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Stenosis of the Tracheostoma Following Total Laryngectomy

Introduction Stenosis of the tracheostoma following laryngectomy is an infrequent but distressing complication that may occur despite meticulous attention to the construction of the tracheostoma. Stenosis can result from a variety of factors and usually occurs in the early months following laryngectomy. However, stenosis may also occur years later despite the type of closure performed at initial surgery. Wax et al. defined tracheal stenosis as a narrowing…

Management of a Tracheocutaneous Fistula and Depressed Scar

Introduction A tracheocutaneous fistula (TCF) is a sequela of a tracheostomy and is usually associated with an unsightly depressed tracheostomy scar ( Fig. 23.1 ). Formation of this fistula is predicated on squamous epithelium migrating from the skin into the trachea, forming an epithelial interface with the mucosa of the trachea, and thereby creating a true fistula that cannot close spontaneously. Marked separation of the strap…

Tracheal Resection

Introduction Tracheal resection may be undertaken for tracheal strictures and tracheal tumors. Most commonly the trachea is exposed through a cervical incision, but for distal tracheal or carinal access either a sternotomy or a right thoracotomy may be required. Up to half the trachea may be resected with construction of a primary tracheal anastomosis. For the extensive resections, release techniques will be required. Preoperative planning is…

Operative Otolaryngology: Laryngotracheal Separation

Introduction 1. Airway protection is the most fundamental role of the mammalian larynx. (See Additional Sources for in-depth discussion.) 2. For some patients, laryngeal function is compromised by disease processes to the extent that its airway protection role becomes inadequate in preventing aspiration. 3. Chronic aspiration can be managed in most patients with alternative feeding, tracheostomy for pulmonary toilet, and oral care ( Box 21.1 ).…

Percutaneous Tracheostomy

Introduction Endoscopic percutaneous dilatational tracheostomy (PDT) is a safe and simple bedside procedure that is particularly well suited to patients in the intensive care unit (ICU). Almost two-thirds of tracheostomies are performed in ICU patients. These critically ill patients, usually with multisystem disease are at high risk for complications. Moving these patients with their monitors and endotracheal tubes (ETTs) to the operating room (OR) for an…

Open Tracheostomy

Introduction Tracheostomy is essentially a “shortcut” into the airway that “bypasses” the upper airway. Most tracheostomies are performed for ventilator support in critically ill patients or as a temporary airway to accompany surgical procedures on the oral cavity, pharynx, or larynx ( Fig. 19.1 ). Less common indications include sleep apnea, chronic lung disease, primary alveolar hypoventilation syndrome (Ondine curse), and conditions requiring prolonged mechanical ventilation.…

Operative Otolaryngology: Bronchoscopy

Introduction Bronchoscopy is an important diagnostic tool that can also be used therapeutically. Both rigid ( Fig. 18.1 ) and flexible bronchoscopes ( Fig. 18.2 ) can be used, and both techniques have relative advantages and disadvantages. Although flexible bronchoscopy has largely replaced rigid bronchoscopy for diagnostic procedures, rigid bronchoscopy remains an important modality for therapeutic procedures. The newer technologies of navigational bronchoscopy and endobronchial ultrasound…

Total Laryngopharyngectomy

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…

Total Laryngectomy

Introduction The most common location of laryngeal cancer is the glottis, followed by the supraglottis, with the least common site being the subglottis. The American Cancer Society estimates that more than 14,000 new cases of laryngeal cancer will occur in the United States in 2016, resulting in about 3620 deaths. It occurs more frequently in males. Tobacco (cigarette smoking) is the primary risk factor for laryngeal…

Supraglottic Transoral Robotic Surgery

Introduction Early supraglottic squamous cell carcinoma may be treated with either surgery or radiation as a single modality with equal results, based on retrospective evidence and extrapolation from larger studies comparing radiation to total laryngectomy. As treatment modalities shifted toward “organ preservation therapy” after the Veterans Affiars Larynx trial, both surgical innovation and a noted decrease in survival have prompted the resurgence of conservation surgical procedures,…

Supracricoid Partial Laryngectomy

Introduction Historically, a variety of partial laryngectomies have been developed to preserve speech and avoid the permanent stoma associated with the classical total laryngectomy. The supracricoid partial laryngectomy was developed to manage selected glottic and/or supraglottic cancers. The procedure can be modified based on the extent of supraglottic involvement; otherwise, supracricoid laryngectomy is distinguished by a standardized approach that has been associated with exceptionally low rates…

Vertical Partial Laryngectomy

Introduction Vertical partial laryngectomy (VLP) is used for cancers extending to or crossing the anterior commissure. Hence the resection as typically performed entails removal of several millimeters of the contralateral vocal cord as well as the midline portion of the thyroid cartilage. This procedure is not actually a “hemi” laryngectomy as it has been termed traditionally, since: the cricoid ring remains intact, the hyoid bone is…

Horizontal Partial Laryngectomy

Introduction Cancer of the larynx arises from three subsites in the larynx: the supraglottis, glottis, and subglottis. Subglottic primaries comprise less than 5% of cancers of the larynx. The incidence of supraglottic versus glottic primaries varies, depending on the relative prevalence of alcohol and tobacco abuse and by geographic area. The optimal treatment of cancer of the larynx depends on primary tumor staging and the functional…

Transoral CO 2 Laser Microsurgery for Cancer of the Larynx

Introduction Transoral CO 2 laser microsurgery is a well-established treatment for cancer of the larynx, particularly for T 1 or T 2 glottic cancer. Alternative treatment options include radiation therapy or hemilaryngectomy for glottic cancer and supraglottic or supracricoid laryngectomy for supraglottic cancers. The advantages of using CO 2 laser with an operating microscope include microsurgical precision, excellent intraoperative detail, and a dry surgical field. Swallowing…

Acquired Laryngeal Stenosis

Introduction Basic functions of the larynx include being the conduit for air, protecting the airway from aspiration, phonating, coughing, fixing the chest for straining activities, maintaining positive end-expiratory pressure, and swallowing. All these functions can be impaired in patients with laryngeal stenosis. Acquired laryngeal stenosis is a rare condition. It may be a result of external or iatrogenic trauma, systemic diseases, infections, and neoplasms. The degree…

Bilateral Vocal Fold Immobility

Introduction Bilateral vocal fold immobility (BVFI) is an uncommon condition with potentially significant negative effects on breathing and quality of life. Patients usually have symptoms of airway obstruction, such as biphasic stridor and dyspnea, with a normal or nearly normal voice. This is in contrast to patients with unilateral vocal fold immobility, who usually complain of a breathy voice and aspiration. Etiologies of BVFI include immobility…

Laryngeal Trauma

Introduction Trauma to the larynx accounts for less than 1% of all trauma. This is explained in part by the fact that the larynx is relatively protected by the mandible, sternum, and flexion mechanism of the neck. An alternative perspective is the percentage of patients with laryngeal injuries who are dead on arrival at the emergency department. Line and associates reported a series of 171 victims…

Excision of Laryngocele

Introduction The ventricle ends in a blind pouch anteriorly called the sacculus or saccule, which is variously known as the appendix ventriculi larynges or Hilton’s sac. Laryngocele refers to a pathologic cystic dilation and enlargement of the saccule of the laryngeal ventricle. It is a rare and benign lesion of the larynx that may present with hoarseness, dyspnea, or dysphagia, depending on its size. Laryngoceles are…

Intraoperative Medialization Laryngoplasty

Introduction Medialization laryngoplasty or thyroplasty type I was first described and later popularized by Ishiki during the 1970s. Netterville first reported on the immediate medialization of the true vocal fold following skull base or head and neck surgeries involving the sacrifice of the vagus or recurrent laryngeal nerves. Glottic insufficiency affects all laryngeal functions and may be caused by vocal fold: Atrophy (i.e., presbylarynx, neuromuscular degenerative…

Medialization Laryngoplasty and Arytenoid Adduction

Introduction Medialization laryngoplasty (type I thyroplasty) and arytenoid adduction are excellent surgical options for rehabilitation of the voice in patients suffering from glottic insufficiency. These are great options for surgical therapy to augment and reposition the vocal folds to improve vocal fold closure and thereby improve vocal function. Glottic insufficiency may be caused by any combination of the following: vocal fold atrophy (presbylarynges), vocal fold scar,…