Laryngeal surgeries

1. Laryngeal Surgeries
Dr Deepika Malik
Resident Radiation Oncology

2. Laryngeal Anatomy
• Larynx is divided embrologically, clinically and
anatomically into
• Supraglottis
• Glottis
• Subglottis

3. Supraglottic Larynx
• Includes the lingual and laryngeal surfaces of epiglottis
, Aryepiglottic folds, and arytenoid cartilage.
• During development , these structures are derived
from branchial arches 3 and 4
• Glottic and Subglottic subunit develop from arches 5
and 6
• Embryonic fusion plane between ‘supraglottic’ and
‘glottic and subglottic’ subunits is represented by a
horizontal line drawn through the ventricle.
• This horizontal plane provides the anatomic and
oncologic basis of supraglottic laryngectomy

4. Supraglottic larynx
• Supraglottic larynx comprises
- Suprahyoid epiglottis( both
lingual and laryngeal surface)
- Infrahyoid epiglottis
- Pre-epiglottic space
- Larygeal aspects of AE folds
- 2 arytenoids
- Ventricular bands( false cords)

5. • Inferior boundary of supraglottis is a
horizontal line passing through apex of
venticle of larynx
• This anatomic divisio is located at the arcuate
line , which marks the change from respiratory
to squamous epithelium and is located at apex
of ventricle
• Thus the roof of ventricle is located in
supraglottis and floor belongs to glottis.

6. • The marginal zone of supraglottis is recognised
because of aggressive clinical behaviours of
cancer in this area
• Because of lack of embryonic seperation from
adjacent hypopharynx , cancers in this zone
behave similarly to more aggressive cancers of
hypopharynx and they carry a worse prognosis
• Mucous glands are in abundance, and the rich
vascularity and lymphatics associated with these
glands are responsible for lymphatic spread.

7. Glottic larynx
Includes
• true vocal cords and
• anterior and posterior
commissures

8. • The lamina propria has a superficial loose fibrous
layer that makes Reinke’s space
• Blood vessels and lymphatics are almost absent
in reinke’s space creating a resistance to spread
of early cancer of glottis.
• No mucous glands on free edge of vocal cords,
only sparse glands are noted on superior aspect
• Conus elasticus extends upwards from superior
border of cricoid cartilage to merge with inferior
surface of vocal ligament; it resists extralaryngeal
spread of glottic and subglottic cancer

9. Subglottic Larynx
• No subsites
• Is the area of larynx inferior to
the glottis down to inferior rim
of cricoid cartilage
• Rare site of origin of cancer,
but is commonly involved by
subglottic extension of glottic
cancer.
• Tumors here have high
incidence of extralaryngeal
spread owing to proximity of
cricothyroid membrane and
rich postcricoid lymphatics.

10. Laryngeal Surgeries

11. • In 1866, Patrick Watson of Edinburg performed
the first laryngectomy for a patient of syphilitic
larynx, who died later from pneumonia . After his
death , the procedure was condemned
• In 1873, Billroth of Vienna , performed the first
successful laryngectomy
• Since then there have been many advances in
laryngeal surgery which are both safe and
reliable.

12. • Organ preservation therapy of the larynx is
offered as a functional alternative to total
laryngectomy.
• The intended goals of preservation therapy
are to circumvent permanent tracheostomy,
maintain laryngeal speech, and preserve
swallow function

13. Surgeries for glottic cancer
• 1. endoscopic resection
• 2. vertical partial Larngectomies

14. Endoscopic resection
• excision of the vocal cord
• May be performed by the transoral
endoscopic approach usually with a laser
• Its use is usually confined to small lesions of
the middle third of the cord. After
cordectomy, a pseudocord is formed, and the
patient has a useful, if somewhat harsh, voice.

15. Transoral endoscopic laser surgery

16. • Advantages nd diadvantages

17. Vertical Partial Laryngectomy
• Open transcervical vertical laryngectomy was
initially proposed by Solis-Colen in 1800’s to
address early T1 and T2 and select T3 glottic
cancer.
• With the advent of primary radiotherapy in
the mid 20th century, open procedures were
replaced as the definitive treatment for T1
and T2 disease.

18. • The central concept in all VPL’s is vertical
transection of thyroid cartilage and paraglottic
space.
• Extent of resection depends on extent of
lesion

19. Types of VPL
• Laryngofissure and cordectomy
• Vertical Hemilaryngectomy
• Extended vertical Hemilaryngectomy

20. Laryngofissure and cordectomy
• T1 glottic lesions
involving the mid true
vocal cords
• An endoscopy
performed followed by
laryngofissure followed
by cordectomy followed
by a tracheostomy.

21. • Increased used of endoscopic cordectomy has
resulted in decreased use of open procedure.

22. Vertical Hemilaryngectomy
• Reserved for T1 and T2 lesions of true vocal
cords
• Result for T3 and T4 lesions have also been
acceptable

23. VHL..
• Endoscopy is
performed before VH
is completed
following which
tracheostomy is
performed from a
separate incision

24. • One entire cord with as much as a third of the
opposite cord with the adjacent thyroid
cartilage is the maximum cordal involvement
suitable for surgery in men;
• women have a smaller larynx, and usually only
one vocal cord may be removed without
compromising the airway.

25. • The maximum subglottic extension suitable
for hemilaryngectomy is 8 to 9 mm anteriorly
and 5 mm posteriorly; this limit is necessary to
preserve the integrity of the cricoid.
• Tumor extension to the epiglottis, false cord,
or both arytenoids is a contraindication to
hemilaryngectomy

26. • Partial fixation of one cord is not a
contraindication to hemilaryngectomy, but
only a few surgeons have attempted
hemilaryngectomy for selected fixed-cord
lesions.

27. Extended Vertical Hemilaryngectomy
• 1. Frontolateral Vertical Hemilaryngectomy-
used for lesions involving anterior commissure
and anterior contralateral vocal cord
• 2. posterolateral Vertical Hemilaryngectomy-
used for lesions involving ipsilateral aytenoid
cartilage

28. Surgeries for supraglottic cancer
• 1. endoscopic resection
• Supraglottic laryngectomy
• Supracricoid partial laryngectomy

29. Endoscopic resection
• Concept of endoscopic management of
supraglottic cancers began in 1939 when
Jackson decribed use of laryngoscope and
punch biopsy forceps to resect cancers of
suprahyoid epiglottis
• Advent of operating microscope , suspension
microlaryngology and CO2 laser led to its
renewed popularity.

30. • Advantages over open surgeries
- Elimination of need of tracheostomy
- Shorter operating times
- Early rehabiliation of swallowing function
- Diadvantages
- Need of specialised equipment
- Prolonged healing time (2nd int
- Poor exposure often leads inadequate
removal of lesion

31. • Qualityof voice following laser surgery for SGL
cancers should be unchanged
• Results are comparable to radiation therapy,
with the latter type being more convinient and
less expensive for patients.

32. • T1 and T2 lesions on suprahyoid epiglottis , AE
fold and vestibular fold with minimal
preepiglottic and paraglottic involvement may
be treated woth endoscopic laser
• Cancers on infrahyoid glottis and false cord
are less amenable to endoscopic resection

33. • CO2 laser is the laser of choice because of its
- Superficial effect which minimises damage to
surrounding tissues
- Ability to be used as cutting tool in focused
mode and coagulation tool in defocused mode

34. Supraglottic laryngectomy
• Indicated in SGL cancers arising from
epiglottis, a single arytenoid, the aryepiglottic
fold, or the false vocal cord.
• The procedure minimises morbidity and
preserved the 3 primary functions of larynx-
airway protection, respiration , phonation

35. SGL..
• Extension of the tumor to the true vocal cord,
the anterior commissure, or both arytenoids;
fixation of the vocal cord; or thyroid or cricoid
cartilage invasion precludes supraglottic
laryngectomy

36. SGL..
• First introduced as a 2 stage procedure ,in
1947 as an alternative to the then prevailing
treatment of SGL cancers, total laryngectomy
and neck dissection
• Later in 1959, it was converted to a single
stage procedure.

37. Temporary tracheostomy

38. • Patient selection is very important as every
patient would develop temporary aspiration
post operatively ; thus making patient’s
cardiopulmonary reserve an importanr factor
in patient selection.
• Patients must have a good cough reflex or
they will aspirate, will not be able to swallow
properly or would develop recurren aspiration
pneumonia my

39. Supracricoid laryngectomy
• Used for selected T2 and T3 glottic carcinomas
and supraglottic cancers involving 1 or both cords
• Variation of SG laryngectomy which is extended
to provide an oncologically sound resection in an
attempt to poresrve voice and avoid permanent
tracheostomy.
• entails removal of both true and false cords as
well as the entire thyroid cartilage. The cricoid is
sutured to the epiglottis and hyoid
(cricohyoidopexy)

41. Total laryngectomy
• Fistly performed by Billroth in 1870
• Despite in advances in organ preservation
treatment protocols , total laryngectomy is
• Surgery of choice for advanced lesions and
and as a salvage procedure for radiation
therapy failures in lesions that are not suited
for conservation surgery.

42. • Criteria for patient selection
- Fitness to undergo general anaesthesia
- Ability to care for permanent tracheostomy
- Psychological ability for adjusting to a
laryngectomy

43. • Entire larynx is
removed
• Pharynx is
reconstructed.
• Permanent
tracheostomy is
required.

45. Near total laryngectomy
• Described by Pearson
• Technically complex procedure to create a
physiological voice shunt based on mobile
arytenoid
• No significant gains over total larygectomy

46. COMPLICATIONS OF LARYNGEAL
SURGERIES
• Neel et al. (78) reported a 26% incidence of
nonfatal complications for cordectomy.
• Immediate postoperative complications included
atelectasis and pneumonia, severe subcutaneous
emphysema in the neck, bleeding from the
tracheotomy site or larynx, wound complications,
and airway obstruction requiring tracheotomy.
• Late complications included granulation tissue
that had to be removed by direct laryngoscopy to
exclude recurrences, extrusion of cartilage,
laryngeal stenosis, and obstructing laryngeal web.

47. • The postoperative complications and sequelae of
hemilaryngectomy include chondritis, wound
slough, inadequate glottic closure, and anterior
commissure webs
• The complications associated with supraglottic
laryngectomy and total laryngectomy for
supraglottic carcinomas include fistula (8%),
carotid artery exposure or blowout (3% to 5%),
infection or wound sloughing (3% to 7%), and
fatal complications (3%) (25).
• .

48. • The risk of complications increased if tumor
margins were involved by tumor; there was no
change in risk associated with age, sex, race,
laryngeal site, stage of primary tumor, size of
primary tumor, use of low-dose preoperative
irradiation, or status of the positive nodes.

49. VOICE REHABLITATION AFTER TOTAL
LARYNGECTOMY
• Major challenge for HNC surgeon and speech
pathologist is restoration of speech
• Patient undergoing TL is offered 3 options
1. Artificial larynx/electrolarynx
2.Esophageal voice
3.Tracheoesophageal voice

50. electrolarynx
• First artificial larynx was
devised by Gussenbauer in
1874
• Available as an external
device which is placed
against the neck, or as an
oral type

51. • Electrically driven
• produce a
mechanical sound
• which is then
articulated by
tongue, lips, teeth
as
understandable
speech.

52. Advantages
• Short learning time
• Can be used in immediate post op period
• Relative availability and low cost
Disadvantages
• Mechanical sound and dependance on batteries
• Need for maintenance of intraoral tubes

53. Esophageal voice
• A speech pathologist or another
laryngectomee teaches the patient
insufflation behaviour in aquiring esophageal
speech
• The patient learns how to rapidly insufflate
and eject air through the esophagus to
produce understandable speech

54. • This entails trapping
air in mouth or
pharynx and
propelling it into
esophagus which
produces a sound
that can be
articulated by
tongue , lips and
teeth

55. Tracheoesophageal voice
• Based on concept of shunting of tracheal air
to pharynx through a fistulous tract during
exhalation to produce sound through
vibration of mucosa of upper esophageal
segment
• Speech is produced by articulation of sound at
level of oral cavity.

58. • Transesophageal puncture can be performed
at time of laryngectomy (primary TEP) or later
as an independent procedure (secondary TEP)

59. • Thankyou.