Conservation Laryngeal Surgery - 22/08/11
Key Points |
• | Four principles of organ-preservation surgery help provide consistent oncologic and functional outcomes: local control; accurate assessment of the 3D extent of tumor; cricoarytenoid unit as the basic functional unit of the larynx; and resection of normal tissue to achieve an expected functional outcome. |
• | Indirect laryngoscopy and staging operative endoscopy are critical to planning conservation laryngeal surgery. Vocal fold fixation must be distinguished from arytenoid fixation, which implies cricoarytenoid joint invasion and is a contraindication to conservation laryngeal surgery. |
• | The overall health of the patient must be assessed. Patients must tolerate some degree of aspiration in the postoperative period. Pulmonary function tests are rarely used. Instead, if a patient is active in daily life and can walk up two flights of stairs without being winded, he or she may be a candidate for a conservation laryngeal procedure. |
• | Open organ-preservation options for glottic carcinomas include vertical partial laryngectomy (VPL) and supracricoid partial laryngectomy with cricohyoido-epiglottopexy (SCPL-CHEP). |
• | The classic VPL and its extensions all share a common approach, which includes a vertical transaction through the thyroid cartilage and paraglottic space, as well as a “blind” entry into the larynx through a narrow exposure. |
• | Functional results with VPL are variable depending on the extent of resection and the type of reconstruction, which varies from imbrication laryngoplasty, to strap muscle flap, to epiglottic laryngoplasty. |
• | Oncologic results for VPL are excellent with T1 glottic carcinomas, but VPL should be avoided with advanced T2 lesions and all T3 and T4 glottic lesions. |
• | The main use for SCPL-CHEP has been in selected T2 and T3 glottic carcinomas, with local control rates greater than 90%. The SCPL-CHEP does not resect the entire supraglottis, so for transglottic tumors, the supracricoid partial laryngectomy with cricohyoidopexy is preferred. |
• | Functional results with SCPL-CHEP are predictable due to the identical resection and reconstruction in all cases. Long-term dysphagia is rare. |
• | Organ-preservation options for supraglottic carcinomas include the supraglottic laryngectomy and the supracricoid partial laryngectomy with cricohyoidopexy (SCPL-CHP). |
• | Supraglottic laryngectomy has produced excellent oncologic results for T1 and T2 supraglottic carcinomas with local control rates greater than 90%, but outcomes are extremely variable with advanced lesions. |
• | Voice results for supraglottic laryngectomy are typically excellent, although a certain degree of temporary dysphagia is to be expected, with more severe dysphagia expected with extended procedures. |
• | SCPL-CHP is indicated for supraglottic carcinomas in which there is glottic level involvement, pre-epiglottic space involvement, decreased vocal fold mobility, or limited thyroid cartilage invasion. |
• | The oncologic success of the SCPL-CHP is attributed to the en bloc resection of bilateral paraglottic spaces, the preepiglottic space, and the entire thyroid cartilage. |
• | Contraindications to the SCPL include (1) subglottic extension greater than 10mm anteriorly and 5mm posteriorly; (2) arytenoid fixation; (3) massive preepiglottic space involvement with involvement of the vallecula; (4) extension to the pharyngeal wall, vallecula, base of tongue, postcricoid region, and interarytenoid region; and (5) cricoid cartilage invasion. |
• | Transoral Robotic Surgery (TORS) is a new technique that offers an alternative to open and transoral laser approaches for the treatment of glottic and supraglottic carcinomas. |
Plan
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