Supracricoid and Supraglottic
SOURCE: Dept. of Otolaryngology, UTMB, Grand Rounds
DATE: April 3, 1996
RESIDENT PHYSICIAN: Kathleen R. McDonald, M.D.
FACULTY: Byron J. Bailey, M.D.
SERIES EDITOR: Francis B. Quinn, Jr., M.D.
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The goal of conservative laryngeal surgery for glottic carcinoma is to achieve local control and also to preserve the physiologic functions of the larynx. In this report I will go into more detail on two of the many conservative laryngectomy procedures and they are the Supracricoid and Supraglottic Laryngectomy.
The supraglottic and supracricoid laryngectomy are surgical procedures that conserve the function of the larynx. The idea of this surgery is based on the known features of laryngeal lymphatics and embryology. The larynx arises from right and left halves and from laryngeal analog that develop above and below the level of the true vocal cords at the site of the embryonic laryngotracheal membrane. The level of the glottis and anterior the lymphatic are sparse, but in the supraglottic and subglottic and posterior half of the larynx the lymphatics are rich and tend to cross the midline. This fact makes all supraglottic primary cancers, with the exception of T1 suprahyoid epiglottic lesion, at risk of metastasizing to the neck. Most are also midline and have the propensity for bilateral neck metastasis due to the crossing of lymphatics.
The laryngeal framework is divided by four fibroelastic membranes which affect the spread of carcinoma. They are the conus elasticus, the quadrangular membrane, the thyrohyoid membrane and the hyoepiglottic ligament. The conus elasticus arises from the cricoid cartilage attaching anteriorly in the midline to the lower margin of the thyroid cartilage, vocalis muscle and ligament. Posteriorly, it attaches to the vocal process of the arytenoid cartilage. The quadrangular membrane extends between the arytenoid cartilage and the margin of the epiglottis. The thyrohyoid membrane connects the superior border of the thyroid cartilage with the inferior margin of the greater cornu of the hyoid bone. The hyoepiglottic ligament is a connective tissue structure that serves as the roof of the paraglottic space and the preepiglottic space. It anatomically separates the supraglottic larynx from the base of the tongue. All four of these membranes inhibit the spread and invasion of carcinoma.
The membranes above form the laryngeal compartments which help us understand the spread of laryngeal carcinoma. The pre-epiglottic space is bounded by the hyoepiglottic ligament superiorly, the thyroid cartilage and the thyrohyoid membrane anteriorly, and the epiglottis and thyroepiglottic ligament posteriorly. The insertion of the vocalis tendon into the thyroid cartilage, Broyles’ tendon, permits tumor invasion of the cartilage because of the lack of thyroid perichondrium in this area. This also allows invasion into the pre-epiglottic space. The pre-epiglottic space is also involved when infrahyoid epiglottis carcinoma invades through the epiglottic cartilage fenestration. Invasion lateral to the ventricle will enter the paraglottic space. The vocal process and arytenoids are more likely be invaded by lesions involving the posterior third of the true vocal cords. Cancers of the epiglottis tend to have a pushing nature and remain supraglottic until late in their progression when paraglottic spread leads to cordal fixation and upstaging of the carcinoma.
Supraglottic laryngectomy was first described by Alonso in 1947 and then later modified to its current form by Ogura and Biller. The supraglottic larynx is comprised of the epiglottis, the false vocal cords, the aryepiglottic fords, the arytenoid cartilages, and the ventricle. The standard supraglottic laryngectomy involves the removal of these part plus the upper one third of the thyroid cartilage and the thyrohyoid membrane. The true vocal cords and arytenoids remain in place to allow vocalization and deglutition. The oncological basis for this procedure is involves the previously mentioned membranes and there resistance to spread into other compartments of the larynx. A recent study by Weinstein et al disputed the resistance to spread of the supraglottic region into the glottis though. The most common application for supraglottic laryngectomy are for carcinomas involving the supraglottis but it may also be used for management of the acutely traumatized supraglottis and in delayed strictures that occur after infection or injury.
A through history and physical exam is needed including Machida scope exam of the larynx to assess vocal cord function and airway. Typically the patients initially experiences some odynophagia on swallowing. As the tumor progresses, significant dysphagia are often present. Laryngeal symptoms are many are many time absent of late findings.
The x-ray examination should include a CT of the larynx and neck, chest x-ray, and barium swallow. Routine metastatic labs should be ordered. The ancillary departments such a Speech Pathology and Radiation Therapy are consulted. In place of a CT a MRI exam my be obtained. This may help in determining of the presence or absence of pre-epiglottic or paraglottic space invasion. suprahyoid epiglottic lesions (T1) by definition do not have pre-epiglottic space invasion. Even though most T1 infrahyoid epiglottic lesions do have occult pre-epiglottic space invasion in a high percentage of cases. A chest CT may be ordered even in the presence of a normal chest x-ray due to the high incidence of pulmonary metastasis with supraglottic carcinoma.
A panendoscopy with thorough mapping of the tumor is vital to planning the proper procedure. It is also important for the search of synchronous tumor in other areas of the upper aerodigestive tract. The physical status of the patient is also important in deciding the proper treatment for supraglottic carcinoma. The patients suffering from severe irreversible lung disease or esophageal stricture are not candidates for partial laryngeal surgery. How to assess pulmonary status is controversial. A study (Chow etal) showed that the measurement of vital capacity and forced expiratory volume in one second (FEV-1) did not reliably predict post-operative pulmonary complications. However Brechardt etal in 1994 showed that less than a 50% FEV1/FVC ratio correlated with a greater risk of severe aspiration and deglutition complications. Many feel that If the patient is able to tolerate a climb of two flights of stairs it is likely they have adequate reserve.
Due to the propensity of neck metastasis, either preoperative or postoperative irradiation or bilateral neck dissection has been advocated for patients with T1 infrahyoid disease or greater. The patient with an N0 neck should either undergo postoperative radiation to the primary side and both necks or bilateral function neck dissections removing the full jugular chain of nodes ( region II, III, IV). Patients with N1-N3 neck disease require more classic modified radical or radical neck dissection. Studies have found the incidence of occult metastasis to be from 30-40%. Weber et al studied an initial 202 patients then his most recent 76 patients who underwent supraglottic laryngectomy. He found that by the performance of bilateral neck dissections for even the N0 neck improved the regional cure rate from 78% to 91%. Post operative radiation therapy did not change the regional cure rate as did bilateral neck dissections.
The supraglottic laryngectomy involves the removal of the epiglottis, the false vocal cords, the aryepiglottic fords, the arytenoid cartilages, and the ventricle. This also includes part of the tongue, the preepiglottic space, upper half of the thyroid cartilage and hyoid bone. The structures that remain after this resection include the TVC, one or both arytenoids, the lower thyroid ala and cricoid cartilage, strap muscles and the suprahyoid musculature. The hyoid bone may be left to facilitate the reconstruction. Anatomical studies have shown the ability to preserve the pre-epiglottic space and not violate it when the hyoid bone is left (vijay etal).
The Larynx is first skeletonized. The infrahyoid strap muscles are separated from the hyoid and thyroid cartilage. The perichondrium of the thyroid cartilage is then elevated down to a level just below the true vocal cords. This will be used in the final closure and must be protected during the remainder of the procedure. The pharynx is entered opposite the tumor. If the tumor is on the infrahyoid epiglottis the entrance may be through the vallecula, if suprahyoid the pyriform opposite is the entrance site. The cartilage cuts using an oscillating saw are made from the superior horn of the thyroid cartilage on the non involved side, down to the mid-cartilage anteriorly and back up superior on the opposite side. The mucosal cuts are made under direct vision. The first cut is made beginning in the anterior ventricle on the side of the larynx farthest from the tumor. This is done parallel to the TVC and FVC in the ventricle. The mucosal cuts are joined with the cartilage cuts using a scissors. The larynx is now opened like a book for the tumor cuts. The supraglottic larynx is removed with the hyoid and pre-epiglottic space.
The reconstruction will reorganize these parts to achieve mucosal integrity, preservation of sensory motor function, and restore the anatomic relationships. The mucosal closure avoids tension or redundancy particularly over the arytenoids. The tongue base is approximated to the preserved external thyroid perichondrium to the TVC level. Precise mucosal closure as with a total laryngectomy is not essential and actually not desired. If closure over the exposed paraglottic soft tissue is done it can cause lateralization or fixation of the vocal cord which puts the laryngeal aperture at risk for bolus shunting.
The laryngeal remnant is repositioned by the approximation of strap muscles to the suprahyoid muscles. It is essential to restore the neolarynx in a near normal position and support which will facilitate the act of swallowing. The suspension being dynamic facilitates its elevation during the act of swallowing. Many surgeons feel a cricopharyngeal myotomy is needed to facilitate bolus entry into the esophagus. Reflux or regurgitation and esophageal dysfunction can be regarded as contraindications to this procedure.
The closure involves placing a single stitch placed in each corner from the base of the tongue to the most lateral point of the preserved perichondrium, with an intermediate stage to pick up the very edge of the lateral pharyngeal mucosa. A series of silk sutures are placed deep in the base of tongue to the perichondrium from one side of the defect to the other, but are not tied. The number of stitches varies from 6 to 12. The head is then flexed and the stitches are tied. The assistant will cross the next stitch tight while the initial stitch is tied and so on down the line until all are tied. The goal is to pull the defect together, however the closure is not a mucosa to mucosa closure.
A leak free closure of the pharyngotomy is confirmed with methylene blue. Residual secretion are suctioned from the trachea and pharynx and local anesthetic solution can be placed to decrease coughing while the patient wakes. The head is supported on a pillow to prevent hyperextension of the neck which would endanger the closure. When the patient is fully awake they are instructed to use a Yankauer suction to remove oral secretions and to minimize pooling at the pharyngotomy repair site.
On the third to fifth postoperative day, the patient’s ability to handle his own secretions signals the patients readiness to resume oral intake. The patient is then examined to confirmed coordination, control and strength of the tongue, jaw and lips. At this time a test bolus such as jello will be used to evaluated the patients swallow. All patients should have instruction and receive assistance from speech pathology. The jello is a suitable test bolus because of minimal consequence if tracheal entry occurs. The diet is gradually advanced to pureed foods up to a mechanical soft diet. Clear liquids thought to be safer by most may be more difficult to swallow than the thicker liquids or gels. Nasogastric tube feedings are removed when the patient demonstrates adequate PO intake.
Once PO feeding has begun, a gradual step-down in tracheotomy tube caliber is performed until a no. 4 tracheotomy tube is in place and can be occluded. Decannulation is delayed until after the patient demonstrates success in managing oral feeding so that a safe airway is assured. The fact that the patient has a tracheotomy aggravates laryngotracheal fixation, inhibits laryngeal elevation, and interferes with swallow recovery. Some authors advocate first removal of the tracheotomy tube prior to starting PO intake as to improve glottic closure.
Supraglottic laryngectomies have an increase risk of aspiration, inability to decanulate and poor swallowing. Many believe that these can be avoided by proper surgical technique. Virtually all patients aspirate to some degree following partial laryngeal surgery therefore good pulmonary reserve is vital. Two critical factors in the recovery of swallowing are good airway closure at the laryngeal inlet, space between arytenoids and base of tongue, and movement of the tongue base to make complete contact with the posterior pharyngeal wall. Focus on both of these aspects will help improve swallowing.
The supraglottic laryngectomy is an oncologically sound procedure with low local recurrence rates. This was seen with the UTMB experience shown below.
36 consecutive supraglottic laryngectomy at UTMB (1970-1987)
|TNM||Patients||Neck Disease||Local Recurrence|
Local control rate was 97% The study also showed that there was no survival benefit from the addition of post-operative radiation, but recommend adjuvant radiotherapy for patients with bilaterally positive nodes, extracapsular spread or nodes present in multiple regions of the neck, and for those with positive primary resection margins. Other studies have shown surgical local control rates for T1,T2 and T3 supraglottic carcinoma of 100 to 90% while radiation local control rates are much lower showing around a 70% control with T1 and T2 while drooping to 60-50% on T3 and only 33% for T4.
Using radiation therapy to treat supraglottic carcinoma may lead to cartilage necrosis and laryngeal edema. This swelling and induration often make the diagnosis of recurrent or residual carcinoma. When local failure results usually a total laryngectomy for salvage is necessary. 50% Salvage was achieved in the patients who underwent salvage surgery.
The presence of positive neck disease drastically affected survival. Also found is that the presence of extracapsular spread and number of positive nodes made regional recurrence worse. The nodal stage is more prognostic than the Tumor stage. Post operative radiation did not appear to affect the local or regional recurrence rate nor did it affect the overall survival in a study by Suarez etal
The CO2 laser has been used in the supraglottic area since 1979 by Strong, Jako, and Vaughan at Boston University. It was commonly used safely for T1 suprahyoid epiglottic carcinoma. The event of excision of larger tumors came about just for stabilization of the airway. In these patients, epiglottectomy, resection of one aryepiglottic fold and in some cases resection of the ventricular fold stabilized the airway and was extremely well tolerated. This became easier with the invention of the adjustable laryngoscope that allowed full view of the supraglottis (Lindholm). The rational in this approach was that removal of all known cancer should increase the effectiveness of definitive radiation therapy. Additionally some of the problems of radiation therapy such as edema seemed to be lessened with the use of the laser.
If the pre-epiglottic space is not grossly invaded and if the tumor has not extended into the anterior commissure at the level of the TVC, the transoral supraglottic resection is both safe and effective. Where there is grossly invaded pre-epiglottic space, therapy entails an open procedure.
The key to successful transoral supraglottic laryngeal resection is good visualization. The laser is used to transsect the epiglottis starting in the area of the pharyngoepiglottic fold rotating the epiglottis inferiorly. The suprahyoid epiglottic lesion is resect in bloc. Most infrahyoid lesions require division across the lesion with the first excision similar to the suprahyoid lesion and the remainder is removed similar to mapping a Moh’s excision. The re-excision is started anterior into the pre-epiglottic space. In this area there is fat and also moderately sized blood vessels which may have to be grasped and cauterized. The inferior extent of the excision is then determined under direct visualization. This procedure has been found beneficial with patients with poor pulmonary reserves due to the fact that the laryngeal sensory innervation is usually preserved. There is also no radiation delay since incisional healing is not necessary.
Tracheotomy is rarely necessary for the patients with T1- T3 transoral resection since the airways are usually significantly improved. The most significant postoperative problem is the propensity towards aspiration. The laser resected lesions compared to the open resection have a tendency to swallow better and leave the hospital earlier though.
Supraglottic carcinomas that are not suitable for horizontal supraglottic laryngectomy because of the contraindications can be resected with the partial horizontal supracricoid laryngectomy with cricohyoidopexy. This procedure results in the complete removal of the paraglottic and pre-epiglottic spaces in continuity with the thyroid and epiglottic cartilages. Maintenance of the cricoid cartilage allows for early decannulation, and the preservation of a mobile arytenoid cartilage results in physiologic speech and swallowing.
This type of resection was first describe by Labayle and Bistmuth in 1959. It was later refined by Piquet. The term partial supracricoid laryngectomy describes the surgical approach and resection, while cricohyoidopexy explains the mode of reconstruction.
|T1 and T2||supraglottic lesions with ventricle extension; infrahyoid epiglottis and posterior 1/3 FVC; supraglottic lesions extending to glottis, anterior commissure with or without TVC mobility|
|T3||transglottic carcinoma with limitation of TVC|
|T4||select invading thyroid cartilage|
There are no age-related contraindications, but special care is necessary in patients over 70 years of age, particularly if GER is present or pulmonary function is poor.
The typical U-shaped incision is made from mastoid tip to mastoid tip is neck dissection is to be performed. A superiorly based subplatysmal flap is elevated up to 1 cm above the hyoid bone. This is to prevent skin retraction at the time of closure. The sternohyoid and thyrohyoid muscles are transected along the superior border of the thyroid cartilage. The sternothyroid muscles are transected along the inferior border of the thyroid cartilage taking care not to injure the underlying thyroid gland and vessels. Along the posterior border of the thyroid cartilage the inferior pharyngeal constrictor muscles and external thyroid perichondrium are transected. The pyriform sinus mucosa is released similar in doing a total laryngectomy. The cricothyroid joints are disarticulated careful so as not to injure the recurrent laryngeal nerves. The isthmus of the thyroid gland is transected. Along the anterior wall of the cervicomediastinal trachea to the level of the carina, blunt finger dissection is performed. Care is taken to stay anterior and close to the trachea to avoid damage to any vascular structure. This allows upward mobility of the trachea at the time of closure and eliminates tension at the suture line. Once the exposure is attained, the periosteum of the hyoid bone is incised anteriorly and laterally. A Freer elevator is used to dissect the pre-epiglottic space from the posterior surface of the hyoid bone. The larynx is entered superiorly through a transvalecular horizontal pharyngotomy, and inferiorly through a transverse medial criothyroidotomy along the superior border of the cricoid cartilage. The entire cricothyroid membrane is left attached to the thyroid cartilage. The inferior incision allows the endotracheal tube to be repositioned. The larynx is grasped with an Allis clamp and pulled inferiorly and anteriorly, which permits direct visualization of the tumor. Under direct vision, the endolaryngeal resection is started on the nontumor side. A vertical prearytenoid incision from the aryepiglottic fold to the superior border of the cricoid cartilage is performed using scissors. The pyriform sinus mucosa is preserved making the first cut by placing the blade of the scissors in the laryngeal lumen and the other between the elevated thyroid perichondrium and the thyroid cartilage. The entire paraglottic space is removed with the specimen. The vertical prearytenoid incision and the medial transverse cricothyroidotomy are then connected on the non-tumor side with an incision that transects the cricothyroid muscle along the superior border of the cricoid cartilage. The thyroid cartilage is then grasped and along the midline opened like a book to expose the tumor. Under direct vision the horizontal incision along the superior border of the cricoid cartilage and a vertical prearytenoid incision is performed. This procedure allows partial or total removal of the arytenoid cartilage on the tumor bearing side. The closure is performed closing only the mucosa of the upper part of the arytenoid cartilage covering the exposed cartilage. The inferior portion is left open. If one arytenoid cartilage is completely removed no attempt should be made to cover this raw surface. Each remaining arytenoid cartilage is pulled forward to the posteriolateral part of the cricoid cartilage. This avoids posterior sliding of the arytenoid cartilage. The hyoid bone and cricoid cartilage are then brought together using three submucosal sutures of 0 prolene which are looped around the cricoid cartilage and the hyoid bone. The sutures are placed midline and then 1 cm for the midline bilaterally. The pulling together of these sutures allows the mobilization of the cervicomediastinal trachea. A tracheotomy is performed at this time through the original skin incision. The anterior borders of the hyoid bone and cricoid cartilage should be carefully aligned. the sternohyoid muscles are sutured. drains are place and the skin incision is closed. the cuffed endotracheal tube is replaced with a cuffless tracheotomy tube and a dressing is applied. The cuffless tracheotomy tube helps preserve the cough reflex and possibly reduces peristomal soft tissue infection.
The tracheotomy tube is removed around the third post operative day. The early stomal closure enhances remobilization of the arytenoid cartilage and allows for physiologic upward ascent of the neolarynx during swallowing. Once decannulation has been attained the patient is encouraged to practice swallowing their own secretions. As with the supraglottic laryngectomy the speech therapist is involved on a daily basis. The “supraglottic diet” is begun once the patient is able to adequately handle their own saliva. Liquids are introduced at a later date after handling thicker foods. If the patient was unable to swallow once out over a month a gastrostomy tube was placed.
In a study by Laccourreye the 3 year survival was 71.4%. No local recurrences were present in the 68 patients. The functional results showed that all patients were decannulated ( average 7 days). Normal deglutition was achieved by 74.6% of their patients. Physiologic phonation was achieved by all patients within 2 months. The vocal quality was harsh but allowed normal social interactions. The sensory and motor innervation to the remaining laryngeal structures are maintained by sparing both the recurrent and superior laryngeal nerves bilaterally. Laryngeal sphincter function is achieved by active opposition of the arytenoid cartilages with the base of the tongue forming a transverse neoglottic opening. The study by Chevalier etal found a three year survival of 83% and a five year survival of 79%.
In concluding the supraglottic and supracricoid laryngectomy are oncologically sound procedures with an extremely high local control rate. The tumors in general have a high propensity to regional and distal metastasis which decreases long term survival. The surgical procedure is more affective than radiation therapy for local control and overall survival. This procedure preserves the function of the larynx with a functional airway and normal deglutition.
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