Problems with supraglottic horizontal laryngectomy

Abstract

In the 20-year period between 1972and 1992we treated 1,265 patients with cancer of the larynx. From this series, we have selected 138 histories of supraglottic horizontal laryngectomy (SHL) valid for this study. Most patients are still under periodic follow-up and constitute a rather heterogeneous group including cases with or without neck dissection (radical or functional, unilateral or bilateral) and with or without postoperative radiotherapy. Also included in the group are 6 patients operated on after failure of curative doses of cobalt-beam therapy. We always have strictly followed the indications set by Alonso in 1954 and, therefore, never considered SHL in more extended tumors, elderly people, or patients with poor bronchopulmonary condition. We had a low complication rate in this type of surgery. Deaths resulting from SHL are rare, and are always ~e­ lated to food aspiration (we had none in our series) . Cardiac infarct, stress ulcers, and other life-threatening complications occurred as frequently as in the rest of pharyngolaryngeal oncological surgical procedures. Postoperative hemorrhages have not been frequent; when they have occurred, they have been treated in the usual way. Wound infection and flap necrosis with salivary pharyngocutaneous fistula have been treated with local cures in the ward. Four out of the 6 previously irradiated patients had more extensive areas of skin necrosis . However, they did not require reconstructive surgery. We seldom perform SHL after radiation failure because it is very difficult to evaluate the limits of the tumor, particularly the lower one. In any case, SHL should have been possible before radiation therapy. We also think that it is very important to diagnose the failure of radiotherapy within 3 months after its completion. Otherwise, it is safer to do a total laryngectomy. There is no doubt that supraglottic cancers can be treated with SHL. However, this is an ambitious operation (Fig 1) aiming at removal of the tumor while at the same time preserving deglutition, phonation, and respiration. Removing the supraglottis (Fig 2) gives rise to problems precisely related to swallowing, talking, and breathing, particularly when the indications of Alonso are not strictly followed. Serious problems will occur if SHL is performed when one or more of the following structures are invaded by the tumor: base of tongue, hypopharynx, arytenoids, and vocal cords. Complications occur more frequently when SHL is performed in elderly people or patients with precarious pulmonary condition.