Supracricoid partial laryngectomy with cricohyoidepiglottopexy

n

SUPRACRICOID PARTIAL LARYNGECTOMY WITH CRlCOHYOlDEPlGLOlTOPEXY STEPHEN Y. LAI, MD, PhD, OLLIVIER LACCOURREYE, GREGORY S. WEINSTEIN, MD

MD,

Supracricoid partial laryngectomy with cricohyoidepiglottopxy (SCPL-CHBP) is an effective surgical procedure for the management of selected glottic carcinomas. Excellent control rates are achieved, and the functional goals of speech and swallowing are attained without a permanent tracheostomy. This article describes the indications, contraindications, surgical techniques and postoperative issues for SCPL-CHEP.

In 1959, Majer and Reider described a partial laryngectomy in which reconstruction was achieved by suturing the hyoid to the cricoid.’ During the years after its introduction, the supracricoid partial laryngectomy (SCPL) was refined and popularized in France and other European countries. The SCPL provides an effective alternative to total laryngectomy (TL) and offers better local control for selected lesions than an extended partial laryngectomy or nonsurgical therapy such as radiation with or without chemotherapy. As with any technique, the key to successful oncologic outcome following SCPL is careful patient selection. There are two types of !XPLs which are employed for distinctly different types of endolaryngeal cancers. The differences in the extent of resection achieved by these two forms of SCPL require different reconstructions. The SCPL with cricohyoidopexy (SCPL-CHP) is used for selected supraglottic and transglottic carcinomas. (described elsewhere in this issue) Selected glottic carcinomas are treated with resection of the true and false vocal folds, both paraglottic spaces, the petiole of the epiglottis and thyroid cartilage. The reconstruction requires suturing the cricoid to the hyoid and the epiglottis, termed a cricohyoidoepiglottopexy (CHEP). The advantage of the SCPL-CHEP over TL is the preservation of speech and swallowing function without a permanent stoma and a very high local control rate for selected glottic cancers. Local control rates for T2 and T3 glottic carcinomas of 90% and higher have been reported. 2A These rates are better than those reported for radiation therapy and other forms of partial laryngectomy. Maintenance of physiologic speech and swallowing without a permanent tracheostomy requires the preservation of at least one cricoarytenoid unit (Fig 1) and an intact cricoid cartilage. Unlike other partial laryngectomies (eg, extended vertical partial laryngectomy) that require variable types of reconstruction, the SCPL-CHEP has a single, From the University of Pennsylvania Health System, Department of Ctorhinolaryngology - Head and Neck Surgery, Philadelphia, PA. Address reprint requests to Dr. Gregory S. Weinstein, MD, University of Pennsylvania Health System, Department of Ctominolaryngology-Head and Neck Surgery, 5 RavdinBilverstein, 3400 Spruce Street, Philadelphia, PA 19104. 0 2003 Elsevier Inc. All rights reserved. 1043-1810/03/1401-0008$30.00/0 doi:lO.1053/otot.2003.36467

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OPERATIVE

TECHNIQUES

IN OTOlARYNGOLOGY-HEAD

fixed method for reconstruction tional outcomes.

to ensure reliable

func-

INDICATIONS Indications

for SCPL-CHEP include the following:5

1. Bilateral true vocal fold involvement with or without anterior commiss ure involvement (ie, horseshoe lesions). 2. Unilateral glottic carcinoma with anterior conunissure involvement. 3. Impaired true vocal fold mobility with limited subglottic (less than 1 cm) and ventricular extension. 4. T3 glottic lesion with fixation of the true vocal fold and either impaired or mobile arytenoid. 5. T4 glottic tumors with limited thyroid cartilage invasion. Despite careful preoperative workup, the final decision concerning the suitability of a particular OPS procedure cannot be made until the time of surgery. Permission must always be obtained preoperatively to perform a total laryngectomy if tumor extent precludes organ preservation surgery. Nonetheless, when an experienced surgeon performs the procedure they should be able to predict the likelihood of intraoperative conversion to total laryngectomy. If a total laryngectomy is highly unlikely, ie, when the indications are ideal, then the patient can be reassured. Indeed, if the surgeon is quite sure that there is a very low risk of intraoperative conversion to total laryngectomy, then this is likely to be a better option than the nonsurgical organ preservation techniques. It should be explained to the patient that even if they choose a nonsurgical approach such as radiation or chemoration for their T2, T3 or T4 cancer, that there is also a small possibility of persistence disease at the end of treatment necessitating total laryngectomy. If the surgeon is less sure that the partial laryngectomy is feasible, it is important to let the patient know, so that they may consider a nonsurgical option that may have either an equivalent or a better chance to preserve the larynx.

CONTRAINDICATIONS The main contraindication for SCPL-CHEP is preoperative evidence of severe respiratory impairment. SCPL alters the sphincteric function of the larynx and adequate pulmonary reserve is necessary for the increased postoperaAND

NECK

SURGERY,

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14, NO 1 (MAR),

2003:

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cricoarytenoid joint and/or musculature. This posterolatera1 cricoid involvement is a major contraindication to any organ preservation surgery techniques. True vocal fold fixation results from invasion of the thyroarytenoid muscle and is not a contraindication to SCPL-CHEP. SURGICAL

FM3URE 1. The cricoarytenoid unit includes an atytenoid cartilage, the adjacent cricoid cartilage, the ipsilateral superior and recurrent laryngeal nerve, the interarytenoid musculature and the ipsilateral lateral and posterior cricoarytenoid musculature. This is the basic functional unit that allows for speech and swallow following organ preservation surgery of the larynx.

tive aspiration with the concomitant risk for atelectasis and pneumonia. Those patients with an inability to climb yo flights of stairs without shortness of breath are strong contraindications against the use of SCPL-CHEP. Oncologic contraindications for SCPL-CHEP include: 1. Tumors originating (epicenter) in the anterior commissure or ventricle. These lesions have a propensity for early invasion of the preepiglottic space. Such lesions may be resected with SCPL-CHP. 2. Tumors of the glottis with ipsilateral fixation of the arytenoid cartilage. 3. Tumors of the glottis with subglottic extent reaching the upper border of the cricoid cartilage or invading the cricoid cartilage. 4. Tumors of the glottis invading the posterior commissure. 5. Tumors of the glottis invading the outer perichondrium of the thyroid cartilage or presenting with extralaryngeal spread of tumor. ‘Before performing SCPL-CHEP, evaluation of the glottic carcinoma must include the evaluation of true vocal fold mobility separately from arytenoid mobility. True fixation of the arytenoid cartilage is always associated with fixation of the true vocal cord, indicating infiltration of the LAI AND

WEINSTEIN

TECHNIQUE

A subplatysmal apron flap is elevated in line with the planned position of the tracheostomy site and is made widely enough to incorporate a unilateral or bilateral neck dissection. The superiorly based flap is elevated 2 cm above the hyoid bone to prevent tethering of the skin in the impaction during reconstruction. The midline raphe of the strap muscles is identified and divided from the hyoid to the sternal notch. The stemohyoid and thyrohyoid are transected bilaterally at the upper border of the thyroid cartilage. If the strap muscles are transected close to the hyoid bone, muscular reconstruction will be difficult. The stemohyoid muscle is elevated laterally and inferiorly to expose the oblique line of the thyroid cartilage. The sternothyroid muscle is identified and transected at the inferior border of the thyroid cartilage. The inferior constrictor muscles are released from the posterolateral edge of the thyroid cartilage. Particular care is taken not to injure the superior laryngeal nerve (SLN), which occasionally overlies the superior comua of the thyroid cartilage. Two 3-O vicryl sutures are attached to the cut edge of the constrictor muscles on each side. These sutures are secured with hemostats and are used during closure to reapproximate the pyriform sinuses. The external thyroid perichondrium is incised and released along the lateral and superior borders of the thyroid cartilage. The internal thyroid perichondrium and pyriform sinus is released with a Freer elevator and blunt finger dissection. A limited dissection of the inner perichondrium is performed on the tumor-bearing side of the larynx. The cricothyroid joints are disarticulated with care taken to avoid damaging the recurrent laryngeal (RLN). (Fig 2) The perichondrium is dissected of the lateral surface of the inferior comua with a Freer elevator. The cricothyroid joint capsule is cut with the Freer elevator or the tip of a #15 blade is inserted into the cricothyroid joint to cut the capsule. A Freer elevator is then used to disarticulate the cricothyroid joint, taking care to avoid damaging the soft tissue posterior to this that harbors the recurrent laryngeal nerve. The thyroid isthmus is transected and ligated to facilitate midline exposure. The final step for exposure is release of the cervicomediastinal trachea. Finger dissection over the anterior wall of the trachea to the level of the carina allows the trachea and cricoid to be pulled superiorly to the hyoid during closure. Care is taken not to dissect laterally and devascularize the trachea. When the operation is being performed for a T3 glottic carcinoma the ipsilateral thyroid lobe is resected separately and an ipsilateral paratracheal node dissection is performed. A transverse cricothyrotomy is performed at the superior level of the cricoid and a flexible armored endotracheal tube is placed. The larynx is entered only in the midline with scissors just above the thyroid notch. (Fig 3) This entry above the false cords spares essentially the whole epiglottis and preepiglottic space. An Allis clamp is applied to the petiole of the epiglottis and pulled through the incision to facilitate direct visualization of the endolarynx. Resection proceeds along the side with less tumor involvement. A curved Mayo scissors is employed for the 35

FIGURE 2. (A and B) The cricothyroid laryngeal nerve.

joint is disarticulated

with a Freer elevator.

vertical portion of the resection. One blade of the scissors is within the lumen of the larynx and the other blade is between the thyroid cartilage and the elevated internal thyroid cartilage perichondrium. (Fig 4) The incision is made anterior to the arytenoid cartilage preserving the vocal process and the cricoarytenoid musculature. The incision resects the entire false vocal fold and is posterior to the ventricle. The entire true vocal fold is resected and the incision continues inferiorly to the level of the cricoid. The incision is taken anteriorly through the cricothyroid musculature and subglottic mucosa to connect with the horizontal cricothyroidotomy. The larynx is cracked open like a book and the resection on the involved side is performed under direct visualization. The resection proceeds from the cricoid superiorly. Resection of the arytenoid cartilage is performed as necessary, but the posterior arytenoid mucosa must be spared on the involved side. In the case of T3 glottic carcinoma the ipsilateral arytenoids cartilage, as well as the ipsilateral lateral cricoarytenoid muscle is always resected to allow for adequate margins around the posterior and inferior paraglottic space. Frozen sections from the inferior and posterior margins of the surgical defect are analyzed to determine the adequacy of the resection. Reconstruction begins by loosely approximating the remaining arytenoid and posterior arytenoid mucosa to the cricoid with 3-O vicryl sutures. Impaction of the hyoid

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Care is taken to prevent

damage

to the recurrent

bone to the cricoid cartilage is performed with three 1-O vicryl sutures on a 65 mm needle. The sutures are placed submucosally around the cricoid and through the epiglottis. The needle is re-grasped and passed through the preepiglottic space, around the hyoid, deep into the tongue base and out 2 cm above the hyoid through the suprahyoid musculature. (Fig 5) The midline suture is placed first and the two lateral sutures are placed precisely 1 cm from the midline suture. The sutures are initially placed and left untied to allow the surgeon to inspect the closure for suture misplacement or asymmetry. The lateral sutures are then held tightly to approximate the cricoid and hyoid so that the tracheostomy can be done in line with the original neck skin incision. The sutures are securely tied and the sutures placed earlier through the inferior constrictor muscles are tied over the impaction to re-approximate the pyriform sinuses. The strap muscles are closed over the reconstruction in a ‘T’ shape. The skin flaps are closed and the tracheostomy site is separated from the remaining portion of the wound. Air tracking superiorly from the tracheostomy site could create a dead space over the operative site. To avoid this complication, the thyroid isthmus is re-approximated and a portion of the thyroid tissue is included within the vertical midline closure of the strap muscles. A running 3-O vicryl suture is placed in a semicircular fashion above SUPRACRICOID

PARTIAL

LARYNGECTOMY

FIGURE 3. through

(A and B) A flexible armored the thyrohyoid membrane.

endotracheal

the tracheostomy site between the inferior upper skin flap and the strap muscles.

WY

SURGICAL

portion

tube

of the

POINTS

An intact, mobile cricoarytenoid unit on the noninvolved side of the larynx is the basis for postoperative laryngeal function. Care is taken to avoid entry into the cricoarytenoid joint by orienting the scissor blades in the coronal

FIGURE 4. (A and B) Transection

with scissors

is placed

through

a horizontal

cricothyrotomy.

The larynx

is entered

plane of the larynx. Subperichondrial disarticulation of the cricothyroid joint always protects the RLN where the nerve enters the larynx. Finally, careful transaction of the inferior constrictor muscles will spare the main trunk of the SLN to ensure sensation of the hypopharynx and remaining larynx postoperatively. A reliable functional outcome from SCPL-CHEP requires that the resection be performed precisely. None of the false and true vocal cords on the noninvolved side of

begins on the less involved

side with care taken to avoid entry into the cricoarytenoid

joint. LAI AND

WEINSTEIN

37

the tongue and reduce swallowing efficiency. The epiglottis is included in the impaction to avoid posterior or horizontal dislocation of the epiglottic cartilage that would result in airway compromise postoperatively. The pexy suture are initially placed and left untied for inspection. The surgeon should avoid rotating the laryngeal skeletal structures with impaction. The anterior border of the cricoid cartilage and the hyoid bone must be carefully aligned to reduce postoperative aspiration. Finally, care must be taken when tying the pexy sutures to avoid fracture of the cricoid arch. If a fracture occurs, the pexy must be done using the first 2 tracheal rings.

POSTOPERATIVE MANAGEMENT AND REHABILITATION

FIGURE 5. A lateral view of the suture placement. The suture remains submucosal around the cricoid and epiglottis. The suture passes deeply into the tongue base to create bulk over the neoglottis and to facilitate proper propulsion of a food bolus during swallowing.

the larynx should be preserved. This additional tissue impedes the apposition of the arytenoid and the base of the tongue, compromising the functional efficiency of the neoglottis. The entire ventricle must be resected to ensure that a postoperative laryngocele does not form and cause airway obstruction. Effort must be made to preserve the posterior arytenoid mucosa on the tumor-bearing side of the larynx if the arytenoids cartilage is resected. This flap will provide additional posterolateral mass that will enhance recovery of swallowing function. A number of steps taken during reconstruction wiII improve functional outcomes. before impaction, a cricopharyngeal myotomy should be performed if palpation of the upper esophageal sphincter reveals hypertonia. However, a history of gastroesophageal reflux might be a contraindication. As described above, the pyriform sinuses should be repositioned by suturing the edges of the inferior constrictor muscles together over the impaction. Finally, suturing the vocal process of the arytenoid and/or the posterior arytenoid mucosa anteriorly to the cricoid prevents the backward prolapse of the arytenoids cartilage and mucosa into the posterior pharynx. This creates a narrow T-shaped larynx in which the arytenoids abut each other and the epiglottis anteriorly. (Fig 6) The vertical portion of the ‘T’ between the arytenoid cartilages and/or mucosa serves as the posterior respiratory glottis. The horizontal portion of the ‘T’ between the arytenoid cartilage and the laryngeal surface of the epiglottis acts as the phonatory glottis. only three pexy sutures are placed during impaction and they should be placed precisely 1 cm apart. Sutures placed too far laterally may damage the hypoglossal nerve or the lingual artery. Additional sutures will only flatten

3s

The goal is to discharge patients within the first postoperative week. The wound is cleaned with saline and treated with antibiotic ointment. A no. 10 Jackson-Pratt drain is placed above the strap muscles and left on bulb suction. This drain is usually removed when output has decreased to less than 20 mL in a 2Phour period. Staples or sutures are removed on postoperative day 6 from patients with no history of head and neck radiation therapy. The tracheostomy cuff is deflated on postoperative day 1. The tracheostomy tube is changed to a No. 4 or No. 6 cuffless tube on approximately postoperative day 3. Visualization of the airway by indirect laryngoscopy should not demonstrate any evidence of significant edema. The tracheostomy is capped if the airway is sufficient or a Passy-Muir valve is placed instead. The date of hospital discharge is based on the patient’s ability to manage their tracheostomy and gastrostomy tube feeds. Postoperative dysphagia is expected, but long-term dysphagia is rare. If placed intraoperatively, the nasogastric feeding tube is removed based on the speed at which the patient recovers swallowing ability. A percutaneous endoscopic gastrostomy (at time of staging endoscopy) may be useful if rehabilitation of swallowing is expected to be difficult or longer than usual. The median time for re-

FIGURE 6. A postoperative view of the neoglottis following SCPL-CHEP. Since there are no true or false vocal folds, the normal V-shaped glottis is changed to a T-shape. SUPRACRICOID

PARTIAL

LARYNGECTOMY

moval of feeding tube in one study of SCPL-CHP was 16 days (range 9 to 40 days).& Early decannulation of the tracheostomy is the norm in France, but in the United States it is more appropriate to change to a cuffless tracheostomy in the hospital and decannulate the patient as an outpatient when the edema has resolved. In France the patients undergo early decannulation and stay in the hospital until swallowing is achieved. If the patient needs to have the tracheostomy replaced for recurrent edema this can be safely done in the hospital. In the United States prolonged hospitalization is not possible because of the nature of the insurance system, and so it is safer to send the patient home with the tracheostomy and remove it later when the larynx is completely stable from the airway perspective. Ultimately, patients are able to communicate with lungpowered speech and engage in normal social interactions. The quality of the voice is permanently hoarse, like chronic laryngitis, and in some patient there is a variable degree of breathiness. This improves somewhat as the mobility of the arytenoid improves. Speech and swallow rehabilitation should commence immediately to maximize postoperative laryngeal function. Patients are encouraged to expectorate all secretions without aid of suction devices beginning on postoperative day 1. Expectoration clears the pharynx and oral cavity of secretions and begins to mobilize the oropharyngeal musculature. Swallowing rehabilitation continues on an outpatient basis. Postoperative mortality and morbidity rates are low and comparable to those for other partial laryngectomy techniques. In one series, the mortality rate was 1% and the morbidity rate was 11.7%.’ Specific complications following SOL-CHEF include postoperative laryngocele, retrodbplacement of the epiglottis, rupture of the pexy, laryngeal stenosis and local carcinoma recurrence. Careful selection of patients should identify those willing to undertake intensive postoperative speech and swallowing rehabilitation and result in less need for a completion total laryngectomy or permanent gastrostomy. CONCLUSIONS SCPL-CHEP is gaining acceptance around the world for the treatment of selected glottic carcinomas. SCPL-CHEP

LAI AND

WEINSTEIN

achieves local control rates comparable to TL for selected laryngeal cancers. Furthermore, the functional goals of speech and swallowing are achieved without a permanent tracheostomy. SCPL-CHEP avoids the stigma of the permanent stoma that remains the primary detractor to quality of life for patients who have undergone a TL. Since SOL-CHEF’ has standard resection boundaries and a fixed closure technique, functional outcomes are predictable and reproducible. Future directions include the careful exploration of extending the indications for these procedures and the use of these procedures as a salvage technique when nonsurgical modalities have failed.” Proper patient selection and preoperative evaluation remain the keys to successful functional and oncologic outcome.

REFERENCES 1. Majer H, Reider W: Technique de laryngecomie permetant de conserver la permeabilite respiratoira la cricohyoido-pexie. Ann Otolaryngol Chir Cervicofac 76:677-683,1959 2. Laccourreye, 0, Weinstein, GS, Brasnu, et al: A clinical trial of continuous cisplatin-fluorouracil induction chemotherapy and supracricoid partial laryngectomy for glottic carcinoma classified as T2. Cancer 74:2781-2790, 1994 3. Laccourreye 0, Weinstein GS, Brasnu, D, et al: Glottic carcinoma with a fixed true vocal cord: Outcomes after neoadjuvant chemotherapy and supracricoid partial laryngectomy with cricohyoidoepiglottopexy. Otol Head Neck Surg 114440446, 1996 4. Piquet JJ, Cevalier D: Subtotal laryngectomy with crico-hyoido-epiglotto-pexy for the treatment of extended glottic carcinomas. Am J Surg 162:357-361, 1991 5. Laccourreye H, Laccourreye 0, Weinstein, GS, et al: Supracricoid laryngectomy with cricohyoidoepiglottopexy: A partial laryngeal procedure for glottic carcinoma. Ann Otol Rhino1 Laryngol 99:421426, 1990 6. Weinstein G, Laccourreye 0, Brasnu D, Laccourreye H: Organ Preservation Surgery for Laryngeal Cancer. San Diego, CA, Singular Publishing Group, 2@30 7. Naudo P, Laccourreye 0, Weinstein GS, et al: Functional outcome and prognosis factors after supracricoid partial laryngectomy with cricohyoidopexy. Ann Otol Rhino1 Laryngol 106:291-295, 1997 8. Laccourreye, 0, Weinstein, GS, Naudo, P, et al: Supracricoid partial laryngectomy after failed radiation therapy. Laryngoscope 106:495498, 1996

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