Supracricoid Partial Laryngectomies
The supracricoid laryngectomy is an open procedure performed almost exclusively for selected laryngeal cancers. It is designed to achieve oncologic completeness while preserving a patent airway, intelligible speech and a functional swallowing mechanism without the need for a long-term tracheotomy.
Indications/Contraindications
Supracricoid partial laryngectomies (SCPLs) are designed to resect selected “early” or “advanced” endolaryngeal tumors (glottic, supraglottic, or transglottic in origin) classified as T1b–T3.
Oncological contraindications for SCPLs completion include the following:
Tumor originating from the epilarynx and/or infraglottis.
Involvement of interarytenoid space or posterior commissure.
Mucosal involvement of both arytenoid cartilages.
Tumor extension reaching the upper border of the cricoid cartilage.
Invasion of the hyoid bone and/or cricoid cartilage.
Major invasion (bulging vallecula or thyrohyoid membranes) of the pre-epiglottic space.
Fixation of the arytenoid cartilage.
Extralaryngeal spread of tumor.
In the Clinical Setting
Key Points
The cricohyoidoepiglottopexy (CEHP) technique is used for tumors of glottic origin, while the cricohyoidopexy (CHP) technique should be use for tumors of either supraglottic or transglottic origin.
Whatever technique used:
Fixation of the true vocal fold should lead to complete ipsilateral arytenoid resection to achieve complete and wide resection of the ipsilateral paraglottic space, which is key to local control.
Reconstruction should attempt to recreate a t-shaped neoglottis and not a triangular anteroposterior neoglottis. Therefore, any tissue (true vocal fold, false vocal fold) anterior to the spared cricoarytenoid unit must be resected, even if not involved by tumor.
Do not forget to insert a nasogastric feeding tube preoperatively, as recovery of normal swallowing may take at least a month.
Pitfall
Postoperative speech and swallowing after SCPLs are made possible by the preservation of at least one cricoarytenoid unit, which includes the cricoarytenoid joint, the superior and inferior laryngeal nerves, as well as the cricoarytenoid (posterior and lateral) muscles. Caution is therefore required on the less tumor-bearing side when (1) disarticulating the cricothyroid joints (not to harm the trunk of the inferior laryngeal nerve) and (2) transecting the aryepiglottic fold (not to harm the trunk of the superior laryngeal nerve).
From a Technical Perspective
Key Point
Performance of this procedure on a cadaveric larynx should prove to be quite helpful, as there are numerous steps that require care and thought.
Pitfall
Avoiding section of the recurrent laryngeal (aka inferior laryngeal) nerve and superior laryngeal nerves is essential for preservation of arytenoid mobility and endolaryngeal sensation.
Stepwise Procedure
Mount a larynx for open dissection.
Step One: Exposure
OR Pearl: Incise the skin as in a standard “utility flap” placed ~ 2 cm cephalad from the sternal notch and then extending laterally and extend this incision toward the mastoid tip if a single or bilateral neck dissection is planned. Later in the procedure, place the tracheotomy through the central portion of this incision.
Raise a broad-based subplatysmal flap to ~ 1 cm above the hyoid bone.
OR Pearl: Incise the linea alba and remove the central compartment lymphatics. If suspicious lymph nodes are encountered, frozen sections are obtained. Positive nodes at this level should lead to the completion of bilateral level II–III neck dissection.
Divide the thyroid isthmus (always ligate and transect the inferior thyroid veins to avoid postoperative bleeding related to trauma by the tracheostomy cannula).
Perform a gentle cervicomediastinal release of the cervicomediastinal trachea (use your finger and stay in close contact with the anterior wall of the trachea, so as not to devascularize the trachea′s lateral or posterior blood supply).
OR Pearl: Along the upper edge of the thyroid cartilage: (1) transect and ligate the anterior jugular veins; and (2) divide the sternohyoid and thyrohyoid muscles. The sternothyroid muscles are then divided at their insertion along the oblique line of the thyroid cartilage and the middle laryngeal vessels are ligated and transected.
OR Pearl: Rotate the larynx to expose the constrictor muscles. Incise the pharyngeal constrictors along the lateral edge of the thyroid cartilage. Then deflect the inner perichondrium of the piriform sinuses as in a total laryngectomy bilaterally.
OR Pearl: Disarticulate the cricothyroid joint bilaterally. Leaving the inferior horn avoids harm to the underlying inferior/recurrent laryngeal nerve.
Step Two: Resection
A horizontal midline cricothyrotomy is performed at the superior edge of the cricoid cartilage ( Fig. 24.1 ). This allows one to evaluate the inferior margin of the tumor and to place the endotracheal tube at this level to ease visualization and tumor resection.
For CHEP, perform a transepiglottic laryngotomy by a median horizontal incision through the preepiglottic space and infrahyoid epiglottis just above the petiole at the superior border of the thyroid cartilage ( Fig. 24.2 ). For CHP, transect the hyo- epiglottic ligaments (median and lateral) at the level of their insertion along the inferior border of the hyoid bone. This maneuver drops the pre-epiglottic space and provides visualization of the mucosa of the vallecula. The mucosa is then incised at its junction with the tongue base.
Use monopolar cautery to reduce bleeding.
A horizontal midline cricothyrotomy is performed at the superior edge of the cricoid cartilage. 
A transepiglottic laryngotomy is performed by a median horizontal incision through the pre-epiglottic space and infrahyoid epiglottis just above the petiole at the superior border of the thyroid cartilage. 
The inferior horn of the left thyroid ala in this specimen is isolated. Dissection posterior to the cricothyroid joint is discouraged, as it risks injury to the recurrent laryngeal nerve.
Move then to the head of the patient to ease visualization. Use an Allis clamp to grasp either the petiole of the epiglottis (CHEP) or the tip of the epiglottis (CHP).
Separation of the inferior horn of the thyroid ala is performed first by isolation of the cricothyroid joint ( Fig. 24.3 ). Undermining of the inferior horn of the thyroid ala allows for division of the horn ( Figs. 24.4, 24.5 ) superior to the cricothyroid joint, which reduces the chance of injury to the recurrent laryngeal nerve, which enters the larynx immediately posterior to the joint.
Start resection by transecting the false vocal fold (CHEP) or the aryepiglottic fold (CHP) and true vocal folds down to just above and anterior to the body of the arytenoid cartilage on the non-tumor-bearing side. Transection ends at the superior border the cricoid cartilage ( Fig. 24.6 ).
Connect this vertical transection with the median cricothyrotomy. Transect the cricothyroid muscle and infraglottic mucosa at the superior border of the cricoid cartilage ( Fig. 24.7 ). At this point, grasp the thyroid cartilage between both hands and break it apart as if you were opening a book. This allows you to rotate the specimen along the most involved side and to perfectly visualize the tumor ( Fig. 24.8 ).
The inferior horn is isolated superior to the cricothyroid joint. 
The inferior horn is transected with scissors to permit mobilization of the posterior attachment of the thyroid ala. This maneuver is performed bilaterally. 
The larynx is viewed from a superior perspective. A forceps is grasping the left arytenoid complex. An incision has been made immediately anterior to the arytenoid complex through the left false and true vocal folds. The superior border of the cricoid cartilage is visible. 
The larynx is viewed from an anterior perspective. The vertical incision just made is carried along the superior border of the cricoid cartilage. 
The specimen has been rotated to the right for a better endolaryngeal view. The thyroid cartilage can be physically broken in the vertical midline to allow for improved endolaryngeal view and this can be practiced in the laboratory.
The inferior cut is continued along the superior border of the contralateral side until it meets the vertical incision made through the false and true vocal folds (CHEP) or the aryepiglottic folds and true vocal folds (CHP) ( Fig. 24.9 ).
The specimen is then removed and can be examined ( Fig. 24.10 ).
OR Pearl: Based on the tumor extent as well as assessment preoperatively of laryngeal mobility (arytenoid cartilage and true vocal folds), make a decision regarding whether or not the arytenoid cartilage on the tumor-bearing side will be removed. Resection of the arytenoid cartilage allows the surgeon to completely resect the paraglottic space, including lateral cricoarytenoid muscle and overlying cricothyroid muscle. If the arytenoid cartilage is resected, the interarytenoid muscle, posterior arytenoid mucosa, and corniculate cartilage are spared to allow for creation of a neoarytenoid that will be useful to reduce postoperative aspiration. Also in CHEP, the ventricles must be inspected bilaterally on the resected specimen to ensure that no mucosa is left behind (transection of Morgani′s ventricle). This prevents postoperative laryngocele formation.
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