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Supracricoid partial laryngectomy with cricohyoidopexy
SUPRACRICOID PARTIAL WITH CRICOHYOIDOPEXY DUANE A. SEWELL,
LARYNGECTOMY
MD
The supracricoid partial laryngectomy (SCPL) with cricohyoidopexy (CHP) is an alternative to total laryngectomy in the treatment of selected glottic and supraglottic cancers. It consists of the resection of the true cords, false cords, thyroid cartilage and epiglottis, while the cricoid cartilage and at least one of the two arytenoid cartilages are spared. Reconstruction is performed by securing the cricoid cartilage to the hyoid bone. Careful patient selection is of paramount importance for the success of this procedure. In general, the indications for SCPL with CHP include selected supraglottic and glottic tumors that do not involve the subglottis or the arytenoid cartilages. When properly performed, the speech and swallowing function is preserved in a high percentage of patients. The specific indications and the surgical technique are presented here.
The supracricoid partial laryngectomy (SCPL) with cricohyoidopexy (CHP) was first described by Austrian surgeons in 1959 as an alternative to total laryngectomy in the tibatrnent of selected glottic and supraglottic cancers.’ Their report describes a procedure in which the true cords, false cords, thyroid cartilage and epiglottis are resected, but the cricoid cartilage and at least one arytenoid cartilage are left in situ. Reconstruction involves the suturing of the cricoid cartilage to the hyoid bone; hence the term “cricohyoidopexy”. The expected result of SCPL with CHP is the surgical eradication of the cancer while preserving speech and swallowing function and avoiding a permanent tracheal stoma. This technique gained popularity in Europe during the ensuing three decades, and in the 1980s several papers were ublished on the indications and functional results.2 2 The other open partial surgical alternatives to total laryngectomy for supraglottic cancer, namely the supraglottic partial laryngectomy, is contraindicated for cancers which involve the glottic level, inpaired mobility of the vocal cord, or have early invasion of the thyroid cartila e (none of which are contraindications to SCPL-CHP). 5,’ Gradually, as performance of the SCPL with CHP became more common in Europe, surgeons in the United States began to perform the procedure with excellent results.‘,”
PATIENT
SELECTION
Patient selection is of paramount importance in the ultimate success of this procedure. When first evaluating a patient suspected of laryngeal cancer, a thorough history must be taken. In addition to asking the standard questions asked of all head and neck cancer patients, careful attention must be paid to the general state of health of the patient and the ability to perform activities of daily living. Inquiries should be made about the patient’s ability for From the Department of Otolaryngology, School of Medicine, Philadelphia, PA Address reprint requests to Duane Sewell, 323 Johnson Pavilion, 3610 Hamilton Walk, (B 2003 Elsevier Inc. All rights reserved. 1043-1610/03/1401-0001$30.00/0 doi:lO.l053/otot.2003.36471 OPERATIVE
TECHNIQUES
University
of Pennsylvania
University Philadelphia,
of Pennsylvania, PA 19104.
IN OTOLARYNGOLOGY-HEAD
AND
NECK
exercise tolerance. Not to be overlooked is the patient’s cognitive function and the willingness to follow instruction, as these are critical components to successful postoperative rehabilitation. Following a general head and neck physical examination, several areas are essential to assess. On neck examination, pain upon palpation of the thyroid cartilage or the region of the thyrohyoid membrane may indicate thyroid cartilage or massive pre-epiglotic space invasion and should be duly noted. On laryngoscopic examination, it is of utmost importance to determine the precise extent of the tumor. Not only must the mobility of the true cord be evaluated, but also the mobility of the arytenoids cartilages. It is critical to distinguish between the two. Although the true cord can be fixed due to thyroartenoid muscle invasion by tumor, the arytenoid cartila es may remain mobile and uninvolved by the tumor.“- 8 Arytenoid fixation is a contraindication to the SCPL-CHP because this may be related to cricarytenoid joint involvement, leading to a positive margin in this area. However, it has been reported that the use of neo-adjuvant chemotherapy has led to the re-mobilization of a fixed arytenoid and has allowed certain patients to then undergo the SCPL-CHP.14 Ultimately, the patient should be brought to the operating room for a direct laryngoscopy and biopsy to complete a thorough examination of the larynx. At that time, a percutaneous gastrostomy can be performed to allow for ease of administration of tube feeds postoperatively and avoidance of a nasogastric tube. Routinely, a computed tomography (CT) scan or magnetic resonance imaging (MRI) of the neck is also performed to help define the extent of the tumor and the status of the nodal involvement.15 Upon completion of the history and physical examination, it can be decided whether the patient is a candidate for organ preservation surgery of the larynx. In general, SCPL-CHP can be considered for selected supraglottic tumors that extend into the ventricle or glottis, and are therefore not amenable to a supraglottic laryngectomy. This procedure may also be indicated for glottic tumors that extend into the supraglottis cross the midline and are not ideal candidates for laser cordectomy or vertical partial hemilaryngectomy. SURGERY,
VOL
14, NO 1 (MAR),
2003:
PP 27-33
27
More specifically, clude the following:
the indications
for this procedure
in-
1. Selected Tl supraglottic tumors involving the infrahyoid epiglottis or ventricle. 2. Selected T2 transglottic and supraglottic tumors. 3. Selected T3 transglottic and supraglottic tumors with true vocal cord fixation and/or limited prepiglottic space invasion, but without arytenoid fixation. 4. Selected T4 transglottic and supraglottic tumors with limited invasion of the thyroid ala without extension through the outer perichondrium.‘,“j The major contraindications
include the following:
1. Arytenoid cartilage fixation. Unlike true vocal fold fixation, arytenoid fixation reflects invasion of the cricoarytenoid musculature or the cricoarytenoid joint. The cricoid cartilage, therefore, cannot be spared in an oncologitally sound fashion. 2. Infraglottic extension of tumor either more than 10 mm anteriorly or more than 5 mm posterolaterally. Again, extension to these levels indicates that the cricoid cartilage is at risk for tumor involvement. 3. Extensive preepiglotte space invasion. Clinical evidence of bulging beneath the vallecula mucosa and/or extension through the thyrohyoid membranes. 4. Tumor extending to the hyoid bone superiorly or the cricoid cartilage inferiorly. Resection of these structures makes the reconstruction impossible to perform. 5. External thyroid cartilage perichondrial invasion. Extralaryngeal spread of tumor is a contraindication to conservation laryngeal surgery. Additional relative contraindications to performing SCPL-CHP include poor medical health, particularly with regard to pulmonary function. One common rule of thumb is that a patient should be able to climb two flights of stairs without experiencing shortness of breath. Poor cognitive function is also a relative contraindication to the procedure, as the post-operative rehabilitation requires a cooperative and compliant patient. Also, the procedure cannot be adequately performed in a patient who required a tracheostomy for airway protection preoperatively.
TECHNIQUE The preparation for the surgical procedure begins in the outpatient clinic. Once the decision to pursue a conservation laryngeal procedure has been made, the patient should be counseled regarding the particular risks and benefits of the procedure. Of paramount importance is obtaining consent for a total laryngectomy if it is deemed necessary intraoperatively. No patient should be brought to the operating room who has not given such consent. In addition, a preoperative or perioperative percutaneous gastrostomy tube should be considered, especially if the patient has had radiation therapy.r7 On the day of surgery the patient should have general anesthesia with oral endotracheal intubation. Preoperative intaveneous antibiotics are given that are specific for skin as well as pharyngeal flora. Preferably, the operating table should be turned 180” so that the primary surgeon can easily stand at the head of the bed during the case. The arms should be tucked at the sides with appropriate padding of the ulnar nerve region and the eyes should be protected with lubricant and tape. The entire neck and face up to the eyes should be prepared and draped in sterile fashion.
The skin incision should be a bimastoid apron flap that extends no more inferiorly than 2 fingerbreadths above the sternal notch. Although some authors have advocated a separate incision for the tracheotomy site, the technique advocated by Laccourreye recommends cheostomy in line with the skin incision. lrf$gyss;: tions are not planned, a smaller incision can be considered. A superiorly-based subplatysmal flap should be raised to a level 2 cm above the hyoid bone. However, an inferiorlybased flap should not be raised so that the tracheostomy site is more easily isolated to prevent air escape into the neck postoperatively. The appropriate unilateral or bilateral neck dissection is then performed. In the region bounded by the carotid artery, hypoglossal nerve and omohyoid muscle, the superior laryngeal nodes should also be dissected and removed. The superior laryngeal neurovascular bundle should be identified and preserved bilaterally. Preservation of sensation to the larynx is essential for a successful postoperative functional course. Once the neck dissections are completed, the cervical fascia enveloping the strap muscles is divided in the midline from the superior border of the thyroid cartilage to the level of the first few tracheal rings. Then, the strap muscles, including the stemohyoid and thyrohyoid, are transected at the level of the superior border of the thyroid cartilage, not at the hyoid bone (Fig 1). These muscle flaps are reflected laterally and then secured in this reflected position with suture bilaterally. In addition, the stemothyroid muscles are again transected at the inferior border of the thyroid cartilage without injuring the underlying thyroid gland. Next, the inferior constrictors are divided along the posterolateral border of the thyroid cartilage bilaterally, and the inner perichondrium of the cartilage is elevated (Fig 2). This manuever releases the pyriform sinuses. The extent to which the perichondrium is raised on the tumorbearing side depends on the tumor’s location; often it is only raised from the posterior third of the cartilage. On the contralateral side the entire pyriform sinus should be released to the midline. Disarticulation of the cricothyroid joint is the next step. This important and delicate maneuver is performed by gently using a Freer elevator on the inferior comu of the thyroid cartilage to release the joint, taking care not to injure the recurrent laryngeal nerve (Fig 3). The surgeon should not visually identify the nerve; the area posterior and lateral to the inferior cornua of the thyroid cartilage is avoided to prevent damage to the nerve in this area. Disarticulation of the cricothyroid joint is performed bilaterally, and then the thyroid isthmus is transected and sutured. Blunt finger dissection is then performed along the anterior wall of the trachea to free the attachments that can hinder the upward mobility of the trachea during the reconstruction. At this point, the first mucosal cuts are made by incising the cricothyroid membrane along the superior border of the cricoid cartilage. The subglottic region is now inspected to rule out subglottic extension of the tumor. If the region is free of tumor, the planned conservation procedure can proceed. The endotracheal tube is removed, and a reinforced ventilation tube is inserted in the cricothyroidotomy. A second cut is now made inferior to the hyoid bone (Fig 4). The transected sternothyroid and stemohyoid muscles are reflected superiorly off the thyrohyoid memPARTIAL
LARYNGECTOMY
WITH
CRICOHYOIDOPEXY
F@lJRE 1. Transection of the strap muscles: Along the superior border of the thyroid cartilage, the stemohyoid, omohyoid and tlqrohyoid muscles are cut. The sternothyroid muscle is also transected. This is performed bilaterally.
FIGURE 3. Disarticulation of the cricothyroid joint: A Freer elevator is placed carefully between the inferior thyroid comu and the cricoid cartilage so that the recurrent laryngeal nerve is not damaged. The nerve is not identified during the dissection.
FIGURE 2. Transection of the constrictor muscles: The inferior pharyngeal constrictor muscles and the thyroid perichondrium are transected with a No. 15 blade along the posterolateral and superolateral borders of the thyroid cartilage. DUANE
SEWELL
brane, and the periosteum of the inferior hyoid bone is incised. A Freer elevator is then used to dissect the preepiglottic space from the inferior and posterior aspect of the hyoid bone. The larynx is now entered through a small transvallecular pharyngotomy, just wide enough to visualize the epiglottis. It is grasped with an Allis clamp and pulled externally. The surgeon now moves to the head of the bed, and further tumor cuts can be made under direct visualization (Fig 5). Using scissors, incisions are made so that the entire preepiglottic space is resected, but the cuts are made medial to the main trunk of the internal branch of the superior laryngeal nerve. Further tumor cuts are now made on the non-tumor bearing side. The scissors are advanced anterior to the previously released pyriform sinus. Precise cuts are made through the aryepiglottic fold and down to the level of the false cord. The false cord is transected just anterior to the arytenoids; the vocal process and true cords are transected just posterior to the ventricle. It is essential that the arytenoid cartilage be preserved on the non-tumor bearing side of the larynx. In addition, it is important not to enter the cricoarytenoid joint inadvertently so that postoperative ankylosis may be avoided. Incisions are now made connecting these prearytenoid cuts to the cricothyroidotomy. The cricothyroid and lateral cricoarytenoid muscles are transected along the superior border of the cricoid cartilage. Complete visualization of the tumor bearing side is necessary. The surgeon takes both thyroid ala in her/his hands and cracks the cartilage down the middle. It is akin to opening a book. The resection along the tumor bearing 29
4. Exposure of the larynx: The larynx is entered just below the hyoid bone, after a cricothyroidotomy is performed and an endotracheal tube placed.
FIGURE
1. Thyrohyoid membrane 2. Cricothyroid membrane.
side now proceeds under direct visualization, with appropriate margins around the tumor (Fig 6). Since the arytenoid was spared on the contralateral side, the ipsilateral arytenoid can be sacrificed partially or completely if necessary. When completely resecting this structure, the overlying mucosa must be incised so that a posteriorly based flap is created. The cricoarytenoid joint is then disarticulated on this side, and the cricothyoid musculature is removed from the cricoid cartilage. Preservation of the posterior arytenoids mucosa is crucial to postoperative swallowing function. The remainder of the resection continues as it was performed on the first side. The completed resection will include the cancer, in addition to the epiglottis, thyroid cartilage, true and false cords, and perhaps one partial or complete arytenoid. The reconstruction begins after appropriate frozen section specimens are sent to pathology. The arytenoid cartilage (or the posterior arytenoid mucosa) must be pulled forward so that it will remain in the proper position postoperatively. This is assured by placing a 4-O vicryl suture just above the vocal process (or in the arytenoid mucosa) and sewing it to the upper border of the cricoid cartilage with an air knot. The arytenoids no longer rest on the posterior pharyngeal wall. A stay suture is placed in the cut edge of the pharyngeal constrictors bilaterally, but is not tied. The cricohyoidopexy is then performed (Fig 7). A 1-O vicryl with a 6!5-mm round needle is used to place a stitch around the cricoid cartilage exactly in the midline and this stitch should be placed submucosally. Next, the needle is placed around the hyoid bone, but deep into tongue base musculature. This must be exactly in the midline and submucosal as well. Lastly, the needle is brought out of the tongue base around the hyoid bone. The stitch is not tied until two similar sutures are placed exactly 1 cm away from the midline bilaterally (Fig 8). The placement of more sutures would tether the tongue base and the neolarynx will not be adequately covered. Before tying, the cricothyroid-
5. Resection of the tumor: From the head of the operating table, the larynx is exposed and the resection begins along the less involved side.
FIGURE
e
PARTIAL
LARYNGECTOMY
WITH
CRlCOHYOlDOPEXY
FFURE 6. Resection of the tumor: After completion of the less involved side, the thyroid cartilage is cracked along its anterior sR(ne, further exposing the tumor-bearing side. The resection proceeds with adequate margins around the tumor.
otomy tube is removed, the trachea is elevated by pulling the two lateral CHP stitches taut, and a tracheotomy is performed in line with the skin incision. The ventilation tube is quickly placed in the tracheotomy. Then, the CHP sutures can be tied - the midline one first, then the two lateral ones. If they do not bring the anterior cricoid cartilage and hyoid bone in perfect symmetrical alignment, the sutures should be removed and redone. Also it is important that the cricoid is perfectly aligned with the hyoid to avoid posterior prolapse of the cricoid. This will lead to problems with laryngeal closure postoperatively and should be avoided. If a cricoid arch fractures during the closure, the CHP sutures are thrown around the first t&o tracheal rings. The stay sutures in the constrictor muscles are tied to each other in the midline loosely, repositioning the pyriform sinuses to a physiologic position. This improves postoperative swallowing function. The strap muscles are reapproximated in the midline. A tracheostomy tube can then be placed. Care should be taken during closure to separate the tracheostomy site from the rest of the wound with subcutaneous sutures. The wound is closed in two layers after suction drams are placed. In the immediate postoperative period, the patient is encouraged not to swallow her/his own secretions. If tolerated, decannulation is attempted seven to ten days postoperatively, and at this point does the patient begin to swallow carefully. The nasogastric tube is removed once that patient can sustain adequate caloric intake orally. DUANE
SEWELL
FIGURE 7. Cricohyoidopexy: Three absorbable sutures are placed in order to perform the reconstruction. The middle suture is placed precisely in the midline, with the two lateral sutures 1 cm away.
FIGURE 8. Cricohyoidopexy: The sutures are placed around the cricoid cartilage; (1) deep within the tongue base musculature (2) and deep to the mucosa of the tongue base; (3). The needle is then brought back around the hyoid bone (4).
31
RESULTS ONCOLOGIC The oncologic results of the SCPL-CHP compare favorably to the results seen with the treatment alternatives, total laryngectomy and radiotherapy.9,‘9-21 Three to fiveyear overall survival rates range from 68%22 to 84%.9,23-2” The average is roughly 75%, although a meta-analysis has not yet been performed that takes into account the differences in patient selection, followup, and method of calculation. The rate of local recurrences in most studies range from 0.0%9 to 16%,= with an average of 7.7%.9*22-24,26,2 FUNCTIONAL Another goal of this procedure is to retain the ability to swallow and maintain adequate caloric intake without permanent enteral tube feeding. Many studies have measured success in maintaining swallow function. Of those studies that calculate an average, the time to nasogastric removal is between 15 and 34 days.9*26,2g33 One to four percent of patients required a permanent gastrostOmY .9,26,33 Another measure of functional success is rate of patients who are decannulated permanently. The ran e is from 0.0% to 15%, with most studies under 10%.9z5 2z26z33 The percentage of patients that required at total laryngectomy for intractable aspiration ranged from 0.0% to ll%, but the larger studies reported rates less than 6%.9*22*u*28-W*32-a‘r Voice quality has been studied in CHP patients in conjuction with CHEP patients.35”7 In those studies, it was determined that patients who had undergone a 5CPL (both CHP and CHEP reconstruction) had speech comparable to normal controls in terms of average fundamental frequency, but had increased variability in shimmer, jitter, and noise to harmonics ratios. However, when the voice is judged objectively by simple intelligibilip an acceptable voice was achieved in 100% of patients.‘, 3,37 COMPLICATIONS The most frequent reported complications from this procedure is pneumonia as a result of aspiration. The rate of post-o erative pneumonia varies from 1.5%9 to x ,303 These pneumonias, 37 90~~.*,16, are not typically chronic and recurrent as evidenced by the low rate of permanent gastrostomy of l-4% and low rate of 6% for laryngectom2 for intractable aspiration reported in the literature. 9S2~23~26~28-30~32-34 Pneumonia was most often managed conservatively with antibiotics. Other corn lications such as dehiscence of the pexy reconstruction 3F:and laryngeal stenosis23J3 are reported but very rare. There is a slightly higher incidence of local corn lications in postradiation therapy patients after SCPL.’ ?,39
REFERENCES 1. Majer H, Reider W: Technique de laryngectomie permetant de conserver la permeabilite respiratoire la cricohyoido-pexie. Ann Otolaryngol Chir Cervicofac 76677-683, 1959 2. Vigneau D, Calvet H, F’esseyJJ, et al: [Reconstructive laryngectomies. Oncologic and functional results]. Rev Laryngol Otol Rhino1 (Bord) 109(2):145-147, 1988 3. Prades J, Martin C: Techniques et indications des laryngectomies reconstruuctives type crico-hyoidopexie et laryngectomie frontale anterieure avec epiglottoplastie. J Fr ORL 341467472, 1985
32
4. Labayle J, Dahan S: [Reconstructive laryngectomy (author’s transl)]. Ann Otolaryngol Chir Cervicofac 98(12):587-592, 1981 5. Brasnu D, Menard M, Fabre A, et al: Les laryngectornies partelles supracricoidiennes: techniques, indications et resultants. J Otolaryngo1 17:173-178, 1988 6. Bonnet P, Amoux B, Guerrier B, et al: La chirurgie reconstructive du larynx a propos de la readaption fonctionelle de malades operes de CHEF’ et de CHP. Les Cahiers d’ORL 23:%5473, 1988 7. Laccourreye 0, Weinstein G, Brasnu D, et al: Vertical partial laryngectomy: A critical analysis of local recurrence. Ann Otol Rhino1 Laryngol 100(1):68-71, 1991 8. Savary M: [Partial transverse surgery of the larynx]. Ther Umsch, 44(2):121-130, 1987 9. Laccourreye H, Laccourreye 0, Weinstein G, et al: Supracricoid laryngectomy with cricohyoidopexy: a partial laryngeal procedure for selected supraglottic and transglottic carcinomas. Laryngoscope 100(7):735-741,199o 10. Weinstein GS, El-Sawy MM, Ruiz C, et al: Laryngeal preservation with supracricoid partial laryngectomy results in improved quality of life when compared with total laryngectomy. Laryngoscope ill(2): 191-199, 2001 11. Brasnu D, Laccourreye H, Dulmet E, et al: Mobility of the vocal cord and arytenoid in squamous cell carcinoma of the larynx and hypopharynx: an anatomical and clinical comparative study. Ear Nose Throat J 69(5):324-330, 1990 12. Kirchner JA, Som ML: Clinical significance of fixed vocal cord. Laryngoscope, 81(7):1029-1244, 1971 13. Hirano M, Kurita S, Matsuoka H, et al: Vocal fold fixation in laryngeal carcinomas. Acta Otolaryngol, ill(2): 449454, 1991 14. Laccourreye 0, Brasnu D, Biacabe B, et al: Neo-adjuvant chemotherapy and supracricoid partial laryngectomy with cricohyoidopexy for advanced endolaryngeal carcinoma classified as T3-T4: Iyear oncologic results. Head Neck, 20(7):595-599, 1998 15. Weinstein GS, Laccourreye 0, Brasnu D, et al: The role of computed tomography and magnetic resonance imaging in planning for conservation laryngeal surgery. Neuroimaging Clin N Am, 6(2):497-504, 1996 16. Brasnu DF, Hart1 DM, Laccourreye H: Supracricoid partial laryngectomy with cricohyoidopexy, in Weinstein GS, Laccourreye 0, Brasnu D, Laccourreye H (eds). Organ Preservation Surgery for Laryngeal Cancer, San Diego, CA, Singular Publishing, 2000, pp 127-143. 17. Laccourreye 0, Weinstein G, Naudo P, et al: Supracricoid partial laryngectomy after failed laryngeal radiation therapy. Laryngoscope 106(4):495498, 1996 16. de Vincentiis M, Minni A, Gallo A: Supracricoid laryngectomy with cricohyoidopexy (CHP) in the treatment of laryngeal cancer: A functional and oncologic experience. Laryngoscope 106(9 Pt l):llO&1114, 1996 19. Robbins KT, Davidson W, Peters LJ, et al: Conservation surgery for T2 and T3 carcinomas of the supraglottic larynx. Arch Otolaryngol Head Neck Surg 114(4):421426, 1988 20. Hinerman RW, Mendenhall WM, Amdur RJ, et al: Carcinoma of the supraglottic larynx: treatment results with radiotherapy alone or with planned neck dissection. Head Neck 24(5): 456-467, 2002 21. Mendenhall WM, Parsons JT, Mancuso AA, et al: Radiotherapy for squamous cell carcinoma of the supraglottic larynx: an alternative to surgery. Head Neck 18(1):2435, 1996 22. Bron L, Brossard E, Monnier P, et al: Supracricoid partial laryngectomy with cricohyoidwpiglottopexy and cricohyoidopexy for glottic and supraglottic carcinomas. Laryngoscope 110(4):627-634, 2000 23. Laccourreye 0, Brasnu D, Merite-Drancy A, et al: Cricohyoidopexy in selected infrahyoid epiglottic carcinomas presenting with pathological preepiglottic space invasion. Arch Otolaryngol Head Neck Surg 119(8):881-886, 1993 24. Chevalier D, Piquet JJ: Subtotal laryngectomy with cricohyoidopexy for supraglottic carcinoma: review of 61 cases. Am J Surg 168(5): 472473, 1994 25. Zietek E, Sieczka J, Jaworowska E, et al: [Own experience in supracricoid laryngectomy with GHP and GHEP type of reconstruction due to larynx cancer]. Otolaryngol Pal. 55(3): 247-253, 2001 26. de Vincentiis M, Minni A, Gallo A, et al: Supracricoid partial laryngectomies: oncologic and functional results. Head Neck 20(6):504 509,1998 PARTIAL LARYNGECTOMY
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27. Piquet JJ, Darras JA, Berrter A, et al: [Functional subtotal laryngectomies with cricohyoidopexy. Technics, indications, results]. Ann Otolaryngol Chir Cervicofac 103(6): 411-415, 1986 28. Pech A, Cannoni M, Giovanni A, et al: [Requisite selection of surgical technics in the treatment of cancer of the larynx]. Ann Otolaryngol Chir Cervicofac 103(8):565-575, 1986 29. Marandas P, Luboinski B, Leridant AM, et al: [Functional surgery in cancer of the laryngeal vestibule. Apropos of 149 cases treated at the lnstitut Gustave-Roussy]. Ann Otolaryngol Chir Cervicofac 104(4): 259-265,
1987
30. Prades JM, Martin C, Garban T, et al: [Reconstructive laryngectomies. Technical and functional aspects]. Ann Otolaryngol Chir Cervicofac lC4(4):281-287, 1987 31. Shenoy AM, Kumar SS, Nanjundappa-Prasad S, et al: Supracricoid laryngectomy with Cricohyoidopexy-a clinico oncological & functional experience. Indian J Cancer 37(2-3):67-73, 2000 32 Junien-Lavillauroy C, Barthez M, Roux 0, et al: [Analysis of failures in cancers of the larynx treated by crico-hyoidopexy]. Rev Laryngol Otol Rhino1 (Bord) 109(1):47-50, 1988 33. Naudo P, Laccourreye 0, Weinstein G, et al: Functional outcome and prognosis factors after supracricoid partial laryngec-
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SWELL
tomy with cricohyoidopexy. 296,
Ann Otol Rhino1 Laryngol
106(4):291-
1997
34. Weinstein GS, Laccourreye 0, Rassekh C: Conservation laryngeal surgery, in Cu mmings C, Fredrickson JM, Harker LA, Krause CJ, Richardson MA, Schuller DE, (eds) Otolaryngology-Head and Neck Surgery. St. Louis, Mosby, 1998, pp 22002228 35. Crevier-Buchman L, Laccourreye 0, Weinstein G, et al: Evolution of speech and voice following supracricoid partial laryngectomy. J Laryngol Otol 109(5):410-413, 1995 36. Laccourreye 0, Crevier-Buchmann L, Weinstein G, et al: Duration and frequency characteristics of speech and voice following supracricoid partial laryngectomy. Ann Otol Rhino1 Laryngol, 104(7):516-521, 1995
Zacharek MA, Pasha R, Meleca RJ, et al: Functional outcomes after supracricoid laryngectomy. Laryngoscope 111(9):1558-1564,2001 38. Laccourreye 0, Brasnu D, Laccourreye L, et al: Ruptured pexis after supracricoid partial laryngectomy. Ann Otol Rhino1 Laryngol 106(2): 159-162, 1997 39. Spriano G, Pelini R, Roman0 G, et al: Supracricoid partial laryngectomy as salvage surgery after radiation failure. Head Neck 24(8):75937.
765‘2002
33
LARYNGECTOMY
MD
The supracricoid partial laryngectomy (SCPL) with cricohyoidopexy (CHP) is an alternative to total laryngectomy in the treatment of selected glottic and supraglottic cancers. It consists of the resection of the true cords, false cords, thyroid cartilage and epiglottis, while the cricoid cartilage and at least one of the two arytenoid cartilages are spared. Reconstruction is performed by securing the cricoid cartilage to the hyoid bone. Careful patient selection is of paramount importance for the success of this procedure. In general, the indications for SCPL with CHP include selected supraglottic and glottic tumors that do not involve the subglottis or the arytenoid cartilages. When properly performed, the speech and swallowing function is preserved in a high percentage of patients. The specific indications and the surgical technique are presented here.
The supracricoid partial laryngectomy (SCPL) with cricohyoidopexy (CHP) was first described by Austrian surgeons in 1959 as an alternative to total laryngectomy in the tibatrnent of selected glottic and supraglottic cancers.’ Their report describes a procedure in which the true cords, false cords, thyroid cartilage and epiglottis are resected, but the cricoid cartilage and at least one arytenoid cartilage are left in situ. Reconstruction involves the suturing of the cricoid cartilage to the hyoid bone; hence the term “cricohyoidopexy”. The expected result of SCPL with CHP is the surgical eradication of the cancer while preserving speech and swallowing function and avoiding a permanent tracheal stoma. This technique gained popularity in Europe during the ensuing three decades, and in the 1980s several papers were ublished on the indications and functional results.2 2 The other open partial surgical alternatives to total laryngectomy for supraglottic cancer, namely the supraglottic partial laryngectomy, is contraindicated for cancers which involve the glottic level, inpaired mobility of the vocal cord, or have early invasion of the thyroid cartila e (none of which are contraindications to SCPL-CHP). 5,’ Gradually, as performance of the SCPL with CHP became more common in Europe, surgeons in the United States began to perform the procedure with excellent results.‘,”
PATIENT
SELECTION
Patient selection is of paramount importance in the ultimate success of this procedure. When first evaluating a patient suspected of laryngeal cancer, a thorough history must be taken. In addition to asking the standard questions asked of all head and neck cancer patients, careful attention must be paid to the general state of health of the patient and the ability to perform activities of daily living. Inquiries should be made about the patient’s ability for From the Department of Otolaryngology, School of Medicine, Philadelphia, PA Address reprint requests to Duane Sewell, 323 Johnson Pavilion, 3610 Hamilton Walk, (B 2003 Elsevier Inc. All rights reserved. 1043-1610/03/1401-0001$30.00/0 doi:lO.l053/otot.2003.36471 OPERATIVE
TECHNIQUES
University
of Pennsylvania
University Philadelphia,
of Pennsylvania, PA 19104.
IN OTOLARYNGOLOGY-HEAD
AND
NECK
exercise tolerance. Not to be overlooked is the patient’s cognitive function and the willingness to follow instruction, as these are critical components to successful postoperative rehabilitation. Following a general head and neck physical examination, several areas are essential to assess. On neck examination, pain upon palpation of the thyroid cartilage or the region of the thyrohyoid membrane may indicate thyroid cartilage or massive pre-epiglotic space invasion and should be duly noted. On laryngoscopic examination, it is of utmost importance to determine the precise extent of the tumor. Not only must the mobility of the true cord be evaluated, but also the mobility of the arytenoids cartilages. It is critical to distinguish between the two. Although the true cord can be fixed due to thyroartenoid muscle invasion by tumor, the arytenoid cartila es may remain mobile and uninvolved by the tumor.“- 8 Arytenoid fixation is a contraindication to the SCPL-CHP because this may be related to cricarytenoid joint involvement, leading to a positive margin in this area. However, it has been reported that the use of neo-adjuvant chemotherapy has led to the re-mobilization of a fixed arytenoid and has allowed certain patients to then undergo the SCPL-CHP.14 Ultimately, the patient should be brought to the operating room for a direct laryngoscopy and biopsy to complete a thorough examination of the larynx. At that time, a percutaneous gastrostomy can be performed to allow for ease of administration of tube feeds postoperatively and avoidance of a nasogastric tube. Routinely, a computed tomography (CT) scan or magnetic resonance imaging (MRI) of the neck is also performed to help define the extent of the tumor and the status of the nodal involvement.15 Upon completion of the history and physical examination, it can be decided whether the patient is a candidate for organ preservation surgery of the larynx. In general, SCPL-CHP can be considered for selected supraglottic tumors that extend into the ventricle or glottis, and are therefore not amenable to a supraglottic laryngectomy. This procedure may also be indicated for glottic tumors that extend into the supraglottis cross the midline and are not ideal candidates for laser cordectomy or vertical partial hemilaryngectomy. SURGERY,
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2003:
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27
More specifically, clude the following:
the indications
for this procedure
in-
1. Selected Tl supraglottic tumors involving the infrahyoid epiglottis or ventricle. 2. Selected T2 transglottic and supraglottic tumors. 3. Selected T3 transglottic and supraglottic tumors with true vocal cord fixation and/or limited prepiglottic space invasion, but without arytenoid fixation. 4. Selected T4 transglottic and supraglottic tumors with limited invasion of the thyroid ala without extension through the outer perichondrium.‘,“j The major contraindications
include the following:
1. Arytenoid cartilage fixation. Unlike true vocal fold fixation, arytenoid fixation reflects invasion of the cricoarytenoid musculature or the cricoarytenoid joint. The cricoid cartilage, therefore, cannot be spared in an oncologitally sound fashion. 2. Infraglottic extension of tumor either more than 10 mm anteriorly or more than 5 mm posterolaterally. Again, extension to these levels indicates that the cricoid cartilage is at risk for tumor involvement. 3. Extensive preepiglotte space invasion. Clinical evidence of bulging beneath the vallecula mucosa and/or extension through the thyrohyoid membranes. 4. Tumor extending to the hyoid bone superiorly or the cricoid cartilage inferiorly. Resection of these structures makes the reconstruction impossible to perform. 5. External thyroid cartilage perichondrial invasion. Extralaryngeal spread of tumor is a contraindication to conservation laryngeal surgery. Additional relative contraindications to performing SCPL-CHP include poor medical health, particularly with regard to pulmonary function. One common rule of thumb is that a patient should be able to climb two flights of stairs without experiencing shortness of breath. Poor cognitive function is also a relative contraindication to the procedure, as the post-operative rehabilitation requires a cooperative and compliant patient. Also, the procedure cannot be adequately performed in a patient who required a tracheostomy for airway protection preoperatively.
TECHNIQUE The preparation for the surgical procedure begins in the outpatient clinic. Once the decision to pursue a conservation laryngeal procedure has been made, the patient should be counseled regarding the particular risks and benefits of the procedure. Of paramount importance is obtaining consent for a total laryngectomy if it is deemed necessary intraoperatively. No patient should be brought to the operating room who has not given such consent. In addition, a preoperative or perioperative percutaneous gastrostomy tube should be considered, especially if the patient has had radiation therapy.r7 On the day of surgery the patient should have general anesthesia with oral endotracheal intubation. Preoperative intaveneous antibiotics are given that are specific for skin as well as pharyngeal flora. Preferably, the operating table should be turned 180” so that the primary surgeon can easily stand at the head of the bed during the case. The arms should be tucked at the sides with appropriate padding of the ulnar nerve region and the eyes should be protected with lubricant and tape. The entire neck and face up to the eyes should be prepared and draped in sterile fashion.
The skin incision should be a bimastoid apron flap that extends no more inferiorly than 2 fingerbreadths above the sternal notch. Although some authors have advocated a separate incision for the tracheotomy site, the technique advocated by Laccourreye recommends cheostomy in line with the skin incision. lrf$gyss;: tions are not planned, a smaller incision can be considered. A superiorly-based subplatysmal flap should be raised to a level 2 cm above the hyoid bone. However, an inferiorlybased flap should not be raised so that the tracheostomy site is more easily isolated to prevent air escape into the neck postoperatively. The appropriate unilateral or bilateral neck dissection is then performed. In the region bounded by the carotid artery, hypoglossal nerve and omohyoid muscle, the superior laryngeal nodes should also be dissected and removed. The superior laryngeal neurovascular bundle should be identified and preserved bilaterally. Preservation of sensation to the larynx is essential for a successful postoperative functional course. Once the neck dissections are completed, the cervical fascia enveloping the strap muscles is divided in the midline from the superior border of the thyroid cartilage to the level of the first few tracheal rings. Then, the strap muscles, including the stemohyoid and thyrohyoid, are transected at the level of the superior border of the thyroid cartilage, not at the hyoid bone (Fig 1). These muscle flaps are reflected laterally and then secured in this reflected position with suture bilaterally. In addition, the stemothyroid muscles are again transected at the inferior border of the thyroid cartilage without injuring the underlying thyroid gland. Next, the inferior constrictors are divided along the posterolateral border of the thyroid cartilage bilaterally, and the inner perichondrium of the cartilage is elevated (Fig 2). This manuever releases the pyriform sinuses. The extent to which the perichondrium is raised on the tumorbearing side depends on the tumor’s location; often it is only raised from the posterior third of the cartilage. On the contralateral side the entire pyriform sinus should be released to the midline. Disarticulation of the cricothyroid joint is the next step. This important and delicate maneuver is performed by gently using a Freer elevator on the inferior comu of the thyroid cartilage to release the joint, taking care not to injure the recurrent laryngeal nerve (Fig 3). The surgeon should not visually identify the nerve; the area posterior and lateral to the inferior cornua of the thyroid cartilage is avoided to prevent damage to the nerve in this area. Disarticulation of the cricothyroid joint is performed bilaterally, and then the thyroid isthmus is transected and sutured. Blunt finger dissection is then performed along the anterior wall of the trachea to free the attachments that can hinder the upward mobility of the trachea during the reconstruction. At this point, the first mucosal cuts are made by incising the cricothyroid membrane along the superior border of the cricoid cartilage. The subglottic region is now inspected to rule out subglottic extension of the tumor. If the region is free of tumor, the planned conservation procedure can proceed. The endotracheal tube is removed, and a reinforced ventilation tube is inserted in the cricothyroidotomy. A second cut is now made inferior to the hyoid bone (Fig 4). The transected sternothyroid and stemohyoid muscles are reflected superiorly off the thyrohyoid memPARTIAL
LARYNGECTOMY
WITH
CRICOHYOIDOPEXY
F@lJRE 1. Transection of the strap muscles: Along the superior border of the thyroid cartilage, the stemohyoid, omohyoid and tlqrohyoid muscles are cut. The sternothyroid muscle is also transected. This is performed bilaterally.
FIGURE 3. Disarticulation of the cricothyroid joint: A Freer elevator is placed carefully between the inferior thyroid comu and the cricoid cartilage so that the recurrent laryngeal nerve is not damaged. The nerve is not identified during the dissection.
FIGURE 2. Transection of the constrictor muscles: The inferior pharyngeal constrictor muscles and the thyroid perichondrium are transected with a No. 15 blade along the posterolateral and superolateral borders of the thyroid cartilage. DUANE
SEWELL
brane, and the periosteum of the inferior hyoid bone is incised. A Freer elevator is then used to dissect the preepiglottic space from the inferior and posterior aspect of the hyoid bone. The larynx is now entered through a small transvallecular pharyngotomy, just wide enough to visualize the epiglottis. It is grasped with an Allis clamp and pulled externally. The surgeon now moves to the head of the bed, and further tumor cuts can be made under direct visualization (Fig 5). Using scissors, incisions are made so that the entire preepiglottic space is resected, but the cuts are made medial to the main trunk of the internal branch of the superior laryngeal nerve. Further tumor cuts are now made on the non-tumor bearing side. The scissors are advanced anterior to the previously released pyriform sinus. Precise cuts are made through the aryepiglottic fold and down to the level of the false cord. The false cord is transected just anterior to the arytenoids; the vocal process and true cords are transected just posterior to the ventricle. It is essential that the arytenoid cartilage be preserved on the non-tumor bearing side of the larynx. In addition, it is important not to enter the cricoarytenoid joint inadvertently so that postoperative ankylosis may be avoided. Incisions are now made connecting these prearytenoid cuts to the cricothyroidotomy. The cricothyroid and lateral cricoarytenoid muscles are transected along the superior border of the cricoid cartilage. Complete visualization of the tumor bearing side is necessary. The surgeon takes both thyroid ala in her/his hands and cracks the cartilage down the middle. It is akin to opening a book. The resection along the tumor bearing 29
4. Exposure of the larynx: The larynx is entered just below the hyoid bone, after a cricothyroidotomy is performed and an endotracheal tube placed.
FIGURE
1. Thyrohyoid membrane 2. Cricothyroid membrane.
side now proceeds under direct visualization, with appropriate margins around the tumor (Fig 6). Since the arytenoid was spared on the contralateral side, the ipsilateral arytenoid can be sacrificed partially or completely if necessary. When completely resecting this structure, the overlying mucosa must be incised so that a posteriorly based flap is created. The cricoarytenoid joint is then disarticulated on this side, and the cricothyoid musculature is removed from the cricoid cartilage. Preservation of the posterior arytenoids mucosa is crucial to postoperative swallowing function. The remainder of the resection continues as it was performed on the first side. The completed resection will include the cancer, in addition to the epiglottis, thyroid cartilage, true and false cords, and perhaps one partial or complete arytenoid. The reconstruction begins after appropriate frozen section specimens are sent to pathology. The arytenoid cartilage (or the posterior arytenoid mucosa) must be pulled forward so that it will remain in the proper position postoperatively. This is assured by placing a 4-O vicryl suture just above the vocal process (or in the arytenoid mucosa) and sewing it to the upper border of the cricoid cartilage with an air knot. The arytenoids no longer rest on the posterior pharyngeal wall. A stay suture is placed in the cut edge of the pharyngeal constrictors bilaterally, but is not tied. The cricohyoidopexy is then performed (Fig 7). A 1-O vicryl with a 6!5-mm round needle is used to place a stitch around the cricoid cartilage exactly in the midline and this stitch should be placed submucosally. Next, the needle is placed around the hyoid bone, but deep into tongue base musculature. This must be exactly in the midline and submucosal as well. Lastly, the needle is brought out of the tongue base around the hyoid bone. The stitch is not tied until two similar sutures are placed exactly 1 cm away from the midline bilaterally (Fig 8). The placement of more sutures would tether the tongue base and the neolarynx will not be adequately covered. Before tying, the cricothyroid-
5. Resection of the tumor: From the head of the operating table, the larynx is exposed and the resection begins along the less involved side.
FIGURE
e
PARTIAL
LARYNGECTOMY
WITH
CRlCOHYOlDOPEXY
FFURE 6. Resection of the tumor: After completion of the less involved side, the thyroid cartilage is cracked along its anterior sR(ne, further exposing the tumor-bearing side. The resection proceeds with adequate margins around the tumor.
otomy tube is removed, the trachea is elevated by pulling the two lateral CHP stitches taut, and a tracheotomy is performed in line with the skin incision. The ventilation tube is quickly placed in the tracheotomy. Then, the CHP sutures can be tied - the midline one first, then the two lateral ones. If they do not bring the anterior cricoid cartilage and hyoid bone in perfect symmetrical alignment, the sutures should be removed and redone. Also it is important that the cricoid is perfectly aligned with the hyoid to avoid posterior prolapse of the cricoid. This will lead to problems with laryngeal closure postoperatively and should be avoided. If a cricoid arch fractures during the closure, the CHP sutures are thrown around the first t&o tracheal rings. The stay sutures in the constrictor muscles are tied to each other in the midline loosely, repositioning the pyriform sinuses to a physiologic position. This improves postoperative swallowing function. The strap muscles are reapproximated in the midline. A tracheostomy tube can then be placed. Care should be taken during closure to separate the tracheostomy site from the rest of the wound with subcutaneous sutures. The wound is closed in two layers after suction drams are placed. In the immediate postoperative period, the patient is encouraged not to swallow her/his own secretions. If tolerated, decannulation is attempted seven to ten days postoperatively, and at this point does the patient begin to swallow carefully. The nasogastric tube is removed once that patient can sustain adequate caloric intake orally. DUANE
SEWELL
FIGURE 7. Cricohyoidopexy: Three absorbable sutures are placed in order to perform the reconstruction. The middle suture is placed precisely in the midline, with the two lateral sutures 1 cm away.
FIGURE 8. Cricohyoidopexy: The sutures are placed around the cricoid cartilage; (1) deep within the tongue base musculature (2) and deep to the mucosa of the tongue base; (3). The needle is then brought back around the hyoid bone (4).
31
RESULTS ONCOLOGIC The oncologic results of the SCPL-CHP compare favorably to the results seen with the treatment alternatives, total laryngectomy and radiotherapy.9,‘9-21 Three to fiveyear overall survival rates range from 68%22 to 84%.9,23-2” The average is roughly 75%, although a meta-analysis has not yet been performed that takes into account the differences in patient selection, followup, and method of calculation. The rate of local recurrences in most studies range from 0.0%9 to 16%,= with an average of 7.7%.9*22-24,26,2 FUNCTIONAL Another goal of this procedure is to retain the ability to swallow and maintain adequate caloric intake without permanent enteral tube feeding. Many studies have measured success in maintaining swallow function. Of those studies that calculate an average, the time to nasogastric removal is between 15 and 34 days.9*26,2g33 One to four percent of patients required a permanent gastrostOmY .9,26,33 Another measure of functional success is rate of patients who are decannulated permanently. The ran e is from 0.0% to 15%, with most studies under 10%.9z5 2z26z33 The percentage of patients that required at total laryngectomy for intractable aspiration ranged from 0.0% to ll%, but the larger studies reported rates less than 6%.9*22*u*28-W*32-a‘r Voice quality has been studied in CHP patients in conjuction with CHEP patients.35”7 In those studies, it was determined that patients who had undergone a 5CPL (both CHP and CHEP reconstruction) had speech comparable to normal controls in terms of average fundamental frequency, but had increased variability in shimmer, jitter, and noise to harmonics ratios. However, when the voice is judged objectively by simple intelligibilip an acceptable voice was achieved in 100% of patients.‘, 3,37 COMPLICATIONS The most frequent reported complications from this procedure is pneumonia as a result of aspiration. The rate of post-o erative pneumonia varies from 1.5%9 to x ,303 These pneumonias, 37 90~~.*,16, are not typically chronic and recurrent as evidenced by the low rate of permanent gastrostomy of l-4% and low rate of 6% for laryngectom2 for intractable aspiration reported in the literature. 9S2~23~26~28-30~32-34 Pneumonia was most often managed conservatively with antibiotics. Other corn lications such as dehiscence of the pexy reconstruction 3F:and laryngeal stenosis23J3 are reported but very rare. There is a slightly higher incidence of local corn lications in postradiation therapy patients after SCPL.’ ?,39
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4. Labayle J, Dahan S: [Reconstructive laryngectomy (author’s transl)]. Ann Otolaryngol Chir Cervicofac 98(12):587-592, 1981 5. Brasnu D, Menard M, Fabre A, et al: Les laryngectornies partelles supracricoidiennes: techniques, indications et resultants. J Otolaryngo1 17:173-178, 1988 6. Bonnet P, Amoux B, Guerrier B, et al: La chirurgie reconstructive du larynx a propos de la readaption fonctionelle de malades operes de CHEF’ et de CHP. Les Cahiers d’ORL 23:%5473, 1988 7. Laccourreye 0, Weinstein G, Brasnu D, et al: Vertical partial laryngectomy: A critical analysis of local recurrence. Ann Otol Rhino1 Laryngol 100(1):68-71, 1991 8. Savary M: [Partial transverse surgery of the larynx]. Ther Umsch, 44(2):121-130, 1987 9. Laccourreye H, Laccourreye 0, Weinstein G, et al: Supracricoid laryngectomy with cricohyoidopexy: a partial laryngeal procedure for selected supraglottic and transglottic carcinomas. Laryngoscope 100(7):735-741,199o 10. Weinstein GS, El-Sawy MM, Ruiz C, et al: Laryngeal preservation with supracricoid partial laryngectomy results in improved quality of life when compared with total laryngectomy. Laryngoscope ill(2): 191-199, 2001 11. Brasnu D, Laccourreye H, Dulmet E, et al: Mobility of the vocal cord and arytenoid in squamous cell carcinoma of the larynx and hypopharynx: an anatomical and clinical comparative study. Ear Nose Throat J 69(5):324-330, 1990 12. Kirchner JA, Som ML: Clinical significance of fixed vocal cord. Laryngoscope, 81(7):1029-1244, 1971 13. Hirano M, Kurita S, Matsuoka H, et al: Vocal fold fixation in laryngeal carcinomas. Acta Otolaryngol, ill(2): 449454, 1991 14. Laccourreye 0, Brasnu D, Biacabe B, et al: Neo-adjuvant chemotherapy and supracricoid partial laryngectomy with cricohyoidopexy for advanced endolaryngeal carcinoma classified as T3-T4: Iyear oncologic results. Head Neck, 20(7):595-599, 1998 15. Weinstein GS, Laccourreye 0, Brasnu D, et al: The role of computed tomography and magnetic resonance imaging in planning for conservation laryngeal surgery. Neuroimaging Clin N Am, 6(2):497-504, 1996 16. Brasnu DF, Hart1 DM, Laccourreye H: Supracricoid partial laryngectomy with cricohyoidopexy, in Weinstein GS, Laccourreye 0, Brasnu D, Laccourreye H (eds). Organ Preservation Surgery for Laryngeal Cancer, San Diego, CA, Singular Publishing, 2000, pp 127-143. 17. Laccourreye 0, Weinstein G, Naudo P, et al: Supracricoid partial laryngectomy after failed laryngeal radiation therapy. Laryngoscope 106(4):495498, 1996 16. de Vincentiis M, Minni A, Gallo A: Supracricoid laryngectomy with cricohyoidopexy (CHP) in the treatment of laryngeal cancer: A functional and oncologic experience. Laryngoscope 106(9 Pt l):llO&1114, 1996 19. Robbins KT, Davidson W, Peters LJ, et al: Conservation surgery for T2 and T3 carcinomas of the supraglottic larynx. Arch Otolaryngol Head Neck Surg 114(4):421426, 1988 20. Hinerman RW, Mendenhall WM, Amdur RJ, et al: Carcinoma of the supraglottic larynx: treatment results with radiotherapy alone or with planned neck dissection. Head Neck 24(5): 456-467, 2002 21. Mendenhall WM, Parsons JT, Mancuso AA, et al: Radiotherapy for squamous cell carcinoma of the supraglottic larynx: an alternative to surgery. Head Neck 18(1):2435, 1996 22. Bron L, Brossard E, Monnier P, et al: Supracricoid partial laryngectomy with cricohyoidwpiglottopexy and cricohyoidopexy for glottic and supraglottic carcinomas. Laryngoscope 110(4):627-634, 2000 23. Laccourreye 0, Brasnu D, Merite-Drancy A, et al: Cricohyoidopexy in selected infrahyoid epiglottic carcinomas presenting with pathological preepiglottic space invasion. Arch Otolaryngol Head Neck Surg 119(8):881-886, 1993 24. Chevalier D, Piquet JJ: Subtotal laryngectomy with cricohyoidopexy for supraglottic carcinoma: review of 61 cases. Am J Surg 168(5): 472473, 1994 25. Zietek E, Sieczka J, Jaworowska E, et al: [Own experience in supracricoid laryngectomy with GHP and GHEP type of reconstruction due to larynx cancer]. Otolaryngol Pal. 55(3): 247-253, 2001 26. de Vincentiis M, Minni A, Gallo A, et al: Supracricoid partial laryngectomies: oncologic and functional results. Head Neck 20(6):504 509,1998 PARTIAL LARYNGECTOMY
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27. Piquet JJ, Darras JA, Berrter A, et al: [Functional subtotal laryngectomies with cricohyoidopexy. Technics, indications, results]. Ann Otolaryngol Chir Cervicofac 103(6): 411-415, 1986 28. Pech A, Cannoni M, Giovanni A, et al: [Requisite selection of surgical technics in the treatment of cancer of the larynx]. Ann Otolaryngol Chir Cervicofac 103(8):565-575, 1986 29. Marandas P, Luboinski B, Leridant AM, et al: [Functional surgery in cancer of the laryngeal vestibule. Apropos of 149 cases treated at the lnstitut Gustave-Roussy]. Ann Otolaryngol Chir Cervicofac 104(4): 259-265,
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30. Prades JM, Martin C, Garban T, et al: [Reconstructive laryngectomies. Technical and functional aspects]. Ann Otolaryngol Chir Cervicofac lC4(4):281-287, 1987 31. Shenoy AM, Kumar SS, Nanjundappa-Prasad S, et al: Supracricoid laryngectomy with Cricohyoidopexy-a clinico oncological & functional experience. Indian J Cancer 37(2-3):67-73, 2000 32 Junien-Lavillauroy C, Barthez M, Roux 0, et al: [Analysis of failures in cancers of the larynx treated by crico-hyoidopexy]. Rev Laryngol Otol Rhino1 (Bord) 109(1):47-50, 1988 33. Naudo P, Laccourreye 0, Weinstein G, et al: Functional outcome and prognosis factors after supracricoid partial laryngec-
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tomy with cricohyoidopexy. 296,
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34. Weinstein GS, Laccourreye 0, Rassekh C: Conservation laryngeal surgery, in Cu mmings C, Fredrickson JM, Harker LA, Krause CJ, Richardson MA, Schuller DE, (eds) Otolaryngology-Head and Neck Surgery. St. Louis, Mosby, 1998, pp 22002228 35. Crevier-Buchman L, Laccourreye 0, Weinstein G, et al: Evolution of speech and voice following supracricoid partial laryngectomy. J Laryngol Otol 109(5):410-413, 1995 36. Laccourreye 0, Crevier-Buchmann L, Weinstein G, et al: Duration and frequency characteristics of speech and voice following supracricoid partial laryngectomy. Ann Otol Rhino1 Laryngol, 104(7):516-521, 1995
Zacharek MA, Pasha R, Meleca RJ, et al: Functional outcomes after supracricoid laryngectomy. Laryngoscope 111(9):1558-1564,2001 38. Laccourreye 0, Brasnu D, Laccourreye L, et al: Ruptured pexis after supracricoid partial laryngectomy. Ann Otol Rhino1 Laryngol 106(2): 159-162, 1997 39. Spriano G, Pelini R, Roman0 G, et al: Supracricoid partial laryngectomy as salvage surgery after radiation failure. Head Neck 24(8):75937.
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