Management of the Airway for Transoral Robotic Supraglottic Partial Laryngectomy.

Introduction: Over the last several decades, transoral resection techniques for treatment of supraglottic lesions have become increasingly favored to reduce the need for either open transcervical resection or primary chemoradiation. Transoral robotic surgery (TORS) offers advantages in visualization, dissection control, and access to remove bulky tumors en bloc. However, the management of the airway for these cases tends to vary, without clear guidelines as to when a tracheostomy is necessary. Materials and Methods: A retrospective review of all patients who underwent transoral robotic supraglottic partial laryngectomy at a large academic center from May 2005 through December 2016 was performed. Airway management was examined, specifically as it pertains to whether a tracheostomy was performed at the time of surgery or otherwise. Demographic and tumor characteristics were also evaluated. Results: Sixty-three patients were included. Forty (63%) were male, the average age at surgery was 63.6, and the majority (90.5%) underwent resection for squamous cell carcinoma of the supraglottis. Thirty-nine patients (62%) underwent the procedure with standard endotracheal intubation using a wire-reinforced tube. Of these, four patients required subsequent tracheostomy- 2 for laryngeal edema postoperatively, one for airway management during a postoperative bleeding event, and one for laryngeal edema following initiation of adjuvant chemoradiation. Twenty patients (32%) underwent tracheostomy at the time of transoral resection for airway management, 17 of whom were decannulated an average of 12.2 weeks following surgery. Those who underwent tracheostomy at the time of surgery had a higher percentage of tumors involving multiple supraglottic subsites (p = 0.031), 85 vs. 54% in the group who did not undergo tracheostomy. No difference in age, BMI, clinical T-stage, or clinical N stage was found between the two groups. Conclusion: Performing a tracheostomy at the time of surgery should be considered for those patients with more extensive malignant disease (≥T2 tumors). While avoiding tracheostomy is often preferred by the patient, the maintenance of the patent airway peri-operatively should be first priority when considering airway management. Furthermore, as the majority of those patients receiving tracheostomy are decannulated within 4 months of surgery, the tracheostomy could be considered a short-term adjunct to the procedure.

Predictable swallowing function after open horizontal supraglottic partial laryngectomy.

OBJECTIVE: After horizontal supraglottic partial laryngectomy, patients have an increased risk of dysphagia as they are not able to close the laryngeal entrance during swallowing, especially if the surgical defect of the tongue base has increased. There is no investigation that studies risk factors for impaired swallow function, or that predicts postoperative swallow outcomes based on radiologically determined tumor dimensions. The present study investigated the impact of the tongue base tumor extension (determined by CT scan in patients undergoing partial laryngectomy) on the recovery rate of swallow function. METHODS: The retrospective study in a tertiary hospital between 2000 and 2015 included all patients who underwent open horizontal supraglottic partial laryngectomy due to oropharyngeal cancer of the tongue base, or supraglottic laryngeal cancer with tongue base infiltration. All clinicopathological data were collected. The dimension of tongue base infiltration was measured using CT scan. Swallow function was recorded by Fiberoptic Endoscopic Evaluation of Swallowing and determined by evaluating both the duration until nasogastric tube removal and changing of the cuffed tracheostomy tube for an uncuffed speech cannula. RESULTS: The study included 26 patients (44-76 years, median 59 years). The clinical tumor (cT) classification included cT2 and cT3, while the pathologic tumor (pT) classification included pT2 and pT3 in 90% and pT1 and pT4 in 10% respectively. The duration until using the speech cannula was not associated with clinicopathological data, including the investigated radiologic tumor dimensions (biggest tumor diameter, tongue base infiltration depth, width, height, area and volume). The duration until nasogastric tube removal was significantly associated with the tongue base infiltration width (p=0.012), height (p=0.026) and area (p<0.0001). The patients were divided into two groups according to the median tongue base infiltration area estimated as 6.20cm(2). In patients <6.20cm(2), 50% of the nasogastric tubes were removed after 4 days (95% CI 0-8.6 days) and in patients ≥6.20cm(2), 50% were removed after 22 days (95% CI 6.8-37.2 days; p<0.0001). CONCLUSION: The postoperative swallow function after open horizontal supraglottic partial laryngectomy depends on the tumor extension of the tongue base. The tongue base infiltration area is a useful tool for surgical planning as it can be used to predict postoperative swallow function. In foreseeably permanent dysphagia, as well as permanent and necessary tracheotomy tube cuffs after organ-preserving surgery, alternative therapy methods should be particularly preferred as the primary chemoradiation.

How the operated larynx ages.

After open partial laryngectomy (HOPL), many patients experience deterioration of laryngeal function over time. The aim of this study was to evaluate laryngeal functional outcome at least 10 years after surgery in a cohort of 80 elderly patients. The incidence of aspiration pneumonia (AP) and objective/subjective laryngeal functional assessments were carried out. Eight patients experienced AP including four with repeated episodes. A significant association was observed between AP and severity of dysphagia (p < 0.001). Dysphagia was more pronounced than in a normal population of similar age, but less than would be expected. There was a significant association between the type of intervention and grade of dysphagia/dysphonia; a difference in voice handicap was found, depending on the extent of glottic resection. After HOPL, laryngeal function was impaired, but this did not significantly affect the quality of life. AP is more frequent in the initial post-operative period, and decreases in subsequent years.

Supraglottic Partial Laryngectomy is Contraindicated in Patients Elder than 70 Years Old? / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Some use age 70 as a cut-off point for supraglottic laryngectomy because of postoperative aspiration and deglutition complications. But the relationship between age and postoperative aspiration and deglutition complications has not been adequately reported. Therefore, we reviewed postoperative aspiration and deglutition complications of supraglottic laryngectomy in patients older than 70 years old and investigated whether age was one of the factors influencing functional outcome in supraglottic laryngectomy. Patients and Method: From 1994 to 2001, the decannulation day and the postoperative day when oral feeding was started were retrospectively investigated on seven patients who underwent supraglottic partial laryngectomies among early (T1, T2) supraglottic squamous cell carcinoma patients elder than 70 years old. RESULTS: There were no cases requiring either a persistent tube feeding and a gastrostomy. Decannulation could be performed in all cases. The average decannulation day was postoperative 20.6 days and the average oral feeding day was 16.3 days. There were no postoperative complications such as aspiration, fistula and dysphagia. There were no differences according to age. CONCLUSION: No differences were found regarding age in the functional outcomes of supraglottic laryngectomy. So, one's chronological age does not necessarily reflect his or her physiological age and therefore cannot be a contraindication of supraglottic laryngectomy.

A New 'Y' Shape Partial Laryngectomy for Supraglottic Carcinoma with Anterior Commissure Invasion or Encroachment / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Supraglottic partial laryngectomy (SPL) is contraindicated when lower margin of the tumor invades the anterior commissure or encroaches on it. Those cases are usually treated with supracricoid laryngectomy or near- total or total laryngectomy. But all these procedures have to sacrifice innocent true vocal cords, not because of oncological concerns but because of reconstruction concerns. We designed a new Y-shape partial laryngectomy with preserving vocal cords for this particular situation. PATIENTS AND METHODS: Thyrotomy consists of two incisions, upper and lower. The upper incision was made oblique from superior cornu down to the anterior commissure. When this incision was made 5 mm lateral to the midline, it went down to the inferior border of thyroid cartilage. This modification enables resection enbloc anterior commissure region with SPI. specimen. At closure, both ends of the true cord is anchored to the thyrotomy margin. Each lamina is connected with one miniplate with 6 holes. Then the closure is reinforced with elevated thyroid perichondrium and strap muscles. RESULTS: Two patients were treated with this type of surgery. Both had negative surgical margins. In the postoperative period, no specific complications were noted. Roth of them could decannulate and swallow without aspiration on the 20th day following the surgery. They retained their voices from the true vocal cords. CONCLUSION: This new partial laryngectomy technique could apply to supraglottic carcinoma cases with anterior commissure invasion or encroachment without sacrificing true cords. This procedure provides satisfactory swallowing and postoperative phonatoty function even with resection of the supraglottic structure.

Pharyngolaryngeal closure after supraglottic partial laryngectomy / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES:Although the various methods of pharyngolaryngeal closure after supraglottic partial laryngectomy(SPL) have been reported, the difference of postoperative function and complications has not been adequately analyzed. Therefore, We investigated the relationship between different pharyngolaryngeal closure methods and postoperative function and complications. PATIENTS AND METHODS: According to the methods of pharyngolaryngeal closure, postoperative complications, decannulation day and postoperative day when to start oral feeding were retrospectively investigated on 22 patients who underwent SPL. We divided the patients into two groups according to the methods of pharyngolaryngeal closure. In cartilage group(13 cases), the closure of pharyngolaryngeal defect was done with direct suture between the thyroid cartilage and base of the tongue. In perichondrial group(9 cases), the closure was done between preserved thyroid perichondrium and base of the tongue. RESULTS: There was no case requiring either a gastrostomy or a persistent tube feeding in our series. Fistula occurred more often in perichodrial group(3 cases) than cartilage group(0 case). In one case of perichondrial group, total laryngectomy was performed because of a fistula. Also, aspiration pneumonia occurred more often in perichodrial group(2 cases) than cartilage group(0 case). Decannulation could be performed relatively earlier in cartilage group than in perichondrial group. Also, oral feeding could be performed relatively earlier in cartilage group than in perichondrial group. CONCLUSION: Direct approximation between cut margin of the thyroid cartilage and base of tongue was safe, time-saving and reliable method of pharyngolaryngeal closure after SPL.

Surgery for the Base of the Tongue Cancer in Conjunction with Supraglottic Partial Laryngectomy / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Cancer arising in the base of the tongue with extension to the supraglottic larynx or cancer of the epiglottis with extension to the base of the tongue require wider surgical approach than conventional supraglottic partial laryngectomy. This paper is to review techniques and postoperative results of mandibular swing approach for resection of the base of the tongue with supraglottic larynx. MATERIALS AND METHODS: We applied mandibular swing approach for three cases of the base of tongue cancer with significant extension to supraglottis. Two patients were stage T3 and the other was T4. RESULTS: In two patients, oral feeding without aspiration was possible with 5X6, 4X5 cm sized base of the tongue resection. Reconstruction was performed using primary repair between resected margin of the tongue and thyroid cartilage. In one case, an unexpected wide submucosal tumor extension to the hypopharynx was found, so a total glossolaryngectomy had to be performed. CONCLUSION: Resection of the base of the tongue beyond foramen cecum and primary repair may be possible without jeopardizing postoperative deglutition. Mandibular swing approach in conjunction with supraglottic partial laryngectomy was useful for the base of tongue cancer with supraglottic extension.