Abstract
A bilobed free radial forearm flap was designed to reconstruct a defect in the epiglottis and tongue base in 2 patients who underwent supraglottic laryngectomy. The flap was initially sutured in the shape of the epiglottis to prevent aspiration during deglutition. Six months after surgery, after a full course of radiation therapy, the flap had flattened and underwent atrophy, but the patients still had good voice production and were able to swallow well without any aspiration. Regardless of the final shape of the reconstructed epiglottis, it will suffice to prevent aspiration if the flap is large enough to occlude the tracheal outlet.
Squamous cell carcinoma involving the supraglottis is frequently managed by supraglottic laryngectomy either primarily or as a salvage procedure for recurrence after failed radiation therapy. When extended supraglottic resection is required for an extensive tumor, it usually entails the removal of endolaryngeal structures from the tip of the epiglottis down to tracheal inlet. After this operation, the patient’s voice quality is often preserved and may in fact be the same as the preoperative voice. However, deglutition problems with dysphagia and aspiration are the most common sequelae. These patients are prone to aspiration because the protective supraglottic mechanism of the epiglottis, and false vocal cords has been removed. Staple et al reported a 33% incidence of pneumonia for the long-term and 4% mortality from chronic aspiration. Murray reported 7 of 36 patients dying of pulmonary complications from chronic aspiration after supraglottic laryngectomy.
The use of free tissue to reconstruct the epiglottis after supraglottic laryngectomy has not been reported. However, satisfactory results have been achieved with radial forearm flaps to repair defects and maintain function after tumor resection in the mouth, oropharynx, and hypopharynx . These reports prompted us to try using such a flap to reconstruct the epiglottis in 2 patients undergoing supraglottic laryngectomy.
1
Surgical procedure and flap design
After supraglottic laryngectomy, the wound was inspected and defect was measured. A pair of appropriate recipient vessels in the neck was identified and trimmed. A bilobed free radial forearm flap was designed in the nondominant forearm, the distal lobe approximating the size of the defect of the tongue base and the proximal lobe about 10 × 6 cm 2 to create a new epiglottis. This was about 30% larger than the original epiglottis to allow for atrophy. A deepithelialized bridge was left between the 2 lobes so that the proximal lobe could be folded on itself to form the neoepiglottis, which was reinforced with a cartilage implant harvested from the excised hyoid. After revascularization, the distal lobe was sutured to the defect of the tongue base and the folded proximal lobe to the stump of the glottis. A permanent tracheostomy was created, and a hemovac drain was placed. The wound was closed in layers. A nasogastric tube was placed during the operation. The patients then underwent combined chemoradiation therapy for 3 months. Three months after completion of radiotherapy, fibroscopic and videoflouroscopic examinations were performed to assess voice and swallowing function.
2
Case 1
A 50-year-old man presented with squamous cell carcinoma of the epiglottis extending to the tongue base. Supraglottic laryngectomy with radical neck dissection was performed ( Fig. 1 ). A bilobed radial forearm flap was harvested from the left forearm and designed to reconstruct the defect ( Fig. 2 ) as described above. The patient’s postoperative course was uncomplicated. He was able to speak on the 10th postoperative day with excellent voice quality and intensity. He began swallowing under supervision 2 weeks after the operation. Initially, the deglutition process was slow, and he occasionally choked. However, after a full course of swallowing therapy, he had no further aspiration. Fibroscopic examination 6 months postoperatively showed that the neoglottis had flattened and lost its initial hooded shape ( Fig. 3 ). However, the patient could still close the tracheal inlet on swallowing, and no dye was seen leaking into the trachea on videofluoroscopic examination ( Fig. 4 ).
