Abstract
Purpose
The aim of the study is to illustrate our experience with horizontal glottectomy (HG), reviewing the indications and results of this uncommon partial laryngectomy.
Materials and Methods
It is a retrospective study. We completed a chart review of patients who underwent partial laryngectomy between May 2003 and June 2010. Patients who underwent HG were included in the study. Data obtained were collected and analyzed.
Results
Seven male patients were included in the study (mean age was 78 years; range, 69–88 years). In all cases, the TNM classification was pT1bN0M0 apart from one patient who had pT1N1M0. Three patients had a moderately differentiated neoplasm (G2), whereas 4 patients had a well-differentiated tumor (G1). Tracheotomy tube removal, oral feeding, and voice analysis have been evaluated and reported in the study. Mean follow-up was 16 months.
Conclusions
Horizontal glottectomy might be a worthwhile treatment option in selected patients nowadays. In older patients with anterior commissure involvement, this procedure guarantees adequate functional and good oncological results. This study may possibly help surgeons dealing with glottic cancer involving the anterior commissure because we believe that some patients could benefit from HG, even in this radiotherapy and transoral laser surgery “era.”
1
Introduction
Oncology in the head and neck district had had some important changes in the last few decades. Instead of just treating cancer, nowadays, physicians pay more attention to functional results and reconstructive surgery, with the same oncological results. Surgical oncology in the head and neck district is different from all other oncological fields because of the importance that this anatomical district has in everyday life. Impairments in speaking, swallowing, and breathing are the main problems related to this kind of surgery. Quality of life in these patients decreases quickly . In the last decade, organ preservation protocols have been published for laryngeal tumors, but in Europe for T2 and T3 glottic tumors, partial laryngeal surgery has been the most popular approach so far . The aim of this surgery is to perform a radical removal of the neoplasm, reconstructing the anatomical crossing of the respiratory and digestive tracts, with the recovery of laryngeal function.
To date, in the international literature, the gold standards of care for T1a and T1b glottic tumors are both radiotherapy and transoral laser microsurgery (TLM) . In the past few decades, a particular type of partial laryngectomy, the horizontal glottectomy (HG), has been described to treat tumors with exclusive glottic extension. Also known as the “Calearo and Teatini technique,” this surgical procedure was probably described for the first time in 1966 by Dr Moser, a German surgeon from Leipzig . This technique allows removal of the entire glottis, with its adjacent cartilaginous framework. It is a segmental resection of the glottis performed by 2 horizontal incisions: the lower through the cricothyroid membrane and the upper across the wings of the thyroid cartilage. The resulting defect is closed by approximating the cricoid to the thyroid remnants (cricothyropexy). This procedure is indicated in bilateral vocal cord cancer with extension to the anterior commissure. Vocal cord mobility should be normal, and there should be no subglottic or supraglottic extension .
In our department, in the last decade, we have acquired much experience both in laryngeal open surgery (ie, horizontal supraglottic laryngectomies, supracricoid laryngectomies, and more extended ones such as tracheohyoidoepiglottopexy) and in TLM. Although, in the most recent years, it could appear to be an out-of-date procedure, we have performed several HGs. Therefore, we thought it might be of interest to perform a chart review of these patients, pointing out the actual indications for HG and reviewing the literature about early glottic cancer treatment. This study might possibly help surgeons dealing with glottic cancer involving the anterior commissure because we believe that some patients could benefit from HG, even in this “era” of radiotherapy and transoral laser surgery.
2
Materials and methods
We carried out a chart review of patients who underwent a partial laryngectomy for squamous cell carcinoma (SCC) in our department between May 2003 and June 2010. Data on patient details, TNM, operation, grading, clinical history, hospital stay, postoperative results, and follow-up were collected.
2.1
Surgical technique
A “U”-shaped skin incision was performed about 3 cm above the sternum. The platysma and subcutaneous skin flap were elevated to expose the infrahyoid fascial plane, from the hyoid bone to the trachea. Strap muscles were cut about 2 cm below the hyoid bone and pulled down. The great horns of the thyroid cartilage were skeletonized to obtain full mobilization of the thyroid cartilage. The thyrohyoid ligaments were cut. The inferior pharyngeal constrictor muscles were cut along the posterior edge of the thyroid shield. Pyriform sinuses were subsequently peeled away. The cricothyroid membrane was cut horizontally to follow the superior edge of the cricoid cartilage. The inferior edge of the thyroid cartilage was anchored with a hook and pulled up to examine the vocal cords from below and detect any subglottic tumor extension. A horizontal thyrotomy was performed with a circular saw. It was really important to perform this section about half a centimeter below the superior notch of the thyroid cartilage. Incision of the soft endolaryngeal tissue was completed reaching posteriorly the vocal process of the arytenoid cartilages. During this procedure, one arytenoid could be excised. The resulting defect was closed approximating the cricoid to the thyroid remnants (cricothyropexy) with 3 resorbable stitches, primarily restoring airway continuity. A temporary tracheotomy was usually performed with a separate incision.
2
Materials and methods
We carried out a chart review of patients who underwent a partial laryngectomy for squamous cell carcinoma (SCC) in our department between May 2003 and June 2010. Data on patient details, TNM, operation, grading, clinical history, hospital stay, postoperative results, and follow-up were collected.
2.1
Surgical technique
A “U”-shaped skin incision was performed about 3 cm above the sternum. The platysma and subcutaneous skin flap were elevated to expose the infrahyoid fascial plane, from the hyoid bone to the trachea. Strap muscles were cut about 2 cm below the hyoid bone and pulled down. The great horns of the thyroid cartilage were skeletonized to obtain full mobilization of the thyroid cartilage. The thyrohyoid ligaments were cut. The inferior pharyngeal constrictor muscles were cut along the posterior edge of the thyroid shield. Pyriform sinuses were subsequently peeled away. The cricothyroid membrane was cut horizontally to follow the superior edge of the cricoid cartilage. The inferior edge of the thyroid cartilage was anchored with a hook and pulled up to examine the vocal cords from below and detect any subglottic tumor extension. A horizontal thyrotomy was performed with a circular saw. It was really important to perform this section about half a centimeter below the superior notch of the thyroid cartilage. Incision of the soft endolaryngeal tissue was completed reaching posteriorly the vocal process of the arytenoid cartilages. During this procedure, one arytenoid could be excised. The resulting defect was closed approximating the cricoid to the thyroid remnants (cricothyropexy) with 3 resorbable stitches, primarily restoring airway continuity. A temporary tracheotomy was usually performed with a separate incision.
3
Results
Seven patients underwent an HG in our department during the period examined. The mean age was 78 years (range, 69–88 years). All patients were male and had SCC. In all cases, the TNM classification was pT1bN0M0 apart from one patient who had pT1bN1M0. Three patients had a moderately differentiated neoplasm (G2), whereas 4 patients had a well-differentiated tumor (G1). Tracheotomy tubes were removed on average 14 days after surgery, and patients achieved normal oral feeding on the 10th postoperative day. Regarding vocal performance, a mean maximum phonation time (MPT) of 5.2 seconds, a mean voice handicap index (VHI) of 30.2, and a mean fundamental frequency (Fo) of 176.6 were obtained. All excision margins were clear of pathology. Six patients were disease free at 16-month mean follow-up, whereas one patient, who had a history of mild long-term cardiac ischemic pathology, died of a myocardial infarction on the 40th postoperative day. A clinical summary is reported in Table 1 .
| Patient no. | Age (y) | pTNM | Grading | Former operations | Tracheotomy tube removal (d) | Oral alimentation (d) | MPT | Fo mean | VHI | Follow-up (mo) | Note |
|---|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 72 | T1bN1M0 | G2 | No | 10 | 9 | 3 | 161 | 53 | 2 | Positive Delphian lymph node; adjuvant radiotherapy |
| 2 | 86 | T1bN0M0 | G1 | 5 n.o.s. operations for in situ carcinoma | 14 | 9 | 2 | N/A | N/A | 3 | Internal laryngocele (for neoplastic involvement) |
| 3 | 88 | T1bN0M0 | G1 | No | 20 | 12 | 7 | 183 | 24 | 50 | Concomitant thyroidectomy for goiter |
| 4 | 79 | T1bN0M0 | G2 | 2 n.o.s. operations for leucoplachia | 15 | 10 | 5 | 179 | 24 | 10 | |
| 5 | 77 | T1bN0M0 | G2 | No | 11 | 9 | 5 | 191 | 37 | 38 | |
| 6 | 69 | T1bN0M0 | G1 | No | 12 | 9 | 9 | 169 | 13 | 8 | |
| 7 | 75 | T1bN0M0 | G1 | No | N/A | 12 | N/A | N/A | N/A | 1 | Myocardial infarction after 15 d. Intensive care stay. Died after 40 d NED |
| Mean | 78 | 13.6 | 9.6 | 5.2 | 176.6 | 30.2 | 16 |
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
