Horizontal Supraglottic Laryngectomy Research Articles

Problems with supraglottic horizontal laryngectomy

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.

Horizontal supraglottic laryngectomy: Modifications to alonso's technique

Horizontal supraglottic laryngectomy (HSL) is an oncologically sound surgical procedure for selected cases of laryngeal cancer. It is based on the characteristic behavior of supraglottic carcinomas that do not invade the vocal cords. This constant finding, corroborated by clinical and anatomic studies, is attributable to the different embryological origin of the supraglottis from the glottis and subglottis. In this article we present a step-by-step description of the surgical technique described by Alonso, along with some technical modifications. The selection criteria and contraindications are briefly discussed.

Cricohyoidopexy in selected infrahyoid epiglottic carcinomas presenting with pathological preepiglottic space invasion.

Nineteen patients who presented with infrahyoid epiglottic squamous cell carcinoma with gross pathological preepiglottic space invasion, not amenable to a partial horizontal supraglottic laryngectomy, were offered a supracricoid partial laryngectomy with a cricohyoidopexy technique; this was an attempt to preserve physiological phonation, respiration, and deglutition while achieving the same local control rate as with a total laryngectomy. Preoperative chemotherapy and bilateral jugulocarotid lymph node dissection were performed in all cases. Patients were monitored for at least 5 years or until death. No patients were unavailable for follow-up. The 5-year actuarial survival (Kaplan-Meier method) was 84.2%. Local recurrence, nodal recurrence, and distant metastasis occurred once in our series, while six patients presented with a second primary tumor. We present, analyze, and compare functional results with those of the previously reported series. Our experience with the supracricoid partial laryngectomy with a cricohyoidopexy, in the face of selected infrahyoid epiglottic squamous cell carcinoma invading the preepiglottic space, not amenable to a partial horizontal supraglottic laryngectomy, suggested that a total laryngectomy might be avoided without decreasing the cure rate.

Analysis of DNA content in supraglottic epidermoid carcinoma.

DNA analysis by flow cytometry is considered to be of prognostic value in epidermoid carcinoma of the head and neck. However, few and contradictory studies have been made on laryngeal carcinomas. We studied 48 epidermoid carcinomas in patients subjected to horizontal supraglottic laryngectomy with a 5-year- followup. The technique described by Hedley for fixated and paraffin-embedded tumors was used. Thirteen tumors were excluded on the grounds of presenting variation coefficients in excess of 10. Of the 35 cases analyzed, 28 (80%) were diploid and seven (20%) aneuploid. No correlation was observed between tumor ploidy and patient survival, recurrence, or any of the histopathological variables studied.

Prognostic value of histopathological parameters in 51 supraglottic squamous cell carcinomas.

The prognosis for supraglottic squamous cell carcinomas is difficult to establish. A study of 19 histopathological parameters (14 from the primary tumor and 5 from the lymph node metastases) was undertaken in 51 supraglottic epidermoid carcinomas. All patients were subjected to supraglottic horizontal laryngectomy with bilateral functional neck dissection and postoperative radiotherapy. A discriminant analysis was performed to relate the different histopathological variables to 5-year survival. Capsule rupture and the number of metastatic lymph nodes were the only two parameters significantly related to survival (P < .01). Histopathology (in particular, lymph node metastases) proved more effective in predicting patient evolution than TNM staging.

Supracricoid laryngectomy with cricohyoidopexy: A partial laryngeal procedure for selected supraglottic and transglottic carcinomas

The partial horizontal supracricoid laryngectomy with cricohyoidopexy consists of resection of the whole thyroid cartilage and paraglottic space, as well as the epiglottis and the whole pre-epiglottic space. The cricoid cartilage, the hyoid bone, and at least one arytenoid cartilage are spared. Sixty-eight patients with squamous cell carcinoma of the supraglottis who underwent this procedure during the period from 1974 through 1986 are presented. Conventional horizontal supraglottic laryngectomy was contraindicated in all cases. All but three patients (95.4%) recovered physiologic deglutition, and none required a permanent tracheostomy. The 3-year actuarial survival rate was 71.4%. No local recurrences were encountered. The indications for the procedure are carcinomas of the supraglottis that 1. involve the glottis and anterior commissure, 2. invade the ventricle, 3. present with a marked limitation of true vocal cord mobility (transglottic lesions), and 4. invade the thyroid cartilage. The procedure is presented as a useful alternative to radiation therapy, horizontal supraglottic laryngectomy, and total laryngectomy in select cases of supraglottic carcinoma.

Hyoid preservation during horizontal supraglottic laryngectomy: A comparison of techniques

The technique of horizontal supraglottic laryngectomy, as originally described, included a resection of all supraglottic structures inclusive of the hyoid bone. In an effort to provide a more secure closure, and to maintain the integrity of the hyomandibular complex, modifications of the classical technique have been described that preserve the hyoid bone. In this brief position article, we illustrate and compare the techniques of horizontal supraglottic laryngectomy with and without hyoid bone preservation, and discuss the theoretical and practical considerations surrounding this issue.

Deglutition following supraglottic horizontal laryngectomy.

In order to determine factors that may contribute to deglutition problems following supraglottic horizontal laryngectomy or its modified techniques, clinical records of 38 patients were studied. Contribution of the following factors was investigated: age; sex; tumor classification; radical neck dissection; extent of and symmetry in removal of the aryepiglottic folds, arytenoid cartilages, and false folds; removal of the base of the tongue, hyoid bone, and a part of the vocal folds; extent of removal of the epiglottis and thyroid cartilage; cricopharyngeal myotomy; and some complications and concomitant diseases. The results suggest that removal of the arytenoid cartilage and asymmetrical removal of the false folds contribute to deglutition problems. We conclude that the standard supraglottic horizontal laryngectomy associated with surgical approximation of the larynx to the base of the tongue and cricopharyngeal myotomy does not usually cause serious deglutition problems. When the arytenoid cartilage is removed, reconstruction of the structure is required for the prevention of severe aspiration.

Pathways and pitfalls in partial laryngectomy.

Some 350 surgical specimens obtained at partial or total laryngectomy were photographed immediately after operation and processed for study by serial section. Intralaryngeal barriers to the spread of cancer are demonstrated on one hand and pathways of infiltration and destruction on the other. The following conclusions are based on these studies: two major elastic tissue barriers that influence the spread of vocal cord cancer are the dense mass of connective tissue at the anterior commissure which prevents invasion of the thyroid cartilage until very late, and the conus elasticus, under which vocal cord cancer may advance subglottically under the intact overlying mucosa. This conceals the actual extent of cancer below the glottis and is the usual cause of local recurrence after hemilaryngectomy. A large subglottic component of a glottic or transglottic cancer is sometimes associated with extension of disease within the cancellous interior of the thyroid ala or cricoid ring under an intact mucosa. A large ventricle or saccule may harbor the bulk of a glottic cancer under an intact ventricular band. Hemilaryngectomy is usually contraindicated once the extent of such a tumor is recognized. Removal of the hyoid bone is rarely necessary at horizontal supraglottic partial laryngectomy. Its preservation facilitates postoperative deglutition. Partial laryngectomy should not be attempted for pyriform sinus cancer if inspection reveals involvement of the apex.

Combined pre-operative telecobalt therapy and supraglottic laryngectomy.

At Groote Schuur Hospital, Cape Town, over a 5-year period (1974 to 1978) 15 patients with squamous cell carcinoma of the larynx or hypopharynx have had planned 2,000 Rad Telecobalt therapy followed by supraglottic horizontal laryngectomy. Five patients following surgery had a further 3,600--4,000 Rad Telecobalt therapy. The peri-operative complications, in addition to those of whole organ resection, included debilitating laryngeal incompetence in three patients, two of whom underwent total laryngectomy. All 15 patients have remained free of recurrent disease for 2 years and 10 have been free for 3 or more years. One patient died 4 years after surgery from a primary bronchial carcinoma.

Supraglottic surgery in vestibular cancer.

This paper deals with the experience acquired in the E.N.T. Clinic of the University of Ferrara regarding horizontal supraglottic laryngectomy in vestibular cancer. The anatomical background of this functional surgery and the most important principles of the technique are specified. The results regard 121 cases (13 T1 cases, 93 T2 cases and 15 T4 cases) divided into three groups: 1. patients who had only surgery (68 cases); 2. patients who for various reasons also had complementary postoperative radiotherapy (39 cases); 3. patients with extralaryngeal expansion who had preoperative radiotherapy (14 cases). The high overall survival rate for the 121 cases is particularly significant, as is the shortening of the high-risk period to less than the usual 5 years. The 4-year cure rate is 78% and remains unchanged right through the 7-year follow-up. The authors feel that these data demonstrate further the validity of supraglottic laryngectomy when its precise indications are rigorously observed.

Parameters of the infiltration of epiglottic cancer and horizontal supraglottic laryngectomy (author's transl)

The study of local infiltration of supraglottic cancer in 34 cases of horizontal supraglottic laryngectomy shows the sharp demarcation of this type of tumour on the cordal plane and the absence of local recurrences.

Reconstruction Surgery After the Partial Laryngectomy.

In order to establish the principles of reconstruction surgery after the partial laryngectomy, the correlation between post-operative function and shape of the remnant larynx was analysed from a acoustical or aerodynamical viewpoint and the following conslusion was obtained. 1) For the vertical partial laryngectomy, convex smooth surface of operated side is necessary to obtain good phonation. 2) For the supraglottic horizontal laryngectomy, supraglottal orifice and shortening of the aryepiglottic fold increase the hoarseness or inhibit the laryngeal vibration. On the other hand, the descendence of the larynx, especially of the aryepiglottic fold provoke mal deglutition. To obtain good post-operative function, therefore, these obstacles must be resolved. Finally, some procedure based upon the above-mentionned principle for the reconstruction surgery was proposed.

The Present Status of Partial Laryngectomy in cancer of the larynx in Japan

This report is the statistical analysis on 139 cases of cancer of the larynx operated by partial laryngectomy during the period of 5 years, 1960 through 1964. The techniques of partial laryngectomy used in these cases were laryngofissure, frontolateral laryngectomy, hemilaryngectomy, epiglottectomy, supraglottic horizontal laryngectomy and pharyngotomy. The postoperative results were analysed according to the techniques of operation, classification of the cases and compared with those of total laryngectomy and radiation therapy.

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.

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.