Open Supraglottic Laryngectomy
Javier Gavilán
INTRODUCTION
In 1947, Justo M. Alonso, a well-known otolaryngologist from Montevideo, Uruguay, proposed a new surgical approach to cancer of the supraglottic larynx. This was the first description of what we call horizontal supraglottic laryngectomy (HSL).
Supraglottic laryngectomy is based on well-known embryologic, anatomic, and clinical findings. The supraglottis is embryologically derived from the buccopharyngeal anlage in the region of the third and fourth branchial arches, whereas the glottis and subglottis originate from the tracheobronchial anlage in the region of the fifth and sixth branchial arches. Despite this embryologic difference, no histologic or anatomical barriers have been demonstrated. However, an important consequence of this embryologic separation is the different lymphatic circulation that exists between the supraglottis and the rest of the larynx. This helps to explain the different clinical behavior of supraglottic cancer as compared to glottic cancer.
The advantages of supraglottic laryngectomy over total laryngectomy are preservation of natural speech and avoidance of a permanent tracheostomy. When compared to endoscopic approaches, it is technically easier, less time-consuming, and technologically uncomplicated. The main drawbacks of this open approach are the need for external incisions and temporary tracheostomy. When properly indicated and performed, its functional and oncologic results can be comparable to both total laryngectomy and endoscopic excision.
Several reasons may explain why this operation is less popular among surgeons in the United States and other Western countries:
Supraglottic cancer is rather uncommon in the Anglo-Saxon population in which, glottic cancer is predominant.
Partial laryngeal surgery has not been widely accepted in these countries, until recently.
The procedure was popularized in Spanish.
In contrast, the operation was widely accepted among head and neck surgeons in Latin and Mediterranean countries. Nowadays, more than 60 years after its development, open HSL faces another challenge: The incorporation of endoscopic CO2 laser calls open partial laryngeal surgery into question. For some surgeons, there is no reason to perform an open procedure when the same can be achieved through a less invasive, transoral operation. For others, open HSL is still a valid tool to remove cancer of the larynx. Since not all surgeons in all countries have access to technologic devices such as lasers, surgical microscopes or robotics. Under such circumstances, the golden rule for the treatment of patients with cancer of the larynx becomes crucial: We do not have treatments of choice, but choices of treatment. Open HSL is an important surgical technique among these options.
HISTORY
Unlike glottic lesions, supraglottic cancer seldom produces noticeable symptoms. This is due to the fact that the supraglottis is a rather silent area of the larynx, and cancer may grow undetected for long periods of time. Early diagnosis of supraglottic cancer is also difficult because the initial symptoms of these lesions are very nonspecific, including common complaints such as foreign body sensations with or without chronic cough, mild dysphagia and odynophagia, hemoptysis, or even otalgia.
The first manifestation of nearly 25% of patients with supraglottic cancer is a mass in the neck. This could be explained partly because of the delayed diagnosis for most patients with supraglottic cancer and partly because of the rich lymphatic drainage of the supraglottic region of the larynx. The widespread lymphatic distribution of the supraglottis also accounts for the high chances of bilateral and contralateral neck metastasis that these patients have.
Once the cancer grows, symptoms become more evident due to invasion of the vocal cords. Patients with advanced supraglottic cancer may present with hoarseness or stridor. Hemoptysis from erosion into a blood vessel may be the first symptom to call attention to a supraglottic cancer.
PHYSICAL EXAMINATION
Laryngoscopy and palpation of the neck are the two basic tools for a correct physical examination of patients with supraglottic cancer. Laryngoscopy can be performed with a laryngeal mirror, a flexible nasopharyngolaryngoscope, or a rigid telescope. Indirect mirror laryngoscopy has been widely surpassed by modern examination techniques with flexible or rigid endoscopes. However, in the lack of technologic devices, the mirror is still a valid tool to examine the endolarynx. Rigid telescopes have the advantage of better quality images but more frequently need topical anesthesia, especially in patients with a marked gag reflex. In my opinion, flexible endoscopes constitute the ideal tool for examination of the larynx. Most patients do not require any type of anesthesia and offer excellent images of the endolarynx. For supraglottic cancer, where accurate assessment of vocal cord mobility and infiltration is crucial, especially at the level of the anterior commissure, flexible endoscopes have the advantage of allowing close-up views, even around bulky cancers that prevent viewing the vocal cords from above. The use of the new chip flexible endoscopes—no longer fiberoptic endoscopes—yields even better quality images.
Palpation of the neck is very important in patients with supraglottic cancer. As mentioned above, a significant number of patients with supraglottic cancer have nodal metastasis at the time of diagnosis. Since cervical lymph node metastasis remains the most important prognostic factor for patients with cancer of the larynx, accurate palpation of the neck will contribute to the development of the best therapeutic approach to every patient with cancer of the supraglottis.
Other diagnostic tools, such as stroboscopy, are less useful in patients with supraglottic cancer than they are in patients with glottic lesions.
INDICATIONS
Despite 60% of all laryngeal cancers in our practice are located in the supraglottis, only 35% of them are suitable for supraglottic laryngectomy. The key to good oncologic and functional results is a thorough evaluation of the patient and the cancer, before supraglottic laryngectomy is undertaken.
Tumor Evaluation
Unimpaired vocal cord mobility is crucial for successful open supraglottic laryngectomy. The cancer must be confined to the supraglottic larynx, with bilateral vocal cord mobility and arytenoids that must be cancer free. Patients with normal vocal cord mobility may complain of throat pain, dysphagia, or odynophagia, but they should not have hoarseness.
The key structures to assess during physical and endoscopic examination are the arytenoids and the anterior commissure. Although it is unusual for supraglottic cancer with mobile vocal cords to invade the arytenoid(s), this fact must be well documented before surgery.
Open supraglottic laryngectomy can be considered for
All T1 and T2 supraglottic cancers
T3 supraglottic cancers with mobile vocal cords and limited extension to the preepiglottic space
T4 supraglottic tumors with superficial invasion of the base of the tongue
Patient Evaluation
Patient age and pulmonary function are the key points to consider for open supraglottic laryngectomy. These two factors have been rigidly used in the past, where patients over 70 years of age were not considered candidates for open supraglottic laryngectomy. However, a more pragmatic approach is suggested today, focusing more on biologic rather than chronologic age. Although most patients are heavy smokers and have chronic bronchitis, this condition may sometimes be optimized preoperatively. Patients with compromised pulmonary function should not be considered for supraglottic laryngectomy.
The patient must be counseled that swallowing will be difficult postoperatively and rehabilitation will be more demanding than after total laryngectomy.
CONTRAINDICATIONS
Tumor Evaluation
Anterior commissure involvement is a contraindication to open supraglottic laryngectomy because the thyroid cartilage and the extralaryngeal soft tissues are usually invaded through the anterior commissure (Broyles ligament). In borderline cases, fine-cut laryngeal computed tomography (CT) or magnetic resonance imaging (MRI) scans may help with the evaluation of the paraglottic and preepiglottic spaces, as well as with the area of the anterior commissure.
When doubt still persists after clinical, endoscopic, and imaging tests, the final decision relies on the pathologic evaluation of the surgical margins.
Even though this may not be considered an absolute contraindication for open supraglottic laryngectomy, I never include one arytenoid or the pyriform sinus in the resection. The reason for this is the high rate of postoperative complications and unsatisfactory functional results that these patients manifest.
The same could be said about major resection of the base of the tongue as part of open supraglottic laryngectomy. The operation can be considered safe from a functional standpoint when the superior extension of the cancer does not reach the circumvallate papillae. If the resection needs to extend beyond this point, or the hypoglossal nerve has to be sacrificed, open supraglottic laryngectomy should not be attempted.
Patient Evaluation
Physiologic contraindications include severe and irreversible pulmonary disease. Neurologic diseases with swallowing problems and esophageal strictures also disqualify the patient for open supraglottic laryngectomy.
PREOPERATIVE PLANNING
Imaging Studies
Imaging techniques can be carried out to assess extensions of the cancer as well as to evaluate the status of the neck. Both CT and MRI scans can be used, but I consider CT scans to be more helpful. With regard to the primary tumor, the information provided by imaging studies may help to identify the limits of the cancer. However, precise identification of extension can only be achieved by means of physical examination as described above. Moreover, sometimes the feasibility of the operation can only be decided during surgery, once the larynx is opened and the limits of the tumor cancer are assessed under direct vision.
Positron emission tomography—computed tomography scan can be useful in demonstrating distant metastasis in selected patients with a bulky cancer and regional metastasis.
Biopsy
Biopsy of supraglottic cancer can be made under either local or general anesthesia. Laryngeal biopsy with traditional mirror technique or by means of a fiberoptic nasopharyngolaryngoscope is an office-based procedure that provides tissue samples for pathologic examination. It was the routine practice several decades ago, but nowadays is less frequently used.
The pros and cons of an independent laryngeal biopsy under general anesthesia must be carefully discussed with the patient. The main advantages of a biopsy procedure prior to definitive treatment are that it gives an accurate diagnosis, provides direct information about extension of the cancer, and allows detailed treatment planning to be discussed with the patient. The disadvantage of this approach is that the patient needs two different operations under general anesthesia to complete the treatment. For most of the patients, I prefer the “all-in-one” approach assuming that more than a supraglottic laryngectomy must be done if the tumor extends beyond
the expected limits. This is always the rule with more comprehensive type of partial laryngectomy. For this reason, all patients must sign an informed consent allowing the surgeon to proceed with a more extensive operation (i.e., total laryngectomy) should the findings exceed the estimates of preoperative margins.
the expected limits. This is always the rule with more comprehensive type of partial laryngectomy. For this reason, all patients must sign an informed consent allowing the surgeon to proceed with a more extensive operation (i.e., total laryngectomy) should the findings exceed the estimates of preoperative margins.
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