Laryngectomy and post laryngectomy rehabilitation

1. LARYNGECTOMIES AND
REHABILITATION
PRESENTER -Dr Oshin Thomas, 3rd yr PG

8.  T1 glottic cancer TOLR
 T2 glottic cancer sx( open surery)
 T3/T4 supra glottic cancer RT alone/ CTRT
 Marginal zone ca+ suprahyoid epiglottic growth TOLR
 T3 (intermediate stage)  concurrent chemoradiation
 T4a advanced ca Total Laryngectomy RT

9. TOTAL LARYNGECTOMY
 Loss of larynx.
 Loss of glottic closure and ability to raise intrathoracic pressure.
 Loss of nasal airflow
 Presence of stoma.

10. TOTAL LARYNGECTOMY
 Bill Roth is credited with performing the first total laryngectomy .
 INDICATIONS
 1. Compromised laryngeal structure
 Locally advanced (T4a) tumours with thyroid cartilage destruction and exolaryngeal spread.
 Subglottic extension with invasion of cricoid cartilage.
 2. Compromised laryngeal function
 Laryngeal cancer patients presenting with symptoms of laryngeal dysfunction such as aspiration or
airway obstruction.
 Post radiotherapy/post chemotherapy, patients with severely dysfunctional larynx , who have
severe dysphagia or intractable aspiration.

11. 3. Failure of organ preservation
 Candidate who cann’t withstand chemotherapy due to medical reasons.
 Residual or recurrent disease post radiotherapy/chemo-radiotherapy that is
not amenable to conservative laryngeal surgery.
 Completion laryngectomy for failed initial laryngeal conservation surgeries.
4. other miscellaneous indications
 Locally advanced tumours of certain histologies that are not amenable to
radiotherapy or TOLR e.g Soft tissue sarcomas of larynx, minor salivary
gland tumours and chondrosarcomas etc.
 Advanced tumours of thyroid with laryngeal extension, not amenable to
conservative procedures.
 Last resort option for severe intractable aspiration due to neurogenic
causes or other causes where other diversion or closure procedures have
not worked.

13. Preop workup and anaesthesia
INDICATIONS
 Advanced laryngeal ca
 Failure of chemoradiotherapy.
CONTRAINDICATION
 Poor general condition.
 Incurable distant mets/ encasement of
CCA/ICA.

14. POSITIONING & INCISION-Gluck Sorenson

15. INCISION AND POSITION OF STOMA
A superiorly based apron flap incision is marked with the horizontal limb placed about 2 cm above
the clavicles with the vertical limbs parallel to and 1cm posterior to the anterior borders of the
sternocleidomastoid muscles (SCM).
The stoma is marked immediately below the horizontal limb .
The size of The stoma should approximate the size of the patient’s thumb to facilitate the use of a
voice prosthesis, or be about 1.5 times the diameter of the trachea.
The lower border of the stoma should be 2 cm above the upper border of the manubrium. It is
important not to place the stoma too low In neck.
Musculocutaneous flaps are elevated in he subplatysmal plane to 2 cm superior to the hyoid bone
above, and to the sternal notch below.

24. FLAP ELEVATION

25. FREEING UP/MOBILIZATION OF LARYNX

26. STRAP MUSCLES DIVIDED

27. HEMITHYROIDECTOMY

31. SUPRAHYOID RESECTION

34. PHARYNGOTOMY

35. Tracheostomy
 A tracheostomy is done at this stage to mobilise the larynx and to facilitate the laryngeal
resection
 Ask the anaesthetist to preoxygenate the patient
 Incise the trachea transversely between the 3rd/4th/5th tracheal rings or below a
preoperative tracheostomy
 With a small trachea, incise the lateral tracheal walls in a superolateral direction to
bevel and enlarge the tracheostoma
 Place a few 3-0 vicryl half-mattress sutures between the anterior wall of the transected
trachea and the skin to approximate mucosa to skin
 Puncture and deflate the cuff of the endotracheal tube, and cut the tube in the
pharynx, and remove the distal end of the tube through the pharyngotomy
 Insert a flexible endotracheal tube e.g. armoured tube into the tracheostoma. Avoid
inserting the tube too deeply as the carina is quite close to the tracheostoma. Fix the
tube to the chest wall or drapes with a temporary suture so that it does not become
displaced, attach the sterile anaesthesia tubing and resume ventilation

36. RESECTION

39. RETROGRADE LARYNGECTOMY

41. MYOTOMY & PRIMARY TEP

42. Total laryngectomy

43. Primary tep insertion

44. Secondary tep

45. PHARYNX REPAIR

46. A 3-layered pharyngeal closure is suggested
 o 1st layer: 3-0 vicryl running modified Connell or true Connell technique (Invert
mucosa) (Figure 32)
 o 2nd layer: 3-0 vicryl running suture of submucosa and muscle
 o 3rd layer: Approximate inferior constrictors and suture constrictors to suprahyoid
muscles with interrupted 3-0 vicryl
Final steps
 Ask the anaesthetist to do a Valsalva manoeuvre to detect bleeding and a chyle leak
 If there is excessive, lax suprastomal skin that may occlude the tracheostomy when
the patient flexes the neck, then trim a crescent of suprastomal skin from the edge
of the apron flap
 Suture the skin to the edge of the tracheostomy with half-mattress interrupted 3-0
vicryl sutures

47.  FASHION THE STOMA
 The final portion of the laryngectomy is completion of the tracheostoma.
 The inferior border is addressed first and sutures of 2-0 nylon are used.
 The stitch is placed through the skin and then from outside to inside the tracheal lumen just below
a tracheal ring. The suture is then passed back through the skin from subcutaneous to external, just
horizontal to the initial entry point.
 In this manner a half mattress is formed for the tracheal part of the stitch around the tracheal ring
thus lending strength to the stoma. Figure 17

49.  Insert a ¼” suction drain
 Irrigate neck with sterile water
 Reapproximate the platysma with 3-0 vicryl running sutures
 Close the skin with a running nylon suture or with skin staples
 Suction blood from trachea
 Insert a cuffed tracheostomy tube, and suture it to skin
Postoperative care
 Antibiotics x 24 hours
 Omeprazole (20mg/day) via Foley or mouth x 14 days to reduce risk of developing
pharyngocutaneous fistulae
 Chest physiotherapy
 Remove suction drains when <50mls drainage per 24hrs
 • Day 1: Mobilise to chair, remove urinary catheter
 • Day 2: Commence oral feeding. Early oral feeding is safe, and does not cause
pharyngocutaneous fistulae

50.  Day 7: Remove sutures
 Day 10: Insert speaking valve; no anaesthetic required (Figures 34, 35)
 • Cover the stoma with a bib (Figure 36)

51. STOMA CREATION & FEEDING

52. FLAP reconstruction REQUIRED??
 Tmr involving hypopharynx
 Pharyngeal repair in salvage laryngectomy to ensure pharyngo-
cutaneous fistula closure.
NECK DISSECTION
Elective lateral neck dissection (level 2-4)
Level 6 if subglottic or pyriform fossa carcinoma

56.  Following pharyngeal reconstruction with a flap,
a contrast swallow X-ray is done on about day 7 to exclude an
anastomotic leak before commencing oral feeding.

57. Complications
Early complications LATE complications
 1. Haemorrhage/hematoma Stomal stenosis
 2. Wound infection Neopharyngeal stenosis & stricture
 3. Pharyngocutaneous fistula Hypothyroidism
 4. Aspiration problems Dysphagia
 5. Pharyngeal leaks
 6. Wound dehiscence

58. Rehabilitation
after
Total Laryngectomy

59. Functional alterations following total Laryngectomy
Changes in normal swallowing mechanism
Changes in the pattern of respiration
Loss of smell
Most importantly -Loss of speechThe
importance of this function is not realised till it
is lost

60.  Swallowing Rehabilitation
 Pulmonary Rehabilitation
 Olfactory Rehabilitation
 Voice Rehabilitation

61. SWALLOWING REHABILITATION

62. Swallowing rehabilitation
• Swallowing rehabilitation for patients dependent on tube
feeding after treatment for head and neck cancer usually
takes about three months, according to a Dutch study.
• although about 20% need help for six months or more.
• Patients with transport problems fared better than those
with aspiration.

63. PULMONARY REHABILITATION

64. • Disconnection between upper & lower respiratory
tract.
• Conditioning of inspired air not occur
• Heat-moisture exchanger humidifies,filter,inspired
air
• It reduces sputum production,cough,
shortness of breathing,forced
expectoration.

65. • AUTOMATIC HANDS FREE SPEEKING VALVE.

66. OLFACTORY REHABILITATION

67. • In laryngectomised pt breathing occur
through stoma
• Anosmia is due to not reaching odour
molecules to olfactory epithelium
• Leads to reduced taste,reduced food
intake,reduced quality of life.

68. NAIM-Nasal Airway Induced Manoeuver
•Repeated extended yawning
•Lowering jaw,floor of mouth,tongue,bot,soft palate while closing the lips.
•Polite yawning/closed mouth yawning
•Induces negative pressure in oral cavity,oropharynx which generate airflow in nasal cavity.
•Need single intervention session.

69. VOCAL REHABILITATION

70. Requirements for normal phonation
• Active respiratory support
• Adequate glottic closure
• Normal mucosal covering of vocal
cord
• Adequate vocal cord length and
tension control

71. Methods of speech following Laryngectomy
• Also known as alaryngeal speech
• Esophageal speech
• Electro larynx
• TEP (Tracheo-oesophageal puncture)

73. Alaryngeal speech
ESOPHAGEAL SPEECH

74. Contd…
All pts develop some degree of esophageal
speech following Laryngectomy
All alaryngeal speech modalities are compared
with this modality
Till 1970’s this was the gold standard for all other
post Laryngectomy speech rehabilitation
procedures

75. •
Esophageal speech - Physiology
• This swallowed air is expelled out
causing vibrations of pharyngeal
mucosa
• These vibrations along with articulations
of tongue cause speech to occur
• The exact vibrating portion of pharynx is the
pharyngo-oesophageal segment ( PE segment)
• The vibrating muscles and mucosa of
cervical oesophagus and hypopharynx
cause speech
Air is swallowed into cervical esophagus

76. Oesophageal speech – PE segment
•
•
•
•
•
This segment is made up of musculature and
mucosa of lower cervical area (C5-C7 segments).
Vibration of this segment causes speech in pts
without larynx
Cricopharyngeal area is important
Cricopharyngeal spasm in these pts. Can lead to failure
in developing Oesophageal speech
Cricopharyngeal myotomy may help these pts. in
developing Oesophageal speech

77. Pumping air into cervical oesophagus
• Injection method
• Inhalational method

78. Injection method
• Enough positive pressure is built inside oral cavity to force air into cervical
oesophagus
• Lip closure and tongue elevation against palate causes increase intraoral pressure
• Air is injected into the cervical oesophagus by voluntary swallowing
• This method is also known as tongue pumping / glossopharyngeal
press / glossopharyngeal closure

79. Inhalational method
• Uses the negative pressure used in normal breathing to allow air to enter cervical
oesophagus
• Air pressure in the cervical oesophagus below Cricopharyngeal
sphincter is the same negative pressure as that of thoracic cavity
• Pts. Learn how to relax Cricopharyngeal sphincter during inspiration
allowing air to flow into cervical oesophagus as it enters the lungs
• Pts. Are encouraged to consume carbonated drinks which facilitates air entry
into cervical oesophagus helping in generation of Oesophageal speech

80. Esophageal speech - Advantages
• Patient’s hands are free
• No additional surgery / prosthesis needed. Hence no extra cost
for the pt.
• Pts. Get easily adapted to esophageal voice

81. Esophageal speech - Disadvantages
• Nearly 40% of pts fail to develop esophageal speech
• Quality of voice generated is rather poor
• Pt. may not be able to continuously speak using esophageal voice without
interruption.
• They will be able to speak only in short bursts
• Significant training is necessary
• Loudness / pitch control is difficult
• Fundamental frequency of esophageal speech is 65 Hz which is lower than that of
male and female frequencies

82. Esophageal speech development causes for failure
• Presence of cricopharyngeal spasm
• Presence of reflux esophagitis
• Abnormalities involving PE segment – like thinning of muscle wall in that
area
• Denervation of muscle in the PE segment
• Poorly motivated patient

83. Cricopharyngeal spasm
• Cricopharyngeal myotomy
• Botulinum toxin injection – 30 units can be injected via
the tracheostome over the posterior pharyngeal wall
bulge

85. Electrolarynx
•
•
•
•
These are battery operated
vibrating devices
It is held in the
submandibular region
Muscle contraction and
changes in facial muscle
tension causes rudiments
of speech
Initial training to use this
equipment should begin
even before surgery

86. Electrolarynx - Types
• Pneumatic
• Neck
• Intraoral type

87. Electrolarynx - Contd
• Neck type is commonly
used
• Hypoesthesia of neck
during early phases of
post op period can cause
difficulties
• If neck type cannot be
used intraoral type is the
next preferred one

88. Intraoral artificial larynx
• Intraoral cup should form a tight
seal over the stoma.
• There should not be any air leak
• Oral tip should be placed in the oral
cavity
• Pts exhaled air rattles the cup placed
over the stoma
• Changes in exhaled pressure can
vary the quality of sound generated

89. Electrolarynx - advantages
• Can be easily learnt
• Immediate communication is possible
• Additional surgery is avoided
• Can be used as a measure till the patient masters the
technique of esophageal speech or gets a TEP inserted

90. Electrolarynx - Disadvantages
• Expensive to maintain
• Speech generated is mechanical in quality
• Difficult while speaking over telephone

91. Types of voice restoration surgeries
• Neoglottic reconstruction
• Shunt technique

92. Neoglottis procedure
• Performing trachea hyoidopexy
• This can restore voice function in alaryngeal
patients
• Abandoned due to increased incidence of
complications like aspiration

93. Shunt technique
•
•
•
•
Developed by Guttmann in
1930
Involves creation of shunt
between trachea and esophagus
Lots of modifications of this
procedure is available, Basic
principle is the same
Aim is to divert air from trachea
into the esophagus

94. Types of Prosthesis

95. Indwelling versus Non-indwellingprosthesis
Indwelling prosthesis Non indwelling prosthesis
Can be left in place for 3-6 months Should be removed and cleaned every couple of
days
Requires specialist to do the job Pt. Can do it themselves
Less maintenance Periodical maintenance
Stoma should be greater than 2 cms Stoma should be greater than 2 cms
Oesophageal insufflation test should be
positive
Oesophageal insufflation test should be
positive

96. TEP
• Was first introduced by Blom and Singer in 1979
• One way silicone valve is introduced via the fistula
• This valve served as one way conduit for air into esophagus while preventing
aspiration
• This prosthesis has two flanges, one enters the esophagus while the other rests
in the trachea.It fits snugly into the trachea-esophageal wound

98. Types of TEP
• Primary TEP – Performed during total laryngectomy
• Secondary TEP – Performed 6 months after surgery

99. Primary - TEP
• Hamaker first performed in 1985
• Primary TEP should be attempted where ever
possible
• In this procedure puncture is performed immediately
after laryngectomy and prosthesis is inserted
• Prosthesis of sufficient length should be used

100. Secondary TEP
• Usually performed 6 weeks following
laryngectomy
• This allows pt time to develop esophageal speech
• Area of fistula identified using rigid
esophagoscope
• Prosthesis can be inserted immediatly

102. Anatomical structures TEP
•
•
•
TEP is performed in
midline (Less bleeding)
Structures that are
penetrated during TEP -
membranous posterior wall
of trachea, esophagus and
its 3 muscle layers and
esophageal mucosa
Interconnecting tissue in
the trachea-esophageal
space

103. Advantages of TEP
• Can be performed after laryngectomy / irradiation
/ chemotherapy / neck dissection
• Fistula can be used for esophago-gastric feeding during
immediate PO period
• Easily reversible
• Speech develops faster than esophageal speech
• High success rate
• Closely resembles laryngeal speech
• Speech is intelligible

104. Disadvantages of TEP
• Pt should manually cover the stoma during
voicing
• Good pulmonary reserve is a must
• Additional surgical procedure is needed to
introduce it
• Posterior esophageal wall can be breached
• Catheter can pass through the posterior wall

105. TEP – Patient selection
• Motivated patient
• Patient with stable mind
• Patient who has understood the anatomy & physiology of the
process
• Patient should not be an alcoholic
• Good hand dexterity
• Good visual acuity
• Positive esophageal air insufflation test
• Patient should not have pharyngeal stricture / stenosis
• Stoma should be of adequate depth and diameter
• Intact trachea-esophageal wall

106. Contraindications of TEP
• Extensive surgery involving pharynx, larynx with separation of trachea-
esophageal wall
• Inadequate psychological preparation
• Patient with doubtful ability to cope up with prosthesis
• Impaired hand dexterity
• Suspected difficulty during PO irradiation

107. Problems with TEP insertion
• Leak through the prosthesis
• Leak around the prosthesis
• Immediate aphonia / dysphonia
• Hypertonicity problems
• Delayed speech

108. Oesophageal insufflation test
• Should be performed before TEP
• Assesses cricopharyngeal muscle response to
esophageal distention
• A catheter is placed through the nostril up to 25 cm
mark. This indicates probable site of puncture
• Pt is asked to count numbers or vocalize “Ah”

110. Management of leak through the prosthesis
Cause Solution
Valve in contact with posterior wall of esophagus Replace prosthesis with different length and size
Prosthesis length too short for the puncture
“Pinched valve”
Remeasure the puncture and replace with
appropriate size prosthesis
Valve deterioration Replace valve
Fungal colonization of valve with yeast Treat with nystatin
Back pressure High resistant prosthesis
Mucous / food lodgment Prosthesis to be cleaned

111. Management of leak around the prosthesis
Cause Solution
TEP location Remove prosthesis allow puncture to close
and repuncture
Unnecessary dilatation during valve placement To be avoided
Thin trachea-esophageal wall 6 mm or less Choose custom prosthesis
Prosthesis of incorrect length and size Choose correct length
Poor tissue integrity due to irradiation Custom prosthesis

113. NEAR TOTAL/SUBTOTAL LARYNGECTOMY
(PEARSON)

114. 1. PRINCIPLE
where the vertical extent of the lesion is such
that a segment of the cricoid ring has to be
resected and yet one arytenoid is supple and
free of disease, a NTL can be performed.

116. INDICATIONS
• 1) T3/T4 lateralised transglottic lesion of the larynx, with no extension to the inter arytenoid
region.
• 2) T3/T4 lateralised cancer of the pyriform sinus with involvement of its apex and causing
fixity of the hemilarynx or even thyroid cartilage erosion.

117. CONTRAINDICATIONS
• Interarytenoid or postcricoid
involvement which makes preservation
of the contralateral arytenoid
oncologically unsafe.
• Mucosal involvement of more than
one-third the length of the
contralateral cord
• Prior radiation therapy is a relative
contraindication to NTL if the tissues
are oedematous.

118. • The perichondrium over the
contralateral thyroid cartilage is
stripped from medial to lateral
side.
• A vertical segment of the thyroid
cartilage is resected to inspect the
paraglottis on the normal side, and
confirm its suppleness.
• Suprahyoid muscles are divided to
skeletonize the hyoid bone.
• After a transvallecular entry into
the larynx as in a total
laryngectomy, the epiglottis is
caught in an Allis forceps and
refracted downwards.

119. • Thereafter the mucosa of the
interarytenoid region and that over the
posterior cricoid lamina is incised.
• The posterior cricoid lamina is now
fractured or cut, care being taken to
avoid damage to the postcricoid
mucosa.
• The resection is now completed,
preserving the opposite arytenoid and
the posterior tracheal wall between
the arytenoid and the tracheotome.

120. Construction of the shunt
• A myomucosal shunt is created from the
laryngotracheal remnant.
• resection of excess cricoid is performed,
sparing the posterior segment of the
cartilage on which the functioning arytenoid
rests.
• The shunt is now formed by tubing the
laryngotracheal remnant with 3-0
interrupted vicryl sutures.
• Some surgeons prefer to stent the shunt
temporarily using 14 no. Foley's or a No.6
red rubber catheter.

121. • Subglottic pressure studies have indicated
that the diameter of the shunt must be at
least 6 mm (14R) to enable the patient to
speak at physiological airway pressures
without straining.
• If the mucosa of the laryngeal remnant is
inadequate, it must be augmented using the
uninvolved hypopharyngeal mucosa.
• The stent also helps the surgeon's
orientation for pharyngeal closure, which is
the next step.

122. Pharyngeal closure
• The neopharynx is closed as in a total
laryngectomy.
• Closure , with particular care at the point
where the pharynx is closed over the
neoglottis i.e. the voice shunt, to avoid •
pharyngocutaneous fistula
postoperatively.
• In case extensive resection,patch
pharyngoplasty should be performed
using a pectoralis major myocutaneous
flap.
If a stent was used for the voice shunt, it
is pulled out from the tracheostome end
once the pharyngeal closure is complete.

123. Stomal Maturation
• The Tracheostome in a near-total laryngectomy is a side stoma unlike a
total laryngectomy which is an end stoma.
• The tracheostoma should be made at 3
shunt.
rd
or 4th
ring to ensure a longer
• The cartilage at the site of the stoma is removed - wide stoma.
• The skin flaps are matured to the tracheal rings above and below.
• Tracheostomy tube may be required for a few months to prevent it from
stenosis.

124. POSTOPERATIVE MANAGEMENT
• A tracheostomy tube is usually not required unless the stoma shows a
tendency for stenosis.
• Feeding is commenced through the nasogastric tube on POD1.
• Oral feeds are started once the wound is healed and there are no signs of
salivary leak, which is usually by the 10th postoperative day.
• Most patients are on a regular diet within three weeks.
• In case of a pharyngeal leak, oral feeding will need to be postponed until
the leak has ceased.

125. COMPLICATIONS
• Pharyngeal leak
– The incidence of pharyngeal leak is higher than that following total laryngectomy, mainly due
to tension on the suture line as the pharynx is closed over the voice shunt. If need be, patch
pharyngoplasty should be done using the pectoral myocutaneous flap, to minimize the
incidence of leak.
• Shunt stenosis
– This can result in failure to develop speech. The complication is almost completely avoidable.
During the formation of the shunt, the size can be augmented, if necessary, by using the
adjacent pyriform mucosa. Shunt stenosis can also be a complication of post operative
radiotherapy, though rarely.
• Aspiration
– The incidence of significant aspiration following near total laryngectomy is extremely low
unlike that following supraglottic or supracricoid partial laryngectomy. Rarely does one need
to convert the procedure to a total laryngectomy because of problems of aspiration. Most
patients are on regular diet including liquids within 2-3 weeks.

126. ADVANTAGES OF NTL OVER TEP
NTL TEP
quality of voice following NTL is superior require the services of a speech therapist
initially.
maintenance free biological shunt which
stays so for life.
silicone voice prosthesis .
Rs.20,000/per piece
lung powered with a success rate more
than 83%.
sensitive stoma, making postoperative
radiotherapy very difficult to tolerate.
speech shunt is constructed at the same
time as the resection of the primary.
secondary procedure, it requires a second
hospital admission and anaesthesia

127. Larynx Preserving Surgeries

128. Treatment decisions in laryngeal Ca.

129. T1 and T2 Supraglottic Cancer

130. Glottic cancer

133. T1 / T2 SUBGLOTTIC CA.
• No scope for voice conservation sx.
• EBRT = manstay of treatment
• LN mets= combined chemo + radiation

134. T3 CA. OF THE LARYNX
• Factors which influence the treatment
– The site and extent of the lesion
– Mobility of the VC vs fixity of the VC vs fixity of the
hemilarynx
– Lateralised lesion vs b/l involvement
– Degree of airway obstruction; functional
incometence
– Age, general health, pulm status.

135. TREATMENT OPTIONS FOR INTERMEDIATE LARYNGEAL
CANCERS

136. T4 CA. OF LARYNX
• T4a= surgery F/B radiotherapy = mainstay.
• N0= I/L thyroid lobectomy + LN 2 3 4 B/L cleared.
• N1=LN 2 to 5
• Subglottic disease= paratracheal LN are also
cleared.
• T4b = symptomatic treatment.
• Chemotherapy may be considered for palliation.

137. Open PartialLaryngectomies

138. PRINCIPLES OF OPEN PARTIAL LARYNGECTOMY
• Preserve speech and nasal respiration,protection of airway.
• Barriers for the spread of disease provides oncologically
safe compartmental resection in early cancer.
• Present indications in early lesions-
– Inadequate transoral access for laser resection
– Post radiation salvage
– Bulky lesions with impaired cord mobility
– Pt. Unsuitable for radiotherapy

139. SURGICAL PRINCIPLES OF OPL
Preservation of the essential functions of the
larynx, i.e., phonation. nasal respiration and
protection of the airway.
- Embryological compartments
- Crico - arytenoid unit
- Cricoid ring
-Innervation
Preservation of an intact cricoid ring and an
intact functioning arytenoid are the most imp.
prerequisite for an OPL.
:

141. RECONSTRUCTION
The aim is to ensure that
• Anteroposterior diameter of the larynx is maintained no stenosis
– Anterior commissure resectiona silicone keel is placed,
temporarily separating the two sides prvt web and stenosis
• The posterior glottic bulk by aretenoids reconstituted
prvt aspiration and good quality voice
– The resected arytenoid is generally replaced with
either a piece of thyroid cartilage or with the strap
muscles to provide the posterior glottic bulk.

142. EXTENDED PARTIAL LARYNGECTOMY
– the tumour extent > assessed preoperatively.
– surgeon undertaking voice conservation surgery must be adept at the full
range of procedures so that an alternative, more extended procedure is
done.
– written consent for total laryngectomy
SALVAGE PARTIAL LARYNGECTOMY
– Preoperative evaluation must confirm
– that the initial lesion prior to radiation therapy was suitable for a conservation
procedure,
– recurrence on the same site as before
– recurrence fulfils all the eligibility criteria required for the particular
conservation to be performed.
– rest of the laryngeal tissues are supple and devoid of post radiation oedema.

143. PROCEDURES
Glottic cancer
vertical plane across the
glottis.
• Cordectomy through
laryngofissure
• Vertical partial
laryngectomy
• Supracricoid partial
laryngectomy with crico-
hyoido-epiglottopexy
(SCPL-CHEP).
Early supraglottic cancer
horizontal plane above the
glottis.
• Supraglottic partial
laryngectomy
• Extended supraglottic
partial laryngectomies.
–
(+Pyriform/base of the
tongue/arytenoid).
Glotto-supraglottic cancer
combination of the vertical
and the horizontal partial
laryngectomies.
• Supracricoid partial
laryngectomy (SCPL) with
Crico-Hyoido-Pexy (CHP)
• Three -Quarter
laryngectomy.

144. OPL-PROCEDURES FOR GLOTTIC CA.
Early glottic cancer spreads superficially preferentially in anterior and inferior direction with minimal
spread or no submucosal extension, and in the vertical direction can be resected in the vertical
plane.
– Laryngofissure and cordectomy
• mid-cord lesions with freely mobile cords. (tolr)
– Vertical Partial Laryngectomy (VPL)
• includes resection of the involved cord along with overlying thyroid cartilage
and paraglottic tissue. Despite the availability of TOLR, VPL has a very definite
place in voice conservation surgery. In fact, it is probably the most frequently.
– supracrioid partial laryngectomy with crico-hyoido-epiglottopexy
(SCPL with CHEP)
• In glottic cancers with either impaired cord mobility and paraglottic fullness or
minimum supraglottic spread.
• offers superior oncologic safety, but VPL is physiologically safer.

145. • adequate and functional laryngeal aditus is
essential after open partial laryngeal procedures.
• SCPL with CHEP is contraindicated in elderly
patients and in those with compromised lung
function or with existing tracheostomy.
• Voice quality with OPL < TOLR and XRT.

146. LARYNGOFISSURE WITH CORDECTOMY
-simplest and oldest open surgical procedure
-Gordon Buck in 1853
-excellent local control rates in T1 glottic cancer confined to the
mid-cord.
-recentky used rarely as most lesions suitable for a cordectomy are now approached
endoscopically and resected using the CO2 laser.
-Is it still a useful procedure? - “Yes”
Inadequate endoscopic exposure/No facilities for CO2 laser.

147. Indications
1. mid-cord lesion,
2. confined to the membranous vocal cord
3. without extension to the anterior commissure
4. with no impairment in vocal cord mobility as this signifies lateral spread into the
underlying soft tissue which renders this procedure inadequate.

148. Procedure
1. Under general anaesthesia administered through a
tracheostomy,
2. a midline vertical thyrotomy is
performed from the thyroid notch
superiorly to the lower border of the thyroid cartilage
inferiorly.
3. The larynx is entered through the
cricothyroid membrane.
4. Cordectomy entails removal of only the soft tissues

153. • The thyroid cartilage and the perichondrium are approximated.
• The mucosal defect is allowed to heal by granulation.
• In a matter of a few weeks a dense fibrous pseudocord forms.
• The tracheotomy is decannulated within a week and allowed to
close.
• Since neither the laryngeal nerve supply nor the pharyngeal
musculature is disturbed by this procedure, it does not cause
aspiration and is very well tolerated even in the elderly.

154. Complications
• Webbing of anterior
commissure.
• Non-healing thyrotomy
e.g. following previous
radiation therapy
• Laryngocutaneous
fistula.

155. RESULTS
• Local control rates following cordectomy 84-98%.
• In properly selected cases, control rates upwards of 90% are
consistently obtained.
• The quality of voice following laryngofissure and cordectomy is
inferior to that following an endoscopic laser cordectomy (TOLR).
• Voice quality is best following successful radiation therapy.
•
Carefully planned TOLR resulting in either
type I (subepithelial resection — utilised in Dysplasia or in-situ cancers) or type II
(subligamental) cordectomy gives very good quality voice.

156. VERTICAL PARTIAL LARYNGECTOMY (VPL)
Aka: vertical hemilaryngectomy
Billroth in 1875.
number of modifications described in surgical literature,
the most notable being those described by Norris, Som, Ogura
and Biller.
Hemilanyngectomy (without involvement of the
anterior commissure or the
arytenoid)
Frontal laryngectomy (anterior commissure lesion)
Frontolateral laryngectomy (extension across the anterior
commissure)
Extended hemilaryngectomy (involving the arytenoid)
Types:

157. These adaptations of VPL give the procedure a very wide scope.
cancers with impairment of cord mobility,
select cases of cord fixity;
involvement of the anterior commissure,
and even the contralateral cord;
extension to the anterior surface of the arytenoids;
limited involvement of the false cord or the subglottis
can all be resected with a VPL

158. INDICATIONS

159. Limitations
VPL is not feasible when a glottic cancer has the following:
i. Subglottic extension of disease more than 10 mm anleriorly
or more than 5 mm posteriorly.
ii. Paraglottic disease extending superiorly above the level of
the ventricle or inferiorly up to 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 the arytenoid.

160. Procedure
• Vertical Partial Laryngectomy involves a full
thickness en-bloc resection of the involved segment
of the glottis along with the overlying segment of
the thyroid cartilage and the intervening paraglottic
tissues.
• The upper margin of mucosal resection includes a
segment of the false cord.
• The lower margin of resection is above the cricoid
cartilage

161. Surgery is performed under general anaesthesia administered through a tracheotomy.
• After reflecting the external perichondrium on both sides of the thyroid cartilage,
two vertical cartilage cuts (fig)are placed depending on the site of the lesion within
the glottis
• Entry into the larynx is via the cricothyroid membrane.
• The first vertical cut across the glottis and the paraglottic tissues is made on the
less involved side.
• As the larynx unfolds to allow exposure inside, the remaining mucosal and soft
tissue cuts are made under vision to complete the resection.
• The epiglottis is not removed.
• Both superior laryngeal nerves are preserved.

166. Reconstruction
Aim to provide an adequate laryngeal aditus which is functional and prevents
aspiration.
Three important steps.
• Reattachment of the remnant vocal cord:
– The contralateral true vocal cord must be anchored anteriorly to the adjoining thyroid
cartilage or to the soft tissue. This helps in keeping the vocal cord taut which results in a
better quality of voice.
• The Mucosal Defect
– silastic keel.
– vertical flange of the keel-separate the two sides from each other horizontal flanges -anchored to the remnant
thyroid cartilages on both sides.
–
After 2-3 weeks,keel is removed endoscopically.
• Reconstruction of the Resected arytenoid:
– It is Important to reconstitute the posterior glottic bulk. (muscle, tendon, fat, cartilage and the
epiglottis.)
–
The authors prefer to use the remnant of the ipsitateral
thyroid cartilage(based on the inferior constrictor muscle )

167. Postoperative management
• POD 1
– Ryle's tube feeding is started
• POD 2-3
– The tracheostomy tube is blocked
• POD 5
– the tracheostomy tube can be removed and oral feeds
started.
– Once this is well tolerated, the Ryle's tube is removed
and oral feeds are gradually stepped up to a regular
diet.

168. Complications
• When a very large segment of the glottis, including the
anterior commissure is resected there is a possibility of
laryngeal stenosis and delayed decannulation.
• When the arytenoid is included in the resection,
chances of aspiration are high.
• Prior radiotherapy can predispose to cartilage necrosis.

169. Results
For T1 lesions of the glottis, the VPL yields local
control rates similar to those following
radiotherapy, which is upwards of 90 per cent.
In T2 and select T3 glottic cancers, surgery (VPL)
yields better cure rates than radiotherapy.

170. SUPRACRICOID PARTIAL LARYNGECTOMY WITH
CRICO-HYOIDO-EPIGLOTTOPEXY (SCPL-CHEP)
1959 and was refined and presented later by Labayle
and Piquet.
It deals essentially with glotto-supraglottic tumours.
involves removal of the entire thyroid cartilage
bilaterally along with the paraglottic spaces.
It involves removal of the infrahyoid epiglottis.
This procedure, more radical than vertical partial
laryngectomy and achieving better cure rates was widely
practised in France and is now accepted globally as a
useful addition to the range of voice conservative
procedures .

171. SUPRACRICOID PARTIAL LARYNGECTOMY WITH
CRICO-HYOIDO-EPIGLOTTOPEXY (SCPL-CHEP)
• While the procedure of SCPL-CHEP is oncologically sound, it
is physiologically much more stressful in the early post-
operative period mainly because of the problems of
aspiration.
• Hence it should be offered only to very fit patients.
• Frail individuals or those with chronic obstructive
pulmonary disease or any chronic respiratory problem are
not candidates for SCPL-CHEP

172. Indications
• T1b, glottic cancer
– Bilateral early glottic cancer (T1b) with
involvement of more than half the vocal cord on
either side;
• T2a glottic cancer:
– Glottic cancer with extension of the disease to the
false cord or to the base of the epiglottis but with
freely mobile vocal cords. (glotto supraglottic
cancer)
• T2b glottic cancer
– (cord mobility impaired)
• T3 glottic cancer
– fixed vocal cord with freely mobile arytenoids:
• Even gross invasion of the paraglottis or erosion
of the inner aspect of the thyroid cartilage is
compatible with this procedure.

173. Limitations
• Fixed hemilarynx
– fixity of the arytenoid indicates subglottic spread involving the cricoanirtenoid joint.
• subglottic spread
– Anterior > 10 mm and posterior > 5 mm.
– Such a spread would not allow preservation of the cricoid cartilage.
• Glotto-supraglottic disease
– above the level of the false cord either along the mucosa or along the paraglottis.
– Such a spread has a tendency for extension into the pre epiglottic space.
• Prior tracheostomy.
– CHEP entails mobilisation of the cervicomediastinal trachea which moves up to meet the hyoid, after which
the tracheostome is positioned.
– Prior tracheostomy will interfere with this.
• Respiratory impairment
– either due to frail health or due to chronic respiratory disease.

174. Technique of Resection
• SCPL-CHEP is performed under general anaesthesia administered through an orotracheal
tube.
• The approach is through a subplatysmal apron flap.
• The sternohyoid and the thyrohyoid muscles are divided on both sides at the level of the
upper border of the thyroid cartilage.
• The sternothyroid muscle is divided at the level of the lower border of the thyroid cartilage.
• The inferior constrictor muscles are divided at the posterolateral edge of the thyroid
cartilage taking care not to injure the superior laryngeal nerve, which may at times overly the superior cornu
of the thyroid cartilage.
• The internal thyroid perichondrium and pyriform sinus is released from the inner surface of the thyroid cartilage
for a short distance. This must not be overdone, because it may transgress the paraglottic space.

178. Technique of Resection
• The cricothyroid joints are disarticulated
– stay absolutely close to the edges of the thyroid cornu and preventing
damage to the soft tissues posterior to the joint.
– This is an extremely important step in the procedure to prevent injury
to the recurrent laryngeal nerves.
• The isthmus of the thyroid gland is divided
• cervico-mediastinal fascia is released over the anterior wall of the
trachea, right down to the carina.This mobilization is necessary to
facilitate the crico-hyoidopexy.
• In order to prevent devascularisation of the trachea, the dissection
is restricted to the anterior surface and not carried laterally.

180. Technique of Resection
• in case of T3 glottic cancer
– Ipsilateral thyroid lobectomy and paratracheal node clearance is carried out.
– Once again, damage to the recurrent laryngeal nerve must be prevented.
• crico-thyrotomy
– at this stage to introduce an armoured endotracheal tube to continue the
general anaesthesia.
– if resectability with a SCPL is at all in doubt, this step should be performed at a
much earlier stage to judge the subglottic extent of the disease.
• Superiorly horizontal incision in the thyrohyoid membrane
– at the level of the upper border of the thyroid cartilage, deepening it to
transect the epiglottis and leaving its superior portion attached to the base of
the tongue.
– care is taken to preserve the superior laryngeal trunk, its internal division and
the posterior descending branch in order to preserve the sensory supply to
the laryngeal remnant.

182. Technique of Resection
• Anterior traction on the thyroid notch facilitates visualisation of the endolarynx.
• Vertical resection cuts are now made first along the side with less tumour involvement.
• incision is made anterior to the arytenoid cartilage and resecting the entire false vocal fold, the ventricle and the
true vocal cord.
• This cut is carried anteriorly through the cricothyroid musculature and the subglottic mucosa to connect with
the anterior horizontal cricothyroid opening.
• With the larynx opening up like a book, the vertical cut on the involved side is made from below upwards under
vision.
• If the arytenoid cartilage needs to be resected, this is done preserving the mucosa over its posterior surface.
• Frozen section examination is carried out from the inferior and posterior cut margins to judge the adequacy of
resection.

184. Reconstruction (Securing the glottic aditus)
• the remaining arytenoid and the posterior arytenoid mucosa is loosely
approximated to the cricoid with 3-0 vicryl sutures.
–
This prevents it from flopping in and out of the laryngeal inlet, like a ball valve causing
respiratory obstruction.
• The Pexy:
– Three 1-0 vicryl sutures are placed 1 cm apart for the crico-hyoidopexy.
– Each suture is placed submucosally around the cricoid and through the epiglottis.
– It is then passed through the preepiglottic space around the hyoid bone, base of the tongue
and the suprahyoid musculature.
– the 3 sutures are tied tightly to ensure that the cricoid abuts the hyoid snugly.
• Tracheotomy:
– is positioned in line with a separate skin incision.
– Anaesthesia is now continued through the tracheotomy
• Muscular Buttress:
– The cut edges of the inferior constrictor muscles are approximated over the impaction.
– The sternohyoid muscles are resutured.
– The skin flaps are sutured taking care to isolate the tracheostome and prevent air leaking into
the main wound.

188. Post-operative management
• The airway is maintained through a non-cuffed tracheostomy tube
with suction performed as required.
• Tube feeding either through a nasogastric tube or a feeding
gastrostomy is commenced on POD1.
• Intermittent blockage of the tracheostomy tube is encouraged after
3-4 days.
• If well tolerated, the tube is uncorked only when suction is required
to be done.
• Depending on the progress after surgery, tracheostomy tube is
removed in about 1-2 weeks.

189. Complications
• pneumonia due to aspiration
• dehiscence of the crico-hyoido-epiglottopexy and
laryngeal stenosis
• The incidence of
– persistent aspiration necessitating a permanent
gastrostomy is 14% and
– intractable aspiration requiring conversion to a total
laryngectomy is 6%

190. Results
Oncologic
Overall survival rates - range from 68 to 84%.
Local recurrence rate - between 0 -16%.
Speech
On phonation (as also on swallowing) the arytenoids abut against
the base of the tongue and remnant epiglottis, occluding the larynx
and generating sound.
The voice quality after SCPL is harsh but is nevertheless a "lung
powered" speech and the patient satisfaction level is very high.

191. OPL- PROCEDURES FOR SUPRAGLOTTIC Ca.
• Early Supraglottic disease is limited to the superior compartment of the
larynx above the ventricle and is suitable for Horizontal Partial
Laryngectomy.
• Bilateral neck nodes should be addressed -potential occult mets>40%.
• lnfrahyoid epiglottic lesions early +pre-epiglottic space & >occult neck
node metastasis.
• Aspiration following supraglottic resection should be managed actively.
– Elderly patients /compromised lung function-not likely candidates.
• Supraglottic partial laryngectomy and its extensions are rarely performed,
today being replaced by TOLR or chemo-radiation.

192. Procedures for supraglottic Ca.
TYPES OF HPL
• 1) Horizontal supraglottic 2) Extended Horizontal
partial laryngectomy
resection includes
• the false cords,
• the epiglottis,
• the pre epiglottic space
• the upper third of the
thyroid cartilage.
• hyoid is included in the
resection when the pre
epiglottic space +
Partial Laryngectomy
• ipsilateral arytenoid,
• the vallecula with the
adjacent base of the
tongue,
• or the pyriform.

193. HorizontalSupraglottic partial
laryngectomy
INDICATIONS
• Open supraglottic partial
laryngectomy is indicated in
those cases of early
supraglottic cancer with
freely mobile vocal cords(T1,
T2 and select T3) where
surgery is the preferred
option and transoral laser
resection is not feasible.

194. Where is Surgery preferred over radiation
therapy/chemo-radiotherapy?
• Cancer of the infrahyoid epiglottis.
– high propensity for invasion of the pre-epiglottic space -
relatively poor blood supply -response to radiotherapy is poor.
– Supraglottic cancer with invasion of the pre epiglottic space
(T3) is amenable to supraglottic partial laryngectomy if the
vocal cords are freely mobile.
• Early supraglottic primary with N2/N3 neck disease.
– The large lymph node metastases respond poorly to
radiotherapy.
• Early supraglottic cancer in very young individuals.
– It is preferable to avoid radiotherapy in the young.

195. CONTRAINDICATIONS
very stressful in the post-operative period-aspiration.
This is more so with the extended supraglottic partial laryngectomy.
• Poor pulmonary reserve
– Elderly patients, frail individuals and those with poor pulmonary reserve are not suitable for
this procedure as even minor degrees of aspiration are not tolerated.
• Impaired cord mobility
– Tumour extension to the glottis or the paraglottis causing impaired cord mobility converts
the lesion into a transglottic carcinoma making supraglottic laryngectomy inadequate.
• Thyroid cartilage erosion
– is a rare feature in early supraglottic cancers and rules out a horizontal partial laryngectomy
• Involvement of the pyriform sinus up to its apex
– Involvement of the interarytenoid or postcricoid region; or Significant involvement of the
base tongue. In all these situations, supraglottic laryngectomy is not feasible.

196. PROCEDURE
Conventional supraglottic
laryngectomy.
Division of thyroid
cartilage
Clearance of pre epiglottic
space
Resection of the tumour
Reconstruction

197. If necessary, a preliminary tracheostomy is performed.
horizontal incision - at the level of the thyroid cartilage.
The sternohyoid and sternothyroid muscles-transected (sup border)
The perichondrium of the cartilage is incised along the upper border and reflected
downwards over the upper half of the thyroid cartilage (it helps in the closure.)
The inferior constrictor muscle is divided on dominant side of the tumour.
Don’t damage superior laryngeal nerve along the neurovascular pedicle.
The perichondrium from the inner surface of the thyroid cartilage is elevated only
postero-laterally to free the pyriform mucosa if there is no tumour extension to this
site.

198. Divisionof the thyroid cartilage
• The thyroid cartilage cuts are made.
• prevent injury to the anterior commissure since this will
result in permanent impairment in the quality of speech.
• The anterior commissure is located at
– the junction of the upper 1/3 and lower 2/3 female.
– halfway between the thyroid notch and the inferior margin in
the male.
• The cartilage cut is made at least 1 mm above the
estimated level of the anterior commissure.

199. Clearance of the pre-epiglottic space
• In early tumours
– entire hyoid can be preserved by subperiosteal dissection of the pre epiglottic
space.
– Preserving the hyoid allows a more secure closure and early rehabilitation.
• With gross infiltration of the space
– at least the body of the hyoid or the entire hyoid is resected to allow
satisfactory clearance of the pre epiglottic space.
– preserve the sensory supply, particularly over and around the arytenoids
– Aspiration-turbulent post—operative period.
– For this, it is vital that the superior laryngeal nerve and the posterior
descending branch of its internal division are preserved on both sides.
(Rassekh et al.)

200. Resectionof the tumour
• If a prior tracheostomy has not been performed, it is undertaken at this stage.
• Entry into the larynx
– transvallecular,
– except in extended resections where the vallecula is involved by tumour.
• After the pharynx is entered,
– the epiglottis is grasped in retracted downwards.
– The pharyngostome is enlarged giving an excellent view of the tumour
– The aryepiglottic folds are now divided well anterior to the arytenoids on both sides.
– Resection is continued inferiorly through the ventricles, preserving the true vocal cords, while
removing both false cords with the specimen.
• The entire specimen is thus removed under direct vision with an adequate tumour
free margin.

201. Resectionof the tumour
• In lateralized lesions,
– there is often a tendency to preserve the uninvolved
supraglottic tissue on the contralateral side.
– This is in fact detrimental and leads to a more difficult
post-operative course.
• It is recommended that resection in supraglottic
horizontal partial laryngectomy should be more
on anatomical lines with an endeavour to
preserve only the arytenoids.

202. Reconstruction
• Following excision,a cricopharyngeal myotomy may be
performed to facilitate post-operative swallowing.
• Closure of the defect
– by suturing the cut edges of the pyriform mucosa below, to the
oropharyngeal mucosa above.
– starting laterally and progressing towards the centre.
– This is not necessary if a classical supraglottic laryngectomy is
done with preservation of the pyriform sinus.
• As the region of the resected supraglottis is approached,
primary mucosal apposition is no longer possible.

203. Reconstruction
• Closure is now obtained by approximating the upper end of the
remaining thyroid cartilage to the base of the tongue.
• This is achieved by using three 1-0 sutures that are passed through
the thyroid cartilage inferiorly and the base tongue musculature
superiorly.
• If the hyoid is preserved during the pre epiglottic space clearance,
the sutures pass around the hyoid superiorly to give a more secure
closure.
• The thyroid perichondrium which was preserved is now sutured to
the base of tongue musculature as the second layer of closure.

204. Extended Supraglottic Laryngectomy
The horizontal supraglottic
laryngectomy can be extended to
include resection of the involved
arytenoid,
the pyriform,
the vallecula with the adjacent base of
the tongue.

205. Arytenoid Resection
totally/partially.
Gently dislocate the cricoarytenoid joint and prevent
damage to the underlying recurrent laryngeal nerve.
After resection, posterior glottic bulk is defecient , the
ipsilateral remnant of the vocal cord must be medialised
by anchoring it in the midline to the superior border of
the cricoid cartilage using a strong non-absorbable
suture.
adequacy- checked by initiating a cough reflex and glottic
closure.

206. Arytenoid Resection
The raw area of the posterior glottis is
resurfaced by advancing the adjoining mucosa
of the pyriform fossa.
If extensive endolaryngeal tissue is excised, the
posterior glottic bulk may have to be
replaced(using muscle/cartilage)

207. Resection of the base tongue/
vallecula
• tumours that involve the lingual surface of the epiglottis.
• vallecula and adjacent portions of the base of the tongue along with the supraglottic larynx.
• At least one half of the base tongue along with its blood supply must be preserved in such a
resection. Should direct closure of the defect be difficult due to the loss of significant amount
of soft tissue, a pectoralis major myocutaneous(PMM) flap is used.
• Resection of the lateral wall of the pyriform fossa along with involved portions of the lateral
and posterior pharyngeal wall is compatible with the extended supraglottic laryngectomy.
• Closure of the defect however requires a myocutaneous flap.

208. COMPLICATIONS
• Aspiration
– is the most common complication following a supraglottic
laryngectomy.
– The degree of aspiration varies from patient to patient and
proportionately with the extent of resection.
– This complication can be prevented in part, by saving at least the
posterior descending branch of both the superior laryngeal nerves.
When the arytenoid is included in the resection, cricovocal
approximation on the ipsilateral
• Pharyngocutaneous fistula is an infrequent complication following
the procedure.
– an increased incidence in the case of extended supraglottic
laryngectomy
– in patients who have had prior radiotherapy.

209. POSTOPERATIVE CARE
• Nasogastric tube feeds are begun 24-48 hours following surgery.
• Tracheotomy Care: After 4-5 days, once the tissue oedema is less,
the tracheostomy is corked and nasal respiration is
encouraged.Once this is well tolerated, the tracheostomy tube is
removed.
• Oral Feeds: After wound healing is complete, (usually at the end of
the first week) and there are no signs of a salivary leak, the patient
is encouraged to start oral intake. The initial diet consists of
semisolids, pureed foods or soft diet.Should aspiration be severe, a
temporary feeding gastrostomy is performed and oral feeding
withheld for a few days.

210. RESULTS
• Following supraglottic laryngectomy,
• Local recurrence rates <2% in properly
selected cases and are comparable to those
following total laryngectomy.
• The most common site of failure is in the
cervical lymph nodes.

212. Procedure for glottosupraglotticca.
• Concept of glotto-supraglottic disease
• Supracricoid Partial Laryngectomy with CricoHyoido-Pexy (SCPL — CHP)
– Indications
– Contraindications
– Procedure
– Reconstruction
– Post-Operative Management
– Complications
– Results

213. CONCEPT OF GLOTTO-SUPRAGLOTTIC DISEASE
• Glotto-supraglottic (transventricular) cancers with mobile VC are T2 cancers.
• Tumours that involve the glottis as well as the supraglottis and cause fixity of the
true vocal cord are defined as transglottic cancers/transventricular cancers.
• Hence by definition transglottic cancer is stage T3 cancer because of cord fixity.
• Fixity of vocal cord - infiltration of the vocalis muscle and the paraglottic space,The
arytenoids in these cases are mobile.
• neither amenable to the HSPL nor to the VPL.
• supracricoid partial laryngectomy is the most widely accepted partial laryngectomy
procedure for transglottic cancers.

214. • Fixity of the vocal cord in transglottic cancer may
also be due to extension of disease subglottically
to involve the cricoarytenoid joint.
• Clinically, not only the vocal cord but also the
arytenoid is immobile (fixed hemilarynx). These
transglottic cancers are not amendable to any
partial laryngectomy procedure and will
necessitate either total or near-total
laryngectomy.

215. • The SCPL may be utilised for those patients with
– fixed cords (but mobile arytenoids) and
– also for those lesions with mobile cords (T2) but where the extent of the
disease or inadequate exposure prohibits the safe use of TOLR.
• Depending on the extent of resection, two types of reconstruction are
needed after an SCPL.
– crico-hyoido-epiglottopexy (CHEP) for predominantly glottic tumours.
– crico-hyoidopexy (CHP) for tumours with significant supraglottic disease.
CHEP CHP 3 QUARTER LAR.
PREDOMINANTLY GLOTTIC
TUMOURS
SIGNIFICANT SUPRGLOTTIC
DISEASE
HORIZONTAL PARTIAL
LARYNGECTOMY+HEMILAR
YNGECTOMY
EPIGLOTTIS PARTIALY
REMOVED
ENTIRE EPIGLOTTIS INFREQUENTLY DONE
LOCALLY ADVANCED
GLOTTIC CA. WITH DEEP
PARAGLOTTIC
INFILTRATION
CLEARANCE OF PRE
EPIGLOTTIS SPACE

216. Indications
I. Spread to the anterior
commissure or across the
ventricle to the vocal cord.
II. Impaired cord mobility or cord
fixity due to paraglottic spread
but with mobile arytenoids.
III. Early thyroid cartilage erosion.
The external perichondrium must
be intact.

217. ContraIndications
i.Fixed Hemilarynx
Fixity of the arytenoid indicates involvement of the cricoarytenoid joint and is not compatible with SCPL.
ii. Subglottic extension
greater than 10 mm anteriorly and 5 mm posteriorly, which makes preservation of the cricoid
oncologically unsafe.
iii. Involvement of the base of tongue, or vallecula or massive involvement of the pre-
epiglottic space, where saving the hyoid bone is oncologically unsafe.
iv. Involvement of the pyriform sinus is not compatible with this procedure since the
resultant pharyngeal defect will not close with a crico-hyoidopexy.
v. Involvement of the postcricoid and interarytenoid regions. Such spread makes it
impossible to preserve at least one arytenoid.
vi. 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.
vii. Poor pulmonary reserve

218. Procedure
• Anaesthesia is administered through an
oro-tracheal tube. Prior tracheostomy
must be avoided.
• Approach The larynx is approached
through a superiorly based
subplatysmal apron flap, the apex of
which is about two finger breadths
above the suprastemal notch where
the final tracheostomy would be
positioned. The incision is carried up to
the mastoid on the side where neck is
carried up to the mastoid on the side
where neck dissection is planned.

219. • The subplatysmal flap=2 cm above the hyoid bone.
• The sternohyoid and thyrohyoid muscles are divided.
– In order to ensure a secure crico-hyoidopexy at the end, it is important that the muscles are
not divided too close to the hyoid bone.
• The 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.
• dislocation of the cricothyroid joint.
• The procedure is repeated on the opposite side .

222. Mobilisation of the cervicomediastinal trachea
• The isthmus of 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 up to the carina.
– This will enable the trachea to move up during the
pexy. Care is taken not to strip the fascia from the
lateral aspects of the trachea in order to preserve
its vascularity.

224. Dissection of the pre-epiglottic space
– The periosteurn along 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.

227. Reconstruction
• The arytenoid cartilage (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. This will prevent a flip-
flop movement, at times blocking the airway
like a ball-valve during inspiration.
• It also prevents posterior prolapse of the
arytenoid.

228. The crico-hyoido-pexy
• in order to minimize the post-operative complications
of dehiscence, aspiration on swallowing, & stenosis.
• i. A portion of the strap muscles must be left attached
to the hyoid bone in order to maintain its viability & to
ensure a secure pexy.
• ii. The disarticulation of the cricothyroid joint must be
done very carefully staying absolutely close to the
thyroid cornu.
• iii. The posterior descending branch of the internal
division of the superior laryngeal nerve must be
preserved to ensure a sensate laryngeal remnant.

229. • iv. The entire length of the true and false cords
must be excised bilaterally even if uninvolved, so
that there is no redundant tissue, and the larynx
is well occluded during swallowing and during
phonation by the arytenoids abutting against the
base of the tongue.
• v. The cut edges of the inferior constrictor muscle
are sutured anteriorly to reposition the pyriform
sinuses to a physiologic position so as to improve
the swallowing function.

230. Postoperative Management
• Extension of 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.
• Decannulation is attempted after a week or two depending on how well the
patient tolerates occlusion of the tracheostomy tube.
• Swallowing is encouraged gradually. 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.
• A small percentage requires permanent gastrostomy. Inability to decannulate is
reported in less than 10% in most series.

231. Complications
• aspiration pneumonitis,
• dehiscence of the crico-hyoidopexy and
• laryngeal stenosis
• The incidence of persistent aspiration necessitating a
permanent gastrostomy is reported to be as high as
14% and intractable aspiration requiring conversionto a
total laryngectomy is reported to be 6 %

232. Results
The 3 to 5 year overall survival rates 68 to 84%.
Local recurrence rate is up to 16%.

238. TRANSORAL ROBOTIC SURGERY(TORS)
 GLOTTIS – Early experience with this modality suggests
equivalent oncologic control rates as for TLM. However the
advantages of a TORS approach for glottic tumours are yet to be
defined.
 SUPRAGLOTTIS – TORS has been a useful addition in the Mx of
supraglottic tumours.
 The high definition three dimensional vision of the operating
field, wristed movement with 7 degrees of freedom and ability
to work without the target being in line of sight ( as for laser
microsurgery) has made supraglottic laryngectomy a procedure
that can be taught and learn with greater ease than TLM
procedures