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Problems with supraglottic horizontal laryngectomy
PROBLEMS WITH SUPRAGLOTTIC HORIZONTAL LARYNGECTOMY ANTONIO MARTINEZ-VIDAL, MD, RAFAEL BARBERA, MD
In the 20-year period between 1972 and 1992we treated 1,265 patients with cancer of the larynx. From this series, we have selected 138 histories of supraglottic horizontal laryngectomy (SHL) valid for this study. Most patients are still under periodic follow-up and constitute a rather heterogeneous group including cases with or without neck dissection (radical or functional, unilateral or bilateral) and with or without postoperative radiotherapy. Also included in the group are 6 patients operated on after failure of curative doses of cobalt-beam therapy. We always have strictly followed the indications set by Alonso in 1954 and, therefore, never considered SHL in more extended tumors, elderly people, or patients with poor bronchopulmonary condition. We had a low complication rate in this type of surgery. Deaths resulting from SHL are rare, and are always ~e lated to food aspiration (we had none in our series) . Cardiac infarct, stress ulcers, and other life-threatening complications occurred as frequently as in the rest of pharyngolaryngeal oncological surgical procedures. Postoperative hemorrhages have not been frequent; when they have occurred, they have been treated in the usual way. Wound infection and flap necrosis with salivary pharyngocutaneous fistula have been treated with local cures in the ward. Four out of the 6 previously irradiated patients had more extensive areas of skin necrosis . However, they did not require reconstructive surgery. We seldom perform SHL after radiation failure because it is very difficult to evaluate the limits of the tumor, particularly the lower one. In any case, SHL should have been possible before radiation therapy. We also think that it is very important to diagnose the failure of radiotherapy within 3 months after its completion. Otherwise, it is safer to do a total laryngectomy. There is no doubt that supraglottic cancers can be treated with SHL. However, this is an ambitious operation (Fig 1) aiming at removal of the tumor while at the same time preserving deglutition, phonation, and respiration. Removing the supraglottis (Fig 2) gives rise to problems precisely related to swallowing, talking, and breathing, particularly when the indications of Alonso are not strictly followed. Serious problems will occur if SHL is performed when one or more of the following structures are invaded by the tumor: base of tongue, hypopharynx, arytenoids, and vocal cords. Complications occur more frequently when SHL is performed in elderly people or patients with precarious pulmonary condition.
From the Department of Otorhinolaryngology, Ramon y Cajal Hospital, Madrid, Spain. Address reprint requests to Antonio Martinez-Vidal, MD, Narvaez 14,22 lzda, 28009 - Madrid, Spain. Copyright © 1993 by W.B. Saunders Company 1043-1810/93/0404·0019$05.00/0
324
In order of importance, the main problems in our patients were (1) difficulties in swallowing, (2) difficulties with decannulation, and (3) voice problems.
SWALLOWING DIFFICULTIES Semisolid oral food (omelet, potatoes, yogurt, creams) is started 10 to 12 days after SHL, maintaining the nasogastric feeding tube . Both the doctor and the nurse stay with the patient to give him or her confidence and explain all the problems to be faced with swallowing, coughing, choking, pains, and fear. Strong will and confidence to achieve success sooner or later are essential for both the patient and the staff. However, it is a hard task because SHL has broken the synchronization between the swallowing movements and the closing of the laryngeal inlet. The pharyngeal contractions are not so effective because the muscles have been cut. The tracheostomy prevents an adequate rise of the pharyngeal pressure, and the coordinated relaxation of the cricopharyngeal sphincter fails. Therefore, during the first attempts to swallow, food enters into the trachea, particularly liquids (Fig 3), and a very good cough reflex is required to clear it of aspirated material. Patients are different in this respect. There is fear and courage, strong will to swallow and apathy, good and bad general and pulmonary condition, trust and mistrust in the staff. However, sooner or later swallowing becomes feasible, the laryngeal wounds heal, and postoperative edema subsides. Then the base of the tongue covers the entrance to the larynx, the glottis closes tightly, and the bolus progresses down the pyriform sinus into the esophagus (Fig 4). At the same time , and after the first postoperative week, we plug the cannula to force the patient to breathe and cough out the secretions naturally. The ideal situation is one in which they know how to do it when they start swallowing. As soon as they are able to feed themselves by mouth, the feeding tube is removed. A good deglutition eases an early decannulation and vice versa. Cricopharyngeal myotomy helps as well in this process and, therefore, it is strongly advised. None of the patients in our series required either a gastrostomy or a permanent nasogastric feeding tube. All of them swallowed sooner or later with more or less difficulty. Nine cases (6.5 %) developed aspiration pneumonia, 4 of them after the immediate postoperative period. Seventy-four patients (53.6%) still cough when they eat, mostly with liquids. The intensity of coughing varies from moderate to violent. However, in no case have we been forced to perform a total laryngectomy to prevent repeated pneumonias or death because of aspiration.
OPERATIVE TECHNIQUES IN OTOLARYNGOLOGY-HEAD AND NECK SURGERY, VOL 4, NO 4 (DEC), 1993: PP 324-327
.:~~
, ":
-- -
. . . ....
FIGURE 1. Diagram of horizontal supraglottic laryngectomy.
FIGURE 2. Surgical defect after horizontal supraglottic laryngectomy.
DIFFICULTIES WITH DECANNULATION
study period, 4 patients (2.9%) already decannulated underwent emergency tracheostomy during their postoperative radiotherapy, when reaching about 5,000 cGy, due to bilateral arytenoid edema. All of them were again decannulated after a long period of time. In our series, 123 patients (89.1%) were decannulated at different times in the postoperative period. Those irradiated after the operation were decannulated between 5 and 12 months after the operation; 1 patient was decannulated 4 years after the operation; and 3 patients needed 12 to 24 months before decannulation. Most nonirradiated patients were decannulated within 4 weeks of SHL. Fourteen cases required microsurgery to remove arytenoid edema. When edema involved both vocal cords, surgery was performed in two sessions at a 3-week interval. Six carefully selected radiation failures underwent SHL and had a rather different outcome. Two of these patients died later with local recurrence and metastasis, although decannulation was achieved. The remaining 4
We do not decannulate our patients until they can swallow without danger of food aspiration. However, as soon as they have a quick, strong, and effective cough reflex, we try oral feeding, closing the tracheostomy with a firm dressing. At the beginning, some food is aspirated but it is immediately coughed out, and progressively an almost normal swallowing is achieved. For this reason, patients with chronic obstructive bronchopulmonary diseases, or elderly patients, do better with a total laryngectomy, although the extension of the tumor would permit a SHL. Early decannulation is tried if postoperative radiotherapy will not be administered. Decannulation helps swallowing because more effective pharyngeal pressure is achieved as the tracheostomy is closed. In patients undergoing postoperative radiotherapy, tracheostomy is closed 2 or 3 months after the termination of radiation therapy. During the first years of our
MARTiNEZ-VIDAL AND BARBERA
325
,-.......
.'
-'
.... .-
-- . ...--.' . .r
~
FIGURE 3. Following horizontal supraglottic laryngectomy, the food easily enters into the trachea.
are decannulated and well, one of them coughing very much on swallowing liquids. None of them had perichondritis, but all had a slow, delayed healing with areas of skin necrosis. Decannulation has not been possible in 15 patients (10.9%). Four of them plug the cannula during the day and open it overnight; 3 wear a valved speaking cannula; and 8 close it with the finger to talk . Postoperative arytenoid edema is the most frequent cause preventing early decannulation. Many times the edema is due to excessive manipulation during the operation-strong repeated suctions, too much swabbingwhich obviously must be avoided. On occasion, edema is caused by the fact of having left supraglottic mucosa unremoved; therefore, it is mandatory to include the ventricular folds in the surgical specimen, even if they are tumor free. Some patients irradiated after the operation (around 6,000 cGy on the laryngeal bed and neck lymphatic areas) also develop arytenoid edema. To avoid it, the larynx field is reduced after 5/000 cGy to spare the arytenoid area. When anti-inflammatory treatment fails to reduce arytenoid edema, this is removed by stripping the edematous tissue by microsurgery. However, in 15 cases in this series (10.9%), edema reappeared and became organized/ or it was obvious a glottic stenosis or fixation of one or both vocal cords and/or arytenoids. We have not
326
FIGURE 4. Normal swallowing becomes possible when the base of the tongue covers the entrance.to the larynx and the glottis closes tightly.
been able to decannulate these patients, who all had troublesome postoperative periods with laryngeal infection and areas of necrosis and slough. The consequent scar retractions accounted for the problem. Four of these patients developed a circular, fibrous, hard stenosis just above the glottic level. We tried unsuccessfully to resect it with CO 2 laser and local microsurgical procedures.
PHONATION PROBLEMS With swallowing and decannulating problems being so difficult, we had paid less attention to the voice quality of these patients. A large number of patients have a husky voice because of a constant state of laryngitis (some con tinue smoking), .Reinke's edema, or vocal cord fixation. Sometimes an irradiated patient undergoes an intubation or suffers from a laryngotracheobronchitis with much coughing, becomes hoarse, and often does not recover his previous voice. So we always make a point in the written report given to the patient that, if intubation is needed in the future, a narrow tube should be used to And in cases in avoid postintubation voice sequela. which the glottic chink has remained somewhat narrow, we advise a rachianesthesia if possible. If Reinke's PROBLEMS WITH SUPRAGLOTTIC LARYNGECTOMY
edema develops after SHL, we do not excise it. However, in 6 patients, we have removed by microsurgery a vocal cord polyp using neuroleptanalgesia to avoid intubation.
CONCLUSION Supraglottic laryngectomy is a useful operation for selected cases of laryngeal cancer. The procedure has a low complication rate. The incidence and severity of the
MARTINEZ-VIDAL AND BARBERA
problems can be minimized with adequate nursing help. Early corking of the tracheostomy tube is recommended except for patients receiving postoperative radiation therapy. In these patients, the irradiation field should be reduced after 5,000 cGy to avoid arytenoid edema. On the other hand, any unsubsiding edema should be surgically removed. In our opinion, cricopharyngeal myotomy facilitates good deglutition and, therefore, it is strongly advised. Keeping postoperative infections to a minimum helps reduce the incidence of complications.
327
In the 20-year period between 1972 and 1992we treated 1,265 patients with cancer of the larynx. From this series, we have selected 138 histories of supraglottic horizontal laryngectomy (SHL) valid for this study. Most patients are still under periodic follow-up and constitute a rather heterogeneous group including cases with or without neck dissection (radical or functional, unilateral or bilateral) and with or without postoperative radiotherapy. Also included in the group are 6 patients operated on after failure of curative doses of cobalt-beam therapy. We always have strictly followed the indications set by Alonso in 1954 and, therefore, never considered SHL in more extended tumors, elderly people, or patients with poor bronchopulmonary condition. We had a low complication rate in this type of surgery. Deaths resulting from SHL are rare, and are always ~e lated to food aspiration (we had none in our series) . Cardiac infarct, stress ulcers, and other life-threatening complications occurred as frequently as in the rest of pharyngolaryngeal oncological surgical procedures. Postoperative hemorrhages have not been frequent; when they have occurred, they have been treated in the usual way. Wound infection and flap necrosis with salivary pharyngocutaneous fistula have been treated with local cures in the ward. Four out of the 6 previously irradiated patients had more extensive areas of skin necrosis . However, they did not require reconstructive surgery. We seldom perform SHL after radiation failure because it is very difficult to evaluate the limits of the tumor, particularly the lower one. In any case, SHL should have been possible before radiation therapy. We also think that it is very important to diagnose the failure of radiotherapy within 3 months after its completion. Otherwise, it is safer to do a total laryngectomy. There is no doubt that supraglottic cancers can be treated with SHL. However, this is an ambitious operation (Fig 1) aiming at removal of the tumor while at the same time preserving deglutition, phonation, and respiration. Removing the supraglottis (Fig 2) gives rise to problems precisely related to swallowing, talking, and breathing, particularly when the indications of Alonso are not strictly followed. Serious problems will occur if SHL is performed when one or more of the following structures are invaded by the tumor: base of tongue, hypopharynx, arytenoids, and vocal cords. Complications occur more frequently when SHL is performed in elderly people or patients with precarious pulmonary condition.
From the Department of Otorhinolaryngology, Ramon y Cajal Hospital, Madrid, Spain. Address reprint requests to Antonio Martinez-Vidal, MD, Narvaez 14,22 lzda, 28009 - Madrid, Spain. Copyright © 1993 by W.B. Saunders Company 1043-1810/93/0404·0019$05.00/0
324
In order of importance, the main problems in our patients were (1) difficulties in swallowing, (2) difficulties with decannulation, and (3) voice problems.
SWALLOWING DIFFICULTIES Semisolid oral food (omelet, potatoes, yogurt, creams) is started 10 to 12 days after SHL, maintaining the nasogastric feeding tube . Both the doctor and the nurse stay with the patient to give him or her confidence and explain all the problems to be faced with swallowing, coughing, choking, pains, and fear. Strong will and confidence to achieve success sooner or later are essential for both the patient and the staff. However, it is a hard task because SHL has broken the synchronization between the swallowing movements and the closing of the laryngeal inlet. The pharyngeal contractions are not so effective because the muscles have been cut. The tracheostomy prevents an adequate rise of the pharyngeal pressure, and the coordinated relaxation of the cricopharyngeal sphincter fails. Therefore, during the first attempts to swallow, food enters into the trachea, particularly liquids (Fig 3), and a very good cough reflex is required to clear it of aspirated material. Patients are different in this respect. There is fear and courage, strong will to swallow and apathy, good and bad general and pulmonary condition, trust and mistrust in the staff. However, sooner or later swallowing becomes feasible, the laryngeal wounds heal, and postoperative edema subsides. Then the base of the tongue covers the entrance to the larynx, the glottis closes tightly, and the bolus progresses down the pyriform sinus into the esophagus (Fig 4). At the same time , and after the first postoperative week, we plug the cannula to force the patient to breathe and cough out the secretions naturally. The ideal situation is one in which they know how to do it when they start swallowing. As soon as they are able to feed themselves by mouth, the feeding tube is removed. A good deglutition eases an early decannulation and vice versa. Cricopharyngeal myotomy helps as well in this process and, therefore, it is strongly advised. None of the patients in our series required either a gastrostomy or a permanent nasogastric feeding tube. All of them swallowed sooner or later with more or less difficulty. Nine cases (6.5 %) developed aspiration pneumonia, 4 of them after the immediate postoperative period. Seventy-four patients (53.6%) still cough when they eat, mostly with liquids. The intensity of coughing varies from moderate to violent. However, in no case have we been forced to perform a total laryngectomy to prevent repeated pneumonias or death because of aspiration.
OPERATIVE TECHNIQUES IN OTOLARYNGOLOGY-HEAD AND NECK SURGERY, VOL 4, NO 4 (DEC), 1993: PP 324-327
.:~~
, ":
-- -
. . . ....
FIGURE 1. Diagram of horizontal supraglottic laryngectomy.
FIGURE 2. Surgical defect after horizontal supraglottic laryngectomy.
DIFFICULTIES WITH DECANNULATION
study period, 4 patients (2.9%) already decannulated underwent emergency tracheostomy during their postoperative radiotherapy, when reaching about 5,000 cGy, due to bilateral arytenoid edema. All of them were again decannulated after a long period of time. In our series, 123 patients (89.1%) were decannulated at different times in the postoperative period. Those irradiated after the operation were decannulated between 5 and 12 months after the operation; 1 patient was decannulated 4 years after the operation; and 3 patients needed 12 to 24 months before decannulation. Most nonirradiated patients were decannulated within 4 weeks of SHL. Fourteen cases required microsurgery to remove arytenoid edema. When edema involved both vocal cords, surgery was performed in two sessions at a 3-week interval. Six carefully selected radiation failures underwent SHL and had a rather different outcome. Two of these patients died later with local recurrence and metastasis, although decannulation was achieved. The remaining 4
We do not decannulate our patients until they can swallow without danger of food aspiration. However, as soon as they have a quick, strong, and effective cough reflex, we try oral feeding, closing the tracheostomy with a firm dressing. At the beginning, some food is aspirated but it is immediately coughed out, and progressively an almost normal swallowing is achieved. For this reason, patients with chronic obstructive bronchopulmonary diseases, or elderly patients, do better with a total laryngectomy, although the extension of the tumor would permit a SHL. Early decannulation is tried if postoperative radiotherapy will not be administered. Decannulation helps swallowing because more effective pharyngeal pressure is achieved as the tracheostomy is closed. In patients undergoing postoperative radiotherapy, tracheostomy is closed 2 or 3 months after the termination of radiation therapy. During the first years of our
MARTiNEZ-VIDAL AND BARBERA
325
,-.......
.'
-'
.... .-
-- . ...--.' . .r
~
FIGURE 3. Following horizontal supraglottic laryngectomy, the food easily enters into the trachea.
are decannulated and well, one of them coughing very much on swallowing liquids. None of them had perichondritis, but all had a slow, delayed healing with areas of skin necrosis. Decannulation has not been possible in 15 patients (10.9%). Four of them plug the cannula during the day and open it overnight; 3 wear a valved speaking cannula; and 8 close it with the finger to talk . Postoperative arytenoid edema is the most frequent cause preventing early decannulation. Many times the edema is due to excessive manipulation during the operation-strong repeated suctions, too much swabbingwhich obviously must be avoided. On occasion, edema is caused by the fact of having left supraglottic mucosa unremoved; therefore, it is mandatory to include the ventricular folds in the surgical specimen, even if they are tumor free. Some patients irradiated after the operation (around 6,000 cGy on the laryngeal bed and neck lymphatic areas) also develop arytenoid edema. To avoid it, the larynx field is reduced after 5/000 cGy to spare the arytenoid area. When anti-inflammatory treatment fails to reduce arytenoid edema, this is removed by stripping the edematous tissue by microsurgery. However, in 15 cases in this series (10.9%), edema reappeared and became organized/ or it was obvious a glottic stenosis or fixation of one or both vocal cords and/or arytenoids. We have not
326
FIGURE 4. Normal swallowing becomes possible when the base of the tongue covers the entrance.to the larynx and the glottis closes tightly.
been able to decannulate these patients, who all had troublesome postoperative periods with laryngeal infection and areas of necrosis and slough. The consequent scar retractions accounted for the problem. Four of these patients developed a circular, fibrous, hard stenosis just above the glottic level. We tried unsuccessfully to resect it with CO 2 laser and local microsurgical procedures.
PHONATION PROBLEMS With swallowing and decannulating problems being so difficult, we had paid less attention to the voice quality of these patients. A large number of patients have a husky voice because of a constant state of laryngitis (some con tinue smoking), .Reinke's edema, or vocal cord fixation. Sometimes an irradiated patient undergoes an intubation or suffers from a laryngotracheobronchitis with much coughing, becomes hoarse, and often does not recover his previous voice. So we always make a point in the written report given to the patient that, if intubation is needed in the future, a narrow tube should be used to And in cases in avoid postintubation voice sequela. which the glottic chink has remained somewhat narrow, we advise a rachianesthesia if possible. If Reinke's PROBLEMS WITH SUPRAGLOTTIC LARYNGECTOMY
edema develops after SHL, we do not excise it. However, in 6 patients, we have removed by microsurgery a vocal cord polyp using neuroleptanalgesia to avoid intubation.
CONCLUSION Supraglottic laryngectomy is a useful operation for selected cases of laryngeal cancer. The procedure has a low complication rate. The incidence and severity of the
MARTINEZ-VIDAL AND BARBERA
problems can be minimized with adequate nursing help. Early corking of the tracheostomy tube is recommended except for patients receiving postoperative radiation therapy. In these patients, the irradiation field should be reduced after 5,000 cGy to avoid arytenoid edema. On the other hand, any unsubsiding edema should be surgically removed. In our opinion, cricopharyngeal myotomy facilitates good deglutition and, therefore, it is strongly advised. Keeping postoperative infections to a minimum helps reduce the incidence of complications.
327