Preepiglottic Space Research Articles

Cancer spread in the larynx.

Submucosal cancer extension through mucous glands occurs in the larynx. In a study of 45 cases, many lesions were too advanced to accurately state what had been the mode of spread. The majority of lesser lesions had clearly invaded according to the pattern predicted by the glandular theory. This theory offers an explanation for many clinical observations hitherto not completely understood—for example, the time honored dictum that supraglottic tumors tend not to invade the glottis but to penetrate the preepiglottic space. Anterior commissure tumors are difficult to treat because of their dissemination throughout the anterior subglottic mucous glands. Many new predictions are made; for example, on the behavior of ventricular and saccular tumors and on the distinction between cancers arising on the superior surface of the vocal cord and those showing mainly subglottic extension.

Preepiglottic space. An anatomic study.

The relation of hyoid bone to the preepiglottic space was studied in human larynges by dissection and dye injections. It was found that removal of the hyoid bone is not essential to the complete removal of the preepiglottic space. Preservation of the hyoid bone may be worth considering if it minimizes the swallowing problems associated with a supraglottic laryngectomy. Other findings were the presence of a septum in the preepiglottic space and a prethyroid bursa. The space does not contain any lymph nodes.

Cineradiography of the swallowing mechanism following supraglottic subtotal laryngectomy.

Since 1955, 150 patients have been subjected to a one-stage supraglottic subtotal laryngectomy for carcinoma of the epiglottis and hypopharynx. Forty-two cineroentgenographic examinations were carried out in 36 patients to demonstrate alterations and adjustments in the swallowing mechanism following larynx-sparing surgery. The studies were evaluated for: (a) degree of aspiration using liquid and thick barium, (b) the degree of apposition of the remaining larynx to the base of the tongue, (c) effectiveness of tongue movement, and (d) effectiveness of esophageal function. Surgical Procedure The epiglottis, both aryepiglottic folds, the pre-epiglottic space, the false cords, the entire upper third of the thyroid cartilage on the affected side, and a smaller segment of the thyroid cartilage on the unaffected side are removed, and a mandatory or elective en bloc neck dissection on the side of significant tumor or lymph node involvement is performed (Figs. 1 and 2). Preoperative irradiation, with a tumor dose r...

Supraglottie Horizontal Laryngectomy

The result of 18 cases operated by the new technics was presented. The preepiglottic space was not opened because the one third of the thyroid cartilage was cut off horizontally, and the hyoid bone was dissected, so that the indication was spred. The rest of the larynx was declined forward, so that the swallowing was not disturbed.The respiration and the phonation was disturbed according to the range of the resected endolaryngeal tissues.When necessary, the neck dissection had been performed at one stage.The last 5 cases was irradiated (4000r) before operation, and the of the skin healed primarily.

Partial Laryngectomy in Cancer of the Larynx

A partial laryngectomy was discussed, and two modification technics were presented. One of them is the vertical partial laryngectomy. The wound surface in the larynx is covered by the mucosa of the nasal septum to prevent the stenosis through the proliferation of granulation. The another is the supraglottic horizontal laryngectomy. Cancer at the upper part of the larynx is extirpated by means of the resection of the hyoid bone, epiglottis and the upper one-third of the thyroid cartilage symmetrically, but the preepiglottic space is not opened. The large pharyngostoma is closed with the skin-platisma flap. The result of both methods is excellent.

Value of laryngography in vocal cord tumors.

Accurate knowledge of the exact site and extent of laryngeal tumors is a vital prerequisite for proper therapeutic management. Although conventional clinical technics, including direct and indirect endoscopy, are reliable and accurate, their limitations in determining the extent of disease do not appear to have been appreciated. Areas where clinical methods may fail to reveal tumor invasion include the pre-epiglottic space, the subglottic region, the laryngeal ventricles, the thyroid cartilage, and the base of the epiglottis (6, 8, 10). Since 1922, when Coutard (7) pointed out the usefulness of the lateral roentgenogram of the neck, this view has been an important adjunct in the evaluation of tumors of the larynx and pharynx. Invasion of the pre-epiglottic space and thyroid cartilage may be detected by this method and the contours of the vallecula, epiglottis, and upper aryepiglottic fold may be demonstrated. Recently, however, a review of a large series of lateral roentgenograms of the neck by Bate, Ruiz, and Bachman (5) showed almost 60 per cent to be unsatisfactory for proper evaluation of the larynx. The introduction of tomography in the frontal projection by Leborgne (10) greatly increased the usefulness of roentgenography in laryngeal disease, but even this refinement frequently fails to provide sufficient detailed information regarding the extent of malignant involvement. Powers, McGee, and Seaman (14) described a roentgenographic method for examining the larynx, utilizing local anesthesia and coating the laryngeal mucosa with Dionosil Oily. This procedure provides a wealth of anatomic detail and a higher incidence of successful examinations than do the other two roentgen methods. Recently Ogura, Powers, et al. (13) reported their experience with the laryngographic technic in a study of 96 surgically proved cases of laryngeal cancer. The accuracy of this method of determining the precise extent of the disease was 92 per cent as compared to an accuracy of 78 per cent achieved in this same group of patients by conventional clinical methods. Since our experience with this procedure has also been favorable, we are presenting here a review of 100 laryngographic examinations performed at the Columbia-Presbyterian Medical Center. Technic Our laryngographic technic is essentially the same as that originally described by Powers, McGee, and Seaman. The most important feature is thorough anesthesia of the laryngopharynx and upper trachea. Xylocaine, in 2 to 4 per cent concentration, is used for a topical spray, and a few cubic centimeters are instilled directly into the trachea through a curved metal cannula. Approximately 5 to 15 c.c. of Dionosil Oily is injected into the larynx and hypopharynx, through a curved metal cannula, and multiple spot-films are obtained in the frontal and lateral positions during quiet respiration, phonation, the Valsalva and the modified Valsalva maneuvers.

Il Cancro Dell'Epiglottide

A correct therapy of the epiglottis cancer is grounded on the exact knowledge of the following points: tumor site; ways of spreading; lymph node metastases. In regard to site, the epiglottis cancer may involve the laryngeal surface, the free edge, or the lingual surface. The ways of spreading are different, in relation to the primary site of the tumors. Those of the laryngeal surface remain long circumscribed when they affect the suprahyoid portion, whereas they tend to invade the pre-epiglottic space when the subhyoid portion is involved; those of the free edge spread along the aryepiglottic and pharyngoepiglottic plicae, those of the lingual surface more frequently to the valleculae and the base of the tongue. Lymph node metastases are more precocious and frequent in the tumors of the subhyoid portion of the laryngeal surface than in those of other sites; they are almost always bilateral. Therapy consists in the horizontal supraglottic partial laryngectomy in the cancers of the laryngeal surface and of the edge; the radiological treatment is indicated for the tumors involving the aryepiglottic and pharyngoepiglottic plicae and the base of the tongue. The bilateral intervention on the lymph nodes is always advised. Such therapeutical criteria are based on the experience of 30 cases of epiglottic cancer observed in the years 1951–1960 in the Otorhinolaryngological Clinic of the University of Milan.

Studies on the lateral neck radiograph.

1. The appearance of certain areas in the lateral radiographs of the neck was studied in 100 randomly selected cases in order to establish their normal variations and aid in the recognition of pathological deviations. 2. The pre-epiglottic space was found to be a fat-filled radiolucent zone. Invasion of this space disturbed and opacified this homogeneous fatty radiolucency. The size and shape of the space did not appear of probable clinical significance. 3. The epiglottico-ventricular angle is usually clearly and sharply defined. In the absence of described normal variations, obliteration of this angle implies a soft tissue swelling in the region of the anterior commissure. 4. Enlarged nodes or other masses in the submaxillary region may be demonstrated on the lateral radiographs of the neck by a downward bulge of the margin of the waterdensity shadow normally seen below the mandible. Criteria for the extent of downward bulging in normal individuals are established and presented. 5. Dissociation of the el...

TOTAL LARYNGECTOMY: SIMPLIFIED TECHNICS WITH THE USE OF A SPECIAL CLAMP WHICH MAKES POSSIBLE THE REMOVAL OF THE LARYNX AND PREEPIGLOTTIC SPACE WITHOUT OPENING THE PHARYNX

We have been working in close cooperation on the surgery of cancer of the larynx and have published a paper presenting in detail our views concerning surgical indications and describing our technic of laryngectomy.1Recently we have been using a new technic2for this operation, more conservative than the one previously described by us. Both technics will be described in this article so as to make their differences and the indications for each well understood. In both operations the preepiglottic space is removed entirely and simultaneously with the larynx. The manner of spreading of a tumor at the base of the epiglottis and ventricular bands, well established by Leroux-Robert, makes it probable that in a large number of cases the removal of the tumor cannot be accomplished with safety if the preepiglottic space is not removed as well as the larynx. By using a special clamp (fig. 1) it is