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CONSERVATIVE LARYNGECTOMY.pptx
- 1.
- 2. • The choiceof therapy for early stage squamous cell cancer of the larynx • Determined by : - patient-related factors - tumour-related factors - physician preference • The main aim : - to maintain speech and swallowing - avoid a tracheostomy
- 3. HISTORY • First PartialLaryngectomy – excision of Glottic carcinoma by External Laryngofissure - by H.B.Sands in 1863 • 1867- Solis Cohen – first documented permanent cure by laryngofissure • 1878 – Theodore Billroth – performed first Vertical Partial Laryngectomy – further developed & refined by Gluck
- 4. PRINCIPLES • Local control •Permit oncologically safe excision of the tumour with preservation of essential functions of larynx, viz. phonation, nasal respiration and protection of the airway • Not only for early (T1/T2) of the larynx; also selected subsets of T3/T4 cancers • Organ preservation surgery should only be used when resection of the tumour can be confidently achieved
- 5. ASSESSMENT OF TUMOUREXTENT • Clinical Examination : • Palpation of Vallecula - in the case of supraglottic cancers to assess the extent of submucosal invasion. • Flexible Laryngoscopy: • for assessment of vocal cord and arytenoid mobility, which helps to determine what deeper structures are invaded • In glottic cancer - impaired cord mobility may be due to the bulk of the tumour on the cord surface or superficial thyroarytenoid muscle invasion. • In supraglottic cancer, cancer invasion into the thyroarytenoid muscle is less likely and the most common cause of cord fixation is deep arytenoid cartilage invasion superiorly • Examination under anaesthesia: • Tumour can be assessed by direct laryngoscopy using angled telescopes to visualize the ventricle, anterior commissure and subglottis
- 6. • CT scan: •Cricoarytenoid area is best assessed by axial CT scans which will show sclerosis if perichondrial or direct arytenoid cartilage invasion has occurred. • MRI scan : • Coronal T1-weighted MRI is useful to assess subglottic extension. • Sagittal MRI is good for the assessment of pre-epiglottic space invasion. • Highly sensitive for assessment of thyroid cartilage invasion • Enhancement into cartilage on postgadolinium fat suppressed scans are highly sensitive to invasion • PET scan : • Assessment of post-treatment effects and the detection of early recurrence.
- 7. CLASSIFICATION Open Partial Laryngeal Surgical Procedures TransoralLaser Endoscopic surgical procedures
- 8.
- 9. GENERAL PRINCIPLES • Thepatient must be able to tolerate a general anaesthesia. • The patient should not have any medical problems that may impair wound healing • The patient should have good pulmonary function to tolerate the postoperative course, which often involves a period of aspiration. • Vertical hemilaryngectomy typically causes little impact on swallowing function • Supraglottic laryngectomy results in dysphagia and aspiration. • A percutaneous gastrostomy tube may be required for patients with a significant prolonged period of aspiration
- 10. • The patientshould play an active role in speech and swallowing rehabilitation. • Any patient undergoing partial laryngectomy should be informed of the complexities of salvage conservation procedures, and must give consent for total laryngectomy. • Careful preoperative planning will reduce the incidence of conversion to total laryngectomy.
- 11. CRICOARYTENOID UNIT • Basicfunctional unit of the larynx. • Consists of : • Arytenoid cartilage • Cricoid cartilage • Associated musculature • Nerve supply from the superior and recurrent laryngeal nerves for that unit. • Preservation of at least one functional unit allows organ preservation laryngeal surgery
- 13. RECONSTRUCTION • Aim : •To ensure anteroposterior diameter is maintained so that there is no stenosis. • Posterior glottic bulk, normally provided by the arytenoids, is reconstituted to prevent aspiration & produce good voice • Resected arytenoid is generally replaced with either a piece of thyroid cartilage or with the strap muscles to provide the posterior glottic bulk
- 14. CONSERVATION SURGERY FOR GLOTTICLARYNGEAL CANCERS Laryngofissure with Cordectomy Vertical Partial Laryngectomy Supracricoid Partial Laryngectomy with cricohyoidoepiglottopexy
- 15.
- 16. • Simplest &oldest open surgical procedure for treatment of Early Glottic Cancer • Described by Gordon Buck in 1853 • Excellent local control rates in T1 glottic cancer confined to mid-cord
- 17. INDICATIONS • Ideal patient– one with a mid-cord lesion • There should be no impairment in vocal cord mobility • Lesion should be confined to membranous vocal cord without extension to anterior commissure
- 18. PROCEDURE • Patient positionedunder GA through a tracheostomy • Midline vertical Thyrotomy is performed • Larynx entered through Cricothyroid membrane • Cordectomy entails removal of only soft tissue deep to ipsilateral thyroid cartilage
- 19. • Mucosal cuts: •Anteriorly 2-3 mm behind the anterior commissure • Posteriorly in front of the vocal process of arytenoid cartilage • Superiorly just above the false cord • Inferiorly along the lower border of the thyroid cartilage • Thyroid cartilage & perichondrium are approximated • Mucosal defect is allowed to heal by granulation • Within a few weeks , dense fibrous pseudocord forms • Tracheostomy decannulated within a week • No risk of aspiration
- 20. RESULTS • Local controlrates : average 84-98% ; properly selected cases – 90% • Quality of voice is inferior to that following Endoscopic Laser Cordotomy (TOLR)
- 21.
- 22. TYPES • Resection dependson location of tumour within the glottis. • Accordingly , procedure can be : a) Hemilaryngectomy (without involvement of Anterior commissure or arytenoid) b) Frontal laryngectomy (anterior commissure lesion) c) Frontolateral laryngectomy (extension across the anterior commissure) d) Extended Hemilaryngectomy (involving arytenoid)
- 24. INDICATIONS • Situations inEarly glottic cancers (T1/T2) where VPL is most useful & scores over RT or TOLR: i. Involvement of anterior commissure ii. Impaired mobility of Vocal Cord (T2b) iii. Subglottic extension of disease iv. Inadequate exposure on microlaryngoscopy & yet surgery is strongly indicated v. Salvage of post-RT recurrence vi. Selected T3 glottic tumours
- 25. LIMITATIONS • VPL notfeasible when a glottic cancer has: i. Subglottic extension >10mm anteriorly & >5mm posteriorly ii. Paraglottic disease extending superiorly above the level of the ventricle or inferiorly upto the cricothyroid level iii. Extension across the anterior commissure involving more than one-third of the contralateral vocal cord iv. Cord fixity associated with fixation of arytenoid
- 26. PROCEDURE • Involves afull thickness en-bloc resection of the involved segment of the glottis along with overlying segment of thyroid cartilage . • Patient positioned under GA through a tracheostomy • Horizontal incision made in skin crease at level of thyroid cartilage, extending from one sternomastoid to the other • Strap muscles separated in midline, exposing larynx. • External Perichondrium reflected on both sides of thyroid cartilage • Two vertical cartilage cuts are placed depending on the site of lesion
- 27. • Entry intolarynx via Cricothyroid membrane • As larynx unfolds to allow exposure inside, remaining mucosal & soft tissue cuts are made under vision to complete the resection. • Epiglottis not removed • Both superior & inferior laryngeal nerves are preserved
- 28. RECONSTRUCTION • 3 importantsteps to achieve good results: i. Reattachment of remnant vocal cord ii. Mucosal defect heals by granulation & fibrosis dense pseudocord forms in cordotomy or a classical vertical hemilaryngectomy. In frontal & frontolateral laryngectomy, anterior fusion is prevented by use of silastic keel. After 23 weeks, keel is removed endoscopically iii. Reconstruction of resected arytenoid : include the use of muscle, tendon, fat, cartilage & the epiglottis
- 29. POSTOPERATIVE MANAGEMENT • Ryle’stube feeding started on POD1. • Tracheostomy tube is blocked on POD2 or 3 • Tracheostomy removed on POD5 & oral feeds started
- 30. COMPLICATIONS • Laryngeal stenosis •Delayed decannulation • Dysphagia • Aspiration (chances are high when arytenoid is resected) • Hoarseness of voice (worsen when resection includes arytenoid or large portions of endolaryngeal soft tissues.)
- 31. ONCOLOGICAL RESULTS T1 glotticcancers : • Local recurrence rates are reported to be <10 %. • If the anterior commissure is not involved, local control of 93 % reported • If the anterior commissure is involved, the local control rate is reduced to 75% due to subglottic recurrence. • Therefore, when the anterior commissure is involved, a wide surgical margin in the subglottis is indicated.
- 32. T2 glottic cancers: •Higher local failure rates of 4–26%. • Due to subglottic and supraglottic invasion. • Subglottic extension is associated with cricoid cartilage invasion, which is not resected in the standard vertical partial laryngectomy. • Extension into the supraglottis through the ventricle may result in thyroid cartilage invasion T3 glottic cancers: • Local recurrence rates are higher, ranging from 11 to 46 %
- 33.
- 34. • Reported asearly as 1959 • Refined & presented later by Labayle & Piquet et al. • Involves resection of both true cords, both false cords, the entire thyroid cartilage, paraglottic spaces bilaterally and a maximum of one arytenoid. • More radical than Vertical Partial Laryngectomy
- 35. INDICATIONS i. T1b glotticcancer with involvement of more than half of VC on either side ii. T2a glottic tumour with extension to false cord or base of epiglottis; but freely mobile cords (glotto supraglottic cancer) iii. T2b glottic cancer (impaired mobility) & T3 glottic cancer (fixed vocalcord) with freely mobile arytenoids
- 36. LIMITATIONS • Not compatiblewith fixed hemilarynx (fixity of arytenoids = cricoarytenoid joint involvement) • Anterior subglottic spread >10mm & posterior subglottic spread >5mm • Glotto supraglotticdisease extending above the level of false cord either along the mucosa or along the paraglottis • Prior tracheostomy (CHEP entails mobilization of cervicomediastinal trachea which moves up to meet hyoid after which the tracheostome is positioned) • Respiratory impairment either due to frail health or due to chronic respiratory disease
- 37. PROCEDURE • Patient positionedunder GA through an orotracheal tube • Approach is through Subplatysmal apron flap • Sternohyoid & thyrohyoid muscles are divided on either sides at the level of upper border of thyroid cartilage • Sternothyroid divided at the level of lower border of thyroid cartilage • Inferior constrictor muscles divided at the posterolateral edge of thyroid cartilage taking care not to injure superior laryngeal nerve • Internal thyroid perichondrium & pyriform sinus is released from the inner surface of thyroid cartilage
- 38. • Cricothyroid jointsare disarticulated on both sides • Isthmus of thyroid gland divided & cervico-mediastinal fascia is released over anterior wall of trachea, right down to carina to facilitate crico-hyoidopexy • Ipsilateral thyroid lobectomy & paratracheal node clearance is carried out in case of T3 glottic cancer • Cricothyrotomy is performed at this stage to introduce an armoured endotracheal tube to continue general anaesthesia • Superiorly the larynx is entered through a horizontal incision in the thyrohyoid membrane at the level of upper border of thyroid cartilage, deepening it to transect epiglottis& leaving its superior portion attached to base of tongue
- 39. • Anterior tractionof thyroid notch facilitates visualization of the endolarynx • Vertical resection cuts are made first along the side with less tumour involvement • Incision is made anterior to the arytenoid cartilage preserving the vocal process & cricothyroid musculature & resecting entire false vocal cord, ventricle & true vocal cord • This cut is carried anteriorly through cricothyroid musculature & subglottic mucosa to connect with anterior horizontal cricothyroid opening • With larynx opening up like a book, vertical cut on the involved side is made below upwards under vision • Frozen section examination is carried to assess adequacy of resection.
- 40. RECONSTRUCTION • Before commencingcricohyoidopexy, remaining arytenoid & posterior arytenoid mucosa is loosely approximated to cricoid with 3-0 vicryl to prevent it from flopping in & out causing respiratory obstruction • PEXY : • Three 1-0 vicryl sutures are placed 1 cm apart for crico-hyoidopexy • Each suture is placed submucosally around cricoid& through epiglottis. • Then passed through preepiglottic space around the hyoid bone, deep into base of tongue & out through suprahyoid musculature.
- 41. • Tracheotomy: positionedin line with a separate skin incision • Muscular buttress : • Cut edges of inferior constrictor muscles are approximated • Sternohyoid muscles resutured • Skin flaps are sutured
- 42. POST-OPERATIVE MANAGAMENT • Airwaymaintained through non-cuffed tracheostomy tube • Intermittent blockage encouraged after 3-4 days • Depending on progress , tracheostomy tube is removed in 1-2 weeks • Tube feeding through Nasogastric tube or a feeding gastrostomy is commenced on POD1 • Swallowing function may take several days or weeks to be restored
- 43. COMPLICATIONS • Temporary dysphagiaand aspiration is expected. • The voice quality is poor initially, but improves over several months. • Hyoid necrosis • Neolaryngeal stenosis.
- 44. RESULTS • ONCOLOGIC : •Overall survival rates : 68-84% • Local recurrence rate : T2 glottic cancers - 4.5 % T3 glottic cancers - 10 % • SPEECH : • Voice quality is harsh but is nevertheless a lung powered speech • Patient satisfaction is very high
- 45. CONSERVATION SURGERY FOR SUPRAGLOTTIC LARYNGEAL CANCER HorizontalPartial Laryngectomy Supracricoid Partial Laryngectomy with Cricohyoidopexy
- 46.
- 47. • Done inearly supraglottic cancers with peculiar characteristics and spread • Involves resection of structures forming the larynx protection mechanism leading to aspiration in recovery period • Therefore, replaced by TOLR foelocalized lesions mainly in marginal zone of supraglottis & by combined chemo-radiotherapy for more bulky lesions.
- 48.
- 49. INDICATIONS • Indicated incases of early supraglottic cancer with freely mobile vocal cords(T1,T2 and select T3) where surgery is preferred option & TOLR is not feasible • Surgery is the preferred option over radiation or chemoradiation therapy in : • Cancer of infrahyoid epiglottis • Early supraglottic primary with N2/N3 neck disease • Early supraglottic cancer in very young individuals • Cervical node metastasis, unilateral or bilateral, does not preclude supraglottic partial laryngectomy as it can be combined with concurrent neck dissection
- 50. CONTRAINDICATIONS • Poor pulmonaryreserve • Impaired cord mobility • Thyroid cartilage erosion • Involvement of pyriform sinus upto its apex • Involvement of interarytenoid or postcricoid region • Significant involvement of base of tongue
- 51. PROCEDURE – CLASSICSUPRAGLOTTIC LARYNGECTOMY • Patient positioned under GA through endotracheal tube or tracheostomy tube • Horizontal incision is placed at the level of thyroid cartilage from one sternocleidomastoid to other • Sternohyoid & sternothyroid muscles are divided on either sides at the level of upper border of thyroid cartilage • Perichondrium of cartilage is incised along the upper border & reflected downwards over the upper half of thyroid cartilage • Inferior constrictor muscles divided at the posterolateral edge of thyroid cartilage on the dominant side of tumour • Internal thyroid perichondrium is elevated only posterolaterally to free pyriform mucosa
- 52. • Thyroid cartilagecuts are made at least 1mm above the estimated level of anterior commissure • In early tumours with little or no infiltration of preepiglottic space, entire hyoid can be preserved by subperiosteal dissection of preepiglottic space which is resected along with tumour • With gross infiltration of space, atleast the body of the hyoid or the entire hyoid is resected
- 53. • If priortracheostomy has not been performed, it is done at this stage • Entry to larynx is transvallecular, except in extended resections where vallecula is involved by tumour • After pharynx is entered epiglottis is retracted downwards • Pharyngotome is enlarged giving an excellent view of tumour & supraglottic larynx • AEFs are now divided well anterior to arytenoids on both sides • Resection continued inferiorly through ventricles, preserving the true cords, while removing both false cords with specimen. • Entire specimen is removed with adequate free margin
- 54. RECONSTRUCTION • Cricopharyngeal myotomymay be performed to facilitate post-operative swallowing • Closure is commenced by suturing cut edges of pyriform musosa below to oropharyngeal mucosa above • Closure is obtained by approximating the upper end of remaining thyroid cartilage to base of tongue using three 1-0 sutures • Thyroid perichondrium which was preserved is now sutured to base of tongue musculature as 2nd layer of closure
- 55. EXTENDED SUPRAGLOTTIC LARYNGECTOMY • Involvesresection of involved Arytenoid,the pyriform or thr vallecula with adjacent base of tongue ARYTENOID RESECTION: • Resection of arytenoid results in deficient glottic bulk which results in significant aspiration & poor quality of speech • To prevent this, ipsilateral remnant of vocal cord must be medialized by anchoring it in the midline to the superior border of cricoid cartilage using a non-absorbable suture • Raw area of posterior glottis is resurfaced by advancing the adjoining mucosa of pyriform fossa
- 56. RESECTION OF BASEOF TONGUE/ VALLECULA: • Indicated in tumours involving lingual surface of epiglottis, vallecula & adjacent portions of BOT along with supraglottic larynx • In this procedure, entry into larynx is through uninvolved ventricle inferiorly • Opening is enlarged by dividing the endolaryngeal soft tissues along the ventricle , progressing posteriorly • Specimen can now be retracted & tumour excision is completed. • Atleast one half of base of tongue along with blood supply must be preserved
- 57. RESECTION OF LATERALWALL OF PYRIFORM: • Resection of lateral wall of PFF along with involved portions of lateral & posterior pharyngeal wall is compatible • Closure of defect requires a myocutaneous flap
- 58. COMPLICATIONS • Aspiration – •most common • Can be prevented in part by saving atleast the posterior descending branch of both superior laryngeal nerves • When arytenoid is resected, cricovocal approximation on the ipsilateral side helps in reducing the chances of aspiration • Pharyngocutaneous fistula – • infrequent • Increased incidence is reported in case of extended supraglottic laryngectomy & in patients who have had prior radiotherapy
- 59. POSTOPERATIVE CARE • NGtube feeds – begun 24-48hrs following surgery • Tracheostomy is corked after 4-5 days & once this is well tolerated, tracheostomy tube is removed • Oral feeds –At the end of 1st week, when there is no signs of salivary leak, oral intake is started (semisolid/pureed foods/soft diet). • Most patients return to satisfactory oral diet by end of 2nd week • I aspiration is severe, a temporary feeding gastrostomy is performed & oral feeding withheld for a few days
- 60. RESULTS ONCOLOGIC: • High localcontrol is obtained for selected T1 and T2 tumours • Extremely variable results are obtained for T3 and T4 lesions - local recurrence of 75 % for T3 and 67 % for T4. • Supraglottic laryngectomy should be considered with extreme caution in T3 and T4 lesions. • Lee et al. reported that improved local control is obtained if postoperative radiotherapy is given, although poorer functional results may occur as a consequence. VOICE : • As vocal cords are undisturbed, speech is near normal unless arytemoids are resected
- 61.
- 62. • It isan extended partial laryngectomy procedure. • Indicated in cases of supraglottic cancers that also involve the glottis or the paraglottic space • Too extensive for the conventional horizontal supraglottic partial laryngectomy. • It is best suited for transglottic cancer with mobile arytenoids, minimal subglottic disease and no extension into the pyriform or the base of the tongue. • Early thyroid cartilage erosion is not a contraindication to this procedure. • The procedure entails resection of the entire thyroid cartilage; the true and false cords bilaterally, both paraglottic spaces, the pre-epiglottic space and the epiglottis. • The cricoid cartilage, hyoid bone and at least one arytenoid are preserved .
- 63. INDICATIONS Supraglottic cancers with: •Spread to the anterior commissure or across the ventricle to the vocal cord • Impaired cord mobility or cord fixity due to paraglottic spread but with mobile arytenoids • Early thyroid cartilage erosion. The external perichondrium must be intact.
- 65. CONTRAINDICATIONS • Fixed Hemilarynx:Fixity of the arytenoid indicates involvement of the cricoarytenoid joint and is not compatible with SCPL. • Subglottic extension greater than 10 mm anteriorly and 5 mm posteriorly, which makes preservation of the cricoid oncologically unsafe. • Involvement of the base of tongue, or vallecula or massive involvement of the pre- epiglottic space, where saving the hyoid bone is oncologically unsafe. • Involvement of the pyriform sinus is not compatible with this procedure since the resultant pharyngeal defect will not close with a crico-hyoidopexy.
- 66. • Involvement ofthe postcricoid and interarytenoid regions. Such spread makes it impossible to preserve at least one arytenoid. • Prior tracheostomy is technically incompatible with the procedure, since the tracheostome needs to be positioned after the trachea and cricoid have moved up for the pexy. • Poor pulmonary reserve due to chronic respiratory disease, poor exercise tolerance, frail health and old age are very strong contraindications. Problems of aspiration in the post- operative period are very significant and call for very good respiratory effort and pulmonary reserve.
- 67. PROCEDURE • Anaesthesia isadministered through an oro-tracheal tube. • Prior tracheostomy must be avoided. • The larynx is approached through a superiorly based subplatysmal apron flap, the apex of which is about two finger breadths above the suprasternal notch where the final tracheostomy would be positioned. • The incision is carried up to the mastoid on the side where neck dissection is planned. • The subplatysmal flap is raised to a level 2 cm above the hyoid bone. • It is not necessary to raise the lower skin flap.
- 68. • The sternohyoidand thyrohyoid muscles are divided at the level of the upper border of thyroid cartilage. • Sternothyroid is divided at the level of the lower border of the thyroid cartilage . • The inferior constrictor muscle along with the perichondrium of the thyroid cartilage is incised along the posterior border of the thyroid cartilage.
- 69. • Using afine periosteum elevator, the inner perichondrium is raised over the posterior third of the cartilage to free the mucosa of the pyriform fossa. • These steps are essentially similar to those in a total laryngectomy. • The cricothyroid joint is now gently dislocated carefully by avoiding recurrent laryngeal nerve injury
- 70. • The isthmusof the thyroid gland is divided. • Pre- tracheal fascia is opened and with blunt finger dissection the entire anterior surface of the cervicomediastinal trachea is freed from the fascia right upto the carina . • This will enable the trachea to move up during the pexy.
- 71. • The firstentry into the larynx is through the cricothyroid membrane . • Absence of subglottic extension of disease to this level is confirmed. • The orotracheal tube is removed and anaesthesia is now maintained through a flexible armoured tube passed through the cricothyroidotomy. • The disease extension at this level contraindicates the procedure of SCPL.
- 72. • The periosteumalong the inferior border of the hyoid bone is incised and stripped off its posterior surface . • This facilitates dissection of the underlying soft tissue and the pre-epiglottic space which will be excised with the specimen, preserving the hyoid bone, as well as the attached cut ends of the strap muscles
- 73. • The larynxis now entered through the vallecula above. • The epiglottis is grasped with an Allis forceps and pulled forwards into the wound • Incisions are made across the aryepiglottic folds bilaterally such that the entire pre-epiglottic space is included in the resection. • Care is taken to make these cuts medial to the main trunk and the internal division of the superior laryngeal nerve.
- 74. • Further cutsare now made, vertically downwards, anterior to the released pyriform sinuses. • The cut is first made on the non-tumour bearing side. • In doing so the false cord is transected just anterior to the arytenoids. • The true cord is transected just posterior to the ventricle. • The arytenoid cartilage must be preserved at least on the non-tumour bearing side of the larynx. • It is important not to enter the crico arytenoid joint inadvertently, lest ankylosis of the joint should occur.
- 75. • Vertical cutis connected to the cricothyroidotomy. The cricothyroid and lateral cricoarytenoid muscles are transected along the superior border of the cricoid cartilage. • In order to get better visualisation of the tumour bearing side, the ala of the thyroid cartilage is rotated outwards and allowed to crack along the midline where it unites with the ala on the opposite side . • This opens up the larynx like a book and allows resection on the tumour bearing side under vision. • The rest of the cuts are made as on the opposite side to complete the resection.
- 76. . RECONSTRUCTION • The arytenoidcartilage (or the posterior arytenoid mucosa) is pulled forward. • A 4-0 vicryl suture anchors the vocal process or the arytenoid mucosa to the upper border of the cricoid cartilage to prevent a flip-flop movement. • The crico-hyoido-pexy is now performed using three sutures of 1-0 vicryl. • The first suture is placed in the midline. • It is passed around the cricoid submucosally and then around the hyoid to include the musculature of the base tongue. • Two similar sutures are placed exactly 1 cm away on either side of the midline
- 77. • Before tying,the endotracheal tube is removed, the trachea is elevated by pulling the sutures taut, and a tracheotomy is performed in line with the skin incision. • The crico-hyoido-pexy sutures are now tied snugly to ensure symmetrical alignment of the anterior cricoid arch and the hyoid bone. • The cut edges of the inferior constrictor muscle are sutured in the midline to reposition the pyriform sinuses to a physiologic position to improve post-operative swallowing. • The strap muscles are approximated in the midline. • The wound is closed leaving a drain and taking care to isolate the tracheostomy with subcutaneous sutures.
- 78. POSTOPERATIVE MANAGEMENT • Extensionof the neck is avoided for a few days to prevent dehiscence of the crico- hyoidopexy. • Postoperative period is marked by problems of aspiration for several days. The patient is encouraged not to swallow saliva for few days. • Tube feeding supplements are continued until adequate oral intake is possible. • Restoration of normal swallowing and removal of the feeding tube may take a few weeks. • Decannulation is attempted after a week or two depending on how well the patient tolerates occlusion of the tracheostomy tube.
- 79. COMPLICATIONS • Aspiration pneumonitis •Dehiscence of crico-hyoidopexy • Laryngeal stenosis
- 80. RESULTS ONCOLOGICAL • The 3ot 5year overall survival rates are reported to range from 68 to 84%. • Local recurrence rate is reported to be up to 16%. SPEECH • On phonation (as also on swallowing) the arytenoids abut against the base of the tongue, occluding the larynx and generating the speech. • Though voice quality after SCPL is harsh, the patient satisfaction level is very high since the speech is "lung-powered"
- 81. FUNCTIONAL RESULTS &COMPLICATIONS • Swallowing and speech problems are to be expected in this procedure. • Nasogastric feeding is required from 30 to 365 days • Total laryngectomy may be required in upto 10 % of patients. • Dysphagia is more common if one arytenoid is resected. • Voice studies have shown these patients have poorer voice due to instability of the neoglottis resulting from a wide surgical resection
- 82.
- 83. • An alternativeto open partial laryngeal surgery and radiotherapy • Oncologic results are comparable between all techniques, but transoral laser microsurgery has potential advantages over both open surgery and radiotherapy
- 85. • Cancer isremoved via a transoral route • Specialized rigid laryngoscopes – to expose the tumour • CO2 laser and microlaryngeal instruments - to remove the tumour under microscopic visualization
- 86. • Removal ofcancer in a blockwise method, resulting in several resection specimens. • Requires cutting through cancerous tissue, which of course is against the principles of conventional oncologic surgery. • With microscopic laser surgery, it is possible to see the structure of the cut surface of the tumour, allowing exposure of the superficial and deep extension of the tumour more precisely and allowing one to differentiate between malignant and non-malignant structure. • Surgeon can individually adjust the safety margin • Microscope can also facilitate the detection of any further dysplastic or neoplastic changes of the mucosa surrounding the tumour (field cancerization).
- 87. ADVANTAGES • Dissection throughhealthy tissue to reach the tumour is not required • Contributes to limited surgical trauma and limited blood loss. • Need for reconstruction is usually not necessary as the resulting defect is smaller and heals spontaneously. This also has a major impact on function of speech and swallowing. • By preserving functionally important structures, such as cartilage, muscle and nerves, a more rapid and effective rehabilitation of the patient is achieved. • However, Significant experience with a large number of patients is required to gain the expertise, technical dexterity and judgement for a successful outcome.
- 88. INDICATIONS • Leukoplakia /Erythroplakia of vocal cord • T1/T2 glottic cancer with freely mobile vocal cords • T1/T2 cancer of the supraglottis • Seleceted T3 supraglottic cancer with early invasion of pre-epiglottic space but with freely mobile vocal cords • T1/T2 cancer of hypopharynx with freely mobile vocal cords and with no invasion of the paraglottis or the para pharynx • Localized residual or recurrent cancer following failure of radiation therapy for early cancers of glottis, supraglottis or hypopharynx • Non-squamous histology which is not radiosensitive
- 89. TRANSORAL LASER RESECTION FORGLOTTIC CARCINOMA
- 90. • Becoming thetreatment of choice in T1 mid-cord cancers being preferred over partial laryngectomy & radiotherapy • TOLR of T2 glottic cancers is recommended in select cases such as glotto- supraglottic lesions with freely mobile cords and without anterior commissure involvement • For lesions of anterior 1/3rd of cord & anterior commissure, if the exposure is inadequate, it is best to first resect the portion of supraglottis, viz the false cord & base of epiglottis
- 91.
- 92. PROCEDURE • Orotracheal tubeused for GA • Proper exposure of the lesion is vital to ensure an adequate excision with oncologically safe margins • Laser beam is focused accurately to a spot size and manipulated with the help of micromanipulator to permit precise excision in a relatively bloodless field • For small lesion, monobloc resection is performed by cutting through normal tissue around tumour • Larger lesion is excised in multiple segments
- 93. • CO2 laseris an excellent cutting tool with limited capability for coagulation • Minor ooze – controlled with a defocused laser beam or with a cottonoid soaked in 1:1000 adrenaline solution • Larger bleed – electrocautery connected to an insulated suction tip is used
- 94. ASSESSMENT OF MARGIN: •As specimen is small in size and is resected with narrow margins, careful orientation & labelling of the specimen is essential • Also, to prevent excessive charring, pulse mode of laser rather than continuous wave mode can be used. • Use of narrow beam also decreases extent of thermal injury
- 95. RESULTS • Transoral laserresection of early T1 and T2 glottic cancers has been reported with excellent oncologic results. • Steiner et al. reported five-year local control rates of 96% with T1a and 85 % with T1b cancers, and a larynx preservation rate of 97.6 and 99 per cent, respectively. • For T2a glottic cancers (n = 129) and T2b cancers (n = 115), five-year local control rates were 84 and 70 %, respectively, with larynx preservation rates of 96 and 86 %. • Excellent results have been reported by Ledda et al. 80 (five-year local control of 98 per cent for 103 patients with T1 or T2 cancers). • For large volume T2, T3 and T4 tumours, organ-preserving chemoradiation is now the standard treatment. • Conservation surgery by endoscopic laser resection is possible for T3 tumours. • Steiner et al. have reported on 95 patients with T3 glottic cancers with a five-year local control rate of %, larynx preservation rate of 84 %, overall survival of 58 % and recurrence-free survival of 60 %.
- 96. TRANSORAL ENDOSCOPIC LASER RESECTIONFOR SUPRAGLOTTIC CARCINOMA
- 97. • Vaughan fromBoston was the first to describe a supraglottic partial laryngectomy carried out transorally with CO2 laser. • Supraglottic cancer with freely mobile vocal cords are best suited for TOLR • Lesions with early invasion of pre-epiglottic space or mucosal extension to base of tongue or pyriform are amenable to TOLR; but should be approached cautiously. • Palpable metastatic nodal disease does not preclude TOLR of primary • Inadequate exposure on microlaryngoscopy is an absolute contraindication
- 98. TECHNIQUE • Transoral resectionof Supraglottic cancer is technically more demanding. • For proper exposure, a distending bivalved laryngopharyngoscope is used. • Insulated monopolar cautery is must as supraglottis is very vascular. • Small tumours of suprahyoid epiglottis, AEFs or ventricular folds can be excised easily, en bloc • Tumour of infrahyoid epiglottis needs to be exposed adequately before resection by resecting suprahyoid portion of epiglottis.
- 100. RESULTS • Steiner hasreported five-year local control rates for T1 (n = 23) and T2 (n = 72) cancers of 95 and 85 % with larynx preservation rates of 96 and 99 %, respectively. • Overall survival rates were 87 and 73 %, respectively. • These results are comparable to open supraglottic laryngectomy, but functional results are superior since clinically relevant aspiration did not occur in the laser- treated patients • Iro et al showed that favourable oncologic results in TOLR could only be achieved with tumour free resection margins (R0) • Adjuvant therapy was not effective in R1 & R2 resections • In case of positive margins, they recommend re-laser resection or open partial laryngectomy or total laryngectomy
- 101.
Editor's Notes
- #10 This is the main problem of conservation laryngeal surgery. The amount of postoperative aspiration varies with the type of surgery.
- #11 All patients should have a speech and swallowing assessment preoperatively and both the patient and family should participate in the work required for rehabilitation.
- #13 This is the reason that subglottic extension of d/s morethan 10 mm ant. Or 5 mm post., is a contraindication for any partial laryngectomy procedures since it would necessitate rsection of the cricoid, as the subglottic disease is too close to the cricoid cartilage. Similarly,
- #17 In the recent years, the procedure is used very rarely as most lesions suitable for a cordectomy are now approached endoscopically& resected using CO2 laser.
- #19 Midline thyrotomy – from thyroid notch superiorly to the lower border of thyroid cartilage inferiorly
- #20 No risk of aspiration as neither laryngeal nerve supply nor the pharyngeal musculature is disturbed
- #25 Involvement of anterior commissure : (RT fails to deliver adequate dose at AC & microlaryngoscopic exposure to the AC may be very difficult making it impossible for R-0 resection) Impaired mobility of Vocal Cord (T2b) : ( Failure rates with RT are higher with deep infiltration of disease; TOLR may necessitate type IV cordectomy resulting in poor quality of voice & yet not give very satisfactory tumour margins) Subglottic extension of disease : (RT & TOLR have high failure rates) Inadequate exposure on microlaryngoscopy & yet surgery is strongly indicated (Eg : Verrucous Ca, Cancer in very young, previous radiation therapy to the neck) Salvage of post-RT recurrence (For partial laryngectomy to be feasible, criteria to be satisfied are : Lesion was amenable to VPL before radiotherapy; Recurrence is in the same area & has not progressed; rest of the laryngeal tissue are supple & non-oedematous) Selected T3 glottic tumours (where cord is fixed, but both arytenoids are freely mobile & there is minimal extension above or below the cord level)
- #33 Excellent oncologic results can therefore be expected for T1 glottic carcinomas, although once the anterior commissure is involved or if there is extension beyond the glottis, vertical partial laryngectomy should be used with caution. It is not recommended for advanced T2 or T3 lesions.
- #45 Transglottic lesions (i.e. lesions which extend across the laryngeal ventricle involving both the true cord and false cord)
- #49 HSPL includes resection of false cords, epiglottis, preepiglottic space, & upper 1/3rd of thyroid cartilage EHSPL : HSPL is extended to include resection of ipsilateral arytenoid, vallecula with adjacent base of tongue or the pyriform
- #53 Anterior commissure is located at the junction of upper 1/3rd & lower 2/3rd of thyroid cartilage in anterior midline in females & halfway b/w thyroid notch & inferior margin in males
- #74 This is to ensure that the posterior descending branch of the internal division is left intact so as to preserve the sensory supply to the larynx.