Introduction
Total laryngopharyngectomy is employed for cancer of the hypopharynx. The hypopharynx forms the inferior part of the pharynx and is located immediately behind the larynx. It has three subsites—that is, postcricoid, posterior pharyngeal wall, and pyriform sinuses bilaterally. Total laryngopharyngectomy may also be performed for primary laryngeal tumors with extension to the aforementioned sites.
Total laryngopharyngectomy includes removal of the larynx as well as the hypopharynx and posterior pharyngeal wall, resulting in a circumferential defect. More extensive cancers involving the cervical esophagus require total laryngopharyngoesophagectomy. A laryngopharyngeal reconstructive procedure is required. Options include myocutaneous flaps (pectoralis major or latissimus dorsi) or fasciocutaneous free flaps (anterolateral thigh, radial forearm), jejunal free flaps, and gastric pull-up procedures.
Lymphatic drainage is typically to levels II and III; however, retropharyngeal and bilateral drainage can occur. Paratracheal and paraesophageal metastases may also be present. Contralateral nodal metastases may occur in cancer of the medial wall of the pyriform sinus and bilateral nodal metastases may occur with cancer of the postcricoid region. Therefore laryngopharyngectomy is generally accompanied by bilateral neck dissections.
Key Operative Learning Points
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Extent of resection should be determined preoperatively to plan for adequate reconstruction.
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2-cm mucosal resection margins should be obtained due to the risk of submucosal spread.
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3 cm of pharyngeal mucosa in the transverse plane is required for closure without flap reconstruction.
Preoperative Period
History
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Hypopharyngeal cancer may present at an advanced stage, as few symptoms may be present until the cancer is advanced.
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Presenting symptoms include progressive pain in the throat, dysphagia, odynophagia, dysphonia, referred otalgia, throat clearing, globus sensation, weight loss, and/or a mass in one or both necks.
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Dyspnea and hoarseness may represent invasion of the larynx or the recurrent laryngeal nerve.
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Dysphagia for solids and liquids implies an advanced cancer.
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Risk factors include the use of tobacco and alcohol, gastroesophageal reflux, and Plummer-Vinson syndrome.
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Plummer-Vinson syndrome is a rare condition generally appearing in women between the ages of 30 and 50. This syndrome consists of iron deficiency anemia, esophageal webs, dysphagia, weight loss, angular stomatitis, and atrophic glossitis.
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Preoperative nutritional evaluation should be performed on patients with hypopharyngeal or cervical esophageal cancer. Prealbumin, albumin, thyroid stimulating hormone, and iron levels provide information regarding nutritional status in conjunction with complete blood counts and basic chemistry. Referral to a nutritionist or dietician may be indicated preoperatively, as well as placement of enteral feeding access. Reconstructive options must be evaluated prior to placement of feeding access, as stomach and jejunum are potential donor sites.
Physical Examination
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Evaluation of the larynx and pharynx with flexible laryngoscopy is mandatory.
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Cancer may represent direct extension from the larynx or be a primary cancer of the hypopharynx.
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Vocal fold motion, patency of the airway, and pooling of secretions in the hypopharynx should be noted.
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Examination of the neck may reveal a mass either from regional metastasis or from direct extension of the cancer.
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Stridor is suggestive of involvement of the larynx.
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Poor nutritional status should be noted.
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Examination of the oral cavity and oropharynx should be performed to rule out synchronous primary cancers.
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Examination of the cranial nerves (hypoglossal, accessory) should be performed to evaluate extension of the cancer from the primary site or regional metastases.
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Paralysis of the vocal folds can occur as a result of invasion of the paraglottic space or cricoarytenoid joint or involvement of the recurrent laryngeal nerve.
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The chest wall, extremities, and abdomen should be examined to note prior surgery or chemoport placement that might affect potential reconstructive options.
Imaging
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Cross-sectional imaging with computed tomography (CT) or magnetic resonance imaging (MRI) with contrast is used to determine the extent of the primary cancer and the presence of regional metastasis. Contrast-enhanced CT imaging is highly sensitive for evaluation of pre-epiglottic and paraglottic space involvement by laryngeal cancer. MRI is more sensitive for detecting pathologic involvement of cartilage.
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Imaging of the lungs is recommended to evaluate for metastasis. CT of the chest is preferable to chest radiographs, given its higher sensitivity and specificity for detecting metastasis. Evidence of restrictive lung disease should be noted, as this may be a relative contraindication for pectoralis major flap reconstruction with a large skin paddle.
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Abdominal imaging may be indicated in patients with a history of prior abdominal surgery and in whom gastric pull-up or jejunal free flap is being considered as a reconstructive option.
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18-fluorodeoxyglucose positron emission tomography (PET) allows for evaluation of whole-body distant metastatic disease.
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Barium swallow esophagram can evaluate esophageal involvement either from direct extension of a laryngeal or hypopharyngeal primary cancer or a second primary cancer of the esophagus. It may also be useful in evaluating possible invasion of the prevertebral fascia.
Indications ( Table 17.1 )
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Advanced stage cancers of the hypopharynx (T3-T4)
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Advanced stage laryngeal cancers with involvement of the postcricoid mucosa, posterior hypopharyngeal wall, or the pyriform sinus with extension across the midline posteriorly
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Salvage surgery following primary chemoradiation in patients who fail organ preservation protocols
| T1 | Cancer limited to one subsite of hypopharynx and/or 2 cm or less in greatest dimension |
| T2 | Cancer invades more than one subsite of hypopharynx or an adjacent site, or measures more than 2 cm but not more than 4 cm in greatest diameter without fixation of hemilarynx |
| T3 | Cancer more than 4 cm in greatest dimension or with fixation of hemilarynx or extension to esophagus |
| T4a | Moderately advanced cancer Cancer invades thyroid/cricoid cartilage, hyoid bone, thyroid gland, or central compartment soft tissue (includes prelaryngeal strap muscles and subcutaneous adipose tissue) |
| T4b | Cancer advanced locally Cancer invades prevertebral fascia, encases carotid artery, or involves mediastinal structures |
Contraindications
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Significant comorbidities precluding primary surgery and reconstruction
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Irresectable cancer such as encasement of the carotid artery or invasion of the prevertebral fascia
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Distant metastases
Preoperative Preparation
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Preoperative evaluation should note whether the patient may be intubated in a standard fashion or whether fiberoptic intubation is indicated. In patients with a large obstructive cancer, awake tracheostomy under local anesthesia may be the safest choice.
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Pan-endoscopy should be performed to map the cancer, obtain tissue for pathologic examination and diagnosis, and to evaluate for involvement of the cervical esophagus. Tumor mapping allows for better prediction of planned cancer resection and coordination with the reconstructive surgeon.
Operative Period
Anesthesia
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General anesthesia
Positioning
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Bed turned 180 degrees and both arms tucked in
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Additional arterial and venous lines may be placed by the anesthesia team, with care taken to ensure that radial and/or femoral vessels are protected if reconstruction with radial forearm or anterolateral thigh free flaps is planned.
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Chest wall should be prepped if a pectoralis major myocutaneous flap is planned.
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Abdomen should be included in the field if there is a need for a jejunal free flap or mobilization of the stomach is required for a gastric pull-up.
Perioperative Antibiotic Prophylaxis
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Perioperative antibiotics are started prior to the surgical procedure and continued for 24 hours postoperatively.
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Organisms covered include gram-positive microbes as well as anaerobes.
Instruments and Equipment to Have Available
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Standard head and neck surgical set
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Microvascular equipment—Sterile tourniquet, microvascular forceps (Jeweler’s forceps), micro needle holders, arterial and venous frame and single clamps, vascular bulldog clamps, 8-0 or 9-0 nylon suture, microvascular anastomosis couplers, microscope or loupe magnification, heparinized saline, implantable Doppler
Key Anatomic Landmarks
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The hypopharynx consists of the pyriform sinuses, the postcricoid mucosa, and the posterior pharyngeal wall.
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The carotid sheaths lie immediately lateral to the hypopharynx.
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Sensory innervation is provided by the glossopharyngeal nerve (CN IX) and internal branches of the superior laryngeal nerve (CN X).
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The hyoid bone is the superior boundary of the hypopharynx, and the inferior boundary is at the lower border of the cricoid cartilage. This border is contiguous with and narrows at the upper end of the esophagus. The postcricoid region is from the arytenoid cartilages to the inferior border of the cricoid cartilage and forms a connection between the bilateral pyriform sinuses. Thus the postcricoid region is the anterior wall of the hypopharynx. The pyriform sinuses extend from the pharyngoepiglottic folds to the superior aspect of the cervical esophagus and are bound medially by aryepiglottic fold, the arytenoid cartilages, and the cricoid cartilage and bound laterally by the thyroid cartilage.
Prerequisite Skills
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Microvascular reconstructive surgeon for free tissue transfer
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General surgeon if gastric pull-up or a jejunal free flaps is indicated
Operative Risks
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Bleeding, infection, injury to accessory/hypoglossal nerves, pharyngocutaneous fistula, wound healing, and flap failure
Surgical Technique—Total Laryngopharyngectomy
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An apron incision is planned with incorporation of the tracheostomy site with extension laterally to allow for bilateral neck dissection.
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Subplatysmal flaps are elevated to the level of the hyoid bone superiorly and laterally, exposing both sternocleidomastoid muscles.
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The cervical fascia is incised along the anterior border of the sternocleidomastoid muscles.
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The fascia on the inferior border of the submandibular gland is incised to identify the posterior belly of the digastric muscle and connected to the fascial incision at the superior border of the sternocleidomastoid muscle.
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Outer tunnels are developed between the strap musculature and the sternocleidomastoid muscles.
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Bilateral neck dissections are performed with removal of lymph node levels II-IV. Neck dissection may be performed separately or left in continuity with the main specimen.
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Arterial stumps including lingual, facial, superior thyroid, and transverse cervical arteries are preserved to allow for microvascular anastomosis.
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Venous stumps including external jugular, anterior jugular, and interior jugular branches such as common facial and transverse cervical veins should be maintained, unless oncologic resection requires sacrifice of the internal jugular vein.
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Strap muscles are divided superior to the tracheostoma, if present, or above the manubrium.
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Dissection is continued superiorly along the trachea to the thyroid isthmus. Selected cancers may allow for sparing one or both lobes of the thyroid gland. In these cases, the thyroid isthmus is divided and the lobes are freed from their attachment to the trachea. Certain cancers may require removal of one or both lobes of the thyroid gland with the main specimen. Dissection is continued superiorly to the first or second tracheal ring.
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Inner tunnels are developed between the carotid sheath and larynx along the prevertebral fascia. The superior laryngeal neurovascular bundle is ligated. Parathyroid glands are preserved, if possible.
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The hyoid bone is exposed and the suprahyoid musculature is incised and dissected off of the superior aspect of the hyoid bone. The central portion may be grasped with a towel clamp and retraced laterally in either direction to expose the lateral cornua. Each cornu is retracted medially to rotate the hyoid away from the hypoglossal nerve and lingual artery. Dissection is continued bilaterally along the hyoid until each cornu can be freed using the finger loops of a hemostat for retraction.
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Depending on the location of the cancer, the larynx may or may not be skeletonized as in a total laryngectomy. If limited circumferential resection is indicated, the larynx may be rotated and the pharyngeal constrictor muscles incised along the lateral border of the thyroid cartilage contralateral to the cancer. The pyriform sinus mucosa is reflected off the thyroid lamina using a Freer elevator. The mucosa is elevated on the side contralateral to the cancer. Alternatively, the deep cervical fascia may be divided medial to the carotid artery along the prevertebral fascia and the pharynx bluntly mobilized off the prevertebral fascia, assessing for tumor extension past the buccopharyngeal fascia. This allows for resection of a larger section of pharynx. Invasion of the prevertebral fascia indicates that the cancer is unresectable. If circumferential mobilization is performed, the pharynx may be entered above the hyoid contralateral to the site of most superior extent of the cancer.
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Pharyngeal mucosal incisions are made horizontally along the posterior pharyngeal wall to free the upper pharynx and entire larynx. Typically a 2-cm margin superior to the highest extent of the lesion is required. Large cancers of the pyriform sinus may require resection of a portion of the base of the tongue as a superior margin.
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Tracheal incisions are performed next, typically between the first and second tracheal rings. The anterior tracheal wall is sutured to the skin to prevent retraction of the distal trachea into the mediastinum. An endotracheal tube is placed and sutured to the skin. Scissors are used to extend the tracheostomy superiorly.
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If cervical esophageal resection is indicated, incisions are made below the cancer. If total esophagectomy is performed, blunt dissection is performed superiorly along the esophagus, with dissection of the esophagus through an abdominal approach.
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Surgical margins are sent for frozen specimen analysis. Wide margins should be taken, as hypopharyngeal cancers may have submucosal spread with diffuse local spread a common finding at surgery. Fig. 17.1 illustrates intraoperative defect from total laryngopharynectomy.
