Abstract
Purpose
Preservation of voice, swallowing and airway is mandatory in early to moderately advanced supraglottic cancers. Here, we propose an endoscopic laryngoplasty to improve swallowing recovery in patients treated by extended CO 2 laser supraglottic laryngectomy.
Methods
We describe a new mucosal flap reconstruction technique in a cohort of seven laryngeal cancer patients with posterior extension, treated by CO 2 laser resection. Clinical endoscopic and videofluoroscopy postoperative exams were performed, and swallow function was tested by the MD Anderson Dysphagia Inventory (MDADI) questionnaire.
Results
No early complications were observed. Absence of aspiration after two days in all cases was confirmed, and MDADI mean value result was 98.
Conclusions
We suggest the harvest of a hypopharyngeal mucosal flap in all patients who require a laryngeal supraglottic posterior resection, with or without arytenoidectomy.
1
Introduction
Surgery for early to moderately advanced supraglottic cancer aims for the preservation of voice, deglutition and airway. Surgical organ preservation should be addressed to treat eligible cases; moreover, age of the patient, pulmonary function, family and social structures, as well as comorbidity factors should be considered too.
Partial laryngectomy by laser microsurgery has become in recent years a recognized alternative to transcervical approach for supraglottic laryngeal cancer treatment. The oncological results are comparable to those achieved by classic supraglottic laryngectomy; despite this, endoscopic approach offers several advantages, e.g., tracheotomies are frequently avoided, pharyngocutaneous fistula incidence is reduced, swallowing rehabilitation is faster, aspiration pneumonia are less frequent, and hospitalization is shorter .
Since supraglottic cancers are often associated to high incidence of regional lymph node metastases, most authors agree that a selective neck dissection should be performed in patients with stage I and II disease .
Supraglottic partial laryngectomies require the resection of natural protective barriers, such as epiglottis, aryepiglottic folds and false vocal folds; this could lead towards penetration and/or aspiration in either latent or clinical manifestation. Moreover, surgical resection extended to the tongue base and/or arytenoid cartilage could expose patients to major risk of swallowing disturbances .
Although magnification supplied by the microscope and hemostatic cutting/ablation characteristics of the CO 2 laser help in cancer resection precision , delayed swallowing recovery and aspiration represent the most frequent postoperative complications which occur in endoscopic partial supraglottic surgery for tumors of the posterior supraglottic region, especially in those cases that require arytenoid partial or total removal.
We therefore suggest, in order to minimize these complications and to improve oral-feeding recovery in patients treated by CO2 laser supraglottic laryngectomy, to perform endoscopic laryngoplasty when tumor resection is extended to laryngeal posterior regions such as the posterior portion of the ary-epiglottic fold and arytenoid mucosal cap.
2
Materials and methods
The protocol for the prospective controlled clinical study was approved by the institutional review board, and it was conducted in accordance with all accepted standards for human clinical research. All patients gave written informed consent prior to study enrollment. All patients initially diagnosed with T2 squamous cell carcinoma of the supraglottis, according to 2010 American Joint Committee on Cancer (AJCC) guidelines , underwent transoral CO 2 laser surgery between September 2011 and February 2012, with associated selective neck dissection (see Table 1 ). No patient had history of prior surgery or chemioradiotherapy for other head and neck cancers. Patients who did not present a posterior laryngeal tumoral extension, involving structures such as the posterior portion of the ary-apiglottic fold and the arytenoid’s mucosal cap, were excluded.
| Variables | Patients |
|---|---|
| Number of patients | 7 |
| Sex, male:female | 6:1 |
| Age, median (range). year | 68 (60–79) |
| TNM classification | |
| T2N0 | 6 |
| T2N2a | 1 |
| Type of endoscopic resection | |
| IVa a | 5 |
| IVb a | 2 |
| Ipsilateral selective neck dissection | 3 |
| MDADI, mean value 5 days after surgery | 98 |
| Early complications | |
| Bleeding with reoperation | 0 |
| Vocal fold immobility | 0 |
| Upper airway obstruction | 0 |
| Aspiration pneumonia | 0 |
| Temporary tracheotomy | 1 |
The study cohort consisted of 7 patients (6 men, 1 woman) with median age of 68 years (range 60–79 years). Patients’ clinical characteristics are summarized in Table 1 .
Clinical exam by indirect flexible and rigid laryngoscopy, together with imaging study (i.e., computed tomography or magnetic resonance exam) helped in preoperative tumor staging, and direct microlaryngoscopy completed the intraoperative diagnostic procedure by endoscopic magnification together with histopathological exam confirming the squamous cell carcinoma nature of the lesion.
Fig. 1 shows two examples of tumor series.
Videofluoroscopy was always performed before surgery in order to identify the presence of a predominant piriform sinus during oral intake.
In a meticulous fashion, all patients underwent, in general anesthesia, direct laryngoscopy, and the laryngoscope was maintained by a chest-torsion holder-stabilizer, which applied the primary force from the chest wall by obtaining an extension at the atlanto-occipital joint and flexion of the neck, in order to achieve a good laryngeal exposure.
Transoral laser microsection of the tumor was performed in accordance with the Remacle et al. classification of endoscopic supraglottic laryngectomy ( Table 1 ) ( Fig. 2 A ). After having ruled out tumor infiltration of surgical resection margins by intraoperative frozen section histopathological analysis, a posterior laryngoplasty was performed. A posterior-based medial wall of piriform sinus cold-instrument microflap was harvested on the same side of the posterior resection ( Fig. 2 B). The healthy unfurled mucosal flap was rotated anteriorly in order to allow its advancement and affixed with one or two stitches 6.0 PDS passing through paraglottic space in order to cover the exposed cartilage or the posterior surgical defect ( Fig. 2 C).
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