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
Headache caused by Eustachian tube obstruction (ETO) is
a distinct clinical entity. Although Eustachian tube obstruction
as one of the principal causes of ‘hearing loss’, and/or ‘ear
fullness’, and/or ‘tinnitus’, and/or ‘headache (including otalgia)’,
and/or ‘vertigo’, has already been recognized by many wellrespected
senior doctors for a long time, it has still received
only scant attention both in the literature and in practice [1,2].
Some researchers mention that Blocked Eustachian tubes can
cause several symptoms, including ears that hurt and feel full,
ringing or popping noises, hearing problems, feeling a little
dizzy [3]. There’s one point which claims our attention. Instead
of headache, otalgia is usually mentioned more frequently in the
literature related to ETO. However, we should keep in mind that
‘otalgia’ can be included in wider sense of the term ‘headache’.
When the acute onset of ETO or acute otitis media, is sudden
and severe, the patients tend to complain of only an otalgia more
commonly than a headache. The cases of insidious onset are the
ones most likely to be overlooked. In these instances, because
headache is predominant than otalgia, the patients are likely to
be subjected to various types of treatment over long periods for
any other several types of headache. They usually complain as
follows; “I suffer from a headache around the ear.”, “I have got no
pain of ear, but just pain of head”, “I have a headache with an ear
ache.”, “Which part of head around ear I have a pain on , but I am
not quite be sure.”
An example of dizziness induced by middle ear pressure
fluctuation is ‘alternobaric vertigo’ -- such as occurs in people
who can “clear” one ear, but not the other [4-8]. This is mainly
a problem in scuba divers and airplane pilots. It seems likely
that this syndrome is either caused by asymmetry in inner ear
pressure accompanying changes in middle ear pressure, or
due to displacement of otolithic membranes associated with
displacement of the ossicular chain accompanying an inequity
between middle ear and external ear pressure. A related group,
but not quite identical, are persons who are sensitive to the ups/
downs of barometric pressure. It seems most likely that this
pattern reflects an interaction between barometric pressure,
migraine, and inner ear disturbance. Barometric pressure (and
weather fluctuations) is a powerful trigger for migraine, and migraine is a powerful modifier of sensory input. People with
migraine are often very sensitive to light (photophobia), sound
(photophobia), smell, motion (if they have a vestibular system
-- 5 times more motion sensitive), medications, sensation
(called allodynia). This is due to a pervasive increase in central
sensitivity to sensory input [4-8].
Anyway, it seems obvious that a headache can be originated
from ETO. And, we can realize that it is necessary to check on the
normal state of middle ear space pressure before confirming a
definite diagnosis of any type of the headache. Like this, for all
its importance of ETO as a crucial variable, it is not easy once I
actually tried to find out the reference that ‘Headache due to ETO’
can be regard as one of headache.
Some researchers mention that Migraine headaches are
often misdiagnosed by patients themselves as sinus headaches.
Schreiber suggested that 88% of 2991 patients who had
diagnosed themselves as having sinus headache, actually had
migraine [9]. Ideally normal middle ear cavity pressure with
perfectly equal balance between both ears is the core prerequisite
before diagnosis and treatment for any symptom and disease
[2]. At this point in time, like the preceding, it is the prerequisite
before making a right diagnosis of migraine or sinus headache,
etc., though it has not been mentioned actually in a concrete form.
In this way of differentiating migraine from sinus headache, it is
necessary to rule out the possibility of ‘headache due to ETO’ first.
It is true, of course, that there are many other conditions which
may cause headache, but since obstruction of the Eustachian tube
is one of the most obvious, and also the most easily corrected,
every patient with symptoms of headache should be subjected
to the therapeutic test of inflation of the tubes as a first step in a
thorough clinical investigation [10].
The middle ear is very much like a specialized paranasal
sinus, called the tympanic cavity; it, like the paranasal sinuses, is a
hollow mucosa-lined cavity in the skull that is ventilated through
the nose [11]. Tympanic cavity and mastoid cavity are named on
the basis of anatomy. However, if we view things from a different
angle, we can regard them as one of ‘paranasal sinuses’, called
‘tympanic sinuses or ‘mastoid sinus’ like maxillary or frontal or
ethmoid or sphenoid sinus in a view of physiology and function
[1]. This point is the reason why I support the theory of ‘sinus headache’ when I need to explain the cause of headache from
Eustachian tube obstruction [1].
Acute sinus headache: poorly studied, commonly diagnosed.
The International Headache Society (IHS) diagnostic criteria for
acute sinus headache (diagnosis code 11.5.1) include (a) purulent
nasal discharge, (b) pathologic sinus findings in tests including
X-ray, CT or MRI, and/or trans illumination, (c) simultaneous
onset of headache and sinusitis, and (d) headache localized to
specific facial and cranial areas near the sinuses [12,13]. Chronic
sinusitis is not validated as a cause of headache (IHS 11.5.3).
Sinus pain caused by inflammation induced by allergens (i.e.,
allergic rhinosinusitis) or by infection (i.e., bacterial or viral
sinusitis) occurs when exudate in inflamed, blocked sinuses
exerts pressure that stimulates local trigeminal nerve fibers
[14-16]. Mechanical obstruction of the Eustachian tube may be
either intrinsic or extrinsic. Intrinsic mechanical obstruction is
usually caused by inflammation of the mucous membrane lining
of the Eustachian tube or an allergic diathesis causing edema
of the tubal mucosa. Extrinsic mechanical obstruction is caused
by obstructing masses such as hypertrophic adenoid tissue or
nasopharyngeal tumors [17].
If it is natural to regard ‘tympanic cavity’ as ‘tympanic sinus’,
isn’t it too obvious to regard ‘otitis media’ as ‘sinusitis’? If the
headache due to ETO was removed, after normalizing the pressure
of middle ear space with Eustachian tube catheterization. What
more definite ‘sinus headache’ than ‘headache due to ETO’? I do
not have the slightest doubt that it is obvious to regard ‘headache
due to ETO’ as ‘sinus headache’. Now, it is reasonable to ask some
questions. Which looks more reasonable theoretically between
sinus headache and migraine in order to explain the mechanism
of headache originated from ETO?
Conclusion
As a clinician who inherited Eustachian tube catheterization through the apprenticeship, and should preserve it, I would like to present you this clear proposition at least as follows: With a view to ‘ideally normal middle ear cavity pressure with perfectly equal balance between both ears’, Eustachian tube catheterization may be of both diagnostic and therapeutic value [1-2].
- Kim HY (2014) Diagnosis & Treatment of Mechanical Obstruction of Eustachian Tube. J Otolaryngol ENT Res 1(1): 00001.
- Young Kim H (2015) Reciprocal Causal Relationship between Laryngopharyngeal Reflux and Eustachian Tube Obstruction. J Otolaryngol ENT Res 2(6): 00046.
- Pai S, Parikh SR (2012) Otitis media. In: AK Lalwani (Ed.), Current Diagnosis and Treatment Otolaryngology Head and Neck Surgery. (3rd edn), McGraw-Hill, New York, USA, pp. 674-681.
- Klingmann C, Knauth M, Praetorius M, Plinkert PK (2006) Alternobaric vertigo--really a hazard? OtolNeurotol 27(8): 1120-1125.
- Subtil J, Varandas J, Galrão F, Dos Santos A (2007) Alternobaric vertigo: prevalence in Portuguese Air Force pilots. Acta Otolaryngol 127(8): 843-846.
- Tjernstrom O (1974) Function of the eustachian tubes in divers with a history of alternobaric vertigo. Undersea Biomed Res 1(4): 343-351.
- Tjernstrom O (1974) Further studies on alternobaric vertigo. Posture and passive equilibration of middle ear pressure. Acta Otolaryngol 78(3-4): 221-231.
- Tjernstrom O (1974) Middle ear mechanics and alternobaric vertigo. Acta Otolaryngol 78(5-6): 376-384.
- Schreiber CP, Hutchinson S, Webster CJ, Ames M, Richardson MS, et al. (2004) Prevalence of migraine in patients with a history of self-reported or physician diagnosed "Sinus" headache. Arch Intern Med: 164(16): 1769-1772.
- Merica FW (1942) Vertigo due to obstruction of the eustachian tubes. Journal of American Medical Association 118(15): 1282-1284.
- Drake, Richard LV, Wayne T, Adam WM, Mitchell (2005) Illustrations by Richard; Richardson, Paul Gray’s anatomy for students. Elsevier/Churchill Livingstone. Philadelphia, USA, pp. 858.
- Headache Classification Committee of the International Headache Society. Classification of headache disorders, cranial neuralgias and facial pain. Cephalalgia (1988) 8 (suppl 7): 1-96.
- Blumenthal HJ (2001) Headache and sinus disease. Headache 41: 883-888.
- Couch JR (1988) Sinus headache: a neurologist’s viewpoint. Semin Neurol 8: 298-302.
- Schuller DE, Cadman TE, Jeffreys WH (1996) Recurrence headaches: what every allergist should know. Ann Allergy Asthma Immunol 76: 219-230.
- Close LG, Aviv J (1997) Headaches and disease of the nose and paranasal sinuses. Semin Neurol 17: 351-354.
- Johnson J, Broniatowski M, Eisele D, Fried M, Hochman M, et al. (2002) Maintenance manual for lifelong learning, Otitis media. (2nd edn), American Academy of Otolaryngology-Head and Neck Surgery Foundation. Kendall/Hunt Publishing Company, Dubuque, Iowa, USA, pp. 139-140.
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.