Laryngeal surgeries

Laryngeal surgeries

1. Laryngeal Surgeries Dr Deepika Malik Resident Radiation Oncology

2. Laryngeal Anatomy Larynx is divided embrologically , clinically and anatomically into Supraglottis Glottis Subglottis

3. Supraglottic Larynx Includes the lingual and laryngeal surfaces of epiglottis , Aryepiglottic folds, and arytenoid cartilage. During development , these structures are derived from branchial arches 3 and 4 Glottic and Subglottic subunit develop from arches 5 and 6 Embryonic fusion plane between ‘ supraglottic ’ and ‘ glottic and subglottic ’ subunits is represented by a horizontal line drawn through the ventricle. This horizontal plane provides the anatomic and oncologic basis of supraglottic laryngectomy

4. Supraglottic larynx Supraglottic larynx comprises Suprahyoid epiglottis( both lingual and laryngeal surface) Infrahyoid epiglottis Pre- epiglottic space Larygeal aspects of AE folds 2 arytenoids Ventricular bands( false cords)

5. Inferior boundary of supraglottis is a horizontal line passing through apex of venticle of larynx This anatomic divisio is located at the arcuate line , which marks the change from respiratory to squamous epithelium and is located at apex of ventricle Thus the roof of ventricle is located in supraglottis and floor belongs to glottis.

6. The marginal zone of supraglottis is recognised because of aggressive clinical behaviours of cancer in this area Because of lack of embryonic seperation from adjacent hypopharynx , cancers in this zone behave similarly to more aggressive cancers of hypopharynx and they carry a worse prognosis Mucous glands are in abundance, and the rich vascularity and lymphatics associated with these glands are responsible for lymphatic spread.

7. Glottic larynx Includes true vocal cords and anterior and posterior commissures

8. The lamina propria has a superficial loose fibrous layer that makes Reinke’s space Blood vessels and lymphatics are almost absent in reinke’s space creating a resistance to spread of early cancer of glottis. No mucous glands on free edge of vocal cords, only sparse glands are noted on superior aspect Conus elasticus extends upwards from superior border of cricoid cartilage to merge with inferior surface of vocal ligament; it resists extralaryngeal spread of glottic and subglottic cancer

9. Subglottic Larynx No subsites Is the area of larynx inferior to the glottis down to inferior rim of cricoid cartilage Rare site of origin of cancer, but is commonly involved by subglottic extension of glottic cancer. Tumors here have high incidence of extralaryngeal spread owing to proximity of cricothyroid membrane and rich postcricoid lymphatics .

10. Laryngeal Surgeries

11. In 1866, Patrick Watson of Edinburg performed the first laryngectomy for a patient of syphilitic larynx, who died later from pneumonia . After his death , the procedure was condemned In 1873, Billroth of Vienna , performed the first successful laryngectomy Since then there have been many advances in laryngeal surgery which are both safe and reliable.

12. Organ preservation therapy of the larynx is offered as a functional alternative to total laryngectomy . The intended goals of preservation therapy are to circumvent permanent  tracheostomy , maintain laryngeal speech, and preserve swallow function

13. Surgeries for glottic cancer 1. endoscopic resection 2. vertical partial Larngectomies

14. Endoscopic resection excision of the vocal cord May be performed by the transoral endoscopic approach usually with a laser Its use is usually confined to small lesions of the middle third of the cord. After cordectomy , a pseudocord is formed, and the patient has a useful, if somewhat harsh, voice.

15. Transoral endoscopic laser surgery

16. Advantages nd diadvantages

17. Vertical Partial Laryngectomy Open transcervical vertical laryngectomy was initially proposed by Solis- Colen in 1800’s to address early T1 and T2 and select T3 glottic cancer. With the advent of primary radiotherapy in the mid 20th century, open procedures were replaced as the definitive treatment for T1 and T2 disease. 

18. The central concept in all VPL’s is vertical transection of thyroid cartilage and paraglottic space. Extent of resection depends on extent of lesion

19. Types of VPL Laryngofissure and cordectomy Vertical Hemilaryngectomy Extended vertical Hemilaryngectomy

20. Laryngofissure and cordectomy T1 glottic lesions involving the mid true vocal cords An endoscopy performed followed by laryngofissure followed by cordectomy followed by a tracheostomy .

21. Increased used of endoscopic cordectomy has resulted in decreased use of open procedure.

22. Vertical Hemilaryngectomy Reserved for T1 and T2 lesions of true vocal cords Result for T3 and T4 lesions have also been acceptable

23. VHL.. Endoscopy is performed before VH is completed following which tracheostomy is performed from a separate incision

24. One entire cord with as much as a third of the opposite cord with the adjacent thyroid cartilage is the maximum cordal involvement suitable for surgery in men; women have a smaller larynx, and usually only one vocal cord may be removed without compromising the airway.

25. The maximum subglottic extension suitable for hemilaryngectomy is 8 to 9 mm anteriorly and 5 mm posteriorly ; this limit is necessary to preserve the integrity of the cricoid . Tumor extension to the epiglottis, false cord, or both arytenoids is a contraindication to hemilaryngectomy

26. Partial fixation of one cord is not a contraindication to hemilaryngectomy , but only a few surgeons have attempted hemilaryngectomy for selected fixed-cord lesions.

27. Extended Vertical Hemilaryngectomy 1. Frontolateral Vertical Hemilaryngectomy - used for lesions involving anterior commissure and anterior contralateral vocal cord 2. posterolateral Vertical Hemilaryngectomy - used for lesions involving ipsilateral aytenoid cartilage

28. Surgeries for supraglottic cancer 1. endoscopic resection Supraglottic laryngectomy Supracricoid partial laryngectomy

29. Endoscopic resection Concept of endoscopic management of supraglottic cancers began in 1939 when Jackson decribed use of laryngoscope and punch biopsy forceps to resect cancers of suprahyoid epiglottis Advent of operating microscope , suspension microlaryngology and CO2 laser led to its renewed popularity.

30. Advantages over open surgeries Elimination of need of tracheostomy Shorter operating times Early rehabiliation of swallowing function Diadvantages Need of specialised equipment Prolonged healing time (2 nd int Poor exposure often leads inadequate removal of lesion

31. Qualityof voice following laser surgery for SGL cancers should be unchanged Results are comparable to radiation therapy, with the latter type being more convinient and less expensive for patients.

32. T1 and T2 lesions on suprahyoid epiglottis , AE fold and vestibular fold with minimal preepiglottic and paraglottic involvement may be treated woth endoscopic laser Cancers on infrahyoid glottis and false cord are less amenable to endoscopic resection

33. CO2 laser is the laser of choice because of its Superficial effect which minimises damage to surrounding tissues Ability to be used as cutting tool in focused mode and coagulation tool in defocused mode

34. Supraglottic laryngectomy Indicated in SGL cancers arising from epiglottis, a single arytenoid , the aryepiglottic fold, or the false vocal cord. The procedure minimises morbidity and preserved the 3 primary functions of larynx- airway protection, respiration , phonation

35. SGL.. Extension of the tumor to the true vocal cord, the anterior commissure , or both arytenoids; fixation of the vocal cord; or thyroid or cricoid cartilage invasion precludes supraglottic laryngectomy

36. SGL.. First introduced as a 2 stage procedure ,in 1947 as an alternative to the then prevailing treatment of SGL cancers, total laryngectomy and neck dissection Later in 1959, it was converted to a single stage procedure.

37. Temporary tracheostomy

38. Patient selection is very important as every patient would develop temporary aspiration post operatively ; thus making patient’s cardiopulmonary reserve an importanr factor in patient selection. Patients must have a good cough reflex or they will aspirate, will not be able to swallow properly or would develop recurren aspiration pneumonia my

39. Supracricoid laryngectomy Used for selected T2 and T3 glottic carcinomas and supraglottic cancers involving 1 or both cords Variation of SG laryngectomy which is extended to provide an oncologically sound resection in an attempt to poresrve voice and avoid permanent tracheostomy . entails removal of both true and false cords as well as the entire thyroid cartilage. The cricoid is sutured to the epiglottis and hyoid ( cricohyoidopexy )

40. Total laryngectomy Fistly performed by Billroth in 1870 Despite in advances in organ preservation treatment protocols , total laryngectomy is Surgery of choice for advanced lesions and and as a salvage procedure for radiation therapy failures in lesions that are not suited for conservation surgery.

41. Criteria for patient selection Fitness to undergo general anaesthesia Ability to care for permanent tracheostomy Psychological ability for adjusting to a laryngectomy

42. Entire larynx is removed Pharynx is reconstructed. Permanent tracheostomy is required.

43. Near total laryngectomy Described by Pearson Technically complex procedure to create a physiological voice shunt based on mobile arytenoid No significant gains over total larygectomy

44. COMPLICATIONS OF LARYNGEAL SURGERIES Neel et al. (78) reported a 26% incidence of nonfatal complications for cordectomy . Immediate postoperative complications included atelectasis and pneumonia, severe subcutaneous emphysema in the neck, bleeding from the tracheotomy site or larynx, wound complications, and airway obstruction requiring tracheotomy. Late complications included granulation tissue that had to be removed by direct laryngoscopy to exclude recurrences, extrusion of cartilage, laryngeal stenosis , and obstructing laryngeal web.

45. The postoperative complications and sequelae of hemilaryngectomy include chondritis , wound slough, inadequate glottic closure, and anterior commissure webs The complications associated with supraglottic laryngectomy and total laryngectomy for supraglottic carcinomas include fistula (8%), carotid artery exposure or blowout (3% to 5%), infection or wound sloughing (3% to 7%), and fatal complications (3%) (25). .

46. The risk of complications increased if tumor margins were involved by tumor ; there was no change in risk associated with age, sex, race, laryngeal site, stage of primary tumor , size of primary tumor , use of low-dose preoperative irradiation, or status of the positive nodes.

47. VOICE REHABLITATION AFTER TOTAL LARYNGECTOMY Major challenge for HNC surgeon and speech pathologist is restoration of speech Patient undergoing TL is offered 3 options 1. Artificial larynx/ electrolarynx 2.Esophageal voice 3.Tracheoesophageal voice

48. electrolarynx First artificial larynx was devised by Gussenbauer in 1874 Available as an external device which is placed against the neck, or as an oral type

49. Electrically driven produce a mechanical sound which is then articulated by tongue, lips, teeth as understandable speech.

50. Advantages Short learning time Can be used in immediate post op period Relative availability and low cost Disadvantages Mechanical sound and dependance on batteries Need for maintenance of intraoral tubes

51. Esophageal voice A speech pathologist or another laryngectomee teaches the patient insufflation behaviour in aquiring esophageal speech The patient learns how to rapidly insufflate and eject air through the esophagus to produce understandable speech

52. This entails trapping air in mouth or pharynx and propelling it into esophagus which produces a sound that can be articulated by tongue , lips and teeth

53. Tracheoesophageal voice Based on concept of shunting of tracheal air to pharynx through a fistulous tract during exhalation to produce sound through vibration of mucosa of upper esophageal segment Speech is produced by articulation of sound at level of oral cavity.

54. Transesophageal puncture can be performed at time of laryngectomy (primary TEP) or later as an independent procedure (secondary TEP)

55. Thankyou .