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 of local cancer recurrence. However, proper patient selection is critical. Careful preoperative mapping of the extent of the cancer is necessary to determine whether this operation is appropriate. This procedure may not be undertaken without the patient providing consent for a total laryngectomy should it be needed based on intraoperative frozen section assessment of the resection margins, because as in all cancer operations, it is not acceptable to perform the operation and knowingly leave cancer behind.

Although a permanent tracheostomy is not needed, a tracheotomy is required for several weeks during the postoperative period. During the recovery, patients experience copious secretions through the tracheostomy, some of which lodge in the lungs potentially causing pneumonia. Patients with chronic obstructive lung disease from a long history of smoking may not be suitable candidates for this operation. Over time, the secretions lessen, as patients heal and swallowing function improves, and the copious secretions that were previously expelled through the tracheostomy are swallowed. Once the tracheostomy is removed, patients learn to use a voice, which although it does not resemble their voice prior to the cancer, is understandable. Ultimately, patients with a partial supracricoid laryngectomy report a better quality of life than those who had their entire larynx removed. The final outcome makes the difficult road to recovery well worthwhile.

However, an alternative to a supracricoid partial laryngectomy should be strongly considered for patients with an active mental health or substance abuse issue or lack of motivation that would impede recovery and preclude rehabilitation therapy compliance. The recovery period after a total laryngectomy is usually far less arduous or protracted. Often, an oral diet may be resumed, without aspiration, within a matter of weeks. In addition, some patients favor an unrestricted oral diet over lung-powered vocalization. Such priorities and preferences should be considered in making treatment recommendations.

Key Operative Learning Points

1.
T1-T2, selected T3N0 glottic and/or supraglottic squamous cell carcinomas with involvement of the anterior commissure or petiole of the epiglottis are often good candidates for a supracricoid partial laryngectomy.
2.
Glottic cancer with limited supraglottic extension may be reconstructed using a cricohyoidepiglottopexy (CHEP); cancers requiring resection of the epiglottis are reconstructed using a cricohyoidopexy (CHP).
3.
Patients with cancer of the larynx after failure of narrow field radiation may be effectively salvaged using a supracricoid partial laryngectomy; however, the swallowing function of patients who received definitive wide field radiation or chemoradiation for cancer of the larynx is poor, and a total laryngectomy should be recommended for salvage.
4.
The function of the residual larynx following a supracricoid partial laryngectomy depends on the preservation of at least one cricoarytenoid unit, which opposes the arytenoid against the residual epiglottis or base of the tongue during deglutition, thus protecting the airway.
5.
Although select T3 laryngeal cancers with vocal cord fixation are suitable for supracricoid partial laryngectomy, concomitant fixation to the cricoid is a contraindication due to the inability to both preserve a functional cricoarytenoid unit and obtain negative surgical resection margins.
6.
Reapproximation of the cricoid to the epiglottis or the base of the tongue is a key technical step and is contingent upon the proper placement of pexy sutures around the cricoid and hyoid; the repair is reinforced by the meticulous closure of the strap muscles.
7.
A supracricoid partial laryngectomy is not undertaken in the absence of consent for a total laryngectomy, should it be come necessary.

Preoperative Period

History

1.
History of present illness
- a.
  Hoarseness
- b.
  Stridor
- c.
  Shortness of breath
- d.
  Mass in the neck
- e.
  Weight loss
- f.
  History of pneumonia
2.
Past medical history
- a.
  Prior treatment, especially radiation, and tumor stage
- b.
  Medical illness and functional status
- c.
  Prior laser surgery does not preclude supracricoid partial laryngectomy (SCPL)
- d.
  Social history of smoking and/or alcohol use; history of other substance use
- e.
  Family history
- f.
  Medications
  - 1)
    Antiplatelet drugs, thyroid hormone replacement
- g.
  Exercise tolerance

Physical Examination

A complete preoperative assessment is necessary to determine whether the patient is an appropriate candidate for a supracricoid partial laryngectomy. This assessment is necessary for patient counseling and involves a careful preoperative physical examination, including laryngoscopy, imaging, and mapping biopsies obtained during a laryngoscopy performed under general anesthesia. Nevertheless, intraoperative findings during the partial laryngectomy such as positive intraoperative frozen resection margins may require conversion to a total laryngectomy. An evaluation for a supracricoid partial laryngectomy starts initially with a careful physical examination.

A complete examination of the head and neck should be performed with particular attention to the following:

1.
General health, vitality, appropriate and cooperative behavior, and evidence of frailty should be noted.
2.
Pulmonary status should be assessed, as the patient has to cope with some aspiration
3.
Voice quality, articulation, hoarseness, or stridor are noted.
4.
In the oral cavity, exclude second primary cancers, and evaluate the mobility of the tongue
5.
In the pharynx, exclude tonsil and base of tongue involvement by cancer
6.
Evaluate the neck for the presence of cervical metastases
7.
For laryngeal examination, laryngoscopy is mandatory.

Assess the following:

Mobility of the vocal cords
Mobility of the arytenoids
Supraglottic and subglottic extension
Arytenoid involvement

Imaging

1.
Computed tomography (CT) scan with intravenous (IV) contrast, magnetic resonance imaging (MRI) of the neck with gadolinium
2.
18F-fluorodeoxyglucose positron emission tomography-computed tomography (PET CT scan)

Although the accuracy of CT scans and MRI scans is limited in defining mucosal extension, they reliably demonstrate findings considered contraindications to supracricoid partial laryngectomy, such as extralaryngeal spread. The PET CT scan is more useful in restaging recurrent larynx cancers after radiation, providing important information regarding the presence of nodal disease and distant metastases.

Indications

1.
T1, T2, selected T3, N0-1 glottic and supraglottic squamous cell carcinoma
2.
Recurrent T1-T2, selected T3, N0-1 SCC after narrow field radiation
3.
Motivated patient, able to participate in swallowing rehabilitation

Contraindications

1.
Medical comorbidities with increased risk for general anesthesia
2.
Inadequate pulmonary reserve
3.
Prior wide field radiation for cancer of the head and neck
4.
Preoperative dysphagia due to prior treatment or medical comorbidities
5.
Anticipated need for postoperative radiation or chemoradiation
6.
Anatomic contraindications
- a.
  Vocal cord immobility with arytenoid fixation
- b.
  Subglottic extension
- c.
  Invasion of the cricoid
- d.
  Invasion of the hyoid
- e.
  Extralaryngeal spread
7.
Active mental health issues including anxiety or depression
8.
Active substance abuse
9.
Lack of motivation to participate in recovery and rehabilitation
10.
Lack of support systems

Select glottic and supraglottic cancers classified as T3 stage may be effectively treated with a supracricoid partial laryngectomy. Cancers with pre-epiglottic space invasion may be managed with an SCPL, provided that the pre-epiglottic space involvement is not extensive. Vocal cord fixation alone is not a contraindication to SCPL, unless associated with arytenoid fixation. Paraglottic space invasion by a cancer of the larynx will usually produce fixation of the vocal cord, but the adjacent arytenoid will retain mobility. Resection of the arytenoid will usually yield a negative resection margin. In contrast, vocal cord immobility associated with arytenoid fixation is frequently a result of cricoarytenoid joint invasion by cancer; resection of the involved arytenoid rarely yields a negative surgical resection margin. Following radiation or chemoradiation, there may be fixation of the cricoarytenoid joint, even in the absence of direct invasion of the cricoarytenoid joint by cancer. Functional rehabilitation following SCPL is critically dependent on the well-preserved mobility of at least one cricoarytenoid unit.

Preoperative Preparation

1.
Medical consultations as necessary
2.
Consultation with radiation and/or radiation oncology if indicated
3.
Review imaging
4.
Informed consent including consent for total laryngectomy
5.
Speech and swallowing therapy evaluation
6.
Intraoperative examination with mapping biopsies

Operative Period

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