Supraglottic Resection
An open supraglottic laryngectomy enables removal of the supraglottic larynx through a transcutaneous approach. The true vocal folds and arytenoids are spared, enabling a patient to achieve normal voice.
Indications/Contraindications
The most common indication is a tumor of the larynx that is confined to the supraglottis.
On rare occasion, supraglottic stenosis from trauma or irradiation may be an appropriate indication.
In patients with severe pulmonary disease and/or significantly impaired swallowing, care must be exercised in patient selection, since this operation will certainly reduce the safety of the swallowing mechanism and potentially put patients at risk for recurrent aspiration pneumonia.
In the Clinical Setting
Key Points
The staging process before surgery is crucial. A combination of computed tomography and direct visualization via endoscopy assists in assessing the resectability of the tumor with this approach.
If the tumor crosses the corner of the laryngeal ventricle (to the glottis) or extends beyond the suprahyoid region of the epiglottis and if arytenoid mobility is impaired, then full tumor extirpation with supraglottic laryngectomy may not be possible. Endoscopy with a telescope, including angled telescopes at the time of staging endoscopy, can be very helpful in assessing the extent of tumor spread. This endoscopy should be repeated immediately prior to beginning the operation, since tumor extent may be rapid in some cases.
The patient should be counseled that a more extensive operation may be required for oncologic completeness.
Speech and language therapy pre- and postoperatively is essential for rehabilitation and assessment of swallowing.
It is possible to carry out supraglottic laryngectomy endoscopically, or as an open procedure.
Radiation or chemoradiation may also be appropriate therapies.
Pitfalls
Swallowing rehabilitation is crucial. Aspiration may result from large lumens of the larynx.
When recurrent aspiration pneumonia occurs, completion laryngectomy may be necessary, although this is more common with extended resections (extended supraglottic [to include arytenoid or base of tongue], supracricoid laryngectomy).
Stepwise Procedure
Mount the larynx for open dissection.
The infrahyoid muscles, including the sternohyoid and thyrohyoid, are transected along the superior border of the thyroid cartilage.
The outer perichondrium of the thyroid cartilage is incised at the superior border. A Freer is then used to elevate the outer perichondrium, extending halfway down the thyroid cartilage ( Fig. 23.1 ).
The level of the vocal folds is approximated at the midpoint of the vertical height of the thyroid cartilage ( Fig. 23.1 ).
A line is made to mark the supero-inferior midpoint of the anterior spine of the thyroid cartilage, 1 mm above the anterior commissure in the mid-line, directed toward the point where the superior cornua arises from the thyroid cartilage, joining up into the ventricles.
A knife or sagittal saw is used for transection of the thyroid cartilage along the previously drawn line ( Fig. 23.2 ).
OR Pearl: The thyroid cartilage should be symmetrically resected to avoid rotation between the tongue base and glottis.
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