hyoid bone, thyroid ala, arytenoid cartilage, epiglottis, aryepiglottic fold, arytenoid eminence and false fold are removed on the affected side. Reconstruction is performed with the use of a pectoralis major myocutaneous (PMMC) flap. The surgery was performed on four cases: two were successful; one suffered from persistent postsurgical aspiration because the reconstructed hypopharynx was too wide; and one developed necrosis of PMMC flap and a secondary reconstruction procedure was performed. Low survival rates remains to be a problem in case of piriform sinus carcinomas. Even in cases of extensive surgery such as total laryngopharyngectomy and radical neck dissection with or without radiotherapy the 5-year survival rates are approximately 40 %or less (HIRANO, SHIN, MIHASHI, ICHIKAWA, MIHASHI, and HIROTO, 1976; BRIANT, BRYCE, and SMITH, 1977; MARKS, KURNIK, POWERS, and OGURA, 1978; RAZACK, SAKO, and KALNINS, 1978; PERSKY and DALY, 1981; ELBADAWI, GOEPFERT, FLETCHER, HERSON, and OSWALD, 1982; HIRANO, KURITA, Received for publication March 25, 1988 This study was supported in part by a Grant-in-Aid for Scientific Research (No. 60480386), the Ministry of Education, Science and Culture of Japan. Presented at the 39th Annual Congress of the Japanese Bro:lcho-Esophageal Society, held on October 22-23, 1987 in Tokyo, Japan. 129
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at.
KURATOMI, and MIHASHI, 1982; YATES and CRUMLEY, 1984). However, frequent causes of death in some selected institutions has not been from recurrent diseases of the primary site but rather from node recurrences, distant metastasis, complications and intercurrent diseases (ELBADAWI et at., 1982; HIRANO et aI., 1982; YATES and CRUMLEY, 1984). In other words, the primary lesion can be successfully treated at high rates. Total laryngectomy which is accompanied by a sacrifice of vocal function is necessary to eradicate the lesion in advanced cases of piriform sinus carcinoma.ln less advanced cases, however, total laryngectomy is performed to avoid possible postsurgical aspiration. In other words, the vocal function is sacrificed to prevent aspiration. In these cases, the larynx could be partly or entirely preserved if there were a device to prevent aspiration. Based on extensive clinical experience and a histopathological study, Ogura and his colleagues established criteria and techniques for conservation surgeries for piriform sinus carcinoma. This contribution made appreciable gains (OGURA, JUREMA, and WATSON, 1960; OGURA and MALLEN, 1965; FREEMAN, MARKS, and OGURA, 1979). Since then, however, conservation surgeries have not been commonly used presumably for one of two major reasons: (1) most patients are in an advanced stage, and (2) surgeons are concerned about postsurgical aspiration. A histopathologic study conducted in our institution indicated that conservation surgery could have been used in nearly half of the cases which had undergone total laryngopharyngectomy (HIRANO, KURITA, and TANAKA, 1987). The purpose of this paper is to present our current criteria and technique for partial laryngopharyngectomy followed by immediate reconstruction and its preliminary results. INDICATION
The partial laryngopharyngectomy procedure described in this paper is indicated only for strictly selected cases. It is indicated for tumors confined to the ipsilateral piriform sinus, aryepiglottic fold, arytenoid eminence and paraglottic space at the level of the false fold. The vocal fold and the paraglottic space at the level of the vocal fold must not be involved. The vocal fold must be normal and mobile. Invasion into the thyroid cartilage is a contraindication unless it is a localized invasion confined to the upper part of the posterior edge. The extent of carcinomatous invasion is determined preoperatively by means of laryngeal mirror examination, videofiberscopy, pharyngo-esophageal barium study, laryngograms and computed tomography. SURGICAL TECHNIQUE
Design o/skin incision (Fig. 1). For removal of the primary lesion and region-
PARTIAL LARYNGOPHARYNGECTOMY
131
Fig. 1. Design of skin incision in original technique.
Fig. 2. Design of skin incision when a back-up deltopectoral flap is preserved.
al lymph nodes, two parallel horizontal skin incisions are marked on the neck. The upper one runs from the tip of the mastoid process to the hyoid bone while the lower one is placed along the upper border of the clavicula. The latter is extended medially over the trachea. For reconstruction of the larynx and hypopharynx, a pectoralis major myocutaneous (PMMC) flap is designed. The size of the PMMC flap is later adjusted depending on the extent of tissue removal. Recently, skin for a deltopectoral flap is preserved in case a back-up is necessary (Fig. 2). Tracheostomy and anesthesia. Tracheostomy is performed under local an-
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Fig. 3. Extent of removal.
esthesia. The medial portion of the lower horizonal cervical incision line is used for the tracheostomy. The isthmus of the thyroid gland is sectioned. The trachea is opened usually at the second, third and fourth rings. An endotracheal tube is inserted through the tracheostoma and general anesthesia is given. Radical neck dissection (RND). Following cervical skin incisions RND is performed ipsilaterally regardless of the existence of palpable hymph nodes. The trapezius branch of the accessory nerve is usually preserved. On both sides, the para tracheal nodes are dissected carefully with the recurrent laryngeal nerve preserved. The ipsilateral thyroid lobe is removed. Partial laryngopharyngectomy. The standard extent of removal is shown in Fig. 3. The suprahyoid muscles on the affected side are detached from the hyoid bone. The sternohyoid, thyrohyoid and omohyoid muscles are sectioned near the hyoid bone. The hyoid bone is divided in the midline. The sternothyoid muscle is sectioned from the thyroid cartilage. Using a saw or cartilage forceps the thyroid cartilage is divided as shown in Fig. 3: It is divided in the midline in the upper half and obliquely from the midline to the base of the inferior cornu in the lower half. The inferior cornu is detached from the cricoid cartilage at the joint. The cricopharyngeal muscle is sectioned from the cricoid arch. The pharynx is first opened at the vallecula by dissecting the tissue along the upper surface of the hyoepiglottic ligament. Once the vallecula is opened a retractor is inserted to retract the base of the tongue upward. Unedr careful inspection through the opening, the pharyngeal wall is sectioned laterally keeping an ample safety margin from the lesion. The epiglottis is divided at around the midline down to the petiolus. The ipsilateral false fold is separated from the vocal fold by sectioning the mucosa of the laryngeal ventricle at the level of the upper surface of the vocal fold. The section of the ventricle mucosa and the underlying structure proceeds in the anteroposterior direction. Near the middle of the interarytenoid notch, the mucosa and the underlying interarytenoid muscle are divided until the cricoid cartilage is reached. The arytenoid eminence including the arytenoid cartilage is detatched from the cricoid cartilage. Only the vocal process of the arytenoid cartilage is preserved. The
PARTIAL LARYNGOPHARYNGECTOMY
Fig. 4. Device for PMMC flap. Split is made in rostral portion. locations where each part of flap is to be sutured.
133
Sites indicated show
mucosa of the hypopharynx is sectioned carefully assuring an adequate safety margin. Thus, the thyroid ala, hyoid bone, arytenoid cartilage, false fold, paraglottic space, aryepiglottic fold, arytenoid eminence, epiglottis and hypopharynx are removed in one block on the affected side. Reconstruction. A PMMC flap is prepared and brought up to the neck. In order to prevent postoperative aspiration it seems to be crucial to construct a structure functionally comparable to the aryepiglottic fold. To do this, a device is made with the PMMC flap. The PMMC flap contains mucle tissue in the major rostral portion while the small caudal portion has no muscular component. The skin is partly split in the rostral portion (Fig. 4). The split is located to the place where the aryepiglottic fold and arytenoid eminence had been located. The medial edge of the split is sutured to laryngeal mucosa whereas the lateral edge of the split is sutured to pharyngeal mucosa. Thus, the rostral portion of the PMMC flap is sutured to the larynx and the lower part of the hypopharynx so that the bulky muscle separates the larynx from the hypopharynx. The caudal portion of the PMMC flap covers the upper part of the pharyngeal opening. The pharyngeal cavity on the operated side should be made smaller than on the unaffected. If it has the same size as that on the normal side, bolus tends to pool there causing swallowing problems. Closure of wound. The primary wound is closed leaving several tubes for continuous negative pressure drainage. PRELIMINARY RESULTS
We have conducted this surgery in four cases carefully selected to meet our strict criteria. Case 1. A 58-year-old male underwent partial laryngopharyngectomy and radical neck dissection followed by primary reconstruction for piriform sinus carcinoma T2NOMO (HARMER, 1978) on the left side on October 15, 1984. He
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started oral feeding on October 31, the 16th postoperative day. On November 13, a partial necrosis of PMMC flap was noted and necrotic portion was removed, causing a pharyngeal fistula. The fistula closed spontaneously and the patient resumed oral feeding on December 9. Postoperative radiotherapy (60 Gy) was given. The tracheostoma was closed on December 29. The patient has been well and alive for three years with no evidence of disease. Case 2. A 68-year-old male underwent partial laryngopharyngectomy and radical neck dissection followed by reconstruction for piriform sinus carcinoma T2NOMO on the right side on June 24, 1985. The postsurgical wound healing was eventless. However, this parient had persistent aspiration postoperatively. Barium swallow studies indicated that aspiration was caused by too large a hypopharyngeal cavity and limited elevation of the larynx during swallowing. On November 21, 1985, the hypopharynx was narrowed by removing a part of the skin flap and the muscle of PMMC flap was sectioned to facilitate laryngeal elevation. Aspiration was reduced but not completely eliminated. Postoperative radiotherapy (60 Gy) was applied. On August II, 1986, a third surgery was performed to reduced aspiration. This procedure consisted of removal of the scar tissue around the larynx and approximation of the thyroid ala to the hyoid bone on the unaffected side. Aspiration was markedly reduced but did not disappear completely. The patient died of pulmonary infection on November 6, 1986, with no evidence of recurrent carcinoma. The tracheostoma was open throughout. Case 3. A 49-year-old male was operated on the piriform sinus carcinoma TlNOMO on the right side on June 12, 1986. Postsurgical course was eventless. He was decanulated and resumed oral feeding on July 4, the 22nd postoperative day. Postoperative radiotherapy (60 Gy) was given. A tiny tracheal opening remained until it was surgically closed 13 months after the first surgery. Closure of the tracheostoma was delayed because the patient wanted it kept open. The patient has been well and alive for 16 months with no evidence of disease. Case 4. A 66-year-old male underwent surgery on October 6, 1986. He developed necrosis of the PMMC flap and, therefore, the larynx and pharynx were ultimately reconstructed with the use of two hinge flaps and a deltopectoral flap, a technique which has been previously described elsewhere (HIRANO and KURITA, 1985). Oral feeding was begun on January 28, 1987, II4 days after the initial surgery. Postoperative radiotherapy (60 Gy) was administered. The tracheostoma has not been closed. The patient has been well with no evidence of disease for a year. Table 1 summarizes the postoperative phonatory function evaluated between 6 and 12 months after the partial laryngopharyngectomy. Case 1, 2 and 3 had clear voices whereas Case 4, the one who developed necrosis of PMMC flap, presented with a hoarse voice. Maximum phonation time and mean airflow rate were in the normal range whereas fundamental frequency and sound pressure
135
PARTIAL LARYNGOPHARYNGECTOMY Table 1. Postoperative phonatory function. Case 1 Maximum 14.3 phonation time Mean airflow rate in 177 mljsec Fundamental 15 frequency range in semi tone Sound pressure level 25 range in dB Voice quality Clear
* Data not available. **
Case 2
Case 3
Case 4
*
25.1
16.2
*
72
224
*
11
18
*
25
16
Clear
Clear
Hoarse** G2ROB2AOS2
Evaluated with GRBAS scale (HIRANO, 1981)
level ranges were slightly limited. COMMENTS
Conservation surgeries for piriform sinus carcinoma have probably not been popular for two major reasons: poor oncological results of treatments and a fear for aspiration. In general, surgery performed for piriform sinus carcinomas, even extended surgeries that include removal of the larynx, have yielded low survival rate (HIRANO et al., 1976; BRIANT et al., 1977; MARKS et al., 1978; RAZACK et al., 1978; PERSKY et al., 1981; ELBADAWI et al., 1982; HIRANO et al., 1982; YATES et al., 1984). However, most failures were attributed not to recurrences at the primary site but to nodal recurrence, distant metastasis, complication and intercurrent diseases (ELBADAWI et al., 1982; HIRANO et ai., 1982; YATES et al., 1984). Histopathological studies have revealed that, in some selected cases, the larynx could have been partially or entirely preserved (HIRANO et a/., 1987). Ogura and his colleagues reported on successful conservation surgery for selected cases of piriform sinus carcinomas (OGURA et al., 1960; OGURA et a/., 1965; FREEMAN et al., 1979). Thus, it seems evident that there exist cases of piriform sinus carcinoma which can be treated with the larynx partially or totally preserved without affecting the survival rate. The greatest issue then is how to determine the extent of carcinomatous invasion preoperatively. Recently, we have been relating preoperative examinations including laryngeal mirror examination, videofiberscopy, laryngography, barium swallow studies and computed tomography to histopathological findings. Determination of the extent of invasion is not very difficult in most cases. Once it has been determined that partial laryngopharyngectomy is indicated, postsurgical aspiration is the greatest concern. The results of the present study have revealed that the reconstruction method described here can assure a good
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protective mechanism of the larynx. Separation of the larynx from the pharynx at the site where the aryepiglottic fold has been located and a narrow pharynx on the side of reconstruction are key points for a good protective mechanism. In treating patients with cancer, the quality of posttherapeutic life should be one of the major concerns. Even though the actual number of good candidates is limited, we believe that every effort should be made to use conservation surgeries for piriform sinus carcinomas when the patient meets the specified criteria. REFERENCES BRIANT, T. D. R., BRYCE, D. P., and SMITH, T. J.: Carcinoma of the hypopharynx-a five year follow-up. J. Otolaryngol. 6: 353-362, 1977. ELBADAWI, S. A., GOEPFERT, H., FLETCHER, G. H., HERSON, J., and OSWALD, M. J.: Squamous cell carcinoma of the pyriform sinus. Laryngoscope 92: 357-364, 1982. FREEMAN, R. B., MARKS, J. E., and OGURA, J. H.: Voice preservation in treatment of carcinoma of the pyriform sinus. Laryngoscope 89: 1855-1863, 1979. HARMER, M. H. (ed.): TNM Classification of Malignant Tumours. International Union Against Cancer, Conseil-General 3, 1205, Geneva, Switzerlant, 1978. HIRANO, M.: Clinical Examination of Voice. Springer-Verlag, New York-Wien, 1981. HIRANO, M., and KURITA, S.: Partial laryngopharyngectomy followed by secondary reconstruction for carcinoma of the piriform sinus. Pract. Otol. (Kyoto) 79: 67-71, 1985. HIRANO, M., KURITA, S., KURATOMI, K., and MIHASHI, S.: Carcinoma of the hypopharynx and cervical esophagus. A retrospective investigation of 67 patients. Kurume Med. J. 29: Suppl. S97-S111, 1982. HIRANO, M., KURITA, S., and TANAKA, H.: Histopathological study of carcinoma of the hypopharynx: Implications for conservation surgery. Ann. Otol. Rhinol. Laryngol. 96: 625629, 1987. HIRANO, M., SHIN, T., MIHASHI, S., ICHIKAWA, A., MIHASHI, K., and HIROTO, 1.: Long term results of treatments for carcinoma of the hypopharynx and/or cervical esophagus. Otologia (Fukuoka) 22: 737-747, 1976. MARKS, J. E., KURNIK, B., POWERS, W. E., and OGURA, J. H.: Carcinoma of the pyriform sinus. An analysis of treatment results and patterns of failure. Cancer 41: 1008-1015, 1978. OGURA, J. H., JUREMA, A. A., and WATSON, R. K.: Partial laryngopharyngectomy and neck dissection for pyriform sinus cancer. Conservation surgery with immediate reconstruction. Laryngoscope 70: 1399-1417, 1960. OGURA, J. H., and MALLEN, R. W.: Partial laryngopharyngectomy for supraglottic and pharyngeal carcinoma. Tr. Am. A cad. Ophthalmol. Otol. 832-845, September-October, 1965. PERSKY, M. S., end DALY, J. F.: Combined therapy vs curative radiation in the treatment of pyriform sinus carcinoma. Otolaryngol. Head Neck Surg. 89: 87-91, 1981. RAZACK, M. S., SAKO, K., and KALNINS, I.: Squamous cell carcinoma of the piriform sinus. Head Neck Surg. 1: 31-34, 1978. YATES, A., and CRUMLEY, R. L.: Surgical treatment of pyriform sinus cancer. A retrospective study. Laryngoscope 94: 1586-1590, 1984.
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M. Hirano, M. D., Department of Otolaryngology-Head and Neck Surgery, Kurume University School of Medicine, Asahi-machi, Kurume 830, Japan
PARTIAL LARYNGOPHARYNGECTOMY FOR PIRIFORM SINUS CARCINOMA. TECHNIQUE AND PRELIMINARY RESULTS Minoru HIRANO, M . D., Shigejiro KURITA, M. D ., Tetsuji YOSHIDA, M. D., Hisashi TANAKA, M. D., and Yoshiaki TAl, M. D.* Department of Otolaryngology-Head and Neck Surgery, Kurume University, Kurume, Japan *Department of Plastic Surgery, Kurume University, Kurume, Japan
This paper presents a technique for partial laryngopharyngectomy followed by a one-stage reconstruction and its preliminary results. This surgery is indicated for carefully selected cases in which the lesion is confined to the ipsilateral piriform sinus, aryepiglottic fold, arytenoid eminence and paraglottic space at the level of the false fold. The hyoid bone, thyroid ala, arytenoid cartilage, epiglottis, aryepiglottic fold, arytenoid eminence and false fold are removed on the affected side. Reconstruction is performed with the use of a pectoralis major myocutaneous (PMMC) flap. The surgery was performed on four cases: two were successful; one suffered from persistent postsurgical aspiration because the reconstructed hypopharynx was too wide; and one developed necrosis of PMMC flap and a secondary reconstruction procedure was performed. Low survival rates remains to be a problem in case of piriform sinus carcinomas. Even in cases of extensive surgery such as total laryngopharyngectomy and radical neck dissection with or without radiotherapy the 5-year survival rates are approximately 40 %or less (HIRANO, SHIN, MIHASHI, ICHIKAWA, MIHASHI, and HIROTO, 1976; BRIANT, BRYCE, and SMITH, 1977; MARKS, KURNIK, POWERS, and OGURA, 1978; RAZACK, SAKO, and KALNINS, 1978; PERSKY and DALY, 1981; ELBADAWI, GOEPFERT, FLETCHER, HERSON, and OSWALD, 1982; HIRANO, KURITA, Received for publication March 25, 1988 This study was supported in part by a Grant-in-Aid for Scientific Research (No. 60480386), the Ministry of Education, Science and Culture of Japan. Presented at the 39th Annual Congress of the Japanese Bro:lcho-Esophageal Society, held on October 22-23, 1987 in Tokyo, Japan. 129
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at.
KURATOMI, and MIHASHI, 1982; YATES and CRUMLEY, 1984). However, frequent causes of death in some selected institutions has not been from recurrent diseases of the primary site but rather from node recurrences, distant metastasis, complications and intercurrent diseases (ELBADAWI et at., 1982; HIRANO et aI., 1982; YATES and CRUMLEY, 1984). In other words, the primary lesion can be successfully treated at high rates. Total laryngectomy which is accompanied by a sacrifice of vocal function is necessary to eradicate the lesion in advanced cases of piriform sinus carcinoma.ln less advanced cases, however, total laryngectomy is performed to avoid possible postsurgical aspiration. In other words, the vocal function is sacrificed to prevent aspiration. In these cases, the larynx could be partly or entirely preserved if there were a device to prevent aspiration. Based on extensive clinical experience and a histopathological study, Ogura and his colleagues established criteria and techniques for conservation surgeries for piriform sinus carcinoma. This contribution made appreciable gains (OGURA, JUREMA, and WATSON, 1960; OGURA and MALLEN, 1965; FREEMAN, MARKS, and OGURA, 1979). Since then, however, conservation surgeries have not been commonly used presumably for one of two major reasons: (1) most patients are in an advanced stage, and (2) surgeons are concerned about postsurgical aspiration. A histopathologic study conducted in our institution indicated that conservation surgery could have been used in nearly half of the cases which had undergone total laryngopharyngectomy (HIRANO, KURITA, and TANAKA, 1987). The purpose of this paper is to present our current criteria and technique for partial laryngopharyngectomy followed by immediate reconstruction and its preliminary results. INDICATION
The partial laryngopharyngectomy procedure described in this paper is indicated only for strictly selected cases. It is indicated for tumors confined to the ipsilateral piriform sinus, aryepiglottic fold, arytenoid eminence and paraglottic space at the level of the false fold. The vocal fold and the paraglottic space at the level of the vocal fold must not be involved. The vocal fold must be normal and mobile. Invasion into the thyroid cartilage is a contraindication unless it is a localized invasion confined to the upper part of the posterior edge. The extent of carcinomatous invasion is determined preoperatively by means of laryngeal mirror examination, videofiberscopy, pharyngo-esophageal barium study, laryngograms and computed tomography. SURGICAL TECHNIQUE
Design o/skin incision (Fig. 1). For removal of the primary lesion and region-
PARTIAL LARYNGOPHARYNGECTOMY
131
Fig. 1. Design of skin incision in original technique.
Fig. 2. Design of skin incision when a back-up deltopectoral flap is preserved.
al lymph nodes, two parallel horizontal skin incisions are marked on the neck. The upper one runs from the tip of the mastoid process to the hyoid bone while the lower one is placed along the upper border of the clavicula. The latter is extended medially over the trachea. For reconstruction of the larynx and hypopharynx, a pectoralis major myocutaneous (PMMC) flap is designed. The size of the PMMC flap is later adjusted depending on the extent of tissue removal. Recently, skin for a deltopectoral flap is preserved in case a back-up is necessary (Fig. 2). Tracheostomy and anesthesia. Tracheostomy is performed under local an-
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M. HIRANO et al.
Fig. 3. Extent of removal.
esthesia. The medial portion of the lower horizonal cervical incision line is used for the tracheostomy. The isthmus of the thyroid gland is sectioned. The trachea is opened usually at the second, third and fourth rings. An endotracheal tube is inserted through the tracheostoma and general anesthesia is given. Radical neck dissection (RND). Following cervical skin incisions RND is performed ipsilaterally regardless of the existence of palpable hymph nodes. The trapezius branch of the accessory nerve is usually preserved. On both sides, the para tracheal nodes are dissected carefully with the recurrent laryngeal nerve preserved. The ipsilateral thyroid lobe is removed. Partial laryngopharyngectomy. The standard extent of removal is shown in Fig. 3. The suprahyoid muscles on the affected side are detached from the hyoid bone. The sternohyoid, thyrohyoid and omohyoid muscles are sectioned near the hyoid bone. The hyoid bone is divided in the midline. The sternothyoid muscle is sectioned from the thyroid cartilage. Using a saw or cartilage forceps the thyroid cartilage is divided as shown in Fig. 3: It is divided in the midline in the upper half and obliquely from the midline to the base of the inferior cornu in the lower half. The inferior cornu is detached from the cricoid cartilage at the joint. The cricopharyngeal muscle is sectioned from the cricoid arch. The pharynx is first opened at the vallecula by dissecting the tissue along the upper surface of the hyoepiglottic ligament. Once the vallecula is opened a retractor is inserted to retract the base of the tongue upward. Unedr careful inspection through the opening, the pharyngeal wall is sectioned laterally keeping an ample safety margin from the lesion. The epiglottis is divided at around the midline down to the petiolus. The ipsilateral false fold is separated from the vocal fold by sectioning the mucosa of the laryngeal ventricle at the level of the upper surface of the vocal fold. The section of the ventricle mucosa and the underlying structure proceeds in the anteroposterior direction. Near the middle of the interarytenoid notch, the mucosa and the underlying interarytenoid muscle are divided until the cricoid cartilage is reached. The arytenoid eminence including the arytenoid cartilage is detatched from the cricoid cartilage. Only the vocal process of the arytenoid cartilage is preserved. The
PARTIAL LARYNGOPHARYNGECTOMY
Fig. 4. Device for PMMC flap. Split is made in rostral portion. locations where each part of flap is to be sutured.
133
Sites indicated show
mucosa of the hypopharynx is sectioned carefully assuring an adequate safety margin. Thus, the thyroid ala, hyoid bone, arytenoid cartilage, false fold, paraglottic space, aryepiglottic fold, arytenoid eminence, epiglottis and hypopharynx are removed in one block on the affected side. Reconstruction. A PMMC flap is prepared and brought up to the neck. In order to prevent postoperative aspiration it seems to be crucial to construct a structure functionally comparable to the aryepiglottic fold. To do this, a device is made with the PMMC flap. The PMMC flap contains mucle tissue in the major rostral portion while the small caudal portion has no muscular component. The skin is partly split in the rostral portion (Fig. 4). The split is located to the place where the aryepiglottic fold and arytenoid eminence had been located. The medial edge of the split is sutured to laryngeal mucosa whereas the lateral edge of the split is sutured to pharyngeal mucosa. Thus, the rostral portion of the PMMC flap is sutured to the larynx and the lower part of the hypopharynx so that the bulky muscle separates the larynx from the hypopharynx. The caudal portion of the PMMC flap covers the upper part of the pharyngeal opening. The pharyngeal cavity on the operated side should be made smaller than on the unaffected. If it has the same size as that on the normal side, bolus tends to pool there causing swallowing problems. Closure of wound. The primary wound is closed leaving several tubes for continuous negative pressure drainage. PRELIMINARY RESULTS
We have conducted this surgery in four cases carefully selected to meet our strict criteria. Case 1. A 58-year-old male underwent partial laryngopharyngectomy and radical neck dissection followed by primary reconstruction for piriform sinus carcinoma T2NOMO (HARMER, 1978) on the left side on October 15, 1984. He
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M. HIRANO et al.
started oral feeding on October 31, the 16th postoperative day. On November 13, a partial necrosis of PMMC flap was noted and necrotic portion was removed, causing a pharyngeal fistula. The fistula closed spontaneously and the patient resumed oral feeding on December 9. Postoperative radiotherapy (60 Gy) was given. The tracheostoma was closed on December 29. The patient has been well and alive for three years with no evidence of disease. Case 2. A 68-year-old male underwent partial laryngopharyngectomy and radical neck dissection followed by reconstruction for piriform sinus carcinoma T2NOMO on the right side on June 24, 1985. The postsurgical wound healing was eventless. However, this parient had persistent aspiration postoperatively. Barium swallow studies indicated that aspiration was caused by too large a hypopharyngeal cavity and limited elevation of the larynx during swallowing. On November 21, 1985, the hypopharynx was narrowed by removing a part of the skin flap and the muscle of PMMC flap was sectioned to facilitate laryngeal elevation. Aspiration was reduced but not completely eliminated. Postoperative radiotherapy (60 Gy) was applied. On August II, 1986, a third surgery was performed to reduced aspiration. This procedure consisted of removal of the scar tissue around the larynx and approximation of the thyroid ala to the hyoid bone on the unaffected side. Aspiration was markedly reduced but did not disappear completely. The patient died of pulmonary infection on November 6, 1986, with no evidence of recurrent carcinoma. The tracheostoma was open throughout. Case 3. A 49-year-old male was operated on the piriform sinus carcinoma TlNOMO on the right side on June 12, 1986. Postsurgical course was eventless. He was decanulated and resumed oral feeding on July 4, the 22nd postoperative day. Postoperative radiotherapy (60 Gy) was given. A tiny tracheal opening remained until it was surgically closed 13 months after the first surgery. Closure of the tracheostoma was delayed because the patient wanted it kept open. The patient has been well and alive for 16 months with no evidence of disease. Case 4. A 66-year-old male underwent surgery on October 6, 1986. He developed necrosis of the PMMC flap and, therefore, the larynx and pharynx were ultimately reconstructed with the use of two hinge flaps and a deltopectoral flap, a technique which has been previously described elsewhere (HIRANO and KURITA, 1985). Oral feeding was begun on January 28, 1987, II4 days after the initial surgery. Postoperative radiotherapy (60 Gy) was administered. The tracheostoma has not been closed. The patient has been well with no evidence of disease for a year. Table 1 summarizes the postoperative phonatory function evaluated between 6 and 12 months after the partial laryngopharyngectomy. Case 1, 2 and 3 had clear voices whereas Case 4, the one who developed necrosis of PMMC flap, presented with a hoarse voice. Maximum phonation time and mean airflow rate were in the normal range whereas fundamental frequency and sound pressure
135
PARTIAL LARYNGOPHARYNGECTOMY Table 1. Postoperative phonatory function. Case 1 Maximum 14.3 phonation time Mean airflow rate in 177 mljsec Fundamental 15 frequency range in semi tone Sound pressure level 25 range in dB Voice quality Clear
* Data not available. **
Case 2
Case 3
Case 4
*
25.1
16.2
*
72
224
*
11
18
*
25
16
Clear
Clear
Hoarse** G2ROB2AOS2
Evaluated with GRBAS scale (HIRANO, 1981)
level ranges were slightly limited. COMMENTS
Conservation surgeries for piriform sinus carcinoma have probably not been popular for two major reasons: poor oncological results of treatments and a fear for aspiration. In general, surgery performed for piriform sinus carcinomas, even extended surgeries that include removal of the larynx, have yielded low survival rate (HIRANO et al., 1976; BRIANT et al., 1977; MARKS et al., 1978; RAZACK et al., 1978; PERSKY et al., 1981; ELBADAWI et al., 1982; HIRANO et al., 1982; YATES et al., 1984). However, most failures were attributed not to recurrences at the primary site but to nodal recurrence, distant metastasis, complication and intercurrent diseases (ELBADAWI et al., 1982; HIRANO et ai., 1982; YATES et al., 1984). Histopathological studies have revealed that, in some selected cases, the larynx could have been partially or entirely preserved (HIRANO et a/., 1987). Ogura and his colleagues reported on successful conservation surgery for selected cases of piriform sinus carcinomas (OGURA et al., 1960; OGURA et a/., 1965; FREEMAN et al., 1979). Thus, it seems evident that there exist cases of piriform sinus carcinoma which can be treated with the larynx partially or totally preserved without affecting the survival rate. The greatest issue then is how to determine the extent of carcinomatous invasion preoperatively. Recently, we have been relating preoperative examinations including laryngeal mirror examination, videofiberscopy, laryngography, barium swallow studies and computed tomography to histopathological findings. Determination of the extent of invasion is not very difficult in most cases. Once it has been determined that partial laryngopharyngectomy is indicated, postsurgical aspiration is the greatest concern. The results of the present study have revealed that the reconstruction method described here can assure a good
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protective mechanism of the larynx. Separation of the larynx from the pharynx at the site where the aryepiglottic fold has been located and a narrow pharynx on the side of reconstruction are key points for a good protective mechanism. In treating patients with cancer, the quality of posttherapeutic life should be one of the major concerns. Even though the actual number of good candidates is limited, we believe that every effort should be made to use conservation surgeries for piriform sinus carcinomas when the patient meets the specified criteria. REFERENCES BRIANT, T. D. R., BRYCE, D. P., and SMITH, T. J.: Carcinoma of the hypopharynx-a five year follow-up. J. Otolaryngol. 6: 353-362, 1977. ELBADAWI, S. A., GOEPFERT, H., FLETCHER, G. H., HERSON, J., and OSWALD, M. J.: Squamous cell carcinoma of the pyriform sinus. Laryngoscope 92: 357-364, 1982. FREEMAN, R. B., MARKS, J. E., and OGURA, J. H.: Voice preservation in treatment of carcinoma of the pyriform sinus. Laryngoscope 89: 1855-1863, 1979. HARMER, M. H. (ed.): TNM Classification of Malignant Tumours. International Union Against Cancer, Conseil-General 3, 1205, Geneva, Switzerlant, 1978. HIRANO, M.: Clinical Examination of Voice. Springer-Verlag, New York-Wien, 1981. HIRANO, M., and KURITA, S.: Partial laryngopharyngectomy followed by secondary reconstruction for carcinoma of the piriform sinus. Pract. Otol. (Kyoto) 79: 67-71, 1985. HIRANO, M., KURITA, S., KURATOMI, K., and MIHASHI, S.: Carcinoma of the hypopharynx and cervical esophagus. A retrospective investigation of 67 patients. Kurume Med. J. 29: Suppl. S97-S111, 1982. HIRANO, M., KURITA, S., and TANAKA, H.: Histopathological study of carcinoma of the hypopharynx: Implications for conservation surgery. Ann. Otol. Rhinol. Laryngol. 96: 625629, 1987. HIRANO, M., SHIN, T., MIHASHI, S., ICHIKAWA, A., MIHASHI, K., and HIROTO, 1.: Long term results of treatments for carcinoma of the hypopharynx and/or cervical esophagus. Otologia (Fukuoka) 22: 737-747, 1976. MARKS, J. E., KURNIK, B., POWERS, W. E., and OGURA, J. H.: Carcinoma of the pyriform sinus. An analysis of treatment results and patterns of failure. Cancer 41: 1008-1015, 1978. OGURA, J. H., JUREMA, A. A., and WATSON, R. K.: Partial laryngopharyngectomy and neck dissection for pyriform sinus cancer. Conservation surgery with immediate reconstruction. Laryngoscope 70: 1399-1417, 1960. OGURA, J. H., and MALLEN, R. W.: Partial laryngopharyngectomy for supraglottic and pharyngeal carcinoma. Tr. Am. A cad. Ophthalmol. Otol. 832-845, September-October, 1965. PERSKY, M. S., end DALY, J. F.: Combined therapy vs curative radiation in the treatment of pyriform sinus carcinoma. Otolaryngol. Head Neck Surg. 89: 87-91, 1981. RAZACK, M. S., SAKO, K., and KALNINS, I.: Squamous cell carcinoma of the piriform sinus. Head Neck Surg. 1: 31-34, 1978. YATES, A., and CRUMLEY, R. L.: Surgical treatment of pyriform sinus cancer. A retrospective study. Laryngoscope 94: 1586-1590, 1984.
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M. Hirano, M. D., Department of Otolaryngology-Head and Neck Surgery, Kurume University School of Medicine, Asahi-machi, Kurume 830, Japan