Background: Supracricoid laryngectomies (SL) were introduced to radically treat laryngeal tumors while respecting laryngeal function.
Despite SL standardized technique allows good functional, only few authors analyzed the influence of different anatomical structures on the
functional outcome of cricohyoidopexy (CHP) and cricohyoidoepiglottopexy (CHEP) with preservation of one (A) or both (AA) arytenoids.
Materials and Methods: Thirty-eight (36M, 2F; mean age: 60.9 years) patients were submitted to SL for laryngeal carcinoma. The surgical
treatment performed was: 6 (15.8%) CHEP+AA, 20 (52.6%) CHEP+A, 4 (10.6%) CHP+AA, and 8 (21%) CHP+A. Postoperative swallowing,
phonation, and breathing functions were examined.
Results: No significant local complication was notice postoperatively. All patients were decannulated; (average time to decannulation was
30.36+4.09 days). Nasogastric tube was removed after 16+2.30 days. All patients could clear their pharynx out of any food remnant with up to
3 swallowing acts one month postoperatively. GIRBAS total score ranged from 1.2 to 3 (mean: 1.79). CHEP patients showed better swallowing,
phonation and breathing results with respect to CHP. Double arytenoid preservation was associated with better pharyngeal clear out, voice
quality and shorter decannulation time with respect to single arytenoid maintenance.
Discussion: our experience confirms the oncological and functional reliability of SL. Despite the good functional outcome offered by
SL in general, our experience shows significant better performances in case of epiglottis maintenance (CHEP vs CHP) and both arytenoids
preservation (AA vs A). The anatomical surgical details of our SL technique are reported.
Keywords: Supracricoid Laryngectomy; Functional Outcome; Surgical Technique; Laryngeal Cancer; Anatomy
Introduction
Supracricoid laryngectomies (SL) were introduced to radically treat laryngeal tumors (LT) while respecting laryngeal function [1-8]. The basic principle of these techniques is to spare at least one cricoarytenoid unit, necessary for the functional recovery of the residual larynx. The first attempts to preserve laryngeal function after treatment of LT were described in 1896 by Foderl [2], who proposed a laryngectomy that spared the epiglottis and the arytenoids followed by a reconstruction of the upper respiratory tract by suturing the epiglottis and the arytenoids to the first tracheal ring. In 1954, Hoffmann Saguez [3] introduced the term ‘‘subtotal or re-constructive laryngectomy’’. In 1959, Majer, Rieder [4] proposed a similar technique, which spared the cricoid cartilage. In 1970, Serafini [5] described the “total laryngectomy maintaining the natural respiration”, which was inspired by Foderl’s technique and later developed by Rizzotto’s “tracheohyoidopexy” [6]. In 1971, Labayle and Bismuth [7] proposed the technique of cricohyoidopexy (CHP), while in 1974; Piquet, Desaulty and Decroix [8] described the cricohyoidoepiglottopexy (CHEP). SL with CHEP and CHP has been widely popular over the last decades, especially in Europe, thanks to their good oncological results. Despite SL standardized technique allows good functional results in terms of swallowing, tracheostomy-occluded breathing function and voice quality, only few authors analyzed the influence of different anatomical structures on SL functional outcome. In this paper, we report the functional outcome of our SL and consider the comparative influence of different anatomical factors on such results.
Patients and Methods
Thirty-eight (36M, 2F) consecutive patients were submitted
to SL (CHEP or CHP) for laryngeal carcinoma between January
2012 and December 2014 at the Department of Otolaryngology-
Head and Neck Surgery of “Carlo Poma” Civil Hospital, Italy.
Patients’ mean age was 60.9 years (age range 51-78 years) (Table
1). For 30 patients, SL was the primary treatment, while 8 patients
(21%) had been treated previously for laryngeal carcinoma: neck computed tomography (CT) or magnetic resonance imaging
(MRI), thorax-CT and nutritional evaluation, performed by
clinical dieticians, who scheduled postoperative enteral nutrition
with a nasogastric feeding tube (12 F diameter).
Indications for CHEP were: (a) T1b involving both true vocal
cords or one vocal cord with radiological suspicion of thyroid
cartilage invasion of the anterior commissure; (b) Glottic T2
with extension to the false vocal fold, to the base of the epiglottis
or anterior surface of the arytenoid and/or with impairment
of cordal mobility; (c) Selected cases of T3 glottic carcinoma,
without invasion of paraglottic space.
Indications for CHP were: (a) Supraglottic-glottic T2 tumors;
(b) Supraglottic-glottic T3 carcinoma with pre-epiglottic/
paraglottic space invasion and/or impairment of vocal fold
mobility without involvement of cricoarytenoid articulations;
(c) Selected cases of T4 carcinoma with invasion of the thyroid
cartilage anteriorly without involvement of cricoarytenoid
articulations and subglottis.
Contraindications for CHEP or CHP were: posterior
commissure involvement; extensive posterior invasion
of paraglottic space; arytenoid fixation (cordal fixation
without arytenoid mobility impairment was not considered a
contraindication); cricoid/subglottis (10mm from free vocal
cord edge); lateral and posterior extralaryngeal spread; low
performance status (Karnofsky’s index < 80%); uncooperative
patients; age older than 80 years [10-11]. All patients signed a
written informed consent.
Surgery
The surgical treatment performed was: 26 (68.4%) CHEP and
12 (31.6%) CHP. Among CHEP, in 6 (15.8%) cases both functioning
cricoarytenoid units were preserved, while in 20 (52.6%) subjects
only one cricoarytenoid unit was maintained. Among CHP, in 4
(10.6%) cases both cricoarytenoid units were preserved, while
in 8 (21%) patients only one cricoarytenoid unit was maintained.
All patients received perioperative antibiotic prophylaxis with
ampicillin/sulbactam 3g twice/day. The pathological TNMstaging
of the CHEP and CHP cases are illustrated in Table 1.
Attitudes to the treatment of the cN0 neck have varied in relation
to on the location purely glottic or glotto-supraglottic cancer
and the size of the primary tumor. A total of 36 patients (94.7%)
underwent some type of neck dissection (ND): ipsilateral to the
tumor in 22 (57.9%) patients and bilateral in 14 (36.8%) cases.
Postoperative histopathological examination showed squamous
cell carcinoma in all cases. Histopathological grading was: well
differentiated in 14 (36.9%) cases, medium differentiated in 14
(36.9%), low differentiated in 8 (21%) and undifferentiated in 2
(5.2%) case. Overall nodal metastases were detected in 12 out of
the 36 patients submitted ND (33.3%); in 4 patients, metastases
were bilateral. All patients were R0. Adjuvant radiotherapy was
planned when the pathology report showed two or more positive
lymph nodes or extracapsular spread. Three patients were
submitted to postoperative radiotherapy for nodal involvement.
The total dose ranged from 45 to 60 Gy.
Postoperative functional assessment
On the 7th-8th postoperative day, patients started an oral diet under logopedic control. The tracheostomy tube was removed
when patients were able to breathe and feed autonomously.
Functional assessment was performed as follows: (a) Swallowing
assessment was carried out with colored water jelly (percent of
inhalation and number of swallowing acts necessary to clear the
pharynx out 30 days after surgery); the nasogastric feeding tube
was removed when satisfactory (at least 70%) swallowing of both
solids and liquids was achieved [12]; (b) Phonation was assessed
by GIRBAS Scale [13]; (c) Breathing function was assessed by
measuring the time necessary to obtain tracheostomy-occluded
satisfactory respiratory function (decannulation) and complete
tracheostomy closure. Complete tracheostomy closure was
obtained by spontaneous healing after placement of compressive
gauze on the stoma. Our patients were divided into four groups
according to the SL procedure: preservation of the epiglottis
with one (CHEP+A) or both arytenoids (CHEP+AA) rather than
removal of the epiglottis with preservation of one (CHP+A) or
both arytenoids (CHP+AA). The differences of functional results
among the different groups were analyzed to assess the impact
of the two main anatomical variables (epiglottis and one/two
arytenoids) on SL functional results.
Statistics
Statistical analyses were performed using the Statistical
Package for Social Sciences Software (SPSS 10.0 for Windows;
SPSS, Inc., Chicago, IL) and STATA 7 (Stata Corp., College Station,
TX). Parametric (Student’s t-test) test and non-parametric
(Mann-Whitney U test for nonpaired data) tests were used to
compare different values. The criteria for statistical significance
were set at a value of p 0.05 (two tailed).
Results
No significant local complication (i.e. surgical field infection,
neck bleeding, etc) was notice postoperatively. During the follow
up (mean follow-up 17 months; range: 32-9 months), 2 (5.3%)
cases (pT3N0) of local recurrence were noticed in patients
previously submitted to radiotherapy, who were therefore
treated with “salvage” total laryngectomy. No recurrence in the
neck has been noticed so far.
Functional results
Functional results in terms of swallowing (days required
to attain a satisfactory swallowing function to remove the
nasogastric feeding tube and number of swallowing acts
necessary to clear the pharynx out one month after surgery),
phonation, and breathing (days required to allow decannulation
and complete tracheostomy closure) are reported in Table 2. As
to breathing, all patients were decannulated. The average time to
decannulation was 30.36+4.09 days after surgery. The nasogastric
tube remained in place for an average of 16+2.30 days. Two
patients developed postoperative aspiration pneumonia, which
resolved with temporary suspension of oral feeding. By the end
of the first postoperative month, all patients could clear their
pharynx out of any food remnant with up to 3 swallowing acts.
No total laryngectomy was required for persistent aspiration.
GIRBAS total score ranged from 1.2 to 3 (mean: 1.79).
When considering the functional results in relation to epiglottis preservation/removal, several differences can be
noticed between SL subgroups (CHEP vs CHP). As to swallowing,
CHEP patients showed better (p=0.024) pharyngeal clear out
and swallowing recovery with respect to CHP subjects (Table 2),
even though no statistically significant difference was noticed in
terms of days required for feeding tube removal (p=0.068). As to
phonation, CHEP subjects showed better voice quality on GIRBAS
Scale (p<0.001) in comparison to CHP patients. CHEP subjects
also showed a shorter decannulation time (p<0.001) and time
required for tracheostomy complete closure (p=0.046) with
respect to CHP patients.
When considering the functional results related to
preservation of one or both arytenoids (CHEP+A vs CHEP+AA;
CHP+A vs CHP+AA), better performances were noticed in AA
groups with respect to the corresponding A groups. In particular,
CHEP+AA group showed better (p=0.041) pharyngeal clear out
(Table 2), superior voice quality on GIRBAS Scale (p<0.001), and
shorter decannulation time (p=0.009) with respect to CHEP+A
patients. No significant difference was noticed between the two
groups in terms of days required for feeding tube removal and
complete tracheostomy closure. As to CHP subgroups, CHP+AA
patients showed better voice quality (p<0.001) with respect to
CHP+A subjects. No significant difference was noticed between
the two subgroups for the other assessed items. When comparing
AA patients (CHEP+AA plus CHP+AA) with A groups (CHEP+A
plus CHP+A), shorter decannulation time was noticed in AA
subjects (p=0.038). No other significant difference was noticed
between the two subgroups for the other items.
Finally, when considering the four subgroups separately,
CHEP+AA patients showed statistically significant better
performances in terms of swallowing, voice quality, and
decannulation time with respect to other 3 subgroups (CHEP+A,
CHP+AA and CHP+A). We did not notice any significant influence
of age or sex on the examined clinical performances. Patients
submitted to preoperative radiotherapy showed a significant
increase of the time required for feeding tube removal (p=0.005)
and tracheostomy complete closure (p=0.002) regardless of the
SL operation performed. A significant increase in GIRBAS Score
and decannulation/tracheostomy closure time was noticed in
patients submitted to postoperative radiotherapy.
Discussion
Supracricoid partial laryngectomies with CHP and CHEP
for glottic or supraglottic squamous cell carcinomas were introduced by Labayle and Bismuth [7], Majer and Rieder
[4], and Piquet et al. [8] in the 1970s [1]. These new surgical
procedures were developed to achieve the same local control as
total laryngectomy, but avoiding a permanent tracheostomy by
creation of a neolarynx thanks to the preservation of at least one
functioning cricoarytenoid unit. Our results confirm the oncologic
reliability of SL already reported in the literature, [1-4,7,8,10-21]
also in treatment of selected locally advanced carcinomas of the
larynx.
From a functional viewpoint, our results confirm the efficacy
of SL in creating a functioning neolarynx allowing swallowing,
voice generation, and tracheostomy-occluded breathing [1-
4,7,8,10-21]. Despite the good functional outcome offered by SL
in general, our experience shows significant better performances
in case of epiglottis preservation (CHEP vs CHP). In particular,
the residual epiglottis seems to permit a shorter decannulation
time, which may be due to the contribution of the epiglottis,
as a solid cartilaginous structure, to the patency of laryngeal
lumen. CHEP patients also displayed an improved voice quality
with respect to CHP subjects, confirming a positive role of the
epiglottis framework in voice generation/modulation in SL
neolarynx. Our experience also shows better swallowing function
in case of epiglottis preservation, probably thanks to the airway
protection guaranteed by the residual epiglottis. These findings
are partially different from those obtained by Alicandri-Ciufelli
et al. [20].who showed similar swallowing results after different
partial laryngectomies.
In addition to the role of the epiglottis, our experience shows
the functional importance of serviceable cricoarytenoid units in
SL [19-21]. However, the role of both arytenoids maintenance
with respect to single arytenoid preservation seems less
significant that epiglottis maintenance for the functional results
of SL. In fact, even though CHEP+AA subjects showed better
pharyngeal clear out and voice quality with respect to CHEP+A
patients, no significant difference was noticed between the two
groups in terms of days required for feeding tube removal and
complete tracheostomy closure. Similarly, voice quality was the
only significant difference between CHP+AA patients and CHP+A
subjects. These findings are in agreement with those obtained by
Alicandri-Ciufelli et al. [20], while they are different from the ones
reported by Akbas et al, who underline the significant difference
of single vs. both arytenoids preservation on decannulation time
[21].
In conclusion, our study confirms the importance of the
association between epiglottis and working cricoarytenoid units
preservation to optimize neolarynx function: patients submitted
to CHEP with preservation of both arytenoids display better
functional performances in terms of swallowing, voice quality and
decannulation time with respect to subjects submitted to other SL
procedures. Such results may be due to a more efficient sphincter
function offered by a two-arytenoid mobile system with respect
to a single-arytenoid neolarynx. The surgical technical details
allowing the preservation of a functioning cricoarytenoid unit
are represented by preservation of the arytenoid (adequately
connected to the cricoid by the cricoarytenoid articulation),
the inferior laryngeal nerve (enabling arytenoid motion), and
the interior branch of the superior laryngeal nerve (allowing
sensitivity of the arytenoid and pyriform sinus mucosa) [6].
According to our experience, in order to optimize the
functional performances of the neolarynx after SL, some surgical
technical principles should be respected: (1) Preservation
of the internal branch of the superior laryngeal nerve; (2)
Preservation of the suprahyoid portion of the epiglottis (CHEP)
when oncologically possible, in order to attain better functional
results; (3) Sectioning (rather than dissecting) with scissors
the thyroid inferior cornu at its base to avoid any injury to the
recurrent laryngeal nerve, located underneath the cricothyroid
articulation; (4) Attention should be paid when sectioning the
vocal process or part of the disease-free arytenoid to avoid
trauma to the cricoarytenoid joint and avoid arytenoid luxation;
(5) Suturing a pyriform sinus mucosal flap over bare cricoid
surface when an arytenoid has been removed for oncologic
reasons; (6) Pexy is performed with three separate 0 vicryl
sutures passing around the cricoid cartilage and hyoid bone;
special care must be taken to trespass the residual epiglottis (if
present) with the median suture vertically in a submucosal plane
to avoid epiglottis posterior dislocations (potentially obstructing
the neolaryngeal lumen). The central suture should also include
an abundant (at least 3 cm) portion of tongue base, while the
lateral pexy should be performed with a minimum amount of
tissue to avoid trapping the lingual artery and hypoglossal nerve;
(7) During ND, it is mandatory to preserve the hypoglossal
nerve to enable tongue movement and swallowing recovery. In
agreement with the literature [15,20], our SL functional results
are negatively influenced by pre-/post-operative radiotherapy,
probably because of the mucosal edema/fibrosis affecting
neolarynx patency and motility.
Conclusion
Supracricoid laryngectomies are oncologically safe and functionally efficacious procedures. They must be included in the armamentarium of any surgeon who treats laryngeal cancer, as it allows organ preservation, thus improving the patient’s quality of life, even in selected patients with locally advanced disease. Key points for a successful outcome are: accurate preoperative staging of the disease, knowledge of indications and contraindications, and accurate surgical technique, with special attention to the technical details that can affect functional outcome. Our experience shows the more normal anatomical structures are preserved (epiglottis and arytenoids), the better postoperative functional results will be. Additional studies with more extended samples may be useful to further optimize SL functional outcome.
Acknowledgements
The support of Giuseppe Rizzotto, Livio Presutti and Giovanni Succo is greatly acknowledged.
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Table 1: Patients submitted to supracricoid laryngectomy. CHP = cricohyoidopexy; CHEP = cricohyoidoepiglottopexy; (AA) = preservation of both functioning cricoaritenoid units; (A-) = preservation of one functioning cricoaritenoid unit; * = preoperative radiotherapy; ° = postoperative radiotherapy.
Table 2: Functional results in patients submitted to supracricoid laryngectomies (mean + standard deviation). CHP = cricohyoidopexy; CHEP = cricohyoidoepiglottopexy; AA = preservation of both functioning cricoarytenoid units; A = preservation of one functioning cricoarytenoid unit; NGT = Nasogastric Feeding Tube.