Conservation laryngeal surgery

Report
Vertical partial laryngectomy
Indications to VPL
• T1, T2 glottic lesion
Contraindications to VPL






Fixed TVC
Involve posterior commissure
Bilat. arytenoid invasion
Bulky transglottic lesion
Thyroid cartilage invasion
>10 mm subglottic extension anteriorly;
>5 mm posteriorly
Hemilaryngectomy
Hemilaryngectomy
• The partial excision of the larynx which is a
voice-conserving procedure
• Consists of dividing the thyroid cartilage in
the midline and resecting in continuity the
thyroid cartilage with the corresponding true
and false vocal cords and ventricle
Hemilaryngectomy
Oncologic results
T1 lesions :
• Local control rates >90%
• Local recurrence rates 0 - 11%
– Without anterior commissure involvement :
local control rates 93%
– Anterior commissure involvement without
impaired mobility or extension beyond the
glottis : local failure rate 25%, most common
site of recurrence is subglottis
Oncologic results
• T2 glottic : Local recurrence rate >14%
High local failure rate for
1) Subglottic extension with cricoid cartilage
invasion
2) Supraglottis extension through ventricle
(possibility of thyroid cartilage invasion)
3) Impaired cord mobility (TA muscle invasion
within paraglottic space)
• T3 glottic : Local failure rates of >36%
Extended procedures
Anterior frontal / Frontolateral vertical
hemilaryngectomy
Posterolateral vertical hemilaryngectomy
Extended vertical hemilaryngectomy
Frontolateral vertical
hemilaryngectomy
Indication
• Lesion involve anterior commissure
• Lesion involve opposite TVC anteriorly
< ant 1/3
Contraindication
• Tumor extend posteriorly beyond the
tip of vocal process, into ventricle or
below the inferior surface of cord
• Vertical thyrotomy made through thyroid lamina of
the less involved side
• Allowing for removal of the anterior angle of
thyroid cartilage, anterior commissure, and a portion
of contralateral true vocal cord
Post op Frontolateral vertical
hemilaryngectomy
Anterior frontal partial laryngectomy
Posterolateral vertical hemilaryngectomy
• The thyrotomy approach same as standard
operation, and modification lies in posterior
extension of resection to encompass part or all of
ipsilateral arytenoid cartilage and mucosa
Indication
• Tumor extend posteriorly to involve
ipsilateral arytenoid mucosa
Extended vertical hemilaryngectomy
• Resection of entire ipsilateral hemilarynx with
resecting superior aspect of cricoid cartilage
• For glottic lesion with subglottic extension
Cricoid cartilage
Reconstruction
• (1) False vocal cord pulldown
• (2) Cartilage preservation with
perichondrial/sternohyoid bipedicle muscle
flap reconstruction
• (3) Epiglottic reconstruction for defects
involving the anterior commissure
Reconstruction
Imbrication laryngoplasty
Bipedicle muscle flap
SUPRACRICOID PARTIAL
LARYNGECTOMY
WITH CRlCOHYOlDEPlGLOlTOPEXY
(SCPL-CHEP)
Surgical resection (SCPL-CHEP)
• Removal of both TVCs and FVCs, bilat paraglottic
spaces, preepiglottic space, thyroid cartilage, (maximum
one arytenoid)
Indication
T1b : involved anterior commissure
T1 : contralateral various dysplasia and
hyperplasia area
T2 : bilateral glottic cancer
Selected T3
Contraindication
• CA joint fixation
 Subglottic extension to level of cricoids or direct
invasion of cricoids
 Invade interarytenoid area
 Extent to outer perichondrium of thyroid cartilage
(Extralaryngeal spread)
 Involved pharyngeal wall, valleculae, BOT,
postcricoid,
 Pulmonary impairment,GERD, age>70 yrs (prefer
lung function test)
Surgical technique
• Upper:
– Along post. Sup. Of thyroid cartilage
• Elevated off pyriform mucosa
• Disarticulate cricoarytenoid jt
• Lower:
– Superior border of cricoid cartilage
• Transection posterior to ventricle, anterior to
vocal process
Surgical technique
Extended SCPL
• Anterior subglottic extension
• Resection of the anterior arch of cricoid
• Closed with pexy between the first two
tracheal rings and the hyoid or
tracheohyoidoepiglottopexy
Functional outcome
•
•
•
•
Temporary dysphagia
But long-term dysphagia: rare
Intractable aspiration 0-4%
NG post-op: 9-50 days
Supraglottic cancer
Transoral laser microsurgery
Horizontal Partial
Laryngectomies
•Supraglottic Laryngectomy
Supracricoid Laryngectomy
with Cricohyoidopexy (CHP)
EXTENDED PROCEDURES
•ARYTENOID, ARYEPIGLOTTIC FOLD, OR
SUPERIOR MEDIAL
PYRIFORM INVOLVEMENT FROM
SUPRAGLOTTIC CARCINOMA.
•BASE OF TONGUE EXTENSION FROM
SUPRAGLOTTIC CARCINOMA.
EXTENDED PROCEDURES.
Supraglottic laryngectomy
Surgical resection
• Removal of both FVCs and AE folds, epiglottis,
preepiglottic space, upper half thyroid cartilage,
hyoid bone (one arytenoid for extended procedure)
• Preserve both TVC, arytenoids, BOT
Indication
• Supraglottic cancer T1, T2
Contraindication
 Invasion of cricoids and/or thyroid cartilage
 Bilateral mucosal invasion of arytenoid cartilage
 Invasion of posterior and anterior commissure
 Fixation of arytenoid cartilage
 Involvement of BOT < 1 cm to circumvallate
papillae
 Impair tongue base mobility (involved deep
intrinsic muscle)
 Invade FOM with valleculae involvement
Bailey
Surgical technique
Sternohyoid and
sternothyroid
muscles transected
at superior border of
thyroid cartilage.
Surgical technique
Perichondrium
incised at upper
border of thyroid
cartilage
Surgical technique
Elevate external thyroid
perichondrium halfway
down the thyroid
cartilage.
Surgical technique
Oncologic outcome
• For T1, T2 local control rate >90%
SUPRACRICOID PARTIAL
LARYNGECTOMY WITH
CRICOHYOIDOPEXY
(SCPL-CHP)
Surgical resection
• Removal of both TVCs and FVCs, bilat paraglottic
spaces, preepiglottic space, thyroid cartilage,
epiglottis, (extended  resect one arytenoid)
Indication
• T1, T2 supraglottic CA with anterior
commissure, ventricle and glottic
involvement
• T3 supraglottic CA (paraglottic and
preepiglottic involvement)
• Selected T4 supraglottic CA (local cartilage
invasion)
Contraindication
 Arytenoid cartilage fixation
Subglottic extension >10 mm anteriorly, >5 mm
posteriorly or direct invasion of cricoid
Extensive preepiglotte space invasion
Tumor extend to hyoid bone superiorly or
cricoid cartilage inferiorly
 Extension to pharyngeal wall ,valleculae,
BOT,interarytenoids and postcricoid
Cummings
Open Conservation Laryngeal Surgery
Early glottic cancer
• Laryngofissure and
cordectomy
• Vertical partial
laryngectomy
Supraglottic cancer
• Horizontal partial
laryngectomy
(Supraglottic
– Hemilaryngectomy
laryngectomy)
– Frontal/Frontolateral
• Supracricoid partial
laryngectomy
laryngectomy with
• Supracricoid partial
cricohyoidopexy
laryngectomy with
cricohyoidoepiglottopexy
(SCPL-CHP)
(SCPL-CHEP)
Postoperative management
• Deflate tracheostomy tube early as possible
• Remove tracheostomy tube day 3-5
– Kept prolong if laryngeal edema or salivary stasis
• Swallowing rehabilitation not begun until
tracheostomy tube is removed, stoma is closed
and can swallow her/his saliva
• Speech rehabilitation early post-op

similar documents